Pubblicato in: Medicina e Biologia, Sistemi Economici, Stati Uniti

USA. Odontoiatri. Fedeli indicatori della crisi. Il 77% ha ripreso il lavoro.

Giuseppe Sandro Mela.

2020-06-21.

Dentista 013

«We’re not really recovered until all the dentists are back to work»

«Dentist offices tend to be stable businesses that stick around for decades, unlike restaurants that open and close frequently.»

«Dentists earn a healthy salary — a median of $159,000 — and offer services with no clear substitute. If you need your teeth cleaned or a cavity filled, the dentist is the only option.»

«This makes them, in the eyes of some economists, the perfect barometer for gauging the country’s recovery from the shock of the pandemic»

«The dental industry has weathered an exaggerated version of the pandemic’s economic impact, experiencing both a steeper decline and a faster recovery than other sectors»

«Half of all dental workers lost their jobs in March and April as states closed businesses to slow the virus’s spread»

«The industry accounted for a staggering 35 percent of all health care jobs lost in those months, even though its workers make up just 6 percent of the industry, according to analysis of federal data by the nonprofit Altarum Institute.»

«The dental industry halted much of its work on March 16, when the Centers for Disease Control and Prevention and the American Dental Association issued joint guidance against elective care»

«By mid-April, 45 percent of dentists had laid off their entire staffs …. Only 13 percent remained fully open, with the remaining offices keeping a skeleton staff»

«Patient visits fell to 7 percent of normal rates.»

«By early May, 33 percent of dental offices had hired their full staffs back. The number rose to 58 percent by mid-May and, most recently, hit 77 percent the first week of June.»

«The dental industry gained a quarter-million jobs in May, accounting for a full 10 percent of the net jobs added across the American economy.»

«An estimated 37 percent of dental offices received funding through the Paycheck Protection Program, meant to help small businesses keep workers on payroll»

«Even after last month’s job gains, the dental industry still has 289,000 fewer workers than it did before the pandemic»

* * * * * * *

Era talmente ricco da potersi permettere la dentiera.

Il volume di affari dei tecnici odontoiatri e dei dentisti in rapporto alla popolazione costituisce un indice indiretto ma efficace sul reale livello di ricchezza di una nazione.

Tranne casi rari, i vari servizi sanitari non coprono le spese odontoiatriche, ma la sola gestione di uno studio richiede spese non indifferenti, che alla fine si riversano sui pazienti. Né ci si può dimenticare del socio di maggioranza: per il fisco un dentista lavorerebbe trentasei ore al giorno a costi nulli e con onorari da capogiro.

La crisi da coronavirus ha associato la necessità del lockdown a quella economica: sarebbe impossibile andare dal dentista tenendo la mascherina e senza disporre del liquido necessario.

Se all’inizio della pandemia gli odontoiatri hanno subito un severissimo calo del giro lavorativo, la ripresa è stata altrettanto rapida, ed alla prima settimana di giugno il 77% degli studi odontoiatrici aveva già ripreso il lavoro.

Questa ripresa ha comportato la generazione di 250,000 posti di lavoro: ne mancano ancora 289,000 per tornare alla norma, ma la via sembrerebbe essere stata delineata, anche se non tutto gli studi hanno ripreso l’usuale giro di clientela. Sono dati che darebbero ben da sperare.

*


The New York Times. How’s the Economy Doing? Watch the Dentists.

A crucial indicator of whether Americans feel safe returning to normal activities.

If not for coronavirus, you’d expect your local dentist office to be doing just fine.

Dentist offices tend to be stable businesses that stick around for decades, unlike restaurants that open and close frequently. Dentists earn a healthy salary — a median of $159,000 — and offer services with no clear substitute. If you need your teeth cleaned or a cavity filled, the dentist is the only option.

This makes them, in the eyes of some economists, the perfect barometer for gauging the country’s recovery from the shock of the pandemic.

“If you look at your typical dentist office, nothing went wrong with their business model,” said Betsey Stevenson, an economics professor at the University of Michigan. “It’s just coronavirus that happened.”

The dental industry has weathered an exaggerated version of the pandemic’s economic impact, experiencing both a steeper decline and a faster recovery than other sectors. Half of all dental workers lost their jobs in March and April as states closed businesses to slow the virus’s spread. The industry accounted for a staggering 35 percent of all health care jobs lost in those months, even though its workers make up just 6 percent of the industry, according to analysis of federal data by the nonprofit Altarum Institute.

How long it takes those jobs to come back entirely will be a crucial indicator of whether Americans feel safe returning to normal activities, and if they have the economic means to do so.

“I’m obsessed with dentists because, if the only thing we’re doing is putting the economy on pause, and then going back to normal, all of them should be coming back,” Ms. Stevenson said. “We’re not really recovered until all the dentists are back to work.”

The dental industry halted much of its work on March 16, when the Centers for Disease Control and Prevention and the American Dental Association issued joint guidance against elective care. Some dentists say they closed even earlier as protective equipment became in short supply.

By mid-April, 45 percent of dentists had laid off their entire staffs, according to data collected by the dental association. Only 13 percent remained fully open, with the remaining offices keeping a skeleton staff. Patient visits fell to 7 percent of normal rates.

Marko Vujicic, the chief economist at the dental association, expected a slow return of workers into dentist offices. But regular surveys, sent out to 12,000 dental practices every two weeks, showed a relatively fast recovery.

“My initial predictions were we’d have an elevator ride down and an escalator ride up,” he said. “But we’re actually seeing a pretty sharp acceleration of the jobs coming back.”

By early May, 33 percent of dental offices had hired their full staffs back. The number rose to 58 percent by mid-May and, most recently, hit 77 percent the first week of June.

New federal data released last week tells a similar story. The dental industry gained a quarter-million jobs in May, accounting for a full 10 percent of the net jobs added across the American economy.

Federal stimulus programs may have played a key role in bringing dentists back to work. An estimated 37 percent of dental offices received funding through the Paycheck Protection Program, meant to help small businesses keep workers on payroll. Dentist practices that participated in the program were more likely to remain open than those that didn’t.

As dentists head back to work, it’s unclear whether patients will follow. While most states have given dentist offices the go-ahead to reopen, patient volumes remain half of what they were before the pandemic.

That suggests it isn’t just stay-at-home orders that have caused patients to cancel appointments. Some may have lost the dental insurance they used to get at work. Others may fear contracting the virus; they may feel safer putting off preventive care that has already waited months. Or they may question the value of regular cleanings altogether.

Dentists understand why coming into their offices — even with the extra protective equipment they’ve invested in — may not be an appealing proposition.

“You have to have someone right in your face,” said Jason Bastida, who practices primarily in Elmhurst, a neighborhood in Queens that was hard hit by coronavirus. “I get to wear an N95 mask, but you have to make yourself vulnerable by taking your mask off.”

He returned to work last week and has about a quarter of his regular patient volume. He graduated from dental school in 2017, and worries about how he’ll pay off his $330,000 in outstanding student debt if his caseload doesn’t pick up soon.

Even after last month’s job gains, the dental industry still has 289,000 fewer workers than it did before the pandemic. That suggests to Ms. Stevenson, the economist, that the industry — and the rest of the American economy — is far from recovered.

“The fact that dentistry employment is down 30 percent tells us that there is income loss, and there is fear,” she said. “We might not see employment in a retail store get back to the levels it had last year. But we should see dental employment get all the way back to where it was.”

Employment in the dental industry — and the rest of the economy — is likely to remain constrained by other areas of the economy that don’t reopen as quickly. This is especially true for day cares and schools, many of which will not reopen full time in the fall.

Abi Adeyeye, a 31-year-old pediatric dentist in Plano, Tex., was among those who returned to work in May. Over the past five weeks, she has been excited to see patient volume rebound to pre-coronavirus levels.

“Before coronavirus, I had a cancellation rate around 30 percent,” she said. “Now nobody cancels. It seems like people are wanting to get out of the house and need something to do.”

Even with a full patient schedule, her office is not at full employment. She used to have six dental assistants, but only four have come back to work. One was pregnant, and one couldn’t secure child care.

The work of dentistry, at the same time, has only become more challenging. Dr. Adeyeye now wears an N95 respirator mask, a surgical mask, a face shield and a surgical cap.

“The first two weeks I had these massive migraines,” she said. “Not only am I hot, I also can’t breathe.” She’s slowly adjusting to the new dentistry: “My headaches have gone down to once a week.”

Pubblicato in: Demografia, Medicina e Biologia

Germania. Aprile. Mortalità in eccesso anno su anno +8%.

Giuseppe Sandro Mela.

2020-06-06.

2020-06-01-_Destatis morti 013

Destatis, l’Istituto di Statistica tedesco, ha rilasciato la comparazione del numero di decessi avvenuti nell’aprile di questo anno e quelli accaduti nella media di alcuni anni precedenti.

In aprile il numero dei decessi è stato 82,246, ossia 5,942 (8%) casi in più rispetto la media dei quattro anni passati, e questo eccesso corrisponde ai morti accertati per Covid-19.

Mentre in Baviera l’eccesso di mortalità è del +18% e nel Baden-Württemberg del +16%, nel Nordrhein-Westfalen è del solo +5%.

Il surplus di mortalità tedesca è minore rispetto a quello riportato per gli altri paesi europei.

*


Destats ha rilasciato il Report

Mortality figures 8% higher in April 2020 than the average across previous years.

According to provisional results, at least 82,246 people died in Germany in April 2020. The Federal Statistical Office (Destatis) also reports that this was 8% (+5,942 cases) more than the average across the previous four years. The last time that more than 80,000 deaths in Germany were recorded in April was in 1977.

In Week 18 (27 April to 3 May 2020), that is the week for which the most recent mortality figures are available, at least 17,312 people died in Germany. Mortality figures were thus down by 799 cases from the previous week (20 to 26 April); they were roughly 2% above the average across 2016 to 2019. When that week is compared with the same week of each individual year, it turns out that the number of deaths was within a range of 3% above the figure recorded for 2018 and 1% above the figure for 2017. Increased mortality figures have been observed since Week 13 (23 to 29 March). The deviation was largest in Week 15 (6 to 12 April) with 2,316 or 13% more deaths compared with the four-year average.

The total number of deaths from Week 13 to Week 18 was by 7,486 cases higher than the average across the previous four years. In regional terms, this development is mainly due to three Länder. Mortality figures in Bayern were by 2,719 deaths (+18%) above the average of the previous four years, in Baden-Württemberg by 1,958 (+16%) and in Nordrhein-Westfalen by 1,254 (+5%).

Connection with corona pandemic seems likely

These findings about excess mortality, as it is called, correspond with the data on confirmed COVID-19 deaths reported to the Robert Koch Institute (RKI) when the absolute figures are considered. According to RKI information, a total 7,083 people with laboratory confirmed COVID-19 disease died in Weeks 13 to 18. The development over time was roughly parallel, too. Both the deviation of totals from the average and the number of COVID-19 deaths were highest in Week 15. However, this does not mean that all additional deaths counted in death statistics were people who died from COVID-19. Decreases or increases in other causes of death may also have an effect on the total number of deaths. This year’s influenza epidemic, which is a possible influencing factor, is deemed to be over since mid-March. Usually, waves of influenza have an impact on mortality figures until mid-April.

Excess mortality comparatively low in Germany

Excess mortality in Germany is low compared with other European countries. The statistical institute of France, for instance, reports that mortality was up 27% in the period from 1 March to 20 April on a year earlier. The national statistical institute of Italy (Istat) reports that there were even 49% more deaths in March 2020 than in the years 2015 to 2019, on average. The national statistical institutes of Belgium, Great Britain, the Netherlands, Austria, Portugal, Sweden, Switzerland and Spain also record higher mortality figures. In many countries, the peak has been passed, and the extent of excess mortality is decreasing, as in Germany. No unusual changes on the preceding years have been observed in Norway and in the Czech Republic.

The figures provided by these countries are based on national methods and individual time periods. Some data refer to the reporting date, not the actual death date. The proportions of missing data reports differ, too, and depend strongly on how recent the missing data are.

Pubblicato in: Devoluzione socialismo, Medicina e Biologia

Italia. Corte dei Conti. 9,000 medici emigrati in otto anni.

Giuseppe Sandro Mela.

2020-06-04.

Mela con il Coltello tra i Denti. - Copia

La Corte dei Conti ha rilasciato il

Rapporto 2020 sul coordinamento della finanza pubblica [11,025 MB PDF].

È un documento ponderoso, scritto con stile asettico e molto diplomatico, ma risulta essere tranchant.

Ne stralciamo solo due capoversi.

«In termini di numero di medici, il nostro Paese è in cima alle graduatorie europee: operano in Italia 3,9 i medici per 1000 abitanti contro i 4,1 in Germania, i 3,1 in Francia e i 3,7 in Spagna. In Italia, per questa categoria si conferma (anche grazie al blocco del turn-over) un incremento dell’età media del personale: ha più di 55 anni oltre il 50 per cento degli addetti, la quota più elevata in Europa e superiore di oltre 16 punti alla media Ocse; si tratta in prevalenza di medici specialisti.

Diverso il caso del personale infermieristico dove, all’opposto, nel nostro Paese è molto inferiore alla media europea il numero degli operatori laureati e più limitati sono i margini di un loro utilizzo, nonostante il crescente ruolo che questi possono svolgere in un contesto di popolazione sempre più anziana.

Negli ultimi anni, inoltre, i vincoli posti alle assunzioni in sanità, pur se resi necessari dal forte squilibrio dei conti pubblici del settore, hanno aumentato le difficoltà di trovare uno sbocco stabile a fine specializzazione e un trattamento economico adeguato. Ciò è alla base della fuga dal Paese di un rilevante numero di soggetti: negli ultimi 8 anni, secondo i dati Ocse, sono oltre 9.000 i medici formatisi in Italia che sono andati a lavorare all’estero. Regno Unito, Germania, Svizzera e Francia sono i mercati che più degli altri hanno rappresentato una soluzione alle legittime esigenze di occupazione e adeguata retribuzione quando non soddisfatte dal settore privato nazionale. Una condizione che, pur deponendo a favore della qualità del sistema formativo nazionale, rischia di rendere le misure assunte per l’incremento delle specializzazioni poco efficaci, se non accompagnate da un sistema di incentivi che consenta di contrastare efficacemente le distorsioni evidenziate.» [ppgg. 24 – 25]

* * * * * * *

Ne enucleiamo alcune affermazioni.

«ha più di 55 anni oltre il 50 per cento degli addetti, …. superiore di oltre 16 punti alla media Ocse»

«personale infermieristico …. molto inferiore alla media europea»

«i vincoli posti alle assunzioni in sanità …. hanno aumentato le difficoltà di trovare uno sbocco stabile a fine specializzazione e un trattamento economico adeguato»

«negli ultimi 8 anni, secondo i dati Ocse, sono oltre 9.000 i medici formatisi in Italia che sono andati a lavorare all’estero»

Formare un medico richiede dai dieci ai quindi anni di studi. In termini di investimenti ciò significa quasi mezzo milione a carico dello stato ed altrettanti a carico della famiglia, comprendendo anche il mancato lavoro.

I pochi concorsi ospedalieri sono tutto fuorché meritocratici, gli stipendi sono miserabili in confronto allo sforzo fatto e alle responsablità assunte, e, soprattutto, il lavoro dei medici ospedalieri è schiacciato sotto il peso di una avvilente burocrazia.

Del tutto sequenziale che i medici cerchino sbocchi all’estero, Regno Unito, Germania, Svizzera e Francia, ove la figura professionale è rispettata, gli emolumenti sono adeguati e lì la burocrazia è estremamente ridotta.

Si noti infine che, avendo la metà dell’organico più di 55 anni, entro dieci anni la metà degli attuali medici al lavoro sarà andato in pensione. Se non si iniziasse ora ad adeguare il settore, alla fine non ci saranno fisicamente medici da assumere, con tutte le conseguenze del caso.

*


Corte Conti: medici in fuga, in 8 anni 9.000 emigrati all’estero.

Per trovare occupazione e adeguata retribuzione.

 Una vera e propria “fuga” dall’Italia per mancanza di posti e bassi stipendi. E’ quella dei medici italiani, in cerca di fortuna all’estero. Secondo quanto riportato dalla Corte dei Conti nell’ultimo Rapporto sul coordinamento della Finanza pubblica, in base ai dati Ocse negli ultimi 8 anni, sono oltre 9.000 i medici formatisi in Italia che sono andati a lavorare all’estero. Regno Unito, Germania, Svizzera e Francia sono i mercati che più degli altri hanno rappresentato una soluzione “alle legittime esigenze di occupazione e adeguata retribuzione quando non soddisfatte dal settore privato nazionale”.

Una condizione che, sottolineano i magistrati contabili, “pur deponendo a favore della qualità del sistema formativo nazionale, rischia di rendere le misure assunte per l’incremento delle specializzazioni poco efficaci, se non accompagnate da un sistema di incentivi che consenta di contrastare efficacemente le distorsioni evidenziate”. 

La concentrazione delle cure nei grandi ospedali verificatasi negli ultimi anni e il conseguente impoverimento del sistema di assistenza sul territorio, divenuto sempre meno efficace, ha lasciato la popolazione italiana “senza protezioni adeguate” di fronte all’emergenza Covid. E’ quanto scrive ancora la Corte dei Conti in un approfondimento sulla sanità contenuto nell’ultimo Rapporto sul coordinamento della finanza pubblica.

*

Pubblicato in: Medicina e Biologia, Persona Umana, Scienza & Tecnica

Archivio delle mutazioni del genoma umano in 141,456 soggetti. – Nature.

Giuseppe Sandro Mela.

2020-05-30.

2020-05-29__Nature geetic variation 013

«E’ pronto il più grande catalogo delle varianti genetiche umane: basato sull’analisi del Dna di oltre 140.000 persone di tutto il mondo, è come una Stele di Rosetta che aiuterà a interpretare il genoma per scoprire la funzione dei geni, identificando quelli responsabili di malattie che possono essere colpiti con farmaci. Il risultato è pubblicato in sette studi sulle riviste Nature, Nature Communications e Nature Medicine dal consorzio di ricerca internazionale gnomAD (Genome Aggregation Database), guidato dal Broad Institute e dal Massachusetts General Hospital. Anche l’Italia partecipa con il cardiologo Diego Ardissino dell’Azienda Ospedaliero-Universitaria di Parma.

Il catalogo, frutto di otto anni di lavoro, contiene oltre 443.000 varianti che determinano la perdita di funzione del gene e quindi impediscono la produzione della forma corretta della proteina corrispondente. I ricercatori guidati da Konrad Karczewski hanno provato a stabilire se le varianti potessero avere effetti sulla salute, arrivando così a identificare geni particolarmente sensibili che potrebbero essere legati a gravi condizioni come le disabilità intellettive.

Lo studio principale è accompagnato da altri due che arricchiscono il catalogo con ben 433.000 varianti genetiche strutturali, ovvero delezioni, duplicazioni o inversioni d’orientamento dei geni, che sono tra i principali ‘motori’ dell’evoluzione umana oltre che delle malattie.

Le altre ricerche pubblicate dal consorzio mostrano invece come le varianti genetiche che danno perdita di funzione possano essere utilizzate per diagnosticare malattie e per riconoscere nuovi target genetici da colpire con i farmaci. E’ il caso del gene Lrrk2 associato al Parkinson: studiando le sue varianti, i ricercatori hanno capito che il gene può essere colpito con farmaci che ne riducono l’attività senza causare gravi effetti collaterali.» [Fonte]

*

«In this paper and accompanying publications, we present the largest, to our knowledge, catalogue of harmonized variant data from any species so far, incorporating exome or genome sequence data from more than 140,000 humans. The gnomAD dataset of over 270 million variants is publicly available»

«Although the gnomAD dataset is of unprecedented scale, it has important limitations. At this sample size, we remain far from saturating all possible pLoF variants in the human exome»

«Examples such as PCSK9 demonstrate the value of human pLoF variants for identifying and validating targets for therapeutic intervention across a wide range of human diseases»

*

«Each dataset, totalling more than 1.3 and 1.6 petabytes of raw sequencing data»

Peta è il prefisso che indica 1015, ossia un milione di miliardi.

Dire che questo lavoro sia mastodontico sarebbe persino restrittivo.

Decisamente la genetica è una scienza assai complessa.

*


Konrad J. Karczewski, Laurent C. Francioli, […] Daniel G. MacArthur.

The mutational constraint spectrum quantified from variation in 141,456 humans.

Nature volume 581, pages 434–443 (2020).

«Abstract.

Genetic variants that inactivate protein-coding genes are a powerful source of information about the phenotypic consequences of gene disruption: genes that are crucial for the function of an organism will be depleted of such variants in natural populations, whereas non-essential genes will tolerate their accumulation. However, predicted loss-of-function variants are enriched for annotation errors, and tend to be found at extremely low frequencies, so their analysis requires careful variant annotation and very large sample sizes1. Here we describe the aggregation of 125,748 exomes and 15,708 genomes from human sequencing studies into the Genome Aggregation Database (gnomAD). We identify 443,769 high-confidence predicted loss-of-function variants in this cohort after filtering for artefacts caused by sequencing and annotation errors. Using an improved model of human mutation rates, we classify human protein-coding genes along a spectrum that represents tolerance to inactivation, validate this classification using data from model organisms and engineered human cells, and show that it can be used to improve the power of gene discovery for both common and rare diseases.»

«The physiological function of most genes in the human genome remains unknown. In biology, as in many engineering and scientific fields, breaking the individual components of a complex system can provide valuable insight into the structure and behaviour of that system. For the discovery of gene function, a common approach is to introduce disruptive mutations into genes and determine their effects on cellular and physiological phenotypes in mutant organisms or cell lines»

«However, recent exome and genome sequencing projects have revealed a surprisingly high burden of natural pLoF variation in the human population, including stop-gained, essential splice, and frameshift variants, which can serve as natural models for inactivation of human genes»

«Here, we describe the detection of pLoF variants in a cohort of 125,748 individuals with whole-exome sequence data and 15,708 individuals with whole-genome sequence data, as part of the Genome Aggregation Database (gnomAD; https://gnomad.broadinstitute.org), the successor to the Exome Aggregation Consortium (ExAC)»

«We aggregated whole-exome sequencing data from 199,558 individuals and whole-genome sequencing data from 20,314 individuals. These data were obtained primarily from case–control studies of common adult-onset diseases, including cardiovascular disease, type 2 diabetes and psychiatric disorders. Each dataset, totalling more than 1.3 and 1.6 petabytes of raw sequencing data, respectively, was uniformly processed, joint variant calling was performed on each dataset using a standardized BWA-Picard-GATK pipeline»

«Among these individuals, we discovered 17.2 million and 261.9 million variants in the exome and genome datasets, respectively; these variants were filtered using a custom random forest process (Supplementary Information) to 14.9 million and 229.9 million high-quality variants»

«Some LoF variants will result in embryonic lethality in humans in a heterozygous state, whereas others are benign even at homozygosity, with a wide spectrum of effects in between»

«we developed the loss-of-function transcript effect estimator (LOFTEE) package, which applies stringent filtering criteria from first principles (such as removing terminal truncation variants, as well as rescued splice variants, that are predicted to escape nonsense-mediated decay) to pLoF variants annotated by the variant effect predictor»

«Applying LOFTEE v1.0, we discover 443,769 high-confidence pLoF variants, of which 413,097 fall on the canonical transcripts of 16,694 genes. The number of pLoF variants per individual is consistent with previous reports»

«The LOEUF metric can be applied to improve molecular diagnosis and advance our understanding of disease mechanisms. Disease-associated genes, discovered by different technologies over the course of many years across all categories of inheritance and effects, span the entire spectrum of LoF tolerance»

«In an independent cohort of 5,305 individuals with intellectual disability or developmental disorders and 2,179 controls, the rate of pLoF de novo variation in cases is 15-fold higher in genes belonging to the most constrained LOEUF decile, compared with controls»

«Schizophrenia and educational attainment are the most enriched traits (Fig. 5c), consistent with previous observations in associations between rare pLoF variants and these phenotypes»

«In this paper and accompanying publications, we present the largest, to our knowledge, catalogue of harmonized variant data from any species so far, incorporating exome or genome sequence data from more than 140,000 humans. The gnomAD dataset of over 270 million variants is publicly available»

«Although the gnomAD dataset is of unprecedented scale, it has important limitations. At this sample size, we remain far from saturating all possible pLoF variants in the human exome»

«Examples such as PCSK9 demonstrate the value of human pLoF variants for identifying and validating targets for therapeutic intervention across a wide range of human diseases»

Pubblicato in: Medicina e Biologia, Stati Uniti

USA. Covid-19. Negli stati repubblicani il 27% dei contagi ed il 21% dei decessi.

Giuseppe Sandro Mela.

2020-05-27.

2020-05-28__Covid Democratici 001

«The Coronavirus Is Deadliest Where Democrats Live»

«there are starkly different realities for red and blue America right now»

«the losses have been especially acute along its coasts, in its major cities, across the industrial Midwest, and in New York City»

«The devastation, in other words, has been disproportionately felt in blue America, which helps explain why people on opposing sides of a partisan divide that has intensified in the past two decades are thinking about the virus differently»

«Democrats are far more likely to live in counties where the virus has ravaged the community, while Republicans are more likely to live in counties that have been relatively unscathed by the illness, though they are paying an economic price»

«Counties won by President Trump in 2016 have reported just 27 percent of the virus infections and 21 percent of the deaths — even though 45 percent of Americans live in these communities»

«The very real difference in death rates has helped fuel deep disagreement over the dangers of the pandemic and how the country should proceed»

«Why has the virus slammed some parts of the country so much harder than others?»

«Part of the answer is population density.»

«In some parts of red America, cities have been virtually unscathed and the sparsely populated outlying areas have been hardest hit»

«Alabama had experienced 11 deaths per 100,000 residents and New Jersey had lost 122 per 100,000. Both states have had a huge spike in unemployment claims»

«Over all, the infection rate is 1.7 times as high in the most urban areas of the country compared with nearby suburbs, and 2.3 times as high in the suburbs as in exurban and rural areas»

«Some of those outbreaks are hitting subsets of the population that historically have not voted for Republicans. In Iowa, for example, Latinos make up 6 percent of the population but nearly a third of those infected. The population is 4 percent black, but 12 percent of those infected are black.»

«Over all, African-Americans and Latinos have had higher infection and death rates from the virus, and are far more likely to identify as Democrats than as Republicans»

«the underlying data they collect shows less social distancing in counties that supported Mr. Trump than in those that supported Hillary Clinton …. But instead they found that Republicans were more skeptical about the effectiveness of social distancing than Democrats and have been traveling more outside their homes»

* * * * * * *

2020-05-28__Covid Democratici 002

Prendiamo atto dei dati raccolti.

Se la densità della popolazione potrebbe essere una spiegazione ragionevole, vi sarebbero tuttavia molti dati che la contrasterebbero.

Stesso ragionamento per il mantenimento delle distanza di sicurezza.

In conclusione, per il momento almeno dobbiamo accontentarci del fatto di non saper spiegare il fenomeno.

*


The New York Times. The Coronavirus Is Deadliest Where Democrats Live

Beyond perception and ideology, there are starkly different realities for red and blue America right now.

The staggering American death toll from the coronavirus, now approaching 100,000, has touched every part of the country, but the losses have been especially acute along its coasts, in its major cities, across the industrial Midwest, and in New York City.

The devastation, in other words, has been disproportionately felt in blue America, which helps explain why people on opposing sides of a partisan divide that has intensified in the past two decades are thinking about the virus differently. It is not just that Democrats and Republicans disagree on how to reopen businesses, schools and the country as a whole. Beyond perception, beyond ideology, there are starkly different realities for red and blue America right now.

Democrats are far more likely to live in counties where the virus has ravaged the community, while Republicans are more likely to live in counties that have been relatively unscathed by the illness, though they are paying an economic price. Counties won by President Trump in 2016 have reported just 27 percent of the virus infections and 21 percent of the deaths — even though 45 percent of Americans live in these communities, a New York Times analysis has found.

The very real difference in death rates has helped fuel deep disagreement over the dangers of the pandemic and how the country should proceed. Right-wing media, which moved swiftly from downplaying the severity of the crisis to calling it a Democratic plot to bring down the president, has exacerbated the rift. And even as the nation’s top medical experts note the danger of easing restrictions, communities across the country are doing so, creating a patchwork of regulations, often along ideological lines.

Why has the virus slammed some parts of the country so much harder than others? Part of the answer is population density. Nearly a third of Americans live in one of the 100 most densely populated counties in the United States — urban communities and adjacent suburbs — and it is there the virus has taken its greatest toll, with an infection rate three times as high as the rest of the nation and a death rate four times as high.

In a country deeply segregated along racial, religious and economic lines, density also aligns with political divisions: Urban America tilts heavily blue. In the 2016 presidential election, Mr. Trump’s vote share increased as population density fell in almost every state.

But the divide in infections has been exacerbated by the path the virus has taken through the nation, which is not always connected to density. In some parts of red America, cities have been virtually unscathed and the sparsely populated outlying areas have been hardest hit. Researchers have also found links between the virus’s effects and age, race and the weather, and have noted that some of the densest cities globally have not been hit as hard.

If seeing is believing, the infection has simply come to some areas of the country on a far different scale than others. As of Friday, Alabama had experienced 11 deaths per 100,000 residents and New Jersey had lost 122 per 100,000. Both states have had a huge spike in unemployment claims.

Texas, solidly Republican territory and the second most populous state in the nation, had one of the country’s hottest economies before the outbreak. The state’s biggest cities have so far escaped the worst of the damage. More than 200 metro areas in the United States have higher infection rates than both Dallas and Houston, which may explain why Texas residents are particularly frustrated by the shutdown.

“The cure is worse than the disease, no doubt,” said Mark Henry, a Republican who oversees the Galveston County government in southeast Texas. “There are businesses that were shut down that are never going to open again.”

In the country as a whole, outbreaks in conservative rural counties are rising, but not on a scale that would close the gap in the virus’s impact on red and blue counties.

Over all, the infection rate is 1.7 times as high in the most urban areas of the country compared with nearby suburbs, and 2.3 times as high in the suburbs as in exurban and rural areas.

Amid the pandemic, there are densely populated red counties near major cities with high infection rates — Suffolk County in New York, Jefferson Parrish in Louisiana, and Monmouth County in New Jersey, for example.

But those are true outliers.

A recent spate of outbreaks in meat plants, prisons and nursing homes has created hot spots in 245 counties that supported Mr. Trump, double the number at the beginning of the month. Some of those outbreaks are hitting subsets of the population that historically have not voted for Republicans. In Iowa, for example, Latinos make up 6 percent of the population but nearly a third of those infected. The population is 4 percent black, but 12 percent of those infected are black.

Over all, African-Americans and Latinos have had higher infection and death rates from the virus, and are far more likely to identify as Democrats than as Republicans.

Several companies have studied social distancing metrics based on anonymized cellphone location data, including the mobility research firms Unacast and Descartes Labs. While the companies do not break down findings by political party, the underlying data they collect shows less social distancing in counties that supported Mr. Trump than in those that supported Hillary Clinton.

Rural and exurban county residents, who tend to favor Republicans, do have to travel more for essential services and are less likely to have jobs that allow for working from home. Yet even in more densely populated suburban areas, there was less evidence of social distancing in counties that voted for Mr. Trump.

The pandemic has divided the country in ways that have never played out so vividly in a public health crisis. For scholars who study party identity and division in the United States, the reality of the different responses was a surprise.

Matthew Gentzkow, a Stanford University economist who is leading a group of researchers tracking partisanship in the virus response, said his team initially thought that a health crisis would minimize differences — assuming that people who disagree over taxes or guns would agree about a pandemic. But instead they found that Republicans were more skeptical about the effectiveness of social distancing than Democrats and have been traveling more outside their homes.

“We initially saw partisanship and thought maybe by the time we looked at the data it would be gone,” Dr. Gentzkow said. “But it turns out that no, this is pretty serious and what we see is that the gap got bigger and bigger. These are real belief differences that should have us really concerned.”

Public opinion polls do show widespread support for stay-at-home orders, but also indicate that Republicans are less likely to see the virus as a significant threat to their health. Some skepticism around the impact of the pandemic can be traced to a distrust of the government that has grown among conservatives in the last decade, according to Arlie Hochschild, a sociologist at the University of California, Berkeley, and the author of a 2016 book about the American right called “Strangers in Their Own Land.”

“In the absence of trust, you just believe your eyes and the information that you see in your Facebook feed,” she said.

The experience of residents in Texas underscores how much direct evidence of the virus’s toll has shaped how people view the measures taken to mitigate it.

At the onset of the crisis, Gov. Greg Abbott, a Republican, tried to appeal to both sides of the political spectrum, allowing local governments to make their own decisions until Texas became one of the last states to issue stay-at-home orders and one of the first to roll them back last month.

In Hardin County in southeast Texas, where the population is about 57,000, there have been just 125 cases and five deaths. Kent Batman, 60, the county Republican chairman, who has spent his life in the region, said he had heard of only two fatalities, both of which he dismissed as anomalies.

To Mr. Batman, like many other Republicans in East Texas, the health crisis has felt far away, like a big city plague. “We’re not New Orleans, we’re just not like that,” he said.

Interviews with dozens of Republicans in southeast Texas and other parts of the country over the past month found a pervasive it’s-not-coming-for-my-neighborhood attitude, with many seeing themselves as a world apart from the regions that have been overwhelmed by the virus. They are enthusiastic backers of rolling back restrictions not just as a way to spur the economy, but also based on the belief that individuals should make their own decisions about risk. They dismiss factual reports from the news media as exaggerated and trying to incite panic, because the reports don’t align with their own experience.

Toward the end of March, Judy Nichols, 60, began monitoring charts daily to see how many people near her had the virus. She lives in Jefferson County, not far from Beaumont, and serves as the chair of the county Republican Party. After two weeks, she stopped keeping tabs on the numbers as her worry subsided.

Over the past several weeks, Ms. Nichols said, she has felt like the winner of a product lottery. She owns several Papa John’s pizza franchises, and business has increased nearly 80 percent — pizza in a time of anxiety seeming to be one thing many people can agree on. But nearly everyone she knows is struggling to pay the bills.

On the other side of the partisan divide in Texas, Lina Hidalgo, a Democrat and the top elected official in Harris County, which includes Houston, put in place stay-at-home orders before the governor did in March. Last week, she extended her “stay home, work safe” guidelines until June 10.

She is concerned about the economic impact. She just doesn’t see a safe alternative. “When you have a political system, there are going to be attacks,” she said. “But let’s debate the politics when this is over.”

im Meadows, a 60-year-old refrigeration parts repairman in Nederland, Texas, who describes himself as an “extreme conservative,” doesn’t think the economic question can be set aside. He is upset by the unemployment and financial devastation, which is clearer to him than what he called “this invisible plague.”

Through his work he has, however, begun taking orders for plexiglass partitions that many businesses around him want to use. He said he was “pandering to the uninformed.”

Rashell Collins Bridle, a 42-year-old mother of five who also lives in Nederland and makes her living selling items on eBay, said a minister she knew had died after contracting the virus. Even so, she said she and her friends were more focused on freedom than on health.

“I guess other people expect us to set our futures on fire to keep their fear warm,” she said. “I think that’s incredibly selfish — if you’re that fearful, then just stay home.”

For Professor Hochschild, who studies division, sentiments like this in a crisis reinforce what she has seen across the country.

“There is an underlying stoicism that was there before the pandemic that is really getting tapped,” she said. “There’s a notion of snowflake liberals who can’t take it, who are too dainty and fragile and not hearty like us.”

On the first weekend that Texas lifted the stay-at-home orders, Ms. Bridle took her family to a state park on the Gulf of Mexico. She said American flags were flying from many cars and trucks on the road “as if it were the Fourth of July.”

She said that if schools open with hefty restrictions on recess or how far desks must be spaced together, she will instead place her daughter in a Christian home school co-op.

And if there is another stay-at-home order this year?

“We probably won’t stand for that again,” she said. “I myself won’t comply. I will never comply with anything else like this ever. ”

Pubblicato in: Istruzione e Ricerca, Medicina e Biologia

SARS-CoV-2. 50% dei soggetti mai esposti ha risposta immunitaria efficiente. – Cell.

Giuseppe Sandro Mela.

2020-05-23.

Coronavirus

Il lavoro della Grifoni et Al pubblicato su Cell potrebbe spiegare, almeno in parte, le differenti risposte al coronavirus.

Il raffreddore potrebbe dare una preimmunità al Covid-19 a chi non è mai entrato in contatto col virus

«Una parte della popolazione potrebbe presentare una sorta di preimmunità al SARS-CoV-2 anche senza essere mai entrata in contatto con il virus, probabilmente per via dell’immunizzazione generata da altri, più banali, coronavirus, come quello del raffreddore. E’ quanto ipotizzato da uno studio di un team di ricercatori californiani del Center for Infectious Disease and Vaccine Research presso La Jolla Institute for Immunology, pubblicato sulla prestigiosa rivista Cell. Gli scienziati hanno analizzato il sangue di una piccola popolazione di pazienti convalescenti (20 persone) e di soggetti mai esposti al virus (altre 20). Il sangue dei soggetti non esposti al virus era stato raccolto tra il 2015 ed il 2018. Nei soggetti convalescenti, si è avuta la conferma di una ottima risposta immunitaria al virus – in questo caso, i ricercatori si sono concentrati su un tipo di cellule del sistema immune chiamate cellule T, ed hanno trovato che il 100% dei convalescenti esprimeva le cellule T che aiutano le B a fare anticorpi e possedeva anche gli anticorpi contro molte delle proteine di SARS-CoV-2, mentre il 70% aveva cellule T di un altro tipo, che intervengono nella distruzione diretta delle cellule infettate dal virus.

Ma la vera sorpresa è arrivata dal sangue dei soggetti mai esposti al virus. In 11 dei 20 campioni è stata riscontrata risposta immune (mediata da cellule T) a SARS-CoV-2. Quindi, una porzione importante della popolazione californiana è stata esposta a qualche coronavirus precedente, che genera una immunità almeno parziale contro il nuovo – forse i coronavirus del raffreddore (il sangue di quei soggetti conteneva infatti anche anticorpi contro due di questi coronavirus del raffreddore). “Un ottima notizia”, commenta il biologo Enrico Bucci, ricercatore in Biochimica e Biologia molecolare e professore alla Temple University di Philadelphia, che allo studio dedica un commento su facebook.

“I soggetti esposti al virus montano una robusta risposta immune, che permane dopo l’infezione, di tipo T”, sottolinea, e “una parte di soggetti mai esposti al virus è “preimmunizzata”, probabilmente a causa dell’incontro con altri coronavirus comuni. Adesso, però – aggiunge – prima che stappate lo champagne, ecco i limiti di questo studio ed alcune altre considerazioni: il campione è molto piccolo; la percentuale di popolazione che può essere “preimmunizzata” non è quindi necessariamente del 50%, ma potrebbe essere molto più piccola (o più grande); il fatto che esistano soggetti le cui cellule T sono in grado di riconoscere il virus, pur non essendo mai stati esposti ad essi, non vuol dire che quei soggetti non svilupperanno sintomi (anche se magari saranno più deboli, chi può dirlo); potenzialmente, se vi è cross-reattività tra coronavirus, l’epidemiologia su base sierologica va a farsi benedire, perché, oltre a cellule T, vi potrebbero essere anche anticorpi cross-reattivi (il significato dei test cambia, e diventa solo immunologico) lo studio va replicato al più presto (su base anche più ampia)”.»

* * * * * * *

Due le frasi da enfatizzare, con la usuale cautela.

«Nei soggetti convalescenti, si è avuta la conferma di una ottima risposta immunitaria al virus …. ed hanno trovato che il 100% dei convalescenti esprimeva le cellule T che aiutano le B a fare anticorpi e possedeva anche gli anticorpi contro molte delle proteine di SARS-CoV-2, mentre il 70% aveva cellule T di un altro tipo, che intervengono nella distruzione diretta delle cellule infettate dal virus»

«Ma la vera sorpresa è arrivata dal sangue dei soggetti mai esposti al virus. In 11 dei 20 campioni è stata riscontrata risposta immune (mediata da cellule T) a SARS-CoV-2. Quindi, una porzione importante della popolazione californiana è stata esposta a qualche coronavirus precedente, che genera una immunità almeno parziale contro il nuovo»

Come tutti i riscontri scientifici, anche questo necessita di essere corroborato da parte di studi più vasti.

Questo studio aprirebbe due scenari, simultanei.

Nel primo caso, potrebbe facilitare la strada verso un vaccino ragionevolmente efficiente.

Nel secondo caso, “l’epidemiologia su base sierologica va a farsi benedire“.

*

Di conseguenza, nessun facile entusiasmo, ma anche nessun scoramento.

Nota.

Alba Grifoni è da tempo specializzata nello studio delle reazioni crociate. Ne citiamo volentieri una delle sue ultime pubblicazioni.

T Cell Responses Induced by Attenuated Flavivirus Vaccination Are Specific and Show Limited Cross-Reactivity with Other Flavivirus Species.

Journal of Virology. May 4, 2020. https://doi.org/10.1128/JVI.00089-20.

*


Alba Grifoni, Daniela Weiskopf, Sydney I. Ramirez, Davey M. Smith, Shane Crotty, Alessandro Sette et Al.

Targets of T cell responses to SARS-CoV-2 coronavirus in humans with COVID-19 disease and unexposed individuals.

Cell, May 14, 2020 DOI: https://doi.org/10.1016/j.cell.2020.05.015

*

Highlights.

– Measuring immunity to SARS-CoV-2 is key for understanding COVID19 and vaccine development

– Epitope pools detect CD4+ and CD8+ T cells in 100 and 70% of convalescent COVID patients

– T cell responses are focused not only on spike but also on M, N and other ORFs

– T cell reactivity to SARS-CoV-2 epitopes is also detected in non-exposed individuals

Summary.

Understanding adaptive immunity to SARS-CoV-2 is important for vaccine development, interpreting coronavirus disease 2019 (COVID-19) pathogenesis, and calibration of pandemic control measures. Using HLA class I and II predicted peptide ‘megapools’, circulating SARS-CoV-2−specific CD8+ and CD4+ T cells were identified in ∼70% and 100% of COVID-19 convalescent patients, respectively. CD4+ T cell responses to spike, the main target of most vaccine efforts, were robust and correlated with the magnitude of the anti-SARS-CoV-2 IgG and IgA titers. The M, spike and N proteins each accounted for 11-27% of the total CD4+ response, with additional responses commonly targeting nsp3, nsp4, ORF3a and ORF8, among others. For CD8+ T cells, spike and M were recognized, with at least eight SARS-CoV-2 ORFs targeted. Importantly, we detected SARS-CoV-2−reactive CD4+ T cells in ∼40-60% of unexposed individuals, suggesting cross-reactive T cell recognition between circulating ‘common cold’ coronaviruses and SARS-CoV-2.

Pubblicato in: Medicina e Biologia

Liguria. Covid-19. Degli 807 morti 312 erano in Rsa. La Procura indaga.

Giuseppe Sandro Mela.

2020-05-21.

Vincent van Gogh - Vecchio che soffre

«La procura di Genova ha aperto un fascicolo, a carico di ignoti, per epidemia colposa»

«E’ una indagine esplorativa …. Abbiamo notato uno scostamento tra i dati dell’epidemia in sé e i dati dei morti e contagiati in questo mese e mezzo.»

«Bisognerà studiare se ciò è una conseguenza normale della pandemia o se l’anomalia forte è stata accompagnata da comportamenti gravemente imprudenti e imperiti»

«ci sono stati diversi esposti su casi specifici che hanno attirato l’attenzione della Procura»

«Non faremo le pulci alle delibere, ma andremo a vedere se ci sono state gravi scorrettezze e discostamenti dalle linee guida decise che abbiano determinato e aggravato il diffondersi della pandemia»

* * * * * * *

Le Rsa sono strutture concepite per ospitare pazienti non più autosufficienti, hanno una ragionevole sorveglianza infermieristica e medica, ma queste non sono strutture ospedaliere.

ISS. Analisi dei pazienti deceduti per coronavirus. Elaborati 68,801 casi.

« – l’età mediana è 78 anni, donne 82, uomini 78;

– solo 84/6,801 (1.2%) dei pazienti aveva età inferiore ai 50 anni;

– il 50.7% dei pazienti presentava tre o più gravi patologie, il 25.9% due gravi patologie, il 21.3% una grave patologia.»

*

Quando il coronavirus entra in una casa di riposo per anziani trova il suo pabulum perfetto.

Ma anche con il più rigoroso degli isolamenti, almeno il personale deve entrare ed uscire, oltre che, ovviamente, stare vicino agli anziani per accudirli.

Che gli anziani ricoverati nella Rsa non godano buona salute è attestato dai 916 decessi totali in tali strutture, essendo solo un terzo dei decessi ascrivibile al Covid-19.

*


Indagati sei direttori delle Rsa di Genova.

Sei persone risultano indagate nell’ambito dell’inchiesta per epidemia colposa aperta dalla procura di Genova per i morti nelle Rsa della provincia. Si tratta dei direttori sanitari della Residenza Anni Azzurri Sacra Famiglia di Rivarolo, del Centro di riabilitazione, del Don Orione Paverano, della La Camandolina, della Residenza San Camillo e della Residenza Protetta Torriglia a Chiavari.   Questa mattina, i carabinieri del Nas e i militari della guardia di finanza, coordinati dal procuratore aggiunto Francesco Pinto, hanno perquisito le strutture e acquisito materiale informatico e documentale relativo ai ricoveri di persone degenti nelle strutture in cui, nel periodo febbraio – aprile 2020, è stata registrata una mortalità di gran lunga superiore alla media delle annualità precedenti nello stesso arco temporale. L’inchiesta della procura ipotizza il reato di epidemia colposa.

*


Coronavirus, la Procura di Genova apre un’inchiesta per epidemia colposa.

Si tratta di un fascicolo contro ignoti. Il procuratore Cozzi: “Valuteremo eventuali discostamenti dalle linee guida su gestione emergenza”.

La procura di Genova ha aperto un fascicolo, a carico di ignoti, per epidemia colposa. “E’ una indagine esplorativa – spiega il procuratore capo Francesco Cozzi – Abbiamo notato uno scostamento tra i dati dell’epidemia in sé e i dati dei morti e contagiati in questo mese e mezzo. Bisognerà studiare se ciò è una conseguenza normale della pandemia o se l’anomalia forte è stata accompagnata da comportamenti gravemente imprudenti e imperiti”. Oltre all’esposto presentato da Codacons (che “nulla c’entra con l’inchiesta” chiarisce il procuratore a Genova24) ci sono stati diversi esposti su casi specifici che hanno attirato l’attenzione della Procura che da lì è andata a vedere i macro dati su contagi e decessi notando numeri che la hanno convinta della necessità di vederci più chiaro.

Nelle prossime ore verrà nominato un pool di tecnici tra epidemiologi, geriatri, statistici, per studiare il flusso di dati. La procura ha chiesto la documentazione ad Alisa, l’azienda sanitaria della Regione Liguria, sulle linee guida, le procedure adottate, il numero dei contagiati, dei morti.

“Non faremo le pulci alle delibere, ma andremo a vedere se ci sono state gravi scorrettezze e discostamenti dalle linee guida decise che abbiano determinato e aggravato il diffondersi della pandemia. Non è sbagliato trasferire i pazienti dall’ospedale a un’altra struttura: ma bisognerà vedere se, quando il paziente è arrivato, siano state adottate tutte le misure per evitare il contagio con le altre persone presenti nella struttura” dice Cozzi, riferendosi anche ai trasferimenti in Rsa.

Ad occuparsi del fascicolo sarà il gruppo Salute e lavoro già presente in procura e coordinato dal procuratore aggiunto Francesco Pinto. In Liguria, a ieri i morti per coronavirus erano 807. Nelle Rsa i morti sono stati 916, di questi 312 sono stati catalogati come decessi per Covid.

*


tragedia Coronavirus, a Genova muore operatore in una casa di riposo, lavorava al San Camillo

rinforzi Coronavirus, l’rsa Torriglia di Chiavari verso il commissariamento

l’indagine Coronavirus, la Procura di Genova apre un’inchiesta per epidemia colposa

inchiesta Coronavirus, in procura 10 esposti su morti nelle rsa, scattano indagini dei Nas

L’inchiesta Rsa, esposti anonimi in Procura a Genova: “Niente dpi per non spaventare gli anziani ospiti”

Pubblicato in: Medicina e Biologia, Stati Uniti

Covid-19. 88% dei pazienti ventilati muore. – Jama.

Giuseppe Sandro Mela.

2020-05-19.

2020-05-13__Jama 001

Le Tabelle sono riportate in calce.


«Sta accadendo qualcosa di strano nei contagiati dal covid-19 che i medici non riescono a spiegare: nell’ultimo mese un numero crescente di persone, arrivate in ospedale con un livello di ossigeno sotto la soglia di sicurezza, riesce a riprendersi senza bisogno dell’aiuto di ventilatori.»

«Fino a poche settimane fa la scarsa presenza di ossigeno, sotto il 95 per cento, era il primo segnale di un quadro clinico destinato al peggioramento: nel giro di pochi giorni i pazienti sarebbero andati incontro a una grave crisi respiratoria, al danneggiamento degli organi e, infine, alla morte»

«le persone riprendono a respirare senza bisogno di aiuto, al punto che i medici stanno cominciando a pensare a terapie alternative, che non prevedono il ricorso ai preziosi ventilatori.»

«In passato …. partivi dall’idea che senza intubarli, li avresti persi”.»

«Nel Regno Unito il 58,8 per cento di contagiati bisognosi di ventilatori è morto, quasi il doppio rispetto alle vittime per altre patologie respiratorie come la polmonite»

«A New York l’88 per cento dei 320 pazienti sottoposti a ossigenazione meccanica non ce l’ha fatta, mentre tra quelli che non ne hanno avuto bisogno il tasso di mortalità è stato dell’11,7»

*

«A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female).»

«The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%).»

«373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, …. and 553 (21%) died.»

«Older persons, men, and those with preexisting hypertension and/or diabetes were highly prevalent in this case series and the pattern was similar to data reported from China»

«The findings of high mortality rates among ventilated patients are similar to smaller case series reports of critically ill patients in the US»

«Mortality rates are calculated only for patients who were discharged alive or died by the study end point»

* * * * * * *

Questi dati sono simili a quelli previamente riportati dall’Istituto Superiore di Sanità:

ISS. Analisi dei pazienti deceduti per coronavirus. Elaborati 68,801 casi.

* * *

La Tabella 5 è chiara. Dei 320 pazienti messi sotto ventilazione invasiva sono morti 107 pazienti di età compresa tra i 18 – 65 anni e 175 soggetti di età superiore ai 65 anni. Il tasso di mortalità in questo gruppo di pazienti è quindi 100 * (107 + 175) / 320 = 88.1%.

Caratteristiche di questi pazienti sono l’età superiore ai 60 anni, e le comorbidità: ipertensione arteriosa (56.6%), obesità (41.7%) e diabete mellito (33.8%)

* * *

In questi pazienti il panno interstiziale causato dal coronavirus diminuisce la superficie ventilante polmonare ancora capace di scambiare l’ossigeno al punto tale da rendere inefficace la ventilazione forzata.

Questi studi aprono il problema di come selezionare i pazienti da mettere sotto ventilazione assistita.

Nel contempo ripropongono con forza la necessità per tutta la popolazione di tenere sotto controllo l’ipertensione arteriosa, il diabete mellito, e di ritornare sul peso corporeo accettabile.

*


Safiya Richardson, MD, MPH; Jamie S. Hirsch, MD, MA, MSB; Mangala Narasimhan, DO; et al

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.

JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775

«Importance  There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19).

Objective  To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system.

Design, Setting, and Participants  Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates.

Exposures  Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission.

Main Outcomes and Measures  Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected.

Results  A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1).

Conclusions and Relevance  This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.»

«Discussion

To our knowledge, this study represents the first large case series of sequentially hospitalized patients with confirmed COVID-19 in the US. Older persons, men, and those with preexisting hypertension and/or diabetes were highly prevalent in this case series and the pattern was similar to data reported from China. However, mortality rates in this case series were significantly lower, possibly due to differences in thresholds for hospitalization. This study reported mortality rates only for patients with definite outcomes (discharge or death), and longer-term study may find different mortality rates as different segments of the population are infected. The findings of high mortality rates among ventilated patients are similar to smaller case series reports of critically ill patients in the US.

ACEi and ARB medications can significantly increase mRNA expression of cardiac angiotensin-converting enzyme2(ACE2), leading to speculation about the possible adverse, protective, or biphasic effects of treatment with these medications. This is an important concern because these medications are the most prevalent antihypertensive medications among all drug classes. However, this case series design cannot address the complexity of this question, and the results are unadjusted for known confounders, including age, sex, race, ethnicity, socioeconomic status indicators, and comorbidities such as diabetes, chronic kidney disease, and heart failure.

Mortality rates are calculated only for patients who were discharged alive or died by the study end point. This biases our rates toward including more patients who died early in their hospital course. Most patients in this study were still in hospital at the study end point (3066, 53.8%).We expect that as these patients complete their hospital course, reported mortality rates will decline.»


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Pubblicato in: Medicina e Biologia, Unione Europea

Europa. Covis-19. Si direbbero in azione ceppi differenti.

Giuseppe Sandro Mela.

2020-05-16.

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COVID-19 situation update for the EU/EEA and the UK, as of 16 May 2020.

As of 16 May 2020, 1 295 781 cases have been reported in the EU/EEA and the UK: United Kingdom (236 711), Spain (230 183), Italy (223 885), Germany (173 772), France (141 919), Belgium (54 644), Netherlands (43 681), Sweden (29 207), Portugal (28 583), Ireland (23 956), Poland (18 016), Romania (16 437), Austria (16 068), Denmark (10 791), Czechia (8 406), Norway (8 197), Finland (6 228), Luxembourg (3 923), Hungary (3 473), Greece (2 810), Croatia (2 222), Bulgaria (2 138), Iceland (1 802), Estonia (1 766), Lithuania (1 523), Slovakia (1 480), Slovenia (1 465), Latvia (970), Cyprus (910), Malta (532) and Liechtenstein (83).

As of 16 May 2020, 154 590 deaths have been reported in the EU/EEA and the UK: United Kingdom (33 998), Italy (31 610), France (27 529), Spain (27 459), Belgium (8 959), Germany (7 881), Netherlands (5 643), Sweden (3 646), Ireland (1 518), Portugal (1 190), Romania (1 056), Poland (907), Austria (628), Denmark (537), Hungary (448), Czechia (295), Finland (293), Norway (232), Greece (160), Luxembourg (104), Slovenia (103), Bulgaria (102), Croatia (95), Estonia (63), Lithuania (54), Slovakia (27), Latvia (19), Cyprus (17), Iceland (10), Malta (6) and Liechtenstein (1).

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A giudicare dai dati sulla mortalità, potrebbe sembrare essere verosimile che Regno Unito, Spagna ed Italia siano state colpite da un ceppo virale differente da quello riscontrato negli altri paesi a basso tasso di deceduti.

Pubblicato in: Medicina e Biologia

SARS-CoV-2. Individuate 198 mutazioni a livello mondiale.

Giuseppe Sandro Mela.

2020-05-15.

Coronavirus

Lucy van Dorp, Mislav Acman, Damien Richard, Liam P. Shaw, Charlotte E. Ford, Louise Ormond, Christopher J. Owen, Juanita Pang, Cedric C. S. Tan, Florencia A. T. Boshier, Arturo Torres Ortiz and François Balloux.

Emergence of genomic diversity and recurrent mutations in SARS-CoV-2.

Infection, Genetics and Evolution. 5 May 2020

DOI: 10.1016/j.meegid.2020.104351

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«Highlights

– Phylogenetic estimates support that the COVID-2 pandemic started sometimes around 6 October 2019–11 December 2019, which corresponds to the time of the host-jump into humans.

– The diversity of SARS-CoV-2 strains in many countries recapitulates its full global diversity, consistent with multiple introductions of the virus to regions throughout the world seeding local transmission events.

– 198 sites in the SARS-CoV-2 genome appear to have already undergone recurrent, independent mutations based on a large-scale analysis of public genome assemblies.

– Detected recurrent mutations may indicate ongoing adaptation of SARS-CoV-2 to its novel human host.

-Monitoring the build-up and patterns of genetic diversity in SARS-CoV-2 has potential to inform targets for drug and vaccine development.»

«Abstract

SARS-CoV-2 is a SARS-like coronavirus of likely zoonotic origin first identified in December 2019 in Wuhan, the capital of China’s Hubei province. The virus has since spread globally, resulting in the currently ongoing COVID-19 pandemic. The first whole genome sequence was published on January 52,020, and thousands of genomes have been sequenced since this date. This resource allows unprecedented insights into the past demography of SARS-CoV-2 but also monitoring of how the virus is adapting to its novel human host, providing information to direct drug and vaccine design. We curated a dataset of 7666 public genome assemblies and analysed the emergence of genomic diversity over time. Our results are in line with previous estimates and point to all sequences sharing a common ancestor towards the end of 2019, supporting this as the period when SARS-CoV-2 jumped into its human host. Due to extensive transmission, the genetic diversity of the virus in several countries recapitulates a large fraction of its worldwide genetic diversity. We identify regions of the SARS-CoV-2 genome that have remained largely invariant to date, and others that have already accumulated diversity. By focusing on mutations which have emerged independently multiple times (homoplasies), we identify 198 filtered recurrent mutations in the SARS-CoV-2 genome. Nearly 80% of the recurrent mutations produced non-synonymous changes at the protein level, suggesting possible ongoing adaptation of SARS-CoV-2. Three sites in Orf1ab in the regions encoding Nsp6, Nsp11, Nsp13, and one in the Spike protein are characterised by a particularly large number of recurrent mutations (>15 events) which may signpost convergent evolution and are of particular interest in the context of adaptation of SARS-CoV-2 to the human host. We additionally provide an interactive user-friendly web-application to query the alignment of the 7666 SARS-CoV-2 genomes.»

«Results

3.1. Emergence of SARS-CoV-2 genomic diversity over time

The 7666 SARS-CoV-2 genomes offer an excellent geographical and temporal coverage of the COVID-19 pandemic ….

These 198 positions in the SARS-CoV-2 genome alignment (0.67% of all sites) were associated with 290 amino acid changes across all 7666 genomes. Of these amino acid changes, 232 comprised non-synonymous and 58 comprised synonymous mutations.»

«Discussion

Modern drug and vaccine development are largely based on genetic engineering and an understanding of host-pathogen interactions at a molecular level. ….

This unprecedented genomic resource has already provided strong conclusions about the pandemic. For example, analyses by multiple independent groups place the start of the COVID-19 pandemic towards the end of 2019. This rules out any scenario that assumes SARS-CoV-2 may have been in circulation long before it was identified, and hence have already infected large proportions of the population. ….

As most (but not all) pathogens capable of causing epidemic at a pandemic scale, SARS-CoV-2 is in all likelihood of zoonotic origin. ….

The vast majority of mutations observed so far in SARS-CoV-2 circulating in humans are likely neutral (Cagliani et al., 2020; Dearlove et al., 2020) or even deleterious (Nielsen et al., 2020).  ….

While the immune response to SARS-CoV-2 is poorly understood at this point, key roles for CD4 T cells, which activate B cells for antibody production, and cytotoxic CD8 T cells, which kill virus-infected cells, are known to be important in mediating clearance in respiratory viral infections (Kohlmeier and Woodland, 2009). ….

However, given the crucial importance of identifying potential signatures of adaptation in SARS-CoV-2 for guiding ongoing development of vaccines and treatments, we have suggested what we believe to be a plausible approach and initial list in order to facilitate future work and interpretation of the observed patterns.»

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Questo è uno studio squisitamente genetico, che volutamente non entra nelle implicanze cliniche.

Queste sono tuttavia evidenti.

Ogni mutazione genera sue proprie difese immunitarie ed anticorpi specifici. A ciò consegue l’attuale impossibilità di un uso estensivo di trattamenti con plasma di pazienti guariti, che agirebbero solo su di un determinato ceppo: ma al momento ne sono stati identificati 198.

La pluralità delle mutazioni costituisce inoltre un grande ostacolo nella messa a punto di un vaccino che possa agire in tutte le situazioni.