tag:blogger.com,1999:blog-46998393507243278802024-02-22T07:18:16.402-08:00Incompletely RandomizedAaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.comBlogger19125tag:blogger.com,1999:blog-4699839350724327880.post-8274652184661559862020-03-18T20:46:00.000-07:002020-03-18T20:46:53.496-07:00MICLIST 3/18/20<br />
- Ask not what your country can do for you, ask what you can do to increase ventilator availability. I typically avoid HuffPost, but <a href="https://pbs.twimg.com/media/BG48ENgCEAAIDl9.jpg" target="_blank">this article</a> offers excellent research into the problem.<br />
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- <a href="https://pbs.twimg.com/media/BG48ENgCEAAIDl9.jpg" target="_blank">This one</a> is definitely a downer - implies that young people have a significant burden of serious disease requiring hospitalization and ICU. It could be that young people are disproportionately infected, or that we're just not seeing the hospitalized older people due to delays in testing. All the same, in a period of uncertainty, I interpret any signal like this as an argument for playing it safe up front.<br />
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- A 50% solution is a lot better than nothing at all. I'm surprised we don't see <a href="https://www.bloomberg.com/news/articles/2020-03-18/hospital-makes-face-masks-covid-19-shields-from-office-supplies" target="_blank">more of this</a> - employees making makeshift PPE. As supplies run out, do we think Mike Pence is going to save the day? By next week?<br />
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- The Brits <a href="https://www.forbes.com/sites/isabeltogoh/2020/03/18/covid-19-expert-advising-british-governments-response-self-isolates-after-cough-and-fever/#510423b14cb1" target="_blank">switch tack</a>. This has me bummed since I was rooting for their approach. Nonetheless, I'm still impressed - it takes guts to change approach when the best understanding changes.<br />
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- Lipsitch <a href="https://www.statnews.com/2020/03/18/we-know-enough-now-to-act-decisively-against-covid-19/" target="_blank">answers back</a> (to Ioannidis piece <a href="https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/" target="_blank">here</a>.) Seems like Ioannidis could be the defender of the Brits' approach, and Lipsitch the rest of the world. Given recent events, it seems Lipsitch's view stands taller.Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-78451326763923705962020-03-17T20:55:00.001-07:002020-03-18T19:27:11.358-07:00MICLIST: Most Interesting COVID Links I Saw Today 3/17/20In no particular order:<br />
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- The top, top thing on my mind is ventilators. This is maybe the most fixable near term way to save lives. Tom Inglesby at the Center for Health Security gives a great status update <a href="https://twitter.com/T_Inglesby/status/1239675564199481347?s=20" target="_blank">here</a>. In WWII, we retrofitted car manufacturing to produce A LOT of tanks, pronto. I think we gotta do the same here AS WELL AS generate the workforce to operate these things.<br />
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- John Ioannidis, famed researcher and medical skeptic, <a href="https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/" target="_blank">threw down</a> some more skepticism. This one really made me stop and think. With information so spotty, perhaps the social interventions will be needed for many months, and once we resume normal life, COVID will come rushing back?<br />
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- <a href="https://www.medrxiv.org/content/10.1101/2020.03.09.20033217v1.full.pdf" target="_blank">This preprint</a> claims that the virus is 1,000 times less infectious after 48 hrs on its favorite surfaces, plastic and steel. Cardboard can support it for about an hour tops. When it gets aerosolized (lighter than air, so it can persists with air currents and travel all over), it still weakens, becoming ten times less infectious in 3 hours. This is good news.<br />
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- <a href="https://twitter.com/trvrb/status/1238643280679563265?s=20" target="_blank">This thread</a> from Defender of Seattle Trevor Bedford shows the simplest explanation I know of for the nationwide spread leading up to this past weekend. Short version - maybe 20,000 people COVID positive in the US. We are flying blind.<br />
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- <a href="https://www.youtube.com/watch?v=xRadMzCKnCU" target="_blank">The Brits are impressive</a>. Gutsy. Their (ironic) plan is to wait until they see the whites of their eyes. By not closing schools (kids will spend less time with grandparents) and not shutting down the country (economy will function, which matters, particularly for people living paycheck to paycheck), they plan to absorb the shock by relying on sick people to stay home. At a time where everyone else is ramping up extreme measures, the Brits seem to be gambling. Except they are using good science. Which reminds me that we're all gambling. I hope it goes well for them. It'll be fascinating to see how it works out.<br />
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- <a href="https://www.imperial.ac.uk/news/196234/covid19-imperial-researchers-model-likely-impact/" target="_blank">This paper</a> from Imperial College London seems to be the talk of Twitter today and, it's a downer. See a good breakdown <a href="https://twitter.com/jasoncrawford/status/1240059370391531520?s=20" target="_blank">here</a>. Bottom line - the least bad options still look bad.<br />
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- Tyler Cowen posts some great COVID material, from well outside the usual sources. If you want perspective, I'd check out <a href="https://marginalrevolution.com/marginalrevolution/2020/03/monday-assorted-links-246.html" target="_blank">Marginal Revolution</a> daily (I'd do that anyway, it's the best website.)<br />
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- <a href="https://www.bbc.com/news/51929628" target="_blank">Give it a rest</a> with handwringing about ibuprofen. Until there's a reason that this largely safe anti-inflammatory is a bad idea, it's not a bad idea.<br />
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- MGH <a href="http://healthcare.partners.org/streaming/Live/MGH/2020.03.12COVID_MedicalGrandRounds.html" target="_blank">telecast their grand rounds</a>. Dynamite. Maybe we'll learn how to be better knowledge workers in medicine when this is all over - if it's worth saying, it's worth recording.<br />
<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-5167589247288880152020-03-06T22:02:00.002-08:002020-03-08T18:45:20.174-07:00Comparing COVID to the flu<div class="separator" style="clear: both; text-align: center;">
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To gauge the seriousness of COVID, the flu is a good comparison because we are familiar with it, it appears to have approximate severity and transmissibility. The case fatality rate for the seasonal flu is commonly listed at 0.1%. However, this number is likely falsely high.<br />
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<a href="https://www.cdc.gov/flu/about/keyfacts.htm" target="_blank">On average</a>, roughly 15% of the US population gets infected with flu virus every year, though this figure varies from 5% to 20% on any given year. However, one quarter of those infected essentially have minimal or no symptoms.<br />
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Since there are so many asymptomatic/mild cases of flu, it is difficult to determine the total burden of disease, and hence the true fatality rate. A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815659/" target="_blank">high quality review</a> found that on average, and across regions, the flu kills 5.9 people out of every 100,000 of the general population, whether infected or not.<br />
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We can extrapolate from this to get a rough estimate of the fatality rate of the flu. If 5.9 out of 100,000 people in a given population die of the flu, and the flu infects roughly 15% of those 100,000, this means that the rate of flu death is around 0.04%. This is less than half of the commonly reported flu fatality rate of 0.1%.<br />
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The best case we have right now for lowest fatality rate of COVID is 0.6% coming out of South Korea. From our analysis above, it seems COVID is around ten times as deadly as the seasonal flu.<br />
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<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-40028809890289365232020-03-05T21:11:00.001-08:002020-03-06T18:10:52.390-08:00Why I'm taking novel coronavirus seriously<div>
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<i>The TL;DR can be found in <span style="color: #bf9000;"><a href="https://docs.google.com/document/d/1vumYWoiV7NlVoc27rMQvmVkVu5cOAbnaW_RKkq2RMaQ/mobilebasic?fbclid=IwAR0If1zzDDldgAy3DZmFhaxAmP046-dwAE_LCj3l9su2XLYpZe2By8mCj1A" target="_blank">this document</a></span> (also pasted below). If found this document after I completed this post and it lines up with almost everything I'm saying. Also note, this post represents my best understanding as of 3/5/2020 and I hope to make addenda as better information becomes available. Also please note that most of these outcomes are in reference to the US. The situation is potentially far worse for the developing world and I don't mean to minimize those consequences.</i><br />
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There is a lot to talk about the novel coronavirus emerging in China, but how do we decide how and when to make significant changes in our lives as opposed to watchful waiting?<br />
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To get a bearing on this, two questions are on my mind - how dangerous is the infection, and how many people will get it. Both factors are required for good estimates of harm.<br />
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Strong answers are challenging because most of the data comes from China and other regions which are in the midst of outbreaks. The numbers aren't gathered in controlled settings, and the areas of outbreak don't necessarily compare well with the US. However, we know much more than nothing.<br />
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<b>Question 1) How severe is it?</b><br />
One way of characterizing severity is by the number of infected people who die, or the case fatality rate. One of the first studies emerging from China was <a href="https://jamanetwork.com/journals/jama/fullarticle/2762130?guestAccessKey=bdcca6fa-a48c-4028-8406-7f3d04a3e932&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=022420" target="_blank"><span style="color: #b45f06;">published in JAMA</span></a> Feb 24, and it suggested a case fatality rate of 2.3%, or 23 deaths out of every thousand infected with the virus.(1) In a <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2002032" style="background-color: white; font-family: arial, helvetica, sans-serif;" target="_blank"><span style="color: #bf9000;">follow up study</span></a> in the New England Journal the death rate was 1.4%, or 14 in every thousand. Finally, at the time of this writing, South Korea <a href="https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6" style="background-color: white; font-family: arial, helvetica, sans-serif;" target="_blank"><span style="color: #bf9000;">has reported</span></a> 6,284 cases and only 40 deaths, for a fatality rate of 0.6%, or 6 in every thousand.<br />
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To give this some quick context, the case fatality rate of the seasonal flu is commonly stated to be 0.1%, or one death per thousand, though a recent review puts it closer to 0.05%.<br />
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These numbers are sobering, as it appears the novel coronavirus is 5 to 50 times as deadly as the flu. These numbers approach the deadliness of the catastrophic 1918 flu pandemic. Fortunately, most researchers think the 2.3% number is an overestimate. That's because in most cases, coronavirus infections are expected to be asymptomatic or mild. And patients with mild symptoms rarely get tested. How often do you go to the doctor if you're only a little sick? <a href="https://www.youtube.com/watch?v=ZhYcbo7rqEQ" target="_blank"><span style="color: #bf9000;">Some researchers</span></a> therefore think the fatality rate is significantly lower than 1%. This makes intuitive sense, and the South Korean data to support this.(2) However, <a data-saferedirecturl="https://www.google.com/url?q=https://www.statnews.com/2020/02/25/new-data-from-china-buttress-fears-about-high-coronavirus-fatality-rate-who-expert-says/&source=gmail&ust=1583462500464000&usg=AFQjCNF5E4dzcqVks2JDiw9I-dzbPGxLCg" href="https://www.statnews.com/2020/02/25/new-data-from-china-buttress-fears-about-high-coronavirus-fatality-rate-who-expert-says/" style="background-color: white; font-family: arial, helvetica, sans-serif;" target="_blank"><span style="color: #bf9000;">an attempt</span></a> to quantify the numbers of asymptomatic or mild infections seemed to corroborate the worst - asymptomatic or mild cases are relatively rare.<br />
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So what to make of this?<br />
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We have to wait and see as the US ramps up testing. My guess is that the numbers in the US will be substantially lower than China or the developing world, if for no other reason than that the US has a stronger social and healthcare infrastructure. It will likely be several weeks before we have a reliable estimate. Until we know better, I think it's reasonable to treat this as a fatality rate between 0.5 to 1%.<br />
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A few caveats that you've probably heard - the fatality is skewed towards those who are older or have serious health issues. Also, there seems to be very little danger for children - the JAMA study reported 416 cases among children less than 10 years old and there were no hospitalizations and no fatalities. For people under 50 with no medical issues, the fatality appears the same or even less than the seasonal flu.<br />
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This graphic summarizing these points can be found <a href="https://raw.githubusercontent.com/jbloom/CoV_vs_flu_CFR/master/CFR-stats.jpg" target="_blank"><span style="color: #bf9000;">here</span></a>.</div>
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<b><br />Question 2) How transmissible is it?</b><br />
Some infections are containable, meaning that dramatic efforts to track down and quarantine early cases can stop the spread of a disease throughout the wider population. This has been successful with SARS and Ebola. Other diseases are unable to be contained, such as the flu. Given the nature of how the flu is spread, when a new strain emerges, it is considered impossible to prevent from disseminating around the globe. At the time of this writing, it is <a href="https://www.statnews.com/2020/02/04/two-scenarios-if-new-coronavirus-isnt-contained/" target="_blank"><span style="color: #bf9000;">widely believed</span></a> that this virus is not containable, although the WHO <a href="https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---3-march-2020"><span style="color: #bf9000;">continues to state</span></a> that containment is a possibility. <br />
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If this virus behaves like the flu and spreads throughout the globe, how many people will be infected? At first, it seems like it will reach everyone, given enough time. However, depending on the nature of the virus itself and its specific modes of transmission, far less than 100% of people would get infected. In a typical year, the seasonal flu <a href="https://academic.oup.com/cid/article/66/10/1511/4682599"><span style="color: #bf9000;">infects roughly 12%</span></a> of the US population, though this can be <a href="https://www.cdc.gov/flu/about/keyfacts.htm"><span style="color: #bf9000;">as high as 20%</span></a>.<br />
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Marc Lipsitch, epidemiologist at Harvard specializing in pandemics, has said in <a href="https://www.theatlantic.com/health/archive/2020/02/covid-vaccine/607000/"><span style="color: #bf9000;">a piece in the Atlantic</span></a> that he envisions 40 to 70% of the adult US population contracting the virus, based on unpublished models. Fortunately, he recently <a href="https://twitter.com/mlipsitch/status/1234878342140026880?s=20"><span style="color: #bf9000;">revised down</span></a> this prediction to 20 - 60% based on new data. <br />
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I haven't seen anyone else modeling transmission, so this 20-60% range seems like the best guess if we assume it cannot be contained.<br />
<b><br />Conclusions from these two questions</b><br />
If we use conservative figures from above, the adult US population is roughly 250,000,000. If 20% of them get infected, that's 50,000,000. A 0.5% mortality rate equals 250,000 deaths. (I leave it to you to run the numbers for a worst case scenario in the US.) For comparison, last year's flu caused 34,000 deaths and 500,000 hospitalizations. <br />
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<b>Putting it all together</b><br />
M<span style="background-color: transparent; color: #222222;">any hospitals are currently at capacity due to this year's unusually active flu season. Speaking of the situation in Springfield, nearly every bed in the building is occupied, and there are people lined up in the halls in the emergency room. Even a modest surge of patients would be overwhelming, forcing the hospital to board patients in the lobby and convert operating rooms and procedure rooms into makeshift intensive care units. Compound this with the need to prevent spread of coronavirus to non-infected patients, and you can see the logistical nightmare this poses to the healthcare system. For numbers, </span><a href="https://jamanetwork.com/journals/jama/fullarticle/2762130" style="background-color: transparent;"><span style="color: #bf9000;">the JAMA study</span></a><span style="background-color: transparent; color: #222222;"> noted hospitalization rates of 20%. If the true number is half that, we are still looking at more than doubling the current number of patients with flu.</span></div>
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The best way to ease the burden of a surge like this is to delay the spread of the disease, as shown in the graphic below which I found <a href="https://birdflujourney.typepad.com/a_journey_through_the_wor/2007/11/pandemic-mitiga.html" target="_blank"><span style="color: #bf9000;">here</span></a>. If everyone gets sick all at once, this will exceed capacity and therefore increase the mortality as patients go without intensive care, and those with non-infectious conditions can't access treatment. Imagine dealing with a burst appendix or a car accident or a pregnancy when the hospital is already overflowing.<br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I often hear the argument that "It's inevitable - we're all going to get it so what's the point?" The point is that, by flattening out the above curve and spreading out the time over which people get infected (what's called mitigation), we can potentially save lives. The benefits of this behavior always go unseen - you never know which 70-year-old did not pick up the disease because you washed your hands that one time - but these actions are matters of life and death.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="color: #222222;">Lastly, preliminary research from the Seattle outbreak indicates there has been </span><a href="https://twitter.com/trvrb/status/1233970559257468928?s=20" target="_blank"><span style="color: #bf9000;">cryptic spreading</span></a><span style="color: #222222;"> in that area for over 6 weeks. There is reason to believe the same is occurring in other cities in the US, but this is masked by the fact that the US has had </span><a data-saferedirecturl="https://www.google.com/url?q=https://www.nytimes.com/2020/03/02/world/coronavirus-updates-news-covid-19.html&source=gmail&ust=1583462500464000&usg=AFQjCNEMbA97gdOxdo-MkR7QuKtqnZ5LyQ" href="https://www.nytimes.com/2020/03/02/world/coronavirus-updates-news-covid-19.html" target="_blank"><span style="color: #bf9000;">delayed testing</span></a><span style="color: #222222;">.</span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Therefore, until better information is available, I am behaving as if the virus is actively spreading in my area. I am doing what I can to flatten the curve.</span></div>
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<b><span style="font-family: "arial" , "helvetica" , sans-serif;">What I'm doing:</span></b></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Called my parents, both over 65, and told them to act as if the virus is already in their area.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Wash my hands or use alcohol gel before during and after entering a public place, before and after eating, after using a commonly touched surface (like any time I use my credit card).</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Carry hand sanitizer in my pocket.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Regularly wipe down my work station and cell phone with alcohol or Clorox wipes.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Don't shake hands.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Keep 6 feet from others when I can and avoid ill-appearing people.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Cough and sneeze into my armpit and dispose of tissues immediately.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Try to avoid touching my face.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">If I get sick: </span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Stay home.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Eat and sleep separately from my family.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Wear a surgical mask.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">- Call ahead before seeing my doctor and ask about getting tested for coronavirus.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="color: #222222;">I have also stocked up on a 60 day supply of essential medications and non-perishable food in line with </span><a data-saferedirecturl="https://www.google.com/url?q=https://www.cdc.gov/cpr/prepareyourhealth/PersonalNeeds.htm&source=gmail&ust=1583462500464000&usg=AFQjCNHS24Yo9Tsod_SoYMQ04ibvGcsjZw" href="https://www.cdc.gov/cpr/prepareyourhealth/PersonalNeeds.htm" target="_blank"><span style="color: #bf9000;">these suggestions</span></a><span style="color: #222222;"> from the CDC.</span></span></div>
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<b><span style="font-family: "arial" , "helvetica" , sans-serif;">Final Thoughts:</span></b></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">There are reasons for optimism - the final numbers on severity and transmissibility could be much lower than what we're currently seeing. Effective mitigation strategies might emerge (such as <a href="https://qz.com/1810651/south-koreans-are-using-smartphone-apps-to-avoid-coronavirus/" target="_blank">apps</a> that enable you to avoid proximity to infections). Warm weather could slow its spread by getting people out of doors. Treatments might emerge faster than expected. And I would be the happiest person if that occurred and all of you reading this concluded that I'm an alarmist. </span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Nonetheless, the most effective time to start safe behavior is at the beginning of a crisis. The best time to avoid infection is at the earliest point of exposure. And the cheapest time to buy preparatory materials is before they are out of stock. </span></div>
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<br />
<i>“Everything we do before a pandemic will seem alarmist. Everything we do after will seem inadequate.”</i><br />
<span style="background-color: transparent; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: xx-small;">Michael Leavitt, Director of the Dept of Health and Human Services 2007</span></div>
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<b>................................................................................................</b><br />
As mentioned at the start, the below summary is from Ethan. I have some quibbles, but mostly agree.</div>
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<span style="font-size: xx-small;"><span style="font-family: "times new roman"; font-weight: 700;">Updated Mar. </span><span style="font-family: "times new roman"; font-weight: 700;">4</span><span style="font-family: "times new roman"; font-weight: 700;">, 2020</span></span></div>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Coronavirus in brief </span></span></div>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Bottom Line.</span></span></div>
<ul class="lst-kix_bifs3jcp3bs3-0 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Coronavirus is significantly worse than the flu, but not the zombie apocalypse. No need to panic, but it probably makes sense to prepare.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">It is going to affect day-to-day-life in western countries, including the U.S.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">You and your family will probably face personal risk of illness by the end of the year.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; font-weight: 700; vertical-align: baseline;"><span style="font-size: xx-small;">You can prepare by</span></span></li>
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<ul class="lst-kix_bifs3jcp3bs3-1 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Stocking at least 1 month of nonperishable food, pet food, and other necessities, and 3 months of prescription medications.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Relocating away from dense cities and/or shifting to working from home, if possible.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">Learning </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://youtu.be/a9CMtzymZTg?t%253D68%26amp;sa%3DD%26amp;ust%3D1583474469503000&sa=D&ust=1583474469548000&usg=AFQjCNEuMyh6ah4d9NucuZQIHtf6S9nQrQ" style="text-decoration: inherit;">how to properly wash</a></span><span style="font-family: "times new roman";"> your </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://mobile.twitter.com/marcelsalathe/status/1233074621186035715/photo/1%26amp;sa%3DD%26amp;ust%3D1583474469503000&sa=D&ust=1583474469548000&usg=AFQjCNGTfZrRkM7OINx1LDn3vtP7HEcR2g" style="text-decoration: inherit;">hands</a></span><span style="font-family: "times new roman"; vertical-align: baseline;">, and practicing not touching your face.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Avoiding travel after March of this year, and/or planning with cancellation option.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Making plans to care for and protect the elderly from exposure to the virus.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">Carrying hand sanitizer, and using it frequently (</span><span style="font-family: "times new roman";">every 30 min</span><span style="font-family: "times new roman"; vertical-align: baseline;"> outside your home, before you eat or touch your face).</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Buying enough hand sanitizer and hand soap for at least 1 month.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Wiping commonly contacted items (phone, keyboard, headphones etc) down with disinfectant regularly.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Avoiding crowded places (e.g. concerts, subways, theatres, buses, airports etc) without protection.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 72pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">For essential travel, b</span><span style="font-family: "times new roman";">uying </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html%26amp;sa%3DD%26amp;ust%3D1583474469504000&sa=D&ust=1583474469548000&usg=AFQjCNHT-O2jyFPbsXLxVRqQCBGl5vku7Q" style="text-decoration: inherit;">N95 respirators</a></span><span style="font-family: "times new roman";">, if you can, and </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://www.youtube.com/watch?v%253DzoxpvDVo_NI%26amp;sa%3DD%26amp;ust%3D1583474469504000&sa=D&ust=1583474469549000&usg=AFQjCNHf1Cd0rxRSYSdP6ChDW2NTq5fImA" style="text-decoration: inherit;">learning how to use them</a></span><span style="font-family: "times new roman";">, including </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://www.cdc.gov/niosh/npptl/pdfs/FacialHairWmask11282017-508.pdf%26amp;sa%3DD%26amp;ust%3D1583474469504000&sa=D&ust=1583474469549000&usg=AFQjCNFcEOGpyyaTtJpEYkZI2_DwKvx7nA" style="text-decoration: inherit;">shaving facial hair.</a></span><span style="font-family: "times new roman";"> </span><span style="font-family: "times new roman"; font-style: italic;">These are probably less effective than hand hygiene, so lower priority.</span></span></li>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*</span></span></div>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">What does the virus do?</span></span></div>
<ul class="lst-kix_6myvow352ff-0 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">The virus causes coughing, sneezing, fever, pneumonia, and in severe cases kidney failure and death.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">80% of cases are relatively mild. The rest look like moderate to severe pneumonia.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Approximately 1% of people who catch the virus die.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">After symptoms show, it takes 3 weeks - 1 month for severe cases to resolve.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">Risk is </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://www.businessinsider.com/coronavirus-death-age-older-people-higher-risk-2020-2%26amp;sa%3DD%26amp;ust%3D1583474469505000&sa=D&ust=1583474469549000&usg=AFQjCNGqcdsymndepXqCyiQUrQk8UsIx1Q" style="text-decoration: inherit;">much higher for people over 40</a></span><span style="font-family: "times new roman"; vertical-align: baseline;">.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Children appear to be relatively unaffected.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Men may be twice as susceptible as women, although it is too early to tell with confidence.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Immunity may not last long, and no-one has it to start with.</span></span></li>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Where is the virus now (Mar 4)?</span></span></div>
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<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman"; font-weight: 700;">94</span><span style="font-family: "times new roman"; font-weight: 700;">,000</span><span style="font-family: "times new roman";">+ confirmed cases worldwide, most in China. </span><span style="font-family: "times new roman"; font-weight: 700;">3,200</span><span style="font-family: "times new roman"; vertical-align: baseline;">+ deaths. Likely more unreported.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman"; font-weight: 700;">36</span><span style="font-family: "times new roman"; vertical-align: baseline;"> countries have more than 10 confirmed cases outside of China.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">Japan, Iran, Italy, and </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://twitter.com/Noahpinion/status/1233104433027796992/photo/1%26amp;sa%3DD%26amp;ust%3D1583474469506000&sa=D&ust=1583474469550000&usg=AFQjCNGY4lCYTjdQCvGqks8KJ2trc8Qv3A" style="text-decoration: inherit;">South Korea</a></span><span style="font-family: "times new roman"; vertical-align: baseline;"> all had an exponential growth of cases from 10s to 100s in less than a week.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman"; font-weight: 700;">138</span><span style="font-family: "times new roman";"> cases in the U.S. </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://www.washingtonpost.com/world/2020/02/27/coronavirus-live-updates/%26amp;sa%3DD%26amp;ust%3D1583474469507000&sa=D&ust=1583474469550000&usg=AFQjCNFTpjZyGTr4bEldkTbWc7hmWOIikg" style="text-decoration: inherit;">1 case, in Northern California, </a></span><span style="font-family: "times new roman"; vertical-align: baseline;">is likely the first spread without link to China, suggesting the virus is spreading undetected in the United States.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="color: #1155cc; font-family: "times new roman"; font-weight: 700;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://www.nytimes.com/2020/03/01/world/coronavirus-news.html%26amp;sa%3DD%26amp;ust%3D1583474469507000&sa=D&ust=1583474469550000&usg=AFQjCNEk5blXlWFuzsFrc5Ku_nkCzXo2bA" style="text-decoration: inherit;"><span style="font-size: xx-small;">New cases in washington appear to be the result of hidden transmission for weeks, suggesting 50-1500 cases may be under the radar there.</span></a></span></li>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">What do we know about the virus?</span></span></div>
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<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">It likely arose from a crossover, or “zoonosis” from animals in China, sometime in late November early december of 2019.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">It is most closely related to a virus called </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome%26amp;sa%3DD%26amp;ust%3D1583474469508000&sa=D&ust=1583474469551000&usg=AFQjCNHaUyX95FdZGhGTFuaGn_O6J5yXtA" style="text-decoration: inherit;">SARS</a></span><span style="font-family: "times new roman"; vertical-align: baseline;"> which caused a small epidemic in 2002. It is also related to viruses that cause the common cold.</span></span></li>
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<span style="font-size: xx-small;"><span style="font-family: "times new roman"; vertical-align: baseline;"></span></span></div>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">How does the virus spread?</span></span></div>
<ul class="lst-kix_6myvow352ff-0" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Probably similarly to the flu. Being within 6 feet of a cough or sneeze, touching a surface that has been coughed on and then touching your face, or eating food that has been coughed on are all ways to spread the virus.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Relatively quickly. Approximately doubling the number of infected people every week.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">The virus can probably survive on many types of surfaces for 2-7 days.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Some people who are infectious and can spread the virus do not show visible symptoms.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">It takes ~5 days (</span><span style="font-family: "times new roman"; font-weight: 700;">range of 2-14</span><span style="font-family: "times new roman"; vertical-align: baseline;">) for symptoms to develop.</span></span></li>
</ul>
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<span style="font-size: xx-small;"><span style="font-family: "times new roman"; vertical-align: baseline;"></span></span></div>
<div style="color: black; font-family: Arial; line-height: 1.15; padding: 0px;">
<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Can we treat it?</span></span></div>
<ul class="lst-kix_kvyn6lul7ppn-0 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Not right now. No vaccine or approved medical countermeasure.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Supportive care like mechanical ventilation can significantly decrease risk of death if ICU rooms are available.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">An antiviral, called remdesivir, is in clinical trials and shows some signs of efficacy.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Historical timelines for new drug / vaccine rollout suggest mass availability in 2021.</span></span></li>
</ul>
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<span style="font-size: xx-small;"><span style="font-family: "times new roman"; vertical-align: baseline;"></span></span></div>
<div style="color: black; font-family: Arial; line-height: 1.15; padding: 0px;">
<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Shouldn’t I be more worried about the flu?</span></span></div>
<ul class="lst-kix_uc29m8n0e3uf-0 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; font-weight: 700; vertical-align: baseline;"><span style="font-size: xx-small;">No. This is worse.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">The seasonal flu kills <0.1% of infected people. This kills ~1%. That is 10X worse.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman";"><span style="font-size: xx-small;">The coronavirus spreads a little faster than the flu.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">You have some natural immunity to flu even though each season the strain is different. You probably have no immunity against this coronavirus.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">We have a reliable vaccine against seasonal flu. We will not have a vaccine or effective treatment for coronavirus for some time.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Seasonal flu is very well characterized and understood. This virus is still under intensive study, and all the numbers I give have uncertainty, which means that it may be worse than our best guess. Long-term effects of catching the virus are unknown.</span></span></li>
</ul>
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<span style="font-size: xx-small;"><span style="font-family: "times new roman"; vertical-align: baseline;"></span></span></div>
<div style="color: black; font-family: Arial; line-height: 1.15; padding: 0px;">
<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">How can I think about my and my family’s risk?</span></span></div>
<ul class="lst-kix_ub5aul6w0qe9-0 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">Look at these charts for risk of death </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://www.businessinsider.com/coronavirus-death-age-older-people-higher-risk-2020-2%26amp;sa%3DD%26amp;ust%3D1583474469509000&sa=D&ust=1583474469552000&usg=AFQjCNHcnWpZzhnHFDEO-bMkPi7ty0T1rA" style="text-decoration: inherit;">by age group</a></span><span style="font-family: "times new roman";">.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">Consider </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://mobile.twitter.com/robertwiblin/status/1233410998893252608/photo/1%26amp;sa%3DD%26amp;ust%3D1583474469510000&sa=D&ust=1583474469552000&usg=AFQjCNF3H504ifGVPoNCULgejxlgfvyMDQ" style="text-decoration: inherit;">risk factors</a></span><span style="font-family: "times new roman";"> (</span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://drive.google.com/file/d/1R-bWh5CDHcKaCooArxQ_2hEy7-WiF3G2/view%26amp;sa%3DD%26amp;ust%3D1583474469510000&sa=D&ust=1583474469552000&usg=AFQjCNE2zjzgqbjevAJTaIf7Pzg0KVP8JQ" style="text-decoration: inherit;">source</a></span><span style="font-family: "times new roman";">)</span><span style="font-family: "times new roman";"> which make the disease more dangerous, such as cardiovascular disease, diabetes, lung conditions + smoking, high blood pressure, and cancer</span><span style="font-family: "times new roman";">.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Think about the population density of places you go to regularly. Ask yourself: “How many people have been here in the last week?”. Avoid places where that number is large, and, take extra precautions.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Think about exponential spread. In the early stages, it will be doubling every week approximately. Really think about that- it means the odds of infection are about 2X higher each week this continues. So it’s twice as safe to travel April 1 than April 7. And twice as safe on April 7 as the 14th. I find that extremely counterintuitive, and chances are you will too.</span></span></li>
</ul>
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<span style="font-size: xx-small;"><span style="font-family: "times new roman"; vertical-align: baseline;"></span></span></div>
<div style="color: black; font-family: Arial; line-height: 1.15; padding: 0px;">
<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">This all sounds crazy.</span></span></div>
<ul class="lst-kix_b4qcdccuxtv-0 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="font-family: "times new roman";">Yeah, it does. The info I’ve presented above makes this look like probably the worst pandemic since the </span><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://en.wikipedia.org/wiki/Spanish_flu%26amp;sa%3DD%26amp;ust%3D1583474469511000&sa=D&ust=1583474469553000&usg=AFQjCNEiHsLqJsNAyODNHVNVezmcnxQgwA" style="text-decoration: inherit;">1918 Flu.</a></span><span style="font-family: "times new roman"; vertical-align: baseline;"> </span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">However, what’s presented above is an aggregation of facts and high-quality estimates from the scientific literature and expert recommendations, as best as I could find them.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">The outlook presented here is largely shared by experts at: the CDC, the World Health Organization, the Harvard School of Public Health, the Johns Hopkins Center for Health Security, MIT, a biosecurity summit I recently attended, and by most of my colleagues in the biosecurity space.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Unfortunately, I think this is the world we live in.</span></span></li>
</ul>
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<span style="font-size: xx-small;"><span style="font-family: "times new roman"; vertical-align: baseline;"></span></span></div>
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<span style="font-family: "times new roman"; vertical-align: baseline;"><span style="font-size: xx-small;">Other resources</span></span></div>
<ul class="lst-kix_ueiux5s93kms-0 start" style="color: black; font-family: Times; list-style-type: none; margin: 0px; padding: 0px;">
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html%2523/bda7594740fd40299423467b48e9ecf6%26amp;sa%3DD%26amp;ust%3D1583474469511000&sa=D&ust=1583474469553000&usg=AFQjCNEQ81dEhf0vknu-oImQuxD9Qy6Uwg" style="text-decoration: inherit;">Dashboard</a></span><span style="font-family: "times new roman"; vertical-align: baseline;"> for tracking the spread.</span></span></li>
<li style="font-family: Arial; line-height: 1.15; margin: 0px 0px 0px 36pt; padding: 0px; text-align: left;"><span style="font-size: xx-small;"><span style="color: #1155cc; font-family: "times new roman"; text-decoration-line: underline; text-decoration-skip-ink: none;"><a href="https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://virologydownunder.com/so-you-think-youve-about-to-be-in-a-pandemic/%26amp;sa%3DD%26amp;ust%3D1583474469512000&sa=D&ust=1583474469553000&usg=AFQjCNGLhFpUJu35MelvFIXCAWg7fK9vKQ" style="text-decoration: inherit;">Article</a></span><span style="font-family: "times new roman"; vertical-align: baseline;"> on prep.</span></span></li>
<li></li>
</ul>
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<b>Recommended:</b></div>
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<span style="color: #bf9000;"><a data-saferedirecturl="https://www.google.com/url?q=https://podcasts.apple.com/us/podcast/the-coronavirus-isnt-going-away/id1460055316?i%3D1000466938203&source=gmail&ust=1583462500464000&usg=AFQjCNFhpV7OUmvfYnPUEE-l4xaphSVeug" href="https://podcasts.apple.com/us/podcast/the-coronavirus-isnt-going-away/id1460055316?i=1000466938203" target="_blank"><span style="color: #bf9000;">This podcast</span></a> </span><span style="color: #222222;">with Marc Lipsitch. It's 27 minutes and it's pretty scary. It comes before Lipsitch's revised-down numbers.</span></div>
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<a data-saferedirecturl="https://www.google.com/url?q=https://www.youtube.com/watch?v%3DZhYcbo7rqEQ&source=gmail&ust=1583462500464000&usg=AFQjCNHcv6rwCVeqel7P7gMjaX3ehTlOIg" href="https://www.youtube.com/watch?v=ZhYcbo7rqEQ" target="_blank"><span style="color: #bf9000;">This talk</span></a><span style="color: #222222;"> on youtube with Amesh Adalja is excellent, and a bit more optimistic than Lipsitch.</span></div>
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<a data-saferedirecturl="https://www.google.com/url?q=https://www.theatlantic.com/health/archive/2020/02/covid-vaccine/607000/&source=gmail&ust=1583462500464000&usg=AFQjCNHAdW8eH7q_RrpV9TU6U2YTNtjNYQ" href="https://www.theatlantic.com/health/archive/2020/02/covid-vaccine/607000/" target="_blank"><span style="color: #bf9000;">You're Likely to get the Coronavirus</span></a><span style="color: #222222;"> in the Atlantic.</span></div>
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<span style="color: #222222;">STATNews has excellent coronavirus coverage, brief informative accessible articles. Their coronavirus topic section is </span><a data-saferedirecturl="https://www.google.com/url?q=https://www.statnews.com/tag/coronavirus/&source=gmail&ust=1583462500464000&usg=AFQjCNG9mohD4xErPxsAAHT6UJ5JWeb9Dg" href="https://www.statnews.com/tag/coronavirus/" target="_blank"><span style="color: #bf9000;">here</span></a><span style="color: #222222;">.</span></div>
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<span style="color: #222222;">Twitter is an excellent way to stay up to date. I have a list of coronavirus epidemiologist and writers, including journalists from STATNews, that you can access </span><a data-saferedirecturl="https://www.google.com/url?q=https://twitter.com/i/lists/1233025724061224966?s%3D20&source=gmail&ust=1583462500464000&usg=AFQjCNENIkdMcl5E0kcG2aoAReRDcK842A" href="https://twitter.com/i/lists/1233025724061224966?s=20" target="_blank"><span style="color: #bf9000;">here</span></a><span style="color: #222222;">. I don't recommend it, but my Twitter handle is </span><a href="https://twitter.com/astupple" target="_blank"><span style="color: #bf9000;">@astupple</span></a><span style="color: #222222;">.</span></div>
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<span style="color: #222222;">If you haven't watched it, the </span><a href="https://www.youtube.com/watch?v=4sYSyuuLk5g" target="_blank"><span style="color: #bf9000;">movie Contagion</span></a><span style="color: #222222;"> is a must see - the drama comes from its verisimilitude, not heroic characters or plot devices.</span></div>
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<a href="https://80000hours.org/2020/02/experimental-episode-about-2019-ncov-coronavirus/" target="_blank"><span style="color: #bf9000;">This podcast</span></a><span style="color: #222222;"> from early February interestingly walks through the thinking on the data almost as it is emerging.</span><br />
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<div style="background-color: white; font-family: arial, helvetica, sans-serif; font-size: small;">
<span style="color: #222222;">For a deeper look at pandemics and human extinction, this </span><span style="color: #bf9000;"><a href="https://80000hours.org/podcast/episodes/we-are-not-worried-enough-about-the-next-pandemic/" target="_blank"><span style="color: #bf9000;">80,000 Hours podcast</span></a> </span><span style="color: #222222;"><span style="color: #222222;">is informative, and </span><a href="https://80000hours.org/podcast/episodes/cassidy-nelson-12-ways-to-stop-pandemics/" target="_blank"><span style="color: #bf9000;">this one</span></a><span style="color: #222222;"> is more specific to coronavirus.</span></span></div>
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<span style="font-size: x-small;">1- Though it acknowledged a wide range, from 2.9% in Hubei vs. 0.4% outside Hubei.<br />2- Important caveat - it takes one to three weeks to get sick enough from coronavirus to die. If South Korea's massive testing campaign is catching people early in their disease course, then they may be testing people before they get sick enough to die.</span><br />
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Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-60689802889450351922019-06-21T12:29:00.003-07:002019-06-21T12:29:40.149-07:00Family Meetings: My Approach<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhC-Mceg7cDfJiDqAcQb8DhnOCdR_g4N1Xvl0gfsJRjTPsWcm0l-5qxQeJyTAi59dS6Zt_db7dXlFDQ6__3_GNYP0t7Snm-HOQpMNuiR-cJOJLDQGBFjalaucPvd_g4zNkaW-LqNv-i/s1600/download.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="183" data-original-width="276" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhC-Mceg7cDfJiDqAcQb8DhnOCdR_g4N1Xvl0gfsJRjTPsWcm0l-5qxQeJyTAi59dS6Zt_db7dXlFDQ6__3_GNYP0t7Snm-HOQpMNuiR-cJOJLDQGBFjalaucPvd_g4zNkaW-LqNv-i/s1600/download.jpg" /></a></div>
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<b>Preparation:</b><br />
- What information do we need from the patient/family? What are the key decisions we are helping them make?<br />
- What key information do we need to give them? (Usually this info supports item 1.)<br />
- What is the basic prognosis? Days to weeks, weeks to months, months to years, more? What information is essential to clarify this? Can we get the consultants to help clarify?<br />
- Confirm who is the decider. Find the paperwork that confirms the healthcare proxy, which is crucial if the patient lacks capacity.<br />
- Make a brief list of all major organ systems that are impaired.<br />
- Schedule a time and place, try to set aside an hour of your time. Who needs to be there? I try to only include consultants who have known the patient a long time and who the patient identifies as their doctor. Otherwise, lots of providers can make for a confusing and long session.<br />
<br />
<b>Get the room ready:</b><br />
- Get chairs for everyone.<br />
- See if there is a separate room where everyone can meet in and try to reserve it.<br />
<br />
<b>Before going in:</b><br />
- Decide who will be the meeting leader. There should be one point-person that the discussion goes through so that the important items get addressed. Others are there for supporting comments and details.<br />
- Review with the care team what the main decision points are.<br />
<br />
<b>During the Meeting:</b><br />
- Close the door and turn off the TV.<br />
- Introduce everyone by relationship to the patient and by role in the care team, and shake their hand.<br />
- Identify the healthcare proxy and verbalize this.<br />
- Orient yourself initially toward the patient.<br />
- Update the patient about the state of things. Review the major organ systems that are impaired, and the basic treatments in very general terms. "You have an infection in your blood and we are giving you antibiotics. Your heart is weak which makes it hard to breathe, and we are giving you medicine to dry out your lungs. Unfortunately, this medicine uses your kidneys, but they are weak too, and so we are having a hard time. And you are also unfortunately bleeding into your bowel so we are giving you blood transfusions."<br />
- Ask if there are any questions. Answer them in the most general terms possible. Avoid getting too specific about the medical details.<br />
- Get straight to the key question you have. Be straightforward in asking it. If the patient does not have capacity, direct the question at the healthcare proxy. "We need to talk about something we call code status. Do you recall anyone discussing this with you before?"<br />
- Deliver the information that you need to deliver. "We have been giving you a blood thinner to protect from stroke, but this medicine makes you bleed. Since we haven't been able to fix the bleeding, we stopped it."<br />
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<b>Closing the Meeting:</b><br />
- Reassure the patient that we are doing as much as you can and want to make sure that everything we are doing lines up with their preferences and wishes.<br />
- Thank everyone for coming and shake their hand.<br />
- Write a "Goals of Care" progress note that includes the names of everyone present, a brief summary of the discussion, and any major decisions that were made.<br />
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<b>Tips:</b><br />
- Focus on the decider, either the patient if lucid or the healthcare proxy. A family member or friend may be the most engaging. Answer their questions briefly, but bring your attention back to the decider.<br />
- Never argue. Give your impression and understanding and recommendation, but don't argue about details. Allow patients and family's to contradict you. Correct only when they are being disrespectful of the staff, and do so gently.<br />
- Try to let the patient/family do most of the talking. Try to let them finish all sentences before jumping in. Let them set the pace of the conversation.<br />
- Try not to be overly cheery. We instinctively greet people upbeat and happy, but it often doesn't match the context. Smile and be pleasant, but not joyful.<br />
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<b>Advance Directive Discussion Tips:</b><br />
I envision a ladder: Full code -> DNR/DNI -> Do Not Escalate Care -> CMO<br />
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I often use language like this:<br />
"For most patients, at some point the burden of treatments reaches a point where those treatments are not worth it. This happens on a spectrum. For an otherwise healthy 24 year old, if they get sick we put them through a lot (machines, lines and tubes, surgeries, etc), because their organs are all healthy and they have so much potential life ahead of them. For an 80 year old with terminal cancer, we don't do that stuff. Most patients fall somewhere in between. Lots of times, patients say 'do what you can using hospitals and intravenous medicines and fluids, but don't hook me up to lines and tubes, don't put me in the intensive care unit.' We call this Do Not Escalate Care. If antibiotics and fluids don't seem to be working and the patient starts declining, we focus on their comfort and let them pass away in peace."<br />
<br />
"We think Mr. Smith is at the end of his life. Some people in this situation want as many days as possible. They are willing to go through anything: 'Keep me in the hospital, poke me with needles for labs and imaging, do procedures, hook me up to lines and tubes and machines. Whatever it takes, even if it means I'm in pain and uncomfortable at the end. Other people would prefer a period of calm and some clarity at the end. They want to focus on maximizing the quality of the days remaining, rather increasing the number of days. They say 'Stop checking labs and vitals, stop with the treatments. If something happens, just let it take it's natural course and carry me off.' We call that Comfort Measures Only. The team that makes this happen is called hospice."<br />
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We often focus on "making the person DNR" or otherwise getting them to change their code status. This is the wrong approach. It's most important to give the proper information and get a clear decision that the whole family acknowledges.<br />
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<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-46404106638991069772019-06-11T17:46:00.003-07:002019-06-11T17:46:33.809-07:00Uncomplicated Gram Neg Bacteremia - I can do oral antibiotics for how long?<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVRAbKo_6Pj10po4PNh4ioUrSuMBTJQaP6yiSsuxj3G_ie2vwJF-AuMhQXwox6xZsh6iiD9K4BmQboG4nvybBknO_KaoUiaT-1FYfva6KVAcDpym030ij8F8z78DVA2RZDLbyHdyTs/s1600/gram.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="194" data-original-width="259" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVRAbKo_6Pj10po4PNh4ioUrSuMBTJQaP6yiSsuxj3G_ie2vwJF-AuMhQXwox6xZsh6iiD9K4BmQboG4nvybBknO_KaoUiaT-1FYfva6KVAcDpym030ij8F8z78DVA2RZDLbyHdyTs/s1600/gram.jpg" /></a></div>
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Someone finally studied it! There's decent evidence that you can switch to oral antibiotics with good bioavailability (in this study they primarily used Bactrim or quinolones for UTI bugs) when patients with gram negative bacteremia become clinically stable and get the same outcomes as with IV therapy. It's not an RCT, but it's almost 5,000 patients at several centers in a cohort that is closely matched with controls. And it's for hospitalized patients.</div>
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<a href="http://decent%20evidence%20that%20you%20can%20switch%20to%20oral%20abx%20with%20good%20bioavailability%20(in%20this%20study%20they%20primarily%20used%20bactrim%20or%20quinolones%20for%20uti%20bugs)%20when%20patients%20with%20gram%20negative%20bacteremia%20become%20clinically%20stable%20and%20get%20the%20same%20outcomes%20as%20with%20iv%20therapy.%20it's%20not%20an%20rct,%20but%20it's%20almost%205,000%20patients%20at%20several%20centers%20in%20a%20cohort%20that%20is%20closely%20matched%20with%20controls.%20and%20it's%20for%20hospitalized%20patients./" target="_blank">Association of 30 Day Mortality with Oral Step-Down vs Continued Intravenous Therapy in Patients Hospitalized with Enterobacteriaceae Bacteremia</a></div>
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Even better, an actual RCT of 600 patients with gram negative bacteremia, uncomplicated (ie- good source control, no mechanical valves or anything like that), which compared 7 to 14 days of antibiotics and showed no difference. </div>
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<a href="https://www.ncbi.nlm.nih.gov/pubmed?term=30535100" target="_blank">Seven versus fourteen Days of Antibiotic Therapy for uncomplicated Gram-negative Bacteremia: a Non-inferiority Randomized Controlled Trial.</a></div>
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It's a good case for doing what feels reasonable - start with IV antibiotics, once patient has been afebrile ~48 hrs and feeling better (no renal failure or stuff like that) and you have sensitivities, then switch to levofloxacin or Bactrim to complete 7 days. No PICC. BAM!</div>
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Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-34698768371730511312019-03-12T10:19:00.001-07:002019-10-15T03:17:22.648-07:00Ward Expectations<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-TogfQzQpkFnelCA03FIPJq8tAAKTg7x7v7WjAwxbBtkopaxbBKsDkSVf_xeRTWFb7tTxIkaUxZNkvF_-n7Lf-FR269j3DRUHhjbTV-gCH9Jx1SUqdhWQLvKGu4DXdlmV0WwwkVrC/s1600/ward.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="194" data-original-width="259" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-TogfQzQpkFnelCA03FIPJq8tAAKTg7x7v7WjAwxbBtkopaxbBKsDkSVf_xeRTWFb7tTxIkaUxZNkvF_-n7Lf-FR269j3DRUHhjbTV-gCH9Jx1SUqdhWQLvKGu4DXdlmV0WwwkVrC/s1600/ward.jpg" /></a></div>
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<span style="font-size: x-small;">Disclaimer: These are my personal expectations and may not overlap with other attendings. I offer them more as a learning tool to see what an experienced clinician considers good performance.</span><br />
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<b>Work hard:</b><br />
- Show up on time, don't leave until your work is done or handed off.<br />
- Do what you say you are going to do, update your team when you make changes to the plan.<br />
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<b>Take Ownership:</b><br />
- Act like you are the main doctor taking care of this patient, and that all patient problems are your problems.<br />
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<b>Medications:</b><br />
We are internal medicine, we own the med list, and we are responsible for an accurate list for any of our patients. This responsibility is easy to dodge by simply importing the existing list, and since we often care for patients for whom we did not do the initial med rec, that means assuming the list is wrong until we have checked it ourselves.<br />
- Double check the following home meds against pharmacy records or patient/family report.<br />
- Anticoagulation<br />
- Antiplatelet (clopidogrel)<br />
- Diuretic<br />
- Immunosuppressives<br />
- Any other drug that is critical<br />
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<b>Interacting with patients:</b><br />
- Introduce yourself in terms of your role in the hospital in terms the patient can understand.<br />
"Hello, I'm Dr. Stupple. I know you have seen a lot of doctors. I'm taking over from Dr. _____. I'm your main doctor right now. I'm on a team that includes Dr. _____. You have gastroenterologists and surgeons who are seeing you as well, so there's three teams. My job is to coordinate everyone."<br />
- Be respectful of everyone. Patients that trigger anger and resentment are often the most vulnerable and suffering the most.<br />
- Give them time to feel heard. Letting someone speak uninterrupted until they get out everything they want to say is maybe the most powerful way to communicate compassion.<br />
- Explain to them what is happening and update them when things change. Ex- if you order a CT scan, tell them why it's happening rather than letting the nurse or transportation tech do it.<br />
- Discuss medical issues at a 6th grade level of language and understanding.<br />
- Speak with the healthcare proxy or close family once every day or two.<br />
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<b>Nursing and other staff:</b><br />
- Be respectful. Among other things, control the urge to be dismissive- when nurses are concerned, patient mortality reliably increases.<br />
- Be approachable.<br />
- Respond to pages quickly, regardless who they are from. It's easy to say you respect everyone, but actions speak louder. Responding quickly to pages tells the recipient that you value their concerns. Think how much you appreciate it when someone "important" gets back to you immediately. It's gold.<br />
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<b>Workflow:</b><br />
- Top priority is generally to call consults, then submit orders, talk to patients and families, and finally get notes done.<br />
- Be skeptical of all incoming information. Double check important vitals, confirm history with the patient or close family.<br />
- Don't dismiss incoming information. Treat emergencies and urgencies as such until you know they are resolved.<br />
- Don't delay placing diet orders.<br />
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<b>Presenting:</b><br />
- Start with chief complaint or one-liner to orient the team. (This is an excellent habit because it teaches you to prioritize and summarize.)<br />
- Save the discussion for the assessment/plan, don't editorialize the data.<br />
- On rounds, take a guess at a diagnosis, list alternatives, and look for tests you could do to make things clearer. Don't obsess about trying to get the diagnosis right, just tell us what you're thinking, including "I don't know."<br />
- Master the problem list. Have a problem for each medication the patient is on at home, including meds that are on hold, and each med in the hospital.<br />
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<b>Master Level:</b><br />
- Focus on solving problems for patients, rather than simply getting your job done. Ex- A patient admitted with CHF can be rapidly improved with IV lasix and tempting to discharge. But focusing on their problem of volume overload and frequent admissions, we can diurese them to their dry weight.<br />
- Prioritize items that will impact care, such as delaying diagnosis and treatment or prolonging hospital stay. This requires good medical knowledge as well as....<br />
- Maintain situational Awareness: Outmaneuver the bottlenecks, such as PICC lines and IV access, procedures, consents.<br />
- Extend your plan all the way until discharge. Clarify what conditions need to be met before you will discharge.<br />
- Speak definitively when you are definite about what you are telling them. Avoid using qualifiers like "we might have to do an LP" or "it looks like you might have bacteria in your blood stream."<br />
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<b>Personal Extras:</b><br />
- I avoid maintenance fluids. If a patient needs fluid, I make an estimate of how much and write to give that amount over a period of a few hours. Then I reassess and consider more fluids. Maintenance fluids are hard to know how much they received and can easily be forgotten about over a period of days.<br />
- I never order colace since several RCT's show it doesn't work.<br />
- With exceptions, I rarely alter patient's diet from home because their treatment should be tailored to what they usually eat, not a special in hospital diet.<br />
<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-35239901181641050192019-03-01T07:35:00.005-08:002019-03-01T07:37:30.685-08:00Assessing Adrenal Suppression while on Steroids<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjr4ovXJf0C-OUhRceu07knGEzs3uM03hzov5pV1b2RdQzMP4QcngyZkIkseKmyHwrpZSayJHljWnuteUsYkT2JB3Hz57j86ilJvtwTutoITj-EV7b_XMvEfEAJDd2zszVtuUHrXzLb/s1600/adrenals.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="194" data-original-width="259" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjr4ovXJf0C-OUhRceu07knGEzs3uM03hzov5pV1b2RdQzMP4QcngyZkIkseKmyHwrpZSayJHljWnuteUsYkT2JB3Hz57j86ilJvtwTutoITj-EV7b_XMvEfEAJDd2zszVtuUHrXzLb/s1600/adrenals.jpg" /></a></div>
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Assessing adrenal function is challenging because false positives and false negatives in the testing is common, particularly when a patient is actively receiving steroids.<br />
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A high-normal serum cortisol essentially rules out adrenal suppression. However, normal values, even in the morning, are inconclusive. This is because physiologic cortisol varies widely throughout the day, making the test inherently unreliable. Furthermore, suppressed adrenal glands can nonetheless produce a baseline cortisol level that falls in the normal range, even though the adrenals are not communicating with the pituitary and therefor not responding to ACTH. Therefore, the stimulation test is preferred.<br />
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There's no role for simply checking serum cortisol in patients on steroids.<br />
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<b>UpToDate Approach</b><br />
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Step 1- Assess their risk of adrenal suppression. <br />
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If high risk (taking 10-20mg pred daily for three weeks or more), then you simply assume they are suppressed and treat them accordingly. Basically, the treatment is gradual, careful weaning of steroids.<br />
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If low risk (getting steroids for less than 3 weeks), assume not suppressed.<br />
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If someone is moderate risk or you're unsure, THEN assessment of adrenal axis is warranted. Go on to step 2:<br />
<br />
Step 2- Assessing adrenal suppression<br />
<br />
Ideally, start with a low dose ACTH stimulation, 1 mcg cosyntropin (which is synthetic ACTH). Measure serum cortisol immediately before the dose and 30 minutes after. This test is more sensitive because it uses physiologic levels of hormone, and it's faster because it can be completed in 30 minutes (as opposed to an hour with the high dose test).<br />
<br />
If the serum cortisol is >17 mcg/dL, they don't have suppression. If greater than 25, their adrenal axis is intact. See below for between 18-25.<br />
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The trouble with the low dose version is that you need an IV (which is not usually a problem in the hospital). The other difficulty is that the cosyntropin dose needs to be mixed--the vial contains 250mcg, and must be appropriately diluted. If pharmacy or nursing can do this reliably, you're in good shape.<br />
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If low dose is not feasible, use the high dose test. This involves 250mg cosyntropin (entire vial) and measuring cortisol immediately before, 30 min, and 60 min after. This high dose is intended to be able to use IM or IV. The serum cortisol cutoff is the same >17. <br />
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Alternatives are the 8 hour and 48 hour stimulation tests. These are rarely used. The 48 hr test may be useful to distinguish secondary from tertiary adrenal suppression.<br />
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COMPLICATORS:<br />
- If cortisol is 18-25 after stimulation, it is unclear what to do. I would repeat the test.<br />
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- Cortisol testing in the ICU is difficult to interpret and controversial, with no clear guidance on how to assess.<br />
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- Birth control can falsely elevate serum cortisol levels (because estrogen increases cortisol binding globulin).<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyjkzgyPNVVpbvIrW1KUBfFd9SkATiyoeaOr-gI51RksBVBxo_axBFXzYAlQgMrYj5gDG82_G2rESVlogvlgEYZ8ungDawZ4YzQz1ki_rkV0kbQs7JvnI0sY5Cuf8nCQACgFgq1px_/s1600/adrenal+axis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="989" data-original-width="892" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyjkzgyPNVVpbvIrW1KUBfFd9SkATiyoeaOr-gI51RksBVBxo_axBFXzYAlQgMrYj5gDG82_G2rESVlogvlgEYZ8ungDawZ4YzQz1ki_rkV0kbQs7JvnI0sY5Cuf8nCQACgFgq1px_/s400/adrenal+axis.jpg" width="360" /></a></div>
<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-6519675167733923092019-01-31T06:23:00.003-08:002019-01-31T06:33:59.761-08:00Managing noninfective interstitial lung disease in the hospital<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-u26EGEwDKYVNFY02V8BPVGx0TAq_LNi05tukvJVOEmaZc_b0PnaKNEbhRVyMRjkR5pX_bgifYvTfoLehiG8zy_6yYSxLyUrPqeZHuClil2j8qkMeD2Cu2hkbKBpwiVw3u51Q3WNU/s1600/fibrosis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="183" data-original-width="275" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-u26EGEwDKYVNFY02V8BPVGx0TAq_LNi05tukvJVOEmaZc_b0PnaKNEbhRVyMRjkR5pX_bgifYvTfoLehiG8zy_6yYSxLyUrPqeZHuClil2j8qkMeD2Cu2hkbKBpwiVw3u51Q3WNU/s1600/fibrosis.jpg" /></a></div>
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Pulmonary fibrosis, or idiopathic interstitial lung disease, is challenging to manage in the hospital, largely because of the alphabet soup naming system, the constantly shifting classification system, overlapping diagnostic criteria, and the lack of effective therapies. Below, I try to simplify these diseases by focusing less on diagnostic criteria and more on therapies. As you'll see, we generally use steroids, with only expert opinion to guide us.<br />
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The below diagram places pulmonary fibrosis and idiopathic interstitial pneumonias in context with other noninfective diffuse lung diseases.<br />
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<a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><b><span style="font-family: "verdana" , "sans-serif"; font-size: 12.0pt;">Diffuse
parenchymal lung diseases </span></b><span style="font-family: "verdana" , "sans-serif"; font-size: 12.0pt;">(From UpToDate)<b><o:p></o:p></b></span></div>
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<span style="font-family: "verdana" , "sans-serif"; font-size: xx-small;">IIP: idiopathic interstitial pneumonia; LAM:
lymphangioleiomyomatosis; PLCH: pulmonary Langerhans cell
histiocytosis/histiocytosis X.</span><span style="font-family: "verdana" , "sans-serif"; font-size: 12.0pt;"><o:p></o:p></span></div>
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<br />
FDiagnosis is driven by high resolution CT. Treatments for Idiopathic Interstitial Pneumonias are largely based on expert opinion.<br />
<br />
<br />
<a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?rinli=1&pli=1&blogID=4699839350724327880" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><b>Idiopathic pulmonary fibrosis:</b><br />
Most common, it's a chronic progressive disease with flares, median survival 2-3 years.<br />
<br />
<div>
Acute presentation/flare: treat underlying cause, can try steroids (not studied)<br />
Chronic: Nintedanib (tyrosine kinase inhibitor to block fibrosis), lung transplant.<br />
<br />
<br />
<b>Idiopathic nonspecific interstitial pneumonia:</b>Less common, usually associated with connective tissue diseases or toxic exposures, when alone it is classified as “idiopathic.” Disease course is chronic progression with waxing and waning.</div>
<div>
Acute presentation/flare: High dose steroids (weakly studied)<br />
Chronic: Treat underlying disease, add steroids, then add immunosuppressants<br />
<br /></div>
<div>
<b>Cryptogenic organizing pneumonia:</b>Less common, can have single onset and resolve, or waxe and wane. Can be fulminant, behaves very similarly to pneumonia.<br />
<br />
Acute presentation/flare: Steroids (weakly studied, but have a strong observational effect)<br />
Chronic: Lower dose steroids, possibly adding immunosuppressants<br />
<br />
<br />
<b>Acute interstitial pneumonia:</b><br />
Rare, fulminant disease with 50% in hospital mortality on initial presentation. Difficult to diagnose. Acute presentation: High dose steroids, lung transplant.<br />
<br />
<br />
<br />
BOTTOM LINE:<br />
The most important condition to look out for, in my mind, is cryptogenic organizing pneumonia. It behaves the most like an infectious pneumonia, presenting with fevers and often a focal infiltrate. However, in my clinical experience, and that of the pulmonologists I hear from, it really does often respond well to steroids; two thirds of cases resolve with initial steroid treatment. This disease can fool you by resisting antibiotics alone, making you think it is a resistant organism, or by vanishing when steroids are used adjunctively.<br />
<br />
Overall, it helps to be suspicious when pneumonia isn't responding to the usual therapy. Have a low threshold to get a high resolution CT, and keep cryptogenic organizing pneumonia in mind in particular because it is easier to modify its disease course. Unfortunately, the other conditions are less important to identify because they usually have a slower onset, giving clinicians enough time to diagnose in the early stages. Acute flares of all of these tend to get the same basic treatments, and, with the exception of cryptogenic organizing pneumonia, the disease course is difficult to modify.</div>
Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-60454151524924537722018-11-21T05:41:00.001-08:002019-03-13T10:24:38.902-07:00What is Sepsis?<br />
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<br />
Sepsis is a commonly used term of unclear definition and utility. A brief history:<br />
<br />
Sepsis was formally defined in 1991 as dysregulated immune response to infection, characterized by the systemic inflammatory response syndrome and identifiable by its SIRS criteria.<br />
<br />
Since sepsis had such a high mortality, the purpose of this definition was to support early recognition and treatment.<br />
<br />
Over the next twenty years, clinical research focused on identifying diagnostic and treatment algorithms for sepsis, such as The Rivers Protocol and <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa010307" target="_blank">Early Goal Directed Therapy</a>. Patients receiving this protocol lived longer, and this was quickly adopted as the standard of care. However, subsequent multicenter RCT's and meta analyses didn't show a mortality benefit (<a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1401602" target="_blank">ProCESS</a>, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1404380" target="_blank">ARISE</a>, <a href="https://www.nejm.org/doi/full/10.1056/nejmoa1500896" target="_blank">ProMISE</a>), suggesting that the success of the Rivers Protocol was related to the specifics of that one intensive care unit.<br />
<br />
Recently, the definition of sepsis was updated by the Third International Consensus Definitions for Sepsis and Septic Shock in 2016, <a href="https://jamanetwork.com/journals/jama/fullarticle/2492881" target="_blank">published in JAMA</a>.<br />
<br />
<b>Here's a quick breakdown of that update:</b><br />
<br />
-The SIRS criteria are abandoned- many patients meet SIRS but do not have systemic infection, and many patients have systemic infection but do not meet SIRS.<br />
<br />
-"Severe Sepsis" is abandoned. Sepsis itself, with a 10% mortality, is already severe.<br />
<br />
-The definition of sepsis is: "life-threatening organ dysfunction caused by a
dysregulated host response to infection."<br />
<br />
-"The task force recognized that no current clinical measures reflect
the concept of a dysregulated host response."<br />
<br />
-Sepsis is "predicated on infection as its
trigger," but the task force "acknowledges the current challenges in the microbiological
identification of infection."<br />
<br />
-Organ dysfunction is best assessed by the SOFA score, which can be obtained through basic labs and PaO2. An increase by 2 or more points on SOFA incurs 10% mortality.<br />
<br />
-qSOFA is NOT a definition of sepsis. It is a prompt to look for sepsis, a screening tool to identify patients who may progress to sepsis.<br />
<br />
-qSOFA is intended as a quick bedside assessment, requiring only assessment of mental status (GCS <15 or not), blood pressure (systolic pressure less than 100), and respiratory rate (>22). A positive qSOFA increases the likelihood of progressing to sepsis.<br />
<br />
-Insurers have not caught up with new definitions and still reimburse according to whether patients meet traditional sepsis criteria.<br />
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<b>Bottom Line:</b><br />
<br />
You need to rely on your best clinical judgment in identifying patients with severe infection to which the body's immune response is dysregulated. Since overwhelming infection is a common cause of death, you need to act quickly to prevent or treat poor tissue perfusion and multi-organ dysfunction. Treatment involves IV antibiotics and aggressive volume resuscitation, with consideration for pulmonary edema. It is also important to identify and resolve the source of infection quickly.<br />
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<br />
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<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com1tag:blogger.com,1999:blog-4699839350724327880.post-83331715792963503652018-10-24T05:44:00.002-07:002018-10-25T05:58:07.654-07:00Cirrhosis in the Hospital<div class="separator" style="clear: both; text-align: center;">
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<br />
<br />
This is a brief outline of big things to look for in the hospitalized patient with cirrhosis.<br />
<br />
<br />
<b>Hepatic Encephalopathy</b><br />
Diagnose: Asterixis? Confusion? Has HE historically?<br />
What’s the cause? Infection, bleeding, HRS (poor renal clearance), worsening liver failure.<br />
What to do? Lactulose, up to q2Hr to maximize clearance, titrate to mental status and stool frequency. Look for/treat underlying cause (pan culture including ascites tap, cxr, rectal, renal workup). Consider rifaximen.<br />
<br />
Key Points: HE is dangerous in itself (aspiration, med non-adherence, falls, delirium), it is often a harbinger of badness (infection, bleed), but it's also fixable. It takes effort, and it's messy, but it's important for every patient.<br />
<br />
<br />
<b>Variceal bleeding</b><br />
Diagnose: Recent melena/BRBPR? Rectal exam? (Not occult blood) Worse anemia? Known varices? Last EGD? On nonselective beta blocker? Known bleed?<br />
What to do? If suspicious but not definite, do rectal exam, NPO, two large bore IV, type and screen, IV PPI BID, consent for blood, call GI to arrange EGD. If definitely bleeding, stat page GI, order blood, can use albumin while waiting, octreotide gtt and prophylactic ceftriaxone, low threshold to transfer to ICU.<br />
What to worry about: Airway protection from blood and/or HE, hemorrhage requiring massive transfusion protocol. Decompensation can happen rapidly and without warning.<br />
<br />
Key Points: The key to managing this condition is to be prepared with IV access, blood products/albumin, GI awareness, etc. Once a patient opens up, there is very little time.<br />
<br />
<br />
<b>Ascites</b><br />
What to do? Main concern is ruling out SBP. If obviously distended, do diagnostic and therapeutic para, though likely need IR guided if you can’t get supervised. If ascites uncertain, get and ultrasound to confirm. Ideally diagnostic fluid prior to antibiotics, but don’t hold antibiotics for delayed paracentesis. Ceftriaxone 2gm daily. For large vol para, need to give albumin to counteract fluid shifts/avoid HRS. Long term treatment is diuretic vs TIPS vs serial para vs transplant.<br />
<br />
Key Points: This rarely becomes an emergency except for overwhelming gram negative sepsis. However, ascites complicates everything, including: Respiratory restriction, urine obstruction, and pain which often necessitates opiates.<br />
<br />
<br />
<b>Hepatorenal Syndrome</b><br />
Diagnose: Prerenal AKI in cirrhosis that doesn’t improve with albumin challenge.<br />
What to do: Hold diuretics. Albumin challenge, if fails needs octreotide and midodrine. Workup and correct underlying drivers. Call renal and hope doesn’t need dialysis.<br />
<br />
Key Points: This is rarely an emergency, but very high mortality. You need to differentiate HRS from prerenal AKI quickly and get the relevant treatment running and renal consulted.<br />
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<br />
<b>Less Urgent Considerations:</b><br />
Transplant Status?<br />
Calculate MELD score, review chart and talk with patient. This is the ultimate and ideal fix for all of the above, but there are several barriers.<br />
<br />
Heptaocellular Carcinoma<br />
Status of last ruq u/s?<br />
<br />
<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-63246760202404936312018-07-09T17:06:00.001-07:002018-07-09T18:10:09.434-07:00Night Medicine TalkThis talk was delivered to the Internal Medicine Residents at Baystate Health, Academic Half Day, July 10, 2018.<br />
<br />
Please feel free to send questions to astupple@gmail.com.<br />
<br />
<br />
<br />
<iframe allowfullscreen="true" frameborder="0" height="569" mozallowfullscreen="true" src="https://docs.google.com/presentation/d/e/2PACX-1vTKtwioA4UdcUOsPfcYxNY60lRDOdpOAtMwFKDBzvfPr4K1njxItzIKwAnw08PIujNrt1M4mIMbaGiR/embed?start=false&loop=false&delayms=3000" webkitallowfullscreen="true" width="780
"></iframe>Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-83444394372721798232017-11-24T20:02:00.002-08:002017-11-24T20:02:23.448-08:00HCAP Replacement<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuOChxYUXvALYt5qDtJA61bKthIFYuG5DQsiV7P-feYJMW3V6AE1ABDBxYhMafiKN68futS6_AdKwS6JZbUChcQB-A8NNojUVhlllDeSEOsGQumV5oymxX6qptgOPYdSBb8sRlr8Ie/s1600/vancomycin.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="275" data-original-width="183" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuOChxYUXvALYt5qDtJA61bKthIFYuG5DQsiV7P-feYJMW3V6AE1ABDBxYhMafiKN68futS6_AdKwS6JZbUChcQB-A8NNojUVhlllDeSEOsGQumV5oymxX6qptgOPYdSBb8sRlr8Ie/s1600/vancomycin.jpg" /></a></div>
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Healthcare Associated Pneumonia is no longer considered a clinically useful category,<span style="font-size: x-small;">[1]</span> there is little guidance about how to treat patients with pneumonia who are nonetheless at higher risk for resistant organisms.<br />
<br />
Since vancomycin for MRSA and antipseudomonal beta lactams are the central considerations for treating resistant organisms, it may be helpful to simply review when one would consider<br />
<br />
Guidance when considering vancomycin for MRSA:<br />
<br />
1- If a patient has received broad spectrum IV antibiotics recently (within the last 90 days is a reasonable cutoff).<br />
<br />
2- Severe illness, where any potential therapeutic advantage is warranted.<br />
<br />
3- The history suggests an acutely worsening viral infection suggestive of bacterial superinfection. The classic example is staph aureus causing a highly morbid superinfection in the wake of influenza or other respiratory virus.<br />
<br />
4- Presence of a cavitary lesion on imaging. Cavitation is a serious infection that suggests necrosis, which suggests staph aureus.<br />
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<br />
Guidance when considering antipseudomonal beta lactams (pipercillin-tazobactam, cefepime, ceftazidime.)<br />
<br />
1- If a patient has received broad spectrum IV antibiotics recently (within the last 90 days is a reasonable cutoff).<br />
<br />
2- Severe illness, where any potential therapeutic advantage is warranted.<br />
<br />
3- If a patient has structural lung disease (bronchiectasis, prior cavitary lesion, cystif fibrosis, etc.)<br />
<br />
<br />
Important caveats:<br />
1- A negative nasal MRSA swab essentially rules out MRSA pneumonia.<span style="font-size: x-small;">[2]</span><br />
<br />
2- Sputum culture is low yield, but harmless and potentially very helpful, especially patients with structural lung disease who often have prior respiratory cultures for guidance.<br />
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<span style="font-size: x-small;"><br /></span>
<span style="font-size: x-small;">[1] Mortality in patients with HCAP appears more likely due to comorbid conditions in these chronically ill patients than due to resistant organisms. </span><br />
<span style="font-size: x-small;">Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. </span><br />
<span style="font-size: x-small;">Clin Infect Dis. 2014 Feb;58(3):330-9. doi: 10.1093/cid/cit734. Epub 2013 Nov 22.</span><br />
<a href="https://www.ncbi.nlm.nih.gov/pubmed/24270053"><span style="font-size: x-small;">https://www.ncbi.nlm.nih.gov/pubmed/24270053</span></a><br />
<span style="font-size: x-small;"><br /></span>
<span style="font-size: x-small;">[2] <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3910879/pdf/zac859.pdf" target="_blank">Predictive Value of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Swab PCR Assay for MRSA Pneumonia</a></span><br />
<span style="font-size: x-small;">Antimicrob Agents Chemother. 2014 Feb; 58(2): 859–864.</span>Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-28201602284922336642017-11-04T01:13:00.005-07:002017-11-04T22:54:21.305-07:00Shortness of Breath: Quick Decision Making<div class="separator" style="clear: both; text-align: center;">
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<br />
<span style="font-size: x-small;">[DISCLAIMER- This piece is not medical advise. It is intended as teaching for medical residents.]</span><br />
<br />
Let's simplify a very complex problem according to the relatively few quick-acting things you can do for someone who is short of breath in the hospital.<br />
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<div>
While you're thinking of what to do, pull up the most recent CXR and if it is more than 12 hrs old, consider ordering a second one.</div>
<div>
<br /></div>
<div>
<b>1- Suction. </b>Mucus plugging can happen soon after repositioning and not be evident on imaging. Chest PT and suctioning are rarely harmful.</div>
<div>
<br /></div>
<div>
<b>2- Ipratropium/albuterol nebulizer</b>. Very commonly helpful, sometimes resolves the problem. Wheezes on exam, history of asthma/reactive airways/COPD, hyperinflated chest x-ray make this a sure bet. Duonebs are very well tolerated. </div>
<div>
<br /></div>
<div>
Potential Harm:</div>
<div>
Albuterol can drive rapid afib, delirium and anxiety. If either has been a problem, you can just give ipratropium. Trying to force a delirious patient to keep a mask on their face is a bad idea. For upper airway issues, particularly tracheobronchomalacia, nebs can be an irritant. Lastly, nebs can give false reassurance- a desperate patient wants to believe that all they need is a quick breathing treatment and can be quick to report improvement. Keep in mind that they are a temporary solution, and further work is needed to root out the underlying problem.</div>
<div>
<br /></div>
<div>
<b>3- Lasix</b>. CHF is very common, even in older patients without a formal diagnosis. Take a moment to look for CHF in the history, lasix in the home med list, congestion on the most recent imaging, how much fluid they got recently (especially maintenance fluids), BNP, extremity or sacral edema. Lasix acts quickly, causes lasting improvement, and is relatively harmless. And it provides some diagnostic utility. Don't forget to aggressively treat other drivers of CHF like hypertension in flash pulmonary edema and rapid A fib. </div>
<div>
<br /></div>
<div>
Potential Harm:</div>
<div>
Watch the kidneys (keeping in mind that volume overload can cause AKI as well).</div>
<div>
<br /></div>
<div>
<b>4- Naloxone</b>. If the patient is somnolent, naloxone is almost always a good idea. It is well tolerated, fast acting, and diagnostic. Even if a patient isn't on opioid meds, they sometimes are using their own surreptitiously. </div>
<div>
<br /></div>
<div>
Potential Harm:</div>
<div>
Almost none. In cancer patients with lots of pain, especially if on comfort focused care, naloxone is very uncomfortable.</div>
<div>
<br /></div>
<div>
<b>5- Steroids</b>. Most COPD/asthma patients are already on steroids, but if not, this can be helpful.</div>
<div>
<br /></div>
<div>
Potential Harm:</div>
<div>
Hyperactive delirium, possibly fluid retention in CHF, though a few doses overnight is unlikely to cause a problem.</div>
<div>
<br /></div>
<div>
<b>6- Noninvasive ventilation</b>. For alert patients who have failed the above, BIPAP is generally well tolerated. Sometimes it makes sense to trial it on the sooner side so that a patient can get acquainted with having a mask over their face before they start to get frantic or delirious and try to pull the mask off. Checking pH and pCO2 is helpful, and a VBG is less painful than an ABG for this.</div>
<div>
<br /></div>
<div>
Potential Harm:</div>
<div>
Hypotension due to increased intrathoracic pressure, aspiration in obtunded patients, unnecessary ICU transfer.</div>
<div>
<br /></div>
<div>
<b>7- Foley or straight cath</b>. Particularly in patients with multifactorial dyspnea (some CHF, some COPD, some anxiety), you are looking for every little bit that can help. Urinary retention is common, and some patients can have more than 1.5L of urine in their bladder.</div>
<div>
<br /></div>
<div>
Potential Harm:</div>
<div>
Catheter associated UTI.</div>
<div>
<br /></div>
<div>
<b>8- Thoracentesis (or paracentesis)</b>. Check the x-ray and breath sounds for signs of pleural effusion, pneumothorax, hemothorax. If it's easy to visualize fluid, then it'll probably feel a lot better when it's drained. Urinary retention or ascites with distended abdomen can cause a restrictive deficit.</div>
<div>
<br /></div>
<div>
Potential Harm:</div>
<div>
All the harms of an invasive procedure. </div>
<div>
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<div>
<b>9- Morphine</b>. 0.5 mg IV morphine, or 0.5mg IV lorazepam can be very helpful for patients in distress. We worry about respiratory suppression, but a small dose is unlikely to tip someone over the edge. For the occasional patient whose anxiety is compromising ventilation, a small dose of sedation can break a feedback loop. Remember that pure anxiety is a diagnosis of exclusion (but some anxiety always accompanies dyspnea.)</div>
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Potential Harm:</div>
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Respiratory depression, delirium.</div>
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<b>10- Pain</b>. Shallow breathing with atelectasis from splinting can cause tachypnea and/or hypoxia (as well as fever and look like pneumonia on chest x-ray). Patients are not usually dyspneic. Treating pain can help, though keep in mind that PE's and pericarditis hurt.</div>
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<br /></div>
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<u>Important considerations, though unlikely to improve quickly</u></div>
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<br /></div>
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- <b>Broaden antibiotics</b>. Patients with worsening symptoms and pneumonia deserve broader coverage. Think of fungi, legionella, and multi drug resistant organisms. </div>
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- <b>Acute coronary syndrome</b>. Dyspnea is often an angina equivalent, and patients with lung disease often have comorbid coronary disease. An EKG and troponin are almost never a mistake.</div>
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<br /></div>
<div>
- <b>Pulmonary embolism</b>. PE is very common in COPD exacerbations. Use the <a href="https://www.mdcalc.com/wells-criteria-pulmonary-embolism" target="_blank">Wells criteria</a> to identify high risk patients, apply the <a href="https://www.mdcalc.com/perc-rule-pulmonary-embolism" target="_blank">PERC rule</a>, and correct D-dimer for age [upper limit of normal = age/50 in mg/L FEU, age x 10 in mcg/L DDU].</div>
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<br /></div>
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-<b> Pericardial effusion</b>. Review CT chest, echocardiogram. Check pulsus paradoxus.<br />
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<br />
Please email criticism/questions/suggestions to astupple at gmail so I can update this post.</div>
Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-82988998215714094442017-10-20T18:45:00.001-07:002017-10-20T18:45:17.213-07:00Trying to Diagnose TB in the Hospital<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_Ovk-xMoN6cTa4uNxnl9_mNKxkyQCWdsDvzZiGJmuji9CvWI0OXyTTmiFrgK1u6LiUl2WrCMr6qo1miiZ8woaBQM25sfdjUF9tmzKzsCR3v-XNnLria7DyvT2dYCABck4FSrBhLqv/s1600/TB.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="548" data-original-width="640" height="274" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_Ovk-xMoN6cTa4uNxnl9_mNKxkyQCWdsDvzZiGJmuji9CvWI0OXyTTmiFrgK1u6LiUl2WrCMr6qo1miiZ8woaBQM25sfdjUF9tmzKzsCR3v-XNnLria7DyvT2dYCABck4FSrBhLqv/s320/TB.jpg" width="320" /></a></div>
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<br />
When you suspect active TB when admitting a patient to the hospital, it turns out it is quite difficult to rule someone in or out. Here is a brief look at how you can get tricked trying to diagnose TB, and some recommendations for workup up these patients.<br />
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Skin test and quantiferon gold assay are bad at diagnosing active TB:<br />
- Quant gold cannot exclude active (or latent) TB because 10-35% of patients with active TB will have a negative quant gold assay.<br />
- The skin test will be negative in 50% of patients with disseminated disease and 5-40% of patients with pulmonary disease.<br />
- This online latent test interpreter is excellent: http://www.tstin3d.com/en/calc.html<br />
<br />
You really can't RULE OUT active TB with sputum tests. All you can do is have a certain degree of confidence about how many TB organisms are present in the patient's airways. If you have a negative sputum smear, you have detected down to a minimum of 5 thousand colony forming units (CFU)/mL. A negative sputum PCR detects down to 150 CFU/mL. A negative culture detects down to 10 CFU/mL.<br />
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Unfortunately, the culture takes weeks, so it's not helpful in the short term when admitting. Many hospitals don't have sputum PCR or Gene Expert testing. That usually leaves us with sputum smear. This will tell you something if the airways are teaming with organisms, but can be falsely negative for disseminated TB or for a lower burden of respiratory disease. The main thing that the negative sputum gives you is confidence that the patient is not contagious to the rest of the hospital.<br />
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Imaging is helpful, but also doesn't rule out TB. 5-15% of active pulm TB have negative CXR, CT is better but not absolute.<br />
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Takeaways:<br />
- If you have even a low suspicion for pulm TB (A respiratory complaint in a patient from an endemic area, HIV, homeless/incarcerated, unexplained wt loss, etc), they need to be on airborne precautions.<br />
- If the sputum smears are negative x3 (you can order them 12 hrs apart), you can be reasonably confident that they're not contagious.<br />
- The skin test and quant gold assays can be negative, but still have pulm or disseminated TB, so they're not very helpful in the inpatient setting. It's worth testing because if positive, they will need TB clinic and likely treatment for at least latent TB and further workup for disseminated disease.<br />
- Your main job in working up active TB is to protect the hospital, patients, their families and staff. An exposure affects hundreds of people, causes lots of hassle, and costs lots of money.<br />
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<br /></div>
Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-13981250885603049882017-09-29T00:27:00.006-07:002017-11-08T07:13:42.990-08:00How urgent is hypertensive urgency?<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMKJfUNNhhrThBpj3FG4KiqQtM6Jt6aNZBF8L-iGDd02HCQO4hiBAloBczVUm_zmkrr8B1ceD-6q0XsLATBwoxLMTyqXvRGk4gZBvl1G_p4YbUUblnvT1swrRCf27sIQBdDdY9Nk19/s1600/HTN+Urgency.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="291" data-original-width="173" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMKJfUNNhhrThBpj3FG4KiqQtM6Jt6aNZBF8L-iGDd02HCQO4hiBAloBczVUm_zmkrr8B1ceD-6q0XsLATBwoxLMTyqXvRGk4gZBvl1G_p4YbUUblnvT1swrRCf27sIQBdDdY9Nk19/s1600/HTN+Urgency.jpeg" /></a></div>
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 13.999999999999998pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span>
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 13.999999999999998pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span>
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 13.999999999999998pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">How quickly do I have to lower blood pressure in “hypertensive urgency”?</span></div>
<b id="docs-internal-guid-8ffa2f9d-cc67-e929-1d7b-4deceba733af" style="font-weight: normal;"><br /></b>
<br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The term hypertensive urgency was established in 1974 as SBP >180, DBP >110 without evidence of end organ damage, and recommended to “lower MAP by 20 over 24-48 hours."</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: xx-small; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><a href="http://www.nejm.org/doi/full/10.1056/NEJM197401242900407" target="_blank">[1]</a></span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> However, there has never been data to quantify the short term cardiovascular risk of hypertensive urgency, let alone the benefit of BP reduction in the short term. </span></div>
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<br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Until now:</span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Characteristics and Outcomes of Patients Presenting with Hypertensive Urgency in the Office Setting. Patel et al. JAMA IM. 2016;176(7) </span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: xx-small; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2527389" target="_blank">[2]</a></span></div>
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<br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bottom line:</span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">There was no significant difference in stroke or MI (Major Adverse Cardiac Events, MACE) between those admitted to the hospital for urgent management and observation vs. those sent home with uptitrated oral meds for patients with SBP >200.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Design: </span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Retrospective cohort study </span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Setting: </span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">One healthcare system from January 2008 – December 2013 </span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Patients: </span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">58,836 adults with hypertensive urgency (SBP >180 or DBP >110, no symptoms)</span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Results:</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> No significant difference between those being treated in the hospital over the course of hours vs. sent home on oral agents. Overall 7 day maximum risk of major adverse cardiac risk for all patients, even those with SBP >220, was 0.5%.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Conclusion:</span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">When a patient is truly asymptomatic, this large observational study showed the risk of a serious cardiovascular event in non-urgent therapy in the next week to be less than 0.5%. There is no evidence for a benefit in reducing blood pressure over the course of hours.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Limitations:</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br class="kix-line-break" /></span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">This is an observational study which is open to unseen confounders, such as whether or not patients who were referred to the ED may have been sicker than those sent home (although baseline characteristics were were well matched). </span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br class="kix-line-break" /></span><br />
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span>
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The reason why this relatively weak study is impactful is that it is the best we have. The orthodoxy of hypertensive urgency is based on expert opinion alone.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span>
<span style="font-family: "arial"; font-size: 11pt; font-weight: 700; white-space: pre-wrap;">Important caveat: </span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">This is weak evidence, which means that decision making should be highly dependent on the clinical situation. Patients should be assessed for evidence of encephalopathy, aortic dissection, pulmonary edema, eclampsia, etc. </span></div>
<b style="font-weight: normal;"><br /></b>
<br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">1- <a href="http://www.nejm.org/doi/full/10.1056/NEJM197401242900407" target="_blank">Hypertensive Emergencies Jan Koch-Weser, M.D. N Engl J Med 1974; 290:211-214</a></span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">2- <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2527389" target="_blank">Characteristics and Outcomes of Patients Presenting with Hypertensive Urgency in the Office Setting. Patel et al. JAMA IM. 2016;176(7)</a> </span></div>
Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-40105352610393108222016-05-02T14:06:00.002-07:002016-05-02T14:06:45.442-07:00The Medical Bait and Switch<img alt="Image result for thinking fast and slow" src="data:image/jpeg;base64,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" 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I just discovered a thinking fallacy featured in the book "<a href="http://www.amazon.com/Superforecasting-Science-Prediction-Philip-Tetlock/dp/0804136696" style="color: #1155cc;">Superforecasting</a>." It happens all the time in medicine.</div>
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It's called the bait and switch. It's similar to anchoring, but different.</div>
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It happens when, confronted with a difficult and foreign problem, a person substitutes an easier-to-solve and more intuitive problem, and then answers that problem. </div>
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When someone comes to the emergency room with shortness of breath, this is a complex problem with many, many possible causes, often mixed together. Rather then get to the bottom of this, we substitute shortness of breath with a simpler problem- pulmonary edema from heart failure. Mild pulmonary edema is a much easier problem than shortness of breath. We give a relatively harmless medicine, furosemide, quantify that we're making progress by measuring its effect on weight loss or negative fluid balance, and then dust our hands of the problem and congratulate ourselves on another job well done. </div>
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Meanwhile, while hospitalized for a few days, the patient is removed from whatever insult caused the shortness of breath (maybe the mold in their apartment triggers asthma, or the challenges of insecure housing, nutrition or basic safety, or substance use). During that remove, they feel better and their shortness of breath improves. </div>
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They feel especially better when suggested by their doctors' leading query: "Are you feeling better?" </div>
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This is even more effective when phrased like "You've lost a liter of fluid and your chest X-ay is clear, are you breathing better?" Who could say no?</div>
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Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-63502360692310180862016-04-26T06:08:00.001-07:002016-04-26T06:08:38.438-07:00Five magnitudes of medical harm<div class="separator" style="clear: both; text-align: center;">
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Despite the dictum to do no harm, everyone agrees that medicine is harmful. But just how harmful is it?<br />
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<b>Level 1- The unavoidable, almost necessary harm of practicing medicine.</b><br />
Example: the pain and discomfort of surgical excision of a ruptured appendix. When slicing into someone's body, causing pain and discomfort simply cannot be avoided. The benefits of surgery dramatically outweigh these travails, and so we simply soldier on. In some ways, the doctor's role is to be the authority, the stoic bearer of bad news who unflinchingly faces the facts, and disregards these unavoidable harms so that they don't impede the grisly work that simply must be done. This role was probably prominent in the early days of medicine, before anesthesia, when on the battlefield, the qualities one wanted in a surgeon were grit and speed. This level can found among retired docs and scattered about a few naive young residents.<br />
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<b>Level 2- The enterprise of medicine is more harmful than it seems.</b><br />
This level is more humble than level one. It is sensitive to the fact that mistakes and pitfalls are everywhere, and they aren't always outweighed by medicine's benefits. It knows that bad things happen just by in the hospital. Reducing this harm depends chiefly on competence, on being a good doctor. Good doctors are careful, they know their craft and try very hard to make the correct diagnoses and perform their procedures with skill. As long as the doctor is diligent, there is a certain fatalism around bad outcomes. This level is embodied by the league of residency program directors and department chairs.<br />
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<b>Level 3- Preventable harm exists on a large scale and requires changes in the systems of care.</b><br />
These were described well in the Institute of Medicine's report "To Err is Human." It detailed the massive scale of health care induced harm (hospital acquired infection, medication error, etc), far exceeding the public and most physicians' worst estimates- over 100,000 preventable deaths a year. It was recognized that medical knowledge and clinical skill had little to do with it, and that the chief drivers or mortality were in the basics-hand hygiene, timeouts before procedures, checklists for surgery. Wide scale harm is a built into the system. Change the system, reduce the harm. And the quality improvement movement was born.<br />
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<b>Level 4- The health care system is so broken and dysfunctional that dramatic action is warranted.</b><br />
This level compares the ideal of health care as a human right that society makes available to all, like education and public safety, to the reality of health care as a deeply unfair, inaccessible and expensive wealth extraction system that serves the revenue streams of multinational pharmaceutical and device companies, large insurers, and sprawling hospital systems and physician organizations. This level seeks major structural changes, such as realigning payment incentives and legislation, to better serve the underserved- the poor, the elderly, the chronically ill. The single payer movement is a prime example of level 4.<br />
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<b>Level 5- The health care system is more harmful than helpful.</b><br />
This radical fringe believes that if all hospitals and doctors' offices were eliminated, society would live better and longer lives. They see harmful corruption and misinformation in almost every facet of health care, from the faulty evidence underlying common treatments and guidelines to the delivery of health care in profit-motivated institutions. When you add up the harm from medicalization of birth and death, overtreatment of most common conditions, and society's lost investment opportunities in education, housing, and public health, coupled with the unmeasurable but devastating crisis of human dignity visited upon more than one million nursing home residents crowded into close quarters, totally dependent on underpaid staff, living out their remaining days immobile in front of a TV, it's at least plausible that these harms outweigh health care's benefit. Proponents of level 5 are mainly found on the books with titles like "We're Doomed."Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0tag:blogger.com,1999:blog-4699839350724327880.post-33678278741029362432015-12-25T22:22:00.002-08:002015-12-25T22:22:34.713-08:00Is Healthcare a Human Right?<br />
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What do we mean when we say that healthcare is a human right?<br />
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The simplest case is that we mean what the United Nations means in the Universal Declaration of Human Rights:asdf<br />
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<span style="background-color: white; color: #333333; font-family: Roboto, 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 13px; line-height: 20.15px;">Article 25 </span><br />
<span style="background-color: white; color: #333333; font-family: Roboto, 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 13px; line-height: 20.15px;">Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.</span><br />
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Critics claim that "just because the UN says it doesn't make it so."<br />
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Fair enough.<br />
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For me, the reason to support the concept of healthcare as a human right requires a simple thought experiment, "What kind of society do I want to live in?"<br />
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More specifically, "How do I want my society to respond to the sick?"<br />
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It's perhaps easiest to begin by describing how I certainly don't want my society to respond. I hope it's a comfortable assumption that I speak for most Americans when I say that allowing the sick to suffer and die, unaided in the street, is abhorrent. Although there are philosophical treatises underlying this position, I think we can save some time and simply agree that callous indifference to the suffering and vulnerable is unacceptable in 2015.<br />
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The real question is not whether or not our society is responsible for the sick and vulnerable, but how responsible is it?<br /><br />
Put another way; it's one thing to say that indifference is unacceptable. It's another thing to compel the citizenry to act on behalf of the vulnerable.<br />
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Fortunately, we already do act, and not out of any compulsion to do so. Anywhere in this country, bystanders routinely call 911 when they witness extremis, summoning the couriers of the emergency medical system to whisk them off to an emergency room replete with all the modern tools of resuscitation. Emergency rooms treat all comers, regardless of their background, their social status, or their ability to pay This is not a small thing, and for those who can sense a righteous tone that may be building in the paragraphs to come, let me say clearly that many wonderful people execute complex care coordination to provide this essential safety net.*<br />
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Emergency services are wonderful, but health requires much more than intervening at the point of desperation. How far should our society go?<br />
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For me, a simple answer is a comparison of our education system. Any child, regardless of the neighborhood they live in, their poverty, or even their beliefs about education, gets to go to school. It is an expectation. Their is a transport system established for those who don't have access. There are support services to help parents navigate the system. There is free lunch for those who need it. The US has provided every child with a right to an education.<br />
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I think we should do the same for health. There should be an expectation that anyone who is ill, regardless of where they live or how impoverished they are, can see a doctor. If they can't get themselves there transportation should be provided. There should be services to aid navigation. Beyond acute illness, patients should have access to preventive care and social supports.<br />
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Almost every other developed nation, and even some that are underdeveloped, has this. The US does not. Unlike other nations, one's access to healthcare depends on their proximity to a clinic (community health centers are closing), on the availability of basic services in that clinic (mental health is notably lacking in primary care), on patients' ability to navigate a complex system (talk to anyone trying to understand their medicare coverage), and last but certainly not least, on the ability to pay for both insurance and out-of-pocket fees.<br />
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Simply put, healthcare is not a right for the poor and marginalized in the US.<br />
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Any discussion of rights necessarily includes a discussion of responsibility. Rights are meaningless without responsibility. The right to life is the responsibility not to kill. More than that, it is the responsibility to set up mechanisms to prevent others from killing through laws and a police force. The right to education is a responsibility not only to not interfere with another's education, but to support students with teachers and infrastructure.<br />
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We all pay taxes to support the criminal justice system and the education system. In fact, if we don't, we can be put in jail. Society compels us to pay through threat of force.<br />
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When we hand out rights, we also hand out coercion, which paradoxically amounts to taking away rights. The right to life takes away my right not to be taxed for law and order. The right to education takes away my right not to pay school taxes.<br />
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Handing out rights is more than a dreamy exercise in imprinting our vision of the world in a high-minded list. It is also handing out obligation and responsibility, collected under threat of jail time. I can understand those who are resistant to the idea of a self-selected group of idealists sitting down at a convention and deciding which obligations the rest of us have.<br />
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So, when I say I want our society to treat healthcare like we treat education, I need to make the case to those who do not want to be saddled with the responsibilities of making this a reality.<br />
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Interestingly, those skeptics often spend a good deal of time extolling the virtues of this nation, its ideals, its strengths, and its standing as a moral force in the world. They trace this virtue back to the founding fathers and the provision of rights as set forth in the Constitution. This society has become what it is, still the envy of much of the world, because of its provision of rights. Human rights serve human dignity, and human dignity is the well-spring of human flourishing.<br />
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Look what happens when we provide our citizens with education?<br />
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We can only gain by doubling down on our commitment to health.<br />
<br />Aaronhttp://www.blogger.com/profile/06754718274193630654noreply@blogger.com0