Daily Archives: July 23, 2020

A good friend recently invited me to meet his spiritual guide via Zoom. The spiritual guide does energy work, which he claims requires no physical proximity and works based on principles of Christianity and quantum mechanics. After some introduction of his methods, the spiritual guide turned his attention to me, rotating a wooden bar in the air and snapping his fingers against his hand in order to confer on me protection from the novel coronavirus. I could see his living room behind him, and his wife joined from a separate device elsewhere in the apartment.

The procedure was brief, and shortly he pronounced me protected. Is the baby protected, too, Lord? he asked. There was a scant pause and then Amen, he said, the baby, too.

Humiliatingly, I started crying. I could not explain it in that moment, so I allowed my friend to believe that I cried because of the power of being conferred such protection. I exited the Zoom, thanking them both, and snapped my laptop closed.

The fact is I was crying because I know there is no way to guarantee safety for my baby, who, at thirty-seven weeks, rides in my uterus through the hospital daily, while I work as a pediatric hospitalist and the pandemic blossoms here in Texas. Nobody can say to meor to any parent, at this pointwhat exactly will protect the little bodies that pertain to us.

This has always been true, and more pointedly so for some parents than others. To have ever believed one could keep a child safe in this world is a marker of privilege, generally reserved for affluent white parents such as myself. Yet I have never been asked so often or so fruitlessly what specific formula might confer protection on the children: if they have playdates but only with one neighbor, if they go to the park and wash hands afterward, if they start school but in the school everyone wears masks.

I tell parents about the data that supports their hope to safely liberate children from home. Though it was initially reasonable to suspect that SARS-CoV-2 would behave like other respiratory viruses and use children as the little viral culture media which God created them to be, evidence is accumulating that, so far, children are not the primary drivers of this particular pandemic. They absolutely do get sick from it, and many, around one in two hundred in some studies, get so sick that they require I.C.U.-level care. But the most frightening manifestation of SARS-CoV-2 infection in childrenmultisystem inflammatory syndrome in children, or MIS-C, which often lands them in I.C.U.s but rarely seems to kill themremains rare.

I have my own fears about infection, however. So far, the diagnostic criteria for MIS-C require proof of current or recent infection with (or documented exposure to) the novel coronavirus. Most cases seem to be occurring two to four weeks after infection. But the inflammatory sequelae of other viruses, such as measles, herpes, and chicken pox, may occur years after infection. As many as one in twenty children infected with measles will develop pneumonia, and around one in a thousand develop encephalitis: swelling and inflammation of the brain. A much smaller percentage (two in a hundred thousand) will develop subacute sclerosing panencephalitis (S.S.P.E.) generally seven to ten years after measles infection. This slow, inflammatory scarring of the brain is fatal. Just as we do not yet know what, if any, long-term complications may lie in wait for children infected with SARS-CoV-2 in utero, we do not yet know if this virus will carry any super-delayed sequelae of childhood infection.

Sometimes I think that the habit of mind that most clearly separates experienced physicians from faith healers is not scientific rigor but prudence. We physicians have seen enough irremediable suffering to know the limitations of our art. We are acquainted with fortuna, the capricious force of destiny that deals suffering and healing without regard for our efforts. We promise to work through the night for our patients, to explain every step, to be at their sides no matter what. We do not, however, promise safety. Even when I am caring for a baby with a very routine respiratory infection, I do not promise parents that their child will recover. I say, Well help your baby by giving her the extra oxygen, and we will watch her very closely. If we see that shes getting sicker even with the oxygen, then well talk to the I.C.U. doctors about the next steps to keep her safe. I know a lot of science, but I also engage with fortuna and a level of magical thinking that would be more appropriate in a four-year-old; I cant escape the fear that some horror will befall any baby whom I promise an easy recovery.

In the case of the novel coronavirus, prudence tells me that I should be at least as worried about actual measles and S.S.P.E. as I am about theoretical risks of long-term sequelae of SARS-CoV-2. Worldwide, childhood-vaccination rates are declining and measles outbreaks are blossoming amid the coronavirus pandemic. I should also worry about children losing their parents or grandparents, missing meals, and falling behind in school. I should worry about kids whose learning disabilities will go undiagnosed without school screenings, L.G.B.T.Q. teens trapped in unsafe homes, and children traumatized from witnessing domestic violence. When my friends ask me how to keep their kids safe, though, they mean safe from infection. I refer them to the guidelines of the C.D.C.

I get the sense, though, that parents dont want my prudence; they want my blessing. They want to move out into the world under the glimmering umbrella of a pediatrician who has said, Amen, the child is safe.

Early in the pandemic, the number of children admitted to my hospital fell. Kids were staying home and avoiding the usual respiratory viruses that drive hospitalization; when kids did get sick, parents were likely avoiding the hospital for as long as possible.

With fewer sick kids, the service was dominated by trauma. We saw plenty of injuries related to neglect: kids burned from having poured gasoline on fires while unsupervised, or shot from playing with unlocked guns. Then there were the abuse cases: children with brain bleeds from abusive head trauma, or liver lacerations from being pummelled in the abdomen. Although my hospital has not published data on these cases, pediatricians across the country are worried that abuse is on the rise. Educators are often the people who detect early signs of child abuse and neglect; with schools closed and fewer cases of suspected maltreatment being reported, some doctors are seeing more severe trauma among children.

When a child comes in with an injury that could be from abuse, we pediatricians go looking for other injuries. We may do X-rays to look for evidence of old broken bones, or a scan of the head to look for bleeds. We may draw blood to look for evidence that the liver has been injured by blunt trauma. We look for characteristic bruises and patterned scars. Sometimes these investigations reveal a long history of physical abuse. These are the children who keep pediatricians up at night: kids whom we probably saw in the office or in the hospital for a so-called sentinel injuryan early, less serious injury that was caused by abuse but went unrecognized. In one study of infants hospitalized for serious physical abuse, just over twenty-seven per cent had a previous sentinel injury, and nearly forty-two per cent of those were reportedly evaluated by a physician.

Original post:

Three Ways of Looking at Children and the Coronavirus - The New Yorker

Dr. Glenn Lopez administered a standard test for the coronavirus to Daniel Contreras at a mobile clinic in South Los Angeles last week. Though highly accurate, such tests can take days or more to process. Mario Tama/Getty Images hide caption

Dr. Glenn Lopez administered a standard test for the coronavirus to Daniel Contreras at a mobile clinic in South Los Angeles last week. Though highly accurate, such tests can take days or more to process.

Anybody who has waited for hours in line for a coronavirus test, or who has had to wait a week or more for results, knows there has to be a better way. In fact, the next generation of tests will focus on speed.

But what should the Food and Drug Administration do with a rapid test that is comparatively cheap but much less accurate than the tests currently on the market? A test like that is ready to go up for FDA approval, and some scientists argue it could be valuable despite its shortcomings.

At first blush, you wouldn't want a medical test to be pushing out untrustworthy results. And that's certainly the case for a medical diagnosis. But rapid test could be valuable if used to screen large numbers of people for infection repeatedly and frequently.

For example, some of the rapid tests under development don't detect the virus in a person who is in the early or late stages of infection they only catch an infection at its peak. Dr. Michael Mina at the Harvard T.H. Chan School of Public Health says that's OK, under certain circumstances.

"As long as you're using the test on a pretty frequent basis," Mina says, "you will be more likely than not to catch the person on the day they might go out and transmit. And they'll know to stay home."

To be useful, such tests need to be widely available and affordable, he says. "I envision a time when everyone can order a pack of 50 tests for $50 and have those and use them every other day for a couple of months."

When it comes to controlling the epidemic, that could be an appealing alternative to the current laboratory-based system, an overburdened process that has become a serious bottleneck. These days, some people are waiting a week or more for results, and by then they have potentially spread the virus to others.

Highly accurate at-home tests are probably many months away. But Mina argues they could be here sooner if the FDA would not demand that tests for the coronavirus meet really high accuracy standards of 80 percent or better.

A Massachusetts-based startup called E25Bio has developed this sort of rapid test. Founder and Chief Technology Officer Irene Bosch says her firm has field-tested it in hospitals. "What we learned is that the test is able to be very efficient for people who have a lot of virus," she says.

It's nowhere near as good at detecting low levels of virus. But you can have the most sensitive test in the world, she says, and if you only test people once a month, that test, too, will miss a lot of people who are infected. So, her company is focusing on quick, easy and cheap.

"These are very simple strips," she says. "They're [like] miniaturized pregnancy tests. So, you can imagine you can't find anything more simple than this."

The sample for this test would come via a swab of the nose or mouth. Results would be available within 15 minutes, according to the manufacturer. Most important is the price.

"The test has to be affordable. It cannot work if it's not affordable," Bosch says. "Right now it might cost $3 to make it [or] $4 to make it. So affordable will be what it costs."

E25Bio would like to set the price at cost, though for the start-up company to stay in business, Bosch says, the test would need a government subsidy. The company has a local partner that's poised to produce a million of these tests a week, she says, adding that another company in the United Kingdom is poised to produce 8 million tests a day.

E25Bio has asked the governor of Massachusetts to approve the rapid test for sale not for use at home just yet, but in pharmacies and out in the community.

To bring people back to work, or teachers and students back to the classroom safely, "this is the kind of test you need," Bosch says.

The company would like to pair the test with a smartphone app. The app would take a photo of the test result and upload it to a public database. The information would be stripped of personal details and precise location, but if people volunteered to take this step, she says, the public could crowdsource information about the spread of the coronavirus that would be useful to researchers. The information would also be available to public health authorities.

The company is in talks with the FDA about approving this test, even though it would be a departure for the federal agency, which has so far required a higher level of accuracy.

She isn't sure how the FDA is responding to the company's request. "This is a Pandora's box and this like is a black box," she says with a laugh.

In other words, the FDA doesn't want to take an action that backfires, and it also doesn't tend to reveal its thinking as it deliberates. The FDA told NPR that the agency weighs the benefits and risks of all coronavirus tests, but didn't elaborate on its thinking about this novel testing strategy.

"There's always a tradeoff here. There's no free lunch," says Trevor Martin, chief executive officer of the Bay Area biotech startup, Mammoth Biosciences. His company is also making a rapid test, based on the gene-editing technology CRISPR. Though CRISPR is best known for its ability to edit DNA, part of that process involves pinpointing specific sequences. And by targeting the coronavirus' genetic sequence, this approach can be highly accurate, he says.

"Our goal is to have a test that delivers extremely high-quality results with a single test. The same as you would get in a lab, or better," Martin says.

His company's test isn't likely to be on the market until the end of the year, which seems like the distant future, considering the pace of the epidemic. He agrees tests need to be affordable, but he didn't name a price range for the test.

Martin says precision has a place in controlling the epidemic, too. A test that can detect very low levels of virus is more likely to pick up someone with a mild infection, even in the absence of symptoms. And that's "super important if you want to prevent spread," he says.

Other labs are pursuing tests based on CRISPR as well. And two companies have temporary approval by the FDA to sell a rapid test that detects certain proteins antigens from the coronavirus. These antigen tests are less accurate than the standard PCR tests, which detect genetic material from the virus. The average wholesale price for antigen tests is in the $20 range. Such tests are currently in limited supply, and available at hospitals, medical clinics and some doctor's offices.

It's unlikely that there will be one single testing solution for the coronavirus, and the best blend of approaches is still a work in progress.

You can contact NPR Science Correspondent Richard Harris at rharris@npr.org.

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How An At-Home Test For COVID-19 Could Help Control The Pandemic : Shots - Health News - NPR

"Trump's press conference today marks a change in tone and a more disciplined and realistic approach," tweeted Republican strategist Matt Mackowiak. "It will be a good message for the public and he will benefit from it politically. Welcome news."

Um, no.

If there is anything we have learned -- or should have learned -- about Donald Trump over these past five-ish years, it's that that there is no "new" Trump, no version 2.0, no new leaf to turn over. There is just Trump. He has been this same person -- bullying, blaming, convinced of his own brilliance, willing to bend and break facts for his own purposes -- his entire adult life. He may be able to subsume those natural characteristics for a day or even a week. But they will come back out -- sooner rather than later. They always, always do.

We've been down this road before. Like, a lot of times.

Go back to the spring of 2016 when Trump was trying to convince the Republican Party that he could rein in his more base instincts (sand Twitter fingers) and be the sort of presidential nominee they had grown to expect.

"His Tuesday night victory speech at Trump Tower in New York City was brief, relatively subdued, and relatively on-message. The roughly ten-minute speech was a far, far cry from the night in March when he celebrated primary wins by hawking Trump steaks, Trump wine and threw a Trump magazine into the crowd of supporters who had gathered at his lush Mar-a-lago resort in Florida."

Trump then went on a media blitz to sell the new him.

That was more than four years ago.

And yet, when Trump delivered his first address to a bicameral session of Congress in 2017, there was still talk of a new tone.

That was more than three years ago.

"For 30 minutes on Tuesday, President Donald Trump pretended to act like something approximating a normal human in discussing the COVID-19 crisis facing our country. He read some platitudes from a script. He expressed support for basic safety precautions in the face of a contagious virus. While not eliminating them entirely he kept the wishcasting and gaslighting and hyperbolic statements about his self-proclaimed greatness to a minimum."

Yes, that.

And, even within Trump's quasi-presidential performance on Tuesday night, there was evidence that the old Trump -- aka the only Trump -- was lurking right below the surface.

Right.

You can hate that Trump. Or love him. But you cannot reasonably think that there is any other iteration of Trump that is emerging. There is not. Trump is just Trump. Always has been. Always will be.

See the original post:

Don't be fooled: There is no 'new' Trump on coronavirus (or anything else) - CNN

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The cuts come next.

The latest news from the Texas comptroller that the state will have $11.6 billion less to spend in its current budget than lawmakers expected leads straight to a conversation about which programs and services in the state budget are expendable.

That conversation is already underway. The timing is tricky. A lot of the lawmakers wholl make those budget decisions are campaigning for reelection in November. The Legislature will be in session in January just six months from now to revise the current budget and write the next one.

And the budgeteers are working without all of the information theyd like to have.

Despite their efforts, the states forecasting flashlights dont shine very far into the darkness. Comptroller Glenn Hegar, revenue estimator Tom Currah and their crew have the sales, franchise, oil and gas, and other tax results from the last quarter to guide them, but everything else is guesswork. When will the states businesses be fully open and operating? When will the oil and gas industry rebound? How is anyone supposed to know when the pandemic will be effectively controlled? When will schools open, and does that mean parents can return to work?

The Texas economy is never easy to predict. Its worse now.

Hegar built that into his latest projections. Its important to note that this revised estimate carries unprecedented uncertainty, he said in the cover letter to state leaders.

Thats a comptrollers way of saying, Hey, there are so many things we dont know, and these numbers might be crazy. Good luck out there!

Lawmakers knew they were going to be in a financial bind as soon as businesses started closing in the spring. Before most economists were willing to do so, Hegar said the states economy was in a recession. He told lawmakers to expect a midsummer revision to the fiscal forecast with billions cut from his earlier projection. State leaders asked agencies to detail 5% proposed cuts in spending.

The comptrollers new numbers include new estimates of how much money will be available in a state savings account known as the rainy day fund. Its lower than before, at $8.8 billion, but thats enough to cover his newly projected shortfall ($4.6 billion) if lawmakers want to hit that account instead of making cuts. Theyll have to find a way to cover large expected deficits in their Medicaid budget, but they might also be getting more relief/response money from the federal government.

The current budget isnt really the problem.

What comes after the current budget is the hard part. In January, lawmakers will write the 2022-23 budget. Theyll have a little more information about the pandemic, a little more information about the state of the economy, and a great deal of uncertainty about how much money will roll into the state treasury, and when.

Republicans in control of state government for most of the last two decades have written the last nine state budgets. The programs that might be on the block this time have their support. And its safe to say the Democrats dreaming of winning a majority in the Texas House arent eager to cut services, either.

But if the past is the guide, legislators are likely to cut spending. The last big dip in state finance came after the global financial crisis in 2008. Texas legislators put together a two-year budget in 2009 that had considerable support from federal stimulus funds. But the economic troubles lingered after the stimulus, and a projected shortfall of $27 billion in 2011 led to deep budget cuts notably including cuts to public education that affected Texas schools for years.

If big cuts are in order, education and health and human services are the biggest spending categories in the Texas budget.

Most other spending targets, however attractive, arent big enough to cover a hole of the size Hegar has described. And the two big ones are hard to hit.

The legislative session in 2019 might seem like ancient history, but that session was marked by a new state commitment to public school finance. Lawmakers said they would increase the states share of the cost of schools. They increased overall spending. And they did all of that in response to the 2018 elections, when voters focused on support for public education showed enough strength to win the attention of the Republicans in control of state government.

It would be politically risky to cut public education in the session after that, especially with the states top elected officials on their way to a 2022 election cycle. So is cutting funding in health and human services agencies especially the ones at the front of responses to the pandemic and the recession.

But it could happen. Theyll have to cut somewhere.

Disclosure: The Texas Comptroller of Public Accounts has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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Coronavirus in Texas is hitting the state budget now - The Texas Tribune