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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Monday, March 14, 2022

Europe is surging again so will the U.S. "wall of immunity" prevent another spring surge.

 As of early March 2022 cases and hospitalization are increasing in several European countries.

Data from Great Britain indicate increases in cases in all age groups and in all parts of the country.See Eric Topol's wonderful twitter feed for detailed data on the European uptick in cases,etc

The hope of many is that in the US the "wall of immunity" is sufficiently robust to prevent further surges.The wall is built on immune protection from vaccines,boosters and infection which, it must be said are known to wane over time. The elderly were a group who received the vaccination and the boosters fairly early so now in England there is a plan for the 4th shot, not so for the US so far.

The US's waves of  alpha,delta,omercron were preceded by waves  in GB and Europe . Maybe now this is different but I struggle to find a reason why. The surges seem to be attributed to some combination of increase in the BA 2 variant,cessation of masking,etc and the waning of immunity all factors seemingly applicable to the US. Actually in one regard GB 's "wall" may be stronger since  90 % of their elderly has been triply vaxed versus 65  % in US.

The much talked about objective of "protect the vulnerable" has largely faded away but the numbers of the vulnerable have not.There are 100 million not vaccinated,seven million with various immunocompromised conditions and millions of kids currently too young for vaccination and the US lags behind Europe in the percent of the elderly who have received the booster shots. What could possibly go wrong?

EKG criteria for differentiation of non-selective His pacing from RV septal capture

 Dr. Marek Jastrzebski has written extensively on the differential diagnosis of  non selective His Bundle pacing (Ns HBP)  versus myocardial only capture.

In Ns HBP  not only is the His bundle captured but also  is a segment of the myocardium in the IV septum.The ORS morphology is influenced by the signal from the captured segment of myocardium  and the electricity traveling along the His Bundle  resulting in  a fusion beat.

His diagnostic algorithm is:

is there QRS notching in lead I v5 or v6 if yes then there is myocardial pacing

If no ,, then ask is the v6RWPT greater than 100 msec if yes then there is myocardial pacing.

However, there are false positives in the use of the notching rule wherein there may be QRS notching in cases of confirmed His Capture. particularly in cases of LBBB. A non corrected intra-hisian conduction defect resulting  in a prolonged HV interval may occasionally result in Lateral lead QRS notching.


1)Jastrzebski M, ECG Pacing criteria for differentiating conduction system pacing from myocardial pacing.Arrhythmia and Electrophysiology Review June 2021 p 172

Friday, March 11, 2022

So how did Federalism work out for you during a pandemic

 By December 2021 almost 800,000 American had died due to Covid 19 and by March 2022 the death toll was approaching one million. The IMHE in a recent Lancet article estimated that by the end of 2021 18 million deaths occurred because of covid.

 The proportion of deaths per capita was not uniform throughout the fifty states with the  proportion of deaths being greater in states that voted for a particular presidential candidate. If there is a causal relationship, what mechanisms could be responsible for such a strange circumstance?

Could it be the some characteristics of voters who favored one particular candidate predisposed them to acquiring and dying from Sars co V 2? Could certain actions of political leaders in some states been such that they lead to more or fewer citizens contracting the disease? Certain risk factors have been linked to greater mortality from covid 19 including obesity,diabetes  and hypertension. Are these and possibly other risk factors found to a greater degree in voters who choose one candidate?

Is it true, as Thom Hartman claims that the Trump administration changed its focus regarding covid mitigation on April 7 2020, when the CDC reported that there were disproportionally more deaths among  black  and brown people and soon after Fox commentators began to downplay the seriousness of covid .

Governors in Texas and Florida have through executive action and by encouraging legislative action limited the ability of businesses to set the terms of their business and to determine with whom they will do business.  This limitation was specifically in regard to so called vaccine passports and requiring their employees to get covid vaccinations. Mask mandates by school districts in those states have been prohibited by either executive order or legislation or both. So much for the venerable old conservative support for the notion expressed by " no shoes,no shirt, no service".Shopkeepers and business men can set the terms regarding who they do business with unless they cross the line and dare to claim they will only serve those who are masked and/or vaccinated for covid.

Of course correlation is not causation and other factors must also  be in play but the vector's direction seems obvious  but the magnitudes are more difficult to determine. 

Advocates of federalism talk about  the states as "Laboratories of democracy" where state governments act as social laboratories  creating and testing policies and legislation in way similar to aspects of the scientific method.What experiments did the red states do and what experiments did the blue states do? What, if anything,was learned?


Thursday, March 10, 2022

The Government's new covid plan 2-Public Health 0

 Gregg Gonsalves writing in The Nation claims that the Biden administration has turned its back on the pandemic and that the perceived public desire for normalcy has lead to an "organized abandonment". 

It is as if the "I've had it with covid" mentality was transformed into a U.S. national policy. 

It would be wonderful if the covid virus would mutate itself into another common cold coronavirus but hope is not usually much of a plan for a respiratory virus than so far had killed almost one million Americans. 

Meanwhile back at the real world covid ranch there are signals that there may be the beginnings of a surge in several countries who have declared masks and other NPI measures are no longer necessary namely  Great Britain, Denmark and more recently Canada.The vulnerables are left with one way masking and so far inadequate supplies of sotrovimab and Paxlavid.The CDC should have emphasized the importance of use of N 95 masks particularly in the context of one way masking since people are no longer admonished to wear masks to protect others.

The apparent nascent recent surge in omicron cases must be due to some combination of increase in the BNA2 variant,cessation of basic mitigation procedures and immunity whether induced by vaccine or disease waning .  

For an amazingly detailed and comprehensive daily update of most things covid you cannot do better than Eric Topol's twitter feed. For detailed  and nuanced discussion of many aspects of covid I highly recommend the writings of Dr. Katelyn Jetilina who writes under the title of "Your Local Epidemiologist"

Wednesday, March 09, 2022

Thoughts on CDC's new low for community spread

 The CDC revised its covid guidelines.  

The new low would have been "substantial spread "according to the old definition new low is 20 times the old low. 

Remember the pro masker's rallying cry "my mask protects you, your mask protects me" and contrast that with the CDC latest package of guidelines that say in part  that mask wearing  is "a personal preference informed by personal level of risk". "Personal preference" and "personal level of risk" sounds more like libertarian or perhaps more accurately faux libertarian thinking than  standard public health which tends to trump personal choice with measurable or at least purported collective good.

I never thought that CDC would make a recommendation so out of resonance with basic health dogma as mask wearing is a " personal preference informed by personal level of risk". This seem little different from the medically ignorance claim that "I harm no one by not wearing a mask" because if covid is spread by aerosol and if there is asymptomatic spread then by not wearing a mask you may well harm others.

 Libertarian thought and fundamental public health recommendations are strange bed fellows. The vulnerable might now well think  that  I need a mask to protect me because not even the CDC is telling people to wear mask to protect me  and the other vulnerables nor to protect the healthy and not so healthy  folks whose jobs put them at high exposures levels by their daily person to person contact.

Beside the elderly who have varying degree of age related diminution in immune responsiveness there are 7 million immunocompromised individuals in the US  and 19 million kids less than five year of age for whom as of March 2022 there is  no available vaccine.

Katherin J. Wu Ph.D. writing in the March 3 2022 on line issue of The Atlantic notes that last week Cook County Illinois was at a high level of transmission  but now according to CDC's redefining of risk levels is at a comfortable low level and masks may be removed. She continued saying that  country wide with the old criteria nearly everyone needed to mask now only 37 % need to.

The new CDC guidelines focus now  more on hospital burden rather than local disease transmission  level to determine what levels of mitigation measures need be implemented even though hospital rates are a lagging indication suggesting that by the time hospitals and filling up the horse is well gone from the barn. 

Somehow by pretending that disease levels are less dangerous by re-defining risk categories we will "control covid rather than covid controlling us" It seems that much of the heavy lifting in that control seems to fall on the elderly and the immunocompromised as others will be wearing masks much less often .

Quoting Dr. Eric Topol " When states and counties proclaim we just need to live with the virus and end all restrictions many people interpret that message [to mean] that the pandemic is over"

My retired epidemiologist friend believes the CDC basically declared the US is now in an endemic phase of covid 19 and by proclamation covid will be considered like the flu and as long as hospitals do not reach some stipulated level of threat of being overwhelmed we will "just live with it". 

It has not gone unnoticed by some pundits that the new covid status is in place  well before the upcoming mid term elections and that the doing away with masks and vaccine mandates might be thought to  deprive reublicans from a major talking point.