Ram_Ruler

The bucs offense isn’t very patient and tries to force things vertically but the Rams do a good job of taking away the big plays. Bucs bury themselves by not adjusting (see the bears game).

Science Has Learned So Much About COVID—and the Trump Administration Hasn’t Learned Anything at All
We’ve come a long way since March, yet our leaders are giving up.

* https://www.motherjones.com/politics/2020/11/science-has-learned-so-much-about-covid-and-the-trump-administration-hasnt-learned-anything-at-all/?utm_campaign=later-linkinbio-motherjonesmag&utm_content=later-12061299&utm_medium=social&utm_source=instagram&fbclid=IwAR0vK6NFHQWS49wak3FxoItjOCV3DXXYSwPDLQzfoT84Nn1jdY7Oitc95kQ

We are in the throes of the coronavirus’ deadly third surge. Daily cases in the United States are getting dangerously close to 200,000, and a map with each state’s case count basically looks like one big hot spot. New stay-at-home advisories and mask mandates have been issued in some communities in the Midwest. California is putting the brakes on its reopening plans. ICUs are filling up fast. In North Dakota, health care workers who test positive but aren’t showing symptoms are being asked to report to work. Dr. Anthony Fauci recently warned that an additional 200,000 people could die of COVID by the spring if we don’t get things under control soon.

How did we get to such a dark place? In part, it’s the fault of the cold weather driving people indoors, where the virus spreads much more efficiently. At Mother Jones, we’ve charted the abject failure of the Trump administration to do anything about the spread of the coronavirus—you can see its sweep in our timeline, which is called Superspreader in Chief. We’ve watched in horror as our leaders sat back and let a quarter of a million Americans die, promoting dangerous misinformation. The Great Barrington Declaration, embraced by White House coronavirus adviser Scott Atlas, basically suggests letting the virus run its course—a plan that would lead to millions of unnecessary deaths, mostly in vulnerable communities. For many reasons, it’s looking like Americans are just giving up.

Our leaders’ attitude of indifference is contagious, and as a result, there’s an all-or-nothing kind of mentality as we go into the holidays: You can hole up in your house alone—or blithely ignore the disease and host a rager with 50 members of your extended family. Indeed, a new Ohio State poll out this week found that 38 percent of people surveyed planned to attend holiday gatherings of 10 or more people.

When looking around for others to blame, the Trump administration has cast public health officials as the enemies—bloodless, liberal data wonks who want to enforce draconian lockdowns while destroying what’s left of the economy. Nothing could be further from the truth: Scientists are working overtime to figure out how we can reduce our risk so we can continue to live our lives. (If we had an effective public health messaging system, we’d know that, but I digress.)

Here’s the secret that the Trump administration doesn’t want you to know: Science can set us free. Though the pandemic may seem to be dragging on indefinitely, we’re learning about the coronavirus at an unbelievable clip. Scientists know so much more now than they did back in March about how the virus spreads—and how to stop it in its tracks.

One of my son’s favorite books is Boy, Were We Wrong About Dinosaurs! It’s all about how paleontologists have revised their hypotheses over the years as they uncover more fossils to learn from. It’s kind of been the same experience for epidemiologists, virologists, and infectious disease experts over these last nine months. Here’s a far from comprehensive list of some of the leaps they’ve made. Let’s call it Boy, Were We Wrong About the Coronavirus!

Back in March, we thought: that the virus was transmitted on surfaces like doorknobs, counters, and food packaging.

Now we know: that while the virus can survive on surfaces, it’s mostly transmitted through respiratory droplets from breathing, talking, laughing, singing, coughing, and sneezing.

What that means: Most public health experts still emphasize the importance of hand-washing and regular surface cleaning, but they don’t recommend wiping down your groceries.

Back in March, we thought: that masks weren’t effective in preventing the spread of the virus.
Now we know: that cloth face coverings can protect both the wearer and those around them. One recent University of Washington study estimated that universal mask-wearing could save 130,000 lives by February. Masks may even act as a crude vaccine, exposing wearers to just enough virus to trigger an immune response.

What that means: You can feel pretty safe running to the grocery store, the doctor’s office, or other public indoor spaces if you and others are wearing masks. You can minimize your risk of transmitting the virus during a holiday gathering if everyone wears masks and stays outside.

Back in March, we thought: that only people who showed symptoms could transmit the coronavirus.

Now we know: that asymptomatic people can and do spread the virus.
What that means: Health care professionals can now tell patients who have been exposed to someone with the virus to isolate right away, even if they don’t feel sick, thereby preventing additional infections.

Back in March, we thought: that we’d never be able to scale up testing enough to make a difference.

Now we know: that while we still have a long way to go, testing is free, quick, and readily available in many places. Just this week, there was more good news on the testing front: The FDA has authorized the first at-home rapid test for the virus.

What that means: We now have the ability to catch cases early, before the infected person has a chance to spread the virus to many others. The key now is convincing people to be tested and investing in systems to warn people who have been in close contact with those who test positive.

Back in March, we thought: that air filtration systems might not help limit the spread of the virus.

Now we know: that while they’re not enough on their own to protect us, when used correctly and in combination with masks, HEPA filters can help.
What that means: Installing filters can offer an additional layer of protection for essential spaces like hospitals and classrooms.

Back in March, we thought: that schools would be the main way that the coronavirus spreads.

Now we know: that while school outbreaks do occur, indoor spaces where adults congregate are much more likely to lead to outbreaks. A recent study in the journal Nature found that in urban areas, restaurants, gyms, hotels, cafes, and houses of worship were the source of most superspreader events. Schools, meanwhile, have not seen as many outbreaks as experts initially feared, especially at the elementary level.

What that means: We can prioritize reopening schools with appropriate safety measures—and putting more restrictions on restaurants, bars, gyms, and other adult-centered businesses.

To explain the power of these measures, public health experts like to use the analogy of layers of slices of Swiss cheese. In one slice, there are many holes. If you add another slice, it covers up a few of those holes, and so on. The more layers, the closer you get to an opaque hunk of cheese. The more virus-protection strategies you layer on, the less likely it is the virus will sneak through.

Of course there are more layers should infection occur: Coronavirus treatments have improved immensely—back in March the ventilator was basically the only tool doctors had, and it wasn’t a very good one. Now we know that “proning”—placing patients on their stomach—can help them breathe better. We have a fleet of promising medications, including, as of last week, an antibody treatment that seems to be effective in preventing severe disease. The brass ring, of course, is the promise of several highly effective vaccines expected to begin distribution before year’s end.

But as I’ve written before, medical breakthroughs on their own won’t stop this virus. What’s more, despite what our leaders say, we don’t have to sit around and wait for a miracle cure, nor must we throw our hands up in despair and let the virus run loose. We do have agency in this situation. We have the power to protect ourselves and our loved ones, thanks to the dazzlingly fast and careful work of scientists. The best way to honor that work is by letting it empower us.

wv wrote:

waterfield wrote:

This following article was on the front page of the L.A. Times this morning under the title “Portland anarchists spark backlash”

“Portland’s anarchists say they support racial justice. Black activists want nothing to do with them….

==================

I have many layers of thoughts/feelings about ‘anarchist’ direct-action campaigns like this. Too many to list.

…On the one hand, i think most-if-not-all of the young-anarchists have a higher Political-IQ than 90 percent of the American population. I think they understand what capitalism is doing to the nation, and to the biosphere.
So, they are smart, informed, passionate, critical-thinkers, for the most part.
(at least the ones who are legit anarchist, and not proud-boy-types doing false-flag games)

But, being young, and passionate the anarchists are utterly stupid when it comes to strategy, tactics, etc. Many are impatient, and reckless and selfish. And they are young, so there is no getting thru to them.

And to just shoot from the hip…I have noticed in my life, that Anarchists tend to be giant pains-in-the-Ass. To everyone. Including other Anarchists.

Switching to another layer….when i put it in a wider context, Corporate-capitalism is causing mass extinctions, fracking poisoning of children, pollution, Climate Change, Mass Incarceration, Ungodly-Inequality which leads to massive suffering and death, Imperialism, Massive Lie-Campaigns, Coups, Torture, etc etc etc.

So you have THAT on one hand. Meanwhile the LA Times focuses on a small group of anarchists breaking windows.

That is corporate media. Perfect example of corporate media. What they cover. How they cover it. And what they dont cover.

w
v

Well-the L.A. Times has published many articles about Portland that run the spectrum. So I don’t subscribe to the notion that they “focus on a small group of anarchists breaking windows”. I also don’t accept the idea that the anarchists were simply breaking windows. I don’t live there and was not there at the time but my childhood and long lasting friend lives outside Portland and said it wasn’t just “windows”. Also my son and his family were visiting Portland after picking up my grandson after a ski camp at Mt. Hood. He said also that it was scary and he is not afraid of broken windows.

As far as anarchists having a higher IQ than 90% of the US population. That’s simply an outburst. Me? I think most “anarchists” love anarchy. Doesn’t matter what the issue is. They love causing unrest. Not because of political issues. They simply love causing unrest. These are not college post grads going back to coffee houses and discussing Marx and Keynesian economics. No these are simple souls saying “hey look at me. Rage against the machine. You don’t like it-fuck you . Ha,Ha,Ha !” That’s my outburst.

from ‘No One Is Listening to Us’
More people than ever are hospitalized with COVID-19. Health-care workers can’t go on like this.

https://www.theatlantic.com/health/archive/2020/11/third-surge-breaking-healthcare-workers/617091/?fbclid=IwAR27_eCSc48uJXsmkaMydzbwbSLSHlRDZmAbvpUss-TEpfW4zpH8hL4yiIo

Every time nurse Megan Ranney returns to the hospital, there are more COVID-19 patients.

In the months since March, many Americans have habituated to the horrors of the pandemic. But health-care workers do not have the luxury of looking away: They’re facing a third pandemic surge that is bigger and broader than the previous two. In the U.S., states now report more people in the hospital with COVID-19 than at any other point this year—and 40 percent more than just two weeks ago.

Emergency rooms are starting to fill again with COVID-19 patients. Utah, where Nathan Hatton is a pulmonary specialist at the University of Utah Hospital, is currently reporting 2,500 confirmed cases a day, roughly four times its summer peak. Hatton says that his intensive-care unit is housing twice as many patients as it normally does. His shifts usually last 12 to 24 hours, but can stretch to 36. “There are times I’ll come in in the morning, see patients, work that night, work all the next day, and then go home,” he told me. I asked him how many such shifts he has had to do. “Too many,” he said.

Hospitals have put their pandemic plans into action, adding more beds and creating makeshift COVID-19 wards. But in the hardest-hit areas, there are simply not enough doctors, nurses, and other specialists to staff those beds. Some health-care workers told me that COVID-19 patients are the sickest people they’ve ever cared for: They require twice as much attention as a typical intensive-care-unit patient, for three times the normal length of stay. “It was doable over the summer, but now it’s just too much,” says Whitney Neville, a nurse based in Iowa. “Last Monday we had 25 patients waiting in the emergency department. They had been admitted but there was no one to take care of them.” I asked her how much slack the system has left. “There is none,” she said.

The entire state of Iowa is now out of staffed beds, Eli Perencevich, an infectious-disease doctor at the University of Iowa, told me. Worse is coming. Iowa is accumulating more than 3,600 confirmed cases every day; relative to its population, that’s more than twice the rate Arizona experienced during its summer peak, “when their system was near collapse,” Perencevich said. With only lax policies in place, those cases will continue to rise. Hospitalizations lag behind cases by about two weeks; by Thanksgiving, today’s soaring cases will be overwhelming hospitals that already cannot cope. “The wave hasn’t even crashed down on us yet,” Perencevich said. “It keeps rising and rising, and we’re all running on fear. The health-care system in Iowa is going to collapse, no question.”

In the imminent future, patients will start to die because there simply aren’t enough people to care for them. Doctors and nurses will burn out. The most precious resource the U.S. health-care system has in the struggle against COVID-19 isn’t some miracle drug. It’s the expertise of its health-care workers—and they are exhausted.

The struggles of the first two COVID-19 surges in the United States helped hospitals steel themselves for the third. Hardened by the crucible of March and April, New York City built up its ability to spot burgeoning hot spots, trace contacts, and offer places where infected people can isolate. “We’re seeing red flags but we’ve prepared ourselves,” says Syra Madad from NYC Health + Hospitals. Experienced health-care workers are less fearful than they were earlier this year. “We’ve been through this before and we know what we have to do,” says Uché Blackstock, an emergency physician who works in Brooklyn. And with the new generation of rapid tests, Blackstock says she can now tell patients if they have the coronavirus within minutes—a huge improvement over the spring, when tests were scarce and slow.

Smaller clinics, nursing homes, and long-term-care facilities are still struggling to provide personal protective equipment, including gloves and masks. “About a third are completely out of at least one type of PPE” despite having COVID-19 cases, says Esther Choo, a physician at Oregon Health and Science University and a founder of Get Us PPE. But larger hospitals are doing better, having built up stockpiles and backup plans in case supply chains become strained again. “The hospital is probably the safest place to work in Iowa, because we actually have PPE,” Perencevich said.

Most important, COVID-19 is no longer a total mystery. Health-care workers now have a clearer idea of what the SARS-CoV-2 coronavirus is capable of. Protocols that didn’t exist in the spring have become habit. “It used to be that to do a single thing, people would start email chains and you’d be 100 emails in before we knew the answer,” Choo says. “Now we’re moving faster. It feels a lot more confident.”

There are still no cures, and the best drug on offer—the steroid dexamethasone—reduces the odds of dying from COVID-19 by at most 12 percent. But doctors know how to triage patients, which tests to order, and which treatments to use. They know that ventilators can sometimes hurt patients, and that “proning”—flipping patients onto their stomach—can help. They know about the blood clots and kidney problems. They know that hydroxychloroquine doesn’t work. This cumulative knowledge means that death rates from COVID-19 are much lower now than they were in the spring. Flattening the curve worked as intended, giving health-care workers some breathing room to learn how to handle a disease that didn’t even exist this time last year.

But these hard-earned successes are brittle. If death rates have fallen thanks to increasing medical savvy, they might rise again as nurses and doctors burn out. “If we can get patients into staffed beds, I feel like they’re doing better,” Perencevich said. “But that requires a functional health-care system, and we’re at the point where we aren’t going to have that.”

Intensive-care units are called that for a reason. A typical patient with a severe case of COVID-19 will have a tube connecting their airways to a ventilator, which must be monitored by a respiratory therapist. If their kidneys shut down, they might be on 24-hour dialysis. Every day, they’ll need to be flipped onto their stomach, and then onto their back again—a process that requires six or seven people. They’ll have several tubes going into their heart and blood vessels, administering eight to 12 drugs—sedatives, pain medications, blood thinners, antibiotics, and more. All of these must be carefully adjusted, sometimes minute to minute, by an ICU nurse. None of these drugs is for treating COVID-19 itself. “That’s just to keep them alive,” Neville, the Iowa nurse, said. An ICU nurse can typically care for two people at a time, but a single COVID-19 patient can consume their full attention. Those patients remain in the ICU for three times the length of the usual stay.

Nurses and doctors are also falling sick themselves. “The winter is traditionally a very stressful time in health care, and everyone gets taken down at some point,” says Saskia Popescu, an infection preventionist at George Mason University, who is based in Arizona. The third COVID-19 surge has intensified this seasonal cycle, as health-care workers catch the virus, often from outside the hospital. “Our unplanned time off is double what it was last October,” says Allison Suttle of Sanford Health, a health system operating in South Dakota, North Dakota, and Minnesota. Many hospitals have staff on triple backup: While off their shifts, they should expect to get called in if a colleague and their first substitute and the substitute’s substitute are all sick. At least 1,375 U.S. health-care workers have died from COVID-19.

The first two surges were concentrated in specific parts of the country, so beleaguered hospitals could call for help from states that weren’t besieged. “People were coming to us in our hour of need,” says Madad, from NYC Health + Hospitals, “but now the entire nation is on fire.” No one has reinforcements to send. There are travel nurses who aren’t tied to specific health systems, but the hardest-hit rural hospitals are struggling to attract them away from wealthier, urban centers. “Everyone is tapping into the same pool, and people don’t want to work in Fargo, North Dakota, for the holidays,” Suttle says. North Dakota Governor Doug Burgum recently said that nurses who are positive for COVID-19 but symptom-free can return to work in COVID-19 units. “That’s just a big red flag of just how serious it is,” Suttle says. (The North Dakota Nurses Association has rejected the policy.)

Short-staffed hospitals could transfer their patients—but to where? “A lot of smaller hospitals don’t have ventilators or staff trained to take care of someone in critical condition,” says Renae Moch, the director of Bismarck-Burleigh Public Health, North Dakota. “They’re looking to larger hospitals,” but those are also full.

Making matters worse, patients with other medical problems are sicker than usual, several doctors told me. During the earlier surges, hospitals canceled elective surgeries and pulled in doctors from outpatient clinics. People with heart problems, cancers, strokes, and other diseases found it harder to get medical help, and some sat on their illness for fear of contracting COVID-19 at the hospital. Now health-care workers are facing an influx of unusually sick people at a time when COVID-19 has consumed their attention and their facilities. “We’re still catching up on all of that,” says Choo, the Oregon physician. “Even the simplest patients aren’t simple.”

For many health-care workers, the toll of the pandemic goes beyond physical exhaustion. COVID-19 has eaten away at the emotional core of their work. “To be a nurse, you really have to care about people,” Neville said. But when an ICU is packed with COVID-19 patients, most of whom are likely to die, “to protect yourself, you just shut down. You get to the point when you realize that you’ve become a machine. There’s only so many bags you can zip.”

As the pandemic moved out of big coastal cities and into rural communities, health-care workers were more likely to treat people they knew personally—relatives, hospital colleagues, the bus driver who drove their kids to school. And across the country, doctors and nurses have struggled with the same anxieties as everyone else—loneliness, extra child-care burdens, the stress of a tumultuous year, fear. “The lines between our personal lives and our careers have completely gone,” says Laolu Fayanju, senior medical director in Ohio of Oak Street Health, a national network of primary-care centers. “We’re often thinking about how we protect ourselves, our families, and our neighborhoods” from the pandemic.

After SARS hit Toronto in 2003, health-care workers at hospitals that treated SARS patients showed higher levels of burnout and posttraumatic stress up to two years later, compared with those at hospitals in nearby cities that didn’t see the disease. That outbreak lasted just four months. The COVID-19 pandemic is now in its tenth month. “I’ve had conversations with people who’ve been nurses for 25 years, and all of them say the same thing: ‘We’ve never worked in this environment before,’” says Jennifer Gil from Thomas Jefferson University Hospital in Philadelphia, who contracted COVID-19 herself in March. “How much can meditation or mental-health resources help when we’re doing this every day?”

Even after cases stop climbing, health-care workers will have to catch up on a new round of procedures that didn’t happen because of COVID-19—but without the adrenaline that a packed hospital brings. “Everyone talks about fatigue during the surge, but one of the hardest things is coming down from it,” Popescu says. “You’re exhausted but you still don’t get that mental break.”

As hard as the work fatigue is, the “societal fatigue” is harder, said Hatton, the Utah pulmonary specialist. He is tired of walking out of an ICU where COVID-19 has killed another patient, and walking into a grocery store where he hears people saying it doesn’t exist. Health-care workers and public-health officials have received threats and abusive messages accusing them of fearmongering. They’ve watched as friends have adopted Donald Trump’s lies about doctors juking the hospitalization numbers to get more money. They’ve pleaded with family members to wear masks and physically distance, lest they end up competing for ICU beds that no longer exist. “Nurses have been the most trusted profession for 18 years in a row, which is now bullshit because no one is listening to us,” Neville said.

…

Choo also studies the impacts of health-care policy, and has found that health-care systems sometimes react to imminent policies months before they are actually come into force.

…

Still, “you can’t just fix a pandemic this far down the rabbit hole,” Popescu says. “I’m hopeful, but I don’t expect this to suddenly turn itself around overnight.”
…

“We can’t just sit on our hands and wait for Jan. 20 to come,” said Megan Ranney, the Rhode Island physician. Several health-care workers I spoke with are trying to keep mild cases of COVID-19 from becoming severe enough to warrant an ICU bed. The Oak Street Health primary-care centers deliver fluids, pulse oximeters, and smart tablets to the homes of newly diagnosed COVID-19 patients, so doctors can check on their symptoms virtually. In North Dakota, South Dakota, and Minnesota, the Sanford Health network has set up outpatient “infusion centers” where elderly COVID-19 patients or those with chronic illnesses can get drugs that might slow the progression of their disease. These drugs will include the antibody therapy bamlanivimab, which received an emergency-use authorization from the FDA on Monday, Suttle told me.

But the best strategy remains the obvious one: Keep people from getting infected at all. Once again, the fate of the U.S. health-care system depends on the collective action of its citizens. Once again, the nation must flatten the curve. This need not involve a lockdown. We now know that the coronavirus mostly spreads through the air, and does so easily when people spend prolonged periods together in poorly ventilated areas. People can reduce their risk by wearing masks and avoiding indoor spaces such as restaurants, bars, and gyms, where the possibility of transmission is especially high (no matter how often these places clean their surfaces). Thanksgiving and Christmas gatherings, for which several generations will travel around the country for days of close indoor contact and constant conversation, will be risky too.

Preliminary results suggest that at least one effective vaccine is on the way. The choices made in the coming weeks will influence how many Americans die before they have a chance to receive it, and how many health-care workers are broken in the process.

COVID-19 Hospitalizations Are Surging. Where Are Hospitals Reaching Capacity?
Surging hospitalizations are straining health care systems around the United States.

https://www.npr.org/sections/health-shots/2020/11/10/933253317/covid-19-hospitalizations-are-surging-where-are-hospitals-reaching-capacity

Throughout the U.S., hospitals and health care workers are tracking the skyrocketing number of new coronavirus cases in their communities and bracing for a flood of patients to come in the wake of those infections. Already, seriously ill COVID-19 patients are starting to fill up hospital beds at unsustainable rates.

U.S. hospitalizations overall have nearly doubled since late September. As of Tuesday, 59,275 COVID-19 patients were hospitalized around the country, nearly on par with the highs of the midsummer and spring surges.

“We have legitimate reason to be very, very concerned about our health system at a national level,” says Lauren Sauer, an assistant professor of emergency medicine at Johns Hopkins University who studies hospital surge capacity.

The spring and summer waves of COVID-19 hospitalizations were concentrated largely in a handful of cities in the Northeast and parts of the South.

With the virus now surging across the country, experts warn that the impact of this next wave of hospitalizations will be even more devastating and protracted.

“I fear that we’re going to have multiple epicenters,” says Dr. Mahshid Abir, an emergency physician at the University of Michigan and researcher at the Rand Corp. who has developed a model that helps hospitals manage surge capacity.

If that happens, Abir warns that there won’t be flexibility to shuffle around resources to the places in need because everywhere will be overwhelmed.

The impact varies state by state with certain areas showing much more rapid increases in hospitalizations. As of Monday, hospitalizations are now rising in 47 states, according to data collected by The COVID Tracking Project, and 22 states are seeing their highest numbers of COVID-19 hospitalizations since the pandemic began.

Where are hospitals at risk of maxing out?

With the numbers growing nearly everywhere, the key question for hospital leaders and policymakers is, when is a community on the brink of having more patients than it can handle?

In parts of the Midwest and the West, hospitals are already brushing up against their capacity to deliver care. Some are struggling to find room for patients, even in large urban hospitals that have more beds.

But the surge in hospitalizations is not evenly spread — and hospitals’ capacity for weathering case surges varies greatly.

One way to gauge the growing stress on a health care system is by tracking the share of hospital beds occupied by COVID-19 patients.

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The federal department of Health and Human Services tracks and publishes this data at the state (but not the local) level. Several experts NPR spoke to say that, though imperfect, this is one of the best metrics communities have to work with.

Though there’s not a fixed threshold that applies to all hospitals, generally speaking, once COVID-19 hospitalizations exceed 10% of all available beds, that signals an increasing risk that the health care system could soon be overwhelmed, explains Sauer.

“We start to pay attention above 5%,” says Sauer. “Above that, 10% is where we think, ‘Perhaps we have to start enacting surge strategies and crisis standards of care in some places.'”

Crisis standards of care is a broad term for how to prioritize medical treatment when resources are scarce. In the most extreme cases, that can lead to rationing of care based on a patient’s chance of survival.

The latest data from HHS shows that in 18 states — mostly in the Midwest — COVID-19 hospitalizations have already climbed above 10%.

Six states are over 15%, including North Dakota and South Dakota, which are now over 20%.

Hospital capacity is flexible … until it’s not

The percentage of hospital beds taken up by COVID-19 patients does not tell a complete story about hospital capacity, says Sauer, but it’s a starting point.

Hospital capacity is not so much a static number, but an ever-shifting balance of resources. “It’s space, staff and stuff, and you need all three, and if you don’t have one, it doesn’t matter if you have the other two,” says Abir.

The level of COVID-19 hospitalizations that would be a crisis in one place might not be in another. Still, a growing share of beds occupied by COVID-19 patients can be a strong signal that the health care system is headed for trouble.

COVID-19 patients can be more labor intensive because health care workers have to follow intricate protocols around personal protective equipment and infection control. And some of the patients take up ICU space.

“When the numbers go up like that, particularly for critical care, that strains the system pretty significantly,” says Abir. “This is a scarce resource. Critical care nurses are scarce. Ventilators are scarce. Respiratory therapists are scarce.”

In Utah, where the share of hospitalized COVID-19 patients is about 8%, state health officials have already warned that hospitals may soon be forced to ration care because of limited ICU space.

There is no “magic number” to indicate when a health care system may be overwhelmed, says Eugene Litvak, who is CEO of the Institute for Healthcare Optimization and helps advise hospitals on how to manage their capacity. But hospitals must be alert to rapid increases in patient load.

“Even a 10% increase can be quite dangerous,” says Litvak. “If you are a hospital that’s half empty, you can tolerate it.” But U.S. hospitals generally run close to capacity, Litvak says, with above 90% of beds already full — especially toward the end of the week.

“Imagine that 10% of extremely sick patients on top of that,” he says. “What are your options? You can not admit ambulances and patients with non-COVID medical needs, or you have to cancel your elective surgeries.”

In the spring, some states ordered that most elective surgeries come to a halt so that hospitals had room for COVID-19 patients, but Litvak says this leads to all kinds of collateral damage because patients don’t get the care they need and hospitals lose money and lay off staff.

State data may miss local hot spots

Statewide COVID-19 hospitalization metrics mask huge variations within a state. Certain health care systems or metro areas may be in crisis.

“It’s very valuable information, but a state average can be misleading,” says Ali Mokdad with the Institute for Health Metrics and Evaluation at the University of Washington, which projects that many states will face big problems with hospital capacity this winter. “It doesn’t tell you where in the states it’s happening.”

Big urban centers may be much better equipped to absorb a rush of patients than smaller towns.

In New York City, Mount Sinai Health System was able to more than double its bed capacity during the spring surge. Other communities don’t have the ability to ramp up capacity so quickly.

“Especially the states that don’t have major cities with major hospitals, you see a lot of stress on them,” Mokdad says.

But it’s hard for researchers and health leaders to get a clear picture of what’s happening regionally without good data, he adds. NPR has reported that the federal government does not share this local data, although it does collect it daily.

Some states publish their own hospital data sets. Texas, which shares the data in detail, provides a striking example. Statewide, COVID-19 hospitalizations have reached about 11%. Meanwhile, El Paso is above 40%, which has pushed the health care system to the brink.

Ultimately, it’s difficult to know the true capacity for a region because many hospitals still don’t coordinate well, says Dr. Christina Cutter, an emergency physician at the University of Michigan who collaborated on the Rand model with Abir.

“It’s really hard to make sure you’re leveraging all the resources and that one hospital is not overburdened compared to another hospital, and that may have unintended loss of life as a consequence,” Cutter says.

Dire consequences of overfilled hospitals

During the height of Arizona’s summer surge, COVID-19 patients filled nearly half of all beds in the state.

“When 50% of our hospital is doing COVID, it means the hospital is overloaded. It means that other services in that hospital are being delayed,” says Mokdad. “The hospital becomes a nightmare.”

Health care workers are pushed to their limits and are required to treat more patients at the same time. Hospitals can construct makeshift field hospitals to add to their capacity, but those can be logistically challenging and still require health care workers to staff the beds.

In Wisconsin, COVID-19 patients account for 17% of all hospitalizations, and many hospitals are warning that they are at or near capacity.

The Marshfield Clinic Health System, which runs nine hospitals in primarily rural parts of the state, is expecting its share of COVID-19 patients to double, if not more, by the end of the month.

“That will push us well beyond our staffing levels,” says Dr. William Melms, chief medical officer at Marshfield. “We can always make more space, but creating the manpower to take care of our patients is the dilemma.”

During earlier surges, many hospitals relied on bringing in hundreds or even thousands of out-of-state health care workers for backup, but Melms says that is not happening this time.

“We are on an island out here,” he says.

An increase in COVID-19 hospitalizations statewide is also associated with higher mortality, according to a recent study that analyzed the relationship between COVID-19 hospitalizations and deaths.

“It’s an indicator that you’re going to have more deaths from COVID as you see the numbers inch up in the hospital,” says Pinar Karaca-Mandic, professor and academic director of the Medical Industry Leadership Institute at the University of Minnesota.

Specifically, Karaca-Mandic’s research found that a 1% increase of COVID-19 patients in a state’s ICU beds will lead to about 2.8 additional deaths in the next seven days.

She says a statewide level of 20% COVID-19 hospitalizations may not look all that alarming, but that number doesn’t capture the constraints on the health care system in adding more ICU beds.

“That’s not very flexible,” she says. “It requires a lot of planning. It requires a lot of investments. So the more you fill up the ICU, the impact is going to be larger.”

…

https://www.dailyposter.com/p/six-takeaways-from-election-night

Six Takeaways From Election Night
Dems’ weak economic message helped Trump, the Lincoln Project embarrassed itself, and a ton of grassroots money was set on fire.

David Sirota, Andrew Perez, and Julia Rock
Nov 3

As the country awaits the final results of the presidential election, there are already six key lessons to be gleaned from election, campaign finance and public opinion data.

1. Democrats’ Weak Economic Message Hugely Helped Trump
The Democratic ticket pretty much ran away from economic issues — sure, it had decent position papers, but economic transformation was not a huge part of its public messaging, and that failure buoyed Trump, according to exit polls from Edison Research.

Trump won 81 percent of the vote among the third of the electorate that listed the economy as its top priority. Even more amazing — Trump and Biden equally split the vote among those whose priority is a president who “cares about people like me.”

2. The Lincoln Project And Rahm Emanuel Embarrassed Themselves
The Lincoln Project, the anti-Trump cash cow for veteran Republican consultants, has raised $40 million from MSNBC-watching Brunch Liberals in just the last few months, and is now set to launch a media brand off the idea that its GOP operatives are political geniuses.

Their ads focused on trying to court disaffected Republican voters and attack Trump’s character, as Biden loaded up the Democratic convention with GOP speakers. When polls during the summer showed that the strategy wasn’t working, galaxy brain Rahm Emanuel defended it to a national televised audience, insisting that 2020 would be “the year of the Biden Republican.”

Now survey data show the strategy epically failed, as Trump actually garnered even more support from GOP voters than in 2016. Indeed, Edison Research exit polls on Tuesday found that 93 percent of Republican voters supported Trump — three percentage points higher than in 2016, according to numbers from the same firm.

The takeaway: There may be a lot of so-called “Never Trump Republicans” promoted in the media and in politics, but “Never Trump Republicans” are not a statistically significant group of voters anywhere in America. They basically do not exist anywhere outside of the Washington Beltway or cable news green rooms — and after tonight’s results, we shouldn’t have to see them on TV or even see their tweets ever again.

As for the Lincoln Project’s focus on trying to scandalize Trump’s character, the exit polls found that voters are far more concerned about policy issues than personality. Seventy-three percent of voters said their candidate’s positions on the issues were more important in their vote for president than their candidate’s personal qualities.

3. People Don’t Love The Affordable Care Act
While it may have made short-term sense for Democrats to focus on the GOP’s efforts to repeal protections for patients with pre-existing conditions, Americans actually aren’t particularly pleased with the Affordable Care Act at a moment when millions have lost health insurance and insurers’ profits are skyrocketing because people can’t or don’t want to go to the doctor.

Edison Research exit polls found that 52 percent of voters think the Supreme Court should keep Obamacare, while 43 percent said the court should overturn it.

A Fox News Voter Analysis survey, which went to more than 29,000 people in all 50 states between Oct. 26 and Nov. 3, found similar numbers but suggests the ACA’s support is fairly thin: 14 percent of people want to leave the law as is while 40 percent of people would like to improve it.

The same poll asked voters if they would support changing the health care system so that any American can buy into a government-run health care plan if they want to — also known as a public health insurance option — and found that 71 percent of people support the idea and only 29 percent oppose.

Although Biden and Senate Democrats both supported a public health insurance option plan, their campaigns and outside spending groups spent more time messaging around protecting the ACA. The Kaiser Family Foundation’s tracking poll has shown consistently middling support for the ACA — and showed that during the summer COVID burst, the law was underwater among Americans aged 50-64.

The ACA’s protections for patients with pre-existing conditions was a key topic in recent weeks in the lead-up to new Trump Supreme Court Justice Amy Coney Barrett’s confirmation, with the court set to hear a challenge to the law soon.

In a speech that Biden gave from Wilmington on Oct. 28, focused on COVID-19 and his health care plan, Biden spoke about the importance of trusting science and mask wearing, and highlighted Trump’s attacks on the ACA, but he only mentioned a public option once.

4. A Lot Of Grassroots Money Was Set On Fire
Democrats raised roughly a quarter billion dollars for senate races in Kentucky, South Carolina, Texas and Alabama — and their candidates all appear to have gone down to defeat by 10 points or more.

These are tough states for Democrats, but there’s a cautionary tale about resource allocation among Democrats’ donor base. While grassroots-funded advocacy and media organizations are starved for resources, a handful of candidates can snap their fingers and be awash in cash at election time — and still get crushed.

Democratic Senate candidates saw a massive surge in donations after Justice Ruth Bader Ginsburg’s death in September — before the party barely put up a fight and Justice Amy Coney Barrett was quickly confirmed to the Supreme Court.

5. Democrats’ Court Calculation Was Wrong
When Trump nominated right-wing extremist Amy Coney Barrett to the Supreme Court, the conventional wisdom was that Democrats shouldn’t seriously combat the nomination, because a court fight would primarily motivate conservative voters. Exit polls prove that false: 60 percent of voters said the court was a significant factor in their vote, and a majority of those voters supported Biden — who barely spoke up against the nomination. Had there been a more intense fight, it might have helped the Democrats.

All but one of the top tier Democratic Senate candidates shied away from talk of adding new Supreme Court court seats if their party won control of the Senate — which doesn’t matter now, since many of them lost anyway.

6. A Large Percentage Of Americans Have Lost Their Minds
In mid-October, Bloomberg News reported that “the proportion of Americans dying from coronavirus infections is the highest in the developed world” — and yet exit polls show 48 percent of Americans believe their government’s efforts to contain the coronavirus pandemic are going very well or somewhat well.

After a season of destructive wildfires and hurricanes, the same exit polls show 30 percent of Americans say climate change is not a serious problem.

https://www.newyorker.com/science/medical-dispatch/how-to-understand-trumps-evolving-condition

How to Understand Trump’s Evolving Condition
Day to day, the news can be confusing. But the treatment of COVID-19 has steps, phases, and milestones that can tell us a lot about how the President is doing.
By Dhruv Khullar

October 4, 2020

The days since Donald Trump tested positive for the coronavirus have been more confusing than usual. Consider this exchange from Saturday’s news conference with Sean Conley, the White House physician:

reporter: Has he also experienced difficulty breathing?

conley: No, no, he has not. Never did. He had a little cough. He had the fever. More than anything he’s felt run-down.

A seemingly straightforward answer. And yet later it emerged that Trump’s oxygen levels had already dipped low enough to warrant supplementary oxygen. Was the President not short of breath when that happened? No one who wasn’t there can say for sure, because the Administration hasn’t been communicating clearly and in a detailed way about Trump’s illness. If the President had a fever, then what was his temperature? Has he sustained any lung damage? When did he last test negative for the virus? One might have hoped that Conley, having been roundly criticized for his evasiveness after his first briefing, would be more forthright at his second, on Sunday. Instead, he dodged again. When asked if Trump had received a second round of supplementary oxygen, he pleaded ignorance: “I’d have to check with the nursing staff,” he said.

The vagueness of the communications we’ve received so far may be intentional: in particular, the question of when and how the President was first diagnosed has become freighted with clinical, epidemiological, and ethical implications. Most reports have placed his first positive test sometime between Wednesday morning and Thursday evening. Clinically, knowing the precise time line would tell us how far into the illness Trump has progressed, and when he will enter the window, usually beginning about a week after the onset of symptoms, in which he’s at the greatest risk for deterioration. Epidemiologically, the timing matters for the many people Trump may have exposed to the virus: the President held campaign events throughout the week, including a fund-raiser in New Jersey on Thursday where he met with dozens of donors—an event that featured a buffet. And, ethically, it affects our judgment of his actions. It’s possible that Trump knew that he had been exposed to the virus, or had even received a diagnosis himself, and yet continued to meet with staff and donors, consciously placing their health at risk.

These possibilities may be adding to the Administration’s caginess. In any event, the coronavirus is already confusing. In the months since the pandemic started, I’ve cared for scores of patients with covid-19, many of whom, like Trump, have been advanced in age. Doctors speak of the “course” of a disease; my patients’ disease courses have been unpredictable, with long plateaus interrupted by sudden reversals. Now that Trump himself has covid-19, the country as a whole faces the diagnostic challenge with which doctors like me have grown familiar. We must figure out where Trump is in the landscape of clinical possibility and try to guess where he’s headed. In a sense, our task is harder: we must do it without an organized, comprehensive overview of what’s happening, piecing together the scattered information as it emerges.

Doctors now recognize two broad and somewhat overlapping phases of covid-19. In the first phase, it’s the replication of the virus that causes problems, such as shortness of breath; especially in the lungs, the virus has hijacked the body’s cells to multiply exponentially, and the immune system is fighting to tamp it down. It’s during this phase that antiviral drugs are thought to have their greatest effect; they are like reinforcements for the immune system, and they help to slow the replication of the virus. In the second phase, it’s the immune system itself that starts to become a problem. The virus provokes an immunological storm that wreaks havoc on many organs; the lungs are still at the center of the disease, but other systems get damaged, too. The body must now fight the virus while weathering its own overreaction. Most patients never enter this second, more dangerous phase, but those who do can grow seriously ill.

To evaluate patients with covid-19, therefore, one must start by determining where in the process they find themselves: are they in the first phase, the second, or the transition between? It’s not unusual for people to be admitted to the hospital during the first phase. Because their lungs are under attack, they often have trouble breathing and need some supportive oxygen; in many cases, an insufficient blood-oxygen level is the primary rationale for hospitalization. (This seems likely to have been true in Trump’s case.) Such patients are monitored closely for changes in oxygen levels and also for other problems that can arise, such as blood clots, heart-muscle damage, bacterial pneumonia, and worsening kidney function. They are likely to receive remdesivir, an antiviral drug, and perhaps the steroid dexamethasone, if their oxygen levels dip low enough. (According to the RECOVERY Trial, a large biostatistical effort in the U.K., dexamethasone may help people who need supplemental oxygen.) We now know that the President has received both remdesivir and dexamethasone; in general, the administration of steroids suggests that a patient is approaching, or has already entered, the second, immune-focused phase of the disease. Still, at this level of illness, a patient might spend a few days on and off small doses of oxygen, delivered through a nasal cannula—a hose with prongs for the nostrils. All this is nerve-racking for patients and their doctors and families, but many people go through this experience and then recover enough to be discharged home.

In some cases, however, oxygen levels continue to fall. The immune system hasn’t been able to subdue the virus, and has started to overreact, causing collateral damage to blood vessels or organs. Once this happens, the second phase has fully arrived. Doctors monitoring a patient in this situation would be especially concerned if lab tests showed that inflammation was surging within the body, or if a CT scan uncovered a blood clot in the lungs or widespread injury to delicate lung tissue. If a steroid had not already been started, it would be administered now. Doctors might also prescribe a blood-thinning medication to treat or prevent a clot, or antibiotics to kill bacteria that are adding insult to viral injury. They could also introduce more sophisticated oxygen-delivery devices—powerful high-flow nasal cannulas, or “non-rebreather” masks—that can provide much higher doses of oxygen to the lungs. The air we breathe normally is about twenty-one per cent oxygen, and a regular nasal cannula might increase this proportion by a few percentage points—but a high-flow nasal cannula can shoot nearly a hundred per cent oxygen up your nose, at sixty litres a minute.

If these maneuvers aren’t enough to maintain blood-oxygen levels above ninety per cent, then doctors turn to mechanical ventilators. A tube is snaked down a patient’s throat and into the lungs. All intubated patients are transferred to an I.C.U. The ventilator takes over the work of breathing; doctors treat what they can and hope for the best. Precise estimates of the likelihood that a person will progress from infection to hospitalization to I.C.U. to death are hard to come by, and vary widely. But a recent meta-analysis suggests that about a third of patients with severe covid-19 end up in the I.C.U., and about a third of those in the I.C.U. go on to die. Although mortality rates for patients requiring I.C.U.-level care have declined since the start of the pandemic, they remain distressingly high.

Because of the scary mortality statistics, the discussion of the President’s illness has often had mortal stakes. The truth, though, is that there’s a vast middle ground of survival, in which patients can beat the virus only to experience residual symptoms and, in some cases, ongoing physical or cognitive deficits. For many covid-19 patients—even those who never move beyond the first phase of the disease—problems such as fatigue and shortness of breath can linger for weeks or months. The risks are much higher for those with severe illness, especially those who end up in the I.C.U. Some patients who recover from covid-19 report fatigue, headaches, memory issues, and breathing and gastrointestinal problems for months after their initial symptoms. Surviving illness and returning to good health are not one and the same.

From a medical perspective, many questions remain about Trump’s illness; some may be answered in the coming days. One set of questions concerns diagnostic tests that could give us a clearer understanding of the seriousness of the President’s condition and the possibility of decline. Disclosure of a CT scan, for example, could offer meaningful information about whether the coronavirus has injured his lungs. (Conley indicated that the President’s scans have shown “expected findings,” but it wasn’t clear what this meant; notably, he did not say the imaging was normal.) Blood tests that analyze inflammatory molecules could reveal the degree of inflammation in Trump’s body, and offer clues about whether the President has crossed from the first phase of illness to the second. Much of the incomplete diagnostic information provided so far has just raised more questions. Conley has said, for instance, that Trump is getting daily ultrasounds, which is not standard medical practice. Ultrasounds of what, and why? If one of them reveals a blood clot in the legs, or damage to the heart—both relatively common complications of covid-19—that would portend a more serious course for the President. In that case, he might be facing a systemic illness, rather than one confined to the lungs; his immune system may have failed to contain the virus and now be contributing to damage of the blood vessels and other organs.

A second set of questions revolves around the treatments Trump is receiving. In the absence of clear communication from his medical team, we can try to work backward, using new steps in his treatment to guess at developments in his illness. For now, we know that the President got a dose of REGN-COV2, Regeneron’s experimental antibody drug, on Friday. The drug has not completed Phase III clinical trials, and hasn’t been approved by the F.D.A. or authorized for emergency use; instead, Trump received the medication under a “compassionate use” request. Last week, Regeneron issued a press release indicating that REGN-COV2 has shown promise for reducing the amount of circulating virus in the body and for alleviating symptoms in non-hospitalized patients. Preliminary results suggest that it is relatively safe, and that patients early in the disease course, who haven’t yet mounted their own immune responses, are more likely to benefit from it. (The average age of trial patients, however, was forty-four—thirty years younger than the President.) The company is still testing to find out whether REGN-COV2 helps hospitalized patients, and whether it can prevent infection in those exposed to the virus. The fact that Trump’s team decided to use an unproven drug suggests something about the perceived seriousness of his disease as early as Friday morning.

The use of dexamethasone is also striking. It likely means that his illness is serious and could be worsening. Dexamethasone can lessen the chances of death for covid-19 patients who are on ventilators or who require supplemental oxygen—but it can be harmful in those without a need for respiratory support. Administering it to someone who isn’t firmly in the second phase of the illness, therefore, involves a careful balancing of risks and trade-offs. It’s a medicine for those with severe disease.

At this point, it’s not clear what the future holds for the President or the country. covid-19 is dangerous and capricious. If we take the White House physician at his word, Trump’s current condition appears stable—but Conley’s evasiveness has created more uncertainty than understanding. In the meantime, we should prepare for a trickle of unsatisfactory, and sometimes contradictory, information from the President’s team. There may be days with no changes, and they may be followed by sudden positive or negative developments. The daily drama of ferreting out Trump’s oxygen levels and test results is worthwhile, but there are key shifts in his clinical care that will be much more telling: the need for a more powerful oxygen-delivery device, for example, or a transfer to a higher level of care, such as the I.C.U. A relatively long hospital stay, even outside the I.C.U., would also be cause for concern. Alternatively, from here, the President could quickly improve and, as Conley suggested on Sunday, be discharged home. These big shifts are far more medically revelatory than whether the President needed two litres of supplemental oxygen or three, and whether he needed them in the morning or the afternoon.

In the hospital, when patients with covid-19 ask me about their prognoses, I respond honestly. Together, we talk through the evidence we have and acknowledge the information we lack. For patients of Trump’s age, and at his stage of the disease, I’m usually able to say that there’s a good chance we’ll get the full recovery we hope for. But I also have to be truthful about the uncertainty we face. I try to choose my words carefully. “It’s hard to predict how things will go,” I often say. “We should prepare for a range of possible outcomes.”

COVID is not a great equalizer

link https://www.kevinmd.com/blog/2020/05/covid-is-not-a-great-equalizer.html?xid=fb-md-cbtm-onc-opd&fbclid=IwAR18HuWb_SDBCM9H4VJyJ6dp7ZHwaYDf-diMekOEQtbvF8fBvtYtzdgDuXc

Some media outlets and public figures have heralded the ongoing pandemic as a great equalizer, referencing the pathogen’s indiscriminate spread and disregard for national borders and tax brackets.

The sobering mortality statistics, however, dispense any notion of an equal-opportunity crisis, revealing a familiar theme among public health challenges in America: significant racial disparities exist, and communities of color are disproportionately affected.

CDC data show that blacks account for 29% of confirmed infections despite comprising 14% of the general population. An Associated Press analysis of 3,300 deaths in early April found 42% of the victims were black, and a recent study estimated the mortality rate for blacks at 2.7 times that for whites.

What explains this dramatic difference in outcomes? It is a complex question that hints at a series of economic, environmental, and health care realities, reinforced by bias, that have plagued black Americans long before the novel coronavirus emerged. This crisis is a microcosm of historical racial disparities in society, forged by decades of systemic racism and discriminatory public policy. Given this milieu of health-associated inequalities, the strikingly lopsided death rate by ethnicity is not just predictable, but inevitable.

Any discussion of health disparities must begin with economic factors, which contribute heavily to the outsized impact of the pandemic on minorities. Black families earn 71 cents of take-home income and hold 32 cents in liquid assets per dollar compared to white families, and 22% of those under the federal poverty level are black.

Given the higher poverty rate, lower-income status, and wealth deficit faced by the black community, a crippled economy can make compliance with stay-at-home orders financially unviable. Furthermore, blacks are overrepresented among low-wage and “gig” workers relative to their share of overall employment, are more often paid hourly, and infrequently benefit from sick leave policies relative to whites. While non-essential staff can “telecommute” and earn wages remotely, self-isolation is unrealistic for many essential workers, who must weigh the threat of infection against the possibility of termination.

Environmental influences further exacerbate the vulnerability of black Americans, who commonly reside in urban settings and represent a higher proportion of public housing residents.

Such areas are often overcrowded and under-funded, with major environmental hazards such as air pollution, poor water quality, lead, pests, and mold. Predictably, blacks have higher rates of chronic lung disease and die nearly thrice as often from asthma as whites.

Growing literature on COVID-19 has established that patients with underlying health conditions are subject to a higher risk of hospitalization and adverse outcomes. Additionally, the high population density in housing projects, shelters, and jails—inhabitants of which are predominately black in the U.S, a legacy of discriminatory housing practices, racist policies such as redlining, and deep-seated inequities in our criminal justice system—make social distancing virtually impossible.

Finally, inadequate access to food due to issues with location, transportation, or infrastructure further compromises health in black communities. Even before coronavirus caused mass unemployment and overwhelmed food pantries, black households were twice as likely to suffer from food insecurity versus the national average. Greater exposure to food deserts and hazardous, cramped living conditions that preclude appropriate distancing make communities of color uniquely susceptible to outbreaks like this one.

Health-wise, blacks are more likely to have chronic conditions and limited access to care. Studies show that “black patients are 40% more likely to have high blood pressure, twice as likely to have heart failure … three times more likely to have chronic kidney disease, twice as likely to be diagnosed with colon and prostate cancer.”

A CDC report found that a startling 89% of hospitalized COVID-19 patients had one or more pre-existing conditions. It is then especially troublesome that black Americans are less likely to have adequate insurance or receive employer-sponsored coverage.

The inability or unwillingness to pursue testing or evaluation portends advanced presentation, hospitalization, and poorer outcomes with infection.

While features of the economy, the built environment, individual health, and access to care render black Americans more susceptible to the novel coronavirus, bias — implicit and explicit — has long driven health disparities among minorities. Consider the curious concept of “allostatic load,” i.e., the physiological cost of chronic stress on the human body over time. Persistent activation of hormone-driven homeostatic mechanisms can overload vital organs, impair the immune system, and generate systemic pathology.

Discrimination and bias are significant stressors, and studies have linked them to higher rates of inflammation among black adults, perhaps also contributing to over-representation among confirmed coronavirus cases. Furthermore, there is robust literature suggesting that black patients are not treated equally once hospitalized, getting less pain medication, undergoing fewer procedures, receiving less explanation, and experiencing poorer quality of care compared to white patients.

One concerning study found a substantial number of white people, from laymen to residents, believe biological differences between races yield differing pain thresholds. Racism and unconscious bias have undergirded the policies and practices that allowed latent racial inequities in health care to fester, and the uneven COVID death toll reminds us as a medical community that there is a long way to go.

Rather than level the playing field, the coronavirus pandemic has exposed and intensified race-based inequities inherent in our health care system and society, fossilized over decades of neglect, de-prioritization, and otherization of communities of color. I have endeavored to highlight inextricable economic, environmental, health-related, and psychological forces that drive poorer health outcomes for black Americans overall and may provide a framework to discuss the disproportionate numbers testing positive and dying during this crisis. These factors engender higher vulnerability through increased risk of exposure and transmission, decreased immunity from stress, acute presentations due to underlying conditions and subpar access to care, and possible discrepancies in treatment upon hospitalization.

Perhaps there is a silver lining. With the pandemic throwing the differential experience of black people in terms of health and health care into sharp relief, the issue may achieve the critical mass of attention necessary to meaningfully address these deep-seated disparities. Only then can we truly dub this coronavirus a great equalizer.

Los Angeles Rams 2020 Season Preview

Eric D. Williams

https://www.si.com/nfl/rams/news/la-rams-2020-season-preview

THOUSAND OAKS, Calif. — After missing the playoffs for the first time in three NFL seasons coming off a Super Bowl run, Los Angeles Rams head coach Sean McVay is in prove-it mode — find a way to get back to the big game, and this time win it.

“We didn’t do a good enough last year,” McVay said about his team’s 9-7 record in 2019. “If your standards are anything less than the expectation to try to win every game and do things the right way — with crisp, sharp operation and execution in all phases — I don’t know what we’re spending all this time here for.

“We’re never going to run away from that. We have high expectations and those things don’t change.”

McVay will try and make a deep postseason again with a much different cast. Running back Todd Gurley, receiver Brandin Cooks, safety Eric Weddle, kicker Greg Zuerlein, inside linebacker Cory Littleton and outside linebackers Clay Matthews III and Donte Fowler Jr. are all gone.

How McVay replaces that lost production will go a long way in determining whether his team reaches the postseason again 2020.

Offense

McVay has to get quarterback Jared Goff playing efficient football after he finished with a career-low 86.5 passer rating for a 16-game season and a career-high 16 interceptions in 2019. New offensive coordinator Kevin O’Connell is focused on improving Goff’s footwork, creating improved accuracy and better decision making for the 25-year-old signal caller when the pocket is muddy.

Along with that, the Rams need to run the football more consistently, taking some pressure off Goff. The Rams averaged just 3.7 yards per carry on first down runs last season, No. 28 in the NFL

The addition of second-round selection Cam Akers adds some juice to the run game. At 5-11 and 215 pounds, Akers has a chance to develop into a complete back. Akers is a patient runner in-between the tackles and a natural hands catcher who should immediately contribute in the passing game.

If they can stay healthy, the Rams should be better up front offensively. During the team’s Super Bowl run, all five starters along the offensive line played all 16 games. However, last season the Rams played five different offensive line combinations, resulting in uneven play.

Defense

New defensive coordinator Brandon Staley, a protégé of longtime NFL defensive coordinator Vic Fangio, is tasked with improving a defense that allowed 23 points per game last season.

Fangio has two talented pieces to build around — who many NFL observers consider the best defensive player in the game in defensive tackle Aaron Donald and Pro Bowl cornerback Jalen Ramsey.

Expect both players to move around the field more. Donald played a career-high 121 snaps at defensive end last season and could be out there even more in 2020.

And Ramsey should be allowed to spread his wings and use his unique skill set, lining up as an outside corner, slot defender and at times safety depending on the weekly matchup.

The key for Staley will be replacing last year’s leading tackler Littleton in the middle of the defense and finding consistent, outside pass rush.

Count safety John Johnson as a believer the Rams’ defense can be even better than Staley’s previous stops as an outside linebackers coach with the Denver Broncos and Chicago Bears.

“In the past, Coach Staley came from Denver, and he came from Chicago,” Johnson said. “I think we have better guys on defense than he had in both of those places. So just picture what they were doing, but with better guys.”

Predicted record

10-6: Football Outsiders has the Rams at an 8.4-win projection with a 48 percent chance of making the playoffs. Part of the reasoning for the bullish prediction is a roster that still has talented players on both sides of the ball led by a young, dynamic coach who generally gets the most out of his team. Even though they play in perhaps the toughest division in football in the NFC West, the Rams have a pretty soft schedule, facing he AFC East and NFC East this season.

Expected depth chart
Offense (West Coast)
Quarterback: Jared Goff
Running back: Cam Akers, Malcolm Brown
Wide Receivers: Robert Woods, Cooper Kupp
Tight ends: Tyler Higbee, Gerald Everett
Left tackle: Andrew Whitworth
Left guard: Joe Noteboom
Center: Austin Blythe
Right guard: Austin Corbett
Right tackle: Rob Havenstein

Defense (3-4)
Outside linebacker: Leonard Floyd
Outside linebacker: Samson Ebukam
Defensive tackle: Aaron Donald
Nose tackle: Sebastian Joseph-Day
Defensive end: Michael Brokers
Inside linebacker: Micah Kiser
Inside linebacker: Travin Howard
Left cornerback: Jalen Ramsey
Right cornerback: Troy Hill
Strong safety: Taylor Rapp
Free safety: John Johnson III

Specialty
Kicker: Lirim Hajrullahu
Punter: Johnny Hekker
Long snapper: Jake McQuaide
Kick/Punt returner: Nsimba Webster

More fast-tracking…this time convalescent plasma

“In other words, President Trump has no basis for giving carte blanche for the use of convalescent plasma. Heads of the FDA and HHS, who do know better, got ordered to smile and nod in agreement with Trump’s convention surprise, lest they get tarred as deep state obstructionists. The rush should be trying to figure out if convalescent plasma really works, but the president has made that impossible since no trials will get funded or enrolled. Instead, the future holds vicious infighting as doctors struggle to grab some of the scarce supply of convalescent plasma for their patients, since the president has all but announced it as a cure.“

Link: https://www.statnews.com/2020/08/24/trump-opened-floodgates-convalescent-plasma-too-soon/

Covid-19 Is Creating a Wave of Heart Disease
Emerging data show that some of the coronavirus’s most potent damage is inflicted on the heart

link https://www.nytimes.com/2020/08/17/opinion/covid-19-heart-disease.html

SARS-CoV-2, the virus that causes Covid-19, was initially thought to primarily impact the lungs — SARS stands for “severe acute respiratory syndrome.” Now we know there is barely a part of the body this infection spares. And emerging data show that some of the virus’s most potent damage is inflicted on the heart.

Eduardo Rodriguez was poised to start as the No. 1 pitcher for the Boston Red Sox this season. But in July the 27-year-old tested positive for Covid-19. Feeling “100 years old,” he told reporters: “I’ve never been that sick in my life, and I don’t want to get that sick again.” His symptoms abated, but a few weeks later he felt so tired after throwing about 20 pitches during practice that his team told him to stop and rest.

Further investigation revealed that he had a condition many are still struggling to understand: Covid-19-associated myocarditis. Mr. Rodriguez won’t be playing baseball this season.

Myocarditis means inflammation of the heart muscle. Some patients are never bothered by it, but for others it can have serious implications. And Mr. Rodriguez isn’t the only athlete to suffer from it: Multiple college football players have possibly developed myocarditis from Covid-19, putting the entire college football landscape in jeopardy.

I recently treated one Covid-19 patient in his early 50s. He had been in perfect shape with no history of serious illness. When the fevers and body aches started, he locked himself in his room. But instead of getting better, his condition deteriorated and he eventually accumulated gallons of fluid in his legs. When he came to the hospital unable to catch a breath, it wasn’t his lungs that had pushed him to the brink — it was his heart. Now we are evaluating him to see if he needs a heart transplant.

An intriguing new study from Germany offers a glimpse into how SARS-CoV-2 affects the heart. Researchers studied 100 individuals, with a median age of just 49, who had recovered from Covid-19. Most were asymptomatic or had mild symptoms.

An average of two months after they received the diagnosis, the researchers performed M.R.I. scans of their hearts and made some alarming discoveries: Nearly 80 percent had persistent abnormalities and 60 percent had evidence of myocarditis. The degree of myocarditis was not explained by the severity of the initial illness.

Though the study has some flaws, and the generalizability and significance of its findings not fully known, it makes clear that in young patients who had seemingly overcome SARS-CoV-2 it’s fairly common for the heart to be affected. We may be seeing only the beginning of the damage.

Researchers are still figuring out how SARS-CoV-2 causes myocarditis — whether it’s through the virus directly injuring the heart or whether it’s from the virulent immune reaction that it stimulates. It’s possible that part of the success of immunosuppressant medications such as the steroid dexamethasone in treating sick Covid-19 patients comes from their preventing inflammatory damage to the heart. Such steroids are commonly used to treat cases of myocarditis. Despite treatment, more severe forms of Covid-19-associated myocarditis can lead to permanent damage of the heart — which, in turn, can lead to heart failure.

But myocarditis is not the only way Covid-19 can cause more people to die of heart disease. When I analyzed data from the Centers for Disease Control and Prevention, I found that since February nearly 25,000 more Americans have died of heart disease compared with the same period in previous years. Some of these deaths could be put down to Covid-19, but the majority are likely to be because patients deferred care for their hearts. That could lead to a wave of untreated heart disease in the wake of the pandemic.

Many patients are understandably apprehensive about coming back to the clinic or hospital. The American Heart Association has started a campaign called “Don’t Die of Doubt” to address the alarming reduction in people calling 911 or seeking medical care after a heart attack or stroke.

Since the beginning of the pandemic, it’s been clear that people with heart disease or related conditions such as diabetes or high blood pressure are at increased risk for severe Covid-19 illness. The C.D.C. recommends that the more than 30 million Americans living with heart disease practice extra precautions to avoid infection. Hospitals and clinics should work overtime both to ensure they are safe for patients and to bolster telemedicine services so that patients can be cared for without having to leave their homes.

Doctors and researchers should no longer think of Covid-19 as a disease of the lungs but as one that can affect any part of the body, especially the heart. The only way to prevent more people dying of heart disease, both from damage caused by the virus as well as from deferred care of heart disease, is to control the pandemic.

Seven months later, what we know about Covid-19 — and the pressing questions that remain

link https://www.statnews.com/2020/08/17/what-we-now-know-about-covid19-and-what-questions-remain-to-be-answered/?fbclid=IwAR3XPSIRhwjuW-wX6EjF96nr29kH4xQDBoTGYQnwpQor0yuQj0UP5QtrKBc

The “before times” seem like a decade ago, don’t they? Those carefree days when hugging friends and shaking hands wasn’t verboten, when we didn’t have to reach for a mask before leaving our homes, or forage for supplies of hand sanitizer. Oh, for the days when social distancing wasn’t part of our vernacular.

In reality, though, it’s only been about seven months since the world learned a new and dangerous coronavirus was in our midst. In the time since Chinese scientists confirmed the rapidly spreading disease in Wuhan was caused by a new coronavirus and posted its genetic sequence on line, an extraordinary amount has been learned about the virus, SARS-CoV-2, the disease it causes, Covid-19, and how they affect us.

Here are some of the things we have learned, and some of the pressing questions we still need answered.

Covid and kids: It’s complicated

Early in the pandemic, it looked like there was a silver lining to the disease cloud sweeping across the world. Children, it seemed, didn’t develop the severe symptoms that were sending adults to hospitals struggling for breath, and they very rarely died. It even seemed that kids didn’t contract the disease at the same rates as adults did.

But everything Covid is complex, and kids are no exception. While deaths among children and teens remain low, they are not invulnerable. And they probably contribute to transmission of SARS-CoV-2, though how much remains unclear.

We’ve learned younger children and teenagers shouldn’t be lumped together when it comes to Covid. Teens seem to shed virus — emit it from their throats and nasal passages — at about the same rates as adults. Kids under 5 have high levels of virus in their respiratory tracts, but it’s still not clear how much they spread it or why they don’t develop symptoms as often as adults do.

A recently published report from a Georgia sleep-away camp shows how quickly the virus can spread among kids. The camp had to be closed within 10 days of starting its orientation for camp staffers, because within days of children arriving, kids and staff started getting sick. (The campers ranged in age from 6 to 19.) The camp did not require campers to wear face masks.

A recent report on Covid infections in children from the Centers for Disease Control and Prevention showed that while they remain low, U.S. hospitalization rates for Covid-19 in children have risen since the pandemic started. And one in three children hospitalized with the disease ends up in intensive care. The highest rate of hospitalizations in children was among those under 2 years of age.

Black and Latino children were hospitalized at higher rates than white children. And like adults, children with other health conditions — obesity, chronic lung diseases, or infants who were born premature — are at higher risk than otherwise healthy children.

Perhaps most alarmingly, it’s become clear that a small proportion of children infected with Covid-19 go on to develop a condition where multiple organs come under attack from their own immune system. Called multisystem inflammatory syndrome in children or MIS-C, this condition seems to occur about two to four weeks after Covid-19 infection. Most children who develop this syndrome recover.

There are safer settings, and more dangerous settings

Research has coalesced on a few key points about what types of setting increase the risk that an infectious person will pass the virus to others.

Essentially, the closer you are to someone infectious and the longer you’re in contact with them, the more likely you are to contract the virus, which helps explain why so much transmission occurs within households. Being indoors is worse, particularly in rooms without sufficient ventilation; the more air flow, the faster the virus gets diluted. Everyday face coverings reduce the amount of virus projected, but aren’t total blockades.

Loud talking, heavy breathing, singing, and screaming expel more virus, which is why experts point to nightclubs and gyms as risky businesses to be open. (That’s not to say it’s impossible to catch the virus while having a quiet conversation with someone outside — it’s just less likely.)

The reason having prolonged, proximate contact with someone is riskier is in part because there is a threshold level of virus you need to be exposed to to become infected. (More on this later.) Also, one hypothesis for why some people get so sick is that they are exposed to higher “doses” of virus.

Researchers are also finding that some relatively small proportion of infected people — maybe 10% to 20% — are driving some 80% of new cases, often through “superspreading” events in indoor settings like bars, meat processing plants, and homes. Whether such transmission occurs depends on a host of variables: how many people are in a given place, what the ventilation in the room is like, and, of course, whether someone with infectious Covid-19 is there. Some people might shed more virus than others, and people are more or less likely to spread the virus during different points in their infection. Evidence suggests that contagiousness spikes in the days before people who will go on to show symptoms start feeling sick.

People can test positive for a long time after they recover. It doesn’t matter

There was a lot of angst a few months ago about some people who had seemingly recovered from Covid-19 infections continuing to test positive for the virus for weeks. Were they infectious? Should recommendations be changed for how long infected people should be isolated?

It turns out it is an issue of testing. Most testing is conducted using a platform called PCR — polymerase chain reaction — that looks for tiny fragments of the SARS-CoV-2 virus. But the test can’t tell if those sections of genetic code are part of actual viruses that can infect someone else, or fragments of viruses that are absolutely no threat.

It’s clear now that people who had mild or uncomplicated infections shed active virus for somewhere up to 10 days after their symptoms started. (“Severely ill or immunocompromised patients do shed infectious virus for longer,” said Malik Peiris, a coronavirus expert at Hong Kong University.)

The weeks and weeks of positive tests — like those that prevented this woman in Quebec from cuddling her infant son for 55 days — don’t tell us that these people are still a risk to others. “In fact, we know that they are not infectious for that long,” said Maria Van Kerkhove, the World Health Organization’s leading coronavirus expert.

After the storm, there are often lingering effects

Name a body part or system and Covid-19 has left its fingerprints there. We know this: Unusually sticky blood can clog vessels on the way to the heart and inside the brain and lungs of infected people, causing heart attacks, strokes, and deadly pulmonary embolisms. There are growing worries that these and other health effects will be long-lasting.

Heart: The hyperinflammation of an immune response triggered by the virus can weaken heart muscles so much that even young people who had mild infections may be at risk for future heart failure, cardiac MRIs in Germany indicate. More immediately, some people have chest pain or feel like their hearts are racing as they recover from the infection. And college athletes are no exception

Brain: People whose first Covid-19 symptom might have been losing their sense of smell and taste may find their anosmia persists. Headaches and dizziness are common. Mood disorders such as anxiety, depression, and PTSD follow in the wake of infection, and the mental confusion called “Covid fog” leaves people searching for words, struggling with simple math, or simply trying to think.

Peripheral nervous system: In Italy, three Covid-19 patients experienced myasthenia gravis, an autoimmune disorder that results in faulty communication between nerves and muscles. Doctors also worry about demyelination, in which the protective coating of nerve cells is attacked by the immune system, causing weakness, numbness, and tingling. In some cases it can spur psychosis and hallucinations. Some patients have Guillain-Barre syndrome, a rare autoimmune disease that interferes with nerve signals, leading to abnormal sensations, weakness, and sometimes paralysis.

SARS-CoV-2, the virus that causes Covid-19, affects more than just the lungs and airways. Here’s how this virus enters cells and the symptoms that can arise from infecting different parts of the body.

‘Long-haulers’ don’t feel like they’ve recovered

They have a name, a growing social media presence, and a problem. They are the “long-haulers,” people who have survived their Covid-19 infections but feel a long way from normal. We know they’re out there, but we don’t know how many, why their symptoms persist, and what happens next.

In July, a survey conducted by the CDC found that 35% of people who tested positive for SARS-CoV-2 and had symptoms of Covid-19 — cough, fatigue, or shortness of breath — but were not hospitalized had not returned to their previous health two to three weeks later. Among those between 18 and 34 years old who had no previous chronic conditions, 20% felt prolonged signs of illness.

The National Heart, Lung, and Blood Institute has launched an observational study to track the long-term effects of Covid-19, aiming to follow 3,000 patients six months after being discharged from 50 hospitals.

Mount Sinai Health System in New York City opened a Center for Post-Covid Care in May to treat long-haulers. David Putrino, director of rehabilitation innovation there, has suggested dysautonomia — when heart rate, blood pressure, and body temperature are disjointed —could be to blame for prolonged and distressing symptoms. Why Covid-19 would cause this isn’t known, nor is the best treatment.

Vaccine development can be accelerated. A lot

The world still doesn’t have a vaccine that has been shown to be protective against Covid-19, though China and Russia have issued emergency use licenses for partially tested vaccines.

But an extraordinary amount of progress toward Covid-19 vaccines has been made, in record time. Trials have been compressed and overlapped, with manufacturers running Phase 1/2 trials in some cases and Phase 2/3 trials in others.

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Meanwhile, they’ve been building out manufacturing capacity to be able to produce hundreds of millions of doses and have started production, even before finding out whether their vaccine candidate actually works. This work is being done with substantial financial support of governments, the Bill and Melinda Gates Foundation, and CEPI, the Coalition for Epidemic Preparedness Innovations.

It’s called “at risk” production — and the term is apt. If some of these vaccines don’t work, that output will have to be junked. But if Phase 3 trials show they do work, deployment could begin as soon as the Food and Drug Administration, or a regulator in another country, approves any of these vaccines.

That means vaccination with fully approved vaccines could begin as soon as about a year after the discovery of the new virus. This constitutes a revolution in vaccine development.

People without symptoms can spread the virus

Discussing asymptomatic cases of Covid-19 automatically raises some headache-inducing semantic issues. Some people are truly asymptomatic throughout their infections, but the word is often also used to describe people who are presymptomatic — those who will show symptoms but haven’t yet. Other people don’t show classic Covid-19 symptoms — fever, cough, loss of smell — but just feel kinda crappy for a day. Where do they fit in?

Whatever group you’re talking about, there are some key implications for the pandemic, and trying to rein it in. One: Some percentage of infected people — roughly 20%, according to one recent review, though other studies have produced higher estimates — do not show symptoms at all. And two: Whether or not someone is asymptomatic or presymptomatic, they can still spread the virus (though whether they spread it as efficiently as people with symptoms is still unknown). That is why public health campaigns have been stressing distancing, masks, and hand hygiene for everyone, not just people who feel sick. Once you do start showing symptoms and try to restrict contact with others, it is too late to prevent spread.

Mutations to the virus haven’t been consequential

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Viruses on surfaces probably aren’t the major transmission route

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People seem to be protected from reinfection, but for how long?

The thinking is that a case of Covid-19, like other infections, will confer some immunity against reinfection for some amount of time. But researchers won’t know exactly how long that protection lasts until people start getting Covid-19 again.

So far, despite some anecdotal reports, scientists have not confirmed any repeat Covid-19 cases.

All that supports the notion that Covid-19 acts like other viral infections, including illnesses caused by other coronaviruses. Researchers are finding that most infected people mount an immune response involving both antibodies and immune cells that clears the virus, and that persists for some amount of time. Reports of waning antibody levels incited some concern that perhaps protection to SARS-CoV-2 might not last very long, with big implications for the frequency of required vaccine boosts. But immunologists have pointed out that antibodies for other viruses wane as well; their levels surge upon re-exposure to the pathogen and they can still halt reinfection.

When a new pathogen causes illness, the immune system creates memories, so its cells can target and kill the invader if it ever comes back again. Here’s how a person becomes develops immunity.

Researchers don’t know for sure what level of antibodies are required to block the virus from gaining a toehold in cells, and what role pathogen-fighting T cells might have in fending off an infection. People who recover from Covid-19 also produce varying levels of antibodies — it’s possible people who generate a weaker initial immune response might not be protected for as long from reinfection.

“We don’t know for how long that immune response lasts,” the WHO’s Van Kerkhove said last week. “We don’t know how strong it is.”

What happens if or when people start having subsequent infections?

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How much virus does it take to get infected?

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How many people have been infected?

There have been 21 million confirmed cases of Covid-19 around the world, and 5.3 million in the United States. Far more people than that have actually had the virus.

Problems with testing, and its limited availability, have contributed to that gap, as has the fact that some people have such mild or no symptoms that they don’t know they’re infected. But researchers don’t know just how big of a gulf they’re dealing with — how much spread they’ve missed.

“Serosurveys” — which rely on testing for the level of SARS-CoV-2 antibodies in a community — are starting to help fill in some knowledge. A recent CDC study of 10 cities and states estimated that in most places, the true number of infections was some 10 times higher than the number of confirmed cases.

Still, that leaves perhaps 20% of people, even in hard-hit communities, with potential immunity to Covid-19. That means that herd immunity — the point at which so many people are immune that the virus can’t circulate — remains far off even in areas that have suffered severe outbreaks.

It’s not clear why some people get really sick, and some don’t

The sheer range of outcomes for people who get Covid-19 — from a truly asymptomatic case, to mild symptoms, to moderate disease leading to months-long complications, to death — has befuddled infectious disease researchers.

There are some clear factors for who faces higher risks of getting severely ill: older people, as well as people with conditions ranging from cancer to obesity to sickle cell disease.

But scientists have postulated that a host of other underlying factors could help dictate why most healthy 30-year-olds shake off the virus after a couple days and some get severely ill. Researchers are studying genetic differences in patients, while others are looking at blood type.

Recent studies have pointed to another potential player. Perhaps up to half the population has immune-system T cells that were initially generated in response to an infection by one of the common cold-causing coronaviruses but that can recognize SARS-CoV-2 as well. These “cross-reactive” T cells could help give the immune system the boost it needs to stave off serious symptoms, but researchers don’t know for sure what role, if any, they actually play.

Greg Beacham@gregbeacham
Rams DT Michael Brockers is impressed by new pass rusher Leonard Floyd: “The guy has a motor that’s out of this world. Even AD noticed that.”

J.B. Long@JB_Long
Name-dropping following Wednesday at @RamsNFL camp:
•Ramsey: big hit on Akers.
•Akers: beautiful vision on a patient TD around right side vs 2D
•Nsimba: btb TDs in red zone from Wolford, who got a high-5 from McVay
•Hill: breakup on a goal line slant by Kupp.

Jourdan Rodrigue@JourdanRodrigue
It appears that Joe Noteboom will work at left guard for a second consecutive day; will be sure to note any possible rotation

Gary Klein@LATimesklein
Sean McVay said OL Rob Havenstein and Joe Noteboom are performing well.

Lindsey Thiry@LindseyThiry
Aaron Donald was asked if there was a leader in trash talk so far this season: “I put my money on Ramsey.”

Stu Jackson@StuJRams
Rams DT Aaron Donald: “All the young guys in the back end have been making plays.”

Lindsey Thiry@LindseyThiry
Rams training camp, Day 2 notes:

Jalen Ramsey welcomes rookie RB Cam Akers with the hit of the day

Great battles between WR Robert Woods and CB Darious Williams

CB Troy Hill goal-line breakup on Goff to Kupp

As Covid-19 Cases Surge, Patients Are Dying At A Lower Rate. Here’s Why

https://www.latimes.com/california/story/2020-08-09/covid-19-coronavirus-survival-rate-improves

When the number of people being sent to the hospital with COVID-19 began to creep up in Los Angeles County early this summer, officials warned that a major increase in deaths was inevitable. A record-breaking number of cases could result in a record-breaking number of deaths, they predicted.

But nearly two months later, that has not materialized. The coronavirus continues to kill hundreds of people every week in L.A. County, but the death toll has remained lower than expected.

The trend is due in part to younger people falling sick, as well as better control over the disease’s spread in high-risk settings, such as nursing homes. But doctors say there’s another factor pushing up survival rates: better treatments.

“It was so grim in the beginning,” said Dr. Armand Dorian, an ER physician and chief medical officer for Verdugo Hills Hospital at USC. “Now we actually have regimens of treatments that do help. … Since the beginning, say, February to now, we’ve learned a lot.”

The trends are not limited to L.A. County. In California, 3.6% of people diagnosed with COVID-19 between March and May died of the disease. Among those diagnosed between June 1 and Aug. 3, that figure dropped to 1.2%, according to a Times analysis of state data. Expanded testing, changing patient demographics and better patient care all played a role in that drop, experts say.

The statistic is what epidemiologists call the case-fatality rate: the number of deaths divided by the number of cases. This measures how deadly the disease is once people catch it — the chance of surviving. While the pandemic remains bleak, the lowered case-fatality rate is a glimmer of progress, experts say.

The case-fatality rate exists alongside another statistic: the mortality rate — deaths divided by the total population — which reflects the spread of the disease within the population.

In an interview with Axios released last week, President Trump discounted the nation’s mortality rate, which is worse than most other countries’, while lauding its case-fatality rate, which is better than most countries’.

But an improved case-fatality rate cannot offset the vast spread of the deadly virus, experts say. California’s mortality rate is rising as the state’s death toll from COVID-19 surpassed 10,000 on Thursday. If many people keep falling ill, then many people will die, even with improvements in survival rates.

Dr. Tim Brewer, an infectious disease specialist and epidemiologist at UCLA, said that even the medical improvements could be negated if the number of patients continues to grow. An overwhelmed healthcare system could hamper physicians’ ability to provide lifesaving care, he said.

“We’ve acquired a tremendous amount of information in the last seven months that has been helpful. We just need everybody to recognize that the virus has not gone away,” Brewer said.

When COVID-19 patients first began showing up in hospitals in the spring, doctors didn’t know which medicines or treatments would be effective. Little was understood about how the virus was transmitted or the best way to protect staff. USC’s Dorian described healthcare workers dealing with that unprecedented crisis as “deer in headlights.”

But that has changed rapidly as doctors around the world study and treat the coronavirus. Research findings in one country may within days become clinical guidelines in another.

“The collaboration between physicians all over the world over how to best treat COVID-19 has been quite extraordinary,” said Dr. Bilal Naseer, a critical care doctor in Sacramento with CommonSpirit Health, a large nonprofit hospital system. “I think the confidence level of physicians and healthcare teams is very high now — how to early-identify patients with COVID-19 and how to prevent severe disease is really much better understood.”

Early in the outbreak, panicked healthcare workers administered multiple drugs to patients to try to save them, unsure which may help. But that strategy made it hard to tell what was and wasn’t working, so physicians couldn’t gain knowledge they could use to help the next patients.

“Physicians around the world and in L.A. were basically throwing anything we could at these patients,” Brewer said. “We needed to get our panic level down a little bit and do research and trials and studies.”

One of those studies, conducted by British scientists, led to a surprising finding. For other deadly coronaviruses, such as SARS and MERS, steroid medications had been shown to worsen symptoms.

But the UK researchers found that dexamethasone, a common and low-cost steroid, reduced mortality for patients on ventilators by a third, and by a fifth for those requiring oxygen, according to the study published in June.

Doctors had already begun administering remdesivir, an antiviral medication developed by Gilead Sciences, that had been shown to shorten the time it takes for patients to recover from the infection. Both medicines are now regularly prescribed by physicians treating COVID-19 patients, they say.

“We’re miles away from having real cures like vaccinations and more specific meds,” Dorian said. “But we have something. It feels good to say, ‘Why don’t we give remdesivir?’”

San Diego State University epidemiologist Eyal Oren pointed out that many people who get sick may not die, but will still endure long-term health consequences. He warned that looking at small improvements in survival rates may elide the reality that thousands continue to die from COVID-19, particularly people of color.

“Why do we have this many cases and this many deaths?” he said. “What’s the big picture?”

But for some, the improved survival rates are a sliver of hope.

Before the latest wave of patients in L.A. County, the most people ever hospitalized with COVID-19 in the county at one time was just over 1,950 in late April. That record was broken in July, when more than 2,200 people were hospitalized with the infection.

Yet, average deaths never exceeded what they had reached in the spring. The county’s case-fatality rate from COVID-19 has dropped from 4% in May to 2% now, according to county data.

“To me, that probably means we’re doing better care,” said Dr. Jeffrey Gunzenhauser with the L.A. County Department of Public Health.

Gunzenhauser said that the decline is probably also due to changes in who is falling ill. Infections have fallen in nursing homes, whose residents are particularly vulnerable to the virus, while cases have increased among young people, who are healthier and more likely to survive, he said.

When patients do end up in the hospital, doctors have new protocols to improve their odds of survival. Early in the pandemic, doctors rushed to put patients on ventilators when they were struggling to breathe.

But now it has become clear that it may not be necessary to intubate these patients, which can open them up to other complications that actually decrease their chance of survival.

Now, physicians lie patients on their stomachs to allow more oxygen into their lungs and give them oxygen through tubes inserted into their nose. Patients are put on ventilators as a last resort, doctors say.

“We were on a hair trigger to put people on vents at the beginning of the epidemic,” said Bradley Pollock, the chair of the department of public health sciences at UC Davis. “If someone looked like they were declining, we’re going to immediately put them on a vent — that was a mistake, in retrospect.”

Doctors have also learned that COVID-19 tends to thicken patients’ blood and form blood clots, which can cause strokes and heart attacks. In some U.S. hospitals, clots were once reported to be the cause of 40% of COVID deaths. Now doctors know to administer anti-coagulants to prevent these deaths.

The knowledge gained over the last several months has improved care simply by making staff more confident, Dorian said. Patients benefit when healthcare workers aren’t stressed and can take their time with them and listen to their needs, he said.

“That’s what turns people around. It’s not just medicine, really,” he said.