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Sunday, October 18, 2020

Chadwick Boseman's Wife Files Probate Petition in Absence of a Will | Hollywood Reporter

Knives Out: Family Fighting After a Death An advance directive is not so much for you as it is for your survivors. It's a gift to your family. Without such directives, infighting and long simmering grivences may rear it's ugly head at a time when family cohesion as well as reflection, celebration and memorializing a departed loved one should be the focus. This is more likely to occur with the death of the last surviving parent. The family loses it last surviving patriarch or matriarch and is adrift. There is no longer a mediator and sage of tolerance and compromise for the family unit. Others may try to fill the roll rapidly but this may breed resentment as they may not be perceived by other family members as legitimate nor credible for the role. Issues related to finance, family, and fairness surface. This type of divisiveness if often the last thing that the departed would have wished for the family. Indeed, they may have spent their whole family life mediating and remedying such conflicts and would be disappointed that a life so endeavored was for naught. The advanced directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them. When I inquire of my patients whether they have established advance directives, responses may be along the lines of “not yet,“ or “I’m not ready yet”—responses using the “I” pronoun. The issue may be reframed to that of, “would your family benefit from such directives if something unintended were to occur to you today?” This is not about the creator of the directives. The directive is for the family. Just as one spent one’s life self-sacrificing for the good of the family, these are instruments for the welfare of the family. Advance Directive forms in Texas:
from Rajesh Harrykissoon, MD

Saturday, October 17, 2020

NSSP Supports the COVID-19 Response | CDC

BioSecurity Measures Protecting Americans Since 2003, the Department of Homeland Security (DHS) manages the BioWatch program, the nation's first early warning network of sensors to detect a biological attack. Project BioShield, signed into law in 2004, is part of the strategy to defend against the threat of weapons of mass destruction. Its purpose is to improve the research, development, purchase, and availability of medical countermeasures against biological, chemical, radiological and nuclear attacks. The CDC coordinates and analyzes laboratory testing. The CDC also manages the National Syndromic Surveillance Program (NSSP), which promotes and advances development of a syndromic surveillance for the timely exchange of syndromic data. A syndrome is a set of medical signs and symptoms and collection of diseases that are not correlated with each other and often associated with a particular disease or disorder. Syndromic data are used to improve nationwide situational awareness and enhance responsiveness to hazardous events and disease outbreaks. Another program managed by the CDC is the BioSense Platform. This is a congressionally funded program launched in 2003 to support national emergency preparedness. It is an integrated national public health surveillance system for early detection and rapid assessment of bioterrorism-related events. In 2011, the program's focus was expanded to include situational awareness for all hazards (including outbreaks). The NSSP promotes a community of practice in which participants collaborate to advance the science and practice of syndromic surveillance. This community is made up of NSSP-funded recipients, nonfunded state and local jurisdictions, public health practitioners, CDC programs, other federal agencies, hospitals, health care professionals, and academic institutions that all contribute data to the BioSense Platform. The data provided to your local and state health departments is passed along to the BioSense Platform to be included in the NSSP database. #biosecurity #COVID19
from Rajesh Harrykissoon, MD

Wednesday, October 14, 2020

Your guide to Medicare open enrollment: How to shop, switch, and compare plans

Medicare Open Enrollment Oct 15-Dec 7 Should you choose original Medicare or a Medicare Advantage Plan?
from Rajesh Harrykissoon, MD

Monday, October 12, 2020

The Federal Budget in 2019: An Infographic | Congressional Budget Office

Healthcare Spending in the US Federal Budget Medicare and Medicaid: 29% Social Security: 24% National defense: 15% Income security: 13% Interest on the national debt: 6% Veterans affairs, 5% Social services and education: 3% Transportation: 2% International affairs: 1% Everything else: ~3% Healthcare spending increased with the affordable care act (ACA) by virtue of expansion of Medicaid. The cost of Medicaid is shared by states and by the federal government. A rollback of ACA seeks to discontinue the Medicaid expansion which would stop the federal spending match. Some questions to answer: -Do the most vulnerable in our society deserve healthcare coverage? -How shall we pay for that coverage? -Are we paying for that coverage in the most efficient way? -What are the long-term solutions to move such vulnerable populations out of their current state such that over years/generations, such coverage is no longer necessary? It is said the government is essentially a public insurance company with a large standing army. That being said, the salient question is, “what insurance coverage do we need as a society and how much are we willing to spend for it?“
from Rajesh Harrykissoon, MD

Sunday, October 4, 2020

Antiviral Drug Remdesivir Shows Promise For Treating Coronavirus In NIH Study

Since this initial post, April 30, 2020, the POTUS has been hospitalized and is reportedly receiving remdesivir antiviral therapy. Presumably, he may also be receiving dexamethasone which has also demonstrated outcomes benefit. How many do we have to treat with remdesivir to save one life? (Repost from April 30, 2020) Remdesivir (an anti-viral drug developed for Ebola treatment) demonstrated a 3% reduction in mortality rates (preliminary data, pending peer review, pending reproduction, pending publication from the NIH). That means in order to save one life with this drug we need to treat 33 patients. Or, to phrase it differently, for every 33 patients we treat with remdesivir, 32 will die and 1 will live. This is called the number needed to treat (NNT). The ideal NNT is 1, where everyone improves with treatment and no one improves with control. A higher NNT indicates that treatment is less effective. As a general rule of thumb, an NNT of 5 or under for treating a symptomatic condition is usually considered to be acceptable and in some cases even NNTs below 10. The NNT for remdesivir is 33. In the sickest of the sick, COVID-19 induces sepsis (an overwhelming infection and systemic failure of the body) with the damage largely due to the body's own immune response rather than to the virus itself. We know that with sepsis of other infectious causes, it's not what we do, it's when we do it. For instance, if we administer sepsis therapies within the initial 6 hours of the patient presenting to the ER, the NNT is 6 (we save one life out of every six). If we do the exact same management outside of that 6-hour window, we save no more lives and mortality remains at 20-30%. It's not what we do, it's when we do it. Take oseltamivir, an antiviral used to treat influenza infection. It's only effective if taken within the first 48 hours of symptom onset. Outside of that window, it's not effective and you just have to let the flu run its course. Likewise, it may be a timing issue with COVID-19 sepsis. We have to act sooner rather than later. From the New York City patient cohort of 5,700 COVID-infected patients, we know that the mortality rate for those age 65 and over who are intubated on mechanical ventilation is 97% (JAMA 2020). Since the mortality rate is high for this patient demographic, perhaps we should offer antiviral therapy sooner in the presentation.
from Rajesh Harrykissoon, MD

Friday, October 2, 2020

Coronavirus Vaccine Tracker

Over 40 vaccines in clinical trials. The fastest we've ever brought a vaccine to market was 4 years (a polio vaccine). I don't believe we should put our hopes in a vaccine. Yes, we should work expediently to that goal, but it should not be a distraction from effective things we can do today to stop a pandemic. Simple things like masking up may be equivalent to (or even superior to) a vaccine. After all, we don't need a vaccine to protect us from salmonella every time we handle raw chicken meat. Just wash your hands. Just mask!
from Rajesh Harrykissoon, MD

Tuesday, September 22, 2020

Looming Health Crisis: Long Term Effects from Covid-19 - Ron DePinho

Long-Term Sequelae of Covid-19 We haven't yet engaged in this conversation. I haven't hitherto brought it up on this blog although it has been on my mind for several months now. Our communal perception seems to have been (and perhaps continues to be), "If you got infected and didn't die, you're ok. No harm, no foul." But, is that the case? Now that we are at a death toll of 200,000 in the US with millions of infection survivors, perhaps it's time to talk about the possible outcomes among the survivors. While it may be months to years for us to recognize the sequelae of the SARS-COV2 infection, we know from similar viral illnesses what may be at hand. Post-infection health morbidities include: - Long-term Neuropsychiatric Sequelae like demyelinating and neurodegenerative disorders as well as encephalopathies. - Long-term cardiac damage from myocarditis - Long-term vascular damage from microthrombosis - Long-term pulmonary damage - A predisposition to more severe illness from other diseases. That is one condition "primes" the body to be more susceptible to other diseases. This often takes decades to recognize. Loss of system-wide organ reserve. Every challenge to the body results in a step down in one's organ function reserve (like taking stair steps down). Organ function reserve may be thought of as akin to driving distractedly on a 10-lane highway. You can be absentminded and deviate from your lane without running off the road. Now, imagine as the miles pass, the highway progressively narrows. At a 9-lane highway, still good--you don't appreciate any consequence. So it is for 8-,5-, 4-lanes. But, what happens when you're now on a single-lane highway? Your risk of running off the road and into a ditch with any deviation in course is high, high, high. This is how illness affects the body's reserve. We lose lanes on the highway. We now have millions that have survived this pandemic with fewer lanes. When I see young adults discharged from the hospital with fibrotic lungs, my heart breaks because I know what they have lost even though they feel "normal". They effectively are walking out with the lungs of someone twice as old. And, where will that 20-year-old be when they are 40, 60 years old? What quality of life will they have at 50 living with the lungs of a 70-year-old? Yes, while 95% of us will survive a COVID-19 infection with no to little perceived symptomatic impact, we have indeed "lost lanes" which may manifest later on in our lives. A mask seems a pragmatic balance of safety and economy.
from Rajesh Harrykissoon, MD