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🇨🇾 OFFICIAL: Elena Tsagkrinou will represent Cyprus in Rotterdam
The young star is our first newly-selected artist for Rotterdam 2021!
Ever since it was confirmed that Sandro would not be returning as the Cypriot artists for Eurovision 2021, rumours around CyBC’s selection have been rife. Today, the rumours were finally put to rest, when it was revealed that Elena Tsagkrinou has been selected to represent the island nation in Rotterdam!
Last night, it was announced that the Cypriot representative for Eurovision 2021 would be revealed today! The announcement from CyBC below:
Despite being a ‘fresh face’ for the Greek industry, Elena is signed to PANIK Records, and has hits to her name such as “Paratheisos”, “Amore” and “Loyia”. Notably, we had reported her expression of interest in Eurovision back in July.
About “El Diablo”
As was revealed yesterday, Elena was described as a “a fresh face of the music industry.” It was also hinted that the composer behind her entry was “a very big name” that would create excitement upon announcement.
We now know this was probably referring to Jimmy Joker, who has written songs for Pitbull, JLO, Nicki Minaj and countless other international stars. He is credited alongside Laurel Barker, who wrote three of the entries of Eurovision 2019 (Switzerland, the UK and Germany), and countless national final songs. They are joined on the songwriting team by Thomas Stengård and Oxa.
Although the exact details of the song are unknown, it has been expected for some time that the broadcaster were seeking an up tempo dance track. From the press release, it sounds like the song is about ‘falling in love with a bad boy’…promising!
Back in the summer, it was confirmed by Head of Delegation Evi Papamichael that the man who was meant to be in control of staging and presentation in 2020, Marvin Dietmann, will also be overseeing the 2021 staging. He was of course the stage director of Conchita Wurst’s winning performance for Austria in 2014 with the song “Rise Like A Phoenix”.
From this information, it’s clear that the delegation are vying for a strong result in Rotterdam next year! You can see our reaction to the announcement below:
How do you feel about the news? Are you excited to hear ‘El Diablo’? Let us know! Be sure to stay updated by following @ESCXTRA on Twitter, @escxtra on Instagram and liking our Facebook page for the latest updates! Also, be sure to subscribe to our YouTube channel to see our reactions to the over the coming months.
🇸🇪 Melodifestivalen 2021 running order revealed
 RIK1 (CyBC)
 Panik Records
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No Defense for Jones Day Defense
OP-ED: Jones Day is a storied law firm. But its inability to judge how closely the public is watching, and its tone-deaf response to criticism is a virtual advertisement for those of us who provide strategic communications and reputation management consulting for a living.
By Karen J. Kessler | November 24, 2020
2020 will go down in history for many reasons, not the least is the fraught transition in the White House.
The rise in political activism, the impact of the pandemic and the exploding social justice movement have ignited public pressure for systemic change—and Corporate America has responded by updating mission and core value statements, and heavily promoting them on social media platforms.
The question is, once Human Resources, Communications and C-Suite executives sign off on those changes, will the mission and value statements guide decisions, or are they merely performative?
For those of us in the field of crisis communications, the failure of corporations, nonprofits and others to match words and action has led to a boom market.
Never have more companies been more attuned to how they handle public affairs issues, knowing that failure to live by their high-minded mission and value statements can instantly undermine reputations carefully built over the course of decades. Consumer firms can see markets disappear when a tone-deaf social media post is met with a viral response driven by “cancel culture.”
Now the prominent Jones Day law firm, facing a backlash over their decision to represent President Trump’s false narrative of voter fraud, has become what will be the “counsel cancel” poster child. In a clumsy attempt to address the problem, Jones Day leadership compounded it by breaking fundamental rules of crisis communications.
Authenticity rules.
If you make a decision to take the client, own that decision. The fact that the company was hired by the Pennsylvania GOP allowed it to claim in a statement, “Jones Day is not representing President Trump or the Republican Party.” But does anyone believe that, when challenging the significant voter plurality for Joe Biden in Pennsylvania, Jones Day was representing an interest other than that of the President? To claim otherwise is a failed attempt to create a distinction without a difference.
Blaming the media won’t change the narrative.
Claiming, on the Jones Day website, that “media reports are false, and we expect them to be corrected,” buys Jones Day only scorn. Keep expecting and let us know how that works out.
Know when no one is buying what you are selling.
The legal world and every election authority sought for comment have concluded the lawsuits challenging non-existent voter fraud are frivolous, yet Jones Day persists in referring to them as “important rule-of-law issues.” Even Sarah Palin knew a pig wearing lipstick is still a pig.
Evaluate reputational harm.
What are the barometers? Well start here: the mocking memes, the fake recruiting videos and extensive coverage in legal media, with snide comments from legal scholars, all call into question the firm leadership’s public statement as well as their commitment to the values they now claim to champion.
Know your stakeholders.
Corporate America agonized, in the wake of 2020’s challenges, to draft value statements with the right tone. It is facing mounting pressure to put those values into practice and honor them. For Jones Day, failure to look beyond this payday means its clients will feel compelled to seek representation elsewhere. Partners will be receptive to recruiters seeking to lure them to competitor firms. Talented law school graduates will look elsewhere to enter the field and build their careers.
Jones Day is a storied law firm. But its inability to judge how closely the public is watching, and its tone-deaf response to criticism is a virtual advertisement for those of us who provide strategic communications and reputation management consulting for a living.
Karen J. Kessler is founder and president of Evergreen Partners, a New Jersey-based public relations firm specializing in reputation management, crisis communications and litigation support. Follow Karen on Twitter at @KarenKesslerPR and on LinkedIn at https://www.linkedin.com/in/karen-j-kessler-6982649/ .
By Evergreen PR|December 1st, 2020|Evergreen|Comments Off on No Defense for Jones Day Defense
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River Rules
by Stevie Z. Fischer (Author), Byron Wagner (Narrateur)
Fiction Thrillers English literature American and Canadian literature
River Rules is a small-town environmental suspense novel with a deep heart and powerful conscience. What the housing bubble didn't break in Bridgeville--a small New England community blessed by the Connecticut River--greed, double-dealing, and rapid-fire change just might. Peter Russo, a part-time farmer and full-time rambler with his rescue dog, has a knack for conflict, and a burning desire to protect Bridgeville's land and water from exploitation.
His best buddy, John Tomassi, a local cop, doesn't want to be his babysitter--nor does his brother, Jeff. Peter's ex-lover, Carmen, has no use for him as she doubles-down on her profitable apple orchard. But Rachel, his niece, needs his partnership in a food truck. Peter's trouble with Bridgeville's bureaucracy reunites him with two of his former club baseball players, Marco Torres, now on the wrong side of the law, and Kenny Johnson, a young cop. Peter's helping hand not only gives Marco the chance he needs, but Marco and Kenny find that there's more that connects them than divides them. The food truck is a lifeline to almost everyone except Nancy, Peter's old friend, sinking fast from health issues and the aftermath of date rape.
Nobody's famous and nobody's rich except Brock Saunders, a local bully turned Ponzi-schemer and sexual predator. With Bridgeville life at the mercy of cultural crosswinds and economic forces seemingly beyond control, love, loss, baseball, and the search for truth create a spinning wheel of unexpected alliances, unsung heroes, and treachery.
Spoken Realms
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Skip to content-main content
Fahrenheit Advisors
KidMed
KidMed, an after-hours alternative to busy emergency rooms and other urgent care providers, was opened in 2009 by three area board-certified pediatricians. The founders recognized and responded to the need for an after-hours alternative to busy emergency rooms and other urgent care providers who do not specialize in the care of children. Since opening their first location, they have expanded with three more offices (three in the Richmond area and one in Stafford County). This success is attributed to the fact their unique and innovative dedication to providing medical care after hours to ill and injured children and young adults, newborn through age 21, meets the needs of parents.
Financial & HR Support
When KidMed found themselves in need of finance and accounting support, they turned to Fahrenheit. At the time, their Practice Administrator/Controller left the company and they needed some assistance with monthly financials and on-going financial analysis. They brought Fahrenheit in to perform that work, as well as fractional accounting support and continued analysis of their operations. Fahrenheit provided key metric data to inform the owners of profitability and performance of core business segments. “Fahrenheit came in and went through our books and helped us through some real tough internal issues as well,” said Dr. Jeffrey Bennett, physician and co-founder of KidMed.
“The high-level consultants at Fahrenheit are the part that makes your company special,” said Bennett. “You can get different levels through Fahrenheit. Sometimes you need high level and sometimes you don’t. At first we didn’t think we needed a high-level consultant, but once we realized we did need someone at a higher level, Fahrenheit was able to provide that for us,” said Bennett.
“Once Fahrenheit began working with us, they quickly realized we are more complex and needed someone there on a day-to-day basis. Fahrenheit could have easily stayed there and kept charging us, but instead recognized this need and helped us form a plan and find someone permanent to fill this role,” said Bennett. “We continue to use Fahrenheit with some of our bigger issues, and it’s nice to know they are there if we need them. It brings us peace of mind to know that we have someone we feel comfortable with in the background,” said Bennett. “We have forged a good relationship that we feel we can count on when we have a question that we feel like we can’t handle,” he said.
“We can’t say enough great things about Fahrneheit. They have been awesome, and we trust them with our business,” said Bennett.
Employee Development is Crucial in Uncertain Times
How to Prepare for Record Level Employee Relocation
CEO Roundtable Organization Grows Through COVID
President Signed Stimulus Bill to Aid Small Businesses
Richmond (HQ)
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Closer to Paradise
Caregiver Champion, Coach and Intuitive
Parent & Caregiver Support
Want a sneak peak into Closer to Paradise: A Mother's Journey through Crisis and Healing? Click here for a FREE chapter download!
You are here: Home / Advocacy
“The silence around mental illness can be deafening”
~ Amy White
As a Caregiver, Amy White experienced the raw and real challenges of supporting a loved one through a mental health crisis. During the more than 18 months of treatment, hospitalizations and residential care for her son, Amy learned not only how to navigate the mental health services maze but also experienced the reality of the deep rooted stigma that exists around mental illness. What surprised Amy the most was that with emergency rooms and treatment centers brimming with families, there were very few people openly sharing their stories and experiences.
Recognizing a real need for more open dialog, Amy shares her experience and lessons learned with parents and caregivers through her mental health advocacy services. Whether it’s a one-on-one coaching sessions with a caregiver who is looking for support and guidance related to a mental health crisis or accompanying family members during treatment team and action planning meetings, Amy shares her expertise and lessons learned to support families in need.
Amy is dedicated to shattering the stigma and breaking the silence around mental illness and regularly speaks on mental health and wellness.
Amy is dedicated to shattering the stigma and breaking the silence around mental illness and regularly speaks on mental health and wellness. She has been featured on podcast interviews, news radio and panel discussions and has been highlighted as a guest blogger on numerous Mental Health related blogs and websites.
If you are interested in scheduling a free 30 minute consultation, please contact Amy today
Visit AmyWhite.co for these offerings:
Intuitive Coaching
Intuitive Mediumship
Prescripts Jewelry
Book Sessions
About Amy White
I’m Amy White.
After my teenaged son's mental health crisis, I started offering parent & caregiver support services through my blog as well as coaching and advocacy work.
My goal is to share my story so that others know they are not alone.
Want to have a sneak peak into Closer to Paradise: A Mother's Journey through Crisis and Healing? Get your FREE Chapter Download NOW! Sign Up Here:
Copyright © 2021 · Amy White - FarFromParadise.org
Far From Paradise Coaching and Advocacy Services are Not a Substitute for Medical, Legal or Other Advice
Coaching, Advocacy and the Site are not a substitute for medical, psychological, psychiatric, wellness, therapeutic or other diagnosis, care, counseling, advice, consulting or treatment, or for any medicine. Coaching, Advocacy and this Site are not a substitute for legal, financial, tax, personnel, personal, religious, spiritual or other types of evaluation, counseling, advice or representation. You should independently assess any decisions, actions or inactions resulting from or relating to the Site or a coaching experience based on medical, psychological, psychiatric, legal, religious, personnel, personal, financial, tax or other advice as applicable.
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Maui Sand Burials & the Grand Heist of 30Mil a Year
Community, Farmers, Feature, Government, Information Forward, Legislative, News
Written by Faith Chase January 2018 January 2018
Eight Meetings, Three Deliberations, Sand Moratorium on Friday Agenda Again
excerpted from Sustainable Action Fund for the Environment (SAFE)
In April last year (2017) Maui Mayor Alan Arakawa asked Mike White and the county council to study central Maui sand mining and consider imposing a moratorium. Councilmember Elle Cochran wrote a bill that proposed a temporary halt to the practice while a proper study is conducted and other permanent legislation is written.
The mayor’s letter pointed out that a study the county commissioned in 2006 estimated that there was only a 5-7 year lifespan on sand resources if mining ‘continued at the current rate.’
We should note that about 2.4 million tons of sand per year have been taken from the central valley, mostly done with ‘grading and grubbing’ permits that never mention mining. At closer inspection, one entity—the Mills Group—(Maui Lani Partners, Ameron, and HC&D) was involved in various profitable stages of this grand heist.
How has it been possible to excavate a mountain of sand with so little oversight? The County Department of Public Works only issues the permits, does not inspect to see what happens after that. The understaffed State Historic Preservation Division (SHPD) of the DLNR, doesn’t even have the right to enter a property without authorization from the owner/contractor. The departments don’t seem to communicate with each other. What authority and power, then, does the county have?
As of the end of December, the council’s Infrastructure and Environmental Management Committee (IEM) has held eight meetings and the entire council has deliberated three times in an attempt to write a moratorium bill that deals with the depletion of a natural resource, cultural concerns regarding Hawaiian burials along with threats, pleas, and promises from developers who have been profiting from the mining operations.
Why has it taken so long to make a fairly straightforward decision? With $30 million a year at stake, there are major players who want to keep the game going no matter what.
On Friday, Jan 5th there will be a rally at 8 am at the County Building, 200 High Street. Public testimony will be taken at 9 a.m. on the 8th floor on this matter under both County Communication 18-12 and Bill No. 117.
As always, the Maui Chamber of Commerce favors delay, often finding a different reason every time they testify. There are also complex legal issues along with cultural concerns that move decision makers first one way, then another as they grapple with this issue.
Some issues: what, exactly, constitutes ‘mining?” What land area would be subject to the moratorium? Is six months enough time to complete a study? Should there be exemptions to the moratorium? If so, for whom?
Maui County Cultural Resources Commission Meeting December 7th, 2017:
The Council majority generally supports whatever is good for business, though in this case Mike White first had qualms about the burials and then later wanted to leave the door open for county builders to keep taking sand for their projects. In fairness, Council Chair White may have lost the thread of the discussion as he missed more than half the meetings. (remember as GM at KBH, he is responsible for running the state’s “most Hawaiian hotel.”)
Council member Carroll shows up but rarely speaks up, while Council member Sugimura has perfect attendance but little enthusiasm for environmental projects. She often urges the council to go into executive session, but bill sponsor Cochran blocked those motions so the public could follow proceedings.
Council member Hokama seems to care but almost always votes for corporate concerns and Council member Crivello feels that there should be no exemptions to a “moratorium”.
As Chair of IEM, Elle Cochran had to do the heavy lifting, defending the bill against attacks from the county legal team as well as from Carol Reimann, head of the Dept. of Housing and Human Concerns, who claimed that the moratorium would affect affordable housing! Council member Atay attended all meetings, asked good questions of department heads and spoke in favor of protecting the inland dunes and the need for respect for sacred sites.
Council member King believes that there has been plenty of discussion, enough for the council to vote in favor of the moratorium.
So why has it taken eight months? Where is the leadership? If Mike White were just doing one job, leading the council to make tough decisions, this matter could have been settled months ago. There are other important issues that need addressing—-like affordable housing, traffic, homelessness.
It’s clear that the council lacks direction and focus, key members have spotty attendance and participation and are conflicted by the influence of special interests.
Deferring and delaying doesn’t cut it, and now it seems they have delayed it just long enough for the developers to secure permits to exclude them from the bill. Our sand mountains have been turned into money pits for O‘ahu millionaires.
Burial Council Burials Culutral Resources maui maui county Maui Lani Sand Moratorium
Ka Manaʻo o ka Lā
Sustainable Agriculture Committee December 2017 Newsletter
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Narrative Essay
PPT Homework
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Movie Critique
"A Clean Well-Lighted Place" (Informative Essay Sample)
/ Samples / Informative / A Clean Well Lighted Place
This is a story about an old deaf man who loves drinking and visits a café in town at night. There are two waiters who engage in some dialogue that enables the reader to understand more about the old man. The two waiters are also of different kinds since one does not like staying up late at night while the other stays late at night as he has difficulties getting sleep at night. The waiters get into an argument as the old waiter is willing to let the old man continue drinking but the younger waiter is in a hurry to go home to his wife and into bed.
The Characters and Character Traits
The old deaf man is the main character in the story as the story revolves around him. The two waiters engage in a dialogue about the old man and from their discussion, the reader learns a lot about the old man and also about the others. The old man is a drunken. This can be depicted from the fact that the waiters describe him as a good client and they knew that if he became too drunk, he would go without paying. From the waiters’ dialogue, they said that the old man is drunk every night. He is suicidal; he attempted killing himself using a rope though his son rescued him. He is also desperate as the waiters said that he had no good reason for attempting suicide but he had despaired in life (Shawna). From the story, the old man is stubborn or adamant. When the waiter told him that if he took another brandy he would get drunk, he didn’t leave but instead, he waited for the waiter to bring the brandy. He is also forlorn as he always went to the café alone and sat alone in his table. We can also say that he is unhappy with his life hence the reason he wanted to commit suicide (Shawna).
The old waiter is also a forlorn; he does not like going home early as he has nobody to go to. He also likes to stay late at night at the café and he also walks home alone. He is empathetic; when the younger waiter was unwilling to sell another brandy to the old man, he asked him to let him get what he wanted. When the younger waiter suggested that the old man would be better with a wife, the old waiter tells him that a wife may not do him any good. The old waiter feels that the young/hurried waiter should have left the man stay for an extra hour and drink some more. This shows that he really felt that some more drink would help the old man. He has some inferiority complex. He feels that the hurried waiter was better than him since he claimed that he had everything. The old waited said he had nothing but work whilst the hurried waiter was young and had confidence in addition to work.
The young or the hurried waiter is rude, when he was asked why the old man wanted to kill himself, he asked rudely “how would I know?”; he said an old man is a nasty thing. He is sarcastic, he asked his colleague whether he didn’t mind going home before the usual hour since he knew had difficulties finding sleep.
Narrator uses the person omniscient style as he lets the reader into the thoughts and feelings of the character. It is clear that the old waiter is concerned about the old man and others who want to stay in the café and pubs late at night. The hurried waiter feels that the old man should have killed himself; he also doesn’t like old people and also feels that a wife would be a good remedy to the old man. The narrator uses dialogue; from the conversation of the waiters, we learn that the old man is a drunken, he wanted to commit suicide and that he has a niece who takes care of him. There is also use of biblical illusion, this can be illustrated where the old waiter says the lords’ prayer in a twisted way; “Our nada who art in nada, nada be thy name thy kingdom nada thy will be nada in nada as it is in nada………..” use of monologue; the old waiter continues to talk to himself after he says goodnight to the hurried waiter. (Shawna)
The old waiter is willing to let the old man stay and drink but the hurried waiter is against it. The old waiter does not mind staying late at night and actually that what he likes. On the contrary the hurried waiter wants to go to bed and to his wife. Both the old man and the old waiter are lonely and they want to stay up at night. This conflict is resolved when the old waiter allows to stay longer and drink some more and this is also the climax of the story.
The setting is in a town or in the urban setting. There is a cafe which is clean. There are streets with street lights where the guard and the girl passed. There is a steam coffee machine at the pub where the old waiter went to have a drink after he left work.
The theme of the story is that there lonely people who have despaired in life and they just want to stay up late at night as they have problems getting sleep.
Need more Informative Essay Examples?
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Home Global Politics
Putin, Netanyahu Agree to Discuss Syria and Iran
FeaturedGlobal PoliticsMiddle East
Russian President Vladimir Putin and Israeli Prime Minister Benjamin Netanyahu agreed to hold a bilateral meeting in a telephonic conversation. This was reported by the press secretary of Russian President Vladimir Putin.
“Putin and Netanyahu agreed (in the near future) to hold a meeting and discuss current issues of bilateral relations and exchange views on several international and regional matters. During the conversation, President Vladimir Putin extended greetings to Israeli Prime Minister Benjamin Netanyahu on the new year. The leaders wished each other and the peoples of both the countries all the very best for 2018 and future.
Netanyahu Wishes Iranians Success In Quest For Freedom’
Meanwhile, Israeli Prime Minister Benjamin Netanyahu wished the Iranian protesters “success” in their quest for freedom, in a video released on YouTube. Netanyahu said “Brave Iranians are hitting the streets. They seek freedom. They seek justice. They seek the fundamental liberties that have been denied them for decades. Iran’s brutal government wastes billions of dollars to spread hate,” Netanyahu said in a remark which sounded very similar to what US President Donald Trump earlier said.
Benjamin Netanyahu Slams Europe’s Double Standard
Fire In Mumbai’s Kamala Mills, 14 Dead, 23 Severely Injured
Vladimir Putin Orders Military Withdrawl from Syria
Erdogan Lashes Out at Trump, says U.S Can’t Buy Turkish Support
Indian Origin Politician – Priti Patel Resign for her Secret Meetings with Israeli PM
Barcelona Protesters Demand Release of Jailed Separatist Leaders
Why are Middle East Allies of US “Turkey and Egypt” Bonding with Russia?
Isreali prime minister
Previous articleDemonstrations in Iran Continues for Ignoring Citizens for Syria and Lebanon
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It’s (not) just a game: Football’s evolving culture. Football Collective Conference 2020
2019. The Football Collective Annual Conference at Sheffield
2018. ‘Challenging the Narrative’ – Critical thinking in football at Glasgow
2017. Football, Politics and Popular Culture at Limerick
Reflections and way forward: Football, Politics and Popular Culture, Limerick 2017
2016. Future Football at FC United
Positive future for football research in 2017
‘90-minute patriots’ and contemporary Scottish politics: exploring the nature of unionism, nationalism and political support amongst Scottish football supporters
Daniel Parnell March 13, 2017 March 16, 2017 Development and Society, Europe, Policy and Politics
By Stuart Whigham
The prospect of Scottish independence has remained a salient issue within the domain of Scottish and British politics, despite the failure of the pro-independence Scottish National Party (SNP) to achieve sufficient electoral support for the proposition in the 2014 Scottish independence referendum. Indeed, further succour for advocates of Scottish independence has emerged due to the outcome of the UK-wide referendum on European Union (EU) membership which resulted in a victory for anti-EU ‘Leave’ campaign, despite strong electoral support in Scotland to ‘Remain’ in the EU as evident in the referendum results. The EU referendum result has therefore been portrayed as further evidence of the Scottish ‘democratic deficit’ which has been argued to impact political representation for the Scottish electorate within the UK (Dalle Mulle, 2016; Ichijo, 2009; Leith and Soule, 2011; Mycock, 2012), with the SNP citing the EU referendum outcome as a potential catalyst for a second Scottish independence referendum in the coming years, with the autumn of 2018 having been cited as a possible date for a second referendum.
Given the growing likelihood of a second Scottish independence referendum, this paper will critically discuss the current academic literature on the interconnection between Scottish nationalism and the domain of sport, and particularly, football support. In particular, this paper will explore the contentions of certain authors that the ethno-religious, socioeconomic and political stratification of supporters of certain football clubs such as Celtic and Rangers may be linked to their personal voting dispositions with regards to the prospect of Scottish independence (Armstrong, 2014; Bissett and McKillop, 2014; Bradley, 1997, 2013; Giulianotti, 2007; Kelly, 2007, 2013; Walker, 2014, 2016). These findings will be discussed in light of an ongoing research project which seeks to further explore the interconnection between football club support and political voting in the Scottish context, drawing upon a mixed-methods approach which utilises large-scale polling preference data and follow-up interviews which explore the potential interconnection between football support and political beliefs.
Stuart is a member of The Football Collective, here is his contact details:
Share across your network:
Policy and Politics, Scotalnd, Stuart Whigham
Previous Monitoring and Achieving Compliance with the World Anti-Doping Code: Learning from the Implementation of Other International Agreements
Next Football Broadcasting in the UK: Paywalls and Eyeballs
Published by Daniel Parnell
View all posts by Daniel Parnell
hellsbellskjell says:
Hi, I was going to publicize this piece as I usually do, but this time I was met by a password protection notice at the front door, and the link promising a possibility to join the collective, as it were, ended in a 404. Please advise. Best, /Kjell
> 13 mars 2017 kl. 11:07 skrev The Football Collective : > >
The Football Collective says:
Hi Kjell,
This one of a number of articles that will be released on Thursday this week in line with the PSA Sport Policy and Politics conference hosted by Manchester Metropolitan University, at FC United. Sorry for the delay and thank you for your support.
#FBCGlasgow2018
Development and Society
Disability and Football
Fans and Spectators
Football Development and Peace
Future Football
Healthy Stadia
Mega-events
Refugees and Displacement
Social Media and Fan Experience
Join the collective on Twitter
FBC on Facebook
MARADONA – why the Irish got him, as much as Argentineans
From Altruism to Racism: Football’s Unique Role in Society
Brazil vs England – Social media influencers and football
How to be successful in the German Bundesliga: What the numbers say
New Book – Against the Elements: The Eruption of Icelandic Football
Follow The Football Collective on WordPress.com
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Sustainable Forest Honey Harvesting – Training at Kelay Sub-district in Berau District
Berau regency is famous for its high quality and quantity of wild honey. However, due to increasing forest conversion for plantations and deforestation, concerns are increasing that the honey production will decrease or even disappear in the future. Therefore, on 26-28 November 2012, the Berau District Forest Service together with The Nature Conservancy (TNC), GIZ FORCLIME, the local NGO Nemdoh Nemdung and the community of Kelay Sub-district conducted a training on Sustainable Harvesting of Wild Honey. The event was attended by community representatives from 6 villages located close to West Berau Forest Management Unit, namely Duhung Long, Long Lanuk, Lesan Dayak, Merabu, Panaan and Merapun villages.
GIZ FORCLIME facilitated the training through providing resource persons from West Kalimantan: a trainer in forest honey harvesting from the Pontianak-based NGO KABAN and a wild honey farmer from the Periau Association of Lake Sentarum (APDS). During the training, participants were introduced to a new method for making artificial beehives called tikung which are popular in Lake Sentarum. A Tikung is an artificial honeycomb made of wood and placed on the tree, but not too high, so that harvesting the honey becomes easier than with the natural hives located high up in the trees. Materials for making the artificial hives are easy to get and they are not too difficult to make. In addition to making and installing tikung, participants also obtained knowledge and information on sustainable harvesting, packaging of harvested honey, and marketing wild honey.
With the technology transfer gained through the training in Kelay local communities will be able to make a real breakthrough with the utilisation of this Non-Timber-Forest-Product. For generations they have harvested the wild honey from a height of 40-70 meters with minimum safety devices, consequently, wild honey harvesting has been a very dangerous business for them. Encouraged by the training villagers were now keen to try the new technique hoping that the bees will accept the artificial hives.
After the training, participants developed follow-up plans, such as (1) Making 10-15 tikung to be installed at their respective villages, (2) Establishing honeybee farmer groups to facilitate coordination between villages, (3) Coordinating with the District Forestry Service for obtaining support for further development. The participants also agreed to meet again in February 2013 to evaluate their action plan.
Advancing Village Forest Development in East Kalimantan
Governmental and non-governmental stakeholders active in the development of community-based forest management in East Kalimantan met in Samarinda on 20-21 November 2012 to exchange experiences, coordinate their efforts and to decide on next steps. The Coordination Meeting on Village Forest Development and Workshop on Indicative Mapping of Village Forest Areas was a collaborative effort between the Watershed Management Agency (DAS BP) Berau Mahakam, GIZ FORCLIME and Kawal Borneo Community Foundation (KBCF). The event was attended by 65 representatives from the Province and District Forestry Services in East Kalimantan, Technical Implementation Units (UPT) of the Ministry of Forestry, Non Governmental Organizations (NGOs), and sub-district and community representatives from several villages in East Kalimantan.
Village Forest, as one of several government-sponsored community-based forest management schemes, is still in its early stages of development in East Kalimantan. Up to now there are two villages whose proposals have been verified by the Ministry of Forestry for permission of village forest management. The verified villages are Long Bentuk (East Kutai) with an area of 800 hectares facilitated by the KBCF, and Setulang (Malinau) which covers 5,314 hectares facilitated by GIZ FORCLIME. Additionally, WWF has proposed an area of 52,000 hectares in West Kutai to be allocated for community based forest management activities.
One important issue and challenge for further progress raised during the Village Forest Coordination Meeting is the local governments’ limited support in developing conducive policies. In addition, limited availability of facilitators is also a main problem in the forest village development processes. Prof. Dr. Ir. San Afri Awang, Special Adviser on Inter-institutional relations to the Minister of Forestry, and Dr. Ir. Haryadi Himawan, Director of Social Forestry of the Ministry of Forestry, made a commitment to carry out a roadshow in East Kalimantan districts to encourage the local governments to provide their support to Village Forest development.
During the second day, the workshop focused on sharing experiences among villagers related to processes of village forest development and district-wide mapping of indicative areas for village forest development. GIZ FORCLIME has supported the District Forestry Services in developing indicative maps for village forest allocation area in Malinau and Kapuas Hulu districts. The resource person from the Directorate General of Forestry Planning of the Ministry of Forestry strongly supported the District Forestry Services’ and FORCLIME’s efforts in preparing the draft indicative maps and considered that the developed maps met with the standards. The indicative village forest allocation maps of Malinau and Kapuas Hulu districts will be finalized by the District Forestry Services and proposed to the Ministry of Forestry for approval. With these maps legalised a big step forward in developing community based forest management in East Kalimantan will be achieved.
Mono Cable Winch and Emission Reduction in the Forestry Sector
The Ministry of Forestry together with FORCLIME held a Focus Group Discussion (FGD) on "Refining a Guideline for the use of the Mono Cable Winch (MCW)” on 14 November 2012. The purpose of the discussion was to finalize the MCW guideline, to increase understanding of the Mono Cable Winch harvesting system, to integrate the use of MCW into forestry policy and increase the ministry’s awareness of the need for a policy on the implementation of MCW as well as to explore ways of making the policy attractive to be implemented.
Dr. Yosep Ruslim from Mulawarman University gave a presentation on “Understanding the Harvesting System using Monocable Winch, its policy and relation to emissions reduction”. The FGD was attended by 23 technical staff from the Ministry of Forestry, The Nature Conservancy (TNC), GIZ-FORCLIME, the forest concession holders association (Asosiasi Pengusaha Hutan Indonesia – APHI) and representatives from forest concessionaires that already have some experience with MCW.
The presenter explained that MCW is one of the tools for Reduced Impact Logging (RIL) since it reduces negative impacts of log skidding. The use of MCW can contribute to reducing carbon emissions, because forest degradation will be reduced and less fossil fuel is used per cubic metre of timber removed. The equipment can be produced domestically with a relatively low price (around Rp. 50 million). Participants discussed ways in which MCW should be promoted in natural forest concessions as part of the overall silvicultural system and improved forest harvesting planning.
The challenges encountered in the application of these tools are that the operators are not accustomed to using the tools and that MCW equipment in the field is often associated with illegal logging.
The FGD participants agreed that a decree at the level of the Director General would be issued as a legal basis and regulatory support. Participants proposed to explore incentives for the use of MCW such as fiscal policy incentives or a price premium reward. Finally, the FGD also reached a decision to review Reduced Impact Logging (RIL) comprehensively in the future.
German Embassy Counsellor visits FORCLIME Programme sites with group of Jakarta-based journalists
Minister of Forestry visits Germany
Initiating an "Expert Pool" to help with FMU development
FMU Info and Media Center launched
FORCLIME supports the development of REDD+ Safeguards Information System
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Shire of DardanupPopulation forecast
Nat'l Demographic Indicators
Nat'l Economic Indicators
Shire of Dardanup
The 2021 population forecast for the Shire of Dardanup is 14,969, and is forecast to grow to 24,097 by 2041.
Current area:
Burekup and District
Dardanup - Picton East and Surrounds
Eaton (East)
Eaton (West)
The Shire of Dardanup is located in the South West Region of Western Australia, about 180km south of Perth. The Shire is bounded by the Shire of Harvey to the north, the Shire of Collie to the east, the Shire of Donnybrook-Balingup to the south, and the City of Bunbury and Shire of Capel to the west.
forecast.id
Change 2021-41
Shire of Dardanup Burekup and District Dardanup - Picton East and Surrounds Eaton (East) Eaton (West) Millbridge Wanju
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Powered by .id - the population experts for Shire of Dardanup
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The copyright in the way .id has modified, transformed or reconfigured the Stats NZ Data as published on this website remains the property of .id. Stats NZ Data can be accessed on the Statistics New Zealand website at www.stats.govt.nz. Unless otherwise specified, content that Stats NZ produce is licensed under the Creative Commons Attribution 4.0 International licence. For further information see https://www.stats.govt.nz/about-us/copyright/.
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West Ham prioritise Rondon
Date: 19th May 2019 at 4:30pm
Whatever happens this summer, it is safe to assume that it will be a busy one for West Ham.
The Hammers have a lot of deadwood in their squad that needs to be cleared out for both footballing and financial reasons, and the sooner that can be done, the sooner that the club can start looking at viable replacements to help them kick on and realise their dream of European football.
One department that is definitely due for a reshuffle is the Irons’ frontline.
Between Javier Hernandez, Andy Carroll, and Lucas Perez, the Hammers were rewarded with just 15 goals in all competitions from their three out and out striking options.
Marko Arnautovic hit 11, but his form and attitude has fluctuated so wildly that he has been entirely unreliable since January.
As such, a new striker is needed – a striker who will perform week in, week out, and who will net a comfortable 15 goals a season by himself.
According to Football.London, the Hammers believe that man could be Salomon Rondon.
The 72 cap Venezuelan ace has been fantastic for Newcastle this season, hitting 12 goals in a side that isn’t always the most creative, and it is easy to see why the Irons are keen on him.
His loan spell on Tyneside is coming to an end, and as reported by Chronicle journalist Lee Ryder, West Brom have set the price of a permanent move at £16.5 million.
Salomon Rondon’s release clause set at £16.5million after West Brom remain in Championship. #nufc
— Lee Ryder (@lee_ryder) May 14, 2019
That’s a lot cheaper than the reported £40 million release clause written into the contract of Celta Vigo target Maxi Gomez, and it is easy to see why the Hammers have reportedly put Rondon ahead of him on their wish list.
He has proven Premier League quality, comes at a decent price, and looks a lot more promising than their current arsenal of misfiring flops.
It’s an absolute no brainer.
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Work Package Breakdown
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The FORMOBILE project is funded by the European Commission’s Horizon 2020 programme under the Grand Agreement No. 832800.
The FORMOBILE Portal is a secure place where information, which has been deemed too sensitive for the general public, is being stored. The use of the Portal enables you to engage with the FORMOBILE community, access information relating to the upcoming Training and Webinars you can join and access the documentation and information about relevant standards in digital forensics.
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We collect your name, e-mail address, company/organisation, position and country when you register to the FORMOBILE Portal. Certain fields are mandatory and needed by us to carry out the registration process. Such information must be provided in order for us to create an account for you. The processing of your IP address and log files is also necessary in order for you to use the services available on the platform. However, not all fields in your profile need to be mandatorily completed so you can finalise your registration. The fields that are not marked with an asterisk (*), allowing you to decide whether you would like to enter the respective piece of information or not.
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So, who wants to help Sword unlock goodies for Mass Effect 3? (requires facebook)
Anyone interested in helping me unlock Mulitplayer items in Mass Effect 3? I need you to like the Mass Effect 2 page on facebook and then freind me. After that I send you a request, all you have to do after that is play the Mass Effect 3 demo and link your origin account to facebook. If...
DiebytheSword
Pre-order Mass Effect 3, and get a free copy of Battlefield 3.
http://store.origin.com/store/ea/en_US/html/pbPage.me3?easid=Origin-ME3_Web_Hero_PreOrderNow&ClickID=cqflnp74iqaizxwv7vnis7xs44enfkxapnka&ClickID=cxpwixiq7kvszlzvvi7vaqwsezixk4as7nka
Mass Effect 3 and how your Shep prepared to meet the Reapers.
So, I've been frequenting BSN, and see miles and miles of lovely debate on the pros and cons of doing things certain ways. I'm curious how you, ESFer, have prepared to meet the Reaper threat for ME3. As a full disclosure, I have the entire leaked game script as of early to mid fall, and...
Mass Effect 3 co-op mode, who's gonna help me help Shep? *SPOILERS*
http://kotaku.com/5848484/mass-effect-3s-co+op-multiplayer-fully-detailed-by-bioware This is going to be sweet. I had the game pre-ordered before the news dropped, but I'm definately going to rock the co-op to The Reapers will know fear. I'll be rocking ME3 on the PC.
MASS EFFECT 333333333333333! (Dedicated to: Damaera)
This game was made for a man who was banned for our sins. http://www.youtube.com/watch?v=ALXXRwo-J6g LETS GOOO!
Deathshot
Mass Effect: The Animation
http://geek-news.mtv.com/2011/04/07/funimation-and-bioware-to-make-anime-of-mass-effect/ Let the **** storm begin from ME fans who hate anime, and anime fans who hate animes based off video games. I thought they would have learned after Halo tanked as an anime, and Dead Space just barely...
Forum: Anime and Manga
Elder Scrolls V? **** that ****, this is even better. (Mass Effect 3)
..............MASS EFFECT THREE DEBUT TRAILERRRRRRRRRRRRRRRRRRRRRRRRRRRRR http://www.youtube.com/watch?v=9WcQvjTcxY0
Damaera
Playing Mass Effect 2(Spoilers included)
So yeah, playing it. Really annoyed how they used the Dues Ex Machina cop out for Shepard. "Oh yes, he DOES die, like in the trailer...but because of advancements in Tech, he can now be revived, not cloned, or a cyborg, but actually him...despite the doctors claiming that all that was left of...
*Sigh* This is why I didn't want EA to touch Mass Effect
http://kotaku.com/5145813/mass-effect-2-coming-in-2010-will-be-multiplatform Sigh. I really hope they meant 360 and PC, because seriously, in my opinion Mass Effect belongs on those two "consoles".
Finally! Mass Effect 2 makes its first appearance in March!
http://kotaku.com/5126650/mass-effect-2-makes-a-guest-appearance-at-gdc This is fantastic, I can't wait.
Mass Effect Movie Optioned
http://kotaku.com/5051994/mass-effect-movie-optioned
Mass Effect 2 + PC Version
Who's getting these? PC version comes out next week, for those who don't have a 360, ME is an AMAZING game. Who's getting the sequel, as well?
The new "kotor" will be released on the PC, I have no idea when. But, get it.
Fox News: Mass Effect is sick and wrong
http://www.youtube.com/watch?v=PKzF173GqTU Its great how they get their "facts" about the game so wrong, but when did facts get in the way of a good story on Fox? Kudos to the guy for defending it as best he could in the few seconds they gave him.
my mass effect re....... DISC UNREADIBLE...... ****
just barely 4 hours into mass effect, i get a "disc is unreadable" error. i noticed it was spinning the disc alot more than most games, and was having more and more trouble loading the normal maps on time, but i just figured the cache was getting clogged up as it did on oblivion. and wouldnt...
Nuttzy
Mass Effect To Ship This November
August 30, 2007 - Today, Microsoft Game Studios and BioWare Corp. announced that the highly anticipated action role-playing game (RPG) "Mass Effect" will ship to retailers throughout North America on November 20, 2007. The recipient of more than 50 awards, including the 2007 Game Critics Awards...
Mass Mail Hoax of Dec 30
Dear ESF Fan Base, This is Cucumba, speaking on behalf of the ESF Forum staff. You have recieved an email, which was created by the coding minions, who were responsible for maliciously attacking our site, defacing both it and the forums. During this raid, or perhaps on a seperate security...
Mass Ball
I say instead when many people want to beam struggle, like in this picture right there... I think that the energy beams should all collect in this giant ball of beam in the middle, and the 2 sides push it back and forth. The more people helping out on either side, the bigger the ball. Here...
DOOM 3 PREORDER AVAILABLE: "guaranteed on 3/15" at EB in Boston, Mass.
Well...the subject says it all...EB has a preorder avaialble that comes with a *****in' figurine of one of the original doom monsters...it said, "Guaranteed on 3/15" on the box...so... ...looks like Doom3 made the first move. Let's see Valve's followup. Probably be earlier, no?
SaiyanPrideXIX
My First Web Attempt
Like the title says... its still WIP (specially tha main banner) , im also thinking of getting rid of dose affects on d side's but tell me wot joo fink... http://www.modded.net/~ef/forums/attachment.php?s=&postid=5276
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Pro Sports Daily HQ
Explosive New FBI Texts Detail Internal Furor Over Handling Of ‘Crossfire Hurricane’
Thread: Explosive New FBI Texts Detail Internal Furor Over Handling Of ‘Crossfire Hurricane’
SpecialFNK
I like cookies
https://thefederalist.com/2020/09/24...investigation/
‘Trump Was Right’: Explosive New FBI Texts Detail Internal Furor Over Handling Of ‘Crossfire Hurricane’ Investigation
Federal Bureau of Investigation (FBI) agents tasked by fired former Director James Comey to take down Donald Trump during and after the 2016 election were so concerned about the agency’s potentially illegal behavior that they purchased liability insurance to protect themselves less than two weeks before Trump was inaugurated president, previously hidden FBI text messages show. The explosive new communications and internal FBI notes were disclosed in federal court filings today from Sidney Powell, the attorney who heads Michael Flynn’s legal defense team.
“[W]e all went and purchased professional liability insurance,” one agent texted on Jan. 10, 2017, the same day CNN leaked details that then-President-elect Trump had been briefed by Comey about the bogus Christopher Steele dossier. That briefing of Trump was used as a pretext to legitimize the debunked dossier, which was funded by the Democratic National Committee and the Clinton campaign and compiled by a foreign intelligence officer who was working for a sanctioned Russian oligarch.
“Holy crap,” an agent responded. “All the analysts too?”
“Yep,” the first agent said. “All the folks at the Agency as well.”
“[C]an I ask who are the most likely litigators?” an agent responded. “[A]s far as potentially suing y’all[?]”
“[H]aha, who knows….I think [t]he concern when we got it was that there was a big leak at DOJ and the NYT among others was going to do a piece,” the first agent said.
The new disclosures made by DOJ also show that the FBI used so-called national security letters (NSLs) to spy on Flynn’s finances. Unlike traditional subpoenas, which require judicial review and approval before authorities can seize an innocent person’s property and information, NSLs are never independently reviewed by courts. One of the agents noted in a text message that the NSLs were just being used as a pretext by FBI leadership to buy time to find dirt on Flynn after the first investigation of him yielded no derogatory information.
The explosive new text messages also show agents believed the investigation was being run by FBI officials who were in the tank for Hillary Clinton.
“[D]oing all this election research – I think some of these guys want a [C]linton presidency,” one agent wrote on Aug. 11, shortly after the FBI opened the Crossfire Hurricane investigation against Trump.
In one series of texts sent the same day as the infamous Jan. 5 Oval Office meeting between Obama, Biden, Comey, Sally Yates, and Susan Rice, one agent admits that “Trump was right” when he tweeted that the FBI was delaying his briefings as incoming president so they could cook up evidence against him. As The Federalist first reported last May, that Jan. 5 meeting was the key to understanding the entire anti-Trump operation run out of Obama’s FBI.
W]hat’s the word on how [Obama’s] briefing went?” one agent asked, referring to the Jan. 5 meeting.
“Dont know but people here are scrambling for info to support certain things and its a mad house,” an FBI agent responded.
“[J]esus,” an agent wrote back. “[T]rump was right. [S]till not put together….why do we do this to ourselves. [W]hat is wrong with these people[?]?
a person is smart. people are dumb, panicky, dangerous animals.
#TrumpDerangementSyndrome
GGGGG-Men
PSD's Kilgore Trout
Where the smog meets the shore
Explosive!
Originally Posted by GGGGG-Men
the left doesn't care, I'm not surprised at all.
when it's the other way and either Trump or someone close to Trump does something it's major news with the left sucking it up.
Originally Posted by SpecialFNK
Did you think this would change anything?
Originally Posted by Scoots
this should be big news, but one side doesn't care.
“There was a lack of letting the evidence lead the investigation and more the attitude of ‘the evidence is there we just have to find it,’”
some already concluded it had to be true, they just wanted to find evidence to support what they already concluded. except it wasn't there.
https://thehill.com/regulation/court...s-about-russia
FBI agent William Barnett said that the investigation had a “get Trump” attitude that moved it forward, according to a 13-page summary of a Sept. 17 interview released Thursday. He also said evidence of collusion is “not there,” that he considered it to be a "dead end,” and that the investigation was based on “supposition upon supposition.”
I don't think either side cares right now.
TylerSL
It's not hard to see Trump's criminality, the FBI should have gone after him MORE if anything.
Originally Posted by TylerSL
Law enforcement should not look for crimes for an individual. If Trump told the FBI to go find something on Biden it would certainly obviously be wrong (and I wouldn't be surprised if it happened).
Brewersfan255
When Durham hands out indictments and people get arrested its going to be a great day
Originally Posted by Brewersfan255
You know when Trump is out of office he won't be free from criminal prosecution from a number of things he's done right? He used campaign funds to pay off women who he was has having affairs with while his current wife was pregnant. That's illegal. His taxes are going to be made public after he leaves office, and it's likely they'll show he has committed fraud for decades. He could also technically be prosecuted for Obstruction of Justice and witness tampering based on the findings of the Mueller Investigation, which absolutely DID NOT exonerate him.
I don't personally believe he will be charged, I'm just bringing it up because you seem to think the people who investigated his wrongdoing should be jailed. You realize he still could be right?
https://www.politico.com/magazine/st...e-house-227050
Last edited by TylerSL; 09-27-2020 at 03:36 AM.
FlakeyFool
explosive diarrhea
Walter_White
When this doesn't happen will you stop posting?
"The hottest places in hell are reserved for those who, in times of great moral crisis, maintain their neutrality.”
-JFK
as in the general America public, or leaders? Republicans should care, this can be used to support what they have said for years.
bold, campaign finance violation, and Obama campaign had the same type of thing.
https://www.politico.com/story/2013/...-375000-085784
Obama 2008 campaign fined $375,000
it's not an investigation's job to exonerate someone.
I don't even think Republicans care.
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US states reimpose virus restrictions; India tops 500,000
June 27, 2020 By WECT
By PAUL J. WEBER and MICHELLE R. SMITH | June 27, 2020 at 2:08 AM EDT – Updated June 27 at 2:37 AM
AUSTIN, Texas (AP) — Two of America’s largest states have reversed course and clamped down on bars again in the nation’s biggest retreat yet as the daily number of confirmed coronavirus infections in the U.S. surged Friday to an all-time high of 45,300.
Texas Gov. Greg Abbott ordered all bars closed, while Florida banned alcohol at such establishments. The two states joined a small but growing number that are either backtracking or putting any further reopening of their economies on hold because of a comeback by the virus, mostly in the country’s South and West.
Fauci: Young people majority of COVID infections
Health experts have said a disturbingly large number of cases are being seen among young people who are going out again, often without wearing masks or observing other social-distancing rules.
“It is clear that the rise in cases is largely driven by certain types of activities, including Texans congregating in bars,” Abbott said.
The Republican governor, who had pursued one of the most aggressive reopening schedules of any state, also scaled back restaurant capacity and said outdoor gatherings of more than 100 people would need approval from local officials.
Mayor Carlos Gimenez in Florida’s Miami-Dade county announced Friday night he would close beaches over the Fourth of July weekend. He said cracking down on recreational activities is prudent given the growing number of infections among young adults.
Stocks fell sharply on Wall Street over the surging case numbers. The Dow Jones Industrial Average shed 730 points, or nearly 3%.
In Asia, a large increase pushed India over half a million cases, the fourth highest in the world, while China and South Korea battled smaller outbreaks in their capitals.
The Indian city of Gauhati, the capital of Assam, will be locked down for two weeks from Sunday midnight with night curfews and weekend lockdowns in the rest of the state. India added 18,552 cases in the past 24 hours, raising its total to 508,953. The death toll reached 15,685.
China saw an uptick in cases, one day after authorities said they expect an outbreak in Beijing to be brought under control in the near future. The National Health Commission reported 17 new cases in the nation’s capital, the most in a week, among 21 nationwide.
South Korea, where a resurgence in the past month threatens to erase the country’s earlier success, reported 51 new cases including 35 in the Seoul metropolitan area. Officials, worried about the fragile economy, have resisted calls to reimpose restrictions eased in April.
Australia braced for more imported cases as citizens return home. About 300 people were due to arrive this weekend from Mumbai, India, with others expected to follow from South America and Indonesia. One state heath official said he is preparing for 5% to 10% of the returnees to be infected, based on arrivals from Indonesia in other states.
In Florida, the agency that regulates bars acted after the daily number of new confirmed cases neared 9,000, almost doubling the record set just two days earlier.
Colleen Corbett, a 30-year-old bartender at two places in Tampa, said that she was disappointed and worried about being unemployed again but that the restrictions are the right move. Most customers were not wearing masks, she said.
“It was like they forgot there was a pandemic or just stopped caring,” Corbett said.
A number of the hardest-hit states, including Florida and Arizona, have Republican governors who have resisted mask-wearing requirements and largely echoed President Donald Trump’s desire to reopen the economy quickly despite warnings the virus could come storming back.
Pence exchange with reporter on Tulsa rally, Ariz. church rally
The White House coronavirus task force, led by Vice President Mike Pence, held its first briefing in nearly two months Friday, and Pence gave assurances that the U.S. is “in a much better place” than it was two months ago.
He said the country has more medical supplies on hand, a smaller share of patients are being hospitalized, and deaths are much lower than they were in the spring.
The count of new confirmed infections, provided by Johns Hopkins University, eclipsed the previous high of 40,000 set the previous day. Newly reported cases per day have risen on average about 60% over the past two weeks, according to an Associated Press analysis.
While the rise partly reflects expanded testing, experts say there is ample evidence the scourge is making a comeback, including rising deaths and hospitalizations in parts of the country and higher percentages of virus tests coming back positive.
About 600 people are dying every day from the coronavirus in the U.S., down from a peak of around 2,200 in mid-April. Some experts doubt that deaths will return to that level, because of advances in treatment and prevention and because younger adults are more likely than older ones to survive.
The virus is blamed for about 125,000 deaths and nearly 2.5 million confirmed infections nationwide, by Johns Hopkins’ count. But health officials believe the true number of infections is about 10 times higher. Worldwide, the virus has claimed close to a half-million lives.
Louisiana reported its second one-day spike of more than 1,300 cases this week. The increasing numbers led Democratic Gov. John Bel Edwards to suspend further easing of restrictions. Republican Gov. Doug Ducey did the same in Arizona, where cases are topping 3,000 a day and 85% of hospital beds are occupied.
But Republican Gov. Bill Lee has been reluctant to reinstate restrictions or call for a mask mandate in Tennessee, which reported its biggest one-day jump in infections for the second time in a week, with more than 1,400,
In a reversal of fortune, New York said it is offering equipment and other help to Arizona, Texas and Florida, noting that other states came to its aid when it was in the throes of the deadliest outbreak in the nation this spring.
“We will never forget that graciousness, and we will repay it any way we can,” Gov. Andrew Cuomo said.
Smith reported from Providence, Rhode Island. Associated Press journalists around the world contributed to this report.
This story corrects the number of new infections in Beijing to 17, not 18.
Here’s your chance to give back on #GivingTuesday
Franklin Graham asks if Pelosi promised 10 Republicans ‘pieces of silver’ to betray Trump
‘QAnon Shaman’ Capitol rioter wants pardon from Trump
New York City bus crashes through barrier, dangles from overpass; 9 injuries reported
Trump turns on some loyalists as others regret his tumultuous exit
Brady and Brees meet up in final battle between Buccaneers, Saints
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Home » Noticias » Qualcomm presents its new 5G modem for the iPhone 12?
Qualcomm presents its new 5G modem for the iPhone 12?
GSMArena February 25, 2020 No Comments
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Qualcomm has just announced its new 5G modem at an event that has taken place in San Diego. The American manufacturer, one of Huawei’s few rivals in the development of 5G technology, presents its new X60 modem that could be the one that will incorporate the next iPhone 12, which are expected to be the first Apple smartphones to have this new technology.
It is expected that after the summer Apple will present its entire range of iPhone 12, which could include up to four different models with a new, more square design. Rumors say that it would have as one of its main novelties the inclusion of 5G support in all of them, using a Qualcomm modem, predictably this new X60. According to the rumors, Apple will have to design its own antenna to adapt it to the iPhone design, but it will continue to depend on Qualcomm modems until it is able to develop its own, something he works on since the acquisition of the Intel modems section. That is why the judicial war that both companies undertook ended with an agreement between them, since they need each other.
This Qualcomm modem, as reported by the manufacturer, uses 5nm technology and supports download speeds of up to 7Gbps and 3Gbps upload. He has also stood out as the first modem to support not only the mmWave band but the entire sub-6Ghz spectrum, including the 4G band. Despite all these figures, the harsh reality will be that we will have to wait a few years for 5G technology to reach most of us., so we most likely cannot take advantage of this technology until long after buying our new iPhone. And, as much as companies insist on telling us otherwise, the 5G icon in the status bar of the iPhone will take time to be seen.
Apple rents a gigantic office space in New York
They steal an iPad and have a fatal accident while being chased with “Find My”
Apple Pay will arrive very soon in Mexico
iPad and MacBook, when is everyone worth it?
Apple “Over Ear” headphones appear in Target’s inventory
The reality behind the durability of “folding” phones
new follow-up comments
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South Vietnam 1967
Posted by Brock Townsend at Tuesday, February 11, 2020 No comments:
Virginian Democrats Vote to Remove War Memorial Protection
Late Tuesday, legislation to repeal Virginia's war memorial protection was passed by both houses in our General Assembly.
The Senate vote was along straight party lines. ALL Republicans voted to protect them. ALL Democrats voted to allow them to be destroyed.
We’ve been telling you all that we knew in November that Democrats in Virginia would likely do everything they could to remove protection of the Commonwealth’s war memorials this session, and continue their efforts to punish us by doing everything they can to erase our history and silence us.
We’ve also been telling you that although we worked with and helped support a coalition working behind the scenes to try and stop this, we were also preparing for the worst.
Next we fight.
We fight every attempt by any locality in Virginia to remove, destroy or desecrate our memorials. We fight to have localities pass their own measures to proactively protect war memorials. We fight by raising flags AND memorials on private property. We fight by continuing to do what is OUR responsibility... honor our Confederate dead.
We have 28 memorial battle flags flying with two more currently under construction. We want our next to be somewhere in Richmond.
Help us make that happen!
Posted by Brock Townsend at Tuesday, February 11, 2020 2 comments:
Jussie Smollett Just Got Indicted On Multiple Counts by a Special Prosecutor
Revenge. Bet he thought he was Scot-free.
In the wake of the scandal of the dismissal of charges against Smollett last year, a special prosecutor was appointed to investigate both Smollett’s actions as well as the actions of Kim Foxx and the Cook County State’s Attorney’s Office.
Now, the special prosecutor Dan Webb has indicted Smollett on six counts of disorder conduct for filing four false reports with the Chicago police “related to his false claims that he was the victim of a hate crime, knowing he was not the victim of a crime.”
More @ Red State
Virginia’s House Has Just Banned America’s Best-Selling Rifle and Approved the Confiscation of Ammo
Ruger has 3 of the top 5. Surprised me.
Do I see blue changing to red?
And away we go…
On Tuesday, in a near-party-line vote, the Virginia House of Delegates passed a bucket of gun control proposals.
The anti-gun legislation made it through the chamber 51-58, with all Republicans and even several Democrats voting against it.
Check out the roll call here:
MEGALOMANIAC GUN BAN ADVOCATE MIKE BLOOMBERG IS COMING TO TOWN
GRNC
Our Protest event will take place from 8:15 am - 10:30 am on the sidewalk. We need EVERYONE we can muster to protest his nanny-statism.
Take time off from work if you have to
Please dress for the press - no inflammatory slogans on clothing or signs.
Megalomaniac Mikey has no use for liberty or the truth, he thinks he knows better than you.
This is a man who doesn’t want to call it gun control because it implies that “you’re going to take away people’s guns” while his comrades in Virginia plot to take people’s guns away.
He is Mr. Astroturf using his billions to buy elections and create front groups of liberty grabbers. This is a man who thinks guns should only have 3 rounds and that you, the average citizen shouldn’t have one. For elitists like mini Mike, you don’t deserve the ability to defend yourself, meanwhile he cowers behind heavily armed men.
This is a man who said “the way you get the guns out of the kids' hands is to throw them up against the wall and frisk them”. Who stated that “If you can stop them from getting murdered, I would argue everything else you do is less important.”
Don’t forget that when Biden drops out and the socialists implode, he will be the only ‘sane’ choice on the field. Never mind that he is as extreme a statist as the rest of them.
Barr Announces Multiple Lawsuits as Part of DOJ Crackdown on Sanctuary Cities
Attorney General William Barr announced Monday the Justice Department is filing three lawsuits against California, New Jersey and a Washington county over their so-called “sanctuary city” policies relating to illegal immigrants.
“Today is a significant escalation in the federal government’s efforts to confront the resistance of ‘sanctuary cities,'” Barr said during remarks at the National Sheriffs’ Association Winter Legislative and Technology Conference.
“Let us state the reality upfront and as clearly as possible: When we are talking about sanctuary cities, we are talking about policies that are designed to allow criminal aliens to escape,” the attorney general said.
In this pause between past and future Deep State seditions, and the full-blown advent of Corona Virus in every region of the world, we pause to consider Mr. Trump’s executive order requiring new federal buildings to be designed in the classical style. The directive has caused heads to explode in the cultural wing of Progressive Wokesterdom, since the worship of government power has replaced religion for them and federal buildings are their churches — the places from which encyclicals are hurled at the masses on such matters as who gets to think and say what, who gets to use which bathroom, and especially whose life and livelihood can be destroyed for being branded a heretic.
More @ Kunstler
Trump Holds Blowout Rally In NH on Eve of Primary ‘to Mess with Dems’, Over 25% of Attendees were Democrats
President Trump just wanted to “mess with” the Democrats last night by holding a massive rally in Manchester, NH on the eve of the first 2020 primary. And mess with them he did. Trump campaign manager Brad Parscale reported there were 52,559 ticket requests. Of those, 24,732 voters were identified, 17% of whom did not vote in 2016. And, as has become the norm for Trump’s rallies, 25.4% of attendees identified as Democrats.
Joe Biden Bails Out of New Hampshire Early and Probably Just Ended His Campaign
Alright, I’m going to just say it. Joe Biden is done.
After having made no headway in New Hampshire, he has left the state early and is headed for South Carolina. That’s big news for two reasons. One, it means he’s going to finish 4th or 5th in New Hampshire, compounding on a 4th place finish in Iowa. But two, it means he’s conceding Nevada to Bernie Sanders, a state Biden led just a month ago. Starting 0-3 in the first primary contests was always his doomsday scenario and it has arrived.
This is what a campaign looks like when it dies.
Suitcase Full Of Dead Birds From China Intercepted At Virginia Airport
No matter what the reason, we should all be able to agree that sending a suitcase full of dead birds – from anywhere, to anywhere – is not right.
The ordeal is made more disturbing by the fact that the suitcase was sent from China, which is currently dealing with the coronavirus and has struggled in the past with a bird flu epidemic. WTHR reported Monday that U.S. Customs and Border Protection (CBP) agents intercepted a package at Dulles International Airport in Virginia that was filled with small dead birds.
How Appalachia's Children Highlight the Region's Best Attributes
MOUNTAIN CITY, Georgia -- Just off U.S. Highway 23, along the spectacular views of the Blue Ridge Mountains, T.J. Smith spends his days continuing the tradition of the iconic Foxfire Fund: an enterprise driven by young people whose respect for the land and culture, and understanding of the importance of preserving that culture's stories, has persevered for more than 50 years.
If you grew up in Appalachia, you likely owned a set of the Foxfire books or had the Foxfire magazine in your home, giving you an opportunity to see your very heritage in those pages.
They carried the stories of the America that stretches 1,500 miles diagonally along the Appalachian Mountains, from southern New York through great big swaths of Pennsylvania, Ohio, West Virginia, Virginia, Kentucky, Tennessee, Mississippi, parts of both Carolinas, Georgia and Alabama.
Virginian Democrats Vote to Remove War Memorial Pr...
Jussie Smollett Just Got Indicted On Multiple Coun...
Virginia’s House Has Just Banned America’s Best-Se...
MEGALOMANIAC GUN BAN ADVOCATE MIKE BLOOMBERG IS CO...
Barr Announces Multiple Lawsuits as Part of DOJ Cr...
Trump Holds Blowout Rally In NH on Eve of Primary ...
Joe Biden Bails Out of New Hampshire Early and Pro...
Suitcase Full Of Dead Birds From China Intercepted...
How Appalachia's Children Highlight the Region's B...
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Trump advisers urge 2022 delisting of U.S.-listed Chinese cos that fail to meet U.S. audit standards
Aug 06, 2020 • Last Updated August 6, 2020 • < 1 minute read
WASHINGTON — Top Trump administration officials have urged the president to delist Chinese companies that trade on U.S. exchanges and fail to meet U.S. auditing requirements by January 2022, Securities and Exchange Commission and Treasury officials said on Thursday.
The remarks came after President Donald Trump tasked a group of key advisers, including Treasury Secretary Steve Mnuchin and SEC Chairman Jay Clayton, with drafting a report offering recommendations to protect U.S. investors in Chinese companies whose audit documents have long been kept from U.S. regulators. (Reporting by Alexandra Alper; editing by Jonathan Oatis)
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Call +353 64 6676100
China trade surplus with US dropped 8.5% to $296 billion
China’s trade surplus with the US narrowed last year as the world’s two biggest economies exchanged punitive tariffs in a bruising trade war, new data show today.
The figures come as the two countries prepare to sign a deal dialling down tensions.
The huge difference in trade traffic is a key bone of contention for Donald Trump in a long-running stand-off that has seen him impose tariffs on goods worth hundreds of billions of dollars, triggering retaliation from Beijing and jolting the global economy.
China’s surplus came in at around $295.8 billion in 2019, down 8.5% from the previous year’s record $323.3 billion, according to customs data.
In December, its surplus with the US was around $23.2 billion, from $24.6 billion the month before.
The mini trade deal announced last month will see Beijing buy an extra $200 billion of US products over a two-year period, according to Washington officials. China has yet to publicly confirm the figures.
The Trump administration called off new tariffs on Chinese-made goods such as electronics that were to take effect last month. It also halved those imposed on September 1 on $120 billion worth of products.
But Washington maintains 25% tariffs on about $250 billion worth of Chinese imports.
In a further sign of de-escalation, Washington yesterday removed the currency manipulator label it imposed on China in the summer.
At a news conference this morning, spokesman for the customs administration Zou Zhiwu said that since November and December, Chinese imports from the US including of soybeans and pork have picked up.
Zou added that the increased imports from the US will not affect China’s purchases from other countries.
He also said the trade tensions had “put some pressure on China’s foreign trade and firms that largely trade with the US”.
“Although our exports to the US have declined, the effectiveness of enterprises diversifying their markets has been significant,” he said, adding that exports to non-US markets have risen and overall exports are still rising.
The signing of the new trade deal, which is part of a planned wider pact, will have an “important and positive significance” not just for China and the US but also the rest of the world, Zou said.
China’s foreign trade volume fell slightly on-year in 2019, and its surplus with the world stood at $421.5 billion.
In December, China’s exports rose 7.6% year-on-year, the highest growth since July and above the 2.9% forecast in a Bloomberg News survey. Imports surged 16.3%, far exceeding estimates.
For the full year, exports rose 0.5% while imports fell 2.8%.
Meat imports spiked over the past 12 months as officials brought in 2.108 million ton of pork – a 75% increase from the year before, while beef imports rose 60%.
The huge jumps come as the country’s pork supply is hammered by an outbreak of African swine fever that has wiped out about 40 percent of the national pig herd.
Nick Marro at The Economist Intelligence Unit said China’s overall export recovery in December is likely due in part to a low base of comparison from the year before.
“It was around this time last year when we first started to see the impact of both the trade war and the global electronics slowdown bite into China’s trade data,” he added.
While shipments to Europe and Southeast Asia are up, Marro said these markets cannot fully replace the US.
“However, China’s efforts to pivot towards alternative sources of demand, as a cushion to lost US market access, may be starting to pay off,” he said, adding that growth in shipments to Vietnam outperformed every other major export market.
Article Source: Click Here
Employees to be given right to request remote working under Govt plan
420,000 workers to receive tax bills for Covid payments
Changes to corporate tax rules will reduce revenue by up to €2bn
Are NI supermarket issues really just Brexit ‘teething troubles’?
Industrial & logistics sector sees spike in demand – Savills
Irish mortgage interest rates joint highest in euro zone
76% of imports into Dublin Port clearing without delays
Ireland to receive €1bn from EU’s post-Brexit fund
Some food and drink exports hit hard by Covid-19 pandemic
Record €1.2 billion spent on groceries in December – Kantar
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First In Freedom Daily
Conservative NC House Stalwart Draws 2020 Primary Challenger
NC HOUSE 83 – Rep. Larry Pittman (R-Cabarrus) is in his fifth term in the N.C House of Representatives, and for the better part of the last decade he has voted consistent with his conservative campaigns and definitely hasn’t been shy taking a stand against the crowd. It can only be expected then, that such a principled conservative be targeted during a primary.
With a newly drawn district, Cabarrus County attorney Jay White has announced his intentions to challenge Pittman to represent the 83rd NC House District on Jones Street.
From White’s announcement:
“I am seeking the Republican nomination for House District 83 because my experience and my proven record of leadership and community involvement will enable me to serve our district. The people of the 83rd District are my friends; you are my family. Together, united by our shared values, we can make Cabarrus County and North Carolin a better place for ourselves and our children.”
Those shared values are evidently Republican ones, just different enough from Pittman’s that he deserves a challenge apparently. In what way they are different will ultimately define that primary race. Somewhat notorious for controversial words on history and it’s widely venerated figures, and White is quick to pounce upon that red meat to fuel his primary launch.
Trending: Cooper Administration’s Vaccine Distribution One of the Worst in Nation, 48th Place
“Mr. Pittman has made national headlines for calling for the resumption of public hangings and comparing President Abraham Lincoln to Adolf Hitler,” he also stated in his announcement.
Like we said, Pittman has made some eyebrow-raising comments. Yet, White immediately adopts the Democrats’ line of attack on Pittman and his past statements. Providing no context, with a plain motivation to smear, reduce the comments to the most damning thing possible. If it sounds familiar, it’s because the tactic is employed everyday against another (considerably more) notable politician whose plain language offends the chattering classes.
Despite it all, Pittman’s voting record is unmistakably conservative and he’s been elected five times. That should indicate that his constituents understand him to be more than those bad headlines. Though with a new district makeup, the voter landscape cab be transformed enough to create an opening, which White is taking advantage of.
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Selena Gomez Workout Routine and Diet Plan
Selena Gomez’s Diet Plan and Nutrition Supplements
Selena Gomez’s Workout Routine
Selena Gomez is a well-known name since her childhood days and her role in Barney and Friends. We have all grown up with her through Disney Channel and saw her change into the smart, young and gorgeous woman she is now. However, being in the entertainment industry comes with its own pros and cons. She has been looked upon with the eyes of scrutiny as far as her body image is concerned. Much recently, she even had to face body shaming and media trolls.
The woman who has had a perfect body structure since forever didn’t take it to heart and became bold about it. She constantly posted about loving herself and accepting the way she is. She has seamlessly spoken about her struggles with both mental and physical disorders and how she is treating them.
In an interview, she opened up about her condition called, Lupus, “As many of you know, I revealed that I have lupus, an illness that can affect people in different ways. I’ve discovered that anxiety, panic attacks, and depression can be side effects of lupus, which can present their own challenges.”
Selena Gomez’s before and after transformation.
To keep her health intact after injury, she took the help of her long time trainer, Amy Rosoff Davis. She even took her with her wherever she traveled to and especially during her tour for her album, Revival.
Now that she is all fit as a fiddle, we have taken out the whole account of what Selena’s diet and workout routine looks like. Se has been blossoming day by day and we really do wanna know all her secrets!
However, before we leap straight for her secrets, this is what her body statistics look like:
Selena Gomez Body Measurements
Height: 165 cm (5’5”)
Weight: 125-130 lb
In was in the last decade when Selena decided to address her inexplicable weight gain. She hired Amy Rosoff Davis in 2015 and has been working hard for her body ever since. With proper workouts, she decided to focus on her nutrition too.
Talking about her diet strategies, Amy states:
“I want to live my life as a French person. I don’t believe in denying yourself, but I also believe in moderation. Life is too short not to enjoy food.”
That’s exactly the key- Moderation. She believes that one can eat anything they want as long as it is in moderation, but at the same time making conscious efforts to eat healthily.
Amy was also recorded saying that one must switch from fast foods to whole and unprocessed foods. She says that Selena loves Mexican food and eats like she’s from Texas. “She loves Tex-Mex and fast food that I would normally not condone,” Amy stated in the interview. “I will walk onto the tour bus and smell fast food, throw it in the trash, and hand her a carrot and hummus.” She even says that Selena’s body is responding very well, “She responds really quickly. We’ll do barely any ab exercises and two days later, I’m like, ‘Whoa!’”
About the quality of food, Rosnoff states,
“I am all about focusing on good-quality fresh ingredients. Real food is so much yummier than something that comes out of a box or bag. I recommend going to your local farmers market or trying to buy organic veggies and fruits and hormone-free/grass-fed meat at the grocery store.” Furthermore, she said, “I personally think learning a few basic skills in the kitchen is super beneficial to your waistline. When you know what goes into your food you are more likely going to make better choices.”
Here’s the sample diet of what Selena is likely to eat every day, but of course, her schedule changes every other day.
Avocado toast and green juice.
Rice cake and peanut butter with sliced apple.
Bagel and cream cheese.
Seldom, she also likes to have eggs, beans, avocado, rice, and chorizo or just some full-fat Greek yogurt with granola.
She likes to have a pretty basic lunch with protein and veggies. She does not neglect carbs completely.
Plain chicken salad
Chicken or turkey sandwich with lettuce slaw.
She also likes to have rice & beans.
Or a simple salad with beans, turkey, and avocado is also a good option.
Like we said before, she loves Mexican food and her dinner is almost always Mexican. She likes to have:
Roast Chicken with Pasta and veggies
Salmon and veggies
Salmon or Chicken Teriyaki bowl with some rice for carbs, avocado for a dose of healthy fat and cucumbers.
She loves to have a good sushi platter for dinner too.
“I’m all about eggs, yogurt, anything teriyaki, and Asian style, and sushi; so this seems like a diet I can get behind”, she said.
Selena’s favorite snacks include tortilla chips with a side of salsa or guacamole. She also loves popcorns or chicken salads.
Once in an interview, she said that she loves to dip her popcorns in pickle juice. She got some pretty weird choices when it comes to food.
Hydration is one of the key factors for Selena Gomez to keep her body in shape. Her instructor makes sure that she is drinking plenty of water each day. Sometimes, she likes to add a little zing to her water by adding cucumbers, lime or lemon, and herbs in it. She loves trying new recipes of detox water which makes drinking water much easier.
Selena Gomez’s Supplements
Since her major surgery, it is important for her to fill up on supplements which makes her body recover faster. This is the list of supplements that she takes:
VITAMINS A, C, AND E
Vitamins A, C, and E are known to be great antioxidants for the body and help with strengthening the immune system.
Vitamin D is necessary to absorb all the other vitamins and minerals from the body.
Post her surgery, calcium has become an important supplement for Selena. Due to medications, she has an increased risk of osteoporosis which causes the weakening of the bones.
Lupus is also associated with a deficiency of this vital vitamin.
Selena Gomez’s trainer’s 45-minute workout.
Selena Gomez does not stick to a particular form of workout and rather switches it up. In the same interview, Rosoff explained her workout routine too.
“Never let your body get bored. Selena has been doing cardio, Pilates, and yoga of all kinds.” So it immediately means that Gomez’s workout is fun and different every time. It does not make it monotonous for her and she sticks to the routine.
Amy further explained what all Selena does in her fitness routine which is primarily fixed for every workout.
Stretch a lot. Amy makes sure that Selena stretches before and after her workout. According to her, it has helped Selena a lot with her flexibility. Just to save some time, she also stretches while practicing for her music too.
Sweat it out. Amy recommended Shape House for Selena which is an urban sweat lodge. Here, the clients are supposed to lie down for an hour under infrared light and it helps enliven the skin. According to Shape House staff, a session usually burns between 800-1600 calories. The infrared is supposed to make people sweat that helps in opening up their pores and cleaning them out.
“I don’t really know how I feel about this, but I’m also naive to the subject of human sweat burritos…”, said Selena.
Gomez is active on her social media and posts a lot of pictures with her friend where they are often seen indulging in activities like bike riding or hiking.
For her, it seems like it is not about going to the gym, but rather move your body as much as you can.
Here are a few more tips which Selena and her trainer shares that helps Selena develop a positive mindset for her body image:
No weighing. “I’ve never weighed her,” Amy said. “I don’t believe in scales — I just don’t think it’s healthy.” However, since, she and Selena workouts together she can make out the differences in her body. “I can definitely see the difference, and other people can too,” she said. “But ultimately, a body that eats well and works are going to look better because it’s healthy.”
Selena doing pilates with her trainer.
Selena trains for at least 5 days a week and that’s because her routine includes group sessions that are done inside a studio. However, there are some other activities present too which involve going outdoors.
Selena Gomez Primary Workout/Training Routine
Selena does not do a lot of strength training but she loves Pilates, Yoga, and cardio. She usually gets herself into these classes at least 3 times per week.
She does a variety of cardio exercises which includes:
HIIT workout: High-Intensity Interval Training
Steady Cardio: Running on Treadmill, Rowing Machine, Stair Master or Elliptical for 40-60 minutes.
Hiking and other outdoor activities can be done for 45-60 minutes. Since outdoor activities do not get monotonous, you can do it for a more amount of time.
Selena Gomez Workout Routine: Secondary Training
While most of Selena’s workouts are in a studio, here is something that Selena has to do every day. That is tracking her steps. She hits of goals of walking 10,000 steps daily.
Tracking the steps ensures that she is active throughout the day.
Here is a proper routine list which includes Selena Gomez’s workout schedule.
Day 1: 20 min circuit
Jogging either on a treadmill or on the running track
Lunges
She ends her workout with basic stretches
It is a 20-minute circuit that she follows which includes:
On day 3 she extends her time from 20-30 minutes to a full one-hour workout.
Day 4: 60 minutes
Day 4 is about pilates
Day 5th is the rest day for her.
After a whole day of rest, day 6 is about one hour of a workout again.
Meditation because mental health is important for her too.
Sunday is a rest day for her.
When asked about the frequency of the workouts regarding total sets and reps, her trainer, Amy, said that “I’d recommend 30 punches forward and back, 30 punches up and down, and then 30 combos. So, up, down, in, and out. So that’s averaging about 100. Every week is different. Some weeks Selena books five workout sessions a week, and some weeks we can only see each other three times a week. So I would recommend anywhere from three to five times a week.”
For abs, Selena does pilates but aside from it, there are abs workouts that she includes. Amy says,
“We also do a lot of plank work, and I’m into varied planks. So, not just holding a basic plank, but doing a plank while taking turns tapping opposite arm to the opposite shoulder, or lifting and lowering one leg in a pulse, or going from your elbow to your hands tilting your hips. Basically, you want to first make sure you have a correct plank so that your shoulders are stacked over your wrists, your hips are low, you’re pushed into your heels, and you’re not arched, but you’re not grounded. So, your core is activated, your belly button is pulled up to your backbone, and you have that good base.”
Amy believes that variation is the key and she also applies it to her plank workout too.
“Take your right arm and then tap it to your left shoulder while still holding up a plank and then try to keep your hips still, and then opposite arms,” she explains. “Do around 40 shoulder taps and you really want to try to keep your hips still, which really pulls your abs up and into your core, back up towards your spine.” Another variation that Amy suggests is the leg pulse. “Take your right leg, lift it up and cross it behind and over your left leg. Then pulse it up in the air and back down. Do 30 of those and then switch sides.”
Amy also focuses a lot on cardio for Selena. They do it for at least 3-4 times a week. There are many different ways that can be taken into account for cardio. You can either do it on a treadmill or outside. Even though Amy and Selena workout together, Selena’s workout changes quite often as per her career demands. “When we were touring, some days we were flying all day, and some days we had four days off and we would go hiking and then go to the gym. So, with her lifestyle adjusting, we were always just trying to incorporate as much fitness and cardio in as possible. There was a lot of jet lag and working out is a great way to deal with jet lag.”
The last piece of advice that Amy gives is to LISTEN TO YOUR BODY. “Listening to your body is a big thing of mine. Pushing it when you can push it, but also really knowing when it needs to rest or maybe just doing a yoga class or a stretch session.” Amy reveals that such an approach is very essential “I incorporate yoga into almost every session as well, so Selena definitely gets her share of downward dog and stretching.”
That’s all about what Selena with the help of her trainer, Amy, does in her day to keep fit.
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Boating Scout
Content and user-driven directory makes waves
Traffic-generating content marketing website
Boating Scout is an online directory and resource for all things boating in North America. It is rich with keyword-focussed content for boaters, making it a traffic-driving engine. We worked with Boating Scout to develop a content strategy and responsive platform where users could discover, explore and share.
Personalized user experiences
BoatingScout is built with Laravel to allow for personalized user experiences across the site. The site houses many types of data, which are cross-referenced to deliver related content that feel personalized and encourages longer site visits. The addition user accounts and the ability to favourite content created a community of loyal return users.
Curated content first
The foundation of almost all content marketing campaigns is simple — more content means more traffic. We worked with BoatingScout to develop a sustainable content strategy that would satisfy both users and search engines. The interplay of these two are essential to long term growth because quality content must capture organic search traffic, but also offer enough intrinsic value that users want to stay and come back. The two major content drivers on the website were enhanced directory listings and long-form blogs related to the boating industry.
The Boating Scout directory offers users something that they cannot get from traditional Google listings. It aims to provide boaters with nuggets of additional information that is specifically useful to boaters like parking capacity and fees at boat launches, what kind of gas is available at service centres, and directions things like small public launches that would never be listed in the Yellow Pages. Boating Scout is not attempting to re-invent the wheel, but simply package information for an extemely specific audience so it can speak directly to their needs instead of indirectly to everyone.
Targeted articles
The long-form articles on BoatingScout are highly targeted. They are written with an understanding of both who they are targeting, and what they are interested in. Each article is hand-crafted to offer valuable insight and in-depth information on each topic to provide users with the answers to the questions they are searching for. These articles generate a significant amount of organic traffic, who stay on the site for longer-than-average visits to read and share the relevant information.
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Who Fought for Alberto Gonzales?
January 31, 2007 News & Politics 0
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike question why Democrats didn’t fight harder to refrain Gonzales from becoming Attorney General.Feingold warns Democrats not to fall into Senator Warner’s trap. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at …
Bush Adminstration is the New Batman Crew
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike proclaim the Bush Adminstration as the new Batman Crew. Feingold warns Democrats not to fall into Senator Warner’s trap. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at http://www.theyoungturks.com New TYT …
Don’t Fall for the Trap!!
Senator Russ Feingold joins the Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike. Feingold warns Democrats not to fall into Senator Warner’s trap.Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at http://www.theyoungturks.com New TYT Network channels: http://www.youtube.com/user/tytsports http://www.youtube.com/user/thetopvlog New TYT …
Why are Rove and Cheney Still in Government?
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike discuss how Karl Rove, Scooter Libby and Dick Cheney outed a CIA agent and stil in office. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at http://www.theyoungturks.com New TYT Network channels: …
Gutting Every Federal Agency….
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike discuss how the new Bush Administration directive will essentially gut every Federal Agency. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at http://www.theyoungturks.com New TYT Network channels: http://www.youtube.com/user/tytsports http://www.youtube.com/user/thetopvlog New TYT …
Hagel, All Talk and No Vote
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike talk about Chuck Hagel’s voting record, it is NOT NICE! Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at http://www.theyoungturks.com New TYT Network channels: http://www.youtube.com/user/tytsports http://www.youtube.com/user/thetopvlog New TYT Facebook Page(!): Subscribe …
Joe Lieberman Could Possibly Vote for a Republican in ’08??
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike express that they can’t continue to criticize Liberman, as he simply left the party and is no longer a Democrat. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at http://www.theyoungturks.com New …
Cenk Questions Story…US/Iraqi Forces Kill 300 Insurgents
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike question the truthfulness about the story. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio. Watch more at http://www.theyoungturks.com New TYT Network channels: http://www.youtube.com/user/tytsports http://www.youtube.com/user/thetopvlog New TYT Facebook Page(!): Subscribe to the FREE Video …
Good Time to Strike a Deal with Iran.. Don’t You Think?
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike discuss why it’s a good time to strike a deal with Iran. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio.
Terry McAuliffe Supports Hillary Clinton for President
The Young Turks: Cenk Uygur, Ben Mankiewicz, and Jill Pike interview Terry McAuliffe and his views on the ’08 Presidential Election. Watch live from 6-9AM ET on http://www.theyoungturks.com. Listen from 6-9AM ET on Air America Radio.
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Of Boys, Beer and Young Women
Published in the Huntington Post July, 2014
Two Sundays ago, before finishing my morning coffee, a friend of mine texted me and told me that I needed to see the front page of the New York Times. The cover story was an expose about a college’s botched handling of a sexual assault case,“Reporting Rape, and Wishing She Hadn’t,” July 12. The reason my friend so “thoughtfully” drew my eye to such an article was because the small liberal arts college in question was where I had gone to school and by the time I finished the damming piece I was irate, tinged with guilt and ashamed.
I was mostly irate at the school for its purported mishandling of the sexual assault case (the article, with its point being that colleges are ill-prepared to handle such complaints, took the administration to task for a poor investigation, dismissing the complaint and accordingly, discouraging the victim from filing criminal charges), an ire that was further inflamed by President Mark D. Gearan’s perfunct and seemingly insensitive letter to alumni and parents, that coldly stated that the school had followed procedure and does not condone sexual assault. Upon receiving that email and a Boston area alumni “Happy Hour” notice within the same hour, I swore I’d never give another dime to the school (not that I gave a lot, but I contributed a small tithe annually). My long held pride in having attended the school had given way to shame. Continue reading →
Tags: Essay, Hobart, Huffington Post, rape, sexual assault
Categories Article, Essay
Rob Reiner, a.k.a. “Meathead” and creative force behind such quirky classics, This is Spinal Tap, When Harry Met Sally and The Princess Bride, gets back to his roots with this bag of mixed nuts about an embittered widower hit with some life-altering events that threaten to melt his icy heart and make him feel again. It’s a clichéd premise no doubt, but thankfully Reiner and cast play up the comedic angle and make what could have been a flat, Lifetime weepy something springy and possessed of an intermittent joy.
Set in the coddled community of Fairfield Connecticut, realtor Oren Little (Michael Douglas) is trying to get over the loss of his wife and sell his palatial estate (for a cool 8 mill), but because of a professional slump and the personal setbacks, he slums it in a four-unit rooming house on the Long Island Sound and grouses about his neighbors with three-olive rancor. The script written by Mark Andrus who pennedAs Good as it Gets (you’ve gotta love these inspired titles) employs some pretty frilly shenanigans—and not all of them stick. Take the fact Oren’s son (Scott Shepherd) is a recovering addict and heading to jail for insider trading. It’s never explained how he got from shooting up to shorting shares, but so it goes. He’s also got a ten-year-old daughter, Sarah (Sterling Jerins), who needs a custodian as mom’s whereabouts are unknown. When asked to take on Sarah, Oren pushes back, declaring he was a lousy dad. That’s the kind of prick we’re dealing with, at least initially. Continue reading →
Tags: Comedy, Diane Keaton, Film, Michael Douglas, Paste Magazine, Review, Rob Reiner, Spinal Tap
A Most Wanted Man
Philip Seymour Hoffman steals the show in A Most Wanted Man
Philip Seymour Hoffman commands attention in A Most Wanted Mman, one of his last performances
Sadly, 2014 has become the year of goodbye performances from Philip Seymour Hoffman. Earlier this year the talented actor who tragically left us far too early appeared in John Slattery’s directorial debut God’s Pocket, and now the release of A Most Wanted Manadds to Hoffman’s posthumous big-screen farewell. (He’ll still appear in the final two films of The Hunger Games series.)
It’s somewhat fitting too, as Hoffman’s role of Günther Bachmann, the head of a spare German intelligence unit charged in the wake of 9/11 to suss out radical Islamic terror cells, requires range, nuance, and an accent — which by many accords, you could see a lesser actor botching to a campy awful degree. The film, based on spymaster John Le Carré’s 21st novel, takes place in Hamburg, where Mohammed Atta set up the 9/11 attacks allegedly because intelligence was weak or nonexistence. Bachmann and his ragtag team take to their task very seriously and are dogged in their pursuit of new assets. Like most characters in Le Carré novels, Bachmann harbors a troubled past (an oversight in Beruit gets some unfortunates killed) and has little time for anything but work, except good scotch of which he consumes plenty. Continue reading →
Tags: charlestoncitypaper, Espionage, Film, Hoffman, Review, spy, thriller
They Came Together
Wet Hot American Summer‘s David Wain and Michael Showalter come together again but fall flat
She’s Come Undone
Satire and send ups are sharp, dangerous implements in the toolbox of cinematic comedy. Wield them right and you get cherished chucklers like Airplane!, There’s Something About Mary, and even Scary Movie, but when held in slack, sloppy hands and rushed to the screen, the result winds up on the other side of funny — just take Date Movie, Meet the Spartans, or anything else by the splice ’em and spoof ’em team of Seltzer-Friedberg. Most unfortunately — or perhaps I should say, most unfunnily — They Came Together lands in the latter camp. The micro-budgeted flick was shot in 20-something days and could have used a bit of camp (pun intended). That’s not to say They Came Together doesn’t have its rewards, but there’s just not enough of them to hold the muddled mass together.
The film, co-written and directed by David Wain, marks a reunion of sorts for Wain and writer Michael Showalter. Back in 2001 the pair churned out the American Pie meets Meatballs cult hit Wet Hot American Summer. In between, Wain made good on his comedic promise with solid efforts like Role Models (2008) and Wanderlust(2012) — but sometimes it’s not wise to go back to the well. Continue reading →
Tags: charlestoncitypaper, Comedy, Film, Review, rom-com, Rudd, SNL
‘Dawn of the Planet of the Apes’: Primates can’t win when hawks lurk in their ranks
The one thing that always struck me about the “Planet of the Apes” franchise – old and new – is the obvious, but not often discussed, allegory for slavery in which the master becomes the slave fighting for freedom. Sure, you can take it as a straight-up sci-fi thriller, but most post-apocalyptic, post-civilization flicks are about man losing control and trying to regain that control or at least a safe foothold where the seeds of civilization can be nurtured back. It’s less intimidating when zombies rule the land, but when those once incarcerated and mistreated are freed and look for a little payback, the nightmare becomes palpable and pulls on our collective social guilt.
Much of this percolates up in the “Dawn of the Planet of the Apes,” the newest chapter in the series reboot that has swapped top-shelf makeup and costume craftsmanship for CGI wizardry and crash bang FX (the old-school costuming is still a wonderment, and more impressive than its computerized successor, especially given the test of time). It’s 10 years after the last episode that left Caesar (Andy Serkis, who as Gollum in “The Lord of the Rings” trilogy elevated animation acting to an art form) and his ape posse living in the woods outside San Francisco. In those years a simian virus has wiped out most of the human population, but pockets persist, including one on the other side of the Golden Gate Bridge in the burned-out bowels of the bay city. The humans wanting to get a dam flowing to get power back on infringe upon the apes’ territory (neither really knew the other existed) and so a rub for resources and rights ensues.
On both sides there’s hawks: Gary Oldman as the shoot-first Dreyfus, leader of the San Fran mob and Koba (Toby Kebbell), the ape scarred in human captivity, who wants a war at all costs and subverts Caesar’s efforts at diplomacy and peace. In the middle looms Malcolm (Jason Clarke, the clear-eyed water torturer in “Zero Dark Thirty”), an engineer, the other voice of reason and a lieutenant to Dreyfus. They’re all idealist, but all that they do is a match in fuel-soaked tinder. Continue reading →
Tags: Ape, Cambridge Day, Film, Planet of the Apes, Review, Sci Fi
Underwater Dreams
Mary Mazzio’s brief but touching pic about five Latin high school boys from an impoverished, landlocked town in Arizona who enter a NASA/Navy sponsored underwater robotics competition, taking on titans like MIT with Exxon sponsorship behind them, percolates with keen social insight that otherwise might have gotten lost in a rote, can-do underdog story. The two high school teachers who sought the opportunity decided to compete on the collegiate level because the disappointment of finishing far back would be mollified by the daunting impressiveness of the field. Had this been a Hollywood “based on” adaptation or a Hallmark fantasy, the Davey vs. Goliath drama would seem trumped up, maudlin and implausible, but as a straight-up documentary with talking heads from both sides of the engineering contest (the Arizona five and the vast MIT squad), it’s head-on, unadulterated and far more affecting than anything that could have been hatched in a studio lab. Continue reading →
Tags: Documentary, Film, Latin, Paste Magazine, Review
‘Life Itself’: Roger Ebert gets his movie, and it’s a romance with film, Chaz, Siskel
Last revised on: Friday, July 4, 2014.
Roger Ebert (loosely paraphrased) felt movies were “machines” for examining life, an extension of dreams, fears, aspirations and so on, places a person might not otherwise venture. The film “Life Itself,” a documentary about Ebert and his final days, is such a poetic reflection, challenging the viewer to take stock of what a life well-lived should look like and what it might be like to confront death.
Ebert, who grew up of modest means in Illinois, was obsessed at a very young age with newspapers and telling stories. At the University of Illinois he relished being the school paper’s editor and making critical editorial and ethical decisions on matters of world-shaping importance, most notably the assassination of John F. Kennedy. He would later stumble into the post of film critic at the Chicago Sun-Times when being a film critic was not a coveted or much respected job. Along with Pauline Kael, Andrew Sarris and Gene Siskel, he helped redefine the role of the critic and transform it into an art form. Continue reading →
Tags: Cambridge Day, Ebert, Film, film critic, Review
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$7.6 million in relief funds paid out to Mississippi agriculture producers
Relief funds have made their way to Mississippi agriculture producers.
Announced by Agriculture and Commerce Commissioner Andy Gipson, over $7.6 has been paid out to 330 farmers, ranchers and agriculture producers through the Mississippi Agriculture Stabilization Act (MASA).
“I am proud to announce that the Mississippi Department of Agriculture and Commerce has been able to directly distribute over $7.6 million to our agriculture producers across the state who have struggled during the pandemic this year,” Commissioner Gipson said. “I want to thank Governor Tate Reeves, Lieutenant Governor Delbert Hosemann, House Speaker Philip Gunn, State Senate Agriculture Chairman Chuck Younger and House of Representatives Agriculture Chairman Bill Pigott for their work on this endeavor.”
The program was created by the Mississippi Legislature using CARES Act funding.
MASA went into law on October 9, 2020, through Senate Bills 3058 and 3061, creating three separate funds within it: the Poultry Farmer Stabilization Grant Fund, the Sweet Potato Farm Sustainment Grant Program Fund and the Mississippi Supplemental CFAP Grant Program Fund. MASA Funds reimbursed agricultural producers for expenses incurred due to the COVID-19 pandemic.
“Our farmers are the lifeblood of Mississippi, and of much of the Nation. They were hit hard by the pandemic,” Lt. Governor Hosemann said. “The Agriculture Stabilization Act created and funded by the Legislature gave hundreds of our farmers a boost of almost $7.7 million during a very difficult time. We are grateful to the Department for administering and marketing this important program.”
“We realize this past year has been a trying time for all Mississippians, including our farmers,” Speaker Gunn said. “I’m glad we were able to quickly pass this legislation out of the House and provide our state’s agricultural producers the help they needed through the Mississippi Agriculture Stabilization Act.”
All unexpended funds were transferred to the state’s Unemployment Compensation Fund.
The post $7.6 million in relief funds paid out to Mississippi agriculture producers appeared first on News Mississippi.
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Home / geography / gk / Agricultural Seasons in India
Agricultural Seasons in India
geography, gk
Agriculture in India dates back to Indus Valley Civilization Era and even before that in some parts of Southern India
The agricultural crop year in India is from July to June.
The Indian cropping season is classified into two main seasons- (i) Kharif and (ii) Rabi based on the monsoon.
The kharif cropping season is from July –October during the south-west monsoon and the Rabi cropping season is from October-March (winter).
CROPPING SEASONS IN INDIA
India has many growing seasons due to prevalence of high temperature through a long period. Different crop seasons are:
(a) Kharif: Crops are sown at the beginning of the south-west monsoon and harvested at the end of the south-west monsoon.
Sowing seasons – May to July
Harvesting season – September to October
Important crops: Jowar, bajra, rice, maize, cotton, groundnut, jute, hemp, sugarcane, tobacco, ete.
(b) Rabi: Crops need relatively cool climate during the period of growth but warm climate during the germination of their seed and maturation.
Sowing season – October to December
Harvesting season – February to April
Important crops: wheat, barley, gram, linseed, mustard, masoor, pea~ and potatoes.
(c) Zaid: Besides the kharif and rabi crops, there are certain crops which are being raised throughout the year due to artificial irrigation.
Zaid kharif crops are sown in August-September and harvested in December-January.
Important crops: rice, jowar, rapeseed, cotton, oilseeds.
Zaid rabi crops are sown in February-March. Harvesting is in April-May.
Important crops: watermelon, toris, cucumber, leafy and other vegetables.
Fact about Indian Agriculture
India ranks second in agricultural output and India is in top five positions for about 80 percent of products produced from farm.
The main food grain of India is rice. India ranks second worldwide in rice production. West Bengal is the top state in rice production followed by Uttar Pradesh, Andhra Pradesh, Punjab, and Bihar. Central rice research institute is located in Cuttack, Odisha.
India ranks fourth in wheat production. Uttar Pradesh is the highest wheat producing state of India.
Some of the millets produced in India are Bajra, Jowar, Ragi. Maharashtra is the highest Jowar producer in India. In Bajra production Rajasthan and in Ragi production Karnataka ranks first.
India is the second most tea producing country and in India Assam is the most tea producing state. Karnataka is the highest coffee producing state.
Sugarcane is one of the main crops produced by India. Uttar Pradesh is the key state in producing sugarcane. Central research centre for sugarcane in located in Lucknow.
Cotton and Jute are the main fiber crops produced in India. Maharashtra is the largest producer of cotton and West Bengal is the largest producer of Jute.
A leading program of Ministry of Agriculture is the Rashtriya Krishi Vikas Yojana, which was launched in 2007 on the recommendations of the National Development Council of India. This program sought to improve the overall state of agriculture in India by providing stronger planning, better co-ordination and greater funding to improve productivity and overall output.
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Human Colonisation in Mars Explained!
Mars Colony
Mars One was founded in 2012, in the Netherlands by Bas Lansdorp. The Program is a non-profit foundation with the goal of establishing a constant human settlement on Mars.
To prepare for this settlement the first unmanned mission is planned to depart in 2020.Crews will depart for their one-way journey to Mars starting in 2026; subsequent crews will depart every 26 months after the initial crew has left for Mars.
200.000 person referred to live in Mars. Mars One announced in 2015 that they selected 100 astronaut candidates.
Mars One Co-Founder & CEO Mr. Lansdorp states about the programme “Since we started Mars One in March 2011, we received support from scientists, engineers, businessmen and –women and aerospace companies from all over the world. The announcement of our plan in May 2012 resulted in the engagement of the general public, and the support from sponsors and investors. To see our mission evolve this way feels like my dream is becoming a reality.”
Bas Lansdorp, Co-Founder & CEO of Mars One, is the Keynote Speaker at “ADDRESS: COLONY STREET NO: 2025, MARS” Session at Global Satshow. Don’t miss this great session about ‘’Early Human Missions’’ on Mars colonisation.
Mars Colonisation: A world beyond the Earth
Mars Colonisation looks distant but feasible. The last few decades have seen the human quest for not to settle for the modest and perseverance to outd ...
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China sidesteps global safety norms, injecting thousands with potentially risky COVID vaccines
Sui-Lee Wee | New York Times | September 30, 2020
A worker performs a quality check in the packaging facility of Chinese vaccine maker Sinovac Biotech. Credit: Thomas Peter/Reuters
The world still lacks a proven coronavirus vaccine, but that has not stopped Chinese officials from trying to inoculate tens of thousands, if not hundreds of thousands, of people outside the traditional testing process. Three vaccine candidates are being injected into workers whom the government considers essential, along with many others, including employees of the pharmaceutical firms themselves.
Officials are laying out plans to give shots to even more people, citing emergency use, amounting to a big wager that the vaccines will eventually prove to be safe and effective.
China’s rush has bewildered global experts. No other country has injected people with unproven vaccines outside the usual drug trial process to such a huge scale.
Related article: Could we be designing babies from a menu of genetic options in 2045?
The vaccine candidates are in Phase 3 trials, or the late stages of testing, which are mostly being conducted outside China. The people in those trials are closely tracked and monitored. It is not clear that China is taking those steps for everyone who is getting the shots within the country.
The unproven vaccines could have harmful side effects. Ineffective vaccines could lead to a false sense of security and encourage behavior that could lead to even more infections.
The wide use of vaccines also raises issues of consent, especially for employees of Chinese vaccine makers and state-owned companies who might feel pressure to roll up their sleeves.
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Matthew Belloni Says THR Exit “100% Amicable,” But “Priorities & Strategies” Friction With Owners
UPDATED WITH BELLONI MEMO: Four years after Matthew Belloni ostensibly took over from Janice Min at The Hollywood Reporter, the long time writer for the Tinseltown trade is exiting in the middle of the challenges of the coronavirus pandemic.
Though stressing in a memo to staff that the move is “100% amicable,” Belloni also revealed some serious tension at the top of the Valence Media-owned magazine that maybe rendered things untenable. “Today’s announcement is the result of a series of conversations I’ve had for a few months with Modi [Valence co-chief Wiczyk] about the direction at THR,” the now former editorial director says. “Some may want to read into that, but I’ll just say that well-meaning, diligent, ambitious people can disagree about fundamental priorities and strategies.” (READ THE FULL MEMO BELOW)
Cinemark Gets Big Vote Of Confidence From Veteran Analyst, Who Sees "Return To Normalcy" For Movie Theaters
Part of that disagreement: Valence wanting a heads up or some say over THR stories that put a harsh spotlight on its industry allies, I hear. “It wasn’t quite editorial control, but they wanted a slant that made them not the bad guy,” a well placed source tells me of the real deal. “They also wanted more ink for their other interests, like Dick Clark Productions.”
None of that was in the standard corporate speak statement from Valence Media’s co-CEOs on Monday
“We respect and like Matt a great deal,” Wiczyk and Asif Satchu said in a statement Monday announcing Belloni’s exit. “It has been enjoyable to work together, and we greatly admire his commitment to impactful journalism,” they added, of Belloni’s long stint at the mag. “He has pushed the team to hold itself to a high standard, and we are proud of the work he and the entire editorial group have done these past years.”
Tellingly, the statement from Wiczyk and Satchu gives no specific indication as to why Belloni was abruptly shown the door, especially during such a time of growing economic hardship for the industry and the world in general. Noticeably, it also did not reveal if this is the first of other changes to come at THR as belts tighten due to the consequences of the COVID-19 crisis.
However, as an indication of lingering friction at the mag, THR’s executive editor Stephen Galloway left to take an academic gig at almost 30 years at the publication.
In a March meeting held by the owners, they promised there would be no layoffs due to coronavirus constraints – but an insider tells me that Belloni’s exit could tug at the loyalty of staffers.
Trained as a lawyer before entering entertainment journalism, Belloni will continue for the next month in an editorial consultant capacity for THR. Unlike when Min left in 2016, no successor has been unveiled for the top THR job as of yet.
READ THE FULL MEMO FROM MATT BELLONI TO THR STAFF HERE:
I’m writing today to break news that many of you thought you’d never read: I’m leaving The Hollywood Reporter.
Change is good; you gotta reinvent to thrive; do something that scares you every day; etc, etc. All the clichés are clichés because they’re true: It’s time for something new for me (and, alas, a new Twitter handle).
But leaving this place is still hard, mostly because I won’t be working with all of you.
My 14 years at THR have been the greatest of my professional life. I arrived as a young lawyer (thanks to Bob Dowling and Norah Weinstein for the opportunity — and the pay cut!), participated in one of the greatest media relaunches ever (thanks to the uniquely talented Janice Min) and had the opportunity to lead this staff at a time of immense disruption and the MeToo movement. It’s been a privilege to lead this group of amazing media people — a nonstop, 24/7 , nerve-wracking, gray hair-inducing, often absurd and hilarious privilege — and most of all challenging and rewarding.
Together we’ve created so much impactful and enlightening journalism. Together we’ve earned all those National Magazine Award nominations. Together we’ve elevated what an industry print magazine can be, blown past our competitors and grown THR’s web audience to nearly 25 million uniques a month (our past three months have been our biggest ever!). And together we have created a collaborative and supportive team culture, one that allows us to maintain a high level of quality and insane volume while only wanting to kill each other a few times a year during awards seasons.
None of this would have been possible without Todd Boehly, THR’s owner for many of these years, who has supported me personally and who understands the value of a thriving brand. Thanks also to the Valence CEOs Modi and Asif for their leadership these past few years, to the incomparable Lynne Segall, who is everything that an editor could want in a publisher, and to Stephen Galloway for mentoring me early on and helping me to grow as an editor and manager.
There are just too many people on this current staff to mention in an email like this, so I’m going to reach out to people personally in the next few days. Thanks to each of you for playing a role in our success, for the relationships we have forged, for the late nights, for the break-the-internet stories, for the gorgeous cover shoots and videos, for enduring the Hollywood screamers, for the frustrating no’s, the improbable yeses and for giving me the confidence to take chances and defy expectations.
Also a shout-out to my wife Kimberlin for living through the many, many intrusions that this crazy job entails. OK, now this is veering into bad Oscar speech territory….
Journalists being journalists, some may wonder: Why now? No, the current global situation didn’t play a role in my exit. (In fact, it makes it even harder to leave this team when we’re rising to the occasion and covering the crisis as well as we are.) Today’s announcement is the result of a series of conversations I’ve had for a few months with Modi about the direction at THR. Some may want to read into that, but I’ll just say that well-meaning, diligent, ambitious people can disagree about fundamental priorities and strategies.
That’s what happened here, and my exit is 100% amicable. I’ll be rooting for THR from afar, and I know that my personal friendships with all my colleagues here will endure. I’ll be around for the next month to tie up loose ends and hopefully position THR for a new editor to make her or his mark. I hope I’ve made mine.
Matthew Belloni
Syl Sylvain Dies: Cofounding Guitarist Of The New York Dolls Was 69
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deemagclinic
chronic migraine and autonomic system
dedicated to neuropsychiatry and epileptology
Breaking Down COVID-19
01/11/2020 · by deemagclinic · in neuropsychiatry · Leave a comment
Carey Kriz • Naiyer Imam Sarah Zaidi
A Living Textbook Publication of First Medicine and Global Clinical Partners
Carey Kriz • Naiyer Imam • Sarah Zaidi
A Living Textbook
Publication of First Medicine and Global Clinical Partners
Overview of COVID-19 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1 Carey Kriz, Naiyer Imam M.D., and Sarah Zaidi Sc.D., MSc.
. 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
. 1.2 COVID-19 Outbreak to Pandemic Status . . . . . . . . . . . . . . . . 2
. 1.3 Human Coronaviruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
. 1.4 Cross-Species Transmission. . . . . . . . . . . . . . . . . . . . . . . . . . . 6
. 1.5 Past Pandemics and COVID-19 in the Context of History . . . 8
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Virology and the Immune System Response to COVID-19 � � � 13 Carey Kriz and Syed Imran Ahmad
. 2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
. 2.2 SARS-CoV-2 Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
. 2.3 The Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
. 2.3.1 Innate Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
. 2.3.2 Adaptive Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . 17
. 2.3.2.1 Humoral immunity . . . . . . . . . . . . . . . . . . 17
. 2.3.2.2 Cell-mediated immunity . . . . . . . . . . . . . . 18
. 2.4 Pathophysiology of SARS-CoV-2 . . . . . . . . . . . . . . . . . . . . . 19
. 2.4.1 Interaction between SARS-CoV-2 and ACE2 . . . . . . 20
. 2.4.2 Pathogenesis and Biochemistry. . . . . . . . . . . . . . . . . 20
. 2.4.3 Pathophysiology of COVID-19-Related
Organ System Involvement . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Transmission, Prevention, and Risk Factors
of COVID-19� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 25 Naiyer Imam M.D., Sarah Zaidi Sc.D., MSc.,
and Arijit Robin Chakraborty 25
. 3.2 Viral Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
. 3.3 Reproductive Rate and Dispersion. . . . . . . . . . . . . . . . . . . . . 27
Outpatient Management: Mild and Moderate
Symptoms of COVID-19 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37 Naiyer Imam M.D., Nooshi Karim M.D.
and Abena Baah-Fordjour
. 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 4.2 COVID-19 Overview of Symptoms. . . . . . . . . . . . . .
. 4.3 Current Management Strategies for Mild Disease. . .
Pulmonary Manifestations of COVID-19 � � � � � � � � � � � � � � � � � � � � � 47 Syed Mehdi M.D., Nishat Mehdi M.D.,
and Sabbir Chowdhury
. 5.2 Origins, Transmission, and Pathogenesis of
. 3.4 Assessing Risk of Transmission. . . . . . . . . . . . . . . . . . . . . . . 28
. 3.5 Individual Disease Prevention . . . . . . . . . . . . . . . . . . . . . . . . 28
. 3.6 Community Prevention: Nonpharmaceutical
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
. 3.7 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
. 3.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
. 4.3.1 Management of Underlying Conditions with COVID-19 Infection . . . . . . . . . . . . . . . . . . .
. 4.3.2 Protective Health Measures. . . . . . . . . . . . . .
4.4 Management by Telemedicine . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 43 . . . . . . 44 . . . . . . 44 . . . . . . 46
COVID-19 Disease . . . .
. 5.3 Pathophysiology. . . . . . .
. 5.3.1 Symptoms . . . . .
. 5.3.2 Happy Hypoxics
. 5.3.3 Mechanism . . . .
. 5.4 Respiratory Failure. . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
. 5.5 COVID-19 and Pulmonary Embolisms . . . . . . . . . . . . . . . . . 52
. 5.6 COVID-19 and COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
. 5.7 COVID-19 and Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
. 5.8 COVID-19 and Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . 55
. 5.9 Acute Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . 55
. 5.9.1 Diagnostic Criteria . . . . .
. 5.9.2 Clinical Features . . . . . . .
. 5.9.3 Types of ARDS . . . . . . . .
. 5.10 Outcome with Ventilated Patients
. 5.11 Treatment . . . . . . . . . . . . . . . . . . .
. 5.11.1 Interferon (IFN-λ) . . . . . .
. 5.11.2 Steroids . . . . . . . . . . . . . .
. 5.11.3 Tocilizumab. . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 55 . . . . . . . . . . . . . . . . . . . . . 56 . . . . . . . . . . . . . . . . . . . . . 56 . . . . . . . . . . . . . . . . . . . . . 57 . . . . . . . . . . . . . . . . . . . . . 57 . . . . . . . . . . . . . . . . . . . . . 58 . . . . . . . . . . . . . . . . . . . . . 58 . . . . . . . . . . . . . . . . . . . . . 58
. . . . . . 37 . . . . . . 37 . . . . . . 38
. 5.11.4 Chloroquine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
. 5.11.5 Remdesivir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Cardiovascular Manifestations of COVID-19 � � � � � � � � � � � � � � � � � 63 Arshad Quadri M.D., Samer Kabbani M.D.,
Syed Raza M.D., and Urmila Bharathan
. 6.2 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
. 6.3 The Role of ACE2 in the Cardiovascular System
during COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
. 6.4 Cardiac In ammation due to SARS-CoV-2. . . . . . . . . . . . . . 65
. 6.5 Heart Failure due to SARS-CoV-2. . . . . . . . . . . . . . . . . . . . . 66
. 6.6 Stress Cardiomyopathy due to SARS-CoV-2 . . . . . . . . . . . .66
. 6.7 Vascular Manifestations of COVID-19 . . . . . . . . . . . . . . . . . 66
. 6.8 Possible Long-Term Cardiovascular Implications
Following COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Central Nervous System (CNS) Manifestations
of COVID-19� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 71 Intezam Khan M.D., Usman Mirza M.D.,
Riyaz Ahmad M.D., MRCP, Naiyer Imam M.D.,
and Eesha Imam
. 7.2 How SARS-CoV-2 Can Infect the Nervous System . . . . . . . 72
. 7.3 Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
. 7.4 Acute Encephalitis and Meningitis . . . . . . . . . . . . . . . . . . . . 75
. 7.5 Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
. 7.6 Peripheral Nervous System Manifestations. . . . . . . . . . . . . .76
. 7.7 Skeletal Muscle Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Gastrointestinal Manifestations of COVID-19� � � � � � � � � � � � � � � � 83 Lawrence Kogan M.D., Chung Sang Tse M.D.,
Farhan Qureshi, and Samir A. Shah M.D., FACG
. 8.1 Introduction . . . . . . . . . . . . . . . . . . . .
. 8.2 Presentation . . . . . . . . . . . . . . . . . . . .
. 8.3 Endoscopy and Risk of Transmission
. 8.4 Liver Diseases . . . . . . . . . . . . . . . . . .
. 8.5 In ammatory Bowel Disease . . . . . . .
. 8.6 Celiac Disease . . . . . . . . . . . . . . . . . .
. 8.7 GI Cancers . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 83 . . . . . . . . . . . . . . . . . . 84 . . . . . . . . . . . . . . . . . . 85 . . . . . . . . . . . . . . . . . . 87 . . . . . . . . . . . . . . . . . . 87 . . . . . . . . . . . . . . . . . . 88 . . . . . . . . . . . . . . . . . . 88
Dermatological Manifestations of COVID-19 � � � � � � � � � � � � � � �113 Saeed Jaffer M.D. and Ashley Slack
. 11.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
. 11.2 Clinical Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
. 11.3 PPE Usage Impact on Patients . . . . . . . . . . . . . . . . . . . . . . . 122
. 11.4 PPE Usage Impact on Health-care Workers. . . . . . . . . . . . . 123
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Ophthalmological Manifestations of COVID-19� � � � � � � � � � � � �125 Ejaz Hussein M.D. and Eesha Imam
. 12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
. 12.2 Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
. 12.3 Precautions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
. 10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 10.2 Mechanisms of Increased COVID-19 Severity in Diabetic Patients . . . . . . . . . . . . . . . . . . . . .
. 10.3 Managing Diabetes in COVID Patients . . . . . .
. . . . . . . . . . 103
. . . . . . . . . . 104 . . . . . . . . . . 105 . . . . . . . . . . 107 . . . . . . . . . . 107 . . . . . . . . . . 108 . . . . . . . . . . 108 . . . . . . . . . . 109 . . . . . . . . . . 109 . . . . . . . . . . 110
. 10.4 Other Endocrine Diseases . . . ..
. 10.4.1 Adrenal Insuf ciency ..
. 10.4.2 Subacute Thyroiditis . . .
. 10.5 Telemedicine . . . . . . . . . . . . . ..
. 10.6 Tools for Health-Care Providers
. 10.7 Conclusion . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . .
. ………. . ………. . . . . . . . . . . . . ………. . ………. . ………. . . . . . . . . . . .
. 8.8 Telehealth in GI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
. 8.9 Proton Pump Inhibitors and COVID-19 . . . . . . . . . . . . . . . . 91
. 8.10 Tools for Health-care Providers . . . . . . . . . . . . . . . . . . . . . . . 92
Renal Manifestations of COVID-19 � � � � � � � � � � � � � � � � � � � � � � � � � � � 95 Syed Muzaffar Ahsan M.D., Shariq Haider Hashmi M.D.,
and Sundus Nasim
. 9.3 Pathophysiology of COVID-19 Renal Manifestations . . . . . 97
. 9.4 Monitoring COVID-19 Patients for AKI . . . . . . . . . . . . . . . . 98
. 9.5 Early Management of AKI. . . . . . . . . . . . . . . . . . . . . . . . . . . 99
. 9.6 Note on Venous Thromboembolism (VTE)
and Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
. 9.7 Note on ACE Inhibitor and ARB Usage in COVID-19 . . . . 101
. 9.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Endocrine Manifestations of COVID-19 � � � � � � � � � � � � � � � � � � � � �103 Sudhir Bansal M.D. and Farhan Qureshi
. 12.3.1 Personal Protective Equipment (PPE). . . . . . . . . . . 126
. 12.3.2 Chloroquine and Hydroxychloroquine . . . . . . . . . . 126
. 12.4 Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
. 12.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Mental Health Manifestations of COVID-19� � � � � � � � � � � � � � � � �131 Syed Ashraf Imam Ph.D.,
Mehran Javeed MBChB, MRCPsych, PGCert,
and Joseph Kennedy
. 13.2 Pandemics in History and Psychological Impacts . . . . . . . . 131
. 13.3 Effects on Different Populations . . . . . . . . . . . . . . . . . . . . . 133
. 13.3.1 Mental Health in Patients with COVID-19 . . . . . . . 133
. 13.3.2 Psychological Health in Patients with
Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
. 13.3.3 Psychological Health in Health-Care Workers . . . . 134
. 13.3.4 Psychological Health in the General Population. . . 135
. 13.4 Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
13.4.1 What you can do (Syed Ashraf Imam, PhD;
Clinical Psychologist) . . . . . . . . . . . . . . . . . . . . . . . 136 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Pediatric Manifestations of COVID-19 � � � � � � � � � � � � � � � � � � � � � �143 Ishrat Quadri M.D. and Nicholas Barresi M.D.
. 14.3 Newborn and Infant Considerations . . . . . . . . . . . . . . . . . . 145
. 14.3.1 Mother-to-Child (Vertical) Transmission . . . . . . . . 145
. 14.3.2 Breastfeeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Syndrome Potentially Associated with COVID-19 . . . . . . . 149 14.9 Update 2: July 1, 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Radiology of Chest Imaging in COVID-19 � � � � � � � � � � � � � � � � � � �155 Vineet R. Jain M.D., Naiyer Imam M.D.,
Khursheed Imam M.D., Sanjay Saini M.D.,
Ruhani Doda Khera M.D., Lilah Sanduby, and Azwade Rahman
15.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
. 14.4 Prevention . . . . . .
. 14.5 Diagnosis . . . . . . .
. 14.6 Management. . . . .
14.6.1 Outpatient
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
14.6.2 Inpatient. .
. 14.7 Discussion . . . . . .
. 14.8 Update 1: Pediatric Multisystem In ammatory
. 15.2 Radiological Manifestations of SARS and MERS . . . . . . 155
. 15.3 Radiological Findings of COVID-19 . . . . . . . . . . . . . . . . . 156
. 15.3.1 Chest X-Rays (CXR) . . . . . . . . . . . . . . . . . . . . . . . 156
. 15.3.2 Computed Tomography . . . . . . . . . . . . . . . . . . . . . 159
. 15.3.3 CT Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
. 15.3.4 CT Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
. 15.3.5 CT Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
. 15.4 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
. 15.5 Magnetic Resonance Imaging (MRI). . . . . . . . . . . . . . . . . 168
Severe COVID-19 and ICU � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �171 Hasmeena Kathuria M.D.,
Syed E. Ahmad M.D., and Bethany Sullivan
. 16.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
. 16.2 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
. 16.3 Initial Testing and Imaging . . . . . . . . . . . . . . . . . . . . . . . . 172
. 16.4 Etiology of Hypoxemic Respiratory Failure
in COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
. 16.5 Management of Hypoxemia in Nonintubated Patients . . . 174
Post-Recovery and Long-Term Complications � � � � � � � � � � � � � �187 Ejaz Ahmad M.D., Sarah Zaidi Sc.D., MSc.,
Gary Shmorgon, and Carmina Rogelio
. 17.2 SARS—Post-Recovery and Long-Term Complications . . 187
. 16.6 Management of Intubated Patients. . . . . . . . . . . . . .
. 16.6.1 Lung Protective Ventilation . . . . . . . . . . . . .
. 16.6.2 PEEP Titration . . . . . . . . . . . . . . . . . . . . . . .
. 16.6.3 Conservative Fluid Management . . . . . . . . .
. 16.6.4 Prone Ventilation . . . . . . . . . . . . . . . . . . . . .
. 16.6.5 Inhaled Pulmonary Vasodilators . . . . . . . . .
. 16.6.6 Veno-Venous Extracorporeal Membrane
Oxygenation (VV ECMO) . . . . . . . . . . . . .
. 16.7 Sedation/Analgesics/Paralytics . . . . . . . . . . . . . . . .
. 16.8 Weaning and Extubation . . . . . . . . . . . . . . . . . . . . .
. 16.9 Tracheostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16.9.1 Tracheotomy Recommendations during the COVID-19 Pandemic. . . . . . . . . . . . . . . . . .
. 16.10 Cytokine Storm . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 16.11 Shock Management . . . . . . . . . . . . . . . . . . . . . . . . .
. 16.12 Anticoagulation in COVID-19 Patients . . . . . . . . . .
. 16.13 Corticosteroids in COVID-19 Patients. . . . . . . . . . .
. 16.14 Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 16.15 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 175 . . . . . 175 . . . . . 175 . . . . . 176 . . . . . 176 . . . . . 177
. . . . . 177 . . . . . 178 . . . . . 179 . . . . . 179
. . . . . 180 . . . . . 180 . . . . . 181 . . . . . 181 . . . . . 182 . . . . . 182 . . . . . 182 . . . . . 183
. 17.3 MERS—Post-Recovery and Long-Term Complications . . . 189
. 17.4 Post-Recovery Phase of COVID-19. . . . . . . . . . . . . . . . . . . 190
Personal Protective Equipment (PPE) and Hospital Preparedness for COVID-19� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �195 Ehsun Mirza M.D. and Arijit Robin Chakraborty
. 18.2 Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . 195
. 18.3 Hospital Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Testing for COVID-19� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �205 Sarah Zaidi Sc.D., MSc., and Naiyer Imam M.D.
. 19.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
. 19.3 Types of Tests—NAAT, Antibody, and Antigen . . . . . . . . . 206
. 19.4 Sensitivity, Speci city, and Accuracy in Testing . . . . . . . . . 208
. 19.5 Interpretation of Tests: Understanding Predictive Values . . 209
Drugs for Treating COVID-19� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �213 Syed E. Ahmad M.D., Nooshi Karim M.D.,
Kruti Shah M.D., Allen Jo, and Carmina Rogelio
. 20.1 Introduction . . . . . . . . . . . . . .
. 20.2 Convalescent Plasma . . . . . . .
. 20.3 Antiviral, Antiretroviral . . . . .
. 20.3.1 Remdesivir . . . . . . . .
. 20.3.2 Lopinavir/Ritonavir. .
. 20.3.3 Favipiravir . . . . . . . . .
. 20.3.4 Oseltamivir (Tami u)
. 20.3.5 SNG001. . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 213 . . . . . . . . . . . . . . . . . . . . . . . 215 . . . . . . . . . . . . . . . . . . . . . . . 216 . . . . . . . . . . . . . . . . . . . . . . . 216 . . . . . . . . . . . . . . . . . . . . . . . 217 . . . . . . . . . . . . . . . . . . . . . . . 218 . . . . . . . . . . . . . . . . . . . . . . . 218 . . . . . . . . . . . . . . . . . . . . . . . 219
20.4 Antimalarial—Hydroxychloroquine/Chloroquine . . . . . . . . 219
. 20.5 Antibiotics . . . . . . . . . . . . . . . . . . . . ……..
. 20.5.1 Azithromycin. . . . . . . . . . . . . . . . . . . .
. 20.5.2 Clofazimine . . . . . . . . . . . . . . . . . . . . .
. 20.6 Monoclonal Antibodies . . . . . . . . . . ……..
20.6.1 Tocilizumab (Actemra) and Sarilumab
. . . . . . . . . . 220 . . . . . . . . . . 220 . . . . . . . . . . 221 . . . . . . . . . . 221
. . . . . . . . . . 221 . . . . . . . . . . 221 . . . . . . . . . . 222 . . . . . . . . . . 222 . . . . . . . . . . 222 . . . . . . . . . . 222 . . . . . . . . . . 223
(Kevzara) . . . . . . . . . . . . . .
. 20.6.2 Canakinumab (Ilaris). . . . .
. 20.6.3 Leronlimab . . . . . . . . . . . .
20.7 Kinase Inhibitor . . . . . . . . . . . . . . .
. 20.7.1 Acalabrutinib (Calquence)
. 20.7.2 Baricitinib (Olumiant). . . .
. 20.7.3 Tofacitinib (Xeljanz) . . . . .
. . . . . . . . . . …….. . …….. . …….. . …….. . …….. . ……..
Vaccines for COVID-19 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �235 Syed E. Ahmad M.D. and Allen Jo
. 21.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
. 21.2 What Are Viral Vaccines? . . . . . . . . . . . . . . . . . . . . . . . . . . 235
. 21.3 What Are the Risks Associated with Viral Vaccines? . . . . . 235
. 21.4 SARS-CoV-2 Vaccines in Development
20.9 Nonspeci c Anti-in ammatory
. 20.9.1 Dexamethasone . . . . . . .
. 20.9.2 Methylprednisolone. . . .
. 20.9.3 Ciclesonide . . . . . . . . . .
. 20.9.4 Budesonide/Formoterol .
. . . . . . . . . . . . . . . . . . . . . 224 . . . . . . . . . . . . . . . . . . . . . 224 . . . . . . . . . . . . . . . . . . . . . 224 . . . . . . . . . . . . . . . . . . . . . 224 . . . . . . . . . . . . . . . . . . . . . 225 . . . . . . . . . . . . . . . . . . . . . 225 . . . . . . . . . . . . . . . . . . . . . 225 . . . . . . . . . . . . . . . . . . . . . 225 . . . . . . . . . . . . . . . . . . . . . 225 . . . . . . . . . . . . . . . . . . . . . 226 . . . . . . . . . . . . . . . . . . . . . 226
. 20.10 Anti-In ammatory Colchicine
. 20.11 Antiparasitic . . . . . . . . . . . . . .
. 20.11.1 Nitazoxanide . . . . . . .
. 20.11.2 Ivermectin . . . . . . . . .
. 20.12 Radiation. . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . .
and WHO Database . . . . . . . . . .
. 21.4.1 Viral Vector Vaccines and Vector Vaccines . . . . . . . .
. 21.4.2 RNA Vaccines . . . . . . . . .
. 21.4.3 DNA Vaccines . . . . . . . . .
. 21.4.4 Live Attenuated Vaccines
. 21.4.5 Inactivated Vaccines . . . .
. 21.4.6 Subunit Vaccines and Viral-Like
Socioeconomic, Racial, and Cultural Considerations� � � � � � � �245 Sarah Zaidi Sc.D., MSc., Rohan Iyer,
and Azwade Rahman
. 22.2 Social Determinants of Health Framework . . . . . . . . . . . . 245
. 22.3 Race and COVID-19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
. 22.4 Caste and COVID-19 in India. . . . . . . . . . . . . . . . . . . . . . . 249
. 22.5 Incarceration and COVID-19 . . . . . . . . . . . . . . . . . . . . . . . 250
Particle Vaccines . . . . . . . . . . . . 21.5 Who will Get the First Vaccines? . . . . .
…. . 21.6 Will these Vaccines Protect against a Mutated SARS-CoV-2 Virus? . . . . . . . . . . . . . . . . . . . .
. 21.7 Will These Vaccines Produce Long-Term Immunity? . . . . 240
. 21.8 Antivaxxers and Vaccine Ef cacy. . . . . . . . . . . . . . . . . . . . 241
. . . . . . . . . . Adenoviral
. . . . . . . . . . 236 . . . . . . . . . . 238 . . . . . . . . . . 238 . . . . . . . . . . 238 . . . . . . . . . . 239
. . . . . . . . . . 239 . . . . . . . . . . 240
. 20.7.4 Ruxolitinib (Jaka ) . . . . . . . . . . . . . . . . . . . . . . . . . 223
. 20.7.5 Apilimod . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
20.8 Immunomodulator: Anakinra (Kineret) . . . . . . . . . . . . . . . 223
. 22.6 Immigrants and COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . 251
. 22.7 Economic Inequalities and COVID-19 . . . . . . . . . . . . . . . . 252
Health-Care Policy and COVID-19� � � � � � � � � � � � � � � � � � � � � � � � � � �257 Apurv Gupta M.D., Hemant Gupta M.D.,
Andrew Cooper J.D., Sarah Zaidi Sc.D., MSc.,
Azwade Rahman, Rohan Iyer, and Terran Cooper
. 23.2 East and Southeast Asian Response . . . . . . . . . . . . . . . . . . . 258
. 23.3 Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
. 23.4 Oceania—Australia and New Zealand. . . . . . . . . . . . . . . . . 264
. 23.5 The Americas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
. 23.6 Conclusion: Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . 267
Looking Beyond the COVID-19 Pandemic� � � � � � � � � � � � � � � � � � �275 Carey Kriz, Chirinjeev Kathuria M.D., MBA,
. 24.2 How Might the Pandemic End? . . . . . . . . . . . . . . . . . . . . . . 275
. 24.2.1 If Immunity is Permanent, then Covid-19 is a Relatively Brief and Intense Pandemic . . . . . . . . . . 276
. 24.2.2 If Immunity is Temporary and not Permanent, then Covid-19 Enters Regular Circulation of Other Respiratory Infections . . . . . . . . . . . . . . . . . . . . . . . 276
. 24.3 The Future of COVID-19 and Dealing with the Years Ahead . . 277
. 24.3.1 Ongoing Mitigation. . . . . . . . . . . . . . . . . . . . . . . . .277
. 24.3.2 Dealing with the Aftermath. . . . . . . . . . . . . . . . . . . 278
List of Contributors� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �283 Index � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �293
Introduction to COVID-19 Living Textbook
COVID-19 Coronavirus disease 2019
HIV Human immunode ciency virus
MERS Middle East respiratory syndrome
SARS Severe acute respiratory syndrome SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2
The world is amidst a pandemic that is presenting one of the greatest public health challenges of the twenty- rst century. A new coronavirus has jumped the interspe- cies barrier, and it possesses the capability of ef cient person-to-person transmis- sion and selectively kills older people and those with underlying chronic conditions. Since its emergence the new coronavirus has resulted in 43.7 million infections and over 1 million deaths as of October 25, 2020—20% of deaths are in the United States followed by Brazil (14%), India (10%), Mexico (7.8%), and the United Kingdom (4%).1
The new disease emerged in December 2019 in Wuhan, China, and the early cases appeared to be associated with a local wholesale sh and live animal market.2 The cluster of patients exhibited respiratory features of pneumonia and acute respi- ratory distress syndrome as seen in the severe acute respiratory syndrome (SARS) coronavirus of 2002–2003, leading the scientists to suspect a virus of zoonotic ori- gins. On December 31, the Chinese authorities informed the World Health Organization (WHO) of the outbreak, putting the organization on emergency foot- ing.3 The WHO issued comprehensive technical guidance online with advise to all countries on how to detect, test, and manage emerging infections based on previous experience with SARS and the Middle East respiratory syndrome (MERS) outbreak of 2012.4 In mid-January, Chinese authorities announced a novel coronavirus with genetic structure similar to SARS (80%), and with its origins in bats, it was the cause of the new disease.5 The virus was of cially named the severe acute respira- tory syndrome coronavirus 2 (SARS-CoV-2) and the disease it caused the Coronavirus Disease 2019, or COVID-19.6
Chinese authorities tried to contain the outbreak by imposing quarantines, social distancing, and testing, contact tracing, and isolating infected people. The entire Wuhan city of 11 million and Hubei Province of nearly 60 million, and later a quar- ter million people in other parts of China, were put under lockdown.7 But global transportation systems having morphed over a period of 100 years from slow trick- les of population from one place to another to instantaneous shifts between conti- nents made it dif cult to contain outbreaks of COVID-19. Forty years earlier, the spread of HIV in the world had established how quickly a virus could spread between continents through simple air travel by an infected person. In this century, SARS, MERS, Zika, and the Ebola virus outbreaks all demonstrated the ease with which travelers could spread emerging pathogens. SAR-CoV-2 is no different, and it is even more ef cient at transmission.8
In the rst 3–4 months of the outbreak, person-to-person transmission taking place before the infected person showed any symptoms of the disease, undetected cases of COVID-19 infection accounted for 79% of documented infections.9 In less than two months, SARS-CoV-2 went from a public health emergency to a disease of pandemic status, declared such on March 11, 2020, by WHO.10 At that time, there were 118,000 cases and 4291 deaths. Over 90% of cases were in just four countries: China (80,955 cases and 3162 deaths), Italy (10,149 cases and 631 deaths), Iran (8042 cases and 291 deaths), and South Korea (7755 cases and 60 deaths).11 But the number of cases in countries kept increasing rapidly.
As SARS-CoV-2 spread rapidly encountering a population that hand no immu- nity and health-care systems that were unprepared, the virus claimed many lives. Although less deadlier than SARS, which had a case fatality rate of 10%, and the in uenza pandemic of 1917 that had a mortality risk of 2%, COVID-19 appeared to be more deadly than seasonal in uenza (0.1% mortality risk).12 Scientists estimated that the mortality risk for COVID-19 ranged from 0.2% to 1.0%, and was to increase substantially for people aged 60 years and older (6.38%) compared with those under 60 years (0.318%). The highest case fatality rates were seen in people in their 70s (8.61%) and 80s (13.4%) years of age.13 However, a number of other factors such as sex (males), chronic comorbidities such as diabetes, obesity, cardiovascular disease, hypertension, and other social determinants were emerging as risk factors for COVID-19 infection and mortality.14, 15
As a new disease, COVID-19 required an effective response to slow down spread and prevent health systems from becoming overwhelmed. Countries implemented travel restrictions and full or partial lockdowns,16 which slowed down transmission but had devastating socioeconomic consequences and resulted in a global reces- sion.17 Nonetheless, it was evident that basic public health measures such as testing, tracing, isolating infected cases and quarantining others, wearing facemasks, and practicing good hand hygiene were important interventions for reducing transmis- sion and mortality.18 Over the past 10 months, promising new vaccines and a number of existing antiviral drugs and other treatments have emerged and are being used to manage the disease.19–21
Since its interspecies jump, the global public health and medical communities have learned a lot about the virus. An unprecedented amount of information has been
published on COVID-19, with tens of thousands of papers being made available for free.22 The sheer deluge of publications makes it dif cult to keep up with the scien- ti c literature and to assess the quality of publications given that many are in the form of preprints awaiting peer-review process. In the face of the ood of scholarly outputs, the impetus for putting together an online textbook is to make available, and easily accessible, information that has been carefully curated and reviewed from the public domain in one place, and to update it as new information comes forward.
The COVID-19 Living Textbook is prepared by 55 experts (medical doctors, social scientists, and medical students, who are experts in their eld and many of them have been working on the frontline of the COVID-19 response). It is aimed at a wide range of audiences, including clinicians, public health specialists, social sci- entists, and the general public. Twenty-four chapters cover a range of topics that are divided into four sections.
• Section 1: Chapters 1, 2, 3, and 4 introduce SARS-CoV-2 and COVID-19, and include the timeline of events; the virology and immunopathology, transmis- sion, prevention; and risk factors for COVID-19; and outpatient management of mild to moderate infection.
• Section 2: Chapters 5–18, forming the bulk of the text, focus on the system responses by the body to COVID-19 and clinical management in hospitals, including in children and adolescents (Chapter 15). Chapter 17 discusses the management of severe cases of COVID-19, and Chapter 18, given the limited available data, examines postrecovery complications and long-term impacts, and compares it with the experience from SARS and MERS.
• Section 3: Chapters 19, 20, and 21 review the situation with personal protec- tive equipment, diagnostics, and treatments and vaccines.
• Section 4: The nal three chapters (Chapters 22–24) discuss the systemic dis- crimination and inequalities that put certain groups at greater risk for the dis- ease, public policy making and leadership, and planning for future epidemics and pandemics as new viruses that make the interspecies jump to humans and begin another evolutionary path in a new host family.
The COVID-19 pandemic, and the global response to it, has demonstrated that emerging and reemerging zoonotic diseases represent a public health challenge. It further reminds the global community about the impact of inequality, the gap between the “haves” and “have-not,” and the importance of social determinants of health. Even in the largest economies of the world, including the United States of America, those groups with less opportunity including Blacks, Hispanics, and Native American have higher rates of mortality.23
The legacy of COVID-19 will have long-lasting effects on society, including on the delivery of medicine. COVID-19 has ushered in, and with great success, telemedicine (TM) services.24 TM is being used to triage and treat basic illnesses, monitor chronic diseases, and diagnose mild cases of COVID-19. While the pandemic is an unfortu- nate occurrence, it provides an opportunity to set up an infrastructure to deliver health care to everyone in an equitable, convenient, and cost-effective manner.
1. Johns Hopkins University. Coronavirus Resource Center. October 9, 2020. Johns Hopkins University. https://coronavirus.jhu.edu/map.html. Accessed October 9, 2020.
2. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavi- rus in Wuhan, China. Lancet. 2020;395(10223):497–506. https://www.thelancet.com/journals/ lancet/article/PIIS0140-6736(20)30183-5/fulltext.
3. World Health Organization. Novel Coronavirus (2019 n-CoV) Situation Report 1. World Health Organization. January 21, 2020. https://www.who.int/docs/default-source/coronavi- ruse/situation-reports/20200121-sitrep-1-2019-ncov.pdf.
4. World Health Organization. WHO Timeline—COVID-19. World Health Organization. April 27, 2020. https://www.who.int/news-room/detail/29-06-2020-covidtimeline.
5. Zhou P, Yang XL, Wang XG, et al. Discovery of a novel coronavirus associated with recent pneumonia in human and its potential bat origin. Microbiology. 2020. https://doi. org/10.1101/2020.01.22.914952.
6. Center for Health Security. SARS-CoV-2 Genetics. Johns Hopkins Bloomberg School of Public Health. April 16, 2020.
7. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239–1242. https://doi. org/10.1001/jama.2020.2648.
8. Contini C, Di Nuzzo M, Barp N, et al. The novel zoonotic COVID-19 pandemic: an expected global health concern. J Infect Dev Ctries. 2020;14(3):254–264. https://doi.org/10.3855/ jidc.12671.
9. Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemi- nation of novel coronavirus (SARS-CoV-2). Science. 2020;368(6490)489–493. https://doi. org/10.1126/science.abb3221.
10. World Health Organization. WHO Director-General’s Opening Remarks at the Media Brie ng on COVID-10. Geneva: World Health Organization; 2020.
11. World Health Orgnization. Coronavirus Disease 2019 (COVID-19) Situation Report-51. Geneva: World Health Organization; 2020.
12. Petersen E, Koopmans M, Go U, et al. Comparing SARS-CoV-2 with SARS-CoV and in u- enza pandemic. Lancet Infect Dis. 2020;20(9):E238–E244. https://www.thelancet.com/ journals/laninf/article/PIIS1473-3099(20)30484-9/fulltext.
13. Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis. 2020;20:669–677. https://doi.org/10.1016/ S1473-3099(2)30243-7.
14. Zhou F, Yu T, Du R. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395(10229)1054– 1062. https://doi.org/10.106/S0140-6736(2)30566-3.
15. Meo SA, Alhowikan AM, Al-Khlaiwi T, et al. Novel coronavirus 2019-nCoV: prevalence, bio- logical and clinical characteristics comparison with SARS-CoV and MERS-CoV. Eur Rev Med Pharmacol Sci. 2020;24(4):2012–2019. https://doi.org/10.26355/eurrev_202002_20379.
16. Kaplan J, Frias L, McFall-Johnsen M. Our ongoing list of how countries are reopening, and which ones remain under lockdown. Business Insider. September 23, 2020. https://www.busi- nessinsider.com/countries-on-lockdown-coronavirus-italy-2020-3.
17. World Bank. COVID-19 to Plunge Global Economy into Worst Recession since World War II. World Bank. June 8, 2020. https://www.worldbank.org/en/news/press-release/2020/06/08/ covid-19-to-plunge-global-economy-into-worst-recession-since-world-war-ii.
18. Han E, Tan MMJ, Tan E. Lesson learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Paci c and Europe. Lancet. 2020;20:32007–32009. https://doi. org/10.1016/S0140-6736(20)32007-9.
19. Editorial. COVID-19 therapies and vaccines. Nature Materials. 2020;19:209. https://www. nature.com/articles/s41563-020-0758-9.
20. McKeevar A. Dozens of COVID-19 Vaccines Are in Development. Here Are the Ones to Follow. National Geographic. October 8, 2020; Online publication. https:// http://www.nationalgeographic.com/science/health-and-human-body/human-diseases/ coronavirus-vaccine-tracker-how-they-work-latest-developments-cvd/#close.
21. Tran J, The Latest Research on COVID-19 Treatments and Medications in the Pipeline. GoodRx. Blog. September 18, 2020. https://www.goodrx.com/blog/coronavirus-treatments-on-the-way/.
22. Center for Disease Control. Stephen B. Thacker CDC Library. COVID-19 Databases and Journal. Center for Disease Control. September 2, 2020. https://www.cdc.gov/library/research
guides/2019novelcoronavirus/databasesjournals.html.
23. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance—
United States, January 22–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:759–765.
https://doi.org/10.15585/mmwr.mm6924e2externalicon.
24. Portnoy J, Waller M, Elliott T. Telemedicine in the era of COVID-19. J Allergy Clin Immunol
Pract. 2020;8(5):1489–1491. https://doi.org/10.1016/j.jaip.2020.03.008.
Overview of COVID-19
Carey Kriz, Naiyer Imam M.D., and Sarah Zaidi Sc.D., MSc.,
CFR MERS-CoV SARS-CoV SARS-CoV-2 COVID-19 WHO
Case fatality rate
Middle East respiratory syndrome coronavirus Severe acute respiratory syndrome coronavirus Severe acute respiratory syndrome coronavirus 2 Coronavirus disease 2019
The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV), at the beginning of the 21st century, signaled a warning of cross-species transmis- sions that had the potential to rapidly spread across the globe. After SARS, several other respiratory viruses—in uenza A strains of avian u H5N1, H1N1, and H7N9 and the Middle East respiratory syndrome coronavirus (MERS-CoV)— spilled over from animal populations into humans. Earlier, the zoonotic transmis- sion of viruses, particularly coronaviruses that existed within bat populations, was identi ed as a signi cant public health threat given the habitat loss, climate change, globalization, and the uneven public health structure.1 Therefore, it should not have been a big surprise when a third human coronavirus (CoV) causing COVID-19 emerged in December 2019. Although the virus emerged in China, and spread rapidly around the world its health and economic consequences were far more complex. The emergence of COVID-19 would turn into the greatest chal- lenge facing global leaders since World War II.2
This chapter provides a short overview of COVID-19, contextualizing it within the family of coronaviruses, cross-species transmission, and past pandemics.
Chapter 1: Overview of COVID-19
1.2 COVID-19 Outbreak to Pandemic Status
The first cluster of patients presenting symptoms of fever, cough, myalgia and fatigue, shortness of breath, and pneumonia of unknown etiology in Wuhan city, Hubei province, central China. The majority of cases were linked to the Huanan Seafood Wholesale Market where a variety of mammals were avail- able for sale.3 The presentation of symptoms and patients association to a wet market pointed to infection of zoonotic origins similar to the SARS outbreak of 2002 and 2003. The authorities informed the local offices of the World Health Organization (WHO) on New Year’s Eve, and moved to close the mar- ket the following day. Retrospective analysis of cases of pneumonia of unknown etiology, as initially classified, identified a 55-year-old person with similar symptoms who had no links to the market with disease onset in mid- November.4 In the early cases, human-to-human transmission was speculated but not confirmed until two family clusters including one in which the hus- band transmitted the disease to his disabled wife were identified in mid-January.
Given the respiratory symptoms, Chinese doctors quickly ruled out other com- mon respiratory pathogens, as well as SARS and the Middle East respiratory syn- drome (MERS) coronaviruses, responsible for the outbreak. Samples of bronchoalveolar-lavage uid from seven patients with severe pneumonia (six were working at the market) were sent to the Wuhan Institute of Virology for diagnosis of the causative pathogen. On January 7, 2020, it was con rmed that a novel coronavi- rus with 80% nucleotide sequence similarity to the SARS coronavirus and 96% similarity with bat coronavirus.5 Five days later, the full genome was globally shared, a step that helped to facilitate the rapid development of diagnostic tests for the 2019 novel coronavirus (2019 n-CoV) and launched a search for multiple vaccines.
The 2019 novel coronavirus (2019 n-CoV) was renamed SARS-CoV-26 and the resulting illness as the Coronavirus Disease 2019, COVID-19.7 As cases began to exponentially increase, it became evident that the virus was spreading quickly through human-to-human transmission probably since the middle of December, and that the R0 was approximately 2.2, meaning that on average each patient had been spreading the infection to more than two other people.8
Researchers soon discovered that infected individuals could transmit the virus without showing any symptoms either when they were presymptomatic or, in some cases, asymptomatic (never developing any symptoms of the disease).9 This posed a great challenge to containing COVID-19. In the case of SARS and MERS, people were most infectious when they had symptoms.
The outbreak of COVID-19 also coincided with the Chinese Lunar New Year, one of the most important holidays of the year when people return to their family homes. Massive transmission had taken place as ve million people (many of whom might have been incubating the virus) spread COVID-19 to other provinces in China and other countries. Chinese authorities tried to contain the outbreak by blocking
COVID-19 Outbreak to Pandemic Status
most travel into and out Wuhan, a city of 11 million, by establishing a cordon sani- taire on January 23, and later expanding it to other cities. But cases had already started to pop up in several Asian countries. Thailand reported its rst case on January 13; Japan on January 15; and Korea on January 20 same day as the United States reported its rst on the northwest coast; and Hong Kong, South Korea, Japan, and Taiwan on January 24. The United States reported its rst case on January 20 on the northwest coast and on January 24, the rst two European cases were con rmed in France.10
Within weeks, a small cluster of cases from Wuhan had started to develop into a “public health emergency of international concern,” with nearly 10,000 cases and 213 deaths, at that time mostly in China.11 However, by the end of January, there were 106 cases in 19 countries. The WHO Emergency Committee advised all gov- ernments to put in place strong measures to test, detect, and isolate positive cases, trace contacts, ban large gatherings, and promote social distancing. Although SARS had a higher transmission rate, R0 of around 312 and no vaccine or treatment, the outbreak was successfully controlled by isolation of patients and infectious disease control measures.
But SARS-CoV-2 was proving harder to contain because of its insidious mode of transmission where presymptomatic or asymptomatic could inadvertently pass on the virus to others. The WHO advised countries to impose mitigation strategies and plan for health-care needs as the epidemic unfolded. Over the next 6 weeks, the world witnessed an exponential rise in cases from the initial cluster in Wuhan to 118,000 infections and 4000 deaths, even though largely in China but gradually spreading to 114 countries.
By March 11, COVID-19 cases would increase by 13-fold outside of China, forcing the WHO Director-General to of cially declare a pandemic, noting that “We have rung the alarm bell loud and clear.”13 With no effective treatments or vaccines and increasing numbers of infections outside China, mathematical mod- els of COVID-19 spread started to predict millions of deaths.14,15 The most high pro les of models, the Imperial Model by Neil Ferguson from Imperial College, London, predicted 2.2 million deaths in the United States and 500,000 in the United Kingdom over the year if no actions were taken to slow down the outbreak. Countries scrambled to promote hand hygiene and put into place nonpharmaceuti- cal measures such as banning large gatherings, closing schools and businesses, and placing people under shelter-at-home orders, easing the burden on health-care systems by spreading out infected cases. The goal of “ attening the curve of COVID-19” became the de ning graphic (Figure 1.1) of the pandemic as it moved West.
As countries implemented lockdowns and near-lockdowns aiming to slow down COVID-19 transmission, adverse social, psychological, and economic conse- quences began to emerge and disproportionately affected the poor and marginal communities (see Chapter 22). The pandemic had massive scal consequences, forcing governments to announce scal measures to protect businesses and peoples’ livelihoods.
1 Delay outbreak peak
2 Decompress peak burden on hospitals\infrastructure 3 Diminish overall cases and health impacts
Figure 1.1 Flatten the curve: the goal is to reduce the incidence of cases. Source: Center for Disease Control and Prevention, 2007.16
Goals of Community Mitigation
    
Pandemic outbreak: No intervention
1.3 Human Coronaviruses
Coronaviruses, named after their spikey projections on their surface (proteins), resembling prongs of a crown, or “corona” in Latin, are enveloped, nonsegmented, single-stranded, positive-sense RNA viruses (Figure 1.2). The important structural proteins include spike (S), envelope (E), membrane (M), and nucleocapsid (N). They have a tendency for recombination and inherently high mutation rates com- pared with DNA viruses, which allows them to adapt to new hosts and ecological niches.17
There are four main subgroupings of coronaviruses—alpha, beta, delta, and gamma—that are broadly distributed in mammals and birds, and only alpha and beta are known to cause disease in humans. These viruses cause respiratory, enteric, cardiovascular, and neurological illnesses. Seven coronaviruses with zoonotic ori- gins from bats, mice, or domestic animals have been identi ed in humans (Table 1.1). Four of the known coronaviruses—229E, OC43, NL63, and HKU1—cause symptoms of the common cold and other respiratory-related symptoms. Two, SARS and MERS coronaviruses, are deadly in humans, and the SARS-CoV-2 is respon- sible for the COVID-19 pandemic.
SARS was the rst human coronavirus to elicit a massive public health response and had a major economic impact in several countries in Asia. Emerging in Guangdong, southern China in November 2002, it spreads to 26 countries, infected 8096 persons, and caused 774 deaths (nearly 10% mortality rate).18 It was contained through strict quarantine of all infected people and their contacts, and in some areas community-level quarantine.19 By interrupting human-to-human transmission, SARS disappeared by July 2003 leaving behind an indelible impression on coun- tries in the region.
Ten years later, a second coronavirus, MERS CoV, jumped from bats through its intermediary host, dromedary camel, in Saudi Arabia. Although it remained limited to individuals from the Arabian peninsula or those who had recently returned from the Middle East.20 There was a major outbreak, lasting 2 months in 2015, in Korea
3 Days Since First Case
Pandemic outbreak: with intervention
Daily Cases
Human Coronaviruses
Membrane Protein (M)
Nucleocapsid Protein (N)
Structural Protein
Nucleocapsid Protein (N) Spike Protein (S)
Envelope Protein (E) Membrane Protein (M)
Function of Protein
x Bound to RNA genome to make up nucleocapsid
x Critical for binding of host cell receptors to facilitate entry of host cell
x Interacts with M to form viral envelope
x Central organizer of CoV assembly
x Determines shape of viral envelope
Envelope Protein (E) Main structure of coronaviruses
It has been noted that some CoVs do not need to have the full ensemble of structural proteins to make virions, highlighting that certain proteins may be dispensable or compensated by the function of non-structural proteins.
Spike Protein (S)
Figure 1.2 General structure of coronaviruses. Source: Seah I, Su X, Lingam G. Revisiting the dangers of the coronavirus in the ophthalmology practice. Eye 2020;34:1155–1157. https://doi. org/10.1038/s41433-020-0790-7.
Table 1.1 Comparison of Origins and Clinical Features of Human Coronaviruses
HCoV
Year Identi ed
Natural Host/ Intermediate Host
229E (alpha)
Bats/ camelids
Common cold—headache, sneezing, malaise and sore throat, fever and cough in 10–20%
OC43 (beta)
Rodents/ bovines
NL63 (alpha)
Bats/ unidenti ed
Moderate upper respiratory infection, severe lower respiratory tract infection, croup, and bronchiolitis
HKU1 (beta)
Rodents/ unidenti ed
Common cold can advance to pneumonia and bronchiolitis
SARS (beta)
Bats/palm civets
2–11 days (median 5 days)
Fever, myalgia, headache, malaise, dry cough, dyspnea, diarrhea, respiratory distress
MERS (beta)
Bats/ dromedary camels
Fever, cough, chills, sore throat, myalgia, arthralgia, dyspnea, pneumonia, diarrhea and vomiting, acute renal impairment
SARS-CoV-2 (beta)
Bats/ pangolins?
3–6 days (5 days)
Fever, dry cough, dyspnea, myalgia, headache, loss of smell and taste, diarrhea
when an infectious traveler subsequently infected ve superspreaders.21 MERS had a very high mortality rate, 34% (857 deaths), and as of January 2020, the total num- ber of con rmed cases was 2519 across 27 countries but the 85% cases were limited to Saudi Arabia.
The most recent coronavirus to make the interspecies jump is SARS-CoV-2. Unlike SARS and MERS, it is a more stealthy virus and can be spread by people who do not display any outward symptoms of the disease but are infectious and expelling virus droplets. In some cases, infected cases are presymptomatic and go on to develop symptoms a few days after exposure. However, an unknown number of infected people never develop any symptoms, remaining asymptomatic who spread the virus (discussed in Chapter 3).22
The actual number of infected cases who are asymptomatic ranges widely for COVID-19. On the Diamond Princess cruise ship 17.9% of cases were asymptom- atic23; on the Mortimer (Antarctica cruise ship) 81%24; in Iceland 43%25; 50–75% in the Italian village of Vo26; and an estimated 30% in South Korea (based on a model),27 but 4% in an actual outbreak.28 The phenomenon of asymptomatic infections was observed in both SARS and MERS. During the SARS outbreak in Singapore in 2003, 7.5% of health-care workers and 13% of cases in the general population were asymptomatic.29 In a retrospective data analysis of MERS, an estimated 28.6% of cases were observed as asymptomatic bringing down the case fatality rate (CFR).30
Because of asymptomatic cases of infection, the CFR associated with COVID- 19 has been dif cult to measure and ranges widely from as high as 15.3% in France to as low as 0.1% in Singapore.31 It is suspected that COVID-19 mortality rate in the general population is greater than the common in uenza virus (0.1%), but far less than SARS and the death rate of 2.5% for the Spanish Flu of 1918. The risk of mor- tality is higher for the elderly (60 years and over) and increases with age, those with comorbidities (such as diabetes, heart disease, among others), those who are immu- nocompromised, and for males. SARS, MERS, and SARS-CoV-2 exhibit a lot of common characteristics and demonstrate that they are not limited by geography, and far more dangerous in an interconnected and densely populated world (Table 1.2).
1.4 Cross-Species Transmission
SARS-CoV-2 and the other recent viruses (such as HIV and Ebola virus) that have jumped from nonhuman to human carriers are examples of species to species migra- tion, with the impact of a species virus on another species not well understood—and they also have the potential to introduce evolutionary changes—mutations—during the jump that could have far more devastating downstream impacts. A pathogen pyramid is useful for understanding successful interspecies virus transmission (host switching) and the emergence of new disease (Figure 1.2).33, 34
The framework has four levels that are crucial for understanding emerging infec- tious diseases in humans. The rst level is the exposure of humans to new patho- gens, which requires contact between people and the host reservoir that can happen because of the changes in human ecology and environment, patterns of agricultural
Cross-Species Transmission
Table 1.2 Comparison Between SARS, MERS, and COVID-19: Epidemiological and Clinical Characteristics
November 2002–July 2003
September 2012 till present
December 2019 till present
2–10 (7) days
2–10 (5.5) days
Infectious period
Displaying symptoms
Presymptomatic/ asymptomatic
Median age of affected individuals (years)
Speed of transmission
Geographic impact
213 countries (two international conveyances)
2,519 (Jan 2020)
10,008,027 (June 27, 2020)
Rate of transmission R0
8.1 in Korea outbreak32
production or domestication of animals, mining, and other such factors. After expo- sure to pathogens, the pathogen, in the second level, has to possess the ability to infect and cause disease in humans. At the third level, once the pathogen has estab- lished its ability to infect humans it has to prove its capacity to transmit the disease to other humans. The pathogens have to effectively exit the body through the upper respiratory tract, lower gut, urogenital tract, skin, or other uids and infect another human. In the nal level of the pathogen pyramid, the pathogen has adapted to the human host without the involvement of the original reservoir and can ef ciently transmit such that a single index case is able to generate more than one secondary infection (the R naught, basic reproductive rate, is greater than one). Pathogens that have worked through these four levels become suf ciently transmissible to cause major outbreaks or to become endemic in human populations.
SARS-CoV-2 has successfully gone through these four levels and exhibits a strong potential of becoming the fth coronavirus to become endemic in humans. What is notable about this coronavirus is that it has demonstrated successful host switching mechanisms along with effective human-to-human transmission through symptomless but infected cases (Figure 1.3). Thus far, mutations that might make the virus more or less lethal or contagious appear rare and the altered strains appear- ing in different regions appear to share similar genetic structures.35
  
x Host ecology/distribution x Host behavior/contact rates x Pathogen transmission route
x Virus–host compatibility x Pathogen host range x Species barrier
x Transmission potential in new host
x Tissue tropism (the ability of cells and tissues of a host to support
growth of pathogen)
x Pathogen is su ciently transmissible within the human population
x Recombination/reassortment
The pathogen pyramid or steps involved in the emergence of host-switching patho- gens. Source: Adapted from Refs.33, 34
1.5 Past Pandemics and COVID-19 in the Context of History
One of the most powerful examples of a global pandemic, the Spanish Flu, occurred in 1918 and is instructive on a number of levels.36 During its brief run, it infected 500 million people (one-third of the world’s population) and claimed an estimated 50 million lives. Mortality was high in people younger than 5 years and those above 65 years, and also among those between 20 and 40 years, which was a unique fea- ture of the pandemic. Although the Spanish Flu did not originate in Spain and the rst case was in the state of Kansas, United States, it was labeled such because Spain having remained neutral during the War had not imposed any censorship. Newspapers were, therefore, free to report on the H1N1 in uenza A virus with avian or swine origins.
The virus had multiple, closely spaced pandemic waves between February 1918 and April 1920.37 The rst wave, beginning in March 1918, spreads across the world facilitated by overcrowding, poor sanitation, travel of people to cities in support of the War and soldiers traveling to battle elds, and an immunologically naive popula- tion. In this rst wave, the disease was relatively mild with symptoms that included high fever and feeling tired lasting around 3 days, but it disrupted the war efforts by causing signi cant numbers of soldiers to fall sick.
In August 1918, the virus mutated, and the second wave of the disease left a far more deadly footprint. In the mutated version, death occurred within 24 h after disease onset. The disease found a perfect transmission environment among soldiers returning home to their countries and bringing back a more virulent
Epidemic spread
     
Past Pandemics and COVID-19 in the Context of History
version that caused, otherwise healthy, patients basically drowning, with their lungs saturated by pneumonia. Later analysis showed that the deaths were not the result of the mutated virus but the patient’s own immune reaction, the “cytokine explosion,” a protective measure by the body designed to promote healthy in ammation.
The In uenza Pandemic of 1918–1919 occurred at a time when the micro- scopes did not have the ability to see a virus and very little was known about the microbiology of diseases. It was understood that the human-to-human transmis- sion took place through respiratory droplets. There was no treatment—no anti- virals or antibiotics (penicillin would not be discovered until 1928)—and physicians used convalescent sera to reduce the risk of death. Community miti- gation strategies relied on nonpharmaceutical interventions including improved hygiene measures, school closures, bans on public gatherings, wearing of face masks, and isolation or quarantine orders.38 These measures helped to slow down the spread of the virus, and by 1920, the pandemic was over and became a historical event.
The precautionary tale of the 1918 In uenza Pandemic contains a few lessons for the current COVID-19 pandemic which include
• Understanding transmission pathways and implementing measures for slow- ing down and eliminating the virus.
• Knowing the etiology and physiology critical for treating the disease.
• Protecting the most-at-risk populations versus those that are relatively safe and recognizing that any measures described as exaggerated are probably
insuf cient.
The current COVID-19 pandemic is a sign of what the world can expect in the future. Even if this current pandemic is not as deadly as the u of 1918–1919, it will have long-term impacts on health, health services, global economies, social poli- cies, and politics. It has already affected people’s nancial and job security, and affected everyone at a deep sociological and psychological level. But for all its uniqueness, the pandemic is not likely to remain a one-off, and there may be next waves of pandemic diseases hitting the world. There have already been reports of a new G4 virus, genetically descended39 from the H1N1 swine u, with “all the essen- tial hallmarks of a candidate pandemic virus.”
Given the immense variability of nature, the fascinating ability of evolution in genetics and nally the almost unlimited number of viral populations waiting to cross from species to species, one thing is clear: there will be other viral attacks and these others will have more dramatic impacts on our population and could lead to far more devastating impacts on society.
The challenge for the global community, and all of its health professionals, is to ensure that all elements of international surveillance systems are enlisted, and that health systems have the ability to quickly identify and classify the nature of the disease and to develop and enforce treatment and prevention models that protect the most vulnerable.
1. Menachery VD, Graham RL, Baric RS. Jumping species—a mechanism for coronavi- rus persistence and survival. Curr Opin Virol. 2017:23:1–7. https://doi.org/10.1016/j. coviro.2017.01.002.
2. Green eld J. No, the Covid ght isn’t like WWII—and that’s the bad news. Politico Magazine. May 9, 2020. Accessed May 9, 2020.
3. Li Q, Med M, Guan X, et al. Early transmission dynamics in Wuhan, China of novel coro- navirus-infected pneumonia. N Engl J Med. 2020;382:1199–1207. https://doi.org/10.1f056/ NEJMoa2001316.
4. HuangC,WangY,LiX,etal.Clinicalfeaturesofpatientsinfectedwith2019novelcoronavirusin Wuhan, China. Lancet. 2020;395:497–507. https://doi.org/10.1016/S0140-6736(20)30183-5.
5. Zhou P, Yang X, Wang X, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579:270–273. https://doi.org/10.1038/s41586-020-2012-7.
6. Johns Hopkins Bloomberg School of Public Health. Center for Health Security. SARS-CoV-2 Genetics. https://www.centerforhealthsecurity.org/resources/COVID-19/COVID-19-fact- sheets/200128-nCoV-whitepaper.pdf. Accessed May 9, 2020.
7. World Health Organization. Novel Coronavirus (2019-nCoV) Situation Report 22. 11 February 2020. Geneva: World Health Organization. https://www.who.int/docs/default-source/corona- viruse/situation-reports/20200211-sitrep-22-ncov.pdf?sfvrsn=fb6d49b1_2. Accessed May 9, 2020.
8. Li Q, Med M, Guan X, et al. Early transmission dynamics in Wuhan, China of novel coro- navirus-infected pneumonia. N Engl J Med. 2020;382:1199–1207. https://doi.org/10.1056/ NEJMoa2001316.
9. Heneghan C, Brassey J, Jefferson T. COVID-19: what proportion are asymptomatic? The cen- ter for evidence-based medicine. https://www.cebm.net/covid-19/covid-19-what-proportion- are-asymptomatic/. Accessed April 6, 2020.
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11. World Health Organization. Novel Coronavirus (2019-nCoV) Situation Report 11. 31 January 2020. Geneva: World Health Organization. https://www.who.int/docs/default-source/corona- viruse/situation-reports/20200131-sitrep-11-ncov.pdf?sfvrsn=de7c0f7_4. Accessed May 9, 2020.
12. Bauch C, Lloyd-Smith J, Coffee M, Galvani A. Dynamically modeling SARS and other newly emerging respiratory illnesses: past, present, and future. Epidemiology 2005;16(6):791–801.
13. World Health Organization. WHO Director-General’s opening remarks at the media brief- ing on COVID-19. https://www.who.int/dg/speeches/detail/who-director-general-s-opening- remarks-at-the-media-brie ng-on-covid-19-20-march-2020. Accessed March 11, 2020.
14. Ferguson NM, Laydon D, Nedjati-Gilani G. Report 9: Impact of non-pharmaceutical interven- tions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College London. https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/ Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf. Published March 16, 2020. Accessed May 9, 2020.
15. McKibbin W and Fernando R. The Global Macroeconomic Impacts of COVID-19: Seven Scenarios (March 2, 2020). CAMA Working Paper No.19/2020. https://ssrn.com/ abstract=3547729. Accessed May 9, 2020.
16. Center for Disease Control and Prevention. Pre-Pandemic Planning Guidance: Community Strategy for Pandemic In uenza Mitigation in the United States—Early, Targeted, Layered Use of Nonpharmaceutical Interventions. 2007. Bethesda, MD: Center for Disease Control. https:// stacks.cdc.gov/view/cdc/11425. Accessed May 9, 2020.
17. Duffy S. Why are RNA virus mutation rates so damn high? PLoS Biol. 2018;16(8):e3000003. https://doi.org/10.1371/journal.pbio.3000003.
18. Oldstone MB. SARS: The First Pandemic of the 21st Century in Viruses, Plagues, and History. Oxford: Oxford University Press; 2010. http://www.academia.dk/BiologiskAntropologi/ Mikrobiologi/PDF/Viruses_Plagues_and_History.pdf. Accessed May 9, 2020.
19. Cetron M, Maloney S, Koppaka R, et al. Isolation and quarantine: containment strategies for SARS 2003. In: Knobler S, Mahmoud A, Lemon S, et al., eds. Learning from SARS: Preparing for the Next Disease Outbreak—Workshop Summary. Washington, D.C.: National Academic Press; 2004. https://www.ncbi.nlm.nih.gov/books/NBK92450.
20. Milne-Price S, Miagzgowiecz KL, Munster VJ. The emergence of the Middle East respiratory syndrome coronavirus. Pathog Dis. 2014:7:121–136.
21. Oh M, Park WB, Park S, et al. Middle East respiratory syndrome: what we learned from the 2015 outbreak in the Republic of Korea. Korean J Intern Med. 2018:33:233–246. https://doi. org/10.3904/kjim.2108.031.
22. Huff HV, Singh A. Asymptomatic transmission during the COVID-19 pandemic and implica- tions for public health strategies. Clin Infect Dis. 2020:ciaa654. https://doi.org/10.1093/cid/ ciaa654.
23. Mizumoto K, Kagaya K, Zarebski A, Chowell G. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill. 2020;25(10):2000180. https://doi.org/10.2807/1560- 7917.ES.2020.25.10.2000180.
24. Ing AJ, Cocks C, Green JP. COVID-19: in the footsteps of Ernest Shackleton. Thorax. 2020;75:693–694. https://doi.org/10.1136/thoraxjnl-2020-215091.
25. Gudbjartsson DF, Helgason A, Jonsson H, et al. Spread of the SARS-CoV-2 in the Icelandic population. New Engl J Med. 2020;382:2302–2315. https://doi.org/10.1056/NEJMoa2006100.
26. Day M. Covid-19: identifying and isolating asymptomatic people helped eliminate virus in
Italian village. BMJ. 2020;368:m1165.
27. Shim E, Tariq A, Choi W, Lee Y, Chowell G. Transmission potential and severity of COVID-19
in South Korea. Int J Infect Dis. 2020;93:339–344.
28. Park SY, Kim YM, Yi S, et al. Coronavirus disease outbreak in call center, South Korea. Emerg
Infect Dis. 2020;26(8):1666–1670. https://doi.org/10.3201/eid2608.201274.
29. Wilder-Smith A, Teleman MD, Heng BH, Earnest A, Ling AE, Leo YS. Asymptomatic SARS coronavirus infection among healthcare workers, Singapore. Emerg Infect Dis.
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(MERS-CoV) infection: extent and implications for infection control: a systematic review.
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39. Sun H, Xiao Y, Liu J, et al. Prevalent Eurasian avian-like H1N1 swine in uenza virus with 2009 pandemic viral genes facilitating human infection. Proc Natl Acad Sci USA. 2020;117:17204– 17210. https://doi.org/10.1p73/pnas.1921186117.
Virology and the Immune System Response to COVID-19
Carey Kriz and Syed Imran Ahmad
ACE2 Angiotensin-converting enzyme 2 ARDS Acute respiratory distress syndrome ORF Open reading frames
PRR Pattern recognition protein
PAMP Pathogen-associated molecular pattern
RBD Receptor binding domain
SARS-CoV-2 Severe acute respiratory syndrome coronavirus-2
In any disease, it is important to understand the structure of the invading patho- gen and the immune response of the host. In COVID-19, the disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), other sys- tems, in addition to the respiratory system, can be affected. The disease is also unusual in that there is very low prevalence and almost no mortality in children, but the severity of the disease and the risk of mortality appear to increase with age (especially among those aged 70 years and older). Furthermore, the course of COVID-19 is in general more severe in those with underlying conditions or immunosuppressed.
This chapter addresses the immunopathology of SARS-CoV-2 infection. It discusses the structure of the virus, presents an overview of the innate and adap- tive immune system, and describes the changes occurring in the bodies of COVID-19 patients, particularly the dysregulation of the host immune system re ected by the cytokine storm. This chapter provides an understanding of the immune system mechanisms that can help with the clinical management of COVID-19 cases.
Structure of SARS-CoV-2 responsible for COVID-19.
Envelope (E) protein
Spike (S) protein Membrane (M) protein
Nucleocapsid (N) protein and RNA genome
Chapter 2: Virology and the Immune System Response to COVID-19
Lipid bilayer envelope
2.2 SARS-CoV-2 Structure
Coronaviruses have the largest genome of all RNA viruses and are classi ed within the order Nidovirales.1 The SARS-CoV-2 is the seventh identi ed coronavirus and in the same beta-coronavirus clade as SARS-CoV and MERS-CoV, sharing almost 80% of the genome with SARS-CoV.2 Similar to other coronaviruses, SARS-CoV-2 contains a single-stranded RNA genome covered with a protein membrane and pro- tein spikes (S) on its surface (Figure 2.1). The S surface protein plays key roles in the viral life cycle and host defense response. The glycoprotein of these protein spikes has a unique way of binding with the cell membrane protein, angiotensin- converting enzyme 2 (ACE2), on the surface of host cells. ACE2 host receptor is required for the host cell entry of SARS-CoV-2, and their expression is not only restricted to the lungs but also to other systems in the human host.3
The entry of SARS-CoV-2 requires conformational changes to the S protein. The serine protease called furin cleaves the S protein and is essential for the fusion of the viral and host cell membranes and viral entry to the cell through endocytosis or nonendocytic cell surface entry.2,4 The S protein contains a S1 component, a surface subunit that binds to the host cellular membrane, and a S2 component, a transmem- brane subunit that allows for fusion. Cleavage at different sites on the S protein not just increase fusion, but also accelerate cell-to-cell spread. Due to its critical role in infection, furin is a possible target for therapeutic interventions.5 In the endocytic pathway (potential targets of drugs such as chloroquine and hydroxychloroquine), the virion fuses with the vesicle and releases its single-segmented RNA genome into the cytosol for immediate replication.
SARS-CoV-2 infection activates innate and adaptive immune responses, which are described in the next section.
The Immune System
2.3 The Immune System
The body’s response to SARS-COV-2 has foundations deeply rooted in our immune system, and thus, a brief review of the basics is essential. The immune system is complex and involves a network of players that interact with each other. An invad- ing pathogen triggers the innate immune response. While many infections can be dealt through this innate system, humans also have an additional layer of defense, the adaptive immune system that actually adapts to protect against speci c invaders. Both aspects of the immune system are described below.
2.3.1 Innate Immunity
The rst line of defense mechanism against foreign microorganisms in humans is mediated by the innate immune system. The key cells in the in ammatory process include neutrophils, macrophages, dendritic cells, and natural killer (NK) cells.6 These cells utilize mechanisms like cellular recognition proteins to identify foreign cells and remove them from the body (Figure 2.2).
Pathogen
Endocytic PRR
PAMP or Pathogen
TH1 IFN-J
CD80/86 MHC-II
T cell
IL-12
Naive TCR
Basic function of innate immunity showcasing the interaction of antigens with toll- like receptors on macrophages. This gure also illustrates the interface between innate and adap- tive immune systems.6
IL-4 IL-5 IL-13 IL-10
Nature Reviews I Immunology
Accommodation C1q
Inhibition of C3 and C5 cleavage and inhibition of formation of membrane pores by C5b-C9
Function of complement response in innate immunity.
C3b or C4b
CD59 C9 CD55
C5b-C8
C3 and C5 convertases
Pattern recognition proteins (PRRs) are the essential component of innate immu- nity. Neutrophils and macrophages have protein receptors on their cell membranes that recognize certain “patterns” on foreign cells and not only recognize them as foreign, but also differentiate them from host cells during elimination. Examples of pathogen-associated molecular patterns (PAMPs) are bacterial endotoxins in gram- negative bacteria, peptidoglycans, lipoteichoic acid, and viral double-stranded RNA (Figure 2.3). 5
One of the most important and well-st udied examples of PRRs is the comple- ment system, a series of circulating peptides that play a crucial role in innate host immunity. A major component of this system, the C1 protein, recognizes antibodies bound to microbial proteins and initiates a downstream event, known as the comple- ment cascade.7 The result of this event is the production of C3b that leads to chemo- taxis, opsonization, and phagocytosis of bacteria, and to the formation of membrane attack complex. Another type of PRR is the toll-like receptor, which is a transmem- brane protein found on neutrophils and macrophages that binds PAMPs and results in the transcription of in ammatory genes, leading to in ammation.
The key players of the innate immune system are the neutrophil, macrophage, and NK cells. Neutrophils are directed to the sites of in ammation or infection by cytokines such as IL-8 and C3b proteins. Macrophages serve a similar function, but they respond somewhat slower than neutrophils. NK cells contain similar protein receptors, which are used to differentiate between host and infected/injured cells. Once recognized, NK cells induce apoptosis. NK cells are especially important in protection from viruses and tumor cells. Other important components of the innate immune system are eosinophils, basophils, and mast cells.
An important point about the innate immunity system is that it does not contain memory cells or “learned responses” to a speci c antigen. The innate immune sys- tem is general and nonspeci c to in ammation. Unlike the adaptive immune system that ne-tunes and modi es itself to combat a speci c infection/injury over a longer period, innate immunity is designed to respond immediately. Innate immunity, how- ever, is the preliminary process that is needed to generate the adaptive immune system.
2�3�2 Adaptive Immunity
Unlike the innate immune system, the adaptive immunity system is a more re ned and calculated mechanism of host defense. The mounted response of the adaptive immunity takes place over a longer period of time compared to the more generalized instantaneous response of the innate immune system. This section will brie y dis- cuss two types of Adaptive immune responses: Humoral immunity and Cell- mediated Immunity.
2.3.2.1 Humoral immunity
Humoral immunity is driven by B-cells that secrete antibodies to protect the body from immediate- and long-term foreign microorganisms. The cardinal event involves receptors on B-cells binding to an antigen.3 This binding promotes activa- tion and differentiation into more specialized cells. The B-cells consist of a B-cell receptor, which is made up of light and heavy immunoglobulin chains, and B-cell co-receptor, which is required for proper antigen binding. Binding of antigens on multiple B-cell receptors leads to a series of intracellular phosphorylation via the IP3 and diacylyglycerol (DAG) pathways, intracellular signaling, which results in the translocation of transcription factors to the nucleus and activation of B-cells.8
B-cells can now bind to thymus-dependent and thymus-independent antigens. The classic examples of thymus-independent antigens are the polysaccharides on capsular organisms such as H. in uenzae and S. pneumonia, which leads to our body mounting an antibody response. This mechanism is also the basis for the unconjugated polysaccharide vaccinations. These capsules contain sugar and are not suited for a more robust T-cell-mediated vaccine response. However, B-cells are the ideal candidates for responding to these foreign pathogens.
Thymus-dependent antigen leads to a specialization of B-cells into assuming more speci c roles. Binding of these antigens primes T-helper cells. These T-cells then activate B-cells into secreting speci c types of antibodies. For example, in the germinal centers of secondary lymphoid tissue, binding of antigen-carrying B-cells to a Th2 cell and its co-receptor leads to the release of IL-4 and IL-5, which signals B-cells to secrete IgE. IgE antibodies then protect against helminthic infections and mediated atopic diseases. This process is called class switching and facilitated by somatic mutations in the heavy chain regions of immunoglobulins. IgM antibody- secreting generalized B-cells differentiate into serving more speci c roles.
This is a brief summary of how B-cells work, and the process is an arduous one. Within the germinal centers of lymphoid tissue, each individual B-cell is faced with essential tasks for it to survive and proliferate. These tasks include competing with other B-cells for binding antigens, processing the antigens, and presenting them to T-helper cells on their MHC-II (proteins that present exogenous antigens), receiving stimulating signals from co-receptors, and then nally specializing. Highly special- ized and differentiated B-cells can also circulate in the plasma as memory B-cells where they “remember” the antigens they once interacted with and can class switch into secreting antibodies.
C3 and C5
C3a and C5a
Complement activation
Donor APC
TH1 cell activation IL-12
MHC Class II
C3aR and C5aR
Allogeneic peptide
TCR CD40L
C3aR or C5aR
TH1 cell
Figure 2.4 Activation of Th1 cells.
B-cells also play a crucial role in innate immunity. As we discussed above, the complement system is a key component of the innate immunity.7 Antigen bound to Fab regions of IgG antibodies get cross-linked to Fc regions of antibodies. Essentially, the antibody serves as a bridge for complement and antigen. Once the bridge is formed, complement can implement the recruitment of neutrophils and eventual phagocytosis of the microbe.
2�3�2�2 Cell-mediated immunity
Cell-mediated immunity is a vigorous system of host defense mechanisms that is designed to combat intracellular microbes such as viruses and mycobacteria along with tumor cells.The same system is also the culprit behind many autoimmune con- ditions. T-cells are the primary driver of cell-mediated immunity. Although there are several types of T-cells, CD4 and CD8 cells, expressed by the cytotoxic T lym- phocytes, are important in measuring immunity of the patients (Figure 2.4).6
CD8+ cells are cytotoxic cells that have cytotoxic mechanisms against infected cells by which after binding, it causes a fusion and release of granules that lead to cellular damage. CD8+ cells also express a Fas ligand that binds to CD-95 receptors on infected cells.6 The binding leads to apoptosis. CD8+ cells take things into their own hands and eliminate virally infected and tumor cells via apoptosis or involve- ment of NK cells. CD8+ cells must be activated via antigen presentation through the MHC-1 class of cells. Since all nucleated cells in the body express MHC-1, CD8+ cells are ideal for eliminating cells that may be infected by viruses since any cells can present antigens to CD8+ cells. However, before CD8+ cells can acquire this ability, they must be activated in lymphoid tissue with the help of CD4+ cells and antigen-presenting T-cells.
CD4+ cells are the helper T-cells and are activated in lymph nodes when den- dritic cells capture foreign antigens and present into T-cells. The binding of T-cell
Pathophysiology of SARS-CoV-2
receptors with these antigen-presenting cells must be accompanied with co-signal binding with the CD-40L on CD+4 cells for the effect to take place. It is also impor- tant to mention that these antigens tend to be peptide-based and also form the basis for peptide-based vaccines, like vaccines for diphtheria.
The interaction of CD+4 cells with antigen determines the fate of these T-cells. Cytokines or cellular messengers drive this differentiation. Through events in the innate immunity, IL-12 and interferon gamma are produced, which induce CD+4 T-cells conversion into Th1 cells.6 These cells then secrete more IL-12 and IFN gamma, which promotes class switching of B-cells into secreting IgG and also acti- vates macrophages. Macrophages are activated by the release of IL-12 and IFN gamma from Th-1 cells. In other words, it becomes a self-regulating cycle. Naive CD+4 cells get converted into Th-1 cells by certain cytokines. Th-1 cells then secrete cytokines of their own, which prepares a robust immune response, resulting in a proin ammatory condition that plays an essential role in eradication of the virus.
A classic example of this pathway is our body’s response to primary tuberculo- sis. As mentioned in the section for humoral immunity, if naive CD+4 cells are met with other stimuli, they can differentiate into Th-2 cells, which play a role in atopy and protection against parasitic infections. Other types of specialized helper T-cells are regulatory T-cells, Th-17 cells, and follicular helper T-cells.
Cell-mediated immunity also displays the phenomenon of memory cells. Interactions with antigens induce changes in surface molecules and intracellular mechanisms which allows T-cells to mount a more rapid and specialized response if exposed to the same antigen again. In other words, T-cells remember antigens they once battled again and know exactly how to defeat them if they return. This forms the basis of life-long immunity and is the reason behind how vaccines work.
Although this discussion is brief, a more detailed study of the immune system can be found in textbooks dedicated entirely to it. These sections are a quick frame- work review of how our body’s defense systems work that can be quickly accessed and referenced when trying to make sense of our body’s response to the SARS- CoV-2 pathologies.
2.4 Pathophysiology of SARS-CoV-2
The virulence of SARS-Cov-2 virus is attributed to its structural proteins that allow it to enter the human body and replicate. Hence, the genomic activity and replication are essential to its pathogenicity. The SARS-CoV-2 virus is a posi- tive sense, single-stranded RNA virus with a 5′cap and 3′ polyA tail.9,10 Transcription of the virus occurs between open reading frames (ORFs) found on the RNA. Up to 6 ORFs can be present in a replication-transcription complex (RCT) .11 The result of this transcription is a set of structural proteins, envelope proteins, spike proteins, and nucleocapsids. Frameshift mutations between these ORFs can lead to new and different types of proteins, increasing the pathogenic- ity (Figure 2.5).
5’UTR
SP 1 13
ORF1a
SARS-CoV (a29.7kb) 3a ORF1b s
SARS-CoV S protein 3b S1 subunit
RBM FP
7a 8b 9b
N 3’UTR
318 424 429 510 679 770 788 892 1,013 1,145 1,215
MERS-CoV (a30.1kb) 4a
5’UTR ORF1a ORF1b s 3 5E M N 3’UTR
HR1 HR2 TM CP
S1 subunit RBD
MERS-CoV S protein
4b 8b
S2 subunit
Figure 2.5 Genomic structure of the SARS-COV and MERS-COV, depicting the ORF regions found in the SARS-COV Virus.9
2.4.1 Interaction between SARS-CoV-2 and ACE2
The interaction between surface glycoprotein or “spike protein” on virions and human ACE2 enzymes starts the in ammatory process. Of note is that the quantity of enzyme may be related to the extent of organ in ammation.8,12 For example, ACE2 is found in the pulmonary capillaries, and development of COVID-19- induced pneumonia and acute respiratory distress syndrome (ARDS) is a common cause of mortality.13 The enterocytes and epithelia of the gastrointestinal tract also contain ACE2 and can be attributed to the gastrointestinal (GI) symptoms of SARS- CoV-2.14 Though it is now known that the virion can cross the blood–brain barrier, neurological symptoms such as anosmia, nausea, and headaches are linked to the presence of ACE2 in the brain. Another crucial organ system that is host to ACE2 enzymes is the myocardium. High expression of the enzyme in the heart increases the chance of infection.12 It is possible that infection leads to thrombosis and vaso- constriction of the vasculature in the myocardium. Hence, the incidence of throm- bosis in intensive care unit (ICU) patients infected with COVID-19 is 31%.15
2�4�2 Pathogenesis and Biochemistry
SARS-CoV-2 is structurally similar to the original SARS virus responsible for the 2002–2003 outbreak. Studies have shown that both of these viruses share a similar spike glycoprotein structure in the receptor-binding domain (RBD) that is respon- sible for their af nity for the ACE2. Speci cally, the 3D structure of the spike pro- tein on both of these viruses is identical. Furthermore, the amino acids in the whole
E M 6 S2 subunit
1,195 1,255 HR2 TM CP
protein that comprise these RBDs are homologous in both of these viruses while also sharing 76–78% of the same amino acid sequences.10 explored this like- ness. The af nity between the RBD on viral cells to host ACE2 cells is crucial in pathogenicity. The virion infects the cell by attaching its glycoprotein into host cell receptors, leading to fusion and insertion of viral replication components into the host. Molecular analysis of crystal structures containing RBD–ACE2 complexes isolated from different hosts and identi ed certain amino acid residues on ACE2 that increased the af nity for binding with the viral glycoprotein.1 The RBD sequence on SARS-COV-2 that interacts with the ACE2 is very similar to the origi- nal SARS virus, showcasing why SARS-CoV-2 enters the human body through the ACE2 cells. Furthermore, the sequence also showed similar receptor binding motifs on the 2019 virus with high af nity for the amino acid residues on ACE2 cells. In other words, ACE2 is required for viral entry and further replication.
The surge of ICU cases and respiratory failure all over the country has demon- strated that lung-related mortality is a key feature of SARS-COV-2. This interaction between the virions and the ACE2 is strongly linked to the severe ARDS and pneu- monias. We will discuss a few studies in the following section to better analyze the relationship between how viral protein binding with ACE2 receptors affects the respiratory system (Figure 2.6).
2�4�3 Pathophysiology of COVID-19-Related Organ System Involvement
Understanding the role of ACE-2 and pathogenesis of SARS paves the way for explaining why SARS-CoV-2 is so destructive to the lungs. SARS-COV 1 was sug- gested to have an af nity for respiratory infection through ACE-2 in a 2005 study titled A crucial role of Angiotensin Converting Enzyme 2 (ACE2) in SARS- coronavirus induced lung injur]. In their research, Kuba et al. infected two groups of mice with the SARS-CoV-2: the control group wild type expressing ACE2 and an experimental group with ACE2 knocked out. They later isolated a much smaller number of infectious viruses from the experimental group, indicating a decreased lung pathogenicity.15
The study titled Single-cell RNA expression pro ling of ACE2, the putative receptor of Wuhan COVID-19 further analyzed the connection between COVID-19 and lung pathogenicity. Zhao et al. studied healthy pulmonary parenchyma from eight donors and found that ACE2 is expressed in 83% of type II alveolar epithelial cells. Gene ontology analysis has revealed that these type II alveolar cells also con- tain genes that somehow promote viral replication and ensure its survival. Though evidence on this phenomenon is inconclusive.11
Introduction of viral particles and its life cycle in the large surface area of the lungs may be the reason behind cases of pneumonia, ARDS, and diffuse alveolar damage. Parenchymal involvement causes acute lung injury and the release of pro- in ammatory cytokines such as IL-8, TNF, and IL-6, activating the innate immune system, as discussed above, and leading to the recruitment of neutrophils and
Cellular receptor
Receptor binding, viral entry, and membrane fusion
RNA replication
Genomic RNA (- sense)
Subgenomic or genomic RNA (+ sense)
Cell membrane Viral receptor
Golgi
Viral RNA release
Genomic RNA (+ sense)
Virus release Mature virion formation
Viral polymerase protein translation
Assembly and budding
Viral RNA
RNA replication and package
Tanscription
E: Envelope
S: Spike
Membrane fusion
6-HB
N: Nucleocapsid
M: Membrane
Viral structural proteins (S, M and E)
NTD RBD
scFv HcAb Nb
S2 S protein
Figure 2.6 The life cycle of the human coronavirus, depicting cellular entry and subsequent replication.
macrophages to the site of infection at the pulmonary capillary epithelium.13 Neutrophil-mediated injury of the capillary epithelium leads to the leakage of uids and protein to the alveoli causing a state of pulmonary edema. Subsequent develop- ment of ARDS becomes imminent, causing an impairment of gas exchange and pulmonary compliance. Depending on the severity of the in ammation, oxygen- ation and worse intubation may become a necessity. This feared chain of events is often the culprit behind SARS-CoV-2-associated mortality.
Examining evidence, we can see that acute lung injury and ARDS progress rap- idly. One study examined 138 hospitalized patients for pneumonia, of which 20% developed ARDS within 8 median days and 12% required mechanical ventilation. A different study from Wuhan showed ARDS in 41% of hospitalized patients from pneumonia. 15What exactly is causing the rapidly worsening respiratory failure? One possible speculation can point towards the idea that the large surface area of
ERGIC
N protein
lungs with type II alveolar cells are invaded by the virus, leading to immune response and subsequent development of ARDS.
Systemic hyperin ammation is another culprit that plays a role in progressively worsening ARDS and may play a role in SARS-CoV-2-induced respiratory failure. Studies have shown that early increase in pro-in ammatory cytokines worsens the prognosis of ARDS and pneumonia.16,17,4 The lymphocytic in ltrates in the systemic in ammation deposit in the lungs and worsen the ARDS.
Historically, the original SARS-COV and MERS-COV both demonstrated increased concentration of pro-in ammatory cytokines such as IL-6, IL-12, and IFN-gamma.7 Not surprisingly, SARS-CoV-2 has shown similar ndings. Furthermore, the quantity of these pro-in ammatory cytokines is higher in patients requiring intubation than in those who did not require mechanical ventilation. Could cytokine-induced in ammation be playing a role in this? The information is cur- rently still under scrutiny. To complicate the discussion even more, SARS-CoV-2 patients have also shown elevated levels of TH-2 helper T-cells which secrete IL-10, an anti-in ammatory cytokine. Therefore, the role of cell-mediated immunity is unclear in the pathophysiology of the infection. Nonetheless, an in-depth explora- tion of cytokine release syndrome is warranted.
Cytokine-release syndrome (CRS) is a dysregulated pro-in ammatory condition where a positive cycle of cytokine release is established leading to systemic shock and multisystem organ failure. As a response to bacterial and viral infections, the mecha- nisms discussed in the immunology section allow cell messengers of the innate immu- nity release cytokines that recruit monocytes and lymphocytes and reinforce the response to eradicate the infection. In most scenarios, especially SARS-CoV-2, this response is suf cient to ght the infection and the host makes recovery. However, failure to eradicate the infection leads to a sustained in ammatory state, where the cytokines exert a positive feedback on the immune cells, which further secrete cyto- kines, thus creating a cycle. The prolonged immune response then becomes detrimen- tal to the host as systemic vasodilation develops leading to shock and organ failure.
To further this discussion, we will include a hematologic perspective into under- standing how coagulation plays a role into SARS-CoV-2-related systemic in am- mation. It is well understood that in ammation can activate the coagulation cascade by several mechanics: down-regulation of antithrombin III and other anticoagulant mechanisms, tissue factor-mediated thrombin generation, and impaired brinolysis. Thrombin itself is known to induce IL-6 and IL-8 in endothelial cells, which plays a role in the sustenance of in ammation. Furthermore, the endothelial injury induced by pro-in ammatory cytokines worsens the coagulation balance.
This may be the possible basis for cases of disseminated intravascular coagulation (DIC), a condition in which blood clots form throughout the body, and thrombosis seen in severe COVID-19 patients. In the study titled Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia, it was found that a large majority of non-survivors met signs of DIC and had signi cantly higher D-dimer levels, Fibrin degradation products, and elevated PT/PTT. It is thus essential to realize that systemic in ammation and the coagulation system in combina- tion can play a crucial role in overall mortality associated with SARS-COV-2.
1. Masters PS. The molecular biology of coronaviruses. Adv Virus Res. 2006;66:193–292. https:// doi.org/10.1016/S0065-3527(06)66005-3.
2. Zumla A, Chan J, Azhar E, et al. Coronaviruses—drug discovery and therapeutic options. Nat Rev Drug Discov. 2016;15:327–347. https://doi.org/10.1038/nrd.2015.37.
3. Kuba K, Imai Y, Rao S, et al. A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced lung injury. Nat Med. 2005;11(8):875–879. https://doi. org/10.1038/nm1267.
4. Jose RJ, Manuel A. COVID-19 cytokine storm: the interplay between in ammation and coag- ulation. Lancet Respir Med. 2020. https://doi.org/10.1016/s2213-2600(20)30216-2.
5. Liu, J., Cao, R., Xu, M. et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discov. 2020;6(16). https://doi. org/10.1038/s41421-020-0156-0.
6. Medzhitov, R. Toll-like receptors and innate immunity. Nat Rev Immunol. 2001;1:135–145. https://doi.org/10.1038/35100529.
7. Nile SH, Nile A, Qiu J, Li L, Jia X, Kai G. COVID-19: Pathogenesis, cytokine storm and thera- peutic potential of interferons. Cytokine Growth Factor Rev. 2020. https://doi.org/10.1016/j. cytogfr.2020.05.002.
8. Alberts B, Johnson A, Lewis J, et al. Molecular Biology of the Cell. 4th ed. New York: Garland Science; 2002.
9. Song Z, Xu Y, Bao L, et al. From SARS to MERS, thrusting coronaviruses into the spotlight. Viruses. 2019;11(1):59.
10. Wan Y, Shang J, Graham R, et al. Receptor recognition by the novel coronavirus from Wuhan: an analysis based on decade-long structural studies of SARS coronavirus. J Virol. 94. https:// doi.org/10.1128/JVI.00127-20.
11. Zhao Y, Zhao Z, Wang Y, Zhou Y, Ma Y, Zuo W. Single-cell RNA expression pro l- ing of ACE2, the putative receptor of Wuhan 2019-nCov. bioRxiv. 2020. https://doi. org/10.1101/2020.01.26.919985.
12. Zhang H, Penninger JM, Li Y, Zhong N, Slutsky AS. Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target. Intens Care Med. 2020;46(4):586–590. https://doi.org/10.1007/s00134-020-05985-9.
13. Hudson LD, Milberg JA, Anardi D, Maunder RJ. Clinical risks for development of the acute respiratory distress syndrome. Am J Respir Crit Care Med. 1995;151:293.
14. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;10223:497–506. https://doi.org/10.1016/ S0140-6736(20)30183-5.
15. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844– 847. https://doi.org/10.1111/jth.14768.
16. Zhang C, Wu Z, Li J-W, Zhao H. Gui-Qiang Wang. Cytokine release syndrome in severe COVID-19: interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality. Int J Antimicrob Agents. 2020;55(5).
17. Coperchini F, Chiovato L, Croce L, Magri F, Rotondi M. The cytokine storm in COVID-19: an overview of the involvement of the chemokine/chemokine-receptor system. Cytokine Growth Factor Rev. 2020. https://doi.org/10.1016/j.cytogfr.2020.05.003.
Transmission, Prevention, and Risk Factors of COVID-19
Naiyer Imam M.D., Sarah Zaidi Sc.D., MSc., and Arijit Robin Chakraborty
BMI Body mass index
NPI Nonpharmaceutical public health intervention SARS-CoV-2 Severe acute respiratory syndrome coronavirus
SSE TB
Super-spreader event Tuberculosis
Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is a respiratory virus that spreads from person-to-person through close contact and causes COVID-19. It is highly contagious. Infected individuals who show no symptoms can transmit the virus without knowing they are infectious, making it dif cult to control community spread. Although all age groups can be infected, those over 60 years old, speci cally males, and those with underlying chronic conditions such as diabetes, pulmonary or heart disease, obesity, or in an immunocompromised state are at higher risk. Until there is a vaccine, COVID-19 prevention will depend on traditional epidemic con- trol measures. This chapter summarizes the latest information on what is known about COVID-19 transmission, prevention, and risk factors.
3.2 Viral Transmission
Previous studies of SARS-CoV indicated a signi cant role of airborne transmission with the virus remaining infectious in aerosol for hours and on surfaces for up to 2 days.1 Considering that the genome of SARS-CoV-2 is similar to SARS-CoV, the transmission behavior is also more similar. Studies have shown that infected indi- viduals can transmit SARS-CoV-2 through large droplets (>5–10 μm)2, and more
Chapter 3: Transmission, Prevention, and Risk Factors of COVID-19
recently through aerosol (≤5 μm)3 exhaled during breathing, speaking, coughing, sneezing, or yelling. The case study of COVID-19 infections on the cruise ship Diamond Princess demonstrated that aerosol transmission contributed to disease progression. The virus is more easily spread in indoor or enclosed environments that have poor or inadequate ventilation.
Viral transmission can also occur through direct contact with an infected person or indirect contact through hand-mediated transfer from contaminated surfaces and objects to the mouth, nose, or eyes. The virus has been detected in various bodily uids and in feces, but so far there is no evidence of its transmission through these modalities has been found. It is recommended that strict precautions should be taken in hospital settings.4
Person-to-person transmission is also dependent on the infectiousness of cases, which is based on the viral load. The viral load is de ned as the concentration of viral particles in the biological medium of transmission. The higher the viral load, then it is more likely an infected person will transmit the virus to others. In the case of COVID-19, the viral load is related to the time course of the illness.5
The incubation period, which is the time between exposure to the virus and symptom onset, for COVID-19 is 4–5 days, and in some cases, it can be up to 14 days. In Figure 3.1, the y-axis represents the viral load, and the x-axis represents the days after symptom onset with the rst day of symptoms designated as 0. During this time, the viral load gradually rises, peaking about 2–3 days prior to the onset of symptoms. In mild cases, the viral load sharply declines over the course of 7 days such that by the fourth to seventh day of symptomatic infection, the patient becomes much less likely to infect others.6 In more severe cases, the viral load begins to decline after the second week.7 But prolonged viral shedding has been reported for up to 63 days in nasopharyngeal swabs among adult patients.8
Figure 3.1 Viral load 30 density of COVID-19.5
–3 –2 –1 0 1 2 3 4 5 6 7 8 Days after symptom onset
Density (%)
Reproductive Rate and Dispersion
In terms of transmission, few concerns are the presymptomatic or asymptomatic cases, transmitting the disease few days before the onset of symptoms when the viral load is highest without being aware that they are infecting others.9 The role of asymptomatic cases in transmission, while reported, has been dif cult to quantify.10 But the risk of transmission from presymptomatic cases is high, and according to some reports contributed to 48% and 62% of transmissions in Singapore and China.11 It is safe to assume that a signi cant proportion of secondary transmission is occurring before the onset of illness and, in some instances, in the absence of symptoms.
A comparison of SARS-CoV-2 to SARS displays the immense power of trans- missibility of this virus since it can be spread by presymptomatic and asymptomatic individuals through airborne transmission and requires greater individual and com- munity vigilance. In contrast, SARS differed in the sense that affected patients became symptomatic soon after infection and could be easily isolated. As a result, SARS was successfully contained using old-style public health measures such as isolation and quarantine.
3.3 Reproductive Rate and Dispersion
R-naught (R0) is an important epidemiological concept for understanding disease transmission, de ned as the average number of new cases generated by every infected case.12 It is not a xed value and depends on a variety of factors such as the host’s population susceptibility to infection, demographics, socioeconomic situa- tion, and seasonaility. R0 is a useful public health measure in terms of disease spread and its eventual containment. Typically the R0 value varies between less than 1 if the disease is controlled and greater than 1 if it is spreading. Throughout the course of an outbreak of disease, interventions aimed at controlling the spread can be described as attempts to lower the value of R0. The average R0 of COVID-19 is estimated at the range between 2.2 and 2.7 with a doubling time of cases in 6–7 days.13
Since R0 is an average value, its meaning can be obscured by a highly dispersed distribution where a handful of infected people are causing most of the secondary transmission. The dispersion factor, k, describes how much a disease clusters through super-spreader events (SSE). A small dispersion factor means that a rela- tively small number of cases are responsible for transmission, while a larger k indi- cates that transmission is more evenly spread.
In the case of COVID-19, a small fraction (10%) of infected individuals is esti- mated to be causing 80% of the secondary infections through SSE.14 In many instances, a single infected person transmits the virus to a large number of people while attending large gathering such as meetings, conferences, religious services, sporting events, or other social get-togethers. Large disease clusters have occurred in meetings, nursing homes, churches, prisons, food processing plants, and on
Work place Cruise ship Shopping malls Amusement parks
Restaurants/bars Weddings/funerals/birthdays Concerts
Meat packing plants
Assisted living housing
Short time
Supermarket Outdoors—jogging/ walking
Public toilets Choir practice Gyms
ships.15 Two other factors affecting clusters of disease outbreak are time and physi- cal space. The longer the period of exposure the group staying together, the likeli- hood of viral spread is greater. Indoor and poorly ventilated spaces are especially conducive to transmission. In one study from Japan, the odds of transmission in a closed environment were estimated to be 18.7 times greater compared to an open air environment.16
3.4 Assessing Risk of Transmission
Understanding the risk of infection is important for beating back the virus, and pro- fessor Erin Bromage17 from the University of Massachusetts Dartmouth has devel- oped an easy formula: Successful Infection = Exposure to Virus Volume × Exposure Time (Table 3.1). Some places of high risk usually will have high volumes of viral particles or low volumes of virus but require extended exposure. A massive out- break was reported in a German slaughterhouse where the virus spreads up to 8 m (26 ft) through the ventilation (air cooling) system infecting 1500 out of 7000 employees.18
The Texas Medical Association has also developed a risk chart for COVID-19 (Figure 3.2).19
3.5 Individual Disease Prevention
As an airborne virus, SARS-CoV-2 spreads very easily as demonstrated by a uid dynamic professor at the Massachusetts Institute of Technology who showed that a turbulent gas cloud created by a cough could reach up to 7–8 m (23–27 ft).20 In combination with the improved hygiene measures such as regular handwashing and coughing into the elbows, it is also very important to wear facemasks and physically distance from other people. The World Health Organization (WHO) has de ned
Table 3.1 Risk of Transmission: Time and Volume of Virus
Individual Disease Prevention
Figure 3.2 Risk of COVID-19 infection in a variety of situations.
close contact as being within 1 m (3 ft) of a COVID-19 infected person for more than 15 min while not wearing a mask.21 In such instances, the recommendation is to quarantine for 14 days, regularly take temperature and monitor symptoms, and to keep a safe distance for other members of the household. The use of facemasks is
recommended during isolation procedures. Only after 14 days or 10 days after the onset of symptoms and two negative tests can a patient come out of quarantine once the symptoms have been cleared.22
In addition to preventative measures such as handwashing, coughing into the elbows, wearing a mask, keeping a distance of 6 ft apart from others outside the home, and avoiding large gatherings, there are other steps that should be taken to keep the immune system strong. These include the following:
• Eating a well-rounded and balanced diet that includes whole grains, fruits, vegetables, beans, nuts, and legumes. Some studies have indicated that Vitamin D23 and zinc24 may reduce the risk of COVID-19, but these protec- tions are not de nitive.
• Exercising regularly as it confers a range of bene ts including reducing stress and improving cardiorespiratory tness.25 The United States Centers for Disease Control (CDC) recommends 30 min of moderate intensity aerobic exercise 5 days a week for adults, and 60 min of exercise daily for children and adolescents.26
• Refraining from smoking27 as it is associated with increased severity of dis- ease and deaths in hospitalized patients.
• Refraining from alcohol use as it has been shown to increase the likelihood of acute respiratory distress syndrome and liver damage.28 A study from Wuhan reported that 53% of patients with COVID-19 experienced liver damage as consequences of the infection.29
• Sleeping for at least 8 h, which is an essential component for stronger immunity.
The WHO publishes updated guidelines and posters for downloading on how to protect yourself and others against COVID-19 which is accessible at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Cleaning hands with soap or alcohol-based sanitizers is the most effective way to kill the virus.
3.6 Community Prevention: Nonpharmaceutical Interventions
In situations where vaccines and antiviral agents are insuf cient or unavailable, the WHO recommended introducing nonpharmaceutical public health interventions (NPIs) to contain infection, delay spread, and reduce the impact of pandemic dis- eases.30, 31 The NPIs are considered outside of health-care settings and focus on measures that (1) limit international spread of the virus (e.g., travel screening and restrictions); (2) reduce spread within national and local populations (e.g., testing, isolation and treatment of positive cases, monitoring and quarantining of exposed persons, and introducing social distancing measures); (3) reduce an individual per- son’s risk of infection; and (4) communicate risk to the public.
Community Prevention: Nonpharmaceutical Interventions
In addition to testing and isolating positive cases, contact tracing, and quarantine measures, governments are recommended to introduce NPI measures to control the spread of infection. Nonpharmaceutical interventions include and are not limited to the following:
1. Universal masking mandate in public areas;
2. Maintaining safe distances between people in public spaces;
3. Banning public events and large gatherings that generate crowds, including
personal responsibility to limit social gatherings;
4. Closing schools and universities;
5. Closing nonessential businesses;
6. Stay at home orders.
For COVID-19, countries around the world implemented aggressive public health measures to control viral spread. Some countries were successful in bringing down the R0 including China where the coronavirus originated. A study32 of the outbreak in Wuhan, the epicenter of the virus, measured the attack rate without any interventions, and after public health interventions were imposed found that the viral attack rate dropped precipitously (Table 3.2). The interventions were estimated to prevent 94.5% of infections.
Although the outbreak started in early December, no strong interventions were implemented until January 20 when human-to-human transmission was con rmed. On January 23, the government imposed an unprecedented policy of cordon sani- taire effectively cutting off the city and Hubei province from the rest of the world, but new cases continued to overwhelm hospitals that faced shortages in supply and were understaffed. The rate of viral infection among health-care workers was high probably due to lower awareness of nosocomial infections. The authors observed that asymptomatic and presymptomatic cases could be a substantial challenge to epidemic control, and the use of traditional NPI measures and policies were neces- sary to control the COVID-19 outbreak.
Table 3.2 Rate of Viral Transmissibility in Wuhan Before and After Implementing NPI Measures32
Estimated R0 (95% CI)
January 1–10, 2020
None—children on school break
3.88 (3.77–3.99)
January 11–22 (Chunyun, Chinese New Year)
None—massive population movement
January 23–February 1
Drastic social distancing measures with no travel in and out of Hubei cordon sanitaire
NPIs with aggressive testing and isolation of positive cases, contact tracing, and quarantine
Stay at home orders
People who were residing in other countries in the regions such as Hong Kong and Taiwan had experienced and learned lessons from the SARS outbreak and moved quickly to test and quarantine suspected cases, trace potential cases, ban large gatherings, impose social distancing, and enforce universal masking measures and instruct people to stay 1.5 m apart.33, 34 They prepared hospitals and staff and communicated accurate up-to-date information to the public. As COVID-19 moved westwards with Europe becoming the next epicenter, countries implemented NPI measures. The NPI measures, for 11 countries, were introduced successively from March 2 to March 20 and had a substantial effect on reducing transmission (81% reduction in attack rate) and brought R0 below 1 (probability Rt < 1 is 99.9%).35
The blanket measures to contain a pandemic can come at very high social and economic costs, but they may be necessary to break the chain of disease transmis- sion. In the case of COVID-19, it was necessary to mitigate the worst effects of the disease such as the overwhelming surge in demand for hospital care, particularly intensive care, and the high levels of mortality.
COVID-19 can affect people of all ages and backgrounds, but the data suggest that some people are more likely than others to get sick if they are exposed to the virus. From the outset of the epidemic, the data from China showed more severe illness and higher rates of infection in older groups and those with preexisting comorbid conditions.36 Age is an independent risk factor for older people that had no underly- ing conditions and also being at increased risk of severe illness. For example, people in their 60s are at higher risk for severe illness than people in their 50s, and those in their 50s are at higher risk than those in their 40s. The greatest risk for severe illness is among those aged 80 years or older. Children under 10 are not at risk and less likely to spread the disease. However, children between ages 10 and 19 are at less risk of severe illness but just as likely as adults to spread the disease.37
The Lancet Global Health recently estimated that one in ve individuals world- wide are at increased risk of severe disease, should they become infected, due to an underlying comorbidity and that risk varies considerably with age.38 The prevalence of one or more comorbidities is approximately 10% by 25 years, 33% by 50 years, and 66% by 70 years. The case fatality rate among those with preexisting comorbid conditions was 10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory diseases, 6.0% for hypertension, and 5.6% for cancer. Males were also at twice the risk compared with females. Obesity, classi ed as a body mass index (BMI) of 30 or above, and severe obesity of BMI of 40, is emerging as an important risk factor in the United States where the prevalence is 40% compared with 24% in Spain, 20% in Italy, and 6.2% in China.39 Obese people with COVID- 19 are more likely to experience severe pneumonia and require ventilation.40, 41
People who are in an immunocompromised state because of organ transplants or chemotherapy for cancers are also vulnerable to COVID-19. One study that
considered COVID-19 in immunocompromised patients reported high case of fatal- ity rate which was estimated to be 21.4%.42 Such a situation presents a conundrum for doctors who need to balance the risk of delaying chemotherapy against the increased risk of infection during the pandemic.
It has been speculated that diseases such as HIV and tuberculosis (TB), which lead to immunocompromised states, are also a risk factor for COVD-19 infection, but at this time there is no enough evidence for a de nitive association. In China, TB was the most common comorbidity in COVID-19 patients with 36% concurrently having a TB infection, compared to a general prevalence of 25% in the general population.43 Furthermore, patients with TB who contracted COVID-19 progressed to severe symptoms much more quickly than those without TB with the time from symptom onset to severe pneumonia averaging 3 days, compared to 7–8 days in cases without TB. For people living with HIV, the risk associated with COVID-19 is inconclusive, and most likely obscured by treatment with antiretrovirals.37 In Barcelona, 1% of COVID-19 patients who required hospitalization were HIV posi- tive, which is much higher than the HIV prevalence of 0.3% in the population.44
Smoking is associated with a high risk of severe symptoms for COVID-19, and a study published by the International Society for the Prevention of Tobacco Induced Diseases found that smokers infected with COVID-19 were 1.4 times more likely to experience severe symptoms and 2.4 times more likely to be admitted to the ICU, require intubation, or die compared to COVID-19 patients who were nonsmokers.45
Other groups who need extra precaution are people in closed settings such as prisons, homeless shelters, homes for people with disabilities and developmental or behavioral disorders, refugee camps, food processing plants, and other manufactur- ing settings.
• SARS-CoV-2 is highly transmissible and can be identi ed in droplets, aero- sols, and on surfaces before the onset of symptoms. A person can be infec- tious for up to 14 days or longer.
• Transmission from presymptomatic and asymptomatic cases makes it dif – cult to contain the spread of disease, and it is therefore recommended that individuals observe good hand hygiene, wear masks, and keep a physical dis- tance of 1.5 m (6 ft) from others.
• The risk of transmission varies by settings, but a closed environment with poor ventilation, large crowds, and prolonged contact with an infected person increase the likelihood of secondary infection.
• Child-to-adult transmission appears uncommon and children do not seem to be at risk for COVID-19 unless there are comorbidities.
• Increasing age and underlying comorbidities increase the risk of severe illness and mortality.
• In the absence of a vaccine or effective treatment, the immune response should be strengthened through a healthy diet, regular exercise, and at least 8 hours of sleep.
1. Doremalen N, Morris DH, Holbrook MG, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020;382:1564–1567. https://doi.org/10.1056/ NEJMc2004973.
2. Zhang R, Li Y, Zhang AL, et al. Identifying airborne transmission as the dominant route for the spread of COVID-19. PNAS. 2020;26(117):14857–14863. https://doi.org/10.1073/ pnas.2009637117.
3. Morawska L, Milton DK. It is time to address airborne transmission of COVID-19. Clin Infect Dis. ciaa939. https://doi.org/10.1093/cid/ciaa939.
4. Mohseni AH, Taghinezhad SS, Xu Z, et al. Body uids may contribute to human-to-human transmission of severe acute respiratory syndrome coronavirus 2: evidence and practical expe- rience. Chin Med. 2020;15:58. https://doi.org/10.1186/s13020-020-00337-7.
5. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med. 2020;26(5):672–675. https://doi.org/10.1038/s41591-020-0869-5.
6. To KK-W, Tsang OT-Y, Leung W-S, et al. Temporal pro les of viral load in posterior oropha- ryngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis. 2020;20(5):565–574. https://doi.org/10.1016/ s1473-3099(20)30196-1.
7. Liu Y, Yan LM, Wan L, et al. Viral dynamics in mild and severe cases of COVID-19. Lancet Infect Dis. 2020;20(6):656-657. https://doi.org/10.1016/S1473-3099(20)30232-2.
8. Liu WD, Chang SY, Wang JT, et al. Prolonged virus shedding even after seroconversion in a patient with COVID-19. J Infect. 2020;S0163-4453(20)30190-0. https://doi.org/10.1016/j. jinf.2020.03.063.
9. Yang R, Gui X, Xiong Y. Comparison of clinical characteristics of patients with asymptomatic vs symptomatic coronavirus disease 2019 in Wuhan, China. JAMA Network Open. 2020;3(5). https://doi.org/10.1001/jamanetworkopen.2020.10182.
10. Aguilar JB, Faust JS, Westafer LM, Gutierrez JB. Investigating the impact of asymptomatic carriers on COVID-19 transmission. medRxiv. 2020. https://doi.org/10.1101/2020.03.18.2003 7994.
11. Ganyani T, Kremer C, Chen D, et al. Estimating the generation interval for COVID-19 based on symptom onset data. medRxiv. 2020. https://doi.org/10.1101/2020.03.05.20031815.
12. Delamater PL, Street EJ, Leslie TF, Yang YT, Jacobsen KH. Complexity of the basic reproduc- tion number (R0). Emerg Infect Dis. 2019;25(1):1–4. https://doi.org/10.3201/eid2501.171901.
13. Sanchez S, Lin Y, Xu C, et al. High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis. 2020;26(7):1470–1477. https://doi.org/10.3201/
eid2607.200282.
14. Endo A, Centre for the Mathematical Modelling of Infectious Diseases COVID-19 Working
Group, Abbott S, et al. Estimating the overdispersion in COVID-19 transmission using outbreak sizes outside China. Wellcome Open Res. 2020;5:67. https://doi.org/10.12688/ wellcomeopenres.15842.2.
15. Leclerc QJ, Fuller NM, Knight LE, et al. What settings have been linked to SARS- CoV-2 transmission clusters?. Wellcome Open Res. 2020:5:83. https://doi.org/10.12688/ wellcomeopenres.15889.2.
16. Nishiura H, Oshitani H, Kobayash T, et al. Closed environments facilitate secondary transmis- sion of coronavirus disease 2019 (COVID-19). medRxiv. 2020. https://doi.org/10.1101/2020.0 2.28.20029272.
17. https://www.erinbromage.com/post/the-risks-know-them-avoid-them.
18. Bloomberg, Coronavirus can travel 26 feet in rooms with cold, stale air-like meat plants. Fortune. https://fortune.com/2020/07/23/covid-in-air-how-long-coronavirus-spreads-in-air-
cold-stale-inside-travels-26-feet/. Accessed July 23, 2020.
19. Texas Medical Association. Be Informed: Know Your Risk during COVID-19. 2020. https://
http://www.texmed.org/TexasMedicineDetail.aspx?Pageid=46106&id=53977.
20. Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions. JAMA. 2020. https://
doi.org/10.1001/jama.2020.4756.
21. WHO. 2020. https://www.who.int/publications/i/item/home-care-for-patients-with-suspected-
novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-
contacts. Accessed 2020.
22. CDC. COVID-19: Quarantine vs. Isolation. 2020. https://www.cdc.gov/coronavirus/2019-
ncov/downloads/if-you-are-sick/317422-A_Quarantine-and-Isolation_508.pdf.
23. Grant WB, Lahore H, Mcdonnell SL, et al. Evidence that vitamin D supplementation could reduce risk of in uenza and COVID-19 infections and deaths. 2020. https://doi.org/10.20944/
preprints202003.0235.v2.
24. Skalny A, Rink L, Ajsuvakova O, et al. Zinc and respiratory tract infections: Perspectives for
COVID-19. Int J Mol Med. 2020. https://doi.org/10.3892/ijmm.2020.4575.
25. Simpson RJ, Katsanis E. The immunological case for staying active during the COVID-19
pandemic. Brain Behav Immun. 2020;87:6–7. https://doi.org/10.1016/j.bbi.2020.04.041.
26. USDHHS. Physical Activity Guidelines for Americans. 2nd ed. 2019. USDHHS.
27. World Health Organization. Smoking and COVID-19. WHO Global Team. 30 June 2020.
28. Sarkar D, Jung MK, Wang HJ. Alcohol and the immune system. Alcohol Res.
2015;37(2):153–155.
29. Ji D, Qin E, Xu J, et al. Non-alcoholic fatty liver diseases in patients with COVID-19: a retro-
spective study. J Hepatol. 2020;73(2):451–453. https://doi.org/10.1016/j.jhep.2020.03.044.
30. World Health Organization Writing Group. Nonpharmaceutical interventions for pan- demic in uenza, international measures. Emerg Infect Dis. 2006:12 (1):81–87. https://doi.
org/10.3201/eid1201.051370.
31. World Health Organization Writing Group. Nonpharmaceutical interventions for pan-
demic in uenza, international measures. Emerg Infect Dis. 2006;12(1):88–94. https://doi.
32. Pan A, Liu L, Wang C, et al. Association of public health interventions with the epidemiology
of the COVID-19 outbreak in Wuhan, China. JAMA. 2020;323(19):1915–1923. https://doi.
org/10.1001/jama.20. https://doi.org/10.1101/2020.03.032003593.
33. Gawande A, Chotiner I, Kormann C. Keeping the coronavirus from infecting health-care work-
ers. The New Yorker. March 21, 2020. https://www.newyorker.com/news/news-desk/keeping-
the-coronavirus-from-infecting-health-care-workers. Accessed March 21, 2020.
34. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020;323(14):1341–1342. https://doi.org/10.1001/
jama.2020.3151.
35. Flaxman, S., Mishra, S., Gandy, A, et al. Estimating the effects of non-pharmaceutical inter-
ventions on COVID-19 in Europe. Nature. 2020;584:257–261. https://doi.org/10.1038/
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36. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus dis-
ease 2019 (COVID-19) Outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239–1242. https:// doi.org/10.1001/jama.2020.2648.
37. Guenther T, Czech-Sioli M, Indenbirken D, et al. Investigation of a superspreading event pre- ceding the largest meat processing plant-related SARS-Coronavirus 2 outbreak in Germany. https://ssrn.com/abstract=3654517. Accessed July 17, 2020.
38. Clark A, Jit M, Warren-Gash C, et al. Global, regional and national estimates of the popu- lation at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modeling study. Lancet Glob Health. 2020;8(8):E1003–E1017. https://doi.org/10.1016/ S2214-109X(20)30264-3.
39. Kass D, Duggal P, Cingolani O. Obesity could shift severe COVID-19 disease to younger ages. Lancet. 2020:395(10236):1544–1545. https://doi.org/10.1016/S0140-6736(20)31024-2.
40. Stefan N, Birkenfeld AL, Schulze MB, Ludwig DS. Obesity and impaired metabolic health in patients with COVID-19. Nat Rev Endocrinol. 2020;16(7):341–342. https://doi.org/10.1038/ s41574-020-0364-6.
41. Cai Q, Chen F, Wang T, et al. Obesity and COVID-19 severity in a designated hospital in Shenzhen, China. Diabetes Care. 2020;43(7):1392–1398. https://doi.org/10.2337/dc20-0576.
42. Fishman JA, Grossi PA. Novel coronavirus-19 (COVID-19) in the immunocompromised
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and disease severity. 2020. https://doi.org/10.1101/2020.03.10.20033795.
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Outpatient Management: Mild and Moderate Symptoms of COVID-19
Naiyer Imam M.D., Nooshi Karim M.D. and Abena Baah-Fordjour
ACAAI ACE II ATII ROS WHO
American College of Allergy, Asthma and Immunology Angiotensin-converting enzyme II
Symptoms of COVID-19 can range from an asymptomatic course to a myriad of manifestations. Most people will experience mild-to-moderate respiratory illness symptoms. The World Health Organization (WHO) reports that “80% of infections are mild or asymptomatic; 15% of infections are severe, which require oxygen; and 5% of infections are critical, requiring ventilation.” For patients with a mild clinical course, the most common symptoms are u-like (ie, fever, dry cough, shortness of breath/dif culty breathing, fatigue, sore throat, chills, and muscle pain). A subset of patients with initially mild symptoms may experience a rapid worsening of their condition, requiring hospitalization. This chapter discusses the current management strategies for mild-to-moderate disease that doesn’t require hospitalization and can be handled at home.
4.2 COVID-19 Overview of Symptoms
The virus has an incubation period of 2–14 days; on average, patients report symp- toms within 3–5 days.1 The time from infection to symptom manifestation appears to be based on the immune system functioning of the individual. Older adults, aged
Chapter 4: Outpatient Management: Mild and Moderate Symptoms of COVID-19
>70 years, having shorter incubation periods and more severe disease courses. Those under 18 years of age are less likely to present with the hallmark symptoms of fever and cough compared to adults aged 18–64.2
CDC reports that 83–99% of COVID patients experience fever, 59–82% cough, 44–70% fatigue, 40–84% anorexia, 31–40% shortness of breath, 28–33% sputum production, and 11–35% myalgia.3 A study of 1099 patients across 552 hospitals in China found that over 75% of cases reported a fever ranging between 37.5°C and 39.0°C (99.5°F–102.2°F), 68.7% reported a cough, 38.1% fatigue, and 33.7% spu- tum production.4 The same study found that comorbidities such as hypertension and diabetes could in uence the severity of disease progression. Table 4.1 also provides information for the ndings of other coexisting disorders.
4.3 Current Management Strategies for Mild Disease
It is currently recommended that those with mild symptoms (or previous exposure to the virus) stay home. For most patients, the disease is self-limited and does not require medical care. To manage symptoms, the Centers for Disease Control and Prevention recommends rest, staying hydrated, and the use of over-the-counter medicines like acetaminophen.5
Infected persons living in a household with others should take extra precautions to avoid the spread of the virus. The most important prophylaxis is frequent hand- washing or the use of an alcohol-based hand sanitizer if handwashing is not possi- ble. It is also recommended for all individuals to not touch their face, especially their nose, eyes, and mouth; this precautionary step decreases the risk of viral entry into the body. To protect others living in the household from becoming infected, CDC recommends a frequent sanitization of shared surfaces, isolation and social distancing of the infected person from the rest of the household (including pets), and the infected person wearing a mask when around others. If possible, the infected person should even have his or her own separate bathroom for the duration of ill- ness. Patients who use CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure) machines and nebulized medications should not use them when other people are around as it can become aerosolized.
The WHO updated the criteria for discharge from isolation as part of the clinical care pathway of a COVID-19 patient. These criteria apply to all COVID-19 cases regardless of isolation location or disease severity.The criteria for discharging patients from isolation (i.e., discontinuing transmission-based precautions) without requiring retesting:
• For symptomatic patients: 10 days after symptom onset, plus at least three additional days without symptoms (including without fever and without respi- ratory symptoms) and
• For asymptomatic cases: 10 days after positive test for SARS-CoV-2.
Current Management Strategies for Mild Disease
                                                                                                                                                                                        
Table 4.1 Clinical Characteristics of the Study Patients, According to Severity and the Presence or Absence of the Primary Composite End Pointa
All Patients (N = 1099)
Disease Severity Nonsevere (N = 926)
Presence of Primary Composite End Pointb
Median (IQR)—years
47.0 (35.0–58.0)
Severe N = 173 52.0 (40.0–65.0)
Yes (N = 67) 63.0 (53.0–71.0)
No (N = 1032) 46.0 (35.0–57)
Distribution—no./total no. (%) 0–14 years
9/1011 (0.9) 557/1011 (55.1) 292/1011 (28.9) 153/1011 (15.1) 459/1096 (42.9)
8/848 (0.9) 490/848 (57.8) 241/848 (28.4) 109/848 (12.9) 386/923 (41.8)
1/163 (0.6) 67/163 (41.1) 51/163 (31.3) 44/163 (27.0) 73/173 (42.2)
12/65 (18.5) 21/65 (32.3) 32/65 (49.2) 22/67 (32.8)
9/946 (1.0) 545/946 (57.6) 271/946 (28.6) 121/946 (12.8) 437/1029 (42.5)
Female sex—no./total no. (%) Smoking history—no./total no. (%)
Never smoked Former smoker Current smoker
927/1085 (85.4) 21/1085 (1.9) 137/1085 (12.6)
793/913 (86.9) 12/913 (1.3) 108/913 (11.8)
134/172 (77.09) 9/172 (5.2) 29/172 (16.9)
44/66 (66.7) 5/66 (7.6) 17/66 (25.8)
Exposure to source of transmission within past 14 days—no./total no. (%)
Living in Wuhan Contact with wildlife Recently visited Wuhanc
483/1099 (43.9) 13/687 (1.9) 193/616 (32.3)
83/173 (48.0) 3/128 (2.3) 27/90 (30.0)
                                                                                                                                                                                    
Table 4.1 (continued) Characteristics
Disease Severity 376/522 (722.0) 4.0 (2.8–7.0)
Had contact with Wuhan residentsc
442/611 (72.3) 4.0 (2.0–7.0)
66/89 (74.2) 4.0 (2.0–7.0)
Medium incubation period (IQR)—daysd
Fever on admission
Patients—no./total no. (%)
Median temperature (IQR)—°C
Distribution of temperature—no./total no. (%)
391/910 (43.0) 37.3 (36.7–38.0)
82/171 (48.0) 37.4 (36.7–38.1)
24/66 (36.4) 36.8 (36.3–37.8)
449/1015 (44.2) 37.3 (36.7–38.0)
<37.5°C 37.05–38.0°C 38.1–39.0°C >39.0°C
608/1081 (56.2) 238/1081 (22.0) 197/1081 (28.2) 38/1081 (3.5)
519/910 (57.0) 201/910 (22.1) 160/910 (17.6) 30/910 (3.3)
89/171 (52.0) 37/171 (21.6) 37/171 (21.6) 8/171 (4.7)
42/66 (63.6) 10/66 (15.2) 11/66 (16.7) 3/66 (4.5)
Fever during hospitalization Patients—no./total no. (%)
Median highest temperature (IQR)—°C
92/926 (10.9) 286/926 (30.9) 434/926 (46.9) 114/926 (12.3)
79/774 (10.2) 251/774 (32.4) 356/774 (46.0) 88/774 (11.4)
13/152 (8.6) 35/152 (23.0) 78/152 (51.3) 26/152 (17.1)
3/54 (5.6) 20/54 (37.0) 21/54 (38.9) 10/54 (18.5)
                                                                                                                                                                                                                      
Symptoms—no. (%) Conjunctival congestion Nasal congestion Headache
9 (0.8)
53 (4.8) 150 (13.6) 745 (67.8) 153 (13.9) 370 (33.7) 419 (38.1) 10 (0.9) 205 (18.7) 55 (5.0) 42 (3.8) 164 (14.9) 126 (11.5)
47 (5.1) 124 (13.4) 623 (67.3) 130 (14.0) 309 (33.4) 350 (37.8) 6 (0.6) 140 (15.1) 43 (4.6) 32 (3.5) 134 (14.5) 100 (10.8)
26 (15.0) 122 (70.5) 23 (13.3) 61 (35.3) 69 (39.9) 4 (2.3)
65 (37.6) 12 (6.9) 10 (5.8) 30 (17.3) 26 (15.0)
8 (11.9) 46 (68.7) 6 (9.0) 20 (29.9) 22 (32.8) 2 (3.0) 36 (53.7) 3 (4.5)
8 (11.9)
Sputum production Fatigue
Hemoptysis Shortness of breath Nausea or vomiting Diarrhea
Myalgia or arthralgia Chills
Signs of infection—no (%) Throat congestion
Tonsil swelling
Enlargement of lymph nodes Rash
19 (1.7) 23 (2.1) 2 (0.2) 2 (0.2)
17 (1.8) 17 (1.8) 1 (0.1) 0
2 (1.2) 6 (3.5) 1 (0.6) 2 (1.2)
1 (1.5) 1 (1.5) 0
                                                                                                                                         
Disease Severity
Coexisting disorders Any
261 (23.7) 12 (1.1)
194 (21.0) 6 (0.6)
67 (38.7) 6 (3.5)
39 (58.2) 7 (10.4)
Coronary heart disease Cerebrovascular disease Hepatitis B infectione Cancerf
Chronic renal disease Immunode ciency
81 (7.4) 165 (15.0) 27 (2.5) 15 (1.4) 23 (2.1) 10 (0.9)
53 (5.7) 124 (23.4) 17 (1.8) 11 (1.2) 22 (2.4)
28 (16.2) 41 (23.7) 10 (5.8) 4 (2.3)
18 (26.9) 24 (35.8) 6 (9.0)
included in the analysis are provided if they differed from the overall numbers in
the group. Percentages may not total
aThe denominators of patients who were
100 because of rounding. COVID-19 denotes coronavirus disease 2019, and IQR interquartile range.
bThe primary composite end point was admission to an intensive care unit, the use of mechanical ventilation, or death.
cThese patients were not residents of Wuhan.
dDate regarding the incubation period were missing for 808 patients (73.5%).
eThe presence of hepatitis B infection was de ned as a positive result testing for hepatitis B surface antigen with or without elevated levels of alanine or aspar- tate aminotransferase.
fIncluded in this category is any type of cancer.
1 (0.6) 3 (1.7) 3 (1.7) 0
4.3.1 Management of Underlying Conditions with COVID-19 Infection
In general, patients with comorbidities are not more likely to get infected with COVID-19 compared to the general population. People with the underlying chronic conditions such as diabetes, obesity, HIV, other immunocompromised states, and hypertension are more likely to suffer from complications when infected with the virus. For patients with comorbidities, recommendations may vary and will be pro- vided by the health-care practitioner, but general guidance is as follows:
• Respiratory disease: Patients with asthma are advised to follow the general precautions listed above as well as to continue the established asthma action plan. The American College of Allergy, Asthma and Immunology (ACAAI) issued a statement to encourage adherence to allergy and asthma maintenance regimens. According to the ACAAI, there is no evidence that intranasal or inhaled corticosteroids increase the risk of getting the COVID-19 infection or lead to a worse outcome if someone does get infected.6
• Cardiovascular conditions: Older patients with cardiovascular comorbidities may have an added protection against severe disease from the virus if on angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) according to an observational study conducted by United Health Group and the Yale University School of Medicine.7 A meta-analysis also found that ACE inhibitors/ARBs do not increase the risk of infection nor developing severe disease.8
• Diabetes: Patients who have diabetes must maintain blood glucose level as infection with COVID-19 can lead to increased complications; this is because high blood glucose levels can suppress the immune system. These complica- tions can come in the form of kidney failure and diabetic ketoacidosis, which are both life-threatening and require immediate medical attention.4 Diabetic patients must continue to take prescribed medications in addition to avoiding the risk factors for the development of COVID-19.
• Immunocompromised: People that are immunocompromised are at an increased risk of developing infections because the immune system is the body’s defense against pathogens. Immunocompromised individuals include but are not lim- ited to, patients with cancer, transplants, and HIV. These patients should con- tinue with their normal treatment regimen for their underlying disease even if it involves immunosuppressants . If a patient develops a fever of 100.4°F (38°C) or higher, he/she must call their physician immediately.9
• Obesity: An often underestimated comorbidity that many Americans face is obesity. It is reported that 42% of adults are obese and 9% are severely obese.10 Obesity is associated with decreased expiratory reserve volume, functional capacity, and respiratory system compliance. It is also associated with increased in ammatory cytokines, which may contribute to the increased morbidity asso- ciated with obesity in COVID‐19 infections.5 For these reasons, patients suffer- ing from obesity should work with their health-care practitioner to develop a lifestyle plan that includes diet modi cation and frequent exercise.11
Chapter 4: Outpatient Management: Mild and Moderate Symptoms of COVID-19 4�3�2 Protective Health Measures
Quality sleep (preferably of 7–8 h in duration), exercise, and a well-balanced diet rich in fruits and vegetables help to bolster the innate immune system. The innate immune system is our body’s rst line of defense against a variety of pathogens before our adaptive immune system can offer additional and stronger protection. It takes about 4–7 days for the adaptive immune response to set in; therefore, in the initial stages of infection, the innate immune response is essential for ghting and clearing the virus (see Chapter 2).
Vitamins and supplements, such as zinc and Vitamin C, while not of cially rec- ognized as treatments for mild symptoms, can possibly be cheap, low-risk, and ef cacious prophylaxis because of their immune-modulating effects on the immune system. Studies have shown that zinc can inhibit the replication of some viruses such as the original coronavirus and arterivirus, thus decreasing the severity of dis- ease.1 Part of how COVID-19 causes disease is by blocking the angiotensin convert- ing-enzyme II (ACE II) receptor, resulting in increased levels of angiotensin II (ATII) and decreased levels of angiotensin 1, 7 (AT 1,7). Both of these changes lead to the formation of reactive oxygen species (ROS) like superoxides, which cause endothelial cell dysfunction; this state predisposes the patient to thrombosis in organs like lungs, and as a result impairing oxygen delivery.12 Vitamin C is a well- known antioxidant and can potentially protect against the effect of ROS, thus decreasing the severity of disease and the chance of developing serious complica- tions from the virus. A 2017 study found that daily or weekly vitamin D supplemen- tation was protective against acute respiratory tract infection,5 which can make this a helpful prophylaxis against COVID-19.
Home oxygen therapy can be considered effective in patients with mild hypoxia with improvement in saturation with oxygen by nasal cannula who can reliably adhere with therapy and follow-up. Such patients will require daily televisits. Thromboprophylaxis at home can be considered in patients at high risk for thrombosis.
Fructose consumption, obesity, and sedentary lifestyle all contribute to chronic systemic in ammation,which results in poor immune function and can render a person more susceptible to developing disease and/or slow recovery/complications from the disease.13
4.4 Management by Telemedicine
Telemedicine is a method that allows health-care practitioners to provide care to patients through electronic means. It is preferable in most of the outpatient manage- ment of COVID-19 patients as it can prevent avoidable in-person medical visits to medical of ces/urgent care centers or emergency rooms (ERs), providing relief to a strained health-care system and preventing unnecessary use of personal protective equipment (PPE). For the general public, the advantage of this service is that patients
Management by Telemedicine
have an increased access to care in an environment that is most convenient and comfortable to them. In the long term, this can promote adherence to treatment plans and decrease loss-to-follow-up rates. For those that lack adequate health insurance, telemedicine is not only cheaper compared to in-person of ce visits, but can even be free in some cases.
In his Washington Post article, primary care physician Michael Barnett writes, “Much of the actual work of primary care happens when patients aren’t in the of ce, whether doctors are coordinating with three specialists to tweak a complex medication regimen or nding a hospice agency for an ailing patient. The only reason we deliver almost all primary care through of ce visits is because that is what insurers will pay for.”.14 For COVID-19 patients with mild symptoms that do not require hospitalization, telemedicine is a great option to provide care while reducing the risk of transmission to the vulnerable public who rely on in-person clinic visits. Patients who are considered stable enough to be managed at home are risk-strati ed into low, moderate, and high risk to determine the frequency of fol- low-up visits.
A large part of telemedicine is a conversation between the health-care provider and the patient. Most health-care practitioners prefer to conduct telemedicine ser- vices, such as physical examinations, physical therapy, and mental health services, through video chat or telephone conversation. This allows the health-care practitio- ner to observe the general appearance of the patient and their ability to perform tasks the provider guides them. Providers can take patient vitals by calculating respiratory rate based on observation and providing equipment for patients to moni- tor their own health such as electronic blood pressure machines and blood glucose monitors. During video televisits, clinicians can judge the level of dyspnea, oxygen saturation, and mental status by observation and can inquire about other symptoms such as orthostasis, dizziness, falls, changes in sensation of smell and taste, hypo- tension, and urine output. Based on the examination, the provider can then recom- mend tests or treatments that can be delivered to a patient from a pharmacy near them or if in-person evaluation is necessary. In a New York Times article, Dr. Emil Baccash, a geriatrician in Brooklyn, N.Y. said of telemedicine, “Telemedicine is not a substitute for seeing and physically examining a patient. But there are some patients, especially elderly patients, who can’t get out of the house. I can talk to them and look at their problem on my computer, take a snapshot, say, of a leg infec- tion and enter it directly into their medical record. If a blood test is needed, I can have a lab technician come to their house”.15 Patients who are less reliable to self- monitor and report may need more intense follow-up to continue the management at home.
Telemedicine also offers a health-care practitioner the opportunity to observe a patient’s living environment. Environment can exacerbate certain conditions or pre- dispose certain demographics, like the elderly, to injury. Rural communities can also bene t from telemedicine as many members of this community have trouble with accessing care due to the de cit of health-care centers and the distance to these sites.
1. Symptoms of Coronavirus. Centers for Disease Control and Prevention; 2020. https://www. cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.
2. Coronavirus Disease 2019 in Children—United States, February 12–April 2, 2020. cdc.gov. 2020. https://www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htm?s_cid=mm6914e4_w.
3. Interim Clinical Guidance for Management of Patients with Con rmed Coronavirus Disease (COVID-19). Centers for Disease Control and Prevention; 2020. https://www.cdc.gov/ coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html.
4. Dietz W, Santos‐Burgoa C. Obesity and its Implications for COVID‐19 Mortality. Obesity. 2020;28(6):1005–1005. https://doi.org/10.1002/oby.22818.
5. Coronavirus disease 2019 (COVID-19) Situation Report—46. Who.int. (2020). https://www. who.int/docs/default-source/coronaviruse/situation-reports/20200306-sitrep-46-covid-19. pdf?sfvrsn=96b04adf_4
6. Important information about COVID-19 for those with asthma. ACAAI Public Website; 2020. https://acaai.org/news/important-information-about-covid-19-those-asthma.
7. Khera R, Clark C, Lu Y, et al. Association of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers with the risk of hospitalization and death in hypertensive patients with coronavirus disease-19. 2020. https://doi.org/10.1101/2020.05.17.20104943.
8. Hughes S. ACE inhibitors and severe COVID-19: Protective in older patients?. The- hospitalist.org. https://www.the-hospitalist.org/hospitalist/article/222622/coronavirus-updates/ ace-inhibitors-and-severe-covid-19-protective-older.
9. People Who Are at Higher Risk for Severe Illness. Centers for Disease Control and Prevention; 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher- risk.html.
10. Hales K, Carroll MD, Fryar CD, Ogden CL. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. NCHS Data Brief, no. 360. Hyattsville, MD: National Center for Health Statistics; 2020.
11. Treatment for Overweight & Obesity. National Institute of Diabetes and Digestive and Kidney Diseases; 2018. https://www.niddk.nih.gov/health-information/weight-management/ adult-overweight-obesity/treatment.
12. MedCram. Coronavirus Pandemic Update 59: Dr. Seheult’s Daily Regimen (Vitamin D, C, Zinc, Quercetin, NAC) [Video]. https://www.youtube.com/watch?v=NM2A2xNLWR4& feature=emb_logo. Accessed June 19, 2020.
13. Pereira RM, Botezelli JD, da Cruz Rodrigues KC, et al. Fructose consumption in the devel- opment of obesity and the effects of different protocols of physical exercise on the hepatic metabolism. Nutrients. 2017;9(4):405. https://doi.org/10.3390/nu9040405.
14. BarnettM.Afterthepandemic,visitingthedoctorwillneverbethesame.Andthat’s ne.Washington Post. 2020. https://www.washingtonpost.com/opinions/2020/05/11/after-pandemic-visiting- doctor-will-never-be-same-thats- ne/.
15. Brody J. A pandemic bene t: the expansion of telemedicine. Nytimes.com. 2020. https://www. nytimes.com/2020/05/11/well/live/coronavirus-telemedicine-telehealth.html.
Pulmonary Manifestations of COVID-19
Syed Mehdi M.D., Nishat Mehdi M.D., and Sabbir Chowdhury
ARDS Acute respiratory distress syndrome BTS British Thoracic Society
COPD Chronic obstructive pulmonary disease HFNC High ow nasal cannula
ICU Intensive care unit
ICS inhaled corticosteroid
ISTH International Society on Thrombosis and Haemostasis NICE National Institute of Clinical Excellence
PE Pulmonary embolism
PEEP Positive end expiratory pressure
SRF VTE
Severe respiratory failure Vascular thromboembolism
The effect of COVID-19 on the respiratory system has become very well recog- nized since this novel coronavirus has been established. The rapid spread of COVID-19 along with its burden on the respiratory system has pressured health- care systems into managing the health status of patients. It is important to compre- hensively understand how COVID-19 manifests in order to overcome this pandemic in a globally resource-limited climate. This chapter summarizes the pathophysiol- ogy, symptoms, and associations with other respiratory diagnoses, as well as clini- cal management.
Chapter 5: Pulmonary Manifestations of COVID-19
5.2 Origins, Transmission, and Pathogenesis of COVID-19 Disease
In December 2019, there was an outbreak of an unknown virus at a seafood market in Wuhan, China; initially, it was referred to as pneumonia of unknown origin. It was thought that the transmission was zoonotic and only the people working in the seafood market were affected. However, human-to-human transmission was later established.1 World Health Organization (WHO) declared a public health emer- gency of international concern on January 30, 2020, and pandemic on March 30, 2020.2
The novel coronavirus was named as severe acute respiratory syndrome corona- virus-2 (SARS-CoV-2) following on from SARS-CoV, which caused acute respira- tory distress syndrome (ARDS) and resulted in high mortality during 2002–2003. Coronaviruses are a family of enveloped, positive, single-stranded RNA viruses that are classi ed within the Coronavirus family and Nidovirales order.3
The predominant mode of transmission is from respiratory droplet spread by coughing, sneezing, and talking, which can easily contaminate surfaces and spread the virus within the households.4 There is an evidence for the spread by a direct contact with infected secretions or large and small aerosol droplets (Figure 5.1). Immunity develops soon after infection, but wanes gradually over time. It is unknown if reinfection is common.
High-risk populations include children, pregnant women, immunocompromised patients, health-care providers, and elderly people. Incubation period can extend up to 14 days from the onset of exposure. Some individuals can be asymptomatic or may have mild severity of fever, shortness of breath, and cough due to a good immune system.
Most COVID-19 patients had mild symptoms in the early onset of disease; how- ever, the condition of some patients declined in the latter half of the disease or dur- ing the recovery phase. The mortality of many patients is attributed to the rapid development of ARDS and multiorgan failure as a result of a cytokine storm. An effective suppression of the cytokine storm is a pivotal way to prevent the deteriora- tion of patients with COVID-19 infection and save the patients’ lives.
5.3 Pathophysiology
The complexity of a cytokine storm’s pathogenesis involves the loss of regulatory control of pro-in ammatory cytokine production, both locally and systemically, thereby causing excessive immune responses with potential immune damage to the human body.5 The cytokine storm is detailed in (Figure 5.2).
Increased serum levels of IL-2R and IL-6 in patients with COVID-19 are associ- ated with an increased severity of disease. Moreover, other studies have found patients in the intensive care unit (ICU) displaying increased serum levels of granu- locyte colony-stimulating factor, IP-10, MCP-1, macrophage in ammatory
Mucus within eyes, ears, nose, and mouth are in direct contact with respiratory droplets or indirect contact from live particles on contaminated inanimate objects called fomites (door knob, surface, clothing)
Entry of virus in respiratory tract, attacking type 2 pneumocyte in alveoli which affects production of surfactant and thus alveoli collapse.
Virus adheres to and mimics ACE2 receptor in alveoli, gaining access into cell.
+ssRNA disassemble and release viral RNA which attaches ribosomes use for translation of proteins into polyprotein in presence of RNA-dependent RNA polymerase virus allowing conversion of—ssRNA into +ssRNA.
Small viral proteins in endoplasmic reticulum are arranged and transported to golgi apparatus where virus is packaged out of the cells as new progeny of viral cells.
Through exocytosis virus progeny are released out of the cells.
In the process of replicating the virus, there is damage to the alveoli. Hence, signals are released in the form of in ammatory cytokines such as interferons, interleukin 6.
Alveolar macrophages detect the cell injury and release IL-6, IL-1, IL-8, TNF D, chemokines.
This in ammatory process in lung parenchyma stimulates the nerve bers and produces a cough re ex
TNF D, IL-6, IL-8 increase the vascular permeability and increase adhesion molecule which causes leakage of uid in interstitium, alveoli, and lung parenchyma causing interstitial edema and pulmonary edema.
Dyspnea and hypoxia
Neutrophils try to engulf the virus, and there is a release of toxins and chemokines, further damaging alveolar cells. Thus, the production of surfactant decreases, leading to alveolar collapse and eventually hypoxia.
Figure 5.1 Flowchart describing the pathogenesis of COVID-19.
protein-1A, and tumor necrosis factor-alpha (TNF-α), compared to COVID-19 patients from general wards.6 Therefore, this suggests that the cytokine storm is positively correlated with disease severity. Given that cytokine storms involve hyperin ammation, immunosuppression is likely to be bene cial.5
The corresponding signs and symptoms include fever, cough, shortness of breath, myalgia, fatigue, ARDS, arrhythmia, and shock. Laboratory results demonstrated altered liver function tests, azotemia, elevated troponin T, elevated d-dimer, and elevated IL-6 levels.
                 
High levels of IL-1B, IFN-J, IP-10, and monocyte chemoattractant protein 1 (MCP-1) have been detected in patients with COVID-19.
These in ammatory cytokines activate the T-helper type 1 (Th1) cell response. Th1 activation is a key event in the activation of speci c immunity.
However, unlike SARS, COVID-19 patients also have elevated levels of Th2 cell-secreted cytokines, such as IL-4 and IL-10, which inhibit the in ammatory response.
Very high level of IL-6.
Increased VEGF and coagulation factors which predispose microthrombi and thrombi formation.
Increased vascular permeability leading to interstitial edema, pulmonary edema, and multiorgan failure.
Figure 5.2 Flowchart describing the pathophysiology of a cytokine storm within COVID-19. 5.3.1 Symptoms
It is critical to understand how patients will present clinically for safe triage and risk assessment, especially considering signs and symptoms of COVID-19 are nonspe- ci c following an incubation period of 2–14 days.7 Moreover, presentations can range from patient’s being asymptomatic to death.
A comprehensive joint report produced by WHO and China on COVID-19 (n = 55,924) demonstrated COVID-19 patients commonly present with pyrexia (87.9%), dry cough (67.7%), sputum production (33.4%), and dyspnea (18.6%). Other com- mon symptoms are myalgia/arthralgia, chills, headache, sore throat, nasal conges- tion, anosmia, and ageusia.7–9 Early reports from China also stated that a few patients experienced rhinorrhea and haemoptysis.10, 11
Anosmia and ageusia are more commonly found within COVID-19 patients who are younger and not hospital inpatients. The majority of patients with the loss of taste or smell noticed an improvement within 2 weeks.12
Similar ndings were present among pregnant patients who developed COVID- 19 pneumonia.13, 14 Interestingly, studies have shown that children may be less likely to be symptomatic or develop severe symptoms compared to adults; however, they are just as likely to be infected. Therefore, the risk of transmission from children is yet to be understood.15, 16
         
5�3�2 Happy Hypoxics
Among the many surprises of the novel coronavirus, some patients seem to defy the basic physiology of hypoxia as they can be well observed generally, and to describe themselves as comfortable with no signs of distress. For such patients, SpO2 and SaO2 have been reported as low as 62% and 69%, respectively. Clinicians call them happy hypoxics.17, 18
5�3�3 Mechanism
Swelling and in ammation in the lungs is likely to make oxygen perfusion dif cult (Figure 5.3). There is evidence that COVID-19 can cause blood clotting with the development of microthrombi, thus affecting the entire body. With a focus on the lungs, microthrombi can occlude the very distal vessels participating in gas exchange. Interestingly, reports have shown anticoagulation drastically improving bluish discoloration of toes and shortness of breath.18 Therefore, the severity of COVID-19 can be indicated by d-dimer levels as it re ects coagulation cascade activation, organ failure, and cytokine storm. A high level of d-dimer during admis- sion is associated with high mortality and morbidity. As such, anticoagulation will de nitely be a cornerstone in the management of COVID-19 patients.
Figure 5.3 Lung CT scan of a COVID-19-positive patient demonstrating a lack of distal perfusion.19
5.4 Respiratory Failure
SARS-CoV causes acute pneumonia and is associated with a high mortality as rela- tively clinically stable patients can suddenly deteriorate to severe respiratory failure (SRF). The most characteristic symptom of patients with COVID-19 is respiratory distress, and most of the patients admitted to ICU cannot breathe spontaneously.20 This is supported by a study which found more than half of the patients admitted with dyspnea needed intensive care—of which 46–65% of the patients worsened in a short period of time and died due to respiratory failure.20
The sudden clinical deterioration 7–8 days after the onset of symptoms suggests that SRF in COVID-19 is driven by a unique pattern of immune dysfunction.21 All patients with SRF displayed either cytokine storm or depletion of CD4 lympho- cytes, CD19 lymphocytes, and natural killer (NK) cells. The production of TNF-α and IL-6 by circulating monocytes was observed to be sustained, unlike in bacterial sepsis or in uenza. This was partially restored by the IL-6 blocker tocilizumab.
Another study noticed that COVID-19 patients with acute respiratory failure present with severe hypercoagulability.22 Therefore, the treatment of respiratory failure should include anticoagulation along with an appropriate management of the cytokine storm and ARDS.
5.5 COVID-19 and Pulmonary Embolisms
Acute infections have been known to cause a transient increased chance for a con- current pulmonary embolism (PE) in the absence of other risk factors for vascular thromboembolisms (VTEs).23 This has been highlighted further in a case report of a COVID-19 patient.24 Nonetheless, many patients will have a lengthy hospitalized disease course with COVID-19 introducing immobilization as a risk factor for PEs too.
D-dimer levels are typically used as a crude indicator for the chance of a patient having a thrombus formation. However, elevated d-dimer levels may be misinter- preted due to its acute-phase reactant properties in light of the COVID-19 infection without appreciating a coexisting PE.
Considering a PE has a high risk of mortality if it is not managed, it is pivotal for a patient’s outcome to identify PEs as soon as possible. However, an autopsy study of a few COVID-19-positive patients revealed that in patients, which were not sus- pected to have VTE, the direct cause of death was from a PE and others experienced deep vein thrombosis.25 Although the study had a small sample size, it emphasizes the need to identify and manage the risk of developing VTE, and thereby improving mortality.
More speci cally with regard to management, the relationship between PEs and COVID-19 has not been extensively studied; the risk and bene t of prophylactic or therapeutic anticoagulation are to be determined. Currently, the International Society on Thrombosis and Haemostasis (ISTH) encourages investigating patients who require admission into hospital with d-dimer level, prothrombin time, platelet
COVID-19 and COPD
Table 5.1 Management of VTE Using LMWH for a Patient Weighing 70 kg and Has a CrCl >30 mL/min29
Standard risk patient
Weight adjusted prophylactic dose LMWH, eg, dalteparin 5000 units OD, enoxaparin 40 mg OD
High-risk patient
Intermediate dose LMWH, eg, dalteparin 5000 units BD, enoxaparin 40 mg BD
Proven or suspected acute VTE
Therapeutic dose LMWH (BD dosing may be preferred with critical care patients)
count, and brinogen level as markers of prognosis in COVID-19,26 particularly considering that increased d-dimer levels are associated with an increased mortality of COVID-19 patients.27 ISTH, supported by experts and physicians across China and Europe,28 also advises the use of prophylactic low-molecular-weight heparin (LMWH) in all patients requiring admission for COVID-19, in the absence of con- traindications, and with monitoring for patients who have severe renal impairment.26 The use of LMWH would reduce the risk of developing a PE, as well as decrease in ammation caused by COVID-19 and other comorbidities.26
The British Thoracic Society (BTS) has suggested possible dosages, using an example of a 70-kg patient with creatinine clearance (CrCl) > 30 Ml/min as outlined in Table 5.1. Patients at high risk of developing VTE following discharge can be considered for extended thromboprophylaxis.29 Nevertheless, BTS encourages liais- ing with hematologists to formulate local protocols.
Cases published thus far have generally shown patients being managed for coro- navirus and receiving prophylactic anticoagulation show an improvement before clinically deteriorating due to hypoxemia and increasing d-dimer levels, as well as require further anticoagulation to manage the PEs.30, 31 This further justi es d-dimer testing throughout an admission, coupled with using computed tomography pulmo- nary angiogram for patients with high d-dimer levels on admission or sudden clini- cal decline to quickly diagnose a PE.
5.6 COVID-19 and COPD
Chronic obstructive pulmonary disease (COPD) is known to increase the mortality rates among community-acquired pneumonias, whereby patients are admitted to ICUs more frequently.32 As COVID-19 can be rapidly transmitted within a popula- tion, it is important to prepare for COVID-19 presentations with a background of COPD. Especially since COPD patients may be more susceptible to COVID-19, a study has shown that patients with a history of COPD express increased levels of ACE2 receptors, the reported entry gate of the virus.33, 34 Meta-analysis showed over vefold increased risk for COPD patients to develop severe COVID-19 infections.35 The association between COPD and COVID-19 is important to understand to risk- stratify patients and optimize the allocation of resources.
Guidelines set by the National Institute of Clinical Excellence (NICE) in the UK advise patients with an existing COPD management plan, which involves inhaled corticosteroids (ICS), to continue adherence and for professionals to delay any plans to withdraw it.36 With regard to self-management, NICE advises patients to follow their tailored rescue pack if they believe they are experiencing an exacerba- tion, as opposed to patients who believe they are experiencing COVID-19 symp- toms who should not start oral corticosteroids and/or antibiotics.36 This poses a problem since management is dependent upon patients to identify the differences between typical exacerbation symptoms and those caused by COVID-19, especially for patients who have been diagnosed with COPD recently.
Contradictory meta-analysis studies have been published regarding the effect of smoking and COPD upon COVID-19 outcomes. Lippi et al.37 did not nd an asso- ciation between active smoking and COVID-19 in a sample study of 1399 patients. However, Zhao et al.38 demonstrated a twofold increase in developing severe COVID-19 for active smokers, which is also supported by Alqahtani et al.39 Despite con icting evidence, smoking cessation continues to be strongly encouraged for the management of COPD and COVID-19 by NICE.36
5.7 COVID-19 and Asthma
Asthma can be triggered generally by viral illness, poor adherence to medication, and allergens. Therefore, it is important to identify if COVID-19 speci cally has exacerbated symptoms and if management needs to be tapered differently to usual protocol.
A study found that the prevalence of asthma among COVID-19 patients was higher than the national average.40 However, once the age, gender, and comorbidi- ties were accounted for in the data, asthma was not found to increase the risk of COVID-19 patients being hospitalized.40 Similarly, ICS and/or systemic corticoste- roids were not found to increase the risk of hospitalization.40
Systemic steroid treatment may increase the viral load, thus increasing the bur- den of symptoms resulting in clinical decline. However, there is some early evi- dence from sputum suggesting that ICS can reduce ACE2 and TMPRSS2 gene expression.41 WHO has further con icting evidence to counter ICS potentially being helpful at early stages.42 Therefore, the use of ICS needs to be studied com- prehensively to understand its effect upon the susceptibility and severity of COVID-19.
Furthermore, the use of nebulizers is generally effective in managing asthmatic patients; however, it is an aerosol-generating treatment, which is best avoided within health-care environments. Instead, for such circumstances, it is recommended to use inhalers containing dry powder or metered dose inhalers accompanied by a valve- holding chamber.43
Biologic treatment is an interesting topic for the management of asthma. Sound evidence supports moderate to severe patients with clinical indications to have
Acute Respiratory Distress Syndrome
therapies targeting IL-5, IL-4/IL-13, and IGE.44 The lack of evidence to suggest biologic treatment is possibly harmful, in the context of COVID-19, which implies it can be used with caution if the drug is effective and well tolerated.45
The main deterrent for a poor outcome with COVID-19 appears to be well-man- aged asthma, as well as adherence to general advice such as hand hygiene, shielding in certain groups of asthmatics, social distancing, effective inhaler technique, and avoiding known triggers.
5.8 COVID-19 and Lung Cancer
Oncology societies and national authorities have been quick to issue guidelines on cancer care during the pandemic offering guidance and training to manage patients with cancer while this pandemic goes on—especially considering individuals who are immunocompromised and over 60 years are at high risk of becoming infected with COVID-19.46 As a result, the UK, together with several other countries, has generally suspended elective procedures.
NHS England warned that certain groups are particularly vulnerable to serious illness if they become infected with SARS-CoV-2. These groups include individuals who are undergoing active chemotherapy or radical radiotherapy for lung cancer, and patients with cancers of the blood or bone marrow.47 This is supported by a study done in China observing that non-small-cell cancer patients had higher inci- dence of COVID-19 especially when the age is more than 60 years. Patients with lung cancer have more severe COVID-19 than those without lung cancer.48 This has been further highlighted in Italy whereby 20% of COVID-19 deaths had a concur- rent active cancer.
5.9 Acute Respiratory Distress Syndrome
ARDS is the most common complication of severe COVID-19. It is a clinical syn- drome characterized by severe respiratory distress, hypoxemia, and noncardiogenic pulmonary edema.
5.9.1 Diagnostic Criteria
All four of the following criteria must be present:
1. Acute onset of illness
2. Chest X-ray showing bilateral in ltrates
3. Pulmonary capillary wedge pressure <18 mm Hg or a lack of congestive car-
diac failure
4. Refractory hypoxemia with pao2:Fio2 <200.49
L – phenotype H – phenotype
Figure 5.4 Chest CT scans demonstrating the difference between L-type and H-type ARDS.51 5.9.2 Clinical Features
Symptoms: Fever, shortness of breath, inability to complete sentences, persistent nonproductive cough.
Signs: Tachypnea, tachycardia, low mean BP, hypoxia resistant to oxygen, rhon- chi, and egophony throughout lung elds.
5.9.3 Types of ARDS
L phenotype of ARDS typically has low elastance, ventilation/perfusion mismatch, low lung weight, and low recruitability (Figure 5.4).50
H phenotype of ARDS typically has high elastance, high right-to-left shunt, high lung weight, and high recruitability.50
Radiologically chest X-rays show bilateral diffuse pulmonary in ltrates, and CT scans show a bilateral ground glass appearance with consolidation compatible with viral pneumonia. Although severe COVID-19 follows all the criteria of ARDS, mor- tality was increasing when high positive end expiratory pressure (PEEP) was given to all patients with SARS-CoV-2. In an independent study, atypical presentation of ARDS in COVID-19 patients was observed, thus stressing the importance to modify the management for ARDS to decrease mortality.52
A patient may also undergo a transition from L to H phenotype as the disease advances to more severe form. This transition may be determined by inspiratory pleural pressure and esophageal pressure swings. Considering esophageal pressure swings between 5 and 10 cmH20 is generally well tolerated, a swing above 15 cmH20 is indicative of a risk for lung injury and warranting intubation as soon as possible.53
5.10 Outcome with Ventilated Patients
Patients who are severely compromised will require ventilatory support. Although oxy- gen delivery may be increased with a non-rebreathe mask or by pronating the patient, additional, albeit limited, measures with non-invasive or invasive ventilation will need to be utilized.54 Multiple facets of challenges regarding ventilators are becoming more evident with the demand carried by this pandemic. For example, the use of ventilators requires training, maintenance, spare parts, and of course the equipment itself.
Hypoxemia is relatively well tolerated in patients without developing exhaustion or acute respiratory distress;18 therefore, the optimal time to ventilate patients is dif- cult to determine. Nonetheless, “happy hypoxic” patients only represent a propor- tion of COVID-19 cases.
High- ow nasal cannula (HFNC) as a means to support COVID-19 patients has been uncertain and appears to be generally avoided. HFNC has the ability to dis- perse aerosol, but with the addition of wearing a surgical mask over the nasal can- nula, the distance of dispersion is markedly reduced.55 Since surgical masks cannot be used over oxygen masks, the microbiological contamination of the surroundings is not increased for patients using a surgical mask over HFNC, compared to those supported by oxygen masks.55 This may be a possible method to manage hypoxemic COVID-19 patients, avoiding intubation.
The use of noninvasive ventilation (NIV) is debatable since it is aerosol generating, thus increasing the risk of further spreading COVID-19 among health-care profes- sionals. This has been countered by, rst, ensuring that there is a good interface tting and the use of PPE by staff will minimize the risk of transmission;56 second, aerosol generation, and thus risk to staff, was found to be higher with intubation.57 Therefore, using NIV allows for invasive measures to be reserved for more poorly patients.
Invasive ventilation demonstrated signi cantly poor outcomes. In the UK, 67% of patients with COVID-19 receiving mechanical ventilation died, as opposed to 22% with viral pneumonias in 3 years prior.58 Early studies from Wuhan highlighted that mortality rates increased from 52–62% for ICU patients to 86–97% when patients received mechanical invasive ventilation.59 This is partly explained by 40% of ventilated patients having ARDS, which is associated with high mortality rates in itself.60 Nonetheless, patients with ARDS and paO2:FiO2 <150 had a better survival rate with early intubation, as opposed to using NIV.
The majority of COVID-19 cases, however, are not associated with ARDS; as such, their lungs have near-normal function, which is not likely to be improved with high PEEP.61 Therefore, other options should be considered.
5.11 Treatment
High virus titer and the subsequent strong in ammatory cytokine and chemokine responses are related to the high morbidity and mortality. Generally, prophylactic dose of LMWH is recommended for hospitalized patients with COVID-19 to pre- vent VTE.62 Potential treatment with other medication has been discussed below.
5.11.1 Interferon (IFN-λ)
IFN-λ primarily activates epithelial cells and reduces the mononuclear macro- phage-mediated pro-in ammatory activity of INFαβ.63 Early administration of interferons has certain bene ts in reducing viral load and improves the clinical symptoms of patients to a certain extent. However, it fails to reduce mortality rate.
5.11.2 Steroids
The timing of administration and the dosage of glucocorticoids are very important to the outcome of the severely ill patients. Administration of glucocorticoids too early inhibits the initiation of the body’s immune defense mechanism, thereby increasing the viral load and ultimately leading to aggravation of the disease; which has been reported in non-ICU patients.63 Timely administration of glucocorticoids in the early stage of in ammatory cytokine storm effectively prevents the occur- rence of ARDS and protects the functions of the patients’ organs. More speci cally regarding the dosage, short-term steroids (3–5 days) are appropriate, and the recom- mended dose is no more than the equivalent of methylprednisolone 1–2 mg/kg/day. Large doses of glucocorticoid may delay the clearance of coronavirus due to immunosuppression.
5.11.3 Tocilizumab
Tocilizumab is an IL-6 antagonist that suppresses the function of the immune sys- tem.63 Tocilizumab itself has a therapeutic effect on the infection-induced cytokine storm. Tocilizumab is effective in treating severely ill patients with extensive bilat- eral lung lesions, who have elevated IL-6 levels. The rst dose was 4–8 mg/kg. The recommended dosage was 400 mg with 0.9% saline diluted to 100 ml. The infusion time was more than 1 h. For patients with poor ef cacy of the rst dose, a repeat dose can be applied after 12 h, with a maximum of two cumulative doses. Tocilizumab reduces patient morbidity and the need for mechanical ventilation but may fail in very advanced disease.6
5.11.4 Chloroquine
Chloroquine inhibits the production and release of TNF and IL-6, which indicates that chloroquine may suppress the cytokine storm in patients infected with COVID-19. Chloroquine has an immune-modulating activity and antiviral activ- ity. Chloroquine is known to block virus infection by increasing endosomal pH required for virus/cell fusion, as well as interfering with the glycosylation of cel- lular receptors of SARS-CoV.63 Chloroquine is a cheap and safe drug that has been used for more than 70 years, and therefore, it is potentially clinically
applicable against the COVID-19. There are various dosing regimens available in the literature.
5.11.5 Remdesivir
Remdesivir is a nucleotide analogue prodrug that inhibits viral RNA polymerase activity against SARS-CoV-2. It also inhibits virus infection ef ciently in a human cell line and recently recognized as a promising antiviral drug.64 Compassionate use of remdesivir in case of severe COVID-19 patients demonstrated a clinical improve- ment in 68% of patients. Effectiveness of a shorter duration of therapy, that is, 5 days as opposed to 10 days, is to be investigated since it would allow the treatment of more patients during the pandemic.
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40. Izquierdo-Domínguez A, Rojas-Lechuga MJ, Chiesa-Estomba C, et al. Smell and taste dys- functions in COVID-19 are associated with younger age in ambulatory settings—a multi- center cross-sectional study. J Investig Allergol Clin Immunol. 2020;30(5):346–357. https://
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43. Abrams EM, ‘t Jong GW, Yang CL. Asthma and COVID-19. CMAJ. 2020;192(20):E551.
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45. Shaker MS, Oppenheimer J, Grayson M, et al. COVID-19: pandemic contingency planning for the allergy and immunology clinic. J Allergy Clin Immunol Pract. 2020;8(5):1477–1488.e5.
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52. Worcester S. Is protocol-driven COVID-19 respiratory therapy doing more harm than good?. The-hospitalist.org. https://www.the-hospitalist.org/hospitalist/article/220301/coronavirus- updates/protocol-driven-covid-19-respiratory-therapy-doing. Published 2020. Accessed July 10, 2020.
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Cardiovascular Manifestations of COVID-19
Arshad Quadri M.D., Samer Kabbani M.D., Syed Raza M.D., and Urmila Bharathan
ACE2 Angiotensin Converting Enzyme 2
ECG Electrocardiogram
HfpEF Heart failure with preserved ejection fraction HFrEF Heart failure with reduced ejection fraction RAAS Renin–angiotensin–aldosterone system SARS-CoV-2 Severe acute respiratory syndrome coronavirus
There is an increased risk of cardiovascular involvement during respiratory viral infections. This has been studied in the context of in uenza. Notably, in most in u- enza epidemics, more patients died of cardiovascular causes compared to pneumo- nia.1 In the context of COVID-19, it has become apparent that cardiovascular complication is a major cause of death, particularly in individuals over 65 years of age who are likely to have various comorbidities such as diabetes, hypertension, and obesity. These patients comprise the majority with cardiac involvement during severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection.2 This chapter will discuss the various cardiovascular manifestations of COVID-19, including cardiac in ammation, heart failure, stress cardiomyopathy, and hyperco- agulability. Additionally, the role of angiotensin converting enzyme 2 (ACE2) will be addressed, as well as possible long-term cardiovascular sequelae that may result from SARS-CoV-2 infection.
6.2 Epidemiology
In a study of 52 critically ill patients with COVID-19, it was found that 40% of patients had comorbidities such as cardiovascular disease, chronic cardiac disease, and cerebrovascular disease.3 Speci cally, more non-survivors of COVID-19 in this
Chapter 6: Cardiovascular Manifestations of COVID-19
study had preexisting cardiovascular disease (53% vs. 20% in survivors) and preex- isting cerebrovascular disease (22% vs. 0% in survivors). Additionally, among the 52 critically ill patients, cardiac injury, indicated by increased levels of troponin I, was reported in 23% of cases.3 Non-survivors also showed higher rates of heart failure and acute cardiac injury, when compared to survivors of COVID-19.3 After taking all of these statistics into consideration, it is apparent that the cardiovascular system is signi cantly affected during SARS-CoV-2 infection, and it is clear that having preexisting cardiovascular conditions places individuals at a signi cant risk to poor outcomes in the face of COVID-19.
Another study found similar results, in which cardiovascular disease was more prevalent in patients who died due to COVID-19 than patients who survived.4 Additionally, patients who died had higher levels of troponin, myoglobin, C-reactive protein, serum ferritin, and interleukin-6. Such ndings are suggestive of a high in ammatory burden in COVID-19 patients and a possible rise in myocarditis- related cardiac events.4
While the mechanism of cardiac injury is not well established, there are a few factors that could be contributing to such injury. First, there is likely an increase in cardiac demand due to the respiratory failure and hypoxemia that commonly occur during COVID-19.5 Second, it is possible that a direct cardiac injury by SARS- CoV-2 occurs. Third, there could be an indirect cardiac injury from the systemic in ammatory response elicited during SARS-CoV-2 infection.5 And lastly, the stress of COVID-19 may destabilize any preexisting cardiovascular pathologies.5 All four possible modalities of cardiac injury can result in arrhythmias, heart failure, or myocardial infarction (Figure 6.1).
Immunopathology, Hyperin ammation
Direct Myocardial Injury
Respiratory failure, Hypoxemia
COVID-19 cardiac effects
Biomarkers of injury
HFpEF, HFrEF
Cardiac In ammation due to SARS-CoV-2
6.3 The Role of ACE2 in the Cardiovascular System during COVID-19
It is well known that SARS-CoV-2 infects cells via the ACE2 receptor. Thus, with the abundant ACE2 expression in heart, it seems to be at an increased risk of infec- tion.6 Notably, SARS-CoV-2 downregulates ACE2 expression, which contributes to myocardial dysfunction. This effect has been observed in ACE2-knockout mice exhibiting severe left ventricular dysfunction.7 Normally, ACE2 degrades angioten- sin II to generate angiotensin,1–7 which has vasodilatory and antiproliferative effects. Such effects along with anti-angiotensin II action prevent pathologic remodeling of the heart during heart failure and myocardial infarction.8
There is a signi cant controversy surrounding the use of renin–angiotensin–aldo- sterone system (RAAS) antagonists, strong in uencers on the cardiovascular system, during COVID-19. These medications have been found to increase ACE2 expression in many animal studies. While such an increase in humans is helpful in cardiovascu- lar disease, it can theoretically increase susceptibility to SARS-CoV-2. However, the directionality of this effect is debated.9, 10 In a study of 8900 patients with COVID-19, there was no association with the use of RAAS antagonists and increased in-hospital mortality.11 Thus, it is currently not recommended that ACE inhibitor and ARB ther- apy, two different modalities of RAAS antagonism, be stopped.11
6.4 Cardiac Inflammation due to SARS-CoV-2
Viral infections are known to commonly cause myocarditis and pericarditis. In some cases, this can be due to viruses exhibiting molecular mimicry, a phenomenon where viral antigens share features with myocyte and/or pericardial cell antigens.12 It is possible that SARS-CoV-2 exhibits molecular mimicry. In fact, autopsies of patients who had con rmed COVID-19 show in ammatory in ltrates composed of macrophages and CD4 T cells. These mononuclear in ltrates were associated with regions of cardiomyocyte necrosis.13 While such indications of myocardial in am- mation are present, there has been no data to suggest the presence of SARS-CoV-2 within myocardial tissue itself. Such a nding would support the idea of SARS- CoV-2 exhibiting molecular mimicry.
The clinical presentation of myopericarditis in COVID-19 can be similar to that of myocardial infarction. Chest discomfort and fatigue have been primarily observed.14 In terms of diagnostic testing, ST elevation on electrocardiogram (ECG) is a key nd- ing, as well as increased levels of troponin T indicative of myocardial damage.14 Both of these ndings are also observed in myocardial infarction. In a case study from Italy, a 53-year-old patient with myopericarditis had no signs or symptoms of severe lung disease.14 The patient had only complained of a dry cough and fatigue in the week preceding her symptoms related to myopericarditis. So it is apparent that in amma- tion of the heart can occur even in seemingly less severe cases of COVID-19.
6.5 Heart Failure due to SARS-CoV-2
Heart failure is another signi cant cardiac manifestation of COVID-19.5 Speci cally, heart failure can occur in the setting of SARS-CoV-2-induced myocarditis. However, it is unclear whether SARS-CoV-2-induced myocarditis more commonly results in heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Though, since most patients with uncomplicated lym- phocytic myocarditis present with normal heart function, this may indicate that HFpEF is more common.15 It is notable that since COVID-19 cases are highly con- tagious, an echocardiograph is risky to obtain so the status of left ventricular func- tion may not be fully established in these patients.
Heart failure can also occur in the setting of arrhythmia, which has been reported frequently in COVID-19 cases.16 Without an adequately functioning cardiac con- duction system, the heart is unable to pump blood effectively, thus resulting in heart failure. It is noteworthy that while arrhythmia can cause heart failure, it can also be a result of heart failure. Such a distinction is important when considering treatment options for the patient.
6.6 Stress Cardiomyopathy due to SARS-CoV-2
Stress, or takotsubo, cardiomyopathy is a condition that primarily affects women and can occur after a signi cant physical or emotional stressor.17, 18 Viral infection has been found to trigger stress cardiomyopathy in some cases.19 In COVID-19, high in ammatory burden is a plausible trigger for this cardiac condition, and there have been a few case reports of women exhibiting this illness.20, 21 Although this condition is rarer than those already discussed, it is worth noting some of its key ndings.
Patients with stress cardiomyopathy have cardiac wall motion abnormalities that are apparent during echocardiography. Additionally, a low left ventricular ejection fraction is observed in this condition—one much lower than that of acute coronary syndrome.17 It is important to differentiate stress cardiomyopathy from myocardial infarction, especially since the ECG ndings for both conditions can be very simi- lar.20 Treatment for stress cardiomyopathy is conservative, and many patients, including one of the COVID-19 patients with this condition, recover left ventricle function without invasive coronary procedures.20 A close monitoring is essential nonetheless, since a declining left ventricle function can result in heart failure.20
6.7 Vascular Manifestations of COVID-19
There are a few possible mechanisms through which the vascular system is damaged in the setting of COVID-19. These mechanisms are similar to those likely affecting the cardiac system. One possibility is that the damage caused by the virus in the lungs can result in hypoxia of the blood vessels and resulting vascular injury.22 Another pos- sibility is that many ACE2 receptors in the vascular systems are prone to an increased risk of SARS-CoV-2 infection.6 Lastly, since COVID-19 affects many different organ
Possible Long-Term Cardiovascular Implications Following COVID-19
systems and promotes an in ammatory state, the vasculature can get damaged as a direct consequence of this state.22 Damage to the vasculature caused by any of these three mechanisms can lead to abnormal activation of the coagulation cascade. Many COVID-19 patients have an increased D-dimer level, indicative of increased clot for- mation.16 These patients have an increased likelihood of death during infection.22 Additionally, it is notable that individuals with preexisting conditions that signi – cantly affect the blood vessels, such as hypertension and diabetes, tend to be at a greater risk of SARS-CoV-2 infection and have poor outcomes during infection.22
A hypercoagulable state, indicated by an increased levels of D-dimer and brino- gen, is common during COVID-19.23 In such a state, patients are at an increased risk of pulmonary embolism, deep vein thrombosis, stroke, and disseminated intravascu- lar coagulation. All of these conditions can be extremely debilitating and potentially fatal. In fact, many COVID-19 patients in their 30s or 40s have presented with a stroke due to this hypercoagulable state.24 This is particularly alarming since the median age for severe stroke is 74.24 Therefore, it is important for clinicians to moni- tor all patients regardless of age, for the conditions caused by hypercoagulability.
6.8 Possible Long-Term Cardiovascular Implications Following COVID-19
While the acute cardiovascular manifestations of COVID-19 are clear in their clinical presentation as discussed above, it is important to keep in mind cardiovascular com- plications that are possible even after recovery from acute illness. Figure 6.2 depicts the concept that once the acute phase of the illness has resolved, the long-term com- plications may arise in the convalescent and chronic phases of disease, long after viral
Host response
Convalescent
        
ARDS Delayed myocarditis? Hyperlipidemia? Acute myocarditis Cardiac arrest? Pulmonary brosis?
Viral response
~ 21 days
TIME COURSE (after symptom onset)
   
Figure 6.2 Long-term sequelae of COVID-19
1. Around one-third of COVID-19 patients have been found to develop cardio- vascular complications.
2. The pathophysiology as to how the cardiovascular system is involved dur- ing SARS-CoV-2 infection is complex and multifactorial.
3. Older patients with comorbidities are likely to suffer from acute atheroscle- rotic complications.
4. Younger and healthy patients rarely may develop acute fulminant myocar- ditis leading to acute cardiac decompensation and malignant arrhythmia resulting in sudden death.
5. The COVID-19 pandemic has changed the way cardiology is routinely practiced.
clearance has been achieved. In some case reports from Italy, fulminant myocarditis has been described to persist even after the resolution of acute respiratory symptoms. While COVID-19 is a nascent pandemic, long-term sequelae are unknown, but we can learn from the SARS-CoV experience. In a study of 25 individuals who had recovered from SARS-CoV infection 12 years ago, 68% had hyperlipidemia and 44% had cardiovascular abnormalities in the 2017 study.25 Additionally, it was found that the lipid metabolisms of these individuals were signi cantly altered when compared to normal controls, resulting in increased levels of serum lipids and free fatty acids.25 Such a hyperlipidemic state places these recovered SARS-CoV patients at an increased risk for conditions such as atherosclerosis and myocardial infarction. Since SARS- CoV-2 is similar to SARS-CoV, it is possible that it will cause similar long-term car- diovascular effects. It will be important in the future for clinicians to keep such effects
in mind as more people get infected with COVID-19 during the pandemic.
It is clear that the cardiovascular system is not spared during SARS-CoV-2 infec- tion. In particular, individuals over 65 years of age with preexisting comorbidities such as diabetes, hypertension, and obesity are at an increased risk of severe cardio- vascular complication.2 Common cardiovascular complications include myocardial infarction, heart failure, cardiac in ammation, arrhythmia, and hypercoagulability. A less common cardiovascular complication is stress cardiomyopathy. In addition to the acute cardiovascular conditions that occur during COVID-19, it is important to also consider the long-term complications that may arise. After the SARS-CoV experience that occurred 12 years ago, many patients who survived infection had altered lipid metabolism resulting in hyperlipidemia, a state known to increase the risk of atherosclerosis and myocardial infarction.25 Since SARS-CoV-2 shares char- acteristics with SARS-CoV, the long-term sequelae that affected SARS-CoV patients may also affect SARS-CoV-2 patients many years from now.
Summary of Cardiovascular Findings in COVID-19
Cardiovascular Complications
Myopericarditis
Possible molecular mimicry exhibited by SARS-CoV-2 results in in ammation of the heart
Preserved ejection fraction heart failure occurs due to myocarditis
Heart failure can also occur due to arrhythmia secondary to cardiac injury
Stress cardiomyopathy can result in heart failure as well
Arrhythmia can be due to heart failure, myocarditis, or the cardiac injury that occurs in SARS-CoV-2 infection
Myocardial infarction can occur due to the cardiac injury caused by SARS-CoV-2 infection
Stress cardiomyopathy
Physiologic stress (high in ammatory burden, hypoxia, etc.) due to SARS-CoV-2 infection results in stress cardiomyopathy
Pulmonary embolism, stroke, deep vein thrombosis, and disseminated intravascular coagulation
Vascular injury caused by SARS-CoV-2 results in a hypercoagulable state that has been found in many COVID-19 patients (indicated by elevated brinogen and D-dimer)
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15. Hu H, Ma F, Wei X and Fang Y. Coronavirus fulminant myocarditis treated with glucocorticoid and human immunoglobulin. Eur Heart J. 2020;ehaa190. https://doi.org/10.1093/eurheartj/ ehaa190.
16. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020;323(11):1061–1069. https://doi.org/10.1001/jama.2020.1585.
17. Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of Takotsubo (Stress) cardiomyopathy. N Engl J Med. 2015;373(10):929–938. https://doi.org/10.1056/ NEJMoa1406761.
18. Minhas AS, Hughey AB, and Kolias TJ. Nationwide trends in reported incidence of Takotsubo cardiomyopathy from 2006 to 2012. Am J Cardiol. 2015;116(7):1128–1131. https://doi. org/10.1016/j.amjcard.2015.06.042.
19. Nef H, Möllmann H, Akashi Y and Hamm C. Mechanisms of stress (Takotsubo) cardiomyopa- thy. Nat Rev Cardiol. 2010;7(4):187–193.
20. Minhas A, Scheel P, Garibaldi B, et al. Takotsubo syndrome in the setting of COVID-19. JACC Case Rep. 2020. https://doi.org/10.1016/j.jaccas.2020.04.023.
21. Nguyen D, Nguyen T, De Bels D and Castro Rodriguez J. A case of Takotsubo cardiomyopathy with COVID 19. Eur Heart J Cardiovasc Imaging. 2020;21(9):1052. https://doi.org/10.1093/ ehjci/jeaa152.
22. Wadman M. How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes. Science. 2020.
23. Spiezia L, Boscolo A, Poletto F, et al. COVID-19-related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure. Thromb Haemost. 2020;120(06):998–1000.
24. Divani A, Andalib S, Di Napoli M, et al. Coronavirus disease 2019 and stroke: clinical mani- festations and pathophysiological insights. J Stroke Cerebrovasc Dis. 2020;29(8):104941.
25. Wu Q, Zhou L, Sun X, et al. Altered lipid metabolism in recovered SARS patients twelve years
after infection. Sci Rep. 2017;7(1).
Central Nervous System (CNS) Manifestations of COVID-19
Intezam Khan M.D., Usman Mirza M.D., Riyaz Ahmad M.D., MRCP, Naiyer Imam M.D., and Eesha Imam
ANE Acute necrotizing encephalitis
ARDS Acute respiratory distress syndrome
CNS Central nervous system
CSF Cerebrospinal uid
CT Computed tomography
EMG Electromyography
ER Emergency room
LVO Large vessel occlusion
MRI Magnetic resonance imaging
PNS Peripheral nervous system
RT-PCR Reverse transcription polymerase chain reaction SARS-CoV-2 Severe acute respiratory syndrome coronavirus
There have been several reported cases that have demonstrated that infection by severe acute respiratory syndrome coronavirus (SARS-CoV-2) can have neurologi- cal manifestations ranging from mild to severe symptoms and may also involve the central nervous system (CNS), peripheral nervous system (PNS), and or skeletal muscle. Among the most common neurological manifestations of SARS-CoV-2 is the loss of sense of taste and/or smell typically by the third day.1 It is important to know that patients may present with neurological symptoms as the rst or only sign of the SARS-CoV-2 infection. This chapter discusses the common and rare neuro- logical manifestations of SARS-CoV-2 that have been reported so far.
Summary of Key Neurological Findings
19/214 COVID-19 patients had PNS manifestations 12 had impaired taste
11 had impaired smell
3 had impaired vision
53/214 COVID-19 hospitalized patients had CNS manifestations 35 had dizziness
28 had headache
16 had impaired consciousness
6 had acute cerebrovascular disease 1 had ataxia
1 had seizure
23/214 COVID-19 hospitalized patients had skeletal muscle injury
Chapter 7: Central Nervous System (CNS) Manifestations of COVID-19
7.2 How SARS-CoV-2 Can Infect the Nervous System
Although the exact manner with which SARS-CoV-2 acts on the nervous system has yet to be found, there are a few probable explanations. The ACE2 receptor has been identi ed as the primary receptor involved with the SARS-CoV-2 virus. Because this receptor is expressed in skeletal muscles and throughout the nervous system, they can be considered as capable of being infected by the SARS-CoV-2 virus via either direct or indirect methods.2
Autopsies of COVID-19-positive patients demonstrated brain tissue that was hyperemicand edematous, and had degenerated neurons.2 It is also probable for SARS-CoV-2 to infect the CNS by dissemination of SARS-CoV-2 through the olfactory bulb and cribriform plate or due to hematogenous spread of the virus from systemic to cerebral circulation.3 Previous coronavirus infections, like SARS-CoV, have demonstrated neurological manifestations of the virus.4 Autopsies of patients infected with SARS-CoV detected the presence of SARS-CoV nucleic acid in the cerebrospinal uid (CSF) and brain tissue.2 Previous studies showed that SARS- CoV-infected patients had developed rhabdomyolysis, myopathy, and seizures.5 There were also reports of Middle East respiratory syndrome (MERS) patients dur- ing the MERS outbreak developing neurological symptoms of confusion and seizures.5
The rst reported neurological study in Wuhan, China,2 examined 214 consecu- tive COVID-19-positive patients (mean age of 52.7 years)3 who were treated at three different hospitals from January 16 to February 19, and their illness was cat- egorized by severity based on the American Thoracic Society guidelines for com- munity-acquired pneumonia (Table 7.1). According to these guidelines, 41.1% (88) of patients had “severe infection” and 58.9%(126) of patients had “nonsevere infec- tion.” Neurological symptoms were categorized into four categories:
Table 7.1 Key Neurological Findings from the Study: Neurologic Manifestations of Hospitalized Patients with Coronavirus Disease 2019 in Wuhan, China2
• CNS: headache, dizziness, altered consciousness
• PNS: nerve pain and loss of senses of smell, taste, and/or vision
• Cerebrovascular disease: seizure, stroke, ataxia
• Skeletal muscle symptoms.
Of the 214 patients, 36.4% had neurologic manifestations (ie, CNS, PNS, skel- etal muscle). Patients with severe infection were more likely to be older and have hypertension and had fewer typical COVID-19 symptoms (cough, fever) compared to those with nonsevere infection, and patients with severe infection were more likely to develop neurologic manifestations compared to those with nonsevere infection.2 38.8% (83) had one or more comorbidity; hypertension, diabetes, cardiac or cerebrovascular disease, malignancy, or chronic kidney disease. Such neurologi- cal symptoms mostly manifested in the early period of the illness (the median time to hospital admission 1–2 days).2
7.3 Cerebrovascular Disease
There have been reports of strokes in patients who have tested positive for COVID- 19 and particularly in younger patients, patients younger than 50 years of age, when patients who typically get strokes are 74+ years.6 Based on the laboratory studies of COVID-19-positive patients done so far, it is known that COVID-19 is frequently associated with increased D-dimer levels. Increased D-dimer levels may be indicative of blood clots through detecting an irregularly high amount of brin degradation material.7 Blood clots have been seen as a very concerning symptom of COVID-19, and it is believed that the SARS-CoV-2 is infecting blood vessels8. One study demonstrated how SARS-CoV-2 had infected the endothelial cells lin- ing the inside of blood cells.8 Blood clotting is especially problematic in patients in critical condition, those who are immobilized, and those with preexisting condi- tions that already put strain on the involved systems such as diabetes and hypertension.
Some patients are presenting with stroke as the rst symptom of COVID-19 and these strokes are also appearing in COVID-19-positive patients with no known heart conditions or no other underlying illnesses such as hypertension or diabetes.9 In the Wuhan study, 14 strokes out of 214 COVID-19-positive patients.3
In a study of 10 COVID-19-positive patients with an age range of 25–75 years who had suffered from an ischemic stroke, 80% had preexisting conditions such as diabetes or hypertension but none had preexisting cerebrovascular disease, coronary disease, or atrial brillation.10 Patients showed increased laboratory values of D-dimer; 80% of these patients also presented to the emergency room (ER) initially with neurological symptoms rather than respiratory symptoms, two passed away from stroke, two passed away from the coronavirus attacking their lungs, and one was in critical condition due to acute respiratory distress syndrome (ARDS).10 Patients had either branch emboli, small vessel, or large vessel occlusion (LVO).10 There were ve patients who had LVO, three of whom ended in mortality and one
Key Neurological Findings
Etiologic subtypes of ischemic stroke in SARS-COV-2 virus patients10
10 COVID-19 hospitalized patients with an age range of 25–75 had suffered ischemic stroke from four centers in New York city
All patients had increased values of D-dimer levels Seven had diabetes
Six had hypertension
One developed atrial brillation during their time in the hospital
Eight presented to the ER initially with neurological complaint
Four passed away
One was in critical condition because of ARDS
SARS2-CoV-2 and Stroke in a New York Health-Care System11
32 of 3556 hospitalized COVID-19-positive patients across three New York hospitals between 3/15/19 & 4/15/19 had imaging-con rmed ischemic strokes
Median age: 63 years 71.9% were men
Large artery ischemic stroke in severe acute respiratory syndrome (SARS)12
5 of 206 COVID-19 hospitalized patients in Singapore had large vessel strokes
Four were in critical condition Three passed away
COVID-19 presenting as stroke13
Four PCR-con rmed COVID-19 patients had imaging- con rmed stroke in this retrospective study
All four presented stroke as the initial symptom
All four patients were in the age range of 73–88 years
of whom was the patient in critical condition due to ARDS.10 Patients with LVO were associated with either cardioembolism or hypercoagulable state.10
A retrospective cohort study published on May 13, 2020, in stroke examined all patients admitted for stroke between March 15, 2020, and April 19, 2020, across New York University Langone Hospital locations in Brooklyn, Long Island, and Manhattan.11 They were divided into three groups: patients who had ischemic stroke and were simultaneously COVID-19-positive, the contemporary controls who were patients who had ischemic stroke and did not have COVID-19, and the historical controls which were patients who had ischemic stroke and who were discharged from the hospital system between Match 15, 2019, and April 15, 2019.11 The results showed that only 32 (0.9%) of the 3556 hospitalized COVID-19-positive patients had imaging-con rmed ischemic strokes with 63 years of age being the median age of the 32 patients and 71.9% being men.11 More studies are needed to clarify if there is an association between SARS-CoV-2 and ischemic stroke (Table 7.2).
Table 7.2 Cases of Stroke Associated with SARS-CoV-2
7.4 Acute Encephalitis and Meningitis
Henry Ford Health System reported one case of a 58-year-old woman developing a rare form of encephalitis called acute necrotizing encephalitis, or (ANE), reported in the journal Radiology.14 She initially presented with fever, cough, and muscle aches, but then later she presented to the ER with confusion and altered mental status.14 A rapid COVID-19 test made in-house con rmed COVID-19 infection when the u test came out negative.14 CT (computed tomography) and MRI (mag- netic resonance imaging) scans con rmed the ANE diagnosis. Acute necrotizing encephalopathy, also known as acute necrotizing encephalopathy of childhood, is a rare type of encephalopathy characterized by multiple bilateral brain lesions.15 It was rst discovered in Eastern pediatric populations in 1995 but is rare in western countries and adult populations.16
Another report described a case of a 24-year-old man who was infected with SARS-CoV-2 and developed meningoencephalitis.17 He presented with a fatigue and fever on day 1, sought a doctor on day 2, and was prescribed laninamivir and antipyretic agents because of clinical symptoms; on day 5, his symptoms worsened with the addition of sore throat and headaches; and on day 9, he was found uncon- scious and rushed to the hospital by ambulance.17 He had generalized seizures for a minute and at the hospital tested negative for SARS-CoV-2 using the nasal swab test, but tested positive for SARS-CoV-2 in his CSF.17 Brain MRIs were taken 20 hours after admission demonstrating right lateral ventriculitis and encephalitis on the right mesial lobe of the hippocampus with a differential diagnosis of hippocam- pal sclerosis.17
There has been one case so far of meningitis seen in a 5-year-old girl. She was complaining of a headache and had a fever for about a month and had tested positive for COVID-19. The child then developed meningitis and spent 2 weeks on a ventila- tor before passing away. She was taken off the ventilator after she was no longer improving and physicians believed she was brain dead.18
A study of HCV-OC42 examines whether a respiratory virus can infect the CNS and cause brain in ammation.3 Because there have not been many cases of SARS- CoV-2 being tied to meningitis and/or encephalitis, more studies need to be done in order to substantiate this relationship (Table 7.3).
7.5 Headaches
Patients who are positive for COVID-19 have presented with headaches as a symp- tom of the virus.3 In the meningitis case of the 5-year-old girl, she initially presented with headaches as the only symptom of COVID-19 for a month.18
However, this appears to be an isolated occurrence. Therefore, headaches may be a result of the systemic disease rather than a direct invasion of the CNS by the virus, and this is especially likely in patients who have no other neurological symptoms.3
COVID 19 linked to rare form of encephalitis14
Case report: Acute necrotizing encephalitis
3 days of fever, cough, muscles aches and altered
Altered mental status
Tested positive for SARS-CoV-2 on a rapid COVID-19 test
A rst case of meningitis/ encephalitis associated with SARS-coronavirus-217
Case report: Meningoencephalitis
Tested positive for SARS-CoV-2 using reverse transcription polymerase chain reaction (RT-PCR) Analysis of CSF
Tested negative for SARS-CoV-2 using RT-PCR Analysis using nasopharyngeal swab test
5-year-old with rare complication becomes rst Michigan child to die of COVID-1918
Case report: Meningitis Age: 5 years old Sex: Female
Table 7.3 Cases of Encephalitis Tied to SARS-CoV-2
7.6 Peripheral Nervous System Manifestations
Some PNS manifestations of COVID-19 include impaired sense of taste, sense of smell, vision, and polyneuropathy. There have been reports that previous coronavi- ruses, such as SARS-CoV and MERS, had PNS manifestations such as weakness and decreased deep tendon re exes.3
According to the Wuhan study, there were no signi cant differences in the labo- ratory studies between patients with and without PNS manifestations, and there were no signi cant differences between those patients with PNS systems and severe infection and those with PNS manifestations and without severe infection.2
There have been 12 reported cases of Guillain–Barrésyndrome in COVID-19- positive patients.3 Guillain–Barrésyndrome is a rare disorder where the body’s immune system attacks its nerves.19 It can cause muscle weakness and occasionally, paralysis.19 Of these 12 patients, 5 were from Northern Italy and they all developed Guillain–Barrésyndrome after the onset of COVID-19 and systemic manifestations of COVID-19.20 At the onset of their neurological symptoms, 4 out of these 5 patients tested positive on the SARS-CoV-2 nasopharyngeal swab test and 1 tested negative.20 Four patients developed weakness in their lower extremities and facial diplegia, and one patient developed paresthesia and ataxia.20 Over a 3- to 4-day period, four of the patients also developed generalized, accid tetraparesis, or tet- raplegia, and three of whom received mechanical ventilation.20
These patients showed rst symptoms of Guillain–Barrésyndrome 5–10 days after rst onset of symptoms of COVID.20 Among the other 7 of the 12 patients,
Peripheral Nervous System Manifestations
there were instances of patients presenting with neurological manifestations prior to COVID-19 diagnosis. Several of these patients had also developed systemic mani- festations, such as fever and cough, and ground-glass lung opacities in either one or both lungs either before or after developing neurological manifestations. There have also been cases of patients who were infected with MERS-CoV and patients who have been infected with HCV-OC43 and who have also developed Guillain–Barré syndrome.17 These are only a few cases so more research needs to be done in order to substantiate that there is a relationship between SARS-CoV-2 and Guillain–Barré syndrome (Table 7.4).
Table 7.4 Cases of Guillain–BarréSyndrome Tied to SARS-CoV-2
Initial Presentation
Neurologic symptoms and COVID-19: What’s known, what isn’t21
Autoimmune neuropathy
Day 8 of hospitalization
• Developed dry cough, fever, ground-glass lung opacities
Day 30 of hospitalization
• Discharged from hospital after recovering
COVID-19 may induce Guillain–Barré syndrome22
Presented to hospital after falling & tearing rotator cuff
Day 1 of symptoms
• 2 days prior to hospital presentation
• Fever and cough
• Nasal swab test was positive for
• Fever subsided
Day 10 of symptoms
• Developed paresthesias in feet and hands
• Flaccid severe tetraparesia
Neurological evaluation
• MRC (power musclestrength) evaluation
• 2/5 in the legs
• 2/5 the arms
• 3/5 in the forearms
• 4/5 in the hands
Guillain– Barrésyndrome associated with COVID-19 infection: acase report23
Presented to the ER with symptoms of acute progressive symmetric ascending quadriparesis
2 weeks prior to ER admission
• Fever, cough, and occasional dyspnea
• COVID-19 was diagnosed via oropharyngeal sampling and reverse transcription-polymerase test
• Treated with hydroxychloroquine, lopinavir/ritonavir, andazithromycin
• Takes metformin
5 days prior to ER admission
• Acute progressive weakness of distal extremities, bilateral facial paresis
• MRC strength evaluation
• 1/5 in thighs
• Generally absent deep tendon
re exes
• Reduced ne touch sensation and
vibration distal to the ankle
• House-Brackmann grade 3 bifacial
nerve palsy
• No spine sensory level
Covid-19 and Guillain–Barré syndrome: more than a coincidence!24
Bilateral weakness and tingling in all 4 extremities within a time period of 48 h
Past medical history Rheumatoid arthritis (RA) for which she was taking 7.5 mg prednisone
3 days prior to neurological symptoms onset
• Dry cough resolving on its own
within 48h
Days 1 and 2 of neurological symptoms
• Bilateral weakness and tingling in
all four extremities
• Diagnosed with RA exacerbation
and given corticosteroids
Day 10 of neurological symptoms
• Tested positive for SARS-CoV-2 on RT-PCR
• Oropharyngeal test
• Admitted to neurology department
of hospital
Neurology examination
• Quadriplegia
• Hypotonia
• Are exia
• Bilateral positive Lasègue sign
• Nerve conduction study showed all
fourlimbs had a signi cant reduction/absence of electrical potentials in both sensory and motor nerves
• Needle electromyography (EMG) showed a signi cant amount of brillation potentials at rest
• Chest CT: ground-glass appearance of left lung
Table 7.4 (continued)
• IV immunoglobulin (2g/kg for 5 days)
• Hydroxychloroquine (600 mg/day)
• Azithromycin (500 mg for the rst
day then 250 mg/day)
• No signi cant improvement in the condition
Guillain–Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence?25
Acute weakness in bilateral lower extremities and severe fatigue that progressed within 1 day
Day 1 of hospital admission
• Neurological examination
• 4/5 in both legs and feet
• Are exia in both legs Day 3 of hospital admission
• 4/5 in both arms and hands
• Thrombocytopenia, lymphocytope- nia, and increased protein levels
• Nerve conduction studies showed signs of demyelinating neuropathy
• Diagnosed with Guillain–Barré syndrome
• Developed a fever and dry cough
• Chest CT showed ground-glass
opacities in both lungs
• Tested positive for SARS-CoV-2 on
• Treatment
• Given IV immunoglobulin and
Antiviral drugs (ritonavir, arbidol,
and lopinavir) for supportive care
Day 20 of hospital admission
• Patient’s condition improved with normal lymphocyte and thrombocyte levels were normal
• Discharged with normal muscle strength in all extremities, normal tendon re exes, no respiratory symptoms, and tested negative on SARS-CoV-2 oropharyngeal
7.7 Skeletal Muscle Injury
According to the laboratory values from the Wuhan study, patients who had skeletal muscle injury had signi cantly higher levels of creatine kinase compared to those who had no skeletal muscle injury regardless of the disease severity.2 The laboratory values of patients with skeletal muscle injury showed an evidence of an increased in ammatory response through increased neutrophil counts, lower lymphocyte counts, and greater C-reactive protein levels, and also showed an evidence of possi- ble blood coagulation dysfunction through the increased D-dimer levels.2 The labo- ratory values of patients who had skeletal muscle injury also showed an evidence of damage to multiple organs: liver (increased lactate dehydrogenase, aspartate amino- transferase, and alanine aminotransferase where the levels in patients with severe infection were signi cantly higher than the levels of those with nonsevere infection) and kidney abnormalities (increased levels of blood urea nitrogen where the blood urea nitrogen levels were signi cantly higher in patients with severe infection than in those with nonsevere infection and increased levels of creatine).2
1. Patients diagnosed with COVID-19 can develop neurological manifestations that can affect the CNS or PNS or cause skeletal muscle injury.
2. Patients may present with neurological manifestation prior to COVID-19 diag- nosis and/or without displaying any of the symptoms typical to COVID-19 such as fever and cough.
3. Possible CNS manifestations seen so far include headache, dizziness, loss of consciousness, and cerebrovascular disease, and there have only been a few cases of encephalitis and meningitis.
4. Possible PNS manifestations seen so far include the loss of sense of taste, smell, and vision and rare manifestation seen in Guillain–Barré syndrome.
5. Patients infected with the SARS-CoV-2 virus who had no comorbidities or risk factors for cerebrovascular disease have been shown to develop cerebrovascular disease as a neurological manifestation.
1. Smell diminishes by day 3 of COVID-19, study says. WebMD. 2020, 14 May. https://www. webmd.com/lung/news/20200514/smell-diminishes-by-day-3-of-covid-19-study-says#1.
2. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with coro- navirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683–690. https://doi. org/10.1001/jamaneurol.2020.1127.
3. Montalvan V, Lee J, Bueso T, De Toledo J, Rivas L. Neurological manifestations of COVID-19 and other coronavirus infections: asystematic review. Clin Neurol Neurosurg. 2020, Elsevier. https://www.sciencedirect.com/science/article/pii/S030384672030264X.
4. Pleasure SJ, Green AJ, Josephson SA. The spectrum of neurologic disease in the severe acute respiratory syndrome coronavirus 2 pandemic infection: neurologists move to the frontlines. JAMA Neurol. 2020. Published online April 10. https://doi.org/10.1001/jamaneurol.2020.1065.
5. Ng Kee Kwong KC,Mehta PR, Shukla G, Mehta AR. COVID-19, SARS and MERS: a neu- rological perspective. J Clin Neurosci.2020; 77;13–16. 5 May. https://doi.org/10.1016/j. jocn.2020.04.124.
6. Cha AE. Young and middle-aged people, barely sick with COVID-19, are dying of strokes. The Washington Post. 2020, WP Company, 25 Apr. https://www.washingtonpost.com/ health/2020/04/24/strokes-coronavirus-young-patients/.
7. D-Dimer. Understand the Test. https://labtestsonline.org/tests/d-dimer#:~:text=A%20posi- tive%20D%2Ddimer%20result,tell%20the%20location%20or%20cause. Accessed June 25, 2020.
8. Smith DG. Coronavirus may be a blood vessel disease, which explains everything. Medium. 2020, Elemental, 31 May. https://elemental.medium.com/amp/p/2c4032481ab2.
9. Rabin RC. Coronavirus may pose a new risk to younger patients: strokes. The New York Times. 14 May, 2020. https://www.nytimes.com/2020/05/14/health/coronavirus-strokes.html.
10. Berekashvili K, Dmytriw AA, Vulkanov V, et al. Etiologic subtypes of ischemic stroke in SARS-COV-2 virus patients. MedRxiv. 2020, Cold Spring Harbor Laboratory Press, 1 Jan. https://www.medrxiv.org/content/10.1101/2020.05.03.20077206v2.
11. Yaghi S, Ishida K, Torres J, et al. SARS2-CoV-2 and stroke in a New York healthcare system. Stroke. https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.030335.
12. Umapathi T. Large artery ischaemic stroke in severe acute respiratory syndrome (SARS). J Neurol. 2004;251(10):1227–1231.
13. Avula A. COVID-19 presenting as stroke. Brain Behav Immun. 2020;87:115–119.
14. OlejarzD.COVID19linkedtorareformofencephalitis.HenryFordHEALTHSYSTEM®,1Apr. 2020. https://www.henryford.com/news/2020/04/covid-19-linked-to-rare-form-of-encephalitis.
15. Iqbal S, St-Amant M and Di Muzio B. Acute necrotizing encephalopathy: radiology refer- ence article. Radiopaedia Blog RSS. https://radiopaedia.org/articles/acute-necrotising-
encephalopathy?lang=us. Accessed June 25, 2020.
16. Pulakanti V and Holland N. A fatal case of adult-onset acute necrotizing encephalitis secondary
to in uenza A virus (P5.398). Neurology. 2018, Wolters Kluwer Health, Inc. on Behalf of the American Academy of Neurology, 9 Apr. https:\\n.neurology.org/content/90/15_Supplement/ P5.398.
17. Moriguchi T, Harii N, Goto J, et al. A rst case of meningitis/encephalitis associated with SARS-coronavirus-2. Int J Infect Dis. 2020. https://www.sciencedirect.com/science/article/ pii/S1201971220301958.
18. Barmore J. 5-year-old with rare complication becomes rst Michigan child to die of COVID-19. Detroit News. 20 Apr, 2020. https://www.detroitnews.com/story/news/local/ detroit-city/2020/04/19/5-year-old- rst-michigan-child-dies-coronavirus/5163094002/.
19. Guillain-Barré syndrome. Centers for Disease Control and Prevention.20 Dec, 2019. https:// http://www.cdc.gov/campylobacter/guillain-barre.html.
20. Toscano G, Palmerini F, Ravaglia S, et al. Guillain–Barré syndrome associated with SARS- CoV-2. N Engl J Med. 2020. https://www.nejm.org/doi/full/10.1056/NEJMc2009191.
21. McNamara D. Neurologic symptoms and COVID-19: what’s known, what isn’t. Hospitalist.1 May, 2020. https://www.the-hospitalist.org/hospitalist/article/220289/coronavirus-updates/ neurologic-symptoms-and-covid-19-whats-known-what.
22. Camdessanche J-P, Morel J, Pozzetto B, Paul S, Tholance Y, Botelho-Nevers E. COVID-19 may induce Guillain-Barré syndrome. Rev Neurol. 2020, Elsevier Masson SAS. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC7158797/.
23. Sedaghat Z and Karimi N. Guillain Barre syndrome associated with COVID-19 infection: a case report. J Clin Neurosci. 2020, Churchill Livingstone. https://www.sciencedirect.com/ science/article/pii/S0967586820308821.
24. El Otmani H, El Moutawakil B, Rafai M-A, et al. Covid-19 and Guillain-Barré syndrome: more than a coincidence!. Rev Neurol. 2020;176(6):518–519. https://doi.org/10.1016/j. neurol.2020.04.007.
25. Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS- CoV-2 infection: causality or coincidence? Lancet Neurol. 2020, Elsevier. https://www.scien- cedirect.com/science/article/pii/S1474442220301095.
Gastrointestinal Manifestations of COVID-19
Lawrence Kogan M.D., Chung Sang Tse M.D., Farhan Qureshi, and Samir A. Shah M.D., FACG
ACG American College of Gastroenterology FIT Fecal immunohistochemistry test
GI Gastrointestinal
IBD In ammatory bowel disease
PPI Proton pump inhibitor
SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2
COVID-19 has many gastrointestinal (GI) manifestations, which can present even in the absence of respiratory symptoms, and also has an impact on many GI dis- eases. Gastroenterology utilizes minimally invasive endoscopic procedures to diag- nose, monitor, and treat pancreatic, GI, and hepatobiliary diseases, including GI bleeding, gastroesophageal re ux disease, pancreatitis, in ammatory bowel disease (IBD), celiac disease, cirrhosis, hepatitis, and colorectal cancer. Immunosuppressive agents, including biologic medications and steroids, are used to treat disorders such as IBD and autoimmune hepatitis. Many nonurgent endoscopies were temporarily put on hold from March 2020 through April 2020 due to concerns for SARS-CoV-2 transmission, particularly with aerosol-generating endoscopic procedures and fecal–oral route of viral spread, and to preserve personal protective equipment (PPE) in the setting of widespread shortage. With adequate supplies of proper PPE and decrease in COVID-19 cases, elective outpatient endoscopic procedures resumed in most facilities by late May 2020. This chapter addresses the GI manifes- tations of COVID-19 and the virus’s impact on various GI diseases and access to endoscopy.
GI Events Symptoms
Anorexia 216
Nausea/ 210 vomiting
Diarrhea 326
Abdominal 52 pain/ discomfort
Any GI 537 symptom
95% CI 16.2 – 40.8
6.6 –15.3 9.6 –16.0 5.7–14.5
Chapter 8: Gastrointestinal Manifestations of COVID-19
8.2 Presentation
Patients infected with SARS-CoV-2 frequently develop, or present with, GI symp- toms, such as anorexia, diarrhea, nausea, vomiting, and abdominal pain.1–3 A gure adapted from a meta-analysis of over 4000 patients positive for COVID-19 showing the distribution of GI symptoms is illustrated in Figure 8.1. Although the prevalence of GI symptoms was low in early studies, there was a large discrepancy between Chinese and non-Chinese studies.3 One possible explanation of the difference between studies is whether anorexia is included as a GI symptom, as it could be included in other organ systems, and was not reported in many early Chinese stud- ies. When reported, anorexia is often times the most frequently reported GI symp- tom and may be present in up to 60% of cases.1, 2, 4, 5 There is a small, but measurable number of cases presenting as acute pancreatitis, which affected Blacks and Hispanics at signi cantly higher rates, highlighting the racial disparities seen with this disease.6
Although respiratory symptoms are the primary presenting symptom of COVID- 19, many patients have co-occurring GI symptoms and some patients develop GI symptoms in the absence of respiratory symptoms. In one study of 206 patients with mild COVID, 23% had only digestive symptoms and 33% had a mixture of diges- tive and respiratory symptoms.7 Multiple studies have shown that patients with GI symptoms in the absence of respiratory symptoms take longer to present to the hospital, rendering the risk of propagating community viral spread for longer
Prevalence (%)
      
Cheung et al.1
Prevalence of GI symptoms in COVID-19-positive patients. Adapted from
Endoscopy and Risk of Transmission
periods of time.1, 7 Additionally, these patients may have a longer duration between symptom onset and viral clearance, taking up to an additional 7 days to clear the virus compared to patients with respiratory symptoms.7 This suggests that GI symp- toms should not be overlooked and should prompt a rapid consideration of addi- tional workup and monitoring.
The virus has been isolated from feces of infected persons, and can persist in the stool up to 10 days after resolution of symptoms after it clears the respiratory sys- tem, raising concern for possible fecal–oral transmission.8, 9 In fact, some case stud- ies have isolated intact virus in the stool, but direct transmission has not yet been observed.10
Patients with COVID-19 often have abnormal liver enzymes which may or may not be present on initial presentation. It has been hypothesized that the development of transaminitis could be related to biology of the virus, which enters cells via the angiotensin-converting enzyme 2 membrane protein receptor and is highly expressed in the colon, liver, and cholangiocytes11; however, there are various other possible etiologies which will be discussed later in this chapter.
8.3 Endoscopy and Risk of Transmission
Gastroenterologists routinely perform aerosol-generating procedures, including esophagogastroduodenoscopy, colonoscopy, sigmoidoscopy, small bowel enteros- copy, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and esophageal manometry.12 The risk of viral transmission during upper endoscopies is of particular concern as viral particles may become aerosolized during the insertion of the endoscopy into the pharynx (triggering the gag re ex) and from the endo- scope’s working channel as instruments are inserted and removed.12 During the surge of the COVID-19 pandemic, elective procedures (colon cancer screening, GI motility testing, variceal surveillance, etc.) were delayed due to the concern for SARS-CoV2 transmission. When urgent/emergent procedures were performed (symptomatic GI bleeding, dysphagia signi cantly impacting oral intake, cholangi- tis, GI obstruction), the following procedural precautions were recommended:12
• Use a tted N95 masks, N99, or powered air-purifying respirators (PAPRs) instead of surgical masks or no masks.
• Double glove instead of single glove.
• If the patient is positive for SARS-CoV2 (or presumptive), use a negative
pressure room or, if unavailable in resource-limited settings, use portable industrial-grade high-ef ciency particulate air (HEPA) lters in a regular endoscopy room.
• Continue to utilize standard cleaning endoscopic disinfection and reprocess- ing protocols, which includes mechanical and detergent cleaning using US Food and Drug Administration (FDA)-approved liquid chemical germicide solutions, followed by high-level disinfection (reduces the number of micro- organisms by 99.99%), rinsing, and sterile drying. The biocidal agents used in
endoscopic disinfecting solutions have been shown to be effective in inacti- vating SARS-CoV.13
Guidance from the American Society for Gastrointestinal Endoscopy (ASGE) for resuming elective endoscopy as the number of COVID-19 cases decreased includes the following:14
• Administer a COVID-19 screening questionnaire to patients within 72 hours prior to the endoscopic procedure to elicit whether the patient had any of the following symptoms within 14 days: fever (100.4 or higher); cough, shortness of breath, dif culty breathing; chest pain; sore throat; loss of sense of smell/ taste; new onset of fatigue, nausea, diarrhea, or other signi cant symptoms. Positive responses should prompt the removal of patients from clinical care areas, (repeat) SARS-CoV2 testing, self-quarantine, and reporting to the proper authorities (eg, Department of Health).
• All members of the endoscopy team should wear N95 respirators (or devices with equivalent or higher ltration rates) for all GI procedures.
• Standard bedside precleaning, followed by manual cleaning and high-level disinfection in the reprocessing facility; no changes are recommended to reprocessing procedures for endoscopes and accessories.
There is exibility in guidance from the American College of Gastroenterology (ACG) in resuming elective procedures depending on the prevalence of COVID-19, availability of testing, and availability of PPE with N95 or equivalent masks (Figure 8.2). The chart below from the ACG suggests a reasonable algorithm for elective outpatient endoscopic procedure performed in free standing endoscopy centers [15].
Low Prevalence Area/ Negative COVID-19 Test/Negative Symptom Screen
Low Prevalence Area/ No COVID-19 Test/Negative Symptom Screen
High Prevalence Area/ Negative or No COVID-19 Test/ Negative
Symptom Screen
High or Low Prevalence Area/ Positive COVID-19 Test or Negative Symptom Screen
Adapted from ACG roadmap for resuming endoscopy.15
Consider standard precautions (surgical masks, face shields, gloves, gowns
N95 or equivalent mask if available
Face shields, gloves, gowns
Delay procedure or perform in hospital setting with N95
or equivalent mask
GI ASC Patient
In ammatory Bowel Disease
8.4 Liver Diseases
Many patients with COVID-19 either present with liver enzyme abnormalities or develop them over the course of their illness. A meta-analysis showed serum amino- transferase levels–AST or ALT–above the upper limit of normal in roughly 15% of patients and elevated bilirubin in 17%.16 One study of 1099 patients in China showed that there were more than double the number of patients with an AST >40 with severe illness compared to those with nonsevere illness,17 and a retrospective study of 1087 patients showed an association between COVID-19 infection and an eleva- tion in baseline liver enzymes, peak liver enzymes, and severity of illness.18 Of note, there are several confounding factors, such as medications used to treat the infection that were also linked with elevated peak liver enzyme levels.18
The mechanism of action of liver injury is unclear but likely secondary to viral infection, in ammatory reaction, or toxin mediated from medications. It is usually transient, but there are case reports of COVID presenting as acute liver injury.19, 20 Upon autopsy, liver pathology revealed moderate microvesicular steatosis and mild lobular and portal activity.21 To our knowledge, there have not been reports of fulmi- nant hepatic failure as a result of COVID-19.
An international database has reported 1097 cases of COVID-19 in patients with chronic liver disease at the time of writing of this chapter. The cohort includes 88% hospitalized patients, but does report 18–29% probability of severe disease requir- ing intensive care admission.22 Patients with cirrhosis had the worst outcomes with a 32% chance of death. Additional prospective studies will be required to further evaluate the relative and overall risk compared to the general population.
8.5 Inflammatory Bowel Disease
In ammatory bowel disease, namely, Crohn’s disease and ulcerative colitis, is esti- mated to have a prevalence of 6.8 million globally.23 An international database (SECURE–IBD) has reported 2,156 cases of con rmed COVID-19 in IBD patients from 57 countries (65 deaths, 3%) as of August 31, 2020.24 The website is available at covidibd.org and is continually updated. So far, the use of any of the biologics or Janus kinase (JAK) inhibitor is not associated with higher death rates or worse outcomes.
Patients with IBD are of special consideration during the COVID-19 pandemic as these patients are often treated with chronic immunosuppressive or immune-modify- ing therapies that include corticosteroids, biologics (including antitumor necrosis factor, anti-integrin, and anti-interleukin therapies), immunomodulators, and 5-ami- nosalicylic acids.25 Moreover, patients with IBD may continue to need frequent encounters at health-care facilities for medication administration (infusion of certain biologic therapies), endoscopy (assessment of disease severity in patients with active IBD symptoms), and emergency department visits or hospitalization for IBD ares.
In addition to the recommendations for the general population (social distancing, hand hygiene, work from home, avoid infected persons), IBD patients are recommended
to continue their IBD medication regimens to avoid the risk of relapsing IBD, defer all nonessential endoscopic procedures during surge of COVID-19 cases (including colon cancer screening), and continue to receive medications at infusion centers with appro- priate safety protocols (fever checks at the door, chairs spaced at least 6 feet apart, disin- fect equipment and furniture after each use, utilize PPE, etc).25–27
For IBD patients with GI symptoms, rule out enteric infections, such as Clostridioides dif cile and other GI pathogens, and test for active in ammation with non-endoscopic approaches, such as biomarkers (serum C-reactive protein, fecal cal- protectin), cross-sectional imaging, and capsule endoscopy. During the COVID-19 pandemic, particularly for patients who test positive for SARS-CoV-2, endoscopic procedures should only perform for urgent and emergent indications that “will urgently change management.” This may include scenarios where there is clinical suspicion for a new diagnosis of severe IBD (endoscopy needed for histological con- rmation) or stricturing disease causing GI obstruction that need urgent endoscopic decompression, stenting, and evaluation of cancer to guide surgical intervention.25, 26
The recommended management of IBD therapies in patients who test positive for SARS-CoV-2 is as follows: continue 5-ASA, budesonide, rectal therapies, and enteral nutrition; hold thiopurines, methotrexate, and tofacitinib; delay 2-week administration of monoclonal biologic therapies; and restart when COVID-19 symptoms resolve or if serological testing demonstrate convalescent stage of the disease.25 These guidelines will be updated as the SECURE-IBD Registry [24] and other studies provide more data/analysis.
8.6 Celiac Disease
A multinational collaboration was created to anonymously report cases of celiac disease and coronavirus.28 At the time of the writing of this chapter, only 62 cases have been reported, with 82% being treated in the outpatient setting, and 18% inpa- tient and 2% (1 patient) requiring the intensive care unit (ICU). These data follow the general trend seen with the coronavirus in the general population. In one Italian study, the majority of patients did not feel more vulnerable to the coronavirus given their celiac disease, and half of those surveyed did not worry about the availability of gluten-free food.29 Overall, it appears that COVID-19 does not impact patients with celiac disease more than the general population.
8.7 GI Cancers
In general, patients with comorbidities, including cancer of all types, have a higher risk for severe COVID-19.30 As such, various oncological and GI professional soci- eties have produced guidelines for which procedures, therapies, and screenings are appropriate.
Currently, there is no evidence which necessitates withholding systemic chemo- therapy or immunotherapy for cancer.31 However, the Infectious Disease Society of America recommends that patients receiving cytotoxic chemotherapy should be
tested for SARS-CoV-2 RNA even if asymptomatic.32 According to the Society of Surgical Oncology, in gastric and esophageal cancers, staging laparoscopy may be skipped in favor of beginning neoadjuvant therapy directly in a COVID-19-positive patient, in order to reduce transmission risk and use of PPE. Patients on neoadjuvant therapy for gastric and esophageal cancers may also continue chemotherapy if they are responding to treatment and there is not enough PPE to proceed with surgical resection. Physicians at Sloan Kettering have deemed resection of colon, stomach, pancreas, and liver cancers as “essential,” as patient outcomes will be worsened with delay.33 This approach was also validated by guidance from the American College of Surgeons (ACS) and the New York State Department of Health. Full guidelines provided by Oncological and Gastrointestinal Societies are provided in the “Cancer Screening Guidelines” section. On the other hand, others advocate that chemotherapy may also be used to delay surgery for hepato-pancreato-biliary can- cer, as long as the patient is responding to and tolerating treatment.34
Cancer screening guidelines have also been changed due to COVID-19. The American College of Physicians recommends a colonoscopy every 10 years or a sigmoidoscopy every 5 years between 50 and 75 years of age.35 However, due to the pandemic, these important screenings are being delayed. A study gathered from the EPIC electronic health records system involving 2.7 million patients across 39 health systems with 190 hospitals and spanning 23 states in the USA demonstrated screening appointments for breast, colon, and prostate cancer in March of 2020 decreased by 86% compared to mean volumes from January 1, 2017, to January 19, 2020 (Figure 8.3).36 The graphs of the drop in colon cancer screening are featured
Colon Cancer Screenings – 2020 5,000
Colon Cancer Screenings 5,000
Weekly Colon Cancer Screenings 5,000
Mean Weekly Screening Volume 2017- Jan 19, 2020
Forecast Trend
Uncertainty Bands
Observed Weekly Screening Volume Since Jan 20, 2020
Screening appointments for cancers between 2017 and March 2020.36
below. The charity Cancer Research UK estimates a backlog of 2.1 million patients waiting for breast, colon, or cervical cancer screening. Normally, about 3800 can- cers would be diagnosed over this time period.37 In Hong Kong, screening endosco- pies and colonoscopies reached a turning point and began to decrease in January 2020. The mean weekly numbers of gastric and colon cancer diagnoses decreased by 46 and 37%, respectively.
• Cancer Research UK’s Dr. Charles Swanton warns that “delays to diagnosis and treatment could mean that some cancers will become inoperable” [37]. While the European Society for Gastrointestinal Endoscopy Guidelines (ESGE) and other GI professional societies recommend noninvasive proce- dures such as the fecal immunohistochemistry (FIT) test in the meantime, there cannot be an inde nite delay—there is a signi cant increase in cancer risk with a >6-month delay in colonoscopy after positive FIT test.35 Already the effects of decreased screening are becoming apparent. As a result of the NHS suspending cancer screening, 3800 people in the UK whose cancer would have been picked up by screening have gone undiagnosed and another 20,300 cancers may also have been missed due to an estimated 290,000 patients with symptoms of possible cancer who were not urgently referred for evaluation.30 Statistical models of data from Hong Kong show that 4.6% of gastric cancers and 6.4% of colon cancers would have a more advanced stage of cancer at detection 6 months after the decrease in screenings.37 The data from these studies from Hong Kong, the UK, and the United States demon- strate the danger of prolonged deferment of screening—many treatable can- cers (not just colorectal cancer) will progress unnoticed until it may be too late for the patient. Gradually resuming elective endoscopic procedures may begin to mitigate some of these effects for colon cancer.38 Tracking patients whose elective procedures have been delayed and getting them rescheduled is an important part of this process. As such, it is of utmost importance for hos- pitals and endoscopy centers to safely resume screening endoscopies and colonoscopies, before there is a major increase in preventable GI cancers.
GI Cancer Treatment Guidelines:
• https://www.facs.org/covid-19/clinical-guidance/elective-case/ colorectal-cancer
• https://www.surgonc.org/resources/covid-19-resources/
• https://www.esmo.org/guidelines/cancer-patient-management-
during-the-covid-19-pandemic
• https://www.futuremedicine.com/doi/10.2217/crc-2020-0010
• Modifying Practices in GI Oncology in the Face of COVID-19:
Recommendations From Expert Oncologists’ Recommendations on Minimizing Patient Risk (https://www.nccn.org/covid-19/pdf/Colorectal%20 COVID-19.pdf)
Proton Pump Inhibitors and COVID-19
8.8 Telehealth in GI
Telehealth in GI is an important tool to allow patients to access care without inter- ruption during the COVID-19 pandemic. Though only a minority of gastroenterolo- gists (private or academic) were offering telehealth services prior to COVID-19, the vast majority have rapidly adapted this technology for offering care and will likely continue this option as patients nd it convenient and cost/time-effective. Most elec- tronic health platforms have incorporated a telehealth option, and there are several inexpensive or free platforms such as Doxy.me or Doximity. This access to care is particularly important in optimally managing chronic conditions, including IBD and liver disease. The American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG) assisted GI practices with their tran- sition to telehealth by partnering the following:
• Rx Health: a Virtual Care Hub and Telehealth platform for digital screening and triaging of patients before in-person appointments, accommodate virtual visits through a dedicated telehealth room, and patient access to GI education modules from the AGA patient education center.
• GI OnDEMAND, a Health Insurance Portability and Accountability Act (HIPAA)-compliant and cloud-based telehealth system where providers can get reimbursed for out-of-of ce patient support and patents can access an online support community and evidence-based health information.
For information on billing and coding of telehealth visits, please refer to the fol- lowing resources:
HHS FAQs on telehealth and HIPAA: https://www.hhs.gov/sites/default/ les/ telehealth-faqs-508.pdf
AMA 2021 E/M codes and guidelines: https://www.ama-assn.org/system/ les/2019-06/cpt-of ce-prolonged-svs-code-changes.pdf
Proton pump inhibitors (PPIs) suppress the production of gastric acid contents and are commonly used to treat esophageal and gastric diseases such as GERD, esopha- gitis, Barrett’s esophagus, and peptic ulcer disease. There is con icting data regard- ing an association or causation between PPI and COVID-19 infection rate as well as severity. One large survey-based study of more than 50,000 patients in the United States showed a dose–responsive relationship between PPIs and COVID infection; however, a larger retrospective study in Korea did not nd any signi cant difference in infection rate between PPI users and nonusers.39, 40 The latter study did nd that PPI use correlated with a more severe course of illness. To date, no randomized con- trol trials have been published regarding PPI use and development of COVID-19.
Studies on SARS-CoV-1 suggested the virus was less infective at lower pH, pro- viding a potential mechanism for increased infectivity.41 Interestingly, with regard to the current studies on SARS-CoV-2, there was no similar association between SARS-CoV-2 and histamine-2 blocker use, which also lowers gastric pH, indicating that there may be other pathophysiologic mechanisms to infection. Famotidine was actually associated with a decreased risk of intubation or death, and is currently being investigated as a potential treatment for the virus.42, 43
An association between PPIs and COVID-19 is concerning, particularly given the prevalence of PPI use in modern society; however, it needs to be further evaluated with prospective studies and randomized controlled trials to determine causation. Until these studies are completed, we recommend that practitioners discuss this data with patients, using shared decision-making to determine whether to continue with PPIs or consider a transition to alternate therapies, such as H-2 blockers. The American Journal of Gastroenterology has also published an information sheet not- ing that the absolute risk of COVID-19 infection is low and that social distancing and masks will have a much greater impact on personal risk of acquiring COVID-19 than adjusting PPI dosing.44 As we await further trials, for now it is prudent to consider the potential increased risk for COVID-19 when discussing the use of PPIs with patients.
8.10 Tools for Health-care Providers
• American College of Gastroenterology—COVID and GI: https://gi.org/ media/covid-19-and-gi/
• AASLD COVID-19 resources https://www.aasld.org/sites/default/ les/2020- 06/AASLD-COVID19-ExpertPanelConsensusStatement-June42020-FINAL. pdf ACG COVID-19 resources: https://gi.org/media/covid-19-and-gi/
• AGA COVID-19 resources: https://www.gastro.org/practice-guidance/prac- tice-updates/covid-19
• ASGE COVID-19 resources: https://www.asge.org/home/advanced-educa- tion-training/covid-19-asge-updates-for-members/
• Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD) https://covidibd.org/
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24. Brenner EJ, Colombel UR, Kappelman JF. SECURE-IBD database public data update. 2020. covidibd.org. Accessed Aug 31, 2020.
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33. COVID19 Subcommittee of the O.R. Executive Committee at Memorial Sloan Kettering. Cancer Surgery and COVID19. Ann Surg Oncol. 2020;27(6):1713–1716. https://doi. org/10.1245/s10434-020-08462-1.
34. Society of Surgical Oncology. Resource for management options of GI and HPB cancers dur- ing COVID-19. April 2020. https://www.surgonc.org/wp-content/uploads/2020/04/GI-and- HPB-Resource-during-COVID-19-4.6.20.pdf. Accessed June 5, 2020.
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https://doi.org/10.1136/gutjnl-2020-322248.
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44. Information sheet and FAQs about proton pump inhibitors (PPIs) and risk of COVID-19. Am J
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Renal Manifestations of COVID-19
Syed Muzaffar Ahsan M.D.,
Shariq Haider Hashmi M.D., and Sundus Nasim
ACE-2 Angiotensin-converting enzyme-2
ACEIs Angiotensin-converting enzyme inhibitors AKI Acute kidney injury
ANP Atrial natriuretic peptide
ARBs Angiotensin receptor blockers
BNP Brain natriuretic peptide
BUN Blood urea nitrogen
CKD Chronic kidney disease
CVP Central venous pressure
GFR Glomerular ltration rate
KDIGO Kidney Disease Improving Global Guidelines ICU Intensive care unit
MAP Mean arterial pressure
PEEP Positive end-expiratory pressure
RRT Renal replacement therapy
VTE Venous thromboembolism
Acute kidney injury (AKI) is a major health concern as it often results in fatal com- plications following intensive care unit (ICU) admission. COVID-19 is a peculiar disease with a highly variable disease course, and it has been seen to have multiple renal manifestations. These can range from symptoms like hematuria to the devel- opment of acute kidney failure. The rapidly progressive kidney damage warrants early admission and a close clinical monitoring.
Multiple mechanisms leading to the development of renal manifestations have been proposed, including volume depletion effects, systemic in ammation, hemo- dynamic disturbances, direct viral invasion, and rhabdomyolysis, among others.
Chapter 9: Renal Manifestations of COVID-19
While maintenance of adequate uid balance is pivotal, parameters such as oxygen saturation, blood urea nitrogen (BUN), creatinine, urine output, and arterial or venous pressures should be closely monitored. Early assessment of volume status through the combined use of physical examination and ultrasound imaging is essen- tial to avoid renal complications. Maintenance of euvolemia using appropriate hydration, uid-reducing medications, and other necessary measures is the single most important step.
Another more worrisome complication is the development of venous thrombo- embolism (VTE) in some patients. Heparin prophylaxis or other anticoagulation may be used in the hospital setting to prevent VTE in COVID-19 patients. Use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in COVID-19 patients is controversial due to the possibility of worsening of the disease course. Thus, we advise that clinicians exercise extreme precaution while using any of these medications.
There is mounting evidence that COVID-19 can manifest as AKI. Though the pool of data collected on this subject is preliminary, it is clear that there is a trend of renal injury beyond simply the baseline level expected in similar populations. A recent study of 193 COVID-19 patients in Wuhan, China, reported that many patients showed signs of kidney dysfunction upon admission to the hospital. More than half of these patients had proteinuria, about half had hematuria, and some had increased BUN and creatinine levels.1 The multinational Acute Kidney Injury-Epidemiologic Prospective Investigation (AKI-EPI) study estimated the baseline level of AKI inci- dence in all ICU admissions to be 57.3%, while 13.5% of all ICU admissions develop severe AKI requiring renal replacement therapy (RRT).2 This latter number is known to be higher in cases of acute respiratory distress syndrome (ARDS). The American Society of Nephrology estimates from many preliminary studies that the incidence of AKI in COVID-19 admissions is likely similar to the baseline, but the percentage of COVID-19 ICU cases with severe AKI requiring RRT is increasing at an upward rate of 30%.3
Thus, the current research suggests that COVID-19 patients often end up with much more severe kidney injury. This is important as AKI can increase an already high mortality risk in these patients. A univariate Cox regression analysis showed that proteinuria; hematuria; and increased BUN, serum creatinine, and uric acid levels were all signi cantly associated with death in COVID-19 patients. This study also found that COVID-19 patients who developed AKI had an increased mortality risk compared to those without AKI by a factor of 5.3.1
Given the propensity of COVID-19 to damage the kidney, it poses an even greater danger to patients who already carry a diagnosis of chronic kidney disease (CKD). A recent meta-analysis preprint reported that patients with CKD have a six-fold increased risk of developing severe COVID-19 infection over the general population.4
Pathophysiology of COVID-19 Renal Manifestations
9.3 Pathophysiology of COVID-19 Renal Manifestations
There have been multiple suggested etiologies of AKI due to COVID-19.3 These etiologies likely work together to attack the kidney from several angles. These can be broadly categorized in the following.
Fluid Balance: Aggressive diuresis is often necessary in the management of COVID-19 patients. This can lead to hypovolemia, causing the body to decrease the glomerular ltration rate (GFR) to preserve uid.
ARDS Side Effects: The lung is one of the main sites of interest for the virus due to the abundance of ACE2 receptors on pneumocytes. The in ammatory process in the lung results in an increased cytokine activity throughout the body. Furthermore, this can lead to increases in neurohormonal pathway activation in the sympathetic nervous system and the renin–angiotensin–aldosterone system, while causing decreases in atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels. Altogether, these effects have a harmful effect on GFR and cause in ammatory damage to renal vessels and parenchyma.
Hemodynamic: The use of high positive end-expiratory pressure (PEEP) in patients on ventilators can increase pressure in the thoracic cavity. This can cause low-pressure venous vessels with large blood-carrying capacity to collapse under the pressure. With less available volume in the thoracic venous vessels, such as the superior and inferior vena cava, venous blood will back up and cause conges- tion in multiple organs, including the kidney. Furthermore, the lower venous return to the heart will lead to decreased preload and cardiac output, hence reduc- ing the pressure in the renal arteries. These two hemodynamic functions together cause a decrease in renal glomerular ltration pressure and can reduce GFR.
Hypoxemia and Hypercapnia: The inability to properly oxygenate blood and of oad carbon dioxide in the lungs can lead to chemical and acid–base anoma- lies, which are harmful to the renal regulatory systems. Hypoxemia on its own can reduce renal blood ow. Carbon dioxide retention acidi es the blood, forc- ing the kidney to work harder to reabsorb bicarbonate and maintain physiologic pH. This in turn increases the oxygen demand in the kidney. Thus, the kidney becomes particularly susceptible to hypoxic damage. In addition, hypercapnia has been known to cause a decrease in the renal autoregulatory system that maintains GFR and protects the kidney from hydrostatic pressure damage.
Rhabdomyolysis: While not common, there have been case reports and a few studies that have reported increases in myoglobin and creatine kinase levels in the blood of COVID-19 patients.
Direct Viral Infection: Though unclear, it has been suggested that the virus can directly infect the renal parenchyma. This may be due to renal expression of the ACE2 surface protein, which acts as a coreceptor for the viral entry of COVID-19 into the cell.
As can be seen, there are multiple possible etiologies for renal damage and AKI due to infection with COVID-19. There is evidence to support each of these etiolo- gies, so it is likely that they work in conjunction to unleash a multifaceted attack on the kidney.3
9.4 Monitoring COVID-19 Patients for AKI
Due to the numerous possible ways that the kidney can be damaged from this virus, it is important to keep a watchful eye on many parameters for patients with this diagnosis. Recognizing AKI in COVID-19 is no different from recognizing it in other situations; the American Society of Nephrology recommends using the well- known KDIGO (Kidney Disease Improving Global) Guidelines.5 This involves con- sistently monitoring parameters such as BUN, serum creatinine, and urine output.3
Beyond these direct parameters, it is also important to monitor multiple values that may indicate an impending AKI.3 As there are many different possible etiolo- gies of AKI as was explained earlier, the parameters to monitor can be broken down by each etiology.
Fluid Balance: It is recommended to assess the true volume status of each patient. This should involve a multifaceted approach involving physical examination, passive leg raise test, pulse wave analysis, point-of-care ultra- sound, and electrolyte levels. Simply estimating the volume status from a few parameters can lead to false assessments of the uid balance. Efforts should be made to maintain the patient at euvolemia with normal electrolytes for best renal protection.
ARDS Side Effects: High levels of cytokines and neurohormonal activity can cause damage to renal structure and function. Thus, it is important to monitor in ammatory markers and BNP to ensure early detection of abnormalities and swift response by the appropriate medical teams.
Hemodynamic: As explained previously, the hemodynamic effects of COVID-19 and its management can have deleterious effects on renal func- tion. It is therefore important to estimate or calculate the central venous pres- sure (CVP), mean arterial pressure (MAP), cardiac output, and renal perfusion pressure. Without appropriate pressure in the renal vessels, the kidneys will not be able to maintain the necessary GFR. Calculating the volume status of the patient will also play a key role in understanding the hemodynamic status in this patient. Furthermore, patients on ventilators should be monitored for appropriate PEEP, tidal volume, and peak inspiratory pressures. Concerns regarding these settings should be discussed with the appropriate teams to ensure the safest balance of ventilation and hemodynamics.
Hypoxemia and Hypercapnia: The blood oxygen saturation is important to monitor in COVID-19 patients not only for the integrity of the lungs, but also
Early Management of AKI
for the kidneys. Beyond just the saturation, imbalance in oxygen and carbon dioxide levels can have many serious effects on kidney function, so it is important to monitor parameters such as the arterial blood gases and the arte- rial pH to assess the acid–base status and gas-exchange function of the patient.
Rhabdomyolysis: Though this is a less common direct etiology of renal dam- age, the medical team can consider monitoring myoglobin and creatine kinase levels, especially when there is a high suspicion of rhabdomyolysis.
Direct Viral Infection: Evidence of direct viral infection of the kidney can occasionally be found on biopsy with immuno uorescence, but this is not recommended as a monitoring strategy.
As can be seen, the list of important parameters to monitor is quite vast. A summary of these parameters, as well as the corresponding pathophysiological importance, is given in Table 9.1. Fortunately, some of these parameters can be measured noninvasively, while many of the invasive tests may provide an expanded value due to their importance to other organ systems beyond the kid- ney. While it may be especially dif cult to nd suf cient time to fully assess the patients regularly due to high patient load in a pandemic setting, every effort should be made by all responsible teams to keep these etiologies in mind when considering each patient.3
9.5 Early Management of AKI
While suspicion of kidney injury should prompt a discussion with a nephrology team, it is important for all medical parties to understand the basic early manage- ment of AKI. The early management heavily depends on the adequate assessment of volume status, as discussed earlier. A combined approach using physical examina- tion (including assessment of edema, weight changes, and capillary re ll), passive leg raise test, pulse wave analysis, and point-of-care ultrasound is essential for assessing the true volume status beyond simple estimation from few parameters, which is prone to error. Once this is established, the initial management goal should be to ensure that the patient is euvolemic. Some evidence suggests the use of furo- semide stress test to predict the progression of AKI. However, the evidence is lim- ited and requires further study.3
It is important to stress here that the use, or lack thereof, of uid-reducing medi- cations is vital for multiple organ systems in COVID-19 patients. Therefore, it is important that all teams responsible for the patient come to an understanding of what steps be taken in managing the patients prior to adding or removing medica- tions. However, any member of the care team can carry out an assessment of the volume status, which is a crucial step in deciding management. Thus, the primary team should initially focus on assessing this in order to facilitate the conversations between the multiple responsible medical teams.
Monitoring Recommendation
Fluid balance
Aggressive diuresis during hospital management can cause iatrogenic hypovolemia
• Assess true volume status with physical examination, passive leg raise test, pulse wave analysis, point-of-care ultrasound, and electrolyte levels
• Maintain patient at euvolemia with normal electrolyte ranges
ARDS side effects
In ammation in the lung causes increased cytokine activity and activates the sympathetic nervous system and the renin–angiotensin– aldosterone system, while decreasing ANP and BNP
• Monitor in ammatory markers and BNP
High PEEP causes decreased venous return. This leads to backup of blood ow in the kidneys as well as lower perfusion due to decreased preload and cardiac output
• Estimate or calculate CVP, MAP, cardiac output, and renal perfusion pressure
• Carefully monitor PEEP, tidal volume, and peak inspiratory pressures
• Maintain good communication with all teams responsible for ventilator adjustments
Hypoxemia and hypercapnia
Decreased lung function causes hypoxemia, hypercapnia, and respiratory acidosis. This has harmful effects on the renal regulatory system, and it increases the energy demand of the kidney as it works to compensate for the acidosis
• Assess acid–base status and gas-exchange function with arterial blood gas, pH, and oxygen saturation
COVID-19 patients have been reported to have increased serum myoglobin and creatine kinase levels
• Consider monitoring myoglobin and creatine kinase levels, especially if there is high suspicion of rhabdomyolysis
Direct viral infection
Renal expression of ACE2 makes it theoretically possible for the virus to directly attack the kidney, though this has not been fully studied
• No current monitoring recommendations
Table 9.1 Etiologies of Kidney Damage in COVID-19 Patients, with Summarized Pathophysiology and Management Strategies
Note on ACE Inhibitor and ARB Usage in COVID-19
9.6 Note on Venous Thromboembolism (VTE) and Prophylaxis
One of the concerns raised in COVID-19 patients was the presence of VTE that proved fatal. However, the evidence for this seems to be mainly from case studies and prelimi- nary observational trials rather than robust, large-scale studies. A single-center cohort study from the University of Amsterdam was conducted with 198 hospitalized COVID patients, 75 of which were admitted to the ICU. The 21-day cumulative incidence of VTE was 42%. The 21-day cumulative incidence of VTE was higher in the ICU (59%) compared to the wards (9.2%).6 These results add to the growing pool of evidence associating COVID-19 infection with VTE, and different health-care institutions have responded to this by devising their own protocols to provide adequate VTE prophylaxis to the patients. Some of these protocols are based on D-dimers and require the admin- istration of heparin as a part of their prophylaxis guidelines. Thus, it is important to consider anticoagulation in COVID-19 patients, and the monitoring and administration practices should be deferred to hospital protocols and case-by-case analysis.3
A study in Tongji Hospital in Wuhan, China, retrospectively analyzed the 28-day mortality between heparin and nonheparin users among severe COVID-19 patients. It was concluded that anticoagulation with low molecular weight heparin was asso- ciated with a better prognosis in patients who met the sepsis-induced coagulopathy criteria with increased levels of D dimers.7 This study can be considered when devising an appropriate protocol for anticoagulation.
9.7 Note on ACE Inhibitor and ARB Usage in COVID-19
The use of medications such as ACEIs and ARBs has been shown in some animal trials to increase the expression of the ACE2 receptor. Given that the COVID-19 virus uses ACE2 as a coreceptor to enter the cells, there is a concern that the use of these medica- tions may increase susceptibility to the infection. ACE2 is present in various body viscera such as kidneys, heart, gastrointestinal system, and type II alveolar cells in the lungs.8 The role of ACE2 in the healthy body is to convert angiotensin II into angioten- sin (1–7), which has a vasodilatory effect that is protective in various lung injury mod- els. Evidence suggests that angiotensin (1–7) prevents oxidative stress and also plays a role in controlling in ammation and brosis in the renal tissues and beyond. In a trial involving rats, it was found that angiotensin (1–7) modulates the vascular responses to vasoconstrictors and prevents nitric oxide-induced oxidative stress.9 Thus, it is cur- rently unknown whether ACE inhibitors or ARBs are bene cial or harmful during COVID-19 infection. The current recommendation is for patients taking ACE inhibi- tors or ARBs to continue their regimen. However, the Randomized Elimination or ProLongation of Angiotensin Converting Enzyme inhibitors and angiotensin receptor blockers in Coronavirus Disease 2019 (REPLACE COVID) trial is currently underway at the University of Pennsylvania, which will investigate the effects of temporarily stopping these medications in patients hospitalized with COVID-19.10
• The development of AKI in COVID-19 patients increases the risk of mortality.
• Monitoring kidney function should be monitored with BUN, creatinine, and
urine output.
• Assessment of volume status and maintenance of euvolemia is an essential man-
agement step. Fluid-reducing medicines should be used with caution to avoid
AKI.
• Measuring in ammatory markers and BNP can assess the level of systemic
in ammation.
• Adequate VTE prophylaxis either using heparin or using other anticoagulating
agent should be considered for hospitalized patients.
• ACEIs and ARBs should be used with care as the ef cacy of these medicines in
COVID-19 patients is poorly understood.
• RRT is recommended for patients who can no longer be managed on
medications.
1. Li Z, et al. Caution on kidney dysfunctions of COVID-19 patients. medRxiv, 2020; preprint. https://doi.org/10.1101/2020.02.08.20021212.
2. Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intens Care Med. 2015;41(8):1411–1423.
3. American Society of Nephrology. COVID-19 associated AKI recognition and management. American Society of Nephrology; 2020. https://www.asn-online.org/covid-19/ASN.
4. Zhao X, Zhang B, Li P, et al. Incidence, clinical characteristics and prognostic factor of patients with COVID-19: a systematic review and meta-analysis. 2020. 2020; preprint. https://doi.org/1 0.1101/2020.03.17.20037572.
5. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179–c184.
6. Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020;18(8):1995–2002. https://doi. org/10.1111/jth.14888.
7. Tang N, Bai H, Chen X, et al. Anticoagulant treatment is associated with decreased mor- tality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020;18(5):1094–1099.
8. Patel AB, Verma A. COVID-19 and angiotensin-converting enzyme inhibitors and angioten- sin receptor blockers: what is the evidence? JAMA. 2020;323(18):1769–1770. https://doi. org/10.1001/jama.2020.4812.
9. Simoes ESAC, Teixeira MM. ACE inhibition, ACE2 and angiotensin-(1-7) axis in kidney and cardiac in ammation and brosis. Pharmacol Res 2016;107:154–162.
10. University of Pennsylvania Institute for Translational Medicine and Therapeutics. 2020. REPLACE COVID-19 Study. https://clinicalresearch.itmat.upenn.edu/clinicaltrial/6409/ covid-19-the-randomized-elimination-or-prolongation-of-angiotensin-converting-enzyme- inhibitors-and-angiotensin-receptor-blockers-in-coronavirus-disease-2019/?qd=1697425.
Endocrine Manifestations of COVID-19
Sudhir Bansal M.D. and Farhan Qureshi
ACE2 Angiotensin-converting enzyme 2 ACTH Adrenocorticotrophic hormone ARB Angiotensin receptor blocker CRP C-reactive protein
DKA Diabetic ketoacidosis
DPP4 Dipeptidyl peptidase 4
ESR Erythrocyte sedimentation rate
GLP-1 Glucagon-like peptide-1
HPA Hypothalamic–pituitary–adrenal
MERS-CoV Middle East respiratory syndrome coronavirus SARS-CoV-1 Severe acute respiratory syndrome coronavirus
SGLT-2 T2D
Sodium/glucose cotransporter-2 Type 2 diabetes
Worldwide, over 400 million are affected by diabetes, with over 1.6 million deaths attributable to diabetes alone in 2016.1 In the United States in 2018, 10.5% of the population had diabetes, which is the seventh leading cause of death.2 Diabetes is a multiorgan disease and leads to worse outcomes in many other diseases when it is a comorbid condition. Previous viral outbreaks have shown us that diabetes is a very important risk factor to consider. Diabetes was associated with poor outcomes dur- ing the severe acute respiratory syndrome coronavirus (SARS-CoV-1) outbreak in the early 2000s3 and the H1N1 outbreak in 2009, and was associated with more severe infection and a higher mortality rate during the Middle East respiratory syn- drome coronavirus (MERS-CoV) outbreak in 2012.4
Currently, diabetes is the third most common comorbidity in COVID-19 patients,5 is associated with more severe disease,6 and increases patients’ risk of ICU
Chapter 10: Endocrine Manifestations of COVID-19
admission.7, 8 Most notable, however, are diabetes and obesity that are both indepen- dently associated with a higher risk of death in COVID-19 patients.8 In light of these data, and by understanding the data from previous viral outbreaks, it is imperative to understand the interaction between this viral pandemic and the global epidemic of diabetes.
10.2 Mechanisms of Increased COVID-19 Severity in Diabetic Patients
In general, diabetic patients are more susceptible to infection due to dysfunctional immune responses such as decreased neutrophil chemotaxis and decreased phago- cytosis by the innate immune cells.9–11 Immune cell function, like killing via respira- tory burst, is also inhibited by hyperglycemia seen in diabetic patients.11 Diabetic patients have decreased proportions of CD4+,CD8+, and anti-in ammatory regula- tory T cells, and also have a higher proportion of pro-in ammatory immune cells (eg, Th17 cells).11 This altered immune landscape may allow in ammatory cascades to go unchecked in diabetic patients. There is also evidence that patients with hyper- tension and diabetes have a delayed clearance of viral load, prolonging infections.10 With respect to SARS-CoV-2 speci cally, it is theorized that diabetes increases the risk of infection due to up-regulation of angiotensin-converting enzyme 2 (ACE2), which the virus uses to infect cells.9, 10
The effects of diabetes on ACE2 are twofold. While acute hyperglycemia has been shown to up-regulate ACE2, there is evidence that chronic hyperglycemia down-regulates ACE2 expression. This effect of ACE2 down-regulation may, how- ever, increase the in ammatory damage caused by COVID-19, as ACE2 is protec- tive against in ammation.9 Diabetic patients also have increased levels of plasmin and plasminogen, and protease enzymes thought to play a role in SARS-CoV-2 infectivity. Plasmin(ogen) cleaves furin sites in SARS-CoV-2 S proteins, which increases infectivity by allowing easier entry, fusion, duplication, and release of viral particles in respiratory cells. Elevated plasmin(ogen) and furin levels are com- mon in COVID-19 diabetes and may also be an independent factor for risk strati – cation.11 Another way diabetes exacerbates COVID-19 symptoms is its effects on the respiratory system. Diabetes can cause altered lung capillary permeability and small airway collapse. Additionally, SARS-CoV-2 can decrease the O2-carrying capacity of hemoglobin, which is exacerbated in the glycated hemoglobin in dia- betic patients.11
Not only does diabetes exacerbate the symptoms of COVID-19, COVID-19 also exacerbates the symptoms of diabetes. A study of 658 patients in Wuhan, China, showed that 6.4% presented with ketosis, and these patients had worse outcomes and longer hospital stays. In a smaller proportion of patients, this ketosis precipi- tated into diabetic ketoacidosis (DKA), which is a serious complication of diabetes. Interestingly, of the ve total DKA cases, two of the patients were nondiabetic.12 A
Managing Diabetes in COVID Patients
case study in Singapore also showed DKA precipitated by COVID-19.13 The mech- anism of COVID-19-induced DKA is unclear; however, it is postulated that direct damage to pancreatic beta cells due to infection causes an acute insulin de ciency that can precipitate DKA.9, 13
10.3 Managing Diabetes in COVID Patients
Management of glycemia is of utmost importance in COVID-19 patients. Data from an Italian study shows that diabetic patients with hyperglycemia are at a higher risk of developing severe COVID-19 and have persistently higher levels of in ammation (measured by IL-6 and D-dimer), than diabetic patients who are normoglycemic. Data from a retrospective study in Hubei Province, China, shows that maintenance of glycemia within 3.9–10 mmol/L in patients with preexisting type 2 diabetes (T2D) is associated with a signi cant reduction in morbidity and mortality.14
Glycemia in T2D patients may be managed by a plethora of medications, which may have implications for SARS-CoV-2 infection. Because ACE2 is important for viral entry into cells, upregulation of ACE2 may be detrimental. Several classes of diabetes medications may be implicated in this: sodium/glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor antagonists, piogli- tazones, and possibly insulin.15 Most notable, however, are the ACE inhibitors and angiotensin receptor blockers (ARB). Preclinical models indicate that ACE2 may be up-regulated by ACE inhibitors/ARBs, raising concerns for their use in COVID-19 patients. However, new clinical data indicates that their use is safe and effective in COVID-19 patients.16 An additional consideration when choosing medications is the involvement of in ammation in the COVID-19 disease process. Dipeptidyl pep- tidase 4 (DPP4), which is involved in in ammatory pathways, is the target of incre- tin-based therapies used for T2D. Preclinical studies show a decreased in ammation with DPP4 inhibition, and similar effects are seen with SGLT-2 inhibitors and pio- glitazone,15 raising the question whether these therapies would be more appropriate for use in diabetic COVID patients.
It must be noted that currently, there have been no changes in guidelines for managing diabetes in COVID-19 patients. Furthermore, there is no evidence of poor outcomes when treating diabetic patients with any of the abovementioned medications,17 which are summarized in Table 10.1 (adapted from Pal et al., 2020). In the inpatient setting, insulin infusion may be the best method for achieving gly- cemic targets and improving outcomes due to its safety and reliability.18 However, other factors must be considered when treating an infectious disease—namely, reduction of contact with COVID-positive patients. Therefore, physicians must choose a regimen that ts their primary target (glycemic control vs. contact fre- quency). For instance, if the physician wishes to reduce contact, they may use an NPH-regular regimen.19 Such pros and cons are listed in Table 10.2 (adapted from Hamdy et al.19).
Antidiabetic Drug
Data from Animal Studies
Data from Human Studies
Concerns for Use during COVID-19 Pandemic
Reduces renal ADAM-17 expression in diabetic mice, thereby reducing urinary ACE2 shedding and increasing intrarenal ACE2 expression
No human data to support poor outcome
No concern
Sulfonylureas
Up-regulation of ACE2 in insulin-sensitive tissues of rats
Down-regulation of ADAM-17 in human skeletal muscles
Theoretical risk of poor outcome; however, no data on human pulmonary ACE2 expression
Liraglutide
Up-regulates ACE2 in cardiac and pulmonary tissues of diabetic rats
SGLT2 inhibitors
Promotion of renal ACE2 activity
DPP4 inhibitors
DPP4 mice develops severe disease with MERS-CoV DPP4i; ACE2 activity is not altered in diabetic mice
DPP4 inhibitor might exert overall anti- in ammatory role
Theoretically, DPP4 modulation might help offset the cytokine-mediated acute respiratory complications of COVID-19
Reduction of viral load in COVID-19
Can be considered as a third-line add-on drug in patients with poor glycemic control
Table 10.1 Commonly Prescribed Antidiabetic Drugs and Concerns Regarding Their Use during COVID-19
Abbreviations: COVID-19, coronavirus disease 2019; ACE2, angiotensin-converting enzyme 2; ADAM-17, a disintegrin and metalloproteinase-17; SGLT-2, sodium/glucose transporter 2; DPP4, dipeptidyl peptidase 4; DPP4, transgenic diabetic mice expressing human DPP4; MERS-CoV, Middle East respiratory syndrome coronavirus.
Other Endocrine Diseases
Table 10.2 Pros and Cons of Several Insulin Regimens Used in the ICU for Patients with Diabetes and COVID-19 on Continuous Tube Feeding
Insulin Infusion, i.v.
Basal Insulin q12h + Regular Insulin q6h for Correction
NPH insulin q8h + Regular Insulin q8h for Correction
Regular Insulin q6h
Contact frequency/day
++++ (best)
Glycemic variability
+ (lowest)
Risk of hypoglycemia upon TF interruption
Mitigation protocol
Relax the target blood glucose and test q2-4h
Reduce doses of basal insulin and add xed doses of regular insulin q6hr plus correction by regular insulin q6h
No mitigation is required
Infuse DI0W at the same rate if TF is interrupted for >2h
Abbreviations: DI0W, dextrose 10% in water; TF, continuous tube feeding.
10.4 Other Endocrine Diseases
10.4.1 Adrenal Insufficiency
SARS-CoV (coronavirus which caused the 2003 SARS epidemic) employs an immunoevasive technique wherein it knocks down the host cortisol stress response. It does so by mimicking amino acid sequences of host adrenocorticotrophic hor- mone (ACTH). Because SARS-CoV-2 is related to SARS-CoV, it is theorized that COVID-19 may affect the hypothalamic–pituitary–adrenal (HPA) axis. There are currently prospective studies underway to analyze this.20
Independently of COVID-19’s effects on the HPA axis, glucocorticoids have been employed to treat the cytokine storm, which causes many of COVID-19’s worst symptoms. Those with adrenal insufficiency should be treated with dou- ble the dose of glucocorticoids, according to the American Association of Clinical Endocrinologists.20, 21 For patients with adrenal insufficiency and COVID-19 presenting persistent fever or severe pneumonias, the preferred treatment is an initial bolus of 50–100 mg hydrocortisone followed by a con- tinuous IV replacement. This regimen reduces the immunosuppressive effects of high peaks of hydrocortisone and has been shown to reduce time in the ICU.21, 22
10.4.2 Subacute Thyroiditis
Subacute thyroiditis is an in ammatory thyroid disease, which is generally pre- cipitated by a viral infection of the upper respiratory tract. The rst reported case of subacute thyroiditis after SARS-CoV-2 infection has been con rmed in Italy. Fifteen days after testing positive for SARS-CoV-2 via oropharyngeal swab, the patient presented with tachycardia and an in amed and painful thy- roid. FT4 and FT3 were high in this patient, with an undetectable TSH, and negative TPOAb and TRAb. High FT4 and FT3 indicate hyperthyroidism, while negative thyroid antibodies indicate a non-autoimmune etiology. In ammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were high along with white blood cell count. After treatment with pred- nisone for over one month, the symptoms resolved and both in ammatory mark- ers and thyroid tests were normal.23 This case represents another clinical manifestation of COVID-19 that should not be overlooked, especially by endocrinologists.
10.5 Telemedicine
Diabetes is a disease which requires a careful management and communication between patients and providers. During a pandemic, this communication is dif- cult, highlighting a need to turn towards telemedicine in order to manage patients. Two cases of new-onset type 1 diabetes in Colorado, one adult and one pediatric, highlight the effectiveness of telemedicine.24 The adult patient used multiple daily insulin injections, and the pediatric patient used a continuous insulin pump. Both patients used continuous glucose monitoring software (Dexcom Clarity and Glooko). By following up with the patient’s glucose moni- toring online, and checking in with them via e-mail, Zoom video conferencing, and telephone calls, both patients have been effectively managed during the pandemic.24
In India, a review of telemedicine guidelines suggests that it is an important tool to use in managing chronic conditions like diabetes.25 However, more research should be done on the long-term impact of telemedicine on health outcomes. The authors caution that because telemedicine cannot replace the physical examination, at least the rst consult should be in-person.25
10.6 Tools for Health-Care Providers
1. Algorithms based on emerging guidelines: https://www.covidindiabetes.org/ (website and app available)
2. https://abcd.care/coronavirus
• UK National diabetes inpatient COVID response group
• Simple, safe, diabetes guidelines for specialists and nonspecialists
• First set of guidelines—for specialists outlines key requirements vital to
maintaining patient safety
• Second set—for EM physicians/acute admitting teams. Provides algorithm
for acute admitting and management of diabetes at the “front door”
3. https://www.ama-assn.org/practice-management/digital/ama-quick-guide- telemedicine-practice?&utm_source=BulletinHealthCare&utm_medium= email&utm_term=031820&utm_content=NON-MEMBER&utm_ campaign=article_alert-morning_rounds_daily&utm_uid=2539335&utm_
effort=MRNRD0
• AMA Guide to Telemedicine
10.7 Conclusion
1. Diabetes is the third most common comorbidity in COVID-19 patients, and is associated with more severe disease, increased ICU admission, and a higher risk of death.
2. Diabetes is a multiorgan disease, and there are numerous mechanisms which may make COVID-19 more severe in diabetic patients:
• Immunocompromised state
• ACE2 upregulation
• Precipitation of DKA by SARS-CoV-2 infection.
3. There are no changes to diabetes management guidelines for COVID-19
4. Glycemic regulation is a major factor in reducing morbidity and mortality.
5. Adrenal insuf ciency and subacute thyroiditis are other endocrine manifesta-
tions of COVID-19, which should not be overlooked.
6. Telemedicine is key to managing new-onset and chronic diabetes during a
1. Diabetes. (n.d.). Retrieved July 09, 2020, from https://www.who.int/news-room/fact-sheets/ detail/diabetes.
2. Fast Facts – Data and Statistics About Diabetes. (n.d.). Retrieved July 09, 2020, from https:// professional.diabetes.org/content/fast-facts-data-and-statistics-about-diabetes.
3. Booth CM, Matukas LM, Tomlinson GA, et al. Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area [published correction appears in JAMA. 2003 Jul 16;290(3):334]. JAMA. 2003;289(21):2801–2809. https://doi.org/10.1001/ jama.289.21.JOC30885.
4. Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: prevalence, pathophysiology, prognosis and practical considerations [published online ahead of print, 2020 Apr 9]. Diabetes Metab Syndr. 2020;14(4):303–310. https://doi.org/10.1016/j.dsx.2020.04.004.
5. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area [published online ahead of print, 2020 Apr 22] [published correction appears in https://doi. org/10.1001/jama.2020.7681]. JAMA. 2020;323(20):2052–2059. https://doi.org/10.1001/ jama.2020.6775.
6. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708–1720. https://doi.org/10.1056/NEJMoa2002032.
7. Roncon L, Zuin M, Rigatelli G, Zuliani G. Diabetic patients with COVID-19 infection are at higher risk of ICU admission and poor short-term outcome. J Clin Virol. 2020;127:104354. https://doi.org/10.1016/j.jcv.2020.104354.
8. Cariou B, Hadjadj S, Wargny M, et al. Phenotypic characteristics and prognosis of inpatients with COVID-19 and diabetes: the CORONADO study [published online ahead of print, 2020 May 29] [published correction appears in Diabetologia. 2020 Jul 2]. Diabetologia. 2020;1–16. https://doi.org/10.1007/s00125-020-05180-x.
9. Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020;8(6):546–550. https:// doi.org/10.1016/S2213-8587(20)30152-2.
10. Angelidi AM, Belanger MJ, Mantzoros CS. Commentary: COVID-19 and diabetes melli- tus: what we know, how our patients should be treated now, and what should happen next. Metabolism. 2020;107:154245. https://doi.org/10.1016/j.metabol.2020.154245.
11. Means C. Letter to the Editor: Mechanisms of increased morbidity and mortality of SARS- CoV-2 infection in individuals with diabetes: what this means for an effective management strategy. Metabolism. 2020;108:154254. https://doi.org/10.1016/j.metabol.2020.154254.
12. Li J, Wang X, Chen J, Zuo X, Zhang H, Deng A. COVID-19 infection may cause ketosis and ketoacidosis [published online ahead of print, 2020 Apr 20]. Diabetes Obes Metab. 2020. https://doi.org/10.1111/dom.14057.
13. Chee YJ, Ng SJH, Yeoh E. Diabetic ketoacidosis precipitated by Covid-19 in a patient with newly diagnosed diabetes mellitus. Diabetes Res Clin Pract. 2020;164:108166. https://doi. org/10.1016/j.diabres.2020.108166.
14. Zhu L, She ZG, Cheng X, et al. Association of blood glucose control and outcomes in patients with COVID-19 and pre-existing type 2 diabetes. Cell Metab. 2020;31(6):1068–1077.e3. https://doi.org/10.1016/j.cmet.2020.04.021.
15. Ceriello A, Stoian AP, Rizzo M. COVID-19 and diabetes management: What should be considered? Diabetes Res Clin Pract. 2020;163:108151. https://doi.org/10.1016/j. diabres.2020.108151.
16. Herman, AO. (2020, May 3). Three studies nd no harm from ACE inhibitors or ARBs in COVID-19. Retrieved July 09, 2020, from https://www.jwatch.org/fw116602/2020/05/03/ three-studies- nd-no-harm-ace-inhibitors-or-arbs-covid.
17. Pal R, Bhadada SK. Should anti-diabetic medications be reconsidered amid COVID- 19 pandemic? Diabetes Res Clin Pract. 2020;163:108146. https://doi.org/10.1016/j. diabres.2020.108146.
18. Sardu C, D’Onofrio N, Balestrieri ML, et al. Outcomes in patients with hyperglycemia affected by COVID-19: can we do more on glycemic control?. Diabetes Care. 2020;43(7):1408–1415. https://doi.org/10.2337/dc20-0723.
19. Hamdy O, Gabbay RA. Early observation and mitigation of challenges in diabetes manage- ment of COVID-19 patients in critical care units. Diabetes Care. 2020 May. https://doi.org/ 10.2337/dc20-0944.
20. Pal R. COVID-19, hypothalamo-pituitary-adrenal axis and clinical implications. Endocrine. 2020;68(2):251–252. https://doi.org/10.1007/s12020-020-02325-1.
21. Isidori AM, Po R, Hasenmajer V, Lenzi A, Pivonello R. Use of glucocorticoids in patients with adrenal insuf ciency and COVID-19 infection. Lancet Diabetes Endocrinol. 2020;8(6):472– 473. https://doi.org/10.1016/S2213-8587(20)30149-2.
22. Arlt W, Baldeweg SE, Pearce SHS, Simpson HL. Endocrinology in the time of COVID-19: management of adrenal insuf ciency. Eur J Endocrinol. 2020;183(1):G25–G32. https://doi. org/10.1530/EJE-20-0361.
23. Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F. Subacute thyroiditis after Sars- COV-2 infection. J Clin Endocrinol Metab. 2020;105(7):dgaa276. https://doi.org/10.1210/ clinem/dgaa276.
24. Garg SK, Rodbard D, Hirsch IB, Forlenza GP. Managing new-onset type 1 diabetes during the COVID-19 pandemic: challenges and opportunities. Diabetes Technol Ther. 2020;22(6):431– 439. https://doi.org/10.1089/dia.2020.0161.
25. Ghosh A, Gupta R, Misra A. Telemedicine for diabetes care in India during COVID19 pan- demic and national lockdown period: Guidelines for physicians [published online ahead of print, 2020 Apr 4]. Diabetes Metab Syndr. 2020;14(4):273–276. https://doi.org/10.1016/j. dsx.2020.04.001.
Dermatological Manifestations of COVID-19
Saeed Jaffer M.D. and Ashley Slack
EBV Epstein–Barr virus
RT-PCR Reverse transcription polymerase chain reaction
As COVID-19 continues to change our daily lives in unimaginable ways, it also continues to pose challenges to all physicians alike, including dermatologists. Many dermatologists have discovered eruptions and lesions associated with COVID-19 infection and its treatment. This chapter summarizes the latest evidence on dermatological manifestations associated with COVID-19, including the usage of personal protective equipment (PPE)-induced skin injuries in patients and health-care providers. Table 11.1 summarizes the dermatological manifestations of COVID-19.
The dermatological manifestations associated with COVID-19 infection are lesions characterized as erythematous rash, urticaria, chickenpox-like vesicles, livedo retic- ularis-like eruptions, chilblain-like lesions, digitate papulosquamous eruptions, and petechiae. One dermatological manifestation that was discovered to be associated with COVID-19 treatment is exanthematous drug eruption characterized by ery- thematous macules or papules possibly due to antiviral medications given to posi- tively diagnosed COVID-19 patients. Health-care workers and patients have also seen the dermatological impacts from PPE usage such as skin lesions, increased acne, dermatitis, and facial itching.
                                                                                   
Chapter 11: Dermatological Manifestations of COVID-19
Table 11.1 Dermatological COVID-19 Case Table
Dermatological Symptoms
Symptom Location
Symptom Characteristics
Patient/s COVID-19 Diagnosis (Positive or Negative)
Treatment of Dermatological Symptoms
Chilblain lesions
All ranges, but mainly median age of 13 and 31 years
Mainly on toes, soles, ngers, extremities, and/or heel
Purpuric, attened, painful upon palpitation
Positive; asymptomatic
Lacy, purple, no associated itching
Resolved without intervention within 24 h
Exanthematous drug eruption/ morbiliform drug eruption
35-year-old in one case
Initially and mainly seen on the trunk; spread to extremities within 24 h
Itchy red/ purple rash seen 10 days after antiviral treatment; possibly due to antiviral medications used to combat COVID-19
Systemic corticosteroids; corticosteroid topical treatment; systemic antihistamines
                                                
Digitate papulosquamous eruption
Laterally on the trunk and thighs, upper arms, shoulders, back, periumbilical
Squamous and erythematous patch, scaly thin plaques, popular lesions could be due to secondary result of immune response against coronavirus
Unavailable; patient expired
Male 48-year-old in one case
Systemic distribution on the buttocks, lower abdomen, proximal anterior thighs, popliteal fossae
Pruritic skin lesions
Nasopharyngeal swab RT-PCR
11.2 Clinical Manifestations
There are a few signi cant dermatologic manifestations of COVID-19. Some of the manifestations that have been reported are chilblain lesions, erythematous rashes, skin lesions due to the hypercoagulable state of COVID-19, livedo reticularis-like eruptions, exanthematous drug eruptions or maculopapular rashes, digitate papulo- squamous eruptions, and petechiae.
There have been a series of cases where suspected COVID-19 patients presented with reddish and papular lesions that seemingly resemble chilblains (Figures 11.1– 11.4).1 These lesions were seen in all age ranges, but mainly in children with a
Figure 11.1 Chilblain lesions on toes and heel.1 a
Figure 11.2 (a) Papular lesions on heel. (b) Same lesions a week later.1
Figure 11.3 Acral lesion with crust.1
Figure 11.4
Erythematous lesions.1
median age of 13 years, and young adults with a median age of 31. After 1 week, these lesions were found to become more purpuric and attened. They eventually disappeared without intervention. Some patients reported the lesions to be painful when palpated; however, they were not very symptomatic. These lesions were dis- covered to be mainly located on the toes, soles, ngers, extremities, and/or heel but are commonly referred to as “COVID toes” (Figure 11.5).1
Erythematous-violaceous lesions in the toe.1
The patients were asymptomatic, but some reported contact with suspected or infected COVID-19 patients.1 Two of the patients had a positive diagnosis of coro- navirus. The chilblain-like lesions could possibly be a late manifestation of COVID- 19. In order to verify if the lesions are related to COVID-19, it is recommended to do a biopsy of them and to possibly perform a reverse transcription polymerase chain reaction (RT-PCR) test, along with an IgM-IgG serological test on patients. These lesions can also help to diagnose COVID-19 patients who are asymptomatic.1
In a study of 88 COVID-19 patients in Italy, 20.4% of patients had skin involve- ment during the viral infection. The lesions were characterized as an erythematous rash in 14 patients, widespread urticaria in three patients, and chickenpox-like ves- icles in one patient. The eruptions were primarily located on patients’ trunks, and there was little to no associated itching with the lesions. The eruptions were present only for a few days before resolving spontaneously.2 These types of exanthems are commonly seen in many other viral infections such as measles and mononucleosis.
In addition to these viral infection-associated exanthems, there have been some reports of skin lesions that are likely due to the hypercoagulable state that many COVID-19 patients are in.3
A few cases of a livedo reticularis-like rash have been reported. The patients’ lesions are described as lacy and purple, with no associated itching. These eruptions resolved within 24 h in most patients.4 Livedo reticularis normally occurs due to the interruption of blood ow that leads to deoxygenated blood pooling in the cutane- ous venous plexus.5 If such a livedo reticularis-like rash is occurring in COVID-19 patients, this raises concern for the interruption of blood ow to other organs in addition to the skin. In fact, one of the COVID-19 patients who was reported to have the livedo reticularis-like rash also had hematuria. This may have been due to the
interruption of the kidney’s blood supply resulting in glomerulonephritis or cysti- tis.5 Thus, it is important for clinicians treating patients with this kind of skin erup- tion to be wary of other possible symptoms of hypercoagulability.
Another possible viral manifestation of COVID-19 is exanthematous drug erup- tion, or morbilliform drug eruption (Figure 11.6).6 This immune reaction is charac- terized by erythematous macules and/or papules that are usually seen in patients with bacterial and viral infections, and about 5 days to 3 weeks after the administra- tion of certain drugs, such as antivirals, anti-hypertensives, anti-in ammatory medi- cations, and antibiotics. However, this condition is mostly seen after administering antiviral medications. Due to the use of lopinavir/ritonavir drug combinations in combating the coronavirus, there have been reports of an increase in maculopapular drug eruptions.
In one example, a 35-year-old, positively infected coronavirus patient was diagnosed with optic neuritis a week before he was admitted to the hospital. He did not present with any symptoms, and reported no history of international travel or exposure to infected COVID-19 patients or patients suspected of having COVID-19.6 The patient was isolated in the hospital’s COVID-19 unit and treated with oral lopinavir/ritonavir 400/100 BID for 10 days. Subsequently, the patient presented with an itchy, maculopapular eruption during his hospitalization. These were initially, and mainly, seen on the skin of the trunk and eventually spread to upper extremities after 24 h. The patient reported to have had no history of contact dermatitis, drug reactions, or other hypersensitivity reactions.6 In order to treat the morbilliform eruption, dermatologists administered an increased dose of systemic corticosteroids and began corticosteroid topical treatment along with systemic antihistamines. At the 10-day follow-up, there was no evidence of the patient’s skin lesions.
Figure 11.6 (a, b) Morbilliform eruption observed on the trunk and neck. These manifestations are primarily seen on the skin of the trunk.6
There is some speculation that there could be a direct association between mor- billiform eruptions and COVID-19 infection. Furthermore, an example showing this link was observed in the data collected by dermatologists analyzing skin lesions in 88 Italian COVID-19 patients. This data re ected that about one- fth of patients developed maculopapular eruptions (Figure 11.7).6 There was also no correlation between the COVID-19 infection severity and the cutaneous ndings. Although there are some reports of morbilliform eruptions seen in COVID-19 patients who were taking antiviral medications such as lopinavir and ritonavir, there is no cer- tainty that this type of presentation is only caused by medications.6 There is suspi- cion that COVID-19 may be another factor for the morbilliform eruptions that were observed. But the association needs to be examined through further research.6
Figure 11.7 (a) Erythematous squamous lesions with periumbilical patch and lesions on the abdomen and thighs. (b) Skin lesions on the left upper arm and ank.7 (c) Spongiosis in the epider- mis and spongiotic vesicles with aggregates of lymphocytes and Langerhans cells.7
A case of digitate papulosquamous eruption was reported during a SARS- CoV-2 infection (Figure 11.8).7 The patient was admitted to the intensive care unit for acute respiratory distress. The patient was diagnosed with COVID-19 through a nasopharyngeal SARS-CoV-2 RT-PCR. The patient developed a squamous and erythematous periumbilical patch and was later seen to have a rapid progression of other similar digitate scaly thin plaques laterally on the trunk and thighs. Papular lesions were found on the upper arms, shoulders, and back. A skin biopsy of the left shoulder showed spongiotic vesicles with aggregates of lymphocytes and Langerhans cells. RT-PCR was performed on the skin biopsy and was nega- tive for SARS-CoV-2. The patient tested positive for Epstein–Barr virus (EBV) through a blood test. The eruption resolved spontaneously within 1 week; how- ever, the patient eventually died of COVID-19-related illness. It was concluded that the cutaneous rash could be a secondary result of the immune response against the coronavirus, as there was no evidence of a cutaneous drug reaction to cefpo- doxime. EBV was not suspected to have caused the cutaneous ndings although EBV was found to be reactivated.7
A case of petechiae was reported during the COVID-19 outbreak in Madrid, Spain. A 48-year-old man with hypertension presented to the emergency department, where he reported a fever, chest pain, and shortness of breath sev- eral days before hospital admission. Three days after the onset of fever, he noticed the appearance of pruritic skin lesions. Petechiae was seen in a sym- metric distribution on the buttocks, popliteal fossae, proximal anterior thighs, and lower abdomen (Figure 11.8).8 A nasopharyngeal swab RT-PCR was per- formed and resulted in a positive diagnosis for SARS-CoV-2 for this patient. Serologic test results were negative for HIV, hepatitis B virus, hepatitis C virus, and parvovirus B19.8
Figure 11.8 Erythematous macules, papules, and petechiae affecting the popliteal fossa, but- tocks, and anterior thighs (a) Posteroinferior view, (b) Close-up view of the buttocks, (c) Anterior view.8
11.3 PPE Usage Impact on Patients
Although not a direct pathophysiologic effect of the virus, many COVID-19 patients have developed dermatologic issues simply due to increased PPE usage and exten- sive personal hygiene measures.9 The resultant friction due to consistent PPE utili- zation along with the hyper-hydration effects of PPE can result in notable skin lesions. Erythema and scaling have been observed, along with burning, stinging, and itching. Lesions are primarily found on the face due to face masks, with some lesions on the hands due to glove use. Many individuals have ampli ed personal hygiene measures by washing their hands several times a day, which can result in hand dermatitis (Figure 11.9).9 In one extreme case, a woman washed her face with 60% ethanol ve times per day and wore a face mask for 6 h per day, two measures which resulted in facial redness and papules (Figure 11.10).9
Figure 11.9 Hand dermatitis from excessive hand washing.9
Figure 11.10 Facial erythema and papules in a 42-year-old female patient who disinfected her face with 60% ethanol and used a protective facial mask for 6 h per day.9
11.4 PPE Usage Impact on Health-care Workers
Health-care workers in particular are uniquely susceptible to PPE-related skin lesions due to the amount of time during which they must wear face masks, gloves, etc. With N95 masks, in particular, many health-care workers report increased acne, dermatitis, and facial itching.10 Recurrent use of lipid-emulsifying detergents that diminish lipids in the stratum corneum layer of the skin can cause skin dryness. Hand sanitizers can also compromise the stratum corneum layer of the skin due to the lipid-dissolving alcohols.10
In order to combat dermatologic reactions to PPE usage and personal hygiene, it is recommended to moisturize the skin and avoid allergens found in disinfectant products containing quaternary ammonium.10 The most ef cient method to combat adverse cutaneous reactions from hygiene practices is to regularly utilize oil-con- taining emollients after handwashing. In a randomized, double-blind trial of health- care workers who all presented with severe hand irritation, it was seen that the scheduled use of oil-containing lotion was better than creams for improving skin scaling, cracking, and pain in the hands.10
It would be bene cial for dermatologists to promote protective methods during the pandemic, such as proper hand-washing procedures, avoiding washing hands with hot water to reduce the possibility of having skin damage, avoiding antibac- terial soaps due to them not being superior to non-antibacterial soaps in prevent- ing infections, avoiding chemicals in soaps to reduce the possibility of having allergic reactions, utilizing a 60% alcohol-based hand sanitizer on hands for 20 s if soap and water are unavailable, avoiding sanitizers containing fragrances to reduce allergic skin reactions, and avoiding a direct skin contact with EPA- registered disinfectant products by wearing gloves and cleaning hands afterward to prevent allergic skin reactions.10 Furthermore, oil-emollient moisturizers to the hands after handwashing can be regularly applied to combat skin damage induced by allergens.10
1. Landa N, Mendieta-Eckert M, Fonda-Pascual P, Aguirre T. Chilblain-like lesions on feet and hands during the COVID-19 pandemic. Int J Dermatol. 2020;59(6):739–743. https://doi. org/10.1111/ijd.14937.
2. Recalcati S. Cutaneous manifestations in COVID-19: a rst perspective. J Eur Acad Dermatol Venereol. 2020;34(5):e212–e213. https://doi.org/10.1111/jdv.16387.
3. Magro C, Mulvey JJ, Berlin D, et al. Complement associated microvascular injury and throm- bosis in the pathogenesis of severe COVID-19 infection: a report of ve cases. Transl Res. 2020;220:1–13. https://doi.org/10.1016/j.trsl.2020.04.007.
4. Manalo IF, Smith MK, Cheeley J, Jacobs R. A dermatologic manifestation of COVID-19: transient livedo reticularis. J Am Acad Dermatol. 2020;83(2):700. https://doi.org/10.1016/j. jaad.2020.04.018.
5. Olin J. 80—other peripheral arterial diseases. In: Goldman’s Cecil Medicine (24th ed.). New York: Elsevier Inc; 2012:493.
6. Mazan P, Lesiak A, Skibińska M, et al. Maculopapular rash in COVID-19 patient treated with lopinavir/ritonavir. Adv Dermatol Allergol. 2020;37(3):435–437. https://doi.org/10.5114/ ada.2020.95029.
7. Sanchez A, Sohier P, Benghanem S, et al. Digitate papulosquamous eruption associated with severe acute respiratory syndrome coronavirus 2 infection. JAMA Dermatol. 2020;156(7):819– 820. https://doi.org/10.1001/jamadermatol.2020.1704.
8. Diaz-Guimaraens B, Dominguez-Santas M, Suarez-Valle A, et al. Petechial skin rash asso- ciated with severe acute respiratory syndrome coronavirus 2 infection. JAMA Dermatol. 2020;156(7):820–822. https://doi.org/10.1001/jamadermatol.2020.1741.
9. Darlenski R, Tsankov N. COVID-19 pandemic and the skin – what should dermatologists know? Clin Dermatol. 2020. https://doi.org/10.1016/j.clindermatol.2020.03.012.
10. Macgibeny MA, Wassef C. Preventing adverse cutaneous reactions from ampli ed hygiene practices during the COVID-19 pandemic: how dermatologists can help through anticipatory guidance. Arch Dermatol Res. 2020;1–3. https://doi.org/10.1007/s00403-020-02086-x.
Ophthalmological Manifestations of COVID-19
Ejaz Hussein M.D. and Eesha Imam
COVID-19 PPE SARS-CoV-2
Severe acute respiratory syndrome coronavirus 2
COVID-19 has changed how ophthalmologists are running their practices and treat- ing their patients. This chapter shares the latest information on the ophthalmological manifestation of COVID-19, and its impact on patients and health-care providers.
12.2 Conjunctivitis
The most common, and only, ophthalmic manifestation of the SARS-CoV-2 virus reported is conjunctivitis.1 Conjunctivitis can present as a rst, or only, sign of infection from SARS-CoV-2. All the reports of conjunctivitis associated with SARS-CoV-2 have been “bilateral, mild, follicular conjunctivitis without corneal involvement” with some exceptions.1 Although initially believed to be a rare mani- festation, conjunctivitis is now being believed to be a primary symptom of the SARS-CoV-2 infection.2 According to an AAAS study, “The estimated proportion of those with ocular symptoms, some consistent with conjunctivitis, ranges widely, from <1% (Centers for Disease Control and Prevention Coronavirus 2019-Associated Hospitalization Surveillance Network) to more than 30%, sug- gesting that conjunctivitis could be a disease feature and potentially a useful diag- nostic sign.”3
Chapter 12: Ophthalmological Manifestations of COVID-19
12.3 Precautions
12.3.1 Personal Protective Equipment (PPE)
To protect against SARS-CoV-2 during regular of ce visits, ophthalmologists are recommended by the American Academy of Ophthalmology to continue using the proper disinfecting practices of instruments and of ces using bleach- and alcohol- based disinfectants before and after every patient encounter.1
Although there is no documented evidence that SAR-CoV-2 can be transmitted via ocular secretions, it may be possible to contract COVID-19 from a COVID-19 patient who has conjunctivitis.1 Precautions should still be taken such as having one’s eyes, mouth, and nose protected using goggles or N95 mask as well as slit- lamp breath shields1
12.3.2 Chloroquine and Hydroxychloroquine
Regarding the usage of the drugs chloroquine and hydroxychloroquine in response to the COVID-19 pandemic, the American Academy of Ophthalmology warns against the potential of developing irreversible maculopathy if these drugs are taken in high doses over short periods of time.1
12.4 Testing
Several of the reports of such patients also demonstrated that these patients tested positive for SARS-CoV-2 by detecting its mRNA on RT-PCR on conjunctival swabs.1 One patient tested positive for SARS-CoV-2 by culturing the virus from an eye swab.1 Expression of mRNA for ACE has been seen in conjunctival epithelial cells as demonstrated in studies by Zou et al.4 and Sungnak et al.5 “One study pur- ported to show that SARS-CoV-2 could infect human conjunctival explants”; how- ever, “its presence in conjunctival epithelium remains controversial” (Table 12.1).1
The key takeaways from an ophthalmological point are as follows:
• Patients presenting with conjunctivitis should be tested for COVID-19.
• Patients with COVID-19 may present with conjunctivitis as the only manifes-
tation of COVID-19.
• Those performing eye examinations should use appropriate PPE such as
masks, gloves, and gowns.
Table12.1 MajorStudiesandFindingsontheRelationshipofOphthalmologicalwithSARS-CoV-21
Journal of Medical Virology study6
Findings: 1/30 hospitalized COVID-19 patients had conjunctivitis and had SARS-CoV-2 RNA in ocular secretions1
Conclusions: Patients with COVID-19 and conjunctivitis can have infectious viral particles in their tears (veri ed by case report from China and another from Italy)
Clinical Characteristics of Coronavirus Disease 2019 in China published in the New England Journal of Medicine7
Findings: 9/1,099 hospitalized COVID-19 patients had conjunctival congestion from 30 hospitals across China None of the patients were seen by ophthalmologists, and tears were not sampled
Ocular Manifestations of Hospitalized Patient with Con rmed 2019 Novel Coronavirus Disease8
Findings: 30-year-old COVID-19 man developed acute follicular conjunctivitis in both eyes 13 days after onset.
SARS-CoV-2 Isolation from Ocular Secretions of a Patient with COVID-19 in Italy With Prolonged Viral RNA Detection9
Findings: A 65-year-old woman demonstrated bilateral conjunctivitis 1 day after onset of COVID-19 symptoms. Ocular swabs on day 3 had a presence of viral RNA, and ocular samples were taken every day for 21 total days. Each day ocular swabs were positive for viral RNA. By day 15, the conjunctivitis was improving and it was gone by day 20.
Neurological Manifestions of Hospitalized Patients with COVID-19 in Wuhan, China10
Findings: Among the 214 hospitalized COVID-19 patients, 3 had impaired vision, 2 of which had severe disease and 1 had nonsevere disease.f
Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China, published March 31 in JAMA Ophthalmology11
Findings: 12/38 hospitalized COVID-19 patients from Hubei, China, had “ocular ‘abnormalities’, characterized most commonly as chemosis and/or secretions”
2 of these patients tested positive for SARS-CoV-2 from conjunctival swabs, 1 of whom had signs of conjunctival hyperemia
The Infection Evidence of SARS-COV-2 in Ocular Surface: A Single-Center Cross-Sectional Study, a study by Zhang et al.12
Findings: 2/72 hospitalized COVID-19 patients from Tongji Medical College had conjunctivitis
Ophthalmologic Evidence Against the Interpersonal Transmission of 2019 Novel Coronavirus through
Conjunctiva, a paper by Zhou et al.13
Findings: 1/63 hospitalized COVID-19 patients from Wuhan had conjunctivitis
One patient had tested negative for SARS-CoV-2 using the conjunctival swab test, 2 showed “probable” results, and 1 other patient without conjunctivitis tested positive.
SARS-CoV-2 Isolation From Ocular Secretions of a Patient With COVID-19 in Italy With Prolonged Viral RNA Detection14
Findings: A COVID-19 patient in Italy also had conjunctivitis1
This patient also had respiratory symptoms, gastrointestinal symptoms, and fever.
This patient also tested positive for SARS-CoV-2 using RT-PCR on conjunctival swab test from the 3rd to 21st day of hospitalization & also on the 27th day when the nasal swabs were negative.
Care Home Nurse Tells of Terrifying and Sudden Ways Coronavirus Struck Her Patients, a story from CNN15
Findings: Red eye was reported as one of the rst symptoms frequently seen among residents in a nursing home in Washington state during a COVID-19 outbreak.
Keratoconjunctivitis As The Initial Medical Presentation of the Novel Coronavirus Disease 2019 (COVID-19)16
Findings: A patient with unilateral conjunctivitis and a coarse epithelial keratitis tested positive for SARS- CoV-2 using RT-PCR on a conjunctival swab
COVID-19 Emergency In The Cruise’s Ship: A Case Report of Conjunctivitis17
Findings: One patient had bilateral pseudomembranous conjunctivitis when they got COVID-19 while on a cruise ship
Hemorrhagic Conjunctivitis with Pseudomembranous Related to SARS-CoV-218
Findings: One hospitalized COVID-19 patient in France had bilateral hemorrhagic, pseudomembranous conjunctivitis
Table12.1 (continued)
1. Chodosh J, COVID-19 background primer for ophthalmologists. American Academy of Ophthalmology. 27 May 2020. https://www.aao.org/headline/covid-19-background-primer- ophthalmologists. Accessed October 14, 2020.
2. Hutton D. Researchers identify pink eye as possible primary symptom of COVID-19. Ophthalmology Times. Accessed June 9, 2020. https://www.ophthalmologytimes.com/view/ coronavirus-pink-eye-symptoms.
3. Deiner MS, Seitzman GD, McLeod SD, et al. Ocular signs of COVID-19 suggested by internet search term patterns worldwide. Ophthalmology. June 17, 2020. https://www.aaojournal.org/ article/S0161-6420(20)30569-8/fulltext.
4. Zou X, Chen K, Zou J, Han P, Hao J, Han Z. Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection. Front Med. 2020;14(2):185–192. https://doi.org/10.1007/s11684-020-0754-0.
5. Sungnak W, Huang N, Bécavin C. et al. SARS-CoV-2 entry factors are highly expressed in nasal epithelial cells together with innate immune genes. Nat Med. 2020;26:681–687. https:// doi.org/10.1038/s41591-020-0868-6.
6. Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secre- tions of patients with SARS‐CoV‐2 infection. J Med Virol. 2020;92(6):589–594. https://doi. org/10.1002/jmv.25725.
7. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China: NEJM. N Engl J Med. 2020;382:1708–1720. https://www.nejm.org/doi/full/10.1056/ NEJMoa2002032.
8. Chen L, Liu M, Zhang Z, et al. Ocular manifestations of a hospitalised patient with con rmed 2019 novel coronavirus disease. Br J Ophthalmol. 2020;104:748–751. https://doi.org/10.1136/ bjophthalmol-2020-316304.
9. Colavita, F, Lapa D, Carletti F, et al. SARS-CoV-2 isolation from ocular secretions of a patient with COVID-19 in Italy with prolonged viral RNA detection. Ann Intern Med. 2020;173(3):242–243. https://mwww.acpjournals.org/doi/10.7326/M20-1176.
10. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with coro- navirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683–690. https://doi. org/10.1001/jamaneurol.2020.1127.
11. Wu P, Duan F, Luo C, et al. Characteristics of ocular ndings of patients with coronavirus dis- ease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020;138(5):575–578. https://doi.org/10.1001/jamaophthalmol.2020.1291.
12. Sun X, Zhang X, Chen X, et al. The infection evidence of SARS-COV-2 in ocular surface: a single-center cross-sectional study. medRxiv. 2020.02.26.20027938. preprint. https://doi.org/1 0.1101/2020.02.26.20027938.
13. Zhou Y, Zeng Y, Tong T, et al. Ophthalmologic evidence against the interpersonal transmission of 2019 novel coronavirus through conjunctiva. medRxiv. 2020.02.11.20021956. https://doi. org/10.1101/2020.02.11.20021956.
14. Colavita F, Lapa D, Carletti F, et al. SARS-CoV-2 isolation from ocular secretions of a patient with COVID-19 in Italy with prolonged viral RNA detection. Ann Intern Med. 2020;173(3):242–243. https://doi.org/10.7326/M20-1176.
15. Sidner S, Inside the First Coronavirus Outbreak in the US. CNN, Cable News Network, March 24, 2020. https://www.cnn.com/2020/03/23/health/coronavirus-nurses-inside-washington- care-home/index.html. Accessed June 13, 2020.
16. Cheema M, Aghazadeh H, Nazarali S, et al. Keratoconjunctivitis as the initial medical presenta- tion of the novel coronavirus disease 2019 (COVID-19). Can J Ophthalmol. 2020;55(4):e125– e129. https://doi.org/10.1016/j.jcjo.2020.03.003.
17. Salducci M, La Torre G. COVID-19 emergency in the cruise’s ship: a case report of conjuncti- vitis. Clin Ter. 2020;171(3):e189–e191. https://doi.org/10.7417/CT.2020.2212.
18. Navel V, Chiambaretta F, Dutheil F. Haemorrhagic conjunctivitis with pseudomembranous related to SARS-CoV-2 [published online ahead of print, 2020 May 6]. Am J Ophthalmol Case Rep. 2020;19:100735. https://doi.org/10.1016/j.ajoc.2020.100735.
Mental Health Manifestations of COVID-19
Syed Ashraf Imam Ph.D.,
Mehran Javeed MBChB, MRCPsych, PGCert, and Joseph Kennedy
CNS COVID-19 ECG
PTSD SARS
Central nervous system Coronavirus disease 2019 Electrocardiogram
Post-traumatic stress disorder Severe acute respiratory syndrome
One unexplored visible impact of coronavirus disease 2019 (COVID-19) is on the mental health of people—patients, their loved ones, and the general public under nationwide lockdowns. Everyone is affected, whether directly or indirectly, high- lighting the massive impact the pandemic has had socially, economically, and psy- chologically. The focus of this chapter is on the psychological crisis facing people and speci c populations, such as health-care workers, patients with underlying mental health disturbances, and patients with COVID-19. This chapter will close with the recommended next steps in addressing current and new issues that may arise.
13.2 Pandemics in History and Psychological Impacts
As noted earlier (see Chapter 7), COVID-19 can potentially have multiple effects on the central nervous system (CNS). But the impact and the full scope of effects are not yet well known, including how long they may last. Recently, more evidence is coming out calling for greater mental health impacts and interventions to address the new gaps in care. This section reviews the history of pandemics and psychologi- cal impacts.
Chapter 13: Mental Health Manifestations of COVID-19
Over the course of human history, human beings have dealt with many mass disastrous events, including natural disasters, famine, disease, and war, just to men- tion a few. These have had innumerable effects on the societies it affected, all the way from the individual to the population level. Epidemics and pandemics, in par- ticular, have played signi cant roles in human history, as evidenced by the Bubonic plague of the Middle Ages and the Spanish u outbreak of the early 1900s. Within this century, we have already had four major disease outbreaks that have signi – cantly affected the human populace: the severe acute respiratory syndrome (SARS) epidemic of 2003, the H1N1 epidemic of 2009, the Ebola epidemic in 2014, and now the COVID-19 pandemic.
There is a signi cant body of research that has come out from prior epidem- ics in this century on the signi cant effects the epidemics had on mental health at many levels, including those who became sick, the health-care workers caring for them, and the population at large. Published literature after the SARS epi- demic, which affected more than 8000 people, resulted in 774 deaths world- wide, and spread to over 30 countries, showed an increased prevalence of persistent psychological symptoms, even months to years after the epidemic had ceased.1–5 During the SARS epidemic, higher rates of completed suicide by older adult were reported and attributed to possibly social isolation and increased stress and anxiety among the elderly in Hong Kong.6–8 In addition, high rates of psychosocial disturbances, such as insomnia, depression, anxiety, and post-trau- matic stress disorder (PTSD), were reported among those who had survived but also in their family members.9 Several studies documented substantial psycho- logical distress in health-care workers caring for SARS patients even years after the event.1, 10, 11 These results are re ected not only in the literature seen after the other epidemics of this century, but also after signi cant trauma and disasters.12
There are two important psychosocial distinctions from general disasters and disease epidemics: the consequences of social isolation and the fear of spreading the contagion if exposed.10 Quarantines, while a necessary part of disease prevention and mitigation, have serious and long-lasting effects on the mental health of those affected. This was the case when entire cities and villages were quarantined and public health measures were put in place in China and Canada and West Africa dur- ing the SARS and Ebola outbreaks, respectively.13 Furthermore, the absence of social support offering protection during times of stress exacerbates psychological trauma.
Fear, complicated by mistrust, misinformation and the policies that impacted on the regions’ cultural and religious beliefs, has been a strong motivator. This can lead to an exponential rise in certain fear-related behaviors that were intended to be that of survival but instead led to increased risk. During the Ebola outbreak, for example, the health-care system highlighted frailties and led to perceived low quality care and lack of trust, leading to harbor and manage loved ones in their own homes.14
E ects on Di erent Populations
13.3 Effects on Different Populations
A variety of mental health and psychological factors, similar to those that have been seen historically, are expected to occur during, and after, the current COVID-19 pandemic.15–19 However, unlike in those disease outbreaks, COVID-19 has strained the entire world and has put a lot of stress on many countries. The mental health exacerbations that may be seen now, and after, are not only due to the similar fears and anxieties evoked by the pandemic itself, but also due to the overwhelming stress this pandemic has placed on the health-care system as a whole. Countries such as China, USA, Italy, Iran, and several others that were hit the hardest are nding their populations experiencing psychological distress, including health-care workers, immigrant populations, the elderly, those with underlying mental illness, and many more groups. Thus, it is crucial to understand now who may be at risk for psycho- logical distress and where mental health services need to be directed.
13.3.1 Mental Health in Patients with COVID-19
One population at risk for mental health distress is the patient, who contracts COVID-19. As mentioned before, the fears of spreading the disease and the subse- quent social isolation places those who are exposed and who contract COVID-19 under tremendous emotional strain. In some instances, COVID-19 patients need intensive care unit (ICU)-level care, which creates psychological distress. One study from New York found that of those requiring hospitalization, 14.2% were treated in the ICU and 12.2% received invasive mechanical ventilation.20 ICU-level care, on its own, can create psychological distress. For example, nearly 20% of patients leav- ing an adult critical care exhibited PTSD, which in turn was related to a higher likelihood of persistent sleep disturbances.21,22 A non-COVID-19 study reported that patients admitted to intensive care with acute respiratory distress syndrome, anxiety, depression, and PTSD occurred at high levels during the 2-year follow-up period with relatively low rate of remission of symptoms.23
Subsequently, those who had been exposed to disease or who may have gotten sick from it have been subject to ostracization and xenophobia if geographical link- ages have been placed to the epidemic, leading to increased fear and anxiety among survivors about reintegrating back into society.24 Thus, it is important to take a mul- tidisciplinary approach to treating patients with COVID-19 to ensure the best-qual- ity care that addresses the mental health needs of the patient as well.
13.3.2 Psychological Health in Patients with Mental Illness
Patients with mental illness are one of the most vulnerable groups due to a degree of stigmatization they receive and the degree of deprivation they encounter; this encompasses other factors such as poverty, poor lifestyle factors, environment, and
unemployment. A number of stressors that include quarantine, isolation, hardship, and the lack of psychosocial approaches to alleviate and optimize their mental health can have negative effects on their mental health. Inpatient psychiatric care and management can be complicated by the lack of movement, liberty, and possible bereavement for patients. Community-based care is likely to have very limited face- to-face consultations, and reduced care contact is likely to negatively impact a patient’s mental health and their concordance.
The challenge to pharmacological management becomes increasingly impor- tant during coronavirus. The Royal College of Psychiatrists in the United Kingdom has set out clear channels of support for patients and their carers as well as approaches clinicians should consider.25 The rates of electroconvulsive therapy, for example, a very effective approach to manage certain severe mental illnesses, has fallen in some parts of the world.26 The presence of psychiatric medications in a patient who becomes positive for COVID-19 requires specialist attention to ensure their respiratory and cardiovascular health is not compro- mised. Sedation, respiratory depression, electrocardiogram (ECG) changes, and delirium are some of considerations that will need to be taken into account. People with dementia are at greater risk of suffering from delirium and their aftercare needs, as well as of those with other mental illnesses, are paramount for their rehabilitation. Those that are hospitalized and those that require intensive care will need an approach that covers physical, social, and psychological needs to optimize their well-being.
13.3.3 Psychological Health in Health-Care Workers
Another high-risk population for psychological distress is the health-care workers themselves. The very nature of health-care work and the high pressure and stress situations health-care workers nd themselves in have been known to be psycho- logically taxing with deleterious consequences to their mental health for quite some time now. In disease outbreaks, the psychological stress and toll it takes is ampli- ed. Health-care workers are already a high-risk group for suicide and mental health disorders, in particular female physicians and physicians in the United States being found to be at higher risk in a review.27, 28 One study had found that emergency phy- sicians in the United States were found to have higher rates of PTSD.29
Other health-care workers, like nurses, are also found to be at higher risk of sui- cide and mental health disturbances.30–32 There is evidence within the nursing pro- fession in the United Kingdom, for example, that rates among female nurses are much higher and female health professionals in general are 24% more likely than the national average female.33
During the SARS outbreak, for example, multiple investigations were released on the prevalence of mental health disorders in health-care workers, and they found signi cantly higher rates of post-traumatic stress and psychological disturbances, even years after the epidemic was declared over.10, 11 Similar ndings were reported in health-care workers who had worked though the Ebola epidemic.18
Many have come out warning of the coming psychological impact this pandemic will have on health-care workers, and it is important to remember this group as already a high-risk group for mental disturbances, and so appropriate measures should be taken to address the mental health needs of the health-care working com- munity.34, 35 Two health-care workers in New York City committed suicide from COVID-19-related stress.36
13.3.4 Psychological Health in the General Population
The wide-ranging impact of this pandemic will affect almost everyone, be it directly or indirectly, in ways we may not yet have anticipated. Those with preexisting men- tal health issues, who are themselves at risk for poorer physical health outcomes and may be at higher risk of contracting COVID-19 and faring worse than the general population, are themselves at high risk for psychological distress and at risk for exacerbating their underlying mental health issues, be it due to limited access to medications and providers or due to the effects of social isolation from quarantine.37, 38 Mental health resources before the pandemic were already limited in many coun- tries, and now as more people become affected and are affected on a psychosocial level, those mental health resources will be stretched thin further.
On top of all that, the massive economic impact of this outbreak by itself can lead to massive psychological trauma, as many citizens have lost their jobs, are unable to buy supplies, and are unable to pay their bills, affecting individuals in all age groups on many levels. There is a great risk of increased alcohol and substance misuse dur- ing such times of economic strain, which in turn can lead to increased prevalence of intimate partner violence and domestic abuse.39, 40 Another study on alcoholism was conducted at USC showed the spurt in alcohol sales up to 55% in late March,41 which, in turn, can affect childhood psychological well-being, and is associated with long-term psychiatric distress.42 (Holt 2008). In areas of the world with recent histories of disasters, there is already a higher rate of PTSD, anxiety, and more psy- chological disturbance than can and will be exacerbated by this pandemic.43, 44 With already a high prevalence of mental health disorders around the world, this pan- demic will further worsen the mental health crises that already exist unless we prop- erly anticipate and tackle these issues now.
13.4 Next Steps
Considering the severe impact this pandemic has had and will have on the mental health of so many, it is important to create next steps on how to tackle the “parallel epidemic” of mental health illnesses. We have already seen a great response that comes from the expedited implementation and use of virtual technologies, speci – cally telemedicine, to continue to provide physical and mental health-care ser- vices.45–47 However, these technologies have their limitations, especially when it comes to access to smartphone or broadband technology services, as is seen in the
United States.48 Often the populations who need these services the most have the lowest amount of access to these technologies and services, so special attention needs to be paid in making these resources available to our most vulnerable popula- tions during such a strenuous time.49
In addition, the role of research cannot be underestimated as we try to move past this pandemic and learn from it.45 Many areas for potential research exist, such as assessing the access to and examining the effectiveness of virtual technology services for providing mental health services, evaluating the psychological impact this pan- demic has had on survivors, health-care workers, and the general population at large, and many more possibilities. The important thing is to have learned as much as we can from this pandemic to be able to best respond to the next crisis, whatever that may be.
13.4.1 What you can do (Syed Ashraf Imam, PhD; Clinical Psychologist)
The adverse condition of social isolation and loneliness amid this pandemic around the globe is causing people to live under constant fear, stress, and anxiety, which may lead to hypertension, sugar imbalance, dysfunctional metabolism, chronic medical condition, reduced immunity, and other psycho-physical state of being in a vulnera- ble condition. Simply put, we can experience increased blood pressure, abnormal glucose levels, insomnia, restlessness, skin disease, depression, hopelessness, irrita- bility, aggression, reduced stress tolerance, and onset of other psycho-medical condi- tions detrimental to our well-being and quality of life. The good news is that we may practice simple things to protect and prevent sickness simultaneously boosting our immune strength with some fresh tools to increase stress tolerance and resiliency.
By now, most of us are pretty well educated about the basic preventive measures such as hand-washing, social distancing, sanitization, social group avoidance, and cleaning. But changing and adapting to small activities mentioned below and plan- ning to adhere to them can make positive change.
1. Sleep: Good sleep rejuvenates our mind and body, boosts our immune system, reduces anxiety/fatigue, and improves our capacity to stay healthy and t on a daily basis. Practice good sleep hygiene, and sleep your regular hours to satisfaction as you did prior to this crisis.
2. Breathing Exercise: Relax yourself; sit or lay down comfortably, close your eyes, listen to your breath while you breathe in and out, and feel the bodily changes as you breathe. Diaphragmatic or belly breathing is better than the chest breathing. Inhale from your nose to the count of 5 sec, hold it for 4 sec, and exhale to the count of 7 sec. Repeat 5 cycles to feel the fresh oxygen in your system.
3. Mindfulness: Mindfulness is as simple as being aware of yourself and your being in your surroundings. It can be any act of mind and body exercise that brings us back to consciousness and self-realization. Any religious prayer, meditation, devotional ritual, and focused spiritual exercises accompanying
meditation could be practiced as mindfulness exercise. It enhances our sym- pathetic nerve response by strengthening our brain pathways that strengthen our coping mechanism in case of adverse situations. Practice mindfulness 3–5 times a day.
4. Physical Exercise: It is vital for life: stretches, walking, treadmill, gardening, or other physical activities that suits your taste. Spend at least 30–60 min every day to nurture your strength and resiliency.
5. Nutrition: Balanced diet/food, natural supplements, and vitamins improve health and immune system.
6. Hydration: Drink 3-4 L of plain water at room temperature every day. Water is life and the best drink. Please consult your physician if you have certain medical conditions that restrict/limit the water intake.
7. Healthy Habits: It costs nothing and keeps you strong. Stay away from drugs/ abusive substances, and limit your caffeine. This is an opportune time to get rid of any addiction.
8. Positive Relationship: This is a high time that we focus on building our posi- tive relationship within and beyond our family system. Resolving con icts by amicable means and appropriate discussion; exploring mutual strength and respect; and building bridges of love, cohesion, and bonding.
9. Acceptance and Forgiveness: Acceptance of others as they are and forgive others and/or seeking forgiveness from others brings a reservoir of positive space and energy into our mind. Cleaning up the clutters and debris from the societal bruise such as grudge, hate, shame, and guilt lls the mind with immense positive energy.
10. Unconditional Love: Love is potent and powerful; it has the power to melt the mountain. Love yourself, nature, the creator, your family, your signi cant others, and anything you could imagine. It changes the perspective on how we perceive self and others. Remember, “What goes around comes around.”
11. Mental Health Care: “Media distancing” is the key; limit your time up to 20 min a day to remain updated with the current news. Stay away from tracking mortality and infection spread on an hourly basis. Find out the appropriate app, YouTube videos/programs per your taste that makes you feel better. Share your feelings and emotions with others, and offer them the space where they can do the same; sharing is caring. Be kind to yourself; no crisis stays forever; the days are longer than the nights. Sun comes out every day to spread the sunshine, and embrace it. Ask for and seek professional help; it is not worth suffering in isolation.
12. Kindness: “An act of kindness a day, keep the sickness away.” Make a plan to do at least one act of kindness each day; this could be as simple as making a phone call to your friend, relatives, and neighbors to check on them. Lend them your ear that they can whisper in. Be generous in providing them com- fort, support, and assurance; even verbal support goes a long way.
13. Reading/Journaling/Hobbies: Read the book(s) that you always wanted to but had no time. Reading keeps you up, engaged, and lls your mind with wisdom and intellect. Journaling is very cathartic and healing; relieves one from trauma
of the past and soothes your brain. Put down your thoughts and feelings, your daily experience on the piece of paper and feel the refreshing effect it has. Brush your skill and bring your nostalgia back; get involved in the activities and hobbies you loved in the past or continue to nurture the one that you do.
Last but not the least, set your routine and customize your day based upon the aforementioned tips, track your progress, and make change as needed in conso- nance with your daily activities and responsibilities. Adhere to the discipline and schedule that you set; keep ne tuning it and enjoy. Start your day with a smile and positive attitude; be grateful for what you have and be kind and compassionate to yourself, others, and the world.
At the end, we would like to close with this small recipe to maintain and get along well with our existential “New Normal” called “Sanity Hymn”;
Sanity Hymn
By Syed Ashraf Imam, PhD
Stay away from TV News
Listen to the Radio instead
Do not track Corona religiously
Keep yourself busy; each day is a new day
Set your goal each day & stay focused
We have plenty to do & achieve
Love & protect yourself; you mean a lot
Love your family; they are yours forever
Adore your Parents; they are most precious
Have solid Faith; it matters
Pray as much as is feasible
Check on your relatives and friends
Give charity if you have cushion
Be grateful to God for what you have
Count on Blessings not on misery
Start your day and continue with Smile;
It releases feel-good Neurotransmitters— Dopamine, endorphins and serotonin, the Stress Busters Smile optimizes Blood Pressure & Heart Rate
Eat & Drink healthy Walk/Stretch/Exercise daily
Watch funny, humorous movies
Listen to what soothes your ears
Stay with the Nature, breath fresh
Look at animals/birds and observe their behavior Trust yourself and the destiny
Take life as it comes, keep it simple & easy
Live for today, tomorrow is gonna be ne
Do whatever lightens & brightens the mood Cheers!
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42. Ćosić K, Popović S, Šarlija M, Kesedžić I. Impact of human disasters and COVID-19 pan-
demic on mental health: potential of digital psychiatry. Psychiatr Danub. 2020;32(1):25–31.
43. Jalloh MF, Li W, Bunnell RE, et al. Impact of Ebola experience and risk perceptions on mental health in Sierra Leone, July 2015. BMJ Glob Health. 2018;3(2):e000471.
44. Valentino LA, Skinner MW, Pipe S. The role of telemedicine in the delivery of healthcare in the COVID-19 pandemic [published online ahead of print May 12, 2020]. Haemophilia. https://doi.org/10.1111/hae.14044.
45. Jones MS, Goley AL, Alexander BE, et al. Inpatient transition to virtual care during COVID- 19 pandemic [published online ahead of print May 12, 2020]. Diabetes Technol Ther. https:// doi.org/10.1089/dia.2020.0206.
46. Pew Research Center. Mobile technology and home broadband 2019. Published June 13, 2019. https://www.pewresearch.org/internet/2019/06/13/mobile-technology-and-home- broadband-2019/.
47. Fang ML, Canham SL, Battersby L, et al. Exploring privilege in the digital divide: implica- tions for theory, policy, and practice. Gerontologist. 2019;59(1):e1–e15.
48. Rajasekaran K. Access to telemedicine—are we doing all that we can during the COVID-19 pandemic [published online ahead of print May 5, 2020]. Otolaryngol Head Neck Surg. https:// doi.org/10.1177/0194599820925049.
49. Polakovic G. Pandemic drives alcohol sales—and raises concerns about substance abuse. USC News. https://news.usc.edu/168549/covid-19-alcohol-sales-abuse-stress-relapse-usc-experts/. Published April 14, 2020. Accessed June 14, 2020.
Pediatric Manifestations of COVID-19
Ishrat Quadri M.D. and Nicholas Barresi M.D.
AAP American Academy of Pediatrics
ACE2 Angiotensin-converting enzyme 2
CDC Centers for Disease Control and Prevention
CRP C-reactive protein
GI Gastrointestinal infection
IBI Invasive bacterial infection
IL-10 Interleukin 10
IgM Immunoglobulin M
PCR Polymerase chain reaction
PIMS-TS Pediatric In ammatory Multisystem Syndrome temporally
The data available at this time demonstrates clear and important differences in coro- navirus disease 2019 (COVID-19) infection in children versus adults. It has been shown that COVID-19 affects pediatric patients less frequently than the adult popu- lation and, when infection takes place, the disease is milder and the prognosis is better. In the United States, from February 12 to April 2, 2020, Centers for Disease Control and Prevention (CDC)-gathered data reports that only 1.7% of COVID- positive patients were children aged <18 years.1 This is reassuring to pediatricians because, in fact, 22% of the US population is <18 years old.2 Additionally, of the COVID-positive children in the United States, about half (49%) were in the age
Chapter 14: Pediatric Manifestations of COVID-19
range of 10–17, the median age was 11 years, and 15% of positive children were infants <1 year.1 Also of note, 91% of these pediatric patients had exposure to a COVID-19 patient in the household or community.1
Just as the infectivity differs in the pediatric community, so too do the clinical mani- festations. The most common presenting symptoms in children were cough and fever, but at a less frequent rate than in adults. In the aforementioned CDC report, 73% of COVID pediatric patients had symptoms of fever, cough, or shortness of breath—which is less than the 93% of adults aged 18–64 years who presented with these symptoms during the same period.1 This goes to show that children may be COVID-positive and shedding the virus, but only display mild cold symptoms (con- gestion, rhinorrhea, sneezing) without cough and fever. In fact, available data from China suggests that pediatric patients may have more upper respiratory tract mani- festations and nasopharyngeal carriage, as opposed to lower respiratory tract involvement.3 Therefore, it may be even more important for children to social dis- tance during this pandemic because of the insidious and mild nature of COVID-19 illness in this age group—especially when coupled with the fact that children typi- cally have undeveloped personal hygiene habits.
Other symptoms that providers should be aware of in children include pharyn- geal erythema (which was present in 46% of pediatric cases in Wuhan Children’s Hospital4) as well as fatigue, conjunctivitis, diarrhea, and vomiting. In fact, some children presented only with gastrointestinal symptoms.5 The Pediatric Infectious Disease Journal reports that children have been shown to have gastrointestinal infection (GI) complaints in up to 57% of human coronavirus infections (including COVID-19), which is more common than in adults.6
As mentioned, the prognosis also seems to differ for children. Available data in the United States shows that 5.7–20% of COVID-positive children were hospital- ized.1 Ostensibly, this is a lower rate than adults aged 18–64 years, of whom 10–33% of COVID-positive patients were hospitalized.1 Intensive care unit (ICU) admis- sions were also less in the pediatric world: 0.58–2.0% (children) versus 1.4–4.5% (adults).1 This is all to say that infected children seem to have a more mild presenta- tion and clinical course. In fact, most children will recover within 1–2 weeks from symptom onset.4
This being said, the age of the child potentially has an impact on the prognosis. Initial Chinese data shows somewhat of a trend between severity of disease with younger age. The widely referenced study from Dong et al., a series of over 2000 children with suspected or con rmed COVID-19, reported that the proportion of severe and critical cases was 10.6 %, 7.3%, 4.2%, 4.1%, and 3.0% for the age group of <1, 1–5, 6–10, 11–15, and ≥16 years, respectively.5 Therefore, closer follow-up and management is warranted of younger children—with particular attention to infants <1 year.
Newborn and Infant Considerations
Likewise, special attention is necessary for children with underlying medical conditions. The CDC details that among 345 children with con rmed COVID-19 and data on underlying conditions, 23% had at least one comorbidity—most com- monly moderate-to-severe asthma, cardiovascular disease, immunosuppression, diabetes, and severe obesity with BMI ≥40 kg/m2.1 This CDC report also states: “Among the 295 pediatric cases for which information on both hospitalization sta- tus and underlying medical conditions was available, 28 of 37 (77%) hospitalized patients, including all six patients admitted to an ICU, had one or more underlying medical condition.”1 Lastly, there were three pediatric deaths in this report, but investigation is still necessary to con rm COVID-19 as the cause.1
14.3 Newborn and Infant Considerations
14.3.1 Mother-to-Child (Vertical) Transmission
At this point, COVID-19 has not been detected in cord blood, amniotic uid, or placenta. A study in China has shown maternal viremia levels to be only 1%.7 With low levels of the virus in maternal blood, placental seeding and vertical transmis- sion are unlikely.8 In a review of 51 pregnant women with COVID-19, there were no cases of intrauterine transmission documented.8 However, there have been reports of infants having positive nasopharyngeal cultures on days 1 or 2 of life, as well as an increased immunoglobulin M (IgM) level.8 Nevertheless, IgM studies are known to be a challenging and unreliable way to diagnose many congenital infections. According to a study by Kimberlin et al., “IgM assays can be prone to false-positive and false-negative results, along with cross-reactivity and testing challenges.”9 Moreover, these early infant infections could have been due to postnatal contact with infected caregivers.8 In sum, more de nitive evidence is needed regarding COVID-19 and vertical transmission.
In terms of delivery outcomes of pregnant women with COVID-19 pneumonia, a study of nine such livebirths provides some valuable information. Reassuringly, these 9 newborns all had 1-min Apgar scores of 8–9 and a 5-min Apgar score of 9–10.10 Also, the amniotic uid, cord blood, neonatal throat swab, and breast milk samples from six of these patients were tested for the virus, and all samples were negative.10
14.3.2 Breastfeeding
The previously mentioned study also has implications for breastfeeding. To reiter- ate, none of the six COVID-positive mothers had the virus detected in their breast milk. Nevertheless, clearly droplet transmission could occur through the close con- tact of breast- or bottle-feeding. Therefore, it is currently advised that mothers with con rmed or suspected infection take precautions to prevent transmission during
feeds: hand hygiene and use of a facemask.11 The other option is to feed the infant expressed breast milk or formula by another healthy caregiver until the mother has recovered.11 If the mother chooses to pump breast milk, she should wash her hands beforehand and wear a mask during breastfeeding. Optimally, the pumping equip- ment should be thoroughly cleaned by a healthy person.11
14.4 Prevention
It is well known that children play a key role in community-based viral transmission, and this may be further augmented in the case of COVID-19 because they have more mild disease that is likely to go undetected, as well as more nasopharyngeal carriage and upper respiratory involvement. Children also have more gastrointestinal symptoms from COVID-19 compared with adults,6 and there has even been evidence of fecal shedding in the stool for several weeks after diagnosis.12 From a public health stand- point, the potential fecal–oral transmission of the virus (and its replication in the GI tract) is especially concerning for infants and children who are not toilet-trained.13
In terms of disease prevention during this pandemic, many pediatricians are being asked the same questions—which we will address here. Alcohol-based hand sanitizer is safe for children when used according to the information on the Drug Facts label: “there is no cause for concern if children eat or lick their hands after the hand sanitizer has fully dried.”14 However, it should be kept out of reach of small children and those <6 years of age should be supervised when using the sanitizer.14 In terms of masks, the CDC recommends cloth face coverings in public places, but they are not recom- mended for children <2 years of age because of concerns about suffocation.
14.5 Diagnosis
The requirements for COVID-19 testing in the pediatric ambulatory setting vary geographically, but generally do not differ from the adult guidelines. Therefore, in the United States, pediatric testing should follow the CDC’s “Priority 1-3” schema: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html. Of note, asymptomatic children, regardless of high-risk medical conditions or household contacts, should not be tested. There are many clinical pathways for screening of children during the pandemic, but we will include the algorithms posted by the Children’s Hospital of Philadelphia:
• Ambulatory Setting: https://www.chop.edu/clinical-pathway/2019-novel- coronavirus-ambulatory-clinical-pathway.
• Inpatient Setting: https://www.chop.edu/clinical-pathway/recommendations- sars-cov-2-testing-clinical-pathway.
Children with fever and no other symptoms are not a high-priority group for COVID testing according to the CDC. However, infants with isolated fever admitted
to rule out invasive bacterial infection (IBI) could also be tested for COVID-19 because young infants have been COVID-positive with fever as their only manifesta- tion.15 Testing this group would also stop potential spread of the virus in the hospital.
In regard to auxiliary testing, laboratory ndings are often normal in pediatric COVID-positive patients, but may include leukopenia, lymphocytopenia, and increased level of procalcitonin or C-reactive protein (CRP).16 In terms of imaging, pediatric chest radiographs vary from unremarkable to bilateral consolidation,17 and imaging ndings may even be present before symptom onset.18
14.6 Management
If the child has suspected or con rmed COVID-19 infection, has mild symptoms, and does not have any of the aforementioned comorbidities, he or she should be managed at home.16 The recommended at-home supportive care is similar for any other viral respiratory illness with a heightened focus on prevention of transmission to others. There should be close follow-up with these patients. Monitor for any signs of clinical deterioration, which in infants could manifest itself as central cyanosis, grunting, or dif culty with breast-/bottle-feeding.
Below are some useful links from the American Academy of Pediatrics (AAP) to provide to families during the pandemic:
• “Simple Ways to Entertain & Boost Your Baby’s Development at Home”:
https://www.healthychildren.org/English/health-issues/conditions/chest- lungs/Pages/Simple-Ways-to-Entertain-and-Boost-Your-Babys- Development-at-Home.aspx
• “Social Distancing: Why Keeping Your Distance Helps Keep Others Safe”:
https://www.healthychildren.org/English/health-issues/conditions/chest- lungs/Pages/Social-Distancing-Why-Keeping-Your-Distance-Helps-Keep- Others-Safe.aspx
• “Breastfeeding During COVID-19 Pandemic”: https://www.healthychildren. org/English/ages-stages/baby/breastfeeding/Pages/Breastfeeding-During- COVID-19.aspx
• “Getting Children Outside While Social Distancing for COVID-19”: https:// http://www.healthychildren.org/English/health-issues/conditions/chest-lungs/ Pages/Getting-Children-Outside.aspx
• “Parenting in a Pandemic: Tips to Keep the Calm at Home”: https://www. healthychildren.org/English/family-life/family-dynamics/communication- discipline/Pages/Positive-Parenting-and-COVID-19_10-Tips.aspx
• “COVID-19: Information for Families of Children and Youth with Special Health Care Needs”: https://www.healthychildren.org/English/health-issues/ conditions/chest-lungs/Pages/COVID-19-Information-for-Families-of- Children-and-Youth-with-Special-Health-Care-Needs.aspx
14.6.2 Inpatient
“Severe” COVID-19 infection, according to Chiotos et al., is de ned as “a new signi cant requirement for supplemental oxygen (or an increased requirement from baseline) without the need for new or increased non-invasive or invasive mechanical ventilation.”19 It has been described that this group tends to recover with supportive care alone—which is generally considered the mainstay of treatment for COVID-19 in children.16
Chiotos et al. de ne “critical” disease in a child with “new or increased require- ment for invasive or non-invasive mechanical ventilation, sepsis, or multi-organ failure; or rapidly worsening clinical trajectory that does not yet meet these crite- ria.”19 This group generally has failed supportive therapy to some extent and, there- fore, could bene t from antiviral medication.19 The Pediatric Infectious Disease Society has endorsed the Chiotos et al.’s report, which has a nal recommendation of the following: “A decision-making framework for antiviral therapy that weighs risks and bene ts based on disease severity as indicated by respiratory support needs, with consideration on a case-by-case basis of potential pediatric risk factors for disease progression.”19 If antiviral is indicated, then remdesivir is the preferred agent.19 Hydroxychloroquine could also be considered if remdesivir is contraindi- cated or unavailable.19
There are many clinical pathways regarding the inpatient treatment of children during the pandemic, but we will include the algorithms posted by the Yale New Haven Children’s Hospital:
• Link #1: https://www.ynhh.org/childrens-hospital/medical-professionals/ clinical-pathways.aspx
• Link #2: (navigate to the “Pharmacologic Treatment” tab) https://www.lucid- chart.com/documents/embeddedchart/7a86fcb7-d313-4313-bd66-f069517fbda6
14.7 Discussion
From a pathophysiologic perspective, why do children have lower frequency of infection and more mild disease from COVID-19? This very important clinical question can and should propel our research forward in order to help us to understand more about this virus and its infectivity. Current theories include a less intense immune/cytokine response from children toward the virus as opposed to adults,20 an interference in respiratory epithelium of young children that causes a lower viral load,16 or perhaps that the angiotensin-converting enzyme 2 (ACE2) receptor is expressed differently in the respiratory tract of children versus adults.21
From a public health standpoint, we would like to address school and daycare openings. These decisions are clearly very dif cult, but those responsible ought to be informed of the differences of this virus in children versus adults. A
Update 1: Pediatric Multisystem In ammatory Syndrome Potentially Associated with COVID-19
decision based on general population data alone would discount the impact that children have as vectors for this virus and could potentially risk another rise of this pandemic. Children have a more insidious nature of active disease, because it is milder, tends to have more upper-respiratory and gastrointestinal involve- ment, and is less likely to present with fever and cough than in adults. The risk of transmission in the community is compounded by children who are not toilet- trained or have underdeveloped personal hygiene habits. Therefore, children are both more likely to be unknowingly sent out of the home while shedding the virus and more likely to spread it while away. Of course, decisions of this mag- nitude must be weighed against the economic burden on families and nations. Moreover, it is self-evident that schools are fundamental to child development and well-being, which also must be considered when planning the timing for school re-entry.
Lastly, we must qualify the data presented in this chapter by stating that all of the referenced studies and reports have their limitations given the newness and acuteness of this crisis. Our knowledge of this virus is limited and evolving daily. We hope this summary acts as a springboard for future research and investigation.
14.8 Update 1: Pediatric Multisystem Inflammatory Syndrome Potentially Associated with COVID-19
There is a rising concern in the pediatric community regarding a potential multi- system in ammatory disease that is related to COVID-19. On April 27, 2020, the Paediatric Intensive Care Society of the UK released a statement about a “small rise in the number of cases of critically ill children presenting with an unusual clinical picture.”22 This alert described pediatric patients presenting with clinical manifestations similar to toxic shock syndrome and atypical Kawasaki disease “with blood parameters consistent with severe COVID-19 in children.”22 These parameters appear to be high CRP, high erythrocyte sedimentation rate (ESR), and high ferritin.22 The report continued: “Abdominal pain and gastrointestinal symptoms have been a common feature as has cardiac in ammation.”22 The latter may present as myocarditis with increased levels of troponin and pro-BNP, and may even “have an appearance of their coronary arteries in keeping with Kawasaki disease.”22
The Royal College of Paediatrics and Child Health later provided the following case de nition for this multisystem in ammatory syndrome:23
1. “A child presenting with persistent fever, in ammation (neutrophilia, elevated CRP and lymphopenia) and evidence of single or multiorgan dysfunction (shock, cardiac, respiratory, renal, gastrointestinal, or neurological disorder) with additional features. This may include children ful lling full or partial criteria for Kawasaki disease.”23
2. “Exclusion of any other microbial cause, including bacterial sepsis, staphylo- coccal or streptococcal shock syndromes, infections associated with myocar- ditis such as enterovirus (waiting for results of these investigations should not delay seeking expert advice).”23
3. “Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing may be positive or negative.”23
On May 4, 2020, the New York City Health Department released a similar state- ment describing 15 pediatric cases (aged 2–15 years) compatible with this same disease in New York City hospitals. According to this report, “All patients had sub- jective or measured fever and more than half reported rash, abdominal pain, vomit- ing, or diarrhea.” Of note, respiratory symptoms were reported in less than half of these patients. In these cases, PCR results for SARS-CoV-2 also varied. Therefore, the International PICU-COVID-19 Collaboration now refers to this emerging syn- drome as “Pediatric Multi-System In ammatory Syndrome Potentially Associated with COVID-19,”24 and they have laid out some key takehome points:24
• “The disease is rare.”24
• “Clinicians who suspect a case should consult promptly with pediatric infec-
tious disease, rheumatology, or critical care specialists.”24
• “Because some children get sicker rapidly, they should be cared for in hospi-
tals with tertiary pediatric/cardiac intensive care units.”24
• “Laboratory evaluation should include the measurement of sequential in am-
matory markers, including complete blood count/differential, CRP, ESR; coagulation parameters, including D-dimer and ferritin; liver function mark- ers; and a cytokine panel. Children should have antibody testing in addition to PCR testing for SARS-CoV-2, since many children are antibody-positive even when PCR-negative.”24
• “Children with this syndrome should have serial echocardiograms, including a detailed assessment of the coronary arteries. Many to date have been found to have low heart function, and some have enlargement of the coronary arter- ies. Children with serious cardiac complications should be followed longer term.”24
Why this is occurring is largely unexplained. There is speculation that this syndrome is due to an acquired immune response to COVID-19, but it is still a mystery at this point. In regard to an etiology, cardiologist and international expert on Kawasaki disease Jane Newburger, MD, MPH states: “If you look at the curves, COVID-19 has plateaued, but there’s an exponential rise in this sec- ondary type of shock syndrome…It is even possible that the antibodies that chil- dren are making to SARS-CoV2 are creating an immune reaction in the body. Nobody knows.”24
More research on this topic is both necessary and forthcoming. For now, it is important that health-care providers be aware of the existence of this disease in children—particularly during this time of pandemic.
Update 2: July 1, 2020
14.9 Update 2: July 1, 2020
Here, we will provide the key pediatric updates to this ever-evolving pandemic cri- sis. We will list the updates in bullet-point form and provide links to important websites and articles.
Last updated on 6/25/2020, the AAP has issued the following statement regarding guidance for school re-entry: “…the AAP strongly advocates that all policy considerations for the coming school year should start with a goal of hav- ing students physically present in school. The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in the spring of 2020.”25 The full AAP docu- ment outlines social distancing and mask use at schools, testing and temperature checks at schools, as well as bussing, cafeteria/mealtime, and playground recom- mendations. The full statement can be found here: https://services.aap.org/en/ pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/ covid-19-planning-considerations-return-to-in-person-education-in-schools/).
Published June 8, 2020, the investigation by Whittaker et al outlines the clinical characteristics of children with Pediatric In ammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS). This was a case series of 58 children admitted to eight different hospitals in England. Brie y, the major results were as follows: “Of these children, all had fever and non-speci c symptoms, such as abdominal pain (31[53%]), rash (30[52%]), and conjunctival injection (26[45%]); 29(50%) developed shock and required inotropic support or uid resuscitation; 13(22%) met diagnostic criteria for Kawasaki Disease; and 8(14%) had coronary artery dilatation or aneurysms.”26 Thus, the key takeaways here are that children with this disease have a wide range of signs, symptoms, and severity and that, when you compare PIMS-TS to Kawasaki disease and Kawasaki disease shock syndrome, you nd that this disorder is unique from other pediatric in ammatory entities. For more information on how, visit the full JAMA article here: https://jamanetwork. com/journals/jama/fullarticle/2767209.
Published in JAMA on June 3, 2020, the case series investigation by Wu et al provides our newest data from Wuhan—with particular attention given to the immu- nologic features of pediatric patients with COVID-19. The full text can be found here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766670.
In brief sum, they examined 157 pediatric patients with COVID-19 and found that systemic inflammation rarely occurred, which importantly is differ- ent from the aggravated inflammatory responses often seen in adults with COVID-19.27 https://pccsociety.uk/covid19/ They also found that moderate dis- ease had higher interleukin 10 (IL-10) levels and lower neutrophil levels than patients with more mild disease. They concluded: “The results of this study suggest that dysregulation of immune response may be involved in the patho- logic process of COVID-19; gaining a deeper understanding of the role of neu- trophils, CD4+ T cells, and B cells in the pathogenesis of severe acute respiratory syndrome coronavirus 2 infection could be important for the clini- cal management of COVID-19.”27
1. CDC COVID-19 Response Team. Coronavirus disease 2019 in children – United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:422.
2. The 2019 United States Census. Populatation estimate. July 1, 2019. https://www.census.gov/ quickfacts/fact/table/US/PST045219. Accessed April 23, 2020.
3. Cruz A, Zeichner S. COVID-19 in children: initial characterization of the pediatric disease. Pediatrics. 2020. https://doi.org/10.1542/peds.2020-0834.
4. Lu X, Zhang L, Du H, et al. SARS-CoV-2 infection in children. N Engl J Med. 2020.
5. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics.
6. Zimmermann P, Curtis N. Coronavirus infections in children including COVID-19. Pediatr
Infect Dis J: May 2020;39(5):355–368. https://doi.org/10.1097/INF.0000000000002660.
7. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of clinical speci-
mens. JAMA. 2020.
8. Berghella, V, Lockwood, C, Barss, V. Coronavirus disease 2019 (COVID-19): pregnancy
issues. In: UpToDate. April 22, 2020.
9. Kimberlin DW, Stagno S. Can SARS-CoV-2 infection be acquired in utero?: more de nitive
evidence is needed. JAMA. 2020.
10. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission
potential of COVID-19 infection in nine pregnant women: a retrospective review of medical
records. Lancet. 2020;395:809.
11. Academy of Breastfeeding. ABM Statement on Coronavirus 2019. March 10, 2020. https://
http://www.bfmed.org/abm-statement-coronavirus. Accessed April 23, 2020.
12. Cai J, Xu J, Lin D, et al. A case series of children with 2019 novel coronavirus infection: clini- cal and epidemiological features [published online ahead of print February 28, 2020]. Clin
Infect Dis. 2020. https://doi.org/10.1093/cid/ciaa198.
13. Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for gastrointestinal infection of SARS-
CoV-2 [published online ahead of print March 3, 2020]. Gastroenterology. 2020;158(6):1831–
1833. https://doi.org/10.1053/j.gastro.2020.02.055.
14. US Food and Drug Administration. Q & A for consumers: hand sanitizers and COVID-19.
Available at: https://www.fda.gov/drugs/information-drug-class/qa-consumers-hand-sanitiz-
ers-and-covid-19. Accessed April 14, 2020.
15. Paret M, Lighter J, Pellett Madan R, et al. SARS-CoV-2 infection (COVID-19) in febrile
infants without respiratory distress. Clin Infect Dis. 2020.
16. Edwards M, Kaplan S, Torchia M. Coronavirus disease 2019 (COVID-19): considerations in
children. In: UpToDate. April 24, 2020.
17. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China.
N Engl J Med. 2020;382:1708–1720.
18. Hu Z, Song C, Xu C, et al. Clinical characteristics of 24 asymptomatic infections with COVID-
19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020;63(5):706–711.
19. Chiotos K, Hayes M, Kimberlin DE, et al. Multicenter initial guidance on use of antivirals for children with COVID-19/SARS-CoV-2. J Pediatric Infect Dis Soc. 2020. Available at: https://academic.oup.com/jpids/article/doi/10.1093/jpids/piaa045/5823622?searchresult=1.
Accessed April 22, 2020.
20. Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and
immunosuppression. Lancet. 2020;395:1033.
21. Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better
prognosis than adults. Acta Paediatr. 2020;109(6):1088–1095.
22. Pediatrics Critical Care Society. Statement on Critical Care of Children with COVID-19.
https://pccsociety.uk/covid19/ note: link is not working. Accessed May 20, 2020.
23. Royal College of Pediatrics and Child Health. Guidance Pediatric Multisystem In ammatory Syndrome Temporally Associated with COVID-19. https://www.rcpch.ac.uk/sites/ default/files/2020-05/COVID-19-Paediatric-multisystem-%20inflammatory%20syn- drome-20200501.pdf. Accessed May 20, 2020.
24. Fleise N. COVID-19 and a Serious In ammatory Syndrome in Children: Unpacking Recent Warnings. Boston Children’s Hospital. May 8, 2020. Boston, MA. Accessed May 20, 2020.
25. American Academy of Pediatrics. COVID-19 Planning Considerations: Guidance for School Re-entry. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clin- ical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools. Accessed June 27, 2020.
26. Whittaker E, Bamford A, Kenny J, et al. Clinical characteristics of 58 children with a pedi- atric in ammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA. Published online June 08, 2020. https://doi.org/10.1001/jama.2020.10369.
27. Wu H, Zhu H, Yuan C, et al. Clinical and immune features of hospitalized pediatric patients with coronavirus disease 2019 (COVID-19) in Wuhan, China. JAMA Netw Open. 2020;3(6):e2010895. https://doi.org/10.1001/jamanetworkopen.2020.10895.
Radiology of Chest Imaging in COVID-19
Vineet R. Jain M.D., Naiyer Imam M.D.,
ARDS CMR COVID-19 CT
CXR MERS MRI RSNA RT-PCR SARS WHO
Acute respiratory distress syndrome Cardiovascular magnetic resonance Coronavirus disease 2019 Computed tomography
Middle East respiratory syndrome
Radiological Society of North America
Reverse transcription polymerase chain reaction Severe acute respiratory syndrome
The rst two decades of the 21st century have been marked by the emergence of three novel coronal viral illnesses with an unique set of systemic clinical and radio- logical manifestations: severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and coronavirus disease 2019 (COVID-19). In this chapter, we brie y touch on the radiological ndings of SARS and MERS, and discuss the common radiological manifestations of COVID-19.
15.2 Radiological Manifestations of SARS and MERS
SARS and MERS are known to have an abnormal initial chest screening in at least 80% of infected patients. In SARS, early ndings include ground-glass opaci ca- tion or consolidations, which are predominantly ill-de ned, unilateral, peripherally distributed with a propensity for the lower lung zones. The abnormalities are focal
Chapter 15: Radiology of Chest Imaging in COVID-19
in 50% of cases, multifocal in 40%, and diffuse in 10%. As SARS progresses, the ndings become progressively multifocal and spread bilaterally over the course of 2 weeks. In one-fourth of patients, ndings can remain focal or unilateral. Computed tomographic scan (CT) ndings typically demonstrate interstitial ground-glass opacity early in the course of disease.2
In MERS, initial radiographic ndings include ground-glass opaci cation or consolidations, which are predominantly ill-de ned, multifocal, and within the lower lung zones. The opacities may extend to perihilar and upper lobes as the dis- ease continues. As in SARS, CT for MERS also typically demonstrates ground- glass opacities in the basilar and peripheral lung zones, interlobular septal thickening, air-space consolidation, and rarely, pleural effusions. After recovery, patients with disease can suffer from instances of brosis.1, 2, 3
Studies comparing SARS, MERS, and COVID-19 have found signi cant simi- larities with some differences. All three diseases upon initial presentation to hospi- tals are found to have abnormal initial lung chest X-ray ndings in at least 69%–85% of patients. Common radiographic and CT ndings include ill-de ned ground-glass opaci cation or consolidation with a propensity of the disease to be peripheral and basilar. Pneumothorax, cavitation, and pleural effusions are rare. Similarities also include a disease progression toward multifocal airspace consolidation and acute respiratory distress syndrome (ARDS) with worsening of pulmonary disease. Notable differences between SARS, MERS, and COVID-19 include the greater likelihood of bilateral and multifocal lung involvement earlier with MERS and COVID-19 as compared with SARS. Table 15.1 summarizes some clinical and ini- tial hospital radiological presentations of these diseases.2 We will discuss the radio- graphic and computed tomographic ndings of COVID-19 in greater detail in subsequent sections.
15.3 Radiological Findings of COVID-19
15.3.1 Chest X-Rays (CXR)
Chest radiographs may show no abnormality with mild or early infection with SARS-CoV-2. With progression of pulmonary infection, hazy interstitial opacities often with ground-glass appearance develop. These tend to be of bilateral, periph- eral, and basilar predominance. This distribution of this opacity is similar to that demonstrated on CT but is more dif cult to detect, requiring careful scrutinization. Airspace consolidation may also develop and present as denser areas of opacity. Worsening of lung disease may lead to an ARDS. The presence of a signi cant pleural effusion is uncommon.
One study from Hong Kong evaluated the radiographs of 64 COVID-19 patients admitted to a hospital. This study showed that baseline chest radiography was posi- tive in 69% of patients as compared to 91% for initial reverse transcription
Radiological Findings of COVID-19
Table 15.1 Brief Summary of Clinical & Radiological Presentations of Novel Coronaviruses. Radiology Perspectives of COV 19, Lessons Learned, AJR May 20202
Feature SARS MERS COVID-19
Clinical Sign or Symptom
Fever or chills Yes Yes Yes
Dyspnea Yes Yes Yes
Malaise Yes Yes Yes
Myalgia Yes Yes Yes
Headache Yes Yes Yes
Cough Dry Dry or productive Dry
Diarrhea Yes Yes Uncommon
Nausea or Yes Yes Uncommon vomiting
Sore throat Yes Uncommon Uncommon
Arthralgia Yes Uncommon
Imaging nding
Initial imaging
Normal 15–20% of patients 17% of patients 15–20% of patients
Peripheral multifocal airspace opacities (GGO, consolidation, or both) on chest radiography and CT
Rare Pneumothorax Pneumothorax Pneumothorax
Not seen Cavitation or Cavitation or Cavitation or lymphadenopathy lymphadenopathy lymphadenopathy
Appearance Unilateral, focal (50%); multifocal (40%); diffuse
Bilateral, multifocal basal airspace on chest radiography or CT (80%); isolated unilateral (20%)
Bilateral, multifocal, basal airspace; normal chest radiography ndings (15%)
Follow-up imaging appearance
Unilateral, focal (25%); progressive (most common, can be unilateral and multifocal or bilateral with multifocal consolidation)
Extension into upper lobes or perihilar areas, pleural effusion (33%), interlobular septal thickening (26%)
Persistent or progressive airspace opacities
Indications of poor prognosis
Bilateral (like ARDS), four or more lung zones, progressive involvement after 12d
Greater involvement of the lungs, pleural effusion, pneumothorax
Consolidation (vs. GG0)
Chronic phase
Unknown, but pleural effusion and interlobar septal thickening have not yet been reported
Transient reticular opacitiesa
Airtrapping
Common (usually persistent)
One-third of patients
Not yet reported
Table 15.1 (continued)
ARD, acute respiratory distress syndrome; COVID-19, coronavirus disease 2019; GG0, ground-glass opacity; MERS, Middle East respiratory syndrome; SARS, severe acute respiratory syndrome.
aOver a period of weeks or months.
polymerase chain reaction (RT-PCR) test for COVID-19 and that chest radiographic abnormalities preceded a positive RT-PCR test in only 9% of patients. Additionally, the study demonstrated that the worst interstitial opacity on CXR occurred 10–12 days after the onset of respiratory symptoms.4
Another study evaluated the initial chest radiographs of 636 COVID-19 patients at urgent care centers in New York City and New Jersey. This study demonstrated that 42% of the initial chest radiographs on these patients were positive. As may be expected, patients presenting to urgent care centers are less sick than patients pre- senting to hospitals, and a higher percentage of chest radiographs may be normal in outpatient settings.5
Another study performed in New York City evaluated 338 young and middle- aged adults (between ages 21 and 50 years) who presented to the emergency room with a positive test for COVID-19 on RT-PCR. The authors focused on correlating initial radiographic ndings with hospitalization and intubation.6 They divided the lungs into 6 zones: a lower zone, middle zone, and upper zone on each side. Each lung zone was given a binary score with airspace opacity present equaling 1 and absence of airspace opacity equaling 0. The maximum score possible was therefore 6. They found that a chest radiograph severity score greater than or equal to 2 was
Figure 15.1 Middle-aged female presented with nausea, vomiting, and cough, and diagnosed by RT-PCR with COVID-19. Top image shows an initial chest radiograph with mild bilateral ground-glass airspace opacity. Bottom image shows the follow-up chest radiograph 3 days later. There is now worse denser more consolidative airspace opacity within the bilateral lungs.
associated with hospital admission and that among these patients, a chest radio- graph severity score greater than or equal to 3 was an independent predictor of the patient becoming intubated (Figure 15.1).6
15.3.2 Computed Tomography
The Fleischner Society is an international multidisciplinary medical society for tho- racic radiology and has made a glossary of terms for thoracic imaging. According to their glossary, the term “ground-glass opacity” is an area of hazy increased lung opacity within which margins of pulmonary vessels may be indistinct.7 On CT, it appears as hazy increased opacity of the lung with preservation of bronchial and vascular margins. Ground-glass opacity is less opaque than consolidation, in which bronchovascular margins are obscured.
On CT, early COVID-19 pneumonia characteristically presents as interstitial, ground-glass opacity most often rounded with bilateral, peripheral, and basilar pre- dominance. A crazy-paving pattern has also been described. According to the Fleischner Society glossary, a crazy-paving pattern appears as thickened interlobu- lar septa and intralobular lines superimposed on a background of ground-glass opacity resembling irregularly shaped paving stones.7 Additionally, a reversed halo sign may be present. A reversed halo sign is a focal rounded area of ground-glass opacity surrounded by a ring of consolidation.7 There may represent areas of micro- vascular dilatation within areas of ground-glass opacity.8 With progression of lung disease, airspace consolidations may develop. Finally, in later stages, ARDS may develop, often leading to intubation. Imaging ndings not typical of COVID-19 pneumonia include isolated lobar or segmental consolidation, numerous small nod- ules, pulmonary parenchymal cavitation, a signi cant pleural effusion, and promi- nent mediastinal lymphadenopathy.
It is important to keep in mind that very early in the course of disease, CT chest may be normal. One retrospective study evaluated 121 symptomatic patients infected with SARS-CoV-2 based on RT-PCR from four centers in China during the months of January and February 2020.9 This study evaluated common CT ndings in relation- ship to the time between onset of patient symptoms, typically fever and/or cough, and time of initial CT. Early phase was de ned as a CT performed within the rst 2 days of onset of symptoms, intermediate phase was de ned as a CT performed between 3 and 5 days of onset of symptoms, and late phase was de ned as a CT performed between 6 and 12 days of onset of symptoms. 56% of patients who were imaged with CT in the early phase had a normal chest CT. With a longer time period between the onset of symptoms and the initial CT, typical CT ndings of COVID-19 pneumonia were more often present. Bilateral lung disease was demonstrated in 28% of patients imaged during the early phase of disease, 76% of patients imaged during the interme- diate phase of disease, and 88% of patients imaged during the late phase of disease.
On the other hand, it is also known that CT ndings may be present preceding symptom onset. One study evaluated chest CT ndings of 104 people who tested positive for COVID-19 with RT-PCR who were on board the cruise ship “Diamond Princess” which had docked in Japan.10 73% (76/104) of infected persons were asymptomatic, and 54% (41/76) of these people had opacities in the lungs on CT. There was more ground-glass opacity than consolidation in these people and milder extent of lung opacities compared with those who had symptomatic infection.
Salehi et al reported on the CT ndings of COVID-19 pneumonia utilizing an extensive literature search of PubMed, Embase (Elsevier), Google Scholar, and World Health Organization databases.11 919 patients with COVID-19 were included in the nal review. The most common nding on initial CT was bilateral multilobar ground-glass opacity which had a peripheral or posterior distribution and was most prevalent in the lower lobes. Follow-up CT demonstrated an increase in ground-glass opacity lesions in both number and size and ground-glass opacity progressively turn- ing into consolidation, septal thickening, and crazy-paving pattern with the worst disease on CT seen approximately 10 days after the onset of symptoms. Disease either regressed or progressed to ARDS, which was the most common reason for transfer of patients to the ICU and the major cause of death. Imaging corresponding
to the improvement of patient symptoms most often occurred after 2 weeks of dis- ease and included gradual improvement and resolution of consolidation and decreased number of pulmonary lesions and number of pulmonary lobes involved.
Another study evaluated the temporal changes of pneumonia as seen on CT in 90 patients with COVID-19 pneumonia who were admitted to the hospital.12 70 patients were discharged from the hospital at the end of the study with criteria being signi cant improvement in respiratory symptoms, afebrile for at least 3 days, imaging improve- ment of disease, and 2 consecutive negative RT-PCR laboratory results at least 24 hours apart. 94% (66/70) of patients discharged had residual disease on CT with ground-glass opacity (60%, 42/70) being the most common nding and pure ground- glass opacity without consolidation (74%, 31/42) being the most common subtype.
Acute pulmonary embolism is not unusual in patients with COVID-19 pneumo- nia. One study demonstrated 23% of patients who had severe clinical COVID-19 pneumonia and had undergone CT pulmonary angiography, had acute pulmonary embolism in addition to pneumonia (Figures 15.2–15.7).13
Figure 15.2 Middle-aged female presented with cough and diagnosed by RT-PCR with COVID-19. Top image shows initial chest radiograph with bilateral mild interstitial opacities, worst in the left upper lobe. Bottom image shows same day CT with typical ndings of COVID-19 pneumonia with bilateral peripheral ground-glass airspace opacities and an area of denser consolidation in the left lower lobe.
Figure 15.3 Elderly female presented with fever and diarrhea, and diagnosed with COVID-19 by RT-PCR. Top image shows an initial chest radiograph with mild ground-glass opacity in the left lung. Bottom image shows same day CT chest with corresponding opacity in the lingula.
Figure 15.4 Same patient as in Figure 15.2. Chest radiograph taken 9 days later on day of death. There are support lines and tubes. There is very signi cantly worse denser more consolidative airspace opacity within the bilateral lungs.
Figure 15.5 Elderly male with newly diagnosed heart failure and positive for COVID-19 by RT-PCR. Top image shows CT with lling defects within bilateral segmental pulmonary artery branches compatible with pulmonary emboli. There are also bilateral pleural effusions due to congestive heart failure. Bottom image shows the same CT (lung windows) with bilateral lower lobe airspace opacity. In the left lower lobe, a reversed halo lesion is beginning to form with a focal rounded area of ground-glass opacity surrounded by a ring of denser consolidation. Even though this nding is typical of COVID-19 pneumonia, a pulmonary infarct due to pulmonary embolism can have the same appearance.
Figure 15.6 Elderly male presented with fever, myalgia, cough, and shortness of breath and positive for COVID-19 by RT-PCR. Top image shows an initial chest radiograph with minimal ground-glass opacity in the retrocardiac left lower lobe. Middle image shows the follow-up chest radiograph performed 5 days later. There is signi cantly worse diffuse ground-glass opacity within the bilateral lungs. Bottom image shows a follow-up chest radiograph performed 10 days later on the day of discharge from hospital. There is still ground-glass opacity within the bilateral lungs but it is improved.
Figure 15.7 Same patient as in Figure 15.5. CT chest performed at time of peak lung disease. There is a crazy-paving pattern of lung disease with thickened interlobular septa and intralobular lines superimposed on a background of ground- glass opacity. This nding is a commonly reported imaging feature of COVID-19 pneumonia.
15.3.3 CT Reports
Some organizations have put forth consensus statements to standardize reporting language or CT scoring systems regarding the possibility of COVID-19 pulmonary infection. The Radiological Society of North America (RSNA) proposes dividing reporting language into four classi cations for cases where COVID-19 pneumonia is a clinical possibility according to Table 15.2.
Proposed reporting language for CT ndings related to COVID-19 includes rationale, CT ndings, and suggested reporting language for each category. Suggested reporting language includes coding of CT ndings for data mining. Associated CT ndings for each category are based upon available literature at the time of writing in March 2020, noting the retrospective nature of many reports, including biases related to patient selection in cohort studies, examination timing, and other potential confounders.
1. Inclusion in a report of items noted in parentheses in the Suggested Reporting Language column may depend upon clinical suspicion, local prevalence, patient status as a UI, and local procedures regarding reporting.
2. CT is not a substitute for RT-PCR; consider testing according to local recom- mendations and procedures for and availability of RT-PCR.
These classi cations are categorized as typical appearance, indeterminate appear- ance, atypical appearance, and negative for pneumonia. A typical appearance would be peripheral bilateral ground-glass opacity with or without denser consolidation or crazy-paving, multiple rounded ground-glass opacities, or reverse halo sign lesions. An indeterminate appearance would be diffuse, perihilar, or unilateral ground-glass opacity, which is not rounded in appearance and not peripheral in distribution. An atypical appearance would be isolated lobar or segmental consolidation without
Routine screening CT for diagnosis or exclusion of COVID-19 is currently not recommended by most professional organizations or the US Centers for Disease Control and Prevention
COVID-19 Pneumonia Imaging Classi cation
CT Findings
Suggested Reporting Language
Typical appearance
Commonly reported imaging features of greater speci city for COVID-19 pneumonia.
Peripheral, bilateral “GGO” with or without consolidation or visible intralobular lines (“crazy-paving”)
Multifocal GGO of rounded morphology with or without consolidation or visible intralobular lines (crazy-paving)
Reverse halo sign or other ndings of organizing pneumonia (seen later in the disease)
“Commonly reported imaging features of (COVID-19) pneumonia are present. Other processes such as in uenza pneumonia and organizing pneumonia, as can be seen with drug toxicity and connective tissue disease, can cause a similar imaging pattern.” [Cov19Typ]a
Indeterminate appearance
Nonspeci c imaging features of COVID-19 pneumonia.
Absence of typical features AND
Presence of: Multifocal, diffuse, perihilar, or unilateral GGO with or without consolidation lacking a speci c distribution and are nonrounded or nonperipheral.
Few very small GGO with a nonrounded and nonperipheral distribution
“Imaging features can be seen with (COVID-19) pneumonia, though are nonspeci c and can occur with a variety of infectious and noninfectious processes.” [Cov19Ind]a
ground-glass opacity, numerous small discrete nodules, cavitation, or smooth inter- lobular septal thickening and pleural effusion. Negative for pneumonia would be no CT ndings of pneumonia. Keep in mind that other infectious or noninfectious dis- eases can have the same appearance as a CT classi cation of typical appearance for COVID-19 pneumonia and a negative for pneumonia CT does not completely exclude the possibility of COVID-19 pulmonary infection. This leads us to the next topic of the utility of CT chest for diagnosis of COVID-19 pneumonia.
Table 15.2 Reporting Language Proposed for CT Findings Related to COVID-19
Atypical appearance
Uncommonly or not reported features of COVID-19 pneumonia.
Absence of typical or indeterminate features AND
Presence of: Isolated lobar or segmental consolidation without GGO
Discrete small nodules (centrilobular, “tree-in-bud”)
Lung cavitation Smooth interlobular septal thickening with pleural effusion
“Imaging features are atypical or uncommonly reported for (COVID-19) pneumonia. Alternative diagnoses should be considered.” [Cov19Aty]a
Negative for pneumonia
No features of pneumonia
No CT features to suggest pneumonia.
“No CT ndings present to indicate pneumonia. (Note: CT may be negative in the early stages of COVID-19).” [Cov19Neg]a
Source: Adapted from:14Published online March 25, 2020 © Radiological Society of North America. GGO, ground-glass opacity.
aSuggested coding for future data mining.
15.3.4 CT Screening
Should CT be used for screening patients for COVID-19 pneumonia? Most radiol- ogy organizations do not recommend CT screening routinely to diagnose COVID- 19 pneumonia. The Fleischner Society came out with a multinational consensus statement addressing this question.15 In it, they stated that imaging with CXR or CT is not indicated in patients suspected of having COVID-19 with mild symptoms unless they are at risk for worsening disease, imaging is indicated in patients who have COVID-19 pneumonia and worsening respiratory status, and in a resource- constrained environment, imaging is indicated to triage patients with moderate to severe clinical features who have a high pretest probability of COVID-19 pneumo- nia. In their statement, the Fleischner Society did not specify in these recommenda- tions whether the imaging modality to be used should be CXR or CT as this would
be based upon local resources and expertise. Although CT is better for detecting early or mild pneumonia and alternative diagnoses, it is signi cantly more expen- sive, more time-consuming, and involves a greater radiation dose.
15.3.5 CT Protocol
Chest CT volume reconstructions at 0.625–1.5 mm slice thickness ideally evaluate interstitial lung disease. Intravenous contrast is not required except in cases where the vasculature needs to be evaluated such as CT pulmonary angiography for the evaluation of pulmonary embolism.
15.4 Ultrasound
Lung ultrasound has advantages in that it is low cost, does not use ionizing radia- tion, and can be done portably at the bedside which is particularly helpful in the emergency department or intensive care unit setting. Findings seen on lung ultra- sound in COVID-19 pneumonia include B-lines, consolidative pattern, thickened pleural lines, and A lines during the recovery phase.16, 17
The World Health Organization (WHO) recently published a guide on imaging in COVID-19 in which they stated that although lung ultrasound has very low- certainty evidence supporting its diagnostic accuracy, it might be helpful with the appropriate expertise as a supplemental or alternative imaging modality particu- larly in pregnant women, children, and patients who are mechanically ventilated.18
15.5 Magnetic Resonance Imaging (MRI)
While CT utilizes X-rays, MRI uses strong magnetic elds and radio waves to produce its images, utilizing the signal obtained from the relaxation of protons within the body. While CT is more available, less expensive, and is a much quicker examination to perform, MRI can provide greater sensitivity for pathology in many cases depending on the organ and what disease is being evaluated for. The strong magnetic elds used in MRI may preclude imaging of patients who have certain ferromagnetic medical devices such as pacemakers although more and more medical devices, including some pacemakers, are becoming MRI compatible.
The clinical utility of MRI for evaluating the lungs is limited. Because the lungs are full of air, and are therefore relatively proton-de cient, MRI has a limited sensi- tivity for pulmonary pathology. Air additionally results in bulk susceptibility arti- facts on MRI, limiting visualization of anatomy in and around structures that contain air. One of the clinical roles for MRI in evaluating the chest is evaluating for cardiac myocarditis.
The Journal of the American College of Cardiology (JACC) scienti c expert panel has updated consensus recommendations for cardiovascular magnetic reso- nance (CMR) diagnosis of myocardial in ammation in patients suspected of having acute or active myocardial in ammation in 2018.19 These updated criteria, referred to as the updated Lake Louise Criteria II, are evaluating for myocardial edema and in ammation, and require abnormality on both T2-based and T1-based magnetic resonance imaging with supportive criteria, including the presence of a pericardial effusion or signs of pericarditis and cardiac left ventricular systolic wall motion abnormality. The administration of MRI gadolinium-based intravenous contrast during the examination, to evaluate for late enhancement of the myocardium in a nonischemic pattern, is helpful to make the diagnosis but is not absolutely necessary.
One study from Germany evaluated the presence of myocardial injury on CMR in 100 patients recently recovered from COVID-19 infection.20 This study showed that there was cardiac involvement in 78% of patients with ongoing myocardial in ammation in 60% of patients independent of preexisting conditions, severity and length of acute illness, time from original diagnosis, or the presence of cardiac symptoms.
1. Radiology lessons for coronavirus from the SARS and MERS epidemics. https://www.itnon- line.com/article/radiology-lessons-coronavirus-sars-and-mers-epidemics. Published May 4, 2020. Accessed July 8, 2020.
2. Hosseiny M, Kooraki S, Gholamrezanezhdad A. Radiology perspective of coronavirus disease 2019 (COVID-19): lessons from severe acute respiratory syndrome and Middle East respi- ratory syndrome. Am J Roentgenol. 2020;214(5):1078–1082. https://www.ajronline.org/doi/ full/10.2214/AJR.20.22969. Published May 2020. Accessed July 8, 2020.
3. Murphy A. Severe acute respiratory syndrome: radiology reference article. Radiopaedia Blog RSS. https://radiopaedia.org/articles/severe-acute-respiratory-syndrome-1?lang=us. Accessed July 8, 2020.
4. Wong H, Lam H, Fong A, et al. Frequency and distribution of chest radiographic ndings in COVID-19 positive patients. Radiology. 2019. https://doi.org/10.1148/radiol.2020201160.
5. Weinstock MB, Echenique A, Russell JW, et al. Chest x-ray ndings in 636 ambulatory
patients with COVID-19 presenting to an urgent care center: a normal chest x-ray is no guar-
antee. J Urgent Care Med. 2020;14(7):13–18.
6. Toussie D, Voutsinas N, Finkelstein M, et al. Clinical and chest radiography features determine
patient outcomes in young and middle age adults with COVID-19. Radiology. 2020. https://
doi.org/10.1148/radiol.2020201754.
7. Hansell D, Bankier A, MacMahon H, McLoud T, Müller N, Remy J. Fleischner Society: glos-
sary of terms for thoracic imaging. Radiology. 2008;246(3):697–722.
8. Zhou S, Wang Y, Zhu T, Xia L. CT features of coronavirus disease 2019 (COVID-19) pneumo-
nia in 62 patients in Wuhan, China. Am J Roentgenol. 2020;214(6):1287–1294.
9. Bernheim A, Mei X, Huang M, et al. Chest CT ndings in coronavirus disease-19 (COVID-
19): relationship to duration of infection. Radiology. 2020;295(3):685–691.
10. Inui S, Fujikawa A, Jitsu M, et al. Chest CT ndings in cases from the cruise ship “Diamond Princess” with coronavirus disease 2019 (COVID-19). Radiol Cardiothorac Imaging.
2020;2(2). https://doi.org/10.1148/ryct.2020200110.
11. Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID-19): a systematic review of imaging ndings in 919 patients. Am J Roentgenol. 2020;215(1):87–93.
12. Wang Y, Dong C, Hu Y, et al. Temporal changes of CT ndings in 90 patients with COVID-19 pneumonia: a longitudinal study. Radiology. 2020. https://doi.org/10.1148/radiol.2020200843.
13. Grillet F, Behr J, Calame P, Aubry S, Delabrousse E. Acute pulmonary embolism associated with COVID-19 pneumonia detected by pulmonary CT angiography. Radiology. 2020. https://
14. Simpson S, Kay F, Abbara S, et al. Radiological Society of North America expert consensus
statement on reporting chest CT ndings related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA. Radiol Cardiothorac Imaging. 2020;2(2). https://doi.org/10.1148/ryct.2020200152.
15. Rubin G, Ryerson C, Haramati L, et al. The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society. Radiology. 2020;296(1):172–180.
16. Zhang Y, Xue H, Wang M, He N, Lv Z, Cui L. Lung ultrasound ndings in patients with coro- navirus disease (COVID-19). Am J Roentgenol. 2020. https://doi.org/10.2214/ajr.20.23513.
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19. Ferreira V, Schulz-Menger J, Holmvang G, et al. Cardiovascular magnetic resonance in nonischemic myocardial in ammation: expert recommendations. J Am Coll Cardiol. 2018;72(24):3158–3176.
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Severe COVID-19 and ICU
Hasmeena Kathuria M.D.,
ARDS CBC
ESR HAPE HFNC HLH
LFT LTVV MAP NIPPV PBW PEEP
Acute respiratory distress syndrome Complete blood count
Creatine phosphokinase
C-reactive protein
High-altitude pulmonary edema
High- ow nasal cannula
Hemophagocytic lymphohistiocytosis
Low tidal volume ventilation
Noninvasive positive pressure ventilation
Predicted body weight
Positive end-expiratory pressure
Veno-venous extracorporeal membrane oxygenation
The epidemiology, etiology, diagnosis, and management of severe COVID-19 patients will be discussed in this chapter. The main focus of this chapter is on the management of hypoxemic respiratory failure in the intubated and nonintubated patient. Special considerations in management, including the role of anticoagula- tion and corticosteroids in COVID-19 patients, will also be discussed.
Chapter 16: Severe COVID-19 and ICU
16.2 Epidemiology
In 20% of cases, COVID-19 can become severe very quickly and some patients rapidly deteriorate 1 week after the start of symptoms. Severe COVID-19 is charac- terized by worsening dyspnea, hypoxia, or greater than 50% lung involvement on imaging within 24–48 h of presenting symptoms.
Wu et al. reported that 14% of COVID-19 patients have severe disease (hypox- emia or greater than 50% lung involvement on imaging) and approximately 5% have critical disease (respiratory failure, multiorgan failure, and/or shock).1 Among those with critical disease, case fatality rate was reported to be 49%. Among patients who develop severe disease, the mean duration to develop dyspnea was 5–8 days; acute respiratory distress syndrome (ARDS) was 8–12 days; and intensive care unit (ICU) admission was 10–12 days.2, 3
Hypoxemic respiratory failure is the most common reason patients with COVID- 19 are admitted to the ICU.4 Mortality among patients admitted to the ICU has been reported to be between 39 and 72%. Of critically ill patients, 71% need mechanical ventilation, often requiring extended mechanical ventilation with a median time to extubation of 11–17 days.5 About 70% eventually require vasopressors and 33% will develop cardiomyopathy.6 Increased age, comorbidities (diabetes, hyperten- sion, coronary artery disease, malignancy, and chronic lung disease), and laboratory abnormalities have been associated with disease severity.
In addition to provider concern, high nursing requirements, and risk of decom- pensation from severe comorbid illness, consideration for transfer or admission to the ICU includes signs of respiratory distress (rapid increase in oxygen require- ment, high work of breathing, oxygen need greater than 6 liters per minute (LPM)), hemodynamic instability, acidosis (pH <7.3), and high levels of lactate (>2). If the decision is made to transfer to the ICU, hospital policy for transfer and personal protective equipment (PPE) must be followed to minimize the risk of transmission to health-care workers.
16.3 Initial Testing and Imaging
For most ICU patients, the COVID-19 nasal swab and comprehensive respiratory panel testing would have already been collected in the emergency department. If not, this will need to be done once admitted to the ICU. Additional laboratory test- ing that will need to be drawn on patients with severe COVID-19 includes chemistry panel and liver function tests (LFTs), including albumin, complete blood count (CBC) with differential, procalcitonin, ferritin, triglycerides, brinogen, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), troponin, lactate dehydroge- nase (LDH), creatine phosphokinase (CPK), D-dimer, and prothrombin time (PT).7 Most of these laboratories are regularly repeated throughout the patient’s ICU stay because they have been found to be markers that may track the disease severity and prognosis (Table 16.1). Troponin as well as an electrocardiogram (ECG or EKG) is used to assess for cardiomyopathy and conduction disturbances in a deteriorating
Initial Testing and Imaging
Table 16.1 Laboratory Markers Associated with Severe COVID-19 Diagnosis
Laboratories associated with severe disease
>10 K/uL
Lymphopenia
<1.00 K/uL
<150 K/uL
>185 U/L
>1.5 mg/dL
>1000 ng/mL
>300 ug/L
High-sensitive cardiac troponin-T
>~20 ng/L
IL-6
>10 pg/mL
LFTs
❤ g/dL
>40 U/L
>0.5 ng/mL
patient. Higher-than-expected cardiovascular deaths (VT/VF, asystole) have been seen in COVID-19 patients. A small subgroup of severe ICU patients develop sec- ondary hemophagocytic lymphohistiocytosis (HLH)8 and acute pulmonary embolism.9
As for imaging, portable chest X-rays (CXRs) are suf cient in most cases for assessing the patient’s lung parenchyma.10 The most common CXR nding is bilat- eral patchy in ltrates which may evolve rapidly.11 Routine chest CT increases the risk of viral transmission to health-care workers and has a low speci city as a screen- ing tool.12, 13 It is generally not recommended by the American College of Radiology.14 On CT scan, COVID-19 pneumonia was similar to a viral pneumonia, but was more likely to have ground-glass opaci cations, vascular thickening, and ne reticular opacities.15 However, early in the course of the disease, a normal chest CT does not exclude COVID-19 and an abnormal CT scan cannot diagnose COVID-19. Therefore, CT scanning is limited to patients who clinically show symptoms of a complication such as an empyema or abscess or concern of pulmonary embolism.
Additionally, bronchoscopy is not recommended or necessary for the purpose of ruling COVID-19 in or out and should be avoided to minimize aerosolization and increasing transmission. Bronchoscopy should only be done if it will change clini- cal management and should be completed in a negative pressure room, if at all possible.
Berlin Criteria for ARDS16
Acute onset of 1 week or less
Bilateral opacities on chest CT or CXR
Must not be fully explained by cardiac failure or failure overload
PaO2/FiO2 > 200 mmHg but ≤ 300 mmHg PEEP or CPAP ≥5 cm H2O
PaO2/FiO2 > 100 mmHg but ≤ 200 mmHg PEEP ≥5 cm H2O
PaO2/FiO2 ≤ 100 mmHg PEEP ≥5 cm H2O
Table 16.2 The Berlin Criteria for ARDS
16.4 Etiology of Hypoxemic Respiratory Failure in COVID-19
In the media, there has been discussion about whether hypoxemic respiratory failure from COVID-19 is ARDS, another process similar to high-altitude pulmonary edema (HAPE), or some other novel syndrome. Since ARDS is not a speci c dis- ease, but rather a clinical syndrome with varying disease severity, COVID-19 ts the spectrum of ARDS as de ned by the Berlin criteria (Table 16.2).7
The noncardiogenic pulmonary edema (edema that develops in the setting of normal left atrial pressures) resulting from HAPE, ARDS from COVID-19, and many other causes is due to an imbalance in Starling forces. The reasons for the imbalance are markedly different between ARDS and HAPE. In ARDS from COVID-19 or other causes, in ammation and the innate immune response leads to damage of the alveolar epithelium and endothelium and increased capillary perme- ability, leading to uid accumulation in both alveolar spaces and interstitium. Proin ammatory cytokines, secreted by alveolar macrophages, sustain in amma- tion and lung injury leading to ventilation–perfusion mismatch and hypoxemia. On the other hand, the noncardiogenic pulmonary edema that results from HAPE is due to excessive hypoxemic pulmonary vasoconstriction, and not an in ammatory pro- cess. Therefore, treating COVID-19 with medications used to manage HAPE is unlikely to be bene cial and may be harmful.
16.5 Management of Hypoxemia in Nonintubated Patients
Case series from Seattle, China, and Italy suggest a range of disease severity, gas exchange impairments, and respiratory compliance.2, 3, 17, 18 For the management of hypoxemia in nonintubated individuals, nasal cannula up to 6 LPM should be the rst-line treatment to meet oxygenation goals (eg, oxygen saturation 90–96%). If not suf cient, a nasal pendant can be used up to 12 L or a non-rebreather up to 15 L should be used to titrate SpO2 saturation to greater than 90%.
Management of Intubated Patients
Self-proning (spending as much time as is feasible and safe in the prone position while receiving oxygen) may improve the recruitment of alveoli in dependent areas of the lung and may improve perfusion to ventilated areas, thus improving V/Q mismatching in nonintubated patients.19 Proning is used in ventilated patients, and while low tidal volumes cannot be guaranteed in spontaneously breathing patients, self-proning in nonintubated patients is likely safe and is being used at some institu- tions.20, 21
There are con icting opinions about using noninvasive ventilation and high- ow nasal cannulas (HFNCs) to extend the time before a patient becomes intubated. In patients who are suffering from ARDS, studies show a frequent need for mechanical ventilation despite the use of these measures. Another signi cant consideration is that both interventions aerosolize the virus, risking infecting the staff and further increasing transmission. Both the WHO and SCCM guidelines make weak recom- mendations for HFNC in select patients.22
16.6 Management of Intubated Patients
Early controlled elective intubation is recommended if there is (1) a rapid pro- gression over hours; (2) persistent or worsening hypoxemia despite nasal pen- dant or non-rebreather; (3) hypercapnia, accessory muscle use, and altered mental status; and/or (4) hemodynamic stability or multiorgan failure. Since intubation is a high-risk procedure for droplet dispersion, airborne PPE should be used and the procedures should be performed in an airborne infection isola- tion room if possible.
Since COVID-19-associated respiratory failure ts the spectrum of ARDS, evi- dence-based management of ARDS should be applied to COVID-19-associated respiratory failure. The principles of ARDS management include lung protective ventilation (low tidal volume ventilation, LTVV),23 positive end-expiratory pressure (PEEP) titration, conservative uid management, and prone ventilation.
16.6.1 Lung Protective Ventilation
The initial ventilator settings should use the volume-assisted control to achieve LTVV [4–8 cc/kg of predicted body weight (PBW), targeting a plateau pressure (Pplat) ≤30 cm H2O]. LTTV, adjusted by PBW and thereby lung size, can minimize volutrauma (overdistension of already-open alveoli)]. This approach is based on several RCTs showing an improved mortality from LTVV in patients with ARDS.24
16.6.2 PEEP Titration
Titrating PEEP can prevent decruitment, thereby increasing functional lung size and decreasing the risk of volutrauma. PEEP and FiO2 are titrated to target oxygenation (goal: SpO2 92–96%) per the ARDS net low PEEP (Table 16.3).7 Patients are
Low PEEP ARDS Net Table
FIO2
Table 16.3 PEEP and FiO2 Levels and ARDS
sometimes started on higher-than-usual levels of PEEP (10–15 cm H2O) since reports suggest that some COVID-19 ARDS patients are responsive to high PEEP and have high lung compliance such that Pplat ≤30 cm H2O is not dif cult to achieve.
16.6.3 Conservative Fluid Management
A conservative uid approach is one of the mainstays of ARDS management.25 ARDS is a form of noncardiogenic pulmonary edema due to increased capillary permeability,26 which can be worsened by an increase in hydrostatic forces. The Fluid and Catheter Treatment trial showed that conservative uid management can improve oxygenation, ventilation-free days, and lung injury.27 Reducing intravascu- lar volume to reduce pulmonary edema needs to be balanced with the need for adequate perfusion to nonpulmonary organs. In practical terms, this translated to avoiding a positive uid balance (sometimes requiring the administration of diuret- ics) in patients post-resuscitation and without ongoing shock.
16.6.4 Prone Ventilation
Prone ventilation is the delivery of mechanical ventilation with the patient in the prone position and is a key component of management of patients with severe ARDS who are intubated. Studies have demonstrated improved oxygenation, and one study showed a mortality bene t with ventilation in the prone position in those with severe ARDS.28–30 Prone positioning is recommended for patients with severe ARDS whose P/F remains less than 150 mmHg for 12 h despite ventilator optimiza- tion with LTVV in the supine position. Prone positioning is usually implemented early in the course of ARDS (within 36 h), and patients are usually maintained in the prone position for 16–18 consecutive hours per 24 h. For patients who have a
sustained improvement in gas exchange, prone positioning is usually stopped when improvement in oxygenation (P/F ≥150 mmHg, FiO2 ≤0.6, PEEP ≤10 cm H2O, Ppl < 30, pH > 7.25) is maintained for at least 4 h after the end of the last prone session. If prone ventilation fails, the patient should be returned to the supine position.
Absolute contraindications to prone positioning include spinal instability or at risk for spinal instability, unstable fractures, shock, anterior burns and open wounds, recent tracheal surgery, pregnancy, and raised intracranial pressure. Other contraindi- cations include abdominal surgery, hemodynamic instability, and life-sustaining car- diac hardware. Common complications include transient desaturations, facial and ocular edema, decubitus ulcers, and dislodgement of catheters and endotracheal tubes.
16.6.5 Inhaled Pulmonary Vasodilators
Inhaled nitric oxide (iNO), a rapid acting vasodilator, selectively vasodilates the already well-ventilated areas, improving V/Q mismatch.31 A systematic review showed an improvement in P/F ratios at 24 h, but not at 48 or 72 h with iNO. There were no differences in duration of mechanical ventilation and length of ICU stay, but a signi cant increase in renal failure in the iNO group.32 There has been one small study in Beijing during the SARS epidemic, showing that iNO improved oxy- genation and decreased the amount of days on the ventilator.33 iNO may also have direct antiviral effects.34–36 iNO or other pulmonary vasodilators like nebulized epo- prostenol (a synthetic analogue of prostacyclin) may therefore have a role as rescue therapy in some patients with COVID-19 who have persistent hypoxemia that is unresponsive to PEEP titration and prone ventilation.
16.6.6 Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO)
VV ECMO is a type of pulmonary bypass allowing oxygenation to occur via an external membrane. Studies suggest that in severe ARDS, ECMO could be used after the failure of optimized ARDS management. Speci cally, ECMO can be con- sidered when there are no reversible causes and P/F is persistently <75 mmHG despite optimized PEEP, neuromuscular blockade, proning, and inhaled vasodilator; PPl >30 cm H2O despite lung protective ventilation; and pH < 7.2. Some studies suggest that referral to ECMO centers should be made early (within 7 days of severe ARDS).37 Absolute and relative contraindications to ECMO include advanced age, active malignancy, severe shock, multiorgan failure, severe neurologic injury, poor functional status, inability to anticoagulate, high body mass index (>40), thrombo- cytopenia (platelets less than 50), and neutropenia (absolute neutrophil count (ANC) <500). In the Extracorporeal Life Support Organization algorithm, there are no absolute contraindications except for end-stage respiratory failure when lung trans- plantation is not an option. Thromboembolism and bleeding are the major compli- cations from ECMO.
16.7 Sedation/Analgesics/Paralytics
Prior studies show that lower levels of sedation and nonbenzodiazepine regimens decrease ICU days and duration of mechanical ventilation.38 To achieve appropri- ate sedation and analgesia, the lowest dose of any medication should be used to achieve the desired effect. Ventilation synchrony is very important to help reduce ventilator-induced lung injury, and this is achieved by appropriately balancing the sedative, analgesic, and neuromuscular blockade agents.7 The Richmond Agitation-Sedation Scale, a validated 10-point scale (−5 to +4) to assess a patient’s level of sedation in the ICU, can be used to help describe the level of alertness or agitation in mechanically ventilated patients to prevent over- or under-sedation.39 The target score is 0 to −1 to maintain synchrony, without agitation (2–4), or over- sedation (−3 to −5).
The preferred therapy for sedation in many centers is propofol so as to avoid the use of benzodiazepines, particularly for patients with ARDS who have renal and/or liver dysfunction. Several cases of propofol-associated triglycerides and pancreati- tis have been reported.40 Although reported in less than 1% of patients, propofol infusion syndrome should be considered in patients receiving either high dose (>5 mg/kg/h) or longer duration (>48 h) who have unexplained metabolic acidosis, rhabdomyolysis, and EKG changes, with or without acute kidney injury, cardiac failure, or higher levels of liver enzymes, lactate, lipids, or potassium. Midazolam is often the second-line therapy for sedation.41 Obese patients are at an increased risk for prolonged sedation given the accumulation of drug and metabolite in excess adipose tissue. A slow and steady decrease in the rate of infusion can facilitate weaning without precipitating a withdrawal syndrome. Since dexmedetomidine is unlikely to provide deep levels of sedation, in the current climate it is often used as an adjunct to other sedatives, or as a 24- to 48-h bridge to wean benzodiazepines to facilitate extubation.
For analgesia in intubated patients, the rst-line therapy is fentanyl or hydromor- phone because these agents are fast-acting and titratable.7 Fentanyl is typically given as a continuous infusion. Since fentanyl is highly lipophilic, accumulation in fat and other tissues can result in prolonged sedation even after discontinuation. Hydromorphone is an alternative to fentanyl with dosing adjusted for hepatic or renal insuf ciency.7 Because of its longer duration of action, hydromorphone is pre- ferred if patients only require intermittent bolus dosing.
A subset of patients with severe ARDS (PaO2:FiO2 < 150 after at least 12 h of mechanical ventilation using FiO2 > 0.6 and PEEP > 5 cm H2O) and ventila- tor dys-synchrony causing high plateau pressures (>30cm H2O) or injurious tidal volumes (TV >8 cc/kg IBW) or hypoxemia may bene t from neuromuscu- lar blockade. Since neuromuscular blockade therapies do not have any analgesic or sedative properties, deep sedation is necessary before neuromuscular block- ade is initiated. Cisatracurium is often used as a rst-line treatment and pre- ferred in patients who have renal and liver dysfunction as well as hemodynamically unstable patients. Alternative agents include vecuronium, rocuronium, and atracurium.7
16.8 Weaning and Extubation
There is extensive literature on liberation from mechanical ventilation.42 Guidelines for consideration of a weaning trial include (1) ability to initiate own breaths, (2) reso- lution of the underlying disease process, (3) improved gas exchange (eg, O2 satura- tion >90% on 40% oxygen or less, or PaO2/FiO2 >150), (4) minute ventilation requirements not excessive (eg, less than 12 L/minute; RR < 30), (5) preserved mental status, (6) lack of excessive pulmonary secretions, and (7) hemodynamic stability.
Once these criteria have been met, daily spontaneous breathing trials (SBT) remain the most effective method to wean from mechanical ventilation.43–45 An SBT consists of a trial on minimal PEEP (5 cm H2O) and pressure support (usually 0–5 cm H2O) for a set period of time (30–120 min). The patient should be assessed for the following respiratory parameters: SpO2 >90 and/or PaO2 > 60 mmHg, sponta- neous tidal volume 4–6 ml/kg PBW, respiratory rate less than 35 per min, pH > 7.3, and no signs of respiratory distress. Once the patient can tolerate the SBT for 30–120 min while remaining hemodynamically stable with noncopious secretions and suf cient mental status, extubation can be considered.46
Prior to extubation, glucocorticoids should be considered due to evidence of pre- venting stridor, laryngeal edema, and reducing the incidence of reintubation.47–49 Therefore, 40 mg of methylprednisolone IV should be given 4–6 h prior to planned extubation, with a maximum dose of 80 mg if extubation is delayed. Patients who have passed an SBT and are considered at high risk for postextubation respiratory failure (age >65, CHF, COPD, hypercapnia during SBT) had improved outcomes with noninvasive positive pressure ventilation (NIPPV) or HFNC in the immediate postextubation period.50–52 Alternatively for patients who develop respiratory failure within 48 h of extubation, NIPPV as a rescue therapy for respiratory failure has been shown in some studies to increase all-cause mortality.53
Since intubation, reintubation, NIPPV, and HFNC are considered aerosol-gener- ating procedures, the following modi cations should be considered in COVID19 patients:
• Consider extending SBT trials to 2 h to ensure higher likelihood of postextu- bation failure.
• Consider an SBT trial with no additional PEEP to ensure patients can tolerate no PEEP postextubation.
• Carefully consider the risk to health-care workers and review hospital policy prior to using NIPPV and HFNC postextubation in COVID-19 patients that have passed an SBT trial but are at high risk for postextubation failure.
16.9 Tracheostomy
Since tracheostomy is an aerosol-generating procedure and increases potential viral exposure to the health-care team, decision-making in tracheostomy should take into account the surgical team and hospital policy. The American Academy of
Otolaryngology-Head and Neck Surgery has issued guidelines on tracheostomy during the COVID-19 pandemic.
16.9.1 Tracheotomy Recommendations during the COVID-19 Pandemic
At the time of this writing, there is no data on the role of tracheostomy in COVID- 19 patients. Tracheostomy can be considered in patients with stable respiratory sta- tus but not sooner than 2–3 from intubation. Overall, early tracheostomy placement (earlier than 10 days) is not recommended due to previous studies showing no improvement in survival, ventilator-associated pneumonia rate, or duration of mechanical ventilation for patients with respiratory failure.54 It is important to note that the average duration of ventilation in COVID-19 patients is about 8 days and the average ICU stay is around 10 days. Therefore, there is minimal evidence to support early tracheostomy placements in COVID-19 patients, even if early trache- ostomies were to reduce health-care resources. Patients who have a tracheostomy placed need long-term care, and this needs to also be considered when thinking of placing early tracheostomies in patients who might be able to be extubated prior to needing a tracheostomy.55
16.10 Cytokine Storm
It has been postulated that a subgroup of patients with severe COVID-19 exhibit a dysregulated immune response, or “cytokine storm” that leads to progressive dis- ease.56 The “cytokine storm” appears to be similar to the hyperin ammation seen in other virally triggered secondary HLH. In HLH, aggressive immune activation of macrophages leads to an excessive cytokine response with both laboratory and clin- ical evidence of severe in ammation.57 This immune activation increases ferritin, ESR, and CRP; decreases platelets; and can lead to worsening respiratory failure and multiorgan failure.
It is unclear if immunosuppression in this subset of patients with severe in am- mation can improve mortality. IL-6 activates T cells and macrophages, and increased levels of IL-6 may be associated with COVID-19 disease severity,58, 59 but it is unclear if blocking this cytokine could lead to improved clinical outcomes. IL-1 is a proin ammatory cytokine elevated in critical illness. Modulation of cytokines with monoclonal antibodies such as tocilizumab and sarilumab (monoclonal anti- bodies against the IL-6 receptor) and anakinra (recombinant antagonist of the IL-1 receptor) is being studied in clinical trials. Trials are additionally underway to test whether treatment with etoposide (by eliminating the cells that are causing the excessive cytokine response) improves clinical outcomes.7 The Hscore may be use- ful in identifying patients with HLH who should be considered for clinical trials.60 This score calculates the probability of HLH by assessing characteristics such as underlying immunosuppression, temperature, hepatomegaly or splenomegaly,
Anticoagulation in COVID-19 Patients
number of cytopenias, ferritin levels, triglyceride and brinogen levels, AST as well as if there are hemophagocytosis features on bone marrow aspirate.61
16.11 Shock Management
While patients rarely present with shock (MAP <65 or SBP< 90 with signs of hypo- perfusion requiring IVF or vasopressors to maintain adequate blood pressure), vaso- pressors are eventually used in about 70% of critically ill patients. The reason for shock in patients with COVID-19 is most often secondary to bacterial infection, cardiac dysfunction, or cytokine storm.7 The workup for shock should include assessing for end-organ damage (altered mental status; decreased urine output; abnormal electrolytes; and high levels of lactate, LFTs, and BUN/creatinine) and obtaining an infectious and cardiac workup. One study reported that 20% of COVID-19 nonsurvivors had a secondary bacterial infection and that 52% of non- survivors had heart failure or cardiogenic shock, usually presenting later in the dis- ease course.62
Management of septic shock should include early antibiotics and maintaining MAP above 65 mmHg. Since the majority of ICU patients with COVID-19 have ARDS, a more conservative uid strategy is preferred over the conventional uid strategy of 30 cc/kg to avoid exacerbating ARDS. Therefore, 250–500 cc of uid should be given and the patient assessed for an increase in MAP or decrease in pres- sor requirements in 15–30 min. 250–500 cc of uid can be repeated. If pressors are needed, norepinephrine is the initial vasopressor of choice (1–30 mcg/min).7 If a second vasopressor is needed, vasopressin of 0.4 units can be used. Cardiogenic shock should be comanaged with the cardiology team. Routine monitoring should include troponin, lactate, LFTs, SCvO2 or MvO2, and daily EKGs. Achieving a mean arterial pressure (MAP) of greater than 65 may require a combination of vaso- pressors (norepinephrine), diuretics, and inotropic support (dobutamine).
16.12 Anticoagulation in COVID-19 Patients
D-dimer, a marker associated with thrombosis, is often increased in patients with severe COVID-19, and several studies have shown high rates of thrombotic events in patients with severe COVID-19.63–66 In addition, ARDS of itself is known to be associated with coagulopathy and both macrovascular and microvascular thrombo- sis. Yet no clinical trials have demonstrated a bene t from therapeutic anticoagula- tion in patients with ARDS.67 Although ARDS and COVID-19 are associated with hypercoagulable states, there is a limited evidence that therapeutic anticoagulation improves outcomes.
Since critically ill patients with COVID-19 have a high rate of thrombosis (23– 43% in ICU patients), prophylactic anticoagulation is imperative for critically ill patients, unless contraindicated. Low molecular weight heparin is preferred, but unfractionated heparin is used if kidney function is impaired (creatinine clearance
<30 ml/min). Some institutions use more aggressive anticoagulation with interme- diate-dose anticoagulation for prophylaxis in patients with very high D-dimer lev- els. Therapeutic dose anticoagulation is used to treat deep vein thrombosis or pulmonary embolism, unless contraindicated.
16.13 Corticosteroids in COVID-19 Patients
Preliminary data from the RECOVERY trial, a randomized trial of >6000 hospital- ized patients with COVID-19, demonstrates that dexamethasone has a mortality bene t in patients with COVID-19 who require oxygen or are mechanically venti- lated.68 Patients who did not require oxygen did not bene t from dexamethasone. Therefore, for patients with COVID-19 on supplemental oxygen (whether sponta- neously breathing or mechanically ventilated), dexamethasone 6 mg either intrave- nously or by mouth for 10 days (the equivalent of 40 mg prednisone daily) should strongly be considered if not contraindicated.
16.14 Palliative Care
In the ICU setting, palliative care consult services have an increasingly important role in helping medical teams with goals of care and advanced care planning discussions with patients and health-care proxies. For patients who are end-of-life, palliative care services also provide support and guidance in symptom management, particularly with opioids and benzodiazepines to help control pain and anxiety. Some hospitals, like the Brigham and Women’s Hospital, implemented COVID-19 Intensive Palliative Care Units during the pandemic to help provide support and comfort-focused care to COVID-19 patients with organ failure and an estimated prognosis of less than 1 week.7
Consultations with palliative care should happen early so that a plan is set in place that is in accordance with patients’ wishes. These discussions are particularly important since cardiopulmonary resuscitation may not offer a bene t in some patients with COVID-19, particularly those with advanced age (>80 years old) and/ or comorbid cardiovascular disease, hypertension, diabetes, and respiratory disease and increase transmission to health-care workers. Several resources are available to help providers initiate and respond to often very dif cult conversations.
• Center to advance palliative care
• VITAL talk.
16.15 Conclusion
• COVID-19 can become severe very quickly, and transfer or admission to ICU should be considered with any of the following: provider concern, high nursing requirements, risk of decompensation from severe comorbid illness, signs of
respiratory distress, hemodynamic instability, acidosis, and increased levels of
lactate (>2).
• Evidence-based management of ARDS, including lung protective ventilation
(LTVV), PEEP titration, conservative uid management, and prone ventilation,
should be applied to COVID-19-associated respiratory failure.
• Prophylactic anticoagulation is imperative for critically ill patients, unless con- traindicated, with some institutions using more aggressive anticoagulation with intermediate-dose anticoagulation for prophylaxis in patients with very high
D-dimer levels.
• If not contraindicated, patients with COVID-19 should be considered for cortico-
steroids if they require supplemental oxygen (whether spontaneously breathing or mechanically ventilated).
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tinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120(6 Suppl):375S–95S.
43. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identi- fying patients capable of breathing spontaneously. New Engl J Med. 1996;335(25):1864–1869.
44. Esteban A, Alía I, Tobin MJ, et al. 1999. Effect of spontaneous breathing trial duration on out- come of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative
Group. Am J Respir Critic Care Med. 159(2):512–518.
45. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from
mechanical ventilation. New Engl J Med. 1995;332(6):345–350.
46. ARDSNET. NIH NHLBI ARDS clinical network mechanical ventilation protocol summary.
https://www.ardsnet.org/ les/ventilator_protocol_2008-07.pdf. Accessed May 20, 2020.
47. François B, Bellissant E, Gissot V, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial.
Lancet 2007;369:1083–1089.
48. Cheng K-C, Hou C-C, Huang H-C, Lin S-C, Zhang H. Intravenous injection of methylpred-
nisolone reduces the incidence of postextubation stridor in intensive care unit patients. Crit
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49. Lee C-H, Peng M-J, Wu C-L. Dexamethasone to prevent postextubation airway obstruc-
tion in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care.
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50. Fan E, Zakhary B, Amaral A, et al. 2017. Liberation from mechanical ventilation in criti-
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51. Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive venti-
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52. Maggiore, Salvatore Maurizio, Francesco Antonio Idone, Rosanna Vaschetto, Rossano Festa, Andrea Cataldo, Federica Antonicelli, Luca Montini, Andrea De Gaetano, Paolo Navalesi, and Massimo Antonelli. Nasal high- ow versus venturi mask oxygen therapy after extuba- tion. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190(3):282–288.
53. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. New Engl J Med. 2004;350(24):2452–2460.
54. Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121–2129.
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Post-Recovery and Long-Term Complications
Ejaz Ahmad M.D., Sarah Zaidi Sc.D., MSc., Gary Shmorgon, and Carmina Rogelio
ARDS CNS COVID-19 DLCO FVC HRQoL MERS PNS SARS TLC
Acute respiratory distress syndrome Central nervous system
Carbon monoxide diffusion capacity Forced vital capacity
Health-related quality of life Middle East respiratory syndrome Peripheral nervous system
Severe acute respiratory syndrome Total lung capacity
Coronavirus disease (COVID-19) is a new disease, with the rst positive cases emerging in December 2019; there are no studies about its long-term impact on health, especially in people with severe symptoms. The evidence from earlier chap- ters suggests that SARS-CoV-2 can attach to, and penetrate, human cells in many parts of the body, including many major organs such as the lungs, heart, kidneys, brains, and even blood vessels. Although it may be too early to know of longer-term complications of COVID-19, this chapter will discuss what has been learned about the pathophysiologies and long-term complications seen in the cases of the other two coronaviruses, Middle East respiratory syndrome (MERS) and severe acute respira- tory syndrome (SARS), and compare potential similarities with COVID-19.1
17.2 SARS—Post-Recovery and Long-Term Complications
The literature assessing long-term complications of SARS is now available given the long follow-up time (18 years), and allows for more complete analysis and under- standing of the aftermath associated with this rst 2003 coronavirus epidemic.
Chapter 17: Post-Recovery and Long-Term Complications
In order to better discuss the health results from SARS, post-recovery will be de ned as symptomology and complications associated with SARS within a 1-year span of disease recovery. Long-term complications will be de ned as any disease symptomology or complications that persist or emerge 1 year following recovery.
In regard to the post-recovery phase of SARS, respiratory complications were seen to persist in people over 60 years who experienced severe symptoms.2 In 15 out of the 24 patients (62%), who underwent computerized tomography (CT) of the thorax 5 weeks post-hospitalization, showed changes associated with pulmonary brosis in 62% of patients but a mild decrease in total lung capacity (TLC) 81% of predicted and forced vital capacity (FVC). In these patients, the residual volume was at 65% of predicted. In the post-recovery phase, 6–20% of SARS patients were found to have a mild to moderate muscle weakness.2
Another data series in the same study evaluated the health impact that SARS had on 258 patients from Xiaotangshan Hospital in Beijing. It was reported that 2 months post-hospitalization, 21% (54 individuals) had impaired carbon monoxide diffusion, while 6% (16) had a restrictive ventilatory defect FVC.2 After an addi- tional month, the carbon monoxide diffusion capacity (DLCO) improved in 80.3% of those 54 patients and 81.3% of those 16 patients had an improved FVC. The authors concluded that while most patients affected by SARS made a complete recovery after 3 months post-discharge, there were a small percentage of people that continued to have persisting respiratory problems.
The long-lasting effects of SARS in some patients were con rmed by another study from Hong Kong that evaluated SARS patients at 6 months and 1 year after infection.3 At 6 months, the researchers found that 33 (30%) of patients presented with abnormal chest radiographs, and 4, 7, and 16% of patients had FVC, TLC, and DLCO below 80% predicted, respectively. At 1-year follow-up, 27 (28%) had abnormal chest radiographs. 4, 5, and 23% of patients had FVC, TLC, and DLCO below 80% predicted, respectively. The study shows that while active recovery takes place within the rst couple months post-hospitalization, the overall number of indi- viduals who make a complete recovery from the SARS infection tapers off with a small subset of patients continuing to experience respiratory dif culties.
SARS studies of longer-term lung function at 12 and 15 years post-infection further reveal that while most patients did make a full recovery, a small subset con- tinued to experience permanent lung-related damage.4, 5 It is important to note that all subjects were normal on the basis of a clinical evaluation at the 12-year mark, and only a more in-depth examination revealed persistent lung injury.
Outside of respiratory concerns, additional long-term complications included muscle weakness, chronic fatigue, depression, nonrestorative sleep, and bone prob- lems prominently among patients. A study of 22 SARS patients in Toronto who were followed for 3 years (mean 19.8 months) found that the group had symptoms similar to bromyalgia, depression, and sleep disturbance.6 In a study of 369 SARS survivors, 40.3% experienced chronic fatigue syndrome 3.5 years after being diag- nosed.7 Viral infections like Epstein–Barr have been linked to chronic fatigue.
MERS—Post-Recovery and Long-Term Complications
Avascular necrosis of the hip was commonly reported as a side effect due to the high-dose steroid treatment.2 A 15-year follow-up study demonstrated that in the rst year, 21% (17) of patients had some form of avascular necrosis on the femoral head of the hip joint. Over time, the clinical stage of femoral head necrosis actually progressed in some of these patients from 2003 to 2007. After 2007, the clinical stage of the femoral head necrosis stabilized in all patients.5
The last two common complications that were associated with post-hospitaliza- tion due to SARS were a reduced health-related quality of life (HRQoL) and poor mental health. At the 1-year follow-up time, the HRQoL was continually lower in the SARS survivor group compared to that of the normal control group assessed by utilizing a standardized 6-minute walk and a 36-item Short-Form General Health Survey.3 In regard to SARS-associated poor mental health, a study reporting on a 5-week follow-up of 101 patients found that 25% experienced anxiety and 14% reported symptoms of depression.2 In the same study, 5% of patients reported expe- riencing severe anxiety or depression 2 months after discharge. Finally, in a 15-year follow-up period, 42.5% (77) of patients experienced at least one active psychiatric illness.5 While many of these individuals with poor mental health do eventually recover, it is alarming that so many experienced poor mental health is a result of SARS infection.
17.3 MERS—Post-Recovery and Long-Term Complications
Ten years after the SARS epidemic in Asia, another deadly coronavirus appeared in the Middle East.8 MERS emerged in Saudi Arabia and was largely contained to the Arabian Peninsula, but in 2015, there was an outbreak in South Korea.9 Mortality analysis of MERS-CoV revealed a 29.8% overall mortality rate, but a 45.2% mor- tality rate for those above the age of 60.10 Similar to SARS, respiratory illness was the largest complication in MERS.
In a study that looked at 73 patients who had MERS, 25% (18) of patients did not have pneumonia, while the remaining 75% of patients experienced varying severi- ties of pneumonia.11 After adjusting for multiple variables, the study found that DLCO and FVC were signi cantly reduced among patients who presented with pneumonia 1 year after, and that it was a dose-dependent relationship—those with more severe pneumonia having lower DLCO and FVC values.11,12 A substantial number of patients recovering from MERS develop lung brosis on imaging stud- ies.9 As in the case of SARS, reduced lung function and pulmonary brosis were the primary results in patients who recovered from MERS.
Aside from respiratory complications, the MERS-CoV infection also resulted in neurological complications and chronic fatigue syndrome. In a case report pub- lished by Algahani, Subahi, and Shirah, the authors present two cases of individuals developing a neurological complication as a result of acquiring MERS. In one case, the patient developed an intracerebral hemorrhage due to platelet dysfunction,
disseminated intravascular coagulation, and thrombocytopenia.12 In the second case, the patient developed critical illness polyneuropathy. In regard to the develop- ment of chronic fatigue syndrome, around 54% of patients who have survived the MERS-CoV infection ended up developing the syndrome within a 2-year time span after being discharged from the hospital.12
The nal major complication should be discussed in the reduction of quality of life in survivors of the MERS-CoV virus. Among those with different disease sever- ities, patients with greater disease severity had a signi cant (p < 0.05) reduction in the quality of life compared to those who experienced a lesser disease severity.13
Overall, the SARS-CoV and MERS-CoV caused a plethora of different compli- cations that provide a framework to better understand what pathologies to expect from SARS-CoV-2. Respiratory, neurological, chronic fatigue syndrome, reduced quality of life, bone-related issues, muscle weakness, and poor mental health are complications that needed to be considered for COVID-19.
17.4 Post-Recovery Phase of COVID-19
The rst wave of COVID-19 pandemic is sweeping across the world, and much of the initial research was focused solely on understanding its health-related impacts, including respiratory issues, coagulopathy and cardiovascular-associated problems, and pediatric in ammatory syndrome found to be associated with the virus.14–16 As the pandemic evolves with some countries managing to control and reduce trans- mission, and others struggling to bring it under control, there is more research dis- cussing post-recovery complications of COVID-19 and eventually, long-term complications associated with it. As more information becomes available, this sec- tion will adapt and expand.
The rst, and most pressing, question that arises after recovering from COVID- 19 is whether an individual develops a robust immune response to the virus that prevents reinfection. The recent literature indicates that detectable levels of IgM and IgG antibodies develop and can be tested for a few days after most individuals are infected with SARS-CoV-2,17 but it is not de nitive whether these are protective. There have been cases in which patients who are discharged return a few days later with positive viral RT-PCR levels, even after having been undetectable during dis- charge.18 It has not been established whether this is a new infection, reinfection, or reactivation. There is evidence to demonstrate the presence of neutralizing antibod- ies and a cellular immune response in macaques, but nothing yet has been estab- lished in live humans.18
The follow-up question then attempts to determine if these antibodies aid in the clinical outcome of patients. While it has been demonstrated in a small nine person study that more antibodies are produced in a more severe case of COVID-19, the relationship between antibody levels and clinical outcome has not been established. This is further complicated by the idea that patients with less severe presentations of COVID-19 recover before seroconversion occurs.17
Post-Recovery Phase of COVID-19
As part of the coronavirus family, SARS-CoV-2 affects lung function in post- recovery especially in severe cases where patients develop acute respiratory distress syndrome (ARDS). In one study where 22 (16%) patients developed ARDS, the long-term complications were not yet established but experts postulated the poten- tial for the virus to develop pulmonary brosis.19 A radiology study of 21 patients demonstrated that maximum lung involvement occurs at day 10 post-infection, which can be easily seen as ground-glass opacities with crazy-paving patterns on lung CT.20 Additional scans post day 14 have shown a gradual resolution of consoli- dation and a decrease in lung involvement, hence indicating full recovery. On the other hand, in another radiology study of 70 patients, 66 (94%) of patients had residual lung disease at hospital discharge with 60% showing ground-glass opaci- ties on lung CT and 74% showing pure ground-glass opacity on lung CT.21
While there is not any clear evidence on post-recovery clinical lung outcomes, on a more anecdotal basis, Dr. Owen Tsang Tak-yin, Medical Director of the authori- ty’s Infectious Disease Centre at Princess Margaret Hospital in Kwai Chung, has noted that some patients experience a 20–30% decrease in lung function post-recov- ery.22 Given this commentary, it is essential that further studies be done both via radiology and via clinically in order to determine the effect of COVID-19 on respi- ratory outcomes.
The next complication that has been found in COVID-19 patients is the develop- ment of cardiac complications. In a case report of 138 patients, 16 (7%) of patients developed arrhythmia, while 7.2% developed some form of acute cardiac injury.23 Other studies have shown that COVID-19 patients present with higher cardiac tro- ponin I and BNP levels indicating myocardial involvement.24,25 Additionally, anec- dotal evidence has shown a higher incidence of cardiac cases such as acute-onset heart failure, myocardial infarction, and myocarditis in COVID-19 patients.23 Given the nature of SARS-CoV-2 affecting the heart and cardiovascular system, cardiac injury is highly probable and needs to be accounted for in the future COVID-19 treatment.
There are also neuropsychiatric and central nervous system (CNS) complications that arise in COVID-19 patients. COVID-19 CNS disease has been linked with encephalopathy, encephalitis, acute disseminated encephalomyelitis, meningitis, ischemic and hemorrhagic stroke, venous sinus thrombosis, and endothelialitis.26 In the peripheral nervous system (PNS), COVID-19 PNS disease has been associated with dysfunction of smell and taste, muscle injury, and the Guillain–Barre syn- drome.26,27 These ndings and associations suggest that it is important to consider these complications during the post-recovery phase and longer-term follow-up of COVID-19 survivors.
The nal complications that have yet to be studied but need to be addressed in the post-recovery phase of COVID-19 are its effect on mental health and quality of life and the development of chronic fatigue syndrome. Given the similar ndings found between SARS and MERS, it is essential to look at these complications in the post- recovery phase of COVID-19. Previous epidemics have set the groundwork on what to investigate in months and years after the initial outbreak of SARS-CoV-2.
While the data is quite limited in regard to COVID-19, the similarities and differ- ences can be easily seen between the previous two epidemics and the current pan- demic. This chapter provides an in-depth overview of what was found in the SARS and MERS outbreaks that allows for a potential framework that can be used to study the current COVID-19 outbreak. This chapter has then identi ed complications that have been studied and need additional investigation in the current COVID-19 out- break. As time progresses and further data becomes available, it is essential to con- tinually build on the foundation that has been set in this chapter.
1. Petrosillo N, Viceconte G, Ergonul O, Ippolito G, Petersen E. COVID-19, SARS and MERS: are they closely related? Clin Microbiol Infect. 2020;26(6):729–734.
2. Chan KS, Zheng JP, Mok YW, et al. SARS: prognosis, outcome and sequelae. Respirology. 2003;8:36–40.
3. Hui DSC, Tong M, Chan DP, Sung JJY, Wong KT, Antonio G. Long-term sequelae of SARS: physical, neuropsychiatric, and quality-of-life assessment. Hong Kong Med J. 2009;15(suppl. 8):21–23.
4. Guo L, Han Y, Li J, et al. Long-term outcomes in patients with severe acute respira- tory syndrome treated with oseltamivir: a 12-year longitudinal study. Int J Clin Exp Med. 2019;12(10):12464–12471.
5. Zhang P, Li J, Liu H, et al. Long-term bone and lung consequences associated with hospital- acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study. Bone Res. 2020;8(1):84–85.
6. Moldofsky H, Patcai J. Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study. BMC Neurol. 2011;11:37. https://doi.org/10.1186/1471-2377-11-37.
7. Lam MHB, Wing YK, Yu MWM, et al. Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors long-term follow-up. Arch Intern Med. 2009;169(22):2142–2147.
8. Memish ZA, Perlman S, Van Kerkhove MD, Zumla A. Middle East respiratory syndrome. Lancet. 2020;395(10229):1063–1077.
9. Park WB, Jun K Il, Kim G, et al. Correlation between pneumonia severity and pulmonary complications in Middle East respiratory syndrome. J Korean Med Sci. 2018;33(24):1–5.
10. Ahmed AE. The predictors of 3- and 30-day mortality in 660 MERS-CoV patients. BMC Infect Dis. 2017;17(1):1–8.
11. Algahtani H, Subahi A, Shirah B. Neurological complications of middle east respiratory syn- drome coronavirus: a report of two cases and review of the literature. Case Rep Neurol Med. 2016;2016:1–6.
12. Soo-youn S. MERS victims suffer traumas 2 years after its outbreak. Korea Biomedical Review. http://www.koreabiomed.com/news/articleView.html?idxno=1731. Published 2017. Accessed June 13, 2020.
13. Batawi S, Tarazan N, Al-Raddadi R, et al. Quality of life reported by survivors after hos- pitalization for Middle East respiratory syndrome (MERS). Health Qual Life Outcomes. 2019;17(1):1–7.
14. Horn A. More than 1 million people have recovered from COVID-19 worldwide. NPR. https:// http://www.npr.org/sections/coronavirus-live-updates/2020/05/01/849065983/more-than-1-million- people-have-recovered-from-covid-19-worldwide. Accessed June 16, 2020.
15. Balachandar V, Mahalaxmi I, Subramaniam M, et al. Follow-up studies in COVID-19 recov- ered patients—is it mandatory? Sci Total Environ. 2020;729:139021.
16. Zaim S, Chong JH, Sankaranarayanan V, Harky A. COVID-19 and multiorgan response. Curr Probl Cardiol. 2020;21(1):1–9.
17. Kirkcaldy RD, King BA, Brooks JT. COVID-19 and postinfection immunity: limited evidence, many remaining questions. JAMA. 2020;323(22):2245–2246.
18. WHO. Coronavirus disease. World Heal Organ. 2020;2019:2633.
19. Spagnolo P, Balestro E, Aliberti S, et al. Pulmonary brosis secondary to COVID-19: a call to
arms? Lancet Respir Med. 2020;2019(20):2019–2020.
20. Pan F, Ye T, Sun P, et al. Time course of lung changes at chest CT during recovery from coro-
navirus disease 2019 (COVID-19). Radiology. 2020;295(3):715–721.
21. Wang Y, Dong C, Hu Y, et al. Temporal changes of CT ndings in 90 patients with COVID-19
pneumonia: a longitudinal study. Radiology. 2020;2020:200843.
22. Cheung E. Coronavirus: some recovered patients may have reduced lung function and are left
gasping for air while walking briskly, Hong Kong doctors nd. South China Morning Post. https://www.scmp.com/news/hong-kong/health-environment/article/3074988/coronavirus- some-recovered-patients-may-have. Accessed June 16, 2020.
23. American College of Cardiology. COVID-19 clinical guidance for the cardiovascular care team. Am Coll Cardiol. 2020:1–4.
24. Akhmerov A, Marbán E. COVID-19 and the heart. Circ Res. 2020:1443–1455.
25. Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized
patients with COVID-19 in Wuhan, China. JAMA Cardiol.
26. Koralnik IJ, Tyler KL. COVID-19: a global threat to the nervous system. Ann Neurol.
2020;5(7):802–810. https://doi.org/10.1001/jamacardio.2020.0950.
27. Troyer EA, Kohn JN, Hong S. Are we facing a crashing wave of neuropsychiatric sequelae
of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms. Brain Behav Immun. 2020;87. https://doi.org/10.1016/j.bbi.2020.04.027.
Personal Protective Equipment (PPE) and Hospital Preparedness for COVID-19
Ehsun Mirza M.D. and Arijit Robin Chakraborty
CDC COVID-19 DIB
EMS NIOSH PPC
Centers for Disease Control and Prevention Coronavirus disease 2019
Doing It’s Best
National Institute for Occupational Safety and Health Pandemic Preparedness Committee
The focus of this chapter is to describe a hospital’s response to a coronavirus disease 2019 (COVID-19) outbreak in their area—including the ideal personal protective equipment (PPE) and the protocol necessary for preparation.
18.2 Personal Protective Equipment
All hospital personnel should have donned PPE prior to entering the room of a patient with COVID-19. This includes, but is not limited to, the use of eye protec- tion, gowns, face masks, respirators, and gloves.1
Eye protection: Eye protection is necessary to reduce the potential for droplet transmission between the air and the eyes. The World Health Organization (WHO) has found that the use of eye protection is associated with a decreased risk of infec- tion.2 It is often not considered, but eye protection can be an effective way to reduce the spread of infection in both the community and the hospital setting. In the context of a widespread shortage of PPE, it is prudent to limit the use of medically appropri- ate goggles to health-care workers. Protection from droplet transmission is only effective if the peripheral areas of the eyes are covered along with the front, so
Chapter 18: Personal Protective Equipment (PPE) and Hospital Preparedness for COVID-19
protection in the form of splash-proof safety goggles or a face shield reaching the front of both ears is recommended. Other forms of eye protection, such as swim- ming goggles or face shield glasses, can be used in the community without fear of depleting medical resources. In the event of limited supply, hospitals may cancel elective procedures that would require the use of eye protection.
Gowns: Since COVID-19 can be spread through fomite transmission, it is neces- sary for health-care personnel to don gowns while treating infected patients. Proper disposal of gowns will prevent the virus from being spread by the health-care per- sonnel’s clothing after contact with a patient. For this reason, ideal gowning should include full-length gowns with shoe covers, leaving no civilian clothing exposed to the environment of the patient’s room. This protocol may need to be adjusted depending on availability at individual hospitals. The use of polyester or polyester- cotton gowns, which can be safely washed and reused, can help mitigate issues with limited supply.
Face masks: Ideally, covering of the mouth should be accomplished through the use of a respirator. If respirators are not available or are in short supply, a face mask can be used. Face masks provide two-way protection, preventing contact with the health-care personnel wearing the mask and preventing the spread by the potentially exposed person wearing the mask. Face masks have been shown to dramatically reduce the risk of infection. A review by the WHO found that a person wearing a face mask is half as likely to become infected than a person not wearing a face mask.2 A recent study on the rate of transmission before and after mask mandates (April 8 to May 15) in 15 US states and the District of Columbia found that mask mandates led to a slowdown in daily COVID-19 growth rate.3 After 5 days, the daily growth rate was 0.9 percentage-points lower compared to the 5 days prior. After 3 weeks, the daily growth rate had slowed down by 2 percentage-points. The authors note that by May 22, as many as 230,000–450,000 cases had been averted.8
The reduction in transmission in a health-care setting is even more dramatic with the use of face masks, largely due to proper tting and consistent use (Figure 18.1). Despite the increased risk of exposure in a hospital, health-care workers are 0.30 times as likely to contract the virus as opposed to only half as likely.1 Proper use of face masks can counteract the increased risk of infection. In the event of limited supply, it is admissible to use face masks past their shelf life. If a box of face masks has lasted past its shelf life with no visible degradation of the material, it can be used in situations of crisis capacity.
In the context of COVID-19, the main difference between protecting the airway with a surgical mask and protecting the airway through use of a respirator is related to the size of the coarse particles released from a patient’s breath. Breath particles are designated either as “droplets” or as “aerosol.” Droplets are de ned as particles greater than 5 μm, and aerosol consists of particles smaller than 5 μm. Face masks and respirators provide protection from COVID-19 transmission from both droplets and aerosol, but respirators provide a higher degree of protection from aerosol.4 This is particularly important in contexts such as the intubation of an affected COVID-19 patient, where the person performing the intubation is more likely to come into contact with aerosolized particles that have a high viral load.
Figure 18.1 The 14 masks used in the test.7
In the United States, there are seven types of particulate ltering face-piece res- pirators that are approved for use by NIOSH (the National Institute for Occupational Safety and Health).4 They are classi ed based on two parameters: their resistance to oil and the percentage of airborne particles they can lter. Those that are not resis- tant to oil are classi ed N, those that are somewhat resistant to oil are classi ed R, and those that are strongly resistant to oil are classi ed P. They can lter, either at least 95% of airborne particles, at least 99%, or at least 99.97%, designating them by the numbers 95, 99, or 100. The seven available types are the N95, the N99, the N100, the R95, the P95, the P99, and the P100. Of these, the most widely available and widely used is the N95.
The N95 respirator is the standard in the United States for personal airway pro- tection, and is also approved by the WHO for the purpose of preventing COVID-19 transmission to health-care workers. The N95 has been shown to be more effective at preventing infection than face masks, including single-layer, 12-layer, or 16-layer
cotton masks.5 The N95 is comparable to the FFP2 which is certi ed for use in Europe, the KN95 in China, the P2 in Australia and New Zealand, the Korea 1st class respirator in Korea, and the DS2 in Japan.6 Due to availability, it is not recom- mended for the general public to use them in the event of a pandemic. They should be limited to use by health-care professionals who need to treat af icted patients. Ideally, patients with COVID-19 in hospitals should be placed in rooms with air- borne isolation, so only the personnel directly in contact with the patients should require the use of respirators. This is the most effective way to maximize a limited supply.
Surgical-grade masks are next most protective, but they can be costly and con- tribute to land ll waste. The evidence on homemade cotton masks is still emerging, but researchers from Duke University cobbled together a low-cost laser device and conducted a study comparing 14 different types of face coverings.7 The results showed that tted N95 masks followed by surgical masks blocked the greatest amount of droplets. N95 masks with valves were less effective. Masks made in three layers or more with vacuum cleaner bags or heavy weight quilter’s cotton were effective, but bandanas and neck eeces were among the least effective. Wearing a neck eece was actually worse than not wearing anything because the neck eece actually makes droplets proliferate in the air.
In COVID-19, viral load peaks in the days before onset of symptoms, speaking is enough to dispel virus-carrying droplets, and asymptomatic people can transmit disease. Centers for Disease Control and Prevention (CDC) and WHO guidance recommends that everyone wear masks to slow down the rate of transmission. If 80% of people wear masks, it could reduce transmission more than lockdowns, and according to the Institute of Health Metrics and Evaluation if 95% of Americans wear masks, then 30,000 deaths can be prevented by October.8
Potential Impact of PPE on Patients: PPE such as face masks, eye protection, and respirators have all been shown to reduce the transmission of COVID-19 and protect health-care workers. The major downside to the use of such strict PPE pro- tocol is the perception of reduced empathy among the patients who are being cared for. Some studies have shown that the use of face masks and face shields can lead to less effective communication between care providers and patients, and feelings of discomfort among patients. Patients experiencing isolation in a hospital are at risk for post-intensive care syndrome, which can be exacerbated by the lack of exposure to live human faces over an extended period of time.7 Fortunately, there are steps we can take to mitigate these issues, as well.
There are many steps health-care workers can take to humanize themselves and mitigate the psychological effects of prolonged isolation in patients with COVID-19. Some hospitals have added virtual visits between health-care personnel and their patients, allowing them an opportunity to interact without PPE. Another simple solu- tion is the PPE portrait project, where health-care workers keep disposable pictures of themselves attached to their PPE after donning them so that the patients can asso- ciate faces with their caretakers. This was started during the Ebola project in Africa, and has been implemented in some hospitals in the United States during the COVID- 19 project. Anecdotally, both patients and health-care workers have reported feeling a stronger sense of connection due to the introduction of PPE portraits.
Figure 18.2 The WHO’s hospital preparedness schematic for COVID-19.
Continuity of essential health services and patient care
Surge capacity
Logistics and management of supplies, including pharmaceuticals
Essential support services
Surveillance: early warning and monitoring
18.3 Hospital Preparedness
In the event of an emerging pandemic, how should a hospital respond? What steps need to be taken to ensure preparedness for a potential pandemic? What infrastruc- ture needs to be in place in order to make sure that a hospital can do its part in miti- gating the effects of a COVID-19 outbreak? To answer these questions, let’s look at the response by the ctional Doing It’s Best (DIB) hospital.
At DIB, the Pandemic Preparedness Committee (PPC) stays in constant contact with the WHO and the CDC as well as global news sources to stay informed of outbreaks everywhere in the world. They establish a speci c location in the hospital to be the center of coordination in the event of a pandemic. This location is equipped with the ability to communicate throughout the hospital as well as the local news, government, and even the WHO. The PPC is organized according to the WHO’s hospital preparedness schematic9, shown below (Figure 18.2).
Incident management system
The PPC consists of 11 members, one person at the head of the committee and 10 members who are each responsible for one of the key components of the incident response delineated by the above schematic.
1. The PPC Communication coordinator is responsible for gathering accurate information and communicating this information to the hospital staff and local community to ensure communal, coordinated, and evidence-based decision-making.
2. The Continuity coordinator maintains hospital services that must be contin- ued and diverts resources away from hospital services that must be postponed in the event of a pandemic.
3. The Surge capacity coordinator keeps inventory of the hospital’s resources and develops contingency plans for an acute increase in the demand for such resources.
4. The HR coordinator ensures adequate staff will be available to respond to a pandemic.
5. The Logistics coordinator communicates with DIB’s suppliers, works in con- junction with the Surge capacity coordinator to be aware of inventory, and maintains an in ux of necessary supplies in the event of an acute increase in need.
6. The Essential Support Services coordinator focuses on maintaining the conti- nuity of laundry services, waste management, cleaning, and other support services at DIB.
7. The Infection Prevention coordinator is responsible for ensuring compliance with infection prevention protocol.
8. The Case Management coordinator is responsible for triage of patients.
9. The Surveillance coordinator is a trained epidemiologist who maintains con-
tact with the WHO and CDC’s surveillance programs.
10. The Laboratory Services coordinator is responsible for ensuring the availabil-
ity of testing as well as the proper implementation or abstention from the use of tests.
The head of the PPC oversees all ten areas to ensure a coordinated response. Each member trains a prospective replacement who could potentially replace them in the event of an emergency. This ensures continuity of decision-making if any of the members of the PPC are incapacitated during a pandemic.
When the Surveillance coordinator identi es an outbreak that may affect their community, the Communication coordinator immediately launches an awareness program that informs the hospital personnel about the potential outbreak as well as the key symptoms and history that would lead to the identi cation of infected patients. This is a process that the PPC and the employees would have already been accustomed to, because it was set in motion in the event of SARS, MERS, H1N1, Ebola, and other potential outbreaks that never made it to the news cycle.
The PPC becomes aware of COVID-19 in the early stages of the outbreak through the CDC, which is in close contact with the WHO’s Global In uenza Programme
that facilitates the identi cation and surveillance of u-like viruses across the world. As a result, the health-care workers at DIB are primed to be on the lookout for any patients with fever, malaise, and dry cough. Any patient presenting with these symp- toms can be recognized upon admission and regarded as potentially infected with COVID-19.
Prior to the outbreak, the Case management coordinator would have already assembled a team of trained hospital personnel who were speci cally assigned the task of handling triage in the event of a pandemic. As soon as they receive word of an outbreak involving an airborne upper respiratory infection, they work with the Surge Capacity and Logistics coordinators to take inventory of face masks, and make sure there will be enough available so they can be given to any patients being admitted with symptoms suggesting COVID-19. They in turn train the admission staff to recognize the symptoms of fever, malaise, and dry cough to maximize the number of people on the lookout for patients that should be offered face masks.
The waiting areas are reorganized in order to keep patients 6 ft apart as well as direct patients with COVID-19 symptoms to a designated area. Simultaneously, the PPC contacts local news sources and advertisers who help them spread the aware- ness of COVID-19 in their community and encourage patients to utilize phone and Telemedicine consultations in order to minimize the risk of spreading the virus. The team also develops a written set of instructions about which patients would require admission, testing, and potentially be put on a ventilator, incorporating consider- ations such as age, comorbidities, and upcoming nonelective surgeries. The team is also in constant contact with the local emergency medical services (EMS) agencies that service DIB in order to identify potential COVID-19 patients being brought via ambulance so that the triage process for them can be done ahead of time. Every staff member in the hospital is informed to report potential cases to the PPC, and the PPC immediately reports any con rmed case to the local health department and the CDC.
DIB is prepared to use the proper PPE and to isolate potentially infected patients. As soon as a potential COVID-19 patient is identi ed, a systematic communication method relays the information between the front desk admissions and hospital per- sonnel responsible for setting up an isolation room, complete with an air ltration system to minimize the presence of airborne virions. Personnel donned with proper PPE escort the patients to their rooms.
Potentially infected patients are tested depending on the type of care the patients may need. If the patients are young, otherwise healthy, presenting with mild symp- toms, not scheduled for an upcoming nonelective surgery, or free of any comorbidi- ties, they are not tested. Whether they are positive or negative for the virus, these patients are sent home and advised to self-quarantine. If patients are older, function- ally limited, presenting with severe symptoms, scheduled for an upcoming nonelec- tive surgery, or positive for comorbidities, they are tested. A positive test means that their hospital stay will continue with isolation protocol.
The staff at DIB are diligent about preventing spread of the virus within the hos- pital from infected patients. Every hospital employee who needs to enter an isola- tion room does so with proper attire, complete with gloves, eye protection, respirator,
gown, and shoe covers. After time spent inside of an isolation room, no employee makes contact with the nonisolated section of the hospital without a changing and washing protocol. Outside the isolation setting, the employees wash their hands regularly, practice physical distancing, wear surgical masks at all times, and are regularly screened for COVID-19 symptoms. Let’s examine each part of their infec- tion prevention plan other than isolation.
Hygiene: Alcohol-based foam hand sanitizer dispensers are installed in conve- nient locations throughout the hospital, and the staff are accustomed to a “foam-in, foam-out” rule where hands are sanitized before and after every patient encounter. Sanitizer is used at least every two hours even without patient encounters.
Physical Distancing: Staff at DIB maintain 6 ft of distance between each other and with patients unless closer contact is necessary for proper medical care. Elevator capacities are adjusted to allow passengers to maintain the distance. Physical Plexiglas barriers are incorporated at nurse’s stations and reception desks.
Masks: The PPC takes inventory of masks and nds that their supply cannot sup- port a worsening pandemic. So, they mandate masks be worn by all health-care work- ers and all symptomatic patients. Once their mask supply is replenished and ready to handle the pandemic, all individuals in the hospital are required to wear masks, including non-health-care staff and all patients regardless of symptoms or diagnosis.
Screening: No staff member is allowed in a DIB hospital building if they are posi- tive for any symptoms of COVID-19 in the past three days, including fever, dry cough, sore throat, or a loss of taste sensation. If a staff member has had such symptoms, they must have two negative COVID-19 tests before being considered for return to work.
Over time, these infection prevention protocols become a normal part of DIB’s culture and are not seen as an inconvenience or imposition on the people who are in the hospital. DIB hospital manages to help patients, prevent spread of the virus, and minimize the death toll of the pandemic until time and new information brought the virus under control.
What were some key steps that DIB took in order to accomplish this? Some key points are below:
1. Appoint a committee for the express purpose of pandemic preparedness.
2. Maintain a constant communication with the WHO, CDC, and local health
departments.
3. Write down a speci c plan that describes triage policy changes in the event of
a pandemic, as well as plans on how to train personnel about recognizing
potentially infected patients.
4. Train and rehearse the plan.
5. Implement the plan before a pandemic arrives in the local area.
6. Communicate with local news sources, and spread information about the pan-
demic to the local community.
7. Maintain a strict protocol to prevent nosocomial infections, involving a com-
prehensive plan incorporating strict hygiene protocol, physical distancing, mandatory wearing of face masks, and regular screening for COVID-19 symptoms.
Dr. Atul Gawande recommends four pillars to effectively stem the spread of COVID-19—hygiene, distancing, screening, and masks.10 The fth pillar, in Dr. Gawande’s strategy, is culture, in hospitals and general community settings, that requires people to care about their own safety as well as the safety of others.11 It means following rules and noting when such rules are lapsing, and being comfort- able in pointing out when standards are slipping.
1. Centers for Disease Control and Prevention. Using personal protective equipment (PPE). https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html. Published April 3, 2020. Accessed July 2, 2020.
2. Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020;395(10242):1973–1987. https://doi.org/10.1016/ s0140-6736(20)31142-9.
3. Centers for Disease Control and Prevention. Approved particulate ltering facepiece respi- rators. https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html. Published April 9, 2020. Accessed July 2, 2020.
4. Lyu W, Wheby GL, Community use of face masks and COVID-19: evidence from a natural experiment of State mandates in the U.S. Health Aff. 2020:39(8):1–7. https://doi.org/10.1377/ hlthaff.2020.00818.
5. Leung NH, Chu DK, Shiu EY, et al. Respiratory virus shedding in exhaled breath and ef cacy of face masks. Nat Med. 2020;26(5): 676–680. https://doi.org/10.21203/rs.3.rs-16836/v1.
6. 3M. Comparison of FFP2, KN95, and N95 and other ltering facepiece respirator classes. Revision 4. 2020.
7. Fisher EP, Fisher MC, Grass D, et al. Low-cost measurement of facemask ef cacy for lter- ing expelled droplets during speech. Sci Adv. Published online 07 August 2020. https://doi. org/10.1126/sciadv.abd3083.
8. IMHE.NewIHMECOVID-19modelprojectsnearly180,000USdeaths.June24,2020.IMHE. http:// http://www.healthdata.org/news-release/new-ihme-covid-19-model-projects-nearly-180000-us-deaths.
9.World Health Organization 2020. https://www.euro.who.int/__data/assets/pdf_
le/0010/430210/Hospital-Readiness-Checklist.pdf. Accessed July 8, 2020.
10. Gawande A. Amid the Coronavirus Crisis, a Regimen for Reëntry. https://www.newyorker. com/science/medical-dispatch/amid-the-coronavirus-crisis-a-regimen-for-reentry. Published
May 13, 2020. Accessed July 6, 2020.
11. Brown-Johnson C, Vilendrer S, Heffernan MB, et al. PPE Portraits—a way to humanize personal
protective equipment. J Gen Intern Med. 2020. https://doi.org/10.1007/s11606-020-05875-2.
Sarah Zaidi Sc.D., MSc., and Naiyer Imam M.D.
BAL Bronchoalveolar lavage
CDC Center for Disease Control
DNA Deoxyribonucleic acid
FIA Fluorescent immunoassay
FIND Foundation for Innovative New Diagnostics GISAID Global Initiative on Sharing all In uenza Data IgG Immunoglobulin G
NAAT Nucleic acid ampli cation test
RNA Ribonucleic acid
RT-PCR Reverse transcriptase polymerase chain reaction SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2
The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as an unprecedented public health threat. As an airborne virus, it is largely transmitted via respiratory droplets with the rst symptoms appearing around 5 days after infection (ranging from 2 to 14 days).1 However, unlike other coronaviruses, a sizable portion of person-to-per- son transmission of SARS-CoV-2 occurs before infected individuals develop symp- toms (presymptomatic) or never develop any symptoms (asymptomatic).2
A country’s ability to contain COVID-19 outbreaks depends on identifying and isolating positive cases, and quarantining their contacts. Large-scale diagnostic test- ing is essential since it allows countries to track viral spread within communities, to safely reopen economies and return life to the new normal, and to better manage clinical progression of illness. Early detection of COVID-19 can aid in the
Chapter 19: Testing for COVID-19
management of patients and prevent deaths. This chapter focuses on diagnostic test- ing currently available for COVID-19, and assesses their effectiveness in accurately detecting positive cases.
19.2 Background
The genomic sequence of the SARS-CoV-2 was released on January 10, 2020,3 and it was soon followed by four other genomes deposited two days later in the viral sequence database curated by the Global Initiative on Sharing all In uenza Data (GISAID).4 As a result of this early sharing of the genome, companies and research groups across the world quickly worked toward developing diagnostic test kits. Researchers from Germany at the German Center for Infection Research (DZIF)5 at Charité in Berlin developed the rst laboratory assay to detect the virus that served as the basis for the rst diagnostic kits shipped by the World Health Organization (WHO) to its regional of ces on February 2 along with guidance on their use.6 Aggressive testing in Hong Kong, Republic of South Korea, Singapore, and Taiwan helped to contain transmission (discussed in Chapter 23). Even European countries relied on scaling up testing to contain outbreaks, isolate infected individuals, and quarantine their contacts. The WHO recommended that governments test as many people as possible and that the rate of positivity in testing should remain at 5% or lower for at least 14 days before reopening and lifting stay at home orders and lockdowns.7
19.3 Types of Tests—NAAT, Antibody, and Antigen
Two types of diagnostic tests were being used to detect COVID-19. First, the real- time reverse transcriptase polymerase chain reaction (RT-PCR), a nucleic acid ampli cation test (NAAT), and second, serological tests that rely on host immuno- globulin G (IgG) or IgM, interleukins, and other host components. The RT-PCR, considered the gold standard, was usually done by swabbing the nose or mouth for the virus. From the swab sample, a speci c section of the viral genome reverse- transcribes the viral ribonucleic acid (RNA) into deoxyribonucleic acid (DNA) and ampli es it through PCR to detectable amounts of the virus. The test requires a laboratory and can also be carried out on automated platforms known as point-of- care diagnostic testing like the Abbott ID NOW. The results can take several hours to complete, and RT-PCR testing requires test kits and materials from nose swabs to chemical reagents, as well as trained health-care professionals to administer.8
RT-PCR testing is nearly 100% accurate, but its accuracy depends on the amount of viral RNA present in the sample, which can depend on a variety of factors such as the timing of the test and the start of infection and/or onset of symptoms, the swabbing technique, and the location of the samples. The viral load samples based on location from within patients can vary. In COVID-19-positive patients, test results, determined by RT-PCR, report the following levels from samples: 93% from
Types of Tests—NAAT, Antibody, and Antigen
the bronchoalveolar lavage (BAL), 72% from sputum, 63% from nasal swab, 32% from pharyngeal swab, 29% from feces, 1% in blood, and 0% in urine.9 Scaling up RT-PCR can be expensive. However, recently, a saliva test, SalivaDirect, instead of respiratory swabs is under consideration by the FDA for approval. The test is inex- pensive ($1.29–$4.37) and doesn’t require as many material inputs.
The other test for COVID-19 also under use are the serological tests that detect viral-speci c antibodies, IgM or IgG. The presence of antibodies (seroconversion) takes time, depending on severity of the illness and the individual’s immune sys- tem.10 Antibodies are typically uniformly distributed in the blood, and therefore, there is less variation. Virus-speci c antibody, IgM, rises 3 days after the onset of symptoms and begins to disappear as the patient recovers. IgG, which typically rises 10 to 11 days after the onset of symptoms, remains in circulation long after the infection. Serological tests are useful in determining if an individual ever had COVID-19, and should not be used to diagnose current infection because of the slow pace of the antibody response or cross-reactivity with other infections, includ- ing those caused by other human coronaviruses. Tests administered too soon when the immune response is evolving can result in inaccuracies (discussed next).
At the population level, antibody tests offer a few advantages over RT-PCR test- ing. Serological tests are easier to administer requiring a small amount of blood, and tend to be less sensitive to spoilage during collection, transport, storage and analy- sis. Antibody testing is also important for understanding the overall prevalence of COVID-19 in a community or for purposes of population-level studies.
Together, these two types of tests can be helpful in determining clinical signi – cance of a patient exposed to COVID-19 infection (Table 19.1).11 A note of caution, in the absence of longitudinal data, it is not clear if the presence of antibodies con- fers long-term immunity (see Chapter 2) and it would be well advised to maintain protective measures.
Table 19.1 Diagnostic Testing and Clinical Outcome at the Individual Level
Clinical Outcome
Patient is in incubation period of infection
Patient is in early stages of infection
Patient is in active disease
Patient is in late stage of infection
Patient could be in early stage of infection; RT-PCR result may be false negative
Patient may have had COVID-19 and has recovered
Patient may be in the recovery stage; RT-PCR result may be false negative
The currently available, as well as emerging, diagnostic tests are conveniently summarized at the Mass General website: https//csb.mgh.harvard.edu/covid.
Antigen tests for COVID-19 can reveal if a person is currently infected with SARS-CoV-2. Almost as accurate as RT-PCR (but with much less sensitivity), anti- gen tests detect proteins or glycans, like the spike proteins on the surface. These tests take longer to develop than molecular and antibody tests because suitable anti- bodies for use in the assays must rst be identi ed and produced. But antigen tests are rapid and relatively cheap, and more amenable to point-of-care technology. The FDA has approved one antigen test from Quidel, So a SARS Antigen Fluorescent Immunoassay (FIA) [https://www.quidel.com/immunoassays/rapid-sars-tests/so a- sars-antigen- a], which takes 15 min.
COVID-19 has triggered innovation in diagnostic thinking. For example, the use of genome-editing technology CRISPR developed for cancer treatment is being used for detecting COVID-19. CRISPR-based tests rely on nucleic acid extraction and ampli cation and can detect as few as 100 coronavirus particles in a swab or saliva sample, and they don’t require many specialty reagents or materials.12 The tests are administered through cartridge-like devices and provide results within an hour, which makes them attractive to use in a variety of settings. Although CRISPR tests are based on RT-PCR, they tend to produce slightly more false negatives in compari- son. Nonetheless, CRISPR-based diagnostics could be an important step toward safely reopening society. The FDA, on May 7, approved the rst CRISPR-based diagnostic product, Sherlock Biosciences’ 1-h test for SARS-CoV-2.13 Mammoth Biosciences and GlaxoSmithKline are working on a 20-min CRISPR-based test.
There are other radical ideas using nanobiotechnology, biophotonics, and nano u- ids.14 For example, researchers are working on facemasks embedded with biosensors that could detect the presence of virus or other devices that could display the virus on piece of silicone or paper. It is likely that the next wave of diagnostics could emerge from the intersection of physical and engineering sciences and biology. The US Congress has doubled the annual budget of the US National Institute of Biomedical Imaging and Bioengineering (NIBIB) by an additional $500 million, and at the same time, the Defense Advanced Research Projects Agency (DARPA) is funding two CRISPR projects that could deliver low-cost, high-volume point-of-care tests.
The US Center for Disease Control (CDC) has developed a new laboratory test that can detect SARS-CoV-2 and in uenza A and B viruses at the same time.15 The CDC In uenza SARS-CoV-2 (Flu SC2) Multiplex Assay allows laboratories to con- tinue in uenza surveillance while testing for COVID-19, and conserves important testing materials that are in short supply. The Flu SC2 Multiplex Assay was issued an Emergency Use Authorization on July 2, 2020.
19.4 Sensitivity, Specificity, and Accuracy in Testing
In COVID-19 diagnostic testing, accuracy matters and interpreting test results can be challenging.16 Validity of a test is measured in terms of its sensitivity and speci c- ity (Table 19.2). Sensitivity is the test’s ability to identify those with infection and
Interpretation of Tests: Understanding Predictive Values
Table 19.2 Determining Sensitivity, Speci city, and Accuracy
Sensitivity = TP/TP + FN
Speci city = TN/FP + TN
Accuracy = (TP + TN)/(TP + FP + TN + FN)
antibodies, true positives—positive test in a patient with disease. Sensitivity levels of tests are very important because patients who are infected but diagnosed as not having COVID-19 can continue to infect others and spread the disease. Speci city is the test’s ability to identify those without infection, true negatives—negative test in a healthy individual. In the case of individuals who are not infected, but deter- mined to be disease-positive, there are not as many concerns in terms of transmis- sion but people could erroneously assume immunity when that is not the case.
Accuracy is the proportion of correct predictions (true positives and true nega- tives) among the total number of cases examined. Accuracy is based upon the inher- ent value of the test, and a higher accuracy of a test re ects a combination of higher sensitivity and speci city (note: the term accuracy in layman’s term differs and is more vague from the term as de ned here as used in statistics).
The NAATs typically have high sensitivity and speci city under ideal condi- tions, but in clinical reality, these measures can vary and depend on the quality of specimen collection, the viral load, and duration of illness. RT-PCR is a good con- rmatory test, but according to researchers, false-negative results (people who are positive for COVID-19 but test negative) are more common than initially thought. In one study from Johns Hopkins, 1 in 5 persons was found to have a false-negative result.17 A systematic review reported false-negative rates between 2% and 29% (equating sensitivity to 71–98%).18
Antibody tests are increasingly available but tend to be less accurate. The Foundation for Innovative New Diagnostics (FIND), a global nonpro t organization, conducted an independent evaluation of SARS-CoV-2 antibody diagnostic tests (https://www. nddx.org/covid-19/dx-data/) and observed that range was between 25% and 75% for sensitivity. In the United States, the FDA had initially loosened its standards allowing companies to sell antibody tests without submitting clinical evi- dence on the accuracy of the test but it has recently tightened regulations.19
19.5 Interpretation of Tests: Understanding Predictive Values
Negative and positive predictive values must be considered in interpretations of a COVID-19 test. A negative predictive value is the proportion of true-negative results with total negative results. A positive predictive value, also known as precision, is the proportion of true-positive results with the total number of positive results.
Disease Yes
Disease No
Test positive
True positive (TP)
False positive (FP)
Test negative
False negative (FN)
True negative (TN)
People with Disease
People without Disease
Table 19.3 Predictive Powers of a Test with 90% Sensitivity and Speci city (5% Prevalence)20
Predictive value of a positive test: 4500/14,000 = 32.1%. Predictive value of a negative test: 85,500/86,000 = 99.4%. Accuracy of test: (4500 + 85,500)/100,000 = 90.0%.
Table 19.4 Predictive Powers of a Test with 90% Sensitivity and Speci city (25% Prevalence)
Predictive value of a positive test: 22,500/30,000 = 75%. Predictive value of a negative test: 67,500/70,000 = 96.4%. Accuracy of test: (22,500 + 67,500)/100,000 = 90.0%.
It is important to understand that the predictive value of tests changes along with the prevalence of disease,20 while accuracy remains xed. Consider a hypothetical situation with a test with 90% sensitivity, speci city, and accuracy. In a community of 100,000 people with 5% prevalence of disease (5000 positive cases) and 90% sensitivity and speci city, there would still be 500 false negatives and 9500 false positives (Table 19.3), and the predictive value of a positive test would only be 32%, meaning 68% would receive incorrect information. In contrast, in a similar com- munity of 100,000 people with 25% prevalence of disease (25,000 positive cases) and 90% sensitivity and speci city, there would be 2,500 false negatives and 7500 false positives (Table 19.4) with a predictive value of a positive test of 75%, mean- ing 25% would receive incorrect information.
Sensitivity, speci city, and accuracy vary among antibody tests, and their inter- pretation based upon predictive values must also take into account the prevalence of COVID-19 in a community or country.
For a more visual depiction of this concept, please see
https://www.youtube.com/watch?v=qtlSu7OhkYE&feature=youtu.be
In conclusion, testing for COVID-19 is critical for containing the disease and safely opening countries. Countries need to put in place testing strategies and use tests that are validated for realistic conditions. It is important to start testing asymptomatic
people who can unknowingly spread COVID-19. Given the uncertainty regarding immunity, all those testing positive for COVID-19 should still maintain protective measures such as wearing masks, practicing hand hygiene, and refraining from large gatherings.
Diagnostic tests should be affordable and easy to use, especially those for screen- ing and for determining prevalence. Serological surveys should be performed regu- larly in high-risk communities and situations. Diagnostic interpretation of tests must take into consideration not only the inherent accuracy of the tests but also the preva- lence of COVID-19 in the community or country. As new diagnostic methods come forward, all people should have equal access to these emerging technological tools.
1. Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus disease 2019 (COVID- 19) from publicly reported con rmed cases: estimation and application. Ann Intern Med. 2020;172(9):577–582. https://doi.org/10.7326/M20-0504.
2. Huff HV, Singh A. Asymptomatic transmission during the COVID-19 pandemic and implica- tions for public health strategies [published online ahead of print, 2020 May 28]. Clin Infect Dis. 2020;ciaa654. https://doi.org/10.1093/cid/ciaa654.
3. GenBank: MN908947.3 Severe acute respiratory syndrome coronavirus 2 isolate Wuhan-Hu-1, completing genome. Available at: https://www.ncbi.nlm.nih.gov/nuccore/MN908947.
4. GISAID, Genomic epidemiology of hCoV-19. https://www.gisaid.org/epi u-applications/ next-hcov-19-app/.
5. Corman VM, Landt O, Kaiser M, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Eurosurveillance. 2020;25(2):23–30.
6. World Health Organization. Timeline of WHO’s response to COVID-19. 29 June 2020. WHO. https://www.who.int/news-room/detail/29-06-2020-covidtimeline.
7. World Health Organization. Public health criteria to adjust public health and social measures in the context of COVID-19. 12 May 2020. WHO. https://www.who.int/publications/i/item/ public-health-criteria-to-adjust-public-health-and-social-measures-in-the-context-of-covid-19.
8. Yan Y, Chang L, Wang L. Laboratory testing of SARS-CoV, MERS-CoV, and SARS- CoV-2 (2019-nCoV): current status, challenges, and countermeasures. Rev Med Virol. 2020;30(3):e2106. https://doi.org/10.1002/rmv.2106.
9. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of clinical speci- mens. JAMA. 2020;323(18):1843–1844. https://doi.org/10.1001/jama.2020.3786.
10. AMA. Serological testing for SARS-CoV-2 antibodies. 13 May 2020. https://www.ama-assn. org/delivering-care/public-health/serological-testing-sars-cov-2-antibodies.
11. Weissleder R, Lee H, Ko J, Pittet MJ. COVID-19 diagnostics in context. Sci Transl Med. 2020;12(546):eabc1931. https://doi.org/10.1126/scitranslmed.abc1931.
12. Interdisciplinary group of scientists at MIT, the McGovern Institute and the Broad Institute. STOPCOVID. https://www.stopcovid.science/approach.
13. FDA. Sherlock CRISPR SARS-CoV-2 Kit. 6 May 2020. https://www.fda.gov/media/137747/ download.
14. Sheridan, C. COVID-19 spurs wave of innovative diagnostics. Nat Biotechnol. 2020;38:769– 772. https://doi.org/10.1038/s41587-020-0597-x.
15. CDC. CDC Diagnostic Tests for COVID-19. 5 August 2020. https://www.cdc.gov/ coronavirus/2019-ncov/lab/testing.html.
16. Watson, J. Interpreting a covid-19 test result. BMJ. 2020;369:m1818. https://doi.org/10:1136/ bmj.m1808.
17. Kucirka LM, Lauer SA, Laeyendecker O, et al. Variations in false-negative rate of reverse transcriptase polymerase chain reaction—based SARS-CoV-2 tests by time since exposure. Ann Intern Med. 13 May 2020. https://doi.org/10.7326/M20-1495.
18. Arevalo-Rodriguez I, Buitrago-Garcia D, Simancas-Racines D, et al. False-negative results of initial rt-PCR assays for COVID-19: a systematic review. medRxiv. 2020.014.15.20066787. https://doi.org/10.1101/2020.04.16.20066787.
19. FDA. Policy for diagnostic tests for coronavirus disease during the Public Health Emergency. 2020. Docket number: FDA-2020-D-0987. https://www.fda.gov/regulatory-information/search- fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health- emergency-revised.
20. Kumleben N, Bhopal R, Czypionka T, et al. Test, test, test for COVID-19 antibodies: the importance of sensitivity, speci city and predictive powers [published online ahead of print, 2020 Jun 11]. Public Health. 2020;185:88–90. https://doi.org/10.1016/j.puhe.2020.06.006.
Drugs for Treating COVID-19
Syed E. Ahmad M.D., Nooshi Karim M.D.,
BTK COVID-19 CQ
Bruton’s tyrosine kinase Coronavirus disease 2019 Chloroquine Deoxyribonucleic acid Emergency use authorization Food and Drug Administration Favipiravir Hydroxychloroquine
Human immunode ciency virus Janus kinase
Post-exposure prophylaxis Remdesivir
Ribonucleic acid
The treatments for COVID-19 can be split up into different categories. It should be noted that there are no FDA-approved drugs for the treatment of COVID-19. However, all treatments right now are experimental. There have been no clinical data that demonstrates bene ts with any of these drugs, but the information on drug treatment is rapidly evolving. Many of these drugs were developed prior to the pan- demic and have been repurposed from their intended use to treat COVID-19 patients while some are new compounds (Table 20.1).
Classi cation
Treatment Strategy
Induce premature termination in RNA replication using an adenosine analogue
NCT04401579 (NIH-sponsored)
May target proteases that cleave polypeptides essential for SARS-CoV2 replication
Targets RNA-dependent RNA polymerase preventing SARS-CoV2 replication
Neuraminidase enzyme inhibitor, which may prevent virion progeny to be released
Antimalarial
Hydroxychloroquine/ chloroquine
Reduce in ammatory response
Possibly prevent viral entry May interfere with viral assembly
Mitigate in ammation Could reduce viral replication in RNA viruses
NCT04358068 (NIH-sponsored) NCT04332107 (Phase 3, 2271 participants)
Clofazimine
Tocilizumab/sarilumab
Antibodies that block IL-6 receptor to diminish cytokine storm effects
NCT04320615 (Tocilizumab, U.S BARDA-funded)
Antibody against pro-in ammatory cytokine IL-1β
NCT04362813 (phase 3, 450 participants)
Kinase inhibitors
Suppresses immune response reducing cytokine storm effects
NCT04380688 (phase 2, 60 participants) NCT0434619 (phase 2, 140 participants)
Both trials are being sponsored by AstraZeneca
Inhibits JAK1/JAK2 to reduce in ammatory response
May also reduce viral entry
NCT04421027 (phase 3, 400 participants) NCT04401579 (NIH- sponsored, baricitinib with Remdesivir)
Inhibits JAK1/JAK3 lessening in ammatory response
NCT04412252 (phase 2, 240 participants, P zer led)
NCT04415151 (phase 2, 60 participants, Yale University led)
JAK1/JAK2 inhibitor to mitigate in ammation
NCT04362137 (phase 3, 402 participants, led by Novartis) NCT04377620 (phase 3, 500 participants)
Prevents SARS-CoV-2 entry and replication
·NCT04446377 (phase 2, 142 participants)
Table 20.1 Summary of New and Repurposed Existing Compounds for COVID-19 Treatment
Chapter 20: Drugs for Treating COVID-19
Immunomodulator
Antagonist for IL-1 receptor reducing in ammatory response
Nonspeci c anti-in ammatory
Glucocorticoid agonist which aids in immune suppression
NCT04381936 (2104 received dexamethasone vs. 4321 received usual care)
Prednisolone-based glucocorticoid that reduces in ammatory response
NCT03852537 (phase 2 study, Mayo clinic led) NCT04374071 (completed with 250 participants)
Glucocorticoid that is commonly inhaled to suppress immune response
NCT04377711 (phase 3, 400 non-hospitalized patients) NCT04435795(phase 3, 454 outpatient participants)
Budesonide and formoterol
Budesonide is an inhaled glucocorticoid steroid to suppress immune response Formoterol is a bronchodilator
NCT04193878 (phase 3, 600 participants, NIH-funded)
Anti-in ammatory
Reduces the secretion of pro-in ammatory cytokines
NCT04322682 (phase 3, 6000 participants)
Prevents viral replication in RNA viruses
NCT04359680 (phase 3, 800 health-care workers receiving prophylaxis treatment) NCT04343248 (phase 3, 800 elderly residents receiving prophylaxis treatment)
Prevents SARS-CoV2 replication
Induces anti-in ammation
20.2 Convalescent Plasma
Convalescent plasma is another experimental therapy that has been postulated. This is when blood is donated from patients who have previously recovered from the virus and the antibodies are then administered to a person who hasn’t recovered. This is potentially a pre- or post-exposure prophylaxis treatment, rather than the treatment of acute illness. This procedure has been researched for many years with different viruses, but there is very limited data showing its ef cacy for COVID-19. Please see the following chart from MGH summarizing the signi cant trials and results:
Primary Result
Soo 2004(7)
Nonrandomized, retrospective, convalescent plasma vs. methylprednisolone
Txt = 19 Comparison = 21
↓ mortality, ↓ hospital stay in convalescent plasma group
Hung 2011 (8)
H1N1 in uenza
Prospective cohort, convalescent plasma vs. standard of care
Txt 20 Control = 73
Convalescent plasma associated with ↓mortality and ↓viral load
RCT of hyperimmune IVIG (concentrated and fractionated convalescent plasma) vs. normal IVIG
Txt = 17 Control = 18
H-IVIG was associated with ↓mortality and ↓ viral load
Beigel 2019(10)
In uenza A
RCT, high-titer anti-in uenza plasma vs. low-titer plasma
High-titer anti- in uenza plasma showed no bene t over low-titer plasma; 34% had adverse events
Van Griensven 2016 (11)
Nonrandomized, convalescent plasma vs. standard of care
Txt 99 Control = 418
No signi cant difference in survival between groups
Recently, there was one trial that showed out of the ve patients that received a transfusion, the viral load decreased and the patients clinically improved. However, there are aws in this treatment because it takes a lot of resources and is expensive. Therefore, as for any of the treatments, additional research needs to be done to weigh the pros and cons.
20.3 Antiviral, Antiretroviral
20.3.1 Remdesivir
Remdesivir (RDV) is a broad-spectrum antiviral which inhibits viral RNA polymer- ases by incorporating an adenosine analogue into nascent RNA chains, causing pre- mature termination.1 Gordon, Tchesnokov, Woolner, et al. (2020) recently proved that the triphosphate form of RDV effectively inserts into the RNA polymerase of MERS-CoV.2 This mechanism was shown to occur even more ef ciently than natu- ral nucleotide pools, making RDV an attractive candidate for further research for targeting SARS-CoV-2. An in vitro study by Wang et al. (2020) corroborates this mechanism against SARS-CoV-2 in Vero E6 cells, at a stage post-virus entry.3 Researchers suggested RDV to be effective in nonhuman primates at its working concentration.
Antiviral, Antiretroviral
Much investigation is underway to determine the ef cacy of RDV for treating COVID-19.4 Published studies show promising results showing shorter recovery times and clinical improvement, yet one study found no signi cant clinical bene ts.5
• In a randomized, double-blind, placebo-controlled multicenter trial, it was found that the drug was not associated with statistically signi cant clinical bene ts. However, there was a reduction in time to clinical improvement that warrants further con rmation. This was the rst study of its kind assessing the effect of intravenous RDV for COVID-19, published in late April.6
• Another study was published in late May, which was also double-blind, ran- domized, and placebo-controlled. Researchers conducted trials of intravenous RDV in adults hospitalized with COVID-19. It was found that RDV led to shorter times to recovery than placebo.7
• A study published in the NEJM investigated the compassionate use of RDV on patients hospitalized with COVID-19.8 Patients were intravenously given a 10-day course of RDV. Clinical improvement was de ned as live discharge from the hospital, a decrease of at least 2 points from baseline on a modi ed ordinal scale (as recommended by the WHO R&D Blueprint Group)8, or both. It was concluded that RDV led to a clinical improvement of 36 of 53 patients (68%).
RDV is one of the few drugs to show bene t in COVID-19. Importantly, RDV is an investigational drug and is not FDA approved for any indication at the present time. It was only given to hospitalized patients on a compassionate use basis in late January and in clinical trials since February. Initially, the US Department of Health and Human Services was the sole allocator of the drug during a ve-month period. As of October 1, 2020, its distribution responsibilities have been returned to the hands of Gilead Sciences, Inc.
On May 1, 2020, the FDA issued Veklury (remdesivir) for treatment of hospital- ized patients with severe COVID-19. Patients with severe disease were de ned as patients with oxygen saturation (SpO2) ≤94% on room air or requiring supplemental oxygen or requiring mechanical ventilation or requiring extracorporeal membrane oxygenation (ECMO). On August 28, 2020, the FDA reissued the May 1st letter and expanded the authorized use of the drug. Now, its use is no longer limited to patients with severe coronavirus disease.
20.3.2 Lopinavir/Ritonavir
Lopinavir and ritonavir are two structurally related protease inhibitors that are coad- ministered or coformulated. Lopinavir is a selective inhibitor of the human immu- node ciency virus (HIV)-1 protease, arresting its maturation and decreasing further infectivity. Ritonavir has a similar activity, however not as effective due to the initial hepatic metabolism. The purpose of coadministration is for low-dose ritonavir to
inhibit metabolic inactivation of lopinavir, acting mainly as an enhancer in an enzy- matic kinetics context.9 This drug combination is widely used for treating HIV-1 infections, ultimately by suppressing plasma viral load.
Pre-pandemic literature shows evidence of lopinavir/ritonavir leading to better clinical outcomes for treating SARS.10 As of June 24, 2020, there are 28 active trials that include the usage of lopinavir/ritonavir as a primary or control treatment for COVID-19 (ClinicalTrials.gov, 2020).
There is evidence of some effectiveness with use of lopinavir/ritonavir as part of a combination with other drugs; however, further con rmation is required. A nota- ble study found a triple combination of interferon beta-1b, lopinavir/ritonavir, and ribavirin to alleviate symptoms and shorten hospital stay for COVID-19 patients.11 In another study, however, Cao et al. (2020) found no bene t to a lopinavir/ritonavir treatment compared to standard care. Researchers conducted a randomized, con- trolled, open-label trial in 199 hospitalized patients with COVID-19 with points of comparison: time to clinical improvement, mortality, and detectable viral RNA. NIH guidelines also advise against lopinavir/ritonavir and other HIV protease inhibitors for COVID-19 due to pharmacodynamic evidence of insuf cient drug levels when taken orally.12, 13 The NIH also cited the previously mentioned trial by Cao et al. (2020) in their justi cation.
20.3.3 Favipiravir
Favipiravir (FPV) targets viral replication and transcription by acting as a pseudo- purine nucleic acid, thereby selectively inhibiting RNA-dependent RNA poly- merase. It is potent against strains of in uenza virus, arena-, bunya-, and aviviruses, as well as members of the alphavirus, paramyxovirus, and norovirus families. It is also useful for viruses that are resistant to neuraminidase inhibitors.14 There are cur- rently a few clinical trials assessing the ef cacy of FPV for treating COVID-19. A study comparing FPV to the control group administered lopinavir/ritonavir found signi cant clinical differences in median viral clearance time (4 vs. 11 days), as well as in the improvement of chest imaging.15 Meanwhile, another study found no signi cant bene ts to FPV in comparison with umifenovir.16
20.3.4 Oseltamivir (Tamiflu)
Oseltamivir, once converted to oseltamivir carboxylate after ingestion, is a neur- aminidase enzyme inhibitor.17 By binding to the active site of neuraminidase enzyme, progeny virions may not be released from the infected cell, greatly reduc- ing the spread of the virus.18 However, the use of oseltamivir as a potential drug for SARS-CoV-1 was also explored prior to the COVID-19 pandemic with unpromis- ing results.19 Despite this, there are currently multiple phase III trials involving osel- tamivir, some of which are in combination with other drugs such as FPV and hydroxychloroquine (HC).20
Antimalarial—Hydroxychloroquine/Chloroquine 20.3.5 SNG001
SNG001 is an inhaled medication that delivers interferon-𝛽 to a patient’s lungs.21 Interferon-𝛽 is released by the body in response to an infection and possesses mul- tiple antiviral properties.19 A recent trial of 101 participants suggests that adminis- tering SNG001 reduced patients’ chances of progressing to a more severe state by 79%.21 The drug is thought to boost inherent antiviral processes in patients, espe- cially those that have reduced interferon-𝛽 production due to age or other condi- tions.22 A larger double-blinded, controlled phase II trial with 400 participants is currently being conducted.23
20.4 Antimalarial—Hydroxychloroquine/Chloroquine
Chloroquine (CQ) and HC are antimalarial agents. CQ is used mainly for treating malaria and amebiasis, while HC is used mainly to treat rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus.24 They function as antima- larials by down-regulation of the immune response against autoantigens. This occurs by disrupting the normal formation of peptide–MHC protein complexes which acti- vate T cells, as a consequence of interference with endolysosomal function and thus, the processing of antigens, in macrophages and other antigen-presenting cells.25
There has been much hype and controversy surrounding the use of HC to prevent or treat COVID-19. Also something to note are its well-publicized endorsements by the US president and billionaire Elon Musk. An early French study26 evaluating HC and HC with azithromycin seemed promising, but has since been widely scrutinized for validity27, even by the president of the journal that published it.28 Another early study which was done in China was initially touted as evidence for the ef cacy of HC29, but was later questioned due to its lack of peer review. These factors may have partly led to an increase in research trials, as well as an uptick in the public actively seeking out these drugs in late April and May this year30. As of late June, there are more than 200 clinical trials studying the ef cacy of CQ, HC, and HC in combina- tion with azithromycin (ClinicalTrials.gov, 2020).
More evidence is surfacing that CQ and HC are not effective for treating COVID-19.
• The FDA previously cautioned against their use for SARS-CoV-2 due to risk of heart rhythm problems (QT interval prolongation31, ventricular tachycar- dia). Their latest stance, given on June 15th, is that of strong opposition as the FDA has revoked its emergency use authorization (EUA). They cite a large, randomized clinical trial which showed no evidence of reducing likelihood of death or increasing recovery time—as well as more recent data showing that the recommended dose did not kill or inhibit the virus.32
• Published in late May, a meta-analysis of 23 studies concludes that the evi- dence for use of HC or CQ to treat COVID-19 is “weak and con icting.”33 The studies included did not evaluate its use as a prophylactic.
• A paper was published in the Lancet which suggested that the use of HC for COVID-19 patients “increased hazard” for heart problems and death.34 Its ndings led to alarm in the health and medical research community that caused some clinical trials to stop.35 The article has since been retracted after researchers were unable to allow an independent peer review due to con den- tiality agreements.34
• In June, researchers announced conclusions of the large randomized trial Recovery (Randomized Evaluation of COVID-19 thERapY) stating that they found no clinical bene t of the use of HC in treating the disease. 1542 patients were given HC and compared to 3132 patients who received usual care. No signi cant difference was observed in patient mortality or hospital stay duration.36
• In mid-May, an observational study of 1376 patients was conducted in a large hospital in New York City. Clinical outcomes were compared between patients who were given HC and those who were not. Results showed no signi cant bene ts of HC use in decreasing or increasing risk of intubation or death.37
Prophylaxis with HC has also been investigated, and no bene ts were identi ed.
A randomized and controlled study with 2250 participants was done in Barcelona, Spain. Researchers evaluated the use of HC as a tool for post-expo- sure prophylaxis (PEP).38 It was found that there was no signi cant difference between the treatment and control groups in developing COVID-19.35 Another study published in early June by researchers in Minnesota conducted a randomized, double-blind, placebo-controlled trial to determine PEP ef – cacy of HC. The study enrolled 821 participants who had had high-risk expo- sure to COVID-19 patients. Researchers found no statistically signi cant difference in incidence of COVID-19 between the HC and placebo groups, when taken 4 days after exposure.39
20.5.1 Azithromycin
Azithromycin’s antibacterial activity comes from its ability to interfere with bacte- rial protein synthesis by binding to the 50s ribosome subunit.40 Although it is pre- scribed for bacterial infections and not viral, it does have anti-in ammatory and antiviral properties, which may be bene cial in treating COVID-19 patients.41–43 The NIH is currently funding a study that is determining whether azithromycin administered with HC results in a better outcome.44 This trial is in its second phase of clinical trials.45 There are also numerous trials looking into other possible
bene cial uses such as proactive care in ambulances, outpatient treatment, and whether azithromycin alone can improve outcomes in COVID-19 patients.46–48
20.5.2 Clofazimine
Clofazimine is an antibiotic that has been traditionally used to treat tuberculosis and leprosy, which also possess anti-in ammatory properties. An in vitro study, clofazi- mine appears to have reduced the viral load. There is a phase II study further explor- ing clofazimine’s possible role in treating SARS-CoV-2 infections, including a possible combination therapy with interferon β-1b.
20.6 Monoclonal Antibodies
20.6.1 Tocilizumab (Actemra) and Sarilumab (Kevzara)
Tocilizumab (Actemra) and sarilumab (Kevzara) are both antibodies that target the human receptor for IL-6, which has been known to be produced at in ammatory sites and to play a key role in chronic in ammation.49, 50 A large release of IL-6 has also been observed in cytokine storms, and it was speculated that an IL-6 blocker could be used to treat them.50
Initial reports of tocilizumab seemed as a promising compound in alleviating effects of cytokine storms and improving clinical outcomes among COVID-19 patients.51, 52 This has led to numerous studies on tocilizumab in the treatment of COVID-19.53 Tocilizumab’s promising results have also led the US Biomedical Advanced Research and Development Authority to invest 25 million dollars in phase III trials.54 There are also two clinical trials looking into tocilizumab’s therapeutic effects in conjunction with RDV and HC.55, 56 Despite sarilumab’s similarity with tocilizumab, initial results reported by Regeneron and Sano (the manufacturers and developers of sarilumab) were not as promising and only those deemed “critically” will advance to phase III studies.57
20.6.2 Canakinumab (Ilaris)
Canakinumab is a monoclonal antibody against human IL-1β, a pro-in ammatory cytokine.58, 59 This drug has traditionally been used to treat mainly immune and in ammatory disorders, such as cryopyrin-associated periodic syndrome and Muckle-Wells syndrome.58, 60
This drug has been used to treat patients suffering from hyperin ammation due to COVID-19; however, without a study with larger samples and controls, its true ef cacy is not well known.61 There are currently phase III trials being conducted by Novartis, the developer of canakinumab, exploring the ef cacy of canakinumab in patients with COVID-19-induced pneumonia that is experiencing cytokine release syndrome (CRS).62, 63
20.6.3 Leronlimab
Leronlimab is a humanized antibody for chemokine receptor CCR5 and was ini- tially developed for HIV treatment.64 The company, CytoDyn, that developed this drug has been also exploring other applications such as COVID-19 treatment.65 Researchers are hoping that by binding antibodies to CCR5, cytokine production can be reduced, which can then alleviate the adverse effects of cytokine storms in COVID-19 patients.65 Initial results reported by the company showed signs of clinical improvement and relative safety.65 As of July 29, 2020, there is a phase II, double-blind, controlled study with 390 participants being sponsored by CytoDyn.66
20.7 Kinase Inhibitor
20.7.1 Acalabrutinib (Calquence)
Acalabrutinib is an irreversible second-generation Bruton’s tyrosine kinase (BTK) inhibitor.67 BTK is an important player in B cell maturation, dendritic cell regula- tion, cytokine production, and phagocytosis.68 Therefore, it has been used to treat malignancies that are B cell in origin.69 This also makes acalabrutinib an immuno- suppressive, so it is being investigated for treating COVID-19.68 There are currently two clinical trials that are in phase II seeing if the drug can reduce mortality in COVID-19 patients.70
20.7.2 Baricitinib (Olumiant)
Baricitinib is a selective inhibitor for JAK1/JAK2 that has been commonly used to treat rheumatoid arthritis.71 These Janus kinase (JAK) proteins initiate an activation cascade that eventually alters cellular transcription, and have been associated with in ammation.72 This connection is thought to be caused by the activation of JAK proteins via cytokine receptors.72 This drug may also provide antiviral properties.73 Baricitinib also binds to AP2-associated protein kinase 1, which may affect endocy- tosis and reduce viral entry.73 However, some have stated that to see this effect requires doses that are much higher than therapeutic doses.74
There are currently multiple clinical trials for COVID-19 taking place in mul- tiple countries, some of which are looking to see the effects of combining barici- tinib with other medications such as with lopinavir/ritonavir and RDV.75, 76 Although an initial report suggests promising outcomes when using the barici- tinib, the same report recognizes that the study had a small sample size and no randomization.73
There are a couple of features that make baricitinib different from ruxolitinib despite both being rst generation of JAK inhibitors.77 Baricitinib is not
Immunomodulator: Anakinra (Kineret)
metabolized by cytochrome P450 and can be excreted by the kidney, while the opposite is true for ruxolitinib.77
20.7.3 Tofacitinib (Xeljanz)
Tofacitinib is a JAK inhibitor that speci cally targets JAK1, JAK3, and to a lesser extent JAK2.77 Tofacitinib has been used to treat a wide array of in ammatory and autoimmune conditions such as rheumatoid arthritis, in ammatory bowel disease, and other dermatological disorders.77
There are currently at least four clinical trials looking into tofacitinib as a form of treatment in patients with COVID-19, one of which is comparing the drug effects to using HC alone.78, 79
20.7.4 Ruxolitinib (Jakafi)
Ruxolitinib is a kinase inhibitor that targets JAK1/JAK2.80 This JAK inhibitor has been mainly used to treat myelo brosis, a form of cancer affecting the bone mar- row.78 Due to its anti-in ammatory properties, there are currently phase III trials and other studies looking into ruxolitinib in treating cytokine storms associated with COVID-19.81, 82
20.7.5 Apilimod
Apilimod is phosphatidylinositol-3-phosphate 5-kinase (PIKfyve) inhibitor and seems to in uence the maturation and function of endosomes. Its possible roles in treating B-cell non-Hodgkin’s lymphoma, lysosomal dysfunction-related disorders, and viral infections have been explored prior to SARS-CoV-2. A study published in July 2020 suggests that the drug may also be useful in preventing the entry of SARS-CoV-2 into human cells as well as replication. There is currently a phase II clinical trial involving COVID-19 outpatients with mild symptoms.
20.8 Immunomodulator: Anakinra (Kineret)
Anakinra acts as an IL-1 receptor antagonist.83 It has been mainly prescribed for patients with rheumatoid arthritis and other autoin ammatory conditions.84 There have been reports where the drug has been reported to reduce systemic in amma- tion and alleviate pulmonary symptoms in some COVID-19 patients.85, 86 There are currently multiple clinical trials exploring the drug’s ef cacy.84 This drug may help reduce mortality as there are reports of hyperin ammation and cytokine storms, resulting in mortality of COVID-19 patients.87
20.9 Nonspecific Anti-inflammatory
20.9.1 Dexamethasone
Dexamethasone is a steroid that works as an anti-in ammatory and immunosup- pressive by acting as a glucocorticoid agonist.88 Results of a randomized clinical trial involving 2104 patients seem encouraging, as results show that daily adminis- tration of the drug (6 mg either orally or by IV) reduced morality by a third in ven- tilated patients and by a fth in patients receiving only oxygen.89 However, experts have urged caution as the of cial papers detailing the results have not been pub- lished.90 The World Health Organization and other countries have previously expressed reservations of using steroids in treating COVID-19 patients, since ste- roids may suppress the immune system to a higher extent than desired, but they have indicated that these results may change WHO clinical guidelines.91, 92 If further data reinforces the bene ts of dexamethasone, this steroid, which is considered inexpen- sive and widely available, may become a key drug in saving many lives.92
20.9.2 Methylprednisolone
Methylprednisolone is a corticosteroid that is based on prednisolone, a glucocorti- coid, but it is reported to have a higher potency than prednisolone and to have a potency that is ve times greater than hydrocortisone in its anti-in ammatory prop- erties.93 The use of methylprednisolone in treating COVID-19 patients with ARDS as well as preventing the worsening of clinical symptoms has been suggested.94 A study of 173 participants in Italy has led the Lazzaro Spallanzani National Institute for Infectious Diseases to recommend doctors in considering the use of methylpred- nisolone in patients that begin to have worsening respiratory functions.95 Another study of 213 participants by Henry Ford Health System also seems to suggest that the use of methylprednisolone can improve outcomes and help prevent worsening of respiratory functions.94 More studies are being conducted, including one by the Mayo clinic, to further support the use of methylprednisolone.96
20.9.3 Ciclesonide
Ciclesonide is a glucocorticoid that reduces in ammation by reducing vasodilation, vascular permeability, and the accumulation of leukocytes and macrophages.97 It has been regularly used as an inhaled corticosteroid, and there were some early reports suggesting ciclesonide as an effective candidate for treating SARS-CoV-2-induced pneumonia.98–101 However, there are claims that it is not clear whether or not inhaled corticosteroid is an effective treatment in patients with COVID-19.102 There are cur- rently multiple clinical trials taking place in Asia, Europe, and North America, including a phase III clinical trial with 400 participants in the United States.103
20.9.4 Budesonide/Formoterol
Budesonide is a glucocorticoid steroid that can be delivered via oral inhalation.104 Formoterol, a long-acting beta agonist, works as a bronchodilator and is routinely administered with budesonide in asthma patients.102, 105 The NIH is funding a phase III clinical trial of this drug combination in patients with acute respiratory failure, including cases involving COVID-19.106
20.10 Anti-Inflammatory Colchicine
Colchicine is a compound that is extracted from plants belonging to the Colchis genus, and has been used to treat a variety of conditions, including in ammatory ones such as pericarditis.107 The compound’s anti-in ammatory properties can come from multiple mechanisms.107 Some of which include the reduction in the secretion of certain cytokines such as IL-1β, IL-8, and IL-18.107–109
A recent study published from Greece consisting of 105 patients suggests that colchicine may be considered as a possible treatment.110 However, even the authors of this paper noted that this data is “hypothesis-generating,” and more studies are needed.110 There are currently multiple phase III trials looking into colchicine, including one that is double-blinded, controlled, and with 6000 participants being conducted in parts of the United States, Canada, and Spain.111
20.11 Antiparasitic
20.11.1 Nitazoxanide
Nitazoxanide is an antiparasitic drug that targets pyruvate ferredoxin/ avodoxin
oxidoreductase electron transfer.112 Although initially developed as an anti-proto-
zoan drug, the compound has also shown to reduce replication in RNA and deoxy-
ribonucleic acid (DNA) viruses, including ones that are resistant to oseltamivir.113
There are currently phase III clinical trials where researchers are seeking to deter-
mine if nitazoxanide can serve as a safe prophylaxis in health-care workers and the elderly.114, 115
20.11.2 Ivermectin
Ivermectin targets invertebrate glutamate-gated chloride channels inducing an in ux in chloride.116 Studies in the past have also indicated that the drug may have antiviral properties causing others to express the possibility of ivermectin as a pos- sible candidate for treating COVID-19 patients.117 This has led to multiple ivermec- tin-based clinical trials, including one by Johns Hopkins University.118
20.12 Radiation
Low-dose radiation has been used to treat conditions like pneumonia before the advent of antibiotics, and it is thought to work by inducing anti-in ammatory pro- cesses.119, 120 The use of low-dose whole lung radiation seems to have improved the condition of some COVID-19 patients.119 On June 16th, 2020, a phase III trial was rst posted which seeks to determine whether low-dose whole lung radiation can be better than the current best supportive practices.121
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106. ClinicalTrials.gov. ARrest RESpiraTory Failure From PNEUMONIA – full text view. https:// clinicaltrials.gov/ct2/show/NCT04193878?term=budesonide&cond=covid&cntry=US&dra w=2&rank=2. Accessed June 23, 2020.
107. Leung YY, Yao Hui LL, Kraus VB. Colchicine—update on mechanisms of action and thera- peutic uses. Semin Arthritis Rheum. 2015;45(3):341–350. https://doi.org/10.1016/j.semar- thrit.2015.06.013. Accessed July 5, 2020.
108. Lopez-Castejon G, Brough D. Understanding the mechanism of IL-1β secretion. Cytokine Growth Factor Rev. 2011;22(4):189–195. https://doi.org/10.1016/j.cytogfr.2011.10.001. Accessed July 5, 2020.
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110. Deftereos SG, Giannopoulos G, Vrachatis DA, et al. Effect of colchicine vs standard care on cardiac and in ammatory biomarkers and clinical outcomes in patients hospi- talized with coronavirus disease 2019: the GRECCO-19 randomized clinical trial. JAMA Netw Open. 2020;3(6):e2013136. Published 2020 Jun 1. https://doi.org/10.1001/jamanet- workopen.2020.13136. Accessed July 5, 2020.
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Vaccines for COVID-19
Syed E. Ahmad M.D. and Allen Jo
COVID-19 MERS VLP
Corona virus disease
Middle East respiratory syndrome viral-like particle
This chapter will brie y discuss viral technologies and categories relevant to corona virus disease (COVID-19) vaccine candidates, which will include advantages, dis- advantages, and strategies to illicit immunity for each type of vaccine mentioned. The availability, possible risks, and how mutations may affect the ef cacy of these vaccines will also be brie y touched upon.
21.2 What Are Viral Vaccines?
Viral vaccines are prepared substances that seek to prevent the manifestation of a disease that is viral in origin, and to prevent the further spread of a viral pathogen.1 There are multiple different types of vaccines based on their composition, and some of these types are adenovirus vector, mRNA, DNA, live attenuated, inactivated, and subunit.1 Vaccines are considered as the primary method for preventing viral infec- tions.1 Vaccinations have been used to contain epidemics and are considered a vital tool in reducing mortality in a pandemic.2
21.3 What Are the Risks Associated with Viral Vaccines?
The risk a viral vaccine may have is dependent on the type of vaccine as well as the patient’s condition.3 In the case of live vaccines, patients who are suf ciently immu- nocompromised should not receive some vaccines as they may lead to an adverse
Chapter 21: Vaccines for COVID-19
reaction or result.3 The contents of the vaccine can also pose a risk in some individu- als as they can lead to an allergic reaction, some of which may lead to asphyxiation.4 In other rare cases, vaccine recipients have actually become more susceptible to infection or a more severe manifestation of the disease.5, 6 This phenomenon is called immune enhancement.6 Although studies suggest immune enhancement may be unlikely for SARS-CoV-2 vaccine candidates, it is a concern that is plausible enough for experts to express the need to monitor for enhancement during trials and to determine the possibility of enhancement.6, 7
21.4 SARS-CoV-2 Vaccines in Development and WHO Database
As of September 25, 2020, approximately 42 potential COVID-19 vaccines are being tested in various stages of clinical trials.8 Over a hundred more are in the pre- clinical phase in development.8 The World Health Organization has a periodically updated table detailing the type of vaccine, its developer, and its current stage of development (Table 21.1).8 (https://www.who.int/who-documents-detail/draft-landscape- of-covid-19-candidate-vaccines).
21.4.1 Viral Vector Vaccines and Adenoviral Vector Vaccines
Viral vector vaccines exploit the existing viral mechanisms to transport genetic material into the vaccine recipient’s cells to express an antigen.9 These viral vector vaccines can be further differentiated into nonreplicating and replicating versions.9 An advantage of a replicating viral vector vaccine is dosage sparing and a stronger immune response, which may allow for more vaccines to be available.9 There are currently 40 viral vector vaccines being developed for SARS-CoV-2 based on the following viruses: the pox virus, the paramyxovirus, the alpha virus, the vaccinia virus, the in uenza virus, and the adenovirus.8 The rst vaccine to enter phase III of clinical trials is an adenoviral vector vaccine developed by Oxford University’s Jenner Institute.8 Published data also shows that this vaccine can produce antibodies and a cellular response in recipients who received doses in April 2020.10
An adenoviral vector vaccine utilizes the adenovirus, which is a double-strand DNA, nonenveloped virus.11 Due to its genetic make-up, concerns of integration were expressed, but studies show that adenoviral vector vaccines remain largely unintegrated.11 Adenoviral vector vaccines have also been attenuated, and its vector has been modi ed to prevent the possibility of replication, further reducing the pos- sibility of adverse effects.11 The vaccine being developed by the Jenner Institute also addressed the issue of preexisting immunity to the adenovirus by developing the vector in chimpanzees.8, 12 Previous work on an adenoviral vector vaccine for Middle East respiratory syndrome (MERS) has shown that an adenoviral vector vaccine can produce a “robust immune response” to a coronavirus, and aided researchers in developing an adenovirus viral vector vaccines for COVID-19.13, 14 However, trials
SARS-CoV-2 Vaccines in Development and WHO Database
Table 21.1 Types of SARS-CoV-2 Vaccines and Promising Vaccine Candidates
University of Oxford/AstraZeneca
Adenoviral vector
U.S. Dept. of HHS—$1.2 billion U.K. Gov.—£84 million CEPI-$750 million
CanSino Biological Inc./Beijing Institute of Biotechnology
Phase 3 Approved for limited use in China NCT04526990 NCT04540419
China’s Ministry of Science and Technology
Gamaleya Research Institute
Phase 3 (approved for limited use in Russia) NCT04530396 NCT04564716
Janssen Pharmaceutical Companies/Johnson and Johnson
Phase 3 NCT04505722
U.S BARDA- $456 million dollars U.S. Government-$1 billion dollars for 100 million doses if approved
Moderna/NIAID
U.S. BARDA—$483 million Bill and Melinda Gates Foundation—$20 million CEPI
BioNTech/P zer
Inactivated
Phase 3 (approved for limited use in China) NCT04456595
Advantech and Vivo Capital-$15 million
Bank of Beijing-$8.5 million
Novavax
Subunit
U.S. Dept. of HHS and DoD-$1.6 billion
CEPI- $384 million
Inovio Pharmaceuticals
U.S. DoD-$71 million CEPI-$17.2 million
for the Oxford University/AstraZeneca’s vaccine were put on pause in the UK due to possible safety concerns, which have been resolved.15
Another adenovirus-based vaccine, being developed by CanSino, is currently in phase III of clinical trials. Unfortunately, current results from this vaccine show the rates of neutralizing antibody production were lower than desired, and side effects reported were relatively high16, 17 As of September 25, 2020, the WHO has reported 45 vaccine candidates using adenovirus technology of which the most advanced and
promising candidates are from the Oxford University/AstraZeneca, and BioNTech/ P zer.8
21.4.2 RNA Vaccines
RNA vaccines seek to induce the expression of a desired antigen in the patient by transporting genetic material into recipient’s cells.18 Moderna’s RNA vaccine, an initial forerunner, has begun its phase III trials and is expected to enroll 30,000 healthy participants who will receive two intramuscular injections, spaced 28 days apart, containing 100 microgram injections of mRNA-1273 or a saline pla- cebo.19 The company has stated that the vaccine may not be available till 2021.20 P zer’s vaccine, another RNA vaccine, may also have results early enough for approval in the fall.21 Both of these vaccines are using lipid nanoparticles to trans- port RNA for translation and production of the antigen.22, 23 By using lipid nanoparticles, issues of degradation, which have been associated with RNA vac- cines, can be reduced while serving as a method of delivery.22 Research also sug- gests that RNA vaccines may elicit humoral and cell-mediated immunity in a single dose.24 As of September 25, 2020, the WHO has reported 24 vaccine candi- dates using RNA technology.8
21.4.3 DNA Vaccines
DNA can also be used to express the antigen in patients and, like RNA vaccines, can illicit a humoral and cell-mediated immune response.25 There are 16 DNA vaccine candidates as of September 25, 2020, four of these candidates are in phase II trials.8 However, DNA vaccines have been reported of having lower immunoge- nicity, and different delivery techniques were explored in response to this phe- nomenon.26 One of the major delivery techniques developed is electroporation, the technique being used by Inovio pharmaceutical’s vaccine candidate.25 Electroporation works by creating electrically induced pores to facilitate the entry of the DNA vaccine into the cell.26 Like adenoviral vector vaccines, concerns of integration seem to be insigni cant.27 Another method to address this issue is the addition of adjuvants, substances that increase vaccine’s immunogenicity, to some DNA vaccine candidates.27
21.4.4 Live Attenuated Vaccines
A live attenuated vaccine is a vaccine that takes a weakened form of the virus to illicit future immunity.28 Since this kind of vaccine emulates a real infection, an antibody and cell-mediated response that is long lasting may occur.28, 29 This response can usually be achieved in one or two doses.30 However, since live
attenuated vaccines emulate a real infection and because there is a small chance a live attenuated vaccine may return to a more pathological form, certain individuals may not be suitable for receiving this form of vaccine.28 Although there are no live attenuated vaccines in the clinical stage, there are three in development as of September 25, 2020.8
21.4.5 Inactivated Vaccines
Inactivated vaccines are vaccines that inject viruses inoculated by using heat, chem- icals, or radiation.29 These vaccines cannot cause infections and can be safely administered to those who are immunocompromised.29 Some inactivated vaccines may also be stored at room temperature, which may provide logistical bene ts.30 Unfortunately, inactivated vaccines do not create a cell-mediated response and may also require booster doses.28 To get a desired immune response, multiple doses are also usually required.28 As of September 25, 2020, there are currently 14 inactivated vaccine candidates, 5 of which are in clinical trials, including three that are in phase III being developed by Chinese companies.8 Adjuvants are also being added to some of these vaccine candidates, which may lead to dose sparing and therefore more available vaccines.8, 27
21.4.6 Subunit Vaccines and Viral-Like Particle Vaccines
Another type of vaccine candidate type are subunit vaccines.8 Some of which are using adjuvants, substances that increase an antigen’s immunogenicity which could allow for more available doses.31 An inactivated vaccine uses the inoculated form of the pathogen, while a subunit vaccine utilizes a speci c portion of the pathogen.32 Since these vaccines also do not mimic an infection like an inactivated vaccine, the immune response is mainly humoral and not cell mediated.32 This inability to cause an infection also makes these vaccines safer for the immunocompromised or those with certain health conditions, but it is important to note that the vaccine’s effective- ness may be reduced in certain immunocompromised inidviduals.3, 33 However, these vaccines usually require multiple doses and/or booster doses to produce suf- cient long-term immunity.29 There are currently 70 subunit vaccine candidates de ned by the WHO, 13 of which are in clinical trials as of September 25, 2020.8
A more speci c type of subunit vaccine is a viral-like particle (VLP) vaccine, and there are 16 VLP vaccine candidates as of September 25, 2020, one of which is in phase II clinical trials, while another is in phase I.8, 34 A VLP vaccine is con- structed utilizing recombinant proteins to create particles that closely resemble the virus.35 The size and high repetitive structure may lead to high immunogenicity without risk to the immunocompromised due to the lack of genetic material in VLP vaccines.36 The nature of VLP vaccine production may provide advantages in increasing production.37
21.5 Who will Get the First Vaccines?
Chinese and Russian governments have approved adenovirus-based vaccines for limited use without conclusive phase III studies, which have raised a concern in the scienti c community.38 Despite initial estimates of a vaccine being available by the end of 2020, experts and company statements are now estimating a vaccine some- times next year.39, 40
Multiple companies have already been investing into vaccine production, but fears that supply will be limited exist.41 Therefore, vulnerable populations may receive the rst doses, including children, the elderly, the immunocompromised, patients with certain preexisting conditions, and health-care workers.42 Yet, this may also be dependent on the vaccine as there are some reports that suggest that certain vaccines may not be suitable for some of these populations.43
21.6 Will these Vaccines Protect against a Mutated SARS- CoV-2 Virus?
Whether or not the vaccines in development will prevent mutated forms of the virus remains unclear.44 The SARS-CoV-2 virus is mutating as expected, and some muta- tions seem to have affected the spike protein (the molecular target of many vaccine candidates).45 In order to prevent future strains from evading vaccines, there have been recommendations for future drugs and vaccines to target areas of the viral genome that are relatively constrained.46 The rate of mutation, however, seems to be slower than that of in uenza, about half as slow.47, 48 Another indicator that muta- tions may not prevent the ef cacy of vaccines is that vaccines can be designed to target multiple sites of the virus, reducing the risk of a mutated virus escaping exist- ing immunity.49, 50
21.7 Will These Vaccines Produce Long-Term Immunity?
There are multiple studies that suggest effective antibody levels may decline within a few months of SARS-CoV-2 infection.51, 52 This may be an issue in vac- cines that produce primarily an antibody response and may only confer short- term immunity. However, this drop in antibody levels does imply the absence of memory B cells, which may allow the rapid production of antibodies if reinfec- tion occurs.51, 53
These studies may also further reinforce the importance of T cells and vac- cines that illicit a cellular-mediated response.52 T cells can also remember patho- gens for many years, and once reinfection occurs, they can activate the immune system and kill any cells infected with the virus.54 Fortunately, the detection of T cells that can recognize SARS-CoV-2 in people once infected and those that received certain vaccine candidates suggest that long-term immunity can be achieved.55
21.8 Antivaxxers and Vaccine Efficacy
Antivaccination sentiments have been increasing and may affect the rates of vacci- nations for SARS-CoV-2.56 Recent polls seem to show that only half of the US population may be willing to receive a vaccine for COVID-19, which is much lower than some estimates for achieving herd immunity, a phenomenon that can protect unvaccinated individuals if enough of the population become immunized.56–58
Populations that are most hesitant may be those with historic mistrust of govern- mental agencies, such as African Americans due to the Tuskegee Study, where members of the African American community were knowingly given syphilis and denied treatment.56, 57 Widespread hesitation can also be accounted for by other fac- tors like the speed of vaccine development and misinformation.56 Experts have expressed concerns how the existence of a vaccine may not stop the COVID-19 pandemic unless public opinion changes.59 John Hopkins Center for Health Security has published a report of strategies and guidance to increase the willingness for receiving a coronavirus vaccine. (https://www.centerforhealthsecurity.org/our- work/pubs_archive/pubs-pdfs/2020/200709-The-Publics-Role-in-COVID-19-Vac- cination.pdf)
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50. Siegel ER. Here are 3 drugs in development to ght coronavirus, 2 vaccines and one ‘passive’ vaccine. NBCNews.com. https://www.nbcnews.com/health/health-care/here-are-3-drugs- development- ght-coronavirus-2-vaccines-one-n1163191. Published March 19, 2020. Accessed May 14, 2020.
51. Salleh A. Scientists say coronavirus antibodies don’t last long. But what does that mean? ABC News. https://www.abc.net.au/news/health/2020-07-16/how-long-does-our-immunity-to- coronavirus-last/12460724. Published July 16, 2020. Accessed July 29, 2020.
52. Woodley M. Study raises questions over long-term COVID-19 immunity. NewsGP. https:// www1.racgp.org.au/newsgp/clinical/study-raises-questions-over-long-term-covid-19-imm. Published June 29, 2020. Accessed July 31, 2020.
53. Lanzavecchia A, Sallusto F. Human B cell memory. Curr Opin Immunol. 2009;21(3):298–304. https://doi.org/10.1016/j.coi.2009.05.019.
54. Pennock ND, White JT, Cross EW, Cheney EE, Tamburini BA, Kedl RM. T cell responses: naive to memory and everything in between. Adv Physiol Educ. 2013;37(4):273–283. https:// doi.org/10.1152/advan.00066.2013
55. Leslie M. T cells found in COVID-19 patients ‘bode well’ for long-term immunity. Science. https://www.sciencemag.org/news/2020/05/t-cells-found-covid-19-patients-bode-well-long- term-immunity. Published May 14, 2020. Accessed July 29, 2020.
56. Hoffman J. Mistrust of a coronavirus vaccine could imperil widespread immunity. The New York Times. https://www.nytimes.com/2020/07/18/health/coronavirus-anti-vaccine.html. Published July 18, 2020. Accessed July 29, 2020.
57. Cornwall W. Just 50% of Americans plan to get a COVID-19 vaccine. Here’s how to win over the rest. Science. https://www.sciencemag.org/news/2020/06/just-50-americans-plan-get- covid-19-vaccine-here-s-how-win-over-rest. Published July 1, 2020. Accessed July 29, 2020.
58. Brum el G. Without a vaccine, researchers say, herd immunity may never be achieved.
NPR. https://www.npr.org/sections/health-shots/2020/07/24/894148860/without-a-vaccine- researchers-say-herd-immunity-may-never-be-achieved. Published July 24, 2020. Accessed July 29, 2020.
59. Cohen E. Fauci says Covid-19 vaccine may not get US to herd immunity if too many people refuse to get it. CNN. https://www.cnn.com/2020/06/28/health/fauci-coronavirus-vaccine-con- tact-tracing-aspen/index.html. Published June 29, 2020. Accessed July 29, 2020.
Socioeconomic, Racial,
and Cultural Considerations
Sarah Zaidi Sc.D., MSc., Rohan Iyer, and Azwade Rahman
CDC Centers for Disease Control and Prevention COVID-19 Coronavirus disease
SdoH Social determinants of health
Coronavirus disease (COVID-19) has been termed the “great equalizer,” capa- ble of sickening anyone, but the reality is that it has increasingly demonstrated that social inequalities in health are profound.1 In times of pandemics and epi- demics, such differences become even more exaggerated. COVID-19 is not an equal-opportunity killer, and its victims are often the poor and economically vulnerable, living in crowded conditions, including prisons, and those without access to health care. These conditions in which people are born, grow, live, work, and age are known as the social determinants of health (SDoH). The SDoH are conditions. They are shaped by the distribution of money, power, and resources, and are mostly responsible for health inequities in the health status of people seen within and between countries.2 This chapter examines the SDoH of COVID-19 in the United States and touches upon some critical issues in devel- oping societies.
22.2 Social Determinants of Health Framework
The SDoH framework includes ve key areas of determinants—economic stability, education, social and community context, health and health care, and neighborhood and built environment3 that affect peoples’ well-being, functioning, and quality-of- life outcomes and risks (Figure 22.1). Each of these ve determinant areas includes a number of subtopics that inform the overall framework (Table 22.1). For example,
Neighborhood and Physical Environment
Community and Social Context
Health-Care System
Employment Income Expenses/ Debt Support
Housing Transportation Safety
Parks Playgrounds Walkability Zip code/ geography
Literacy Language Early education Vocational training Higher education
Hunger Access to healthy options
Social integration Social systems Community engagement Discrimination Stress
Health coverage Provider availability/ accessibility Linguistic competence Quality of care
Health Outcomes: Mortality, Morbidity, Health Status
Figure 22.1 The social determinants of health.
Neighborhood and Built Environment
SDOH
SDoH Elaborated
Chapter 22: Socioeconomic, Racial, and Cultural Considerations
Social and Community Context
under economic stability, subtopics such as employment, food insecurity, housing instability and poverty would be included, and social and community context would include civic participation, discrimination, incarceration, and social cohesion. In addition, SDoH also include access to green spaces; exposure to environmental tox- ins; and discrimination based on gender, race or ethnicity, immigration status, and religion among others.
Unequal distributions and access to resources, exposure to discrimination, and administrative failures to ensure safety and maintenance all lead to the creation of
Race and COVID-19
phenomena called health disparities, that is, difference in outcomes as a result of economic, social, or environmental disadvantages.4 These are not singular, or indi- vidual, acts of injustice, but rather systemic and structural failures in the system and deliberate aws in the infrastructure of society. In contrast, health equity aims to create situations that would avoid bad health outcomes for people through access to opportunities and resources and instituting certain protections that would reduce the burden of disease on disadvantaged groups.
The COVID-19 crisis has revealed that not all care is delivered equally, and there are gaps in health care and health disparities, which have grown wider as a result of the neoliberal policies and austerity measures. There are communities that are dis- proportionately affected by COVID-19.
22.3 Race and COVID-19
Racial bias in the age of COVID-19 has occurred in two forms. First, the United States and other pro-nationalistic governments politically stoked bias against people of Asian origins. Second, the virus ampli ed the structural inequalities and racial bias against Black Americans and other racial minorities in the United States.
The virus was scienti cally named SARS-CoV-2, based on its similar structure to SARS-CoV. Although the virus could have popped up anywhere where the envi- ronment was conducive to interspecies transfer, SARS-CoV-2 originated in Wuhan, China. The US President Trump repeatedly referred to it as the “Chinese virus” or “Wuhan virus.”5 This deliberate labeling was politically motivated to single out and blame the Chinese government and shield the Administration its inadequate response, and instead, it led to acts of aggression, and even physical violence, against people of Asian descent. In the eyes of the public, there was a strong asso- ciation between the virus and East Asians. Cities like New York, Los Angeles, and rural states like Indiana have all reported incidents of discrimination and outright attacks on Asians due to the perception that they were directly responsible for the virus.6 The singling out of Asians was not limited to America, but a global phenom- enon.7 Increases in racist rhetoric coincided with racially motivated attacks on East Asians in Europe, Africa, and Latin America, and against migrant workers in the Middle East and parts of Asia like Malaysia.
Second, racial bias in the United States is deeply seeded and plays out in terms of worse health outcomes for Black communities.8 The situation with COVID-19 is no different. COVID-19 data collected at the national level from counties showed that the disease was more prevalent, and deadly, among Black and Hispanic com- munities. Even though Black Americans accounted for 22% of the United States, they had 52% of reported cases and 58% of deaths nationally.9 A study from the Centers for Disease Control and Prevention (CDC) found that after adjusting for age, indigenous (Native) Americans and Blacks had a hospitalization rate ve times that of white person, and Hispanic or Latino person four times, and attributed these differences to long-standing systemic health and social inequities.10 The New York City Health Department created a report on infection and fatalities. Among Black
Americans, the death rate was 92.3 deaths per 100,000, Latin Americans had a death rate of 74.3, white Americans had a death rate of 45.2, and Asian Americans had a death rate of 34.5, in the lowest category.
Viruses do not discriminate on the basis of skin color, so why in the United States is there such disparity in mortality rates? The answer to this simple question is com- plex, and wrapped in layers of structural inequities and health disparities. The SDoH affects health outcomes. The living conditions for disadvantaged groups are but one reason. America has had a long-standing policy on residential segregation through redlining, a systematic policy put in place by city planners that made higher-valued properties inaccessible to underprivileged groups, either through high pricing or through outright refusal to sell to Black Americans and Hispanic people. The afford- able housing available to Black communities was often poorly built and maintained, crowded and cramped, and included several generations sharing the same housing unit, factors that contributed to poor health outcomes.11–13
Living under such conditions makes it dif cult for people to follow the rule of physical distancing recommended by CDC for COVID-19. With no green spaces and cramped quarters with many people living in high rises, the risk of exposure to COVID-19 increases, and especially vulnerable are the elderly family members and those with underlying conditions. At the same time, Blacks and Hispanics face dis- proportionately high risk because they are more likely to work in essential, low- paying jobs. Under the pandemic, people ful lling such jobs have been designated as essential workers and face high risk of disease exposure through their employ- ment.14, 15
On the ip side, racial minorities often do not have jobs that provide bene ts such as paid parental leave, sick leave, or leave to care for elderly or ill family mem- bers. Black Americans and Hispanics are 7–13% less likely than their white coun- terparts to have access to these bene ts.16
Racial minorities have typically faced signi cantly diminished access to paid parental leave, paid sick leave, and paid leave to care for sick family members. Compared to white individuals, African Americans faced diminished access to any of these accommodations by up to 7% across three models of calculation, with Hispanic individuals facing up to 13%. These disparities are long-standing and exist despite controlling for education and employment. Since health insurance in America is tied to employment, Black Americans and Hispanics usually have lower rates of health insurance and encounter dif culties in co-payments even with access through Medicaid.17 In general, Black and Hispanic communities face discrimina- tion in access health services, which are only magni ed by the COVID-19 pandemic.
Unequal treatment of patients based on their race or ethnicity is well documented among health-care workers. In 2015, a study in Patient Education and Counseling found that patients from disadvantaged racial or ethnic backgrounds received less information from their doctors about treatment recommendations.18 Princeton University found that white medical students and residents can hold onto false beliefs about biological difference between black and white patients, in doing so incorrectly report lower pain ratings for black patients. In simpler terms, students
Caste and COVID-19 in India
and doctors with prejudices are less likely to believe black patients when they say they are in pain, and it affected their treatment recommendations negatively.19 Bias like this has affected many medical elds. One of the most popular topics in public health today is the racial difference in maternal mortality. Black women are far more likely than their white counterparts to have negative outcomes, including death, during pregnancy. Racism in health care was speci cally emphasized as a contributing factor.20 In general, these types of actions and reactions can be classi- ed under the umbrella term implicit bias. This refers to the prejudices and stereo- types that dictate an individual’s actions without explicit intention to do so. And it did not stop when the pandemic hit.
A biotech data company, Rubix Life Sciences based in Boston, Massachusetts, reviewed recent billing information in several states and found that African Americans with symptoms like cough and fever were less likely to be given a test for the coronavirus.21 Testing sites in historically black institutions also experienced greater delay in acquiring necessary testing equipment and protective gear. A heat map of Memphis of where coronavirus testing is taking place revealed that most screening was happening in predominantly white and well-off suburbs, and not the majority Black, lower-income neighborhoods.15, 21 Disadvantaged racial groups are highly more likely to have comorbidities for coronavirus like hypertension, diabe- tes, HIV/AIDS, etc.
Diagnosis is the rst step in receiving appropriate care for these patients. Identifying positive cases can encourage people to self-isolate and adhere to social distancing, keeping them from spreading the diseases if they end up being sent home. Delaying testing can allow for symptoms to worsen and result in hospitaliza- tion or even death, which could have been avoided.
22.4 Caste and COVID-19 in India
COVID-19 has created an unforeseen resurgence of caste-based discrimination, with fundamentalist using social distancing to re-enforce the idea of untouchables in Hinduism. The Hindu caste system India, and the current Bharatiya Janata Party (BJP) government steeped in religious ideology, has long ensured social segregation based on one’s place in the hierarchy composed of four main groups—Brahmins, Kshatriyas, Vaishyas, and the Shudras—and the last group of Dalits or untouchables that number around 200 million. This group takes on the most menial and low- paying jobs, and for a variety of reasons, poverty being chief among them, are vul- nerable to most diseases.22
In 2007, the Global institute of Public Health and the Santhigiri Research Foundation found that women from the lower cast have greater likelihood of ane- mia, higher neonatal and infant mortality rates, and their children have a 30% higher likelihood of dying before their fth birthday and only one in two have access to vaccinations.23, 24 Another study reported that waiting time when visiting private doctors increased for those from lower social caste.25 COVID-19 has resulted in social exclusion of Dalits from accessing government bene ts or humanitarian aid,
and at the same time made them vulnerable to exposure given that they work essen- tial jobs such as waste-pickers and sanitation workers. Since Dalits do not have the required government ID cards, they are unable to access any government bene ts such as subsidies to food, access to public health-care services, or any other form of social protection. They were particularly affected by Prime Minister Modi’s order of a nationwide lockdown on March 23 that gave only four hours’ warning for these largely casual, migrant labors to pack up and leave urban centers.26 Caste-based discrimination creates barriers to health services and increases risk of exposure, morbidity, and mortality.
22.5 Incarceration and COVID-19
America is known to have the largest prison population in the world, a problem called mass incarceration, referring not only to the total number of people in prison but also to the rate of imprisonment. Since 1970, the number of incarcerated people far outpaces population growth and crime, increasing 500% to 2.1–2.2 million peo- ple in jail and prisons today (655 incarcerated people per 100,000 people).27, 28 The increase in incarceration is a result of changes in laws and policies, such as the “three-strikes” law, which automatically gives a person 25 years in prison for a third felony and prisoners who have been sentenced to life without parole.29, 30
Today one in nine people in prison are serving a life sentence, of which a third are sentenced to life without parole. Race plays an important role in incarceration, and research shows that Black citizens are six times more likely than white people to be incarcerated, and almost three times more likely than their Latino counter- parts, who in turn are two times more likely to be incarcerated than white men.31 According to a report by the Department of Justice, the population of prisoners aged 55 and older increased by 400% between 1993 and 2003, in part to longer sentences and in general an increase of admissions of older persons.
Mass incarceration has set up a perfect storm for a public health disaster such as COVID-19 in prisons. There are thousands of people kept in poorly ventilated con- ned space in close proximity with others and living conditions that create extreme stress on the body and mind. Despite being a closed facility, there is ample opportu- nity for exposure with prison staff entering and exiting daily, prisoners being trans- ferred between facilities, and prisoners have little ability to maintain social distancing or safe hygienic practices. A federal prison in central Florida in February 2020 experienced an outbreak of Legionnaire’s disease.32 Ross Macdonald of the Riker’s Island jail system described the happening as a “public health disaster unfolding before our eyes” to the Guardian, while reporting on 200 COVID-19 cases in 12 days in April.33
By June 6, there were 42,107 cases of COVID-19 and 510 deaths among 1,295,285 prisoners with a case rate of 3,251 per 100,000 prisoners.34 The COVID- 19 case rate for prisoners was 5.5 times higher than the US population case rate, a truly sobering statistic.35 Women and minorities face particularly high risk since both groups have higher rates of chronic diseases. Correctional staff and their
Immigrants and COVID-19
families also share the high risks as they share the same environment and physical space. COVID-19 transmission is unlikely to be contained in US prisons without implementation of more effective policies that acknowledge responsibility, test, iso- late and treat infected prisoners and their contacts, employ compassionate release for elderly and in rm prisoners, improve sanitation and provide personal protective equipment, and implement physical distancing.
22.6 Immigrants and COVID-19
In the middle of April, the US government made signi cant changes to the immigra- tions system, including postponing immigration hearings, pausing deportation ight, suspending refugee admissions, and moving forward to blocking entry for asylum seekers and at the same time expelling anyone encountered at the border.36 These measures were taken to protect the American economy from the impact of foreign workers on US labor market, but they also brought into sharp focus the intersection of immigration issues and public health policy.
According to data from the US Immigration and Customs Enforcement (ICE) Service as of July 1, more than 3,000 detainees have tested positive for COVID-19, that is, 25% of all detainees tested (11,828), or 13% of all detainees.37 The largest number of positive cases (250) is from the Eloy Federal Contract Facility in Phoenix, Arizona. People living in detention centers face conditions similar to those in pris- ons, and cannot socially distance and have a limited access to soap.38 They are also subject to deportation even though this can spread the virus. Those who are not under detention, but undocumented, often working in occupations such as agricul- ture or large meatpacking plants, are afraid to seek care when they are sick. Immigrants have been disproportionately affected by COVID-19.
Much of this information for medical care professionals is important with regard to understanding the pressures certain groups may be facing during clinical appoint- ments. That is to say, keep in mind many patients may only be going to the doctor at the last possible moment because of nancial needs or fears of how it may affect their immigration status. Furthermore, treatment plans should incorporate the likeli- hood of patients being able to return for an appointment or afford one. Another aspect is helping patients who are symptomatic or will understand the importance of isolating within the home, especially since it is known that people of color and immigrant groups tend to live with extended family. Some groups may have cultural healing practices or rely on religious prayer for healing, which may either expose them to more people or expose them to risk factors that worsen illnesses. Understanding the facts about different groups and cultures is what is known as cultural competence.39
While cultural competency is extremely important in setting patient care and understanding their risk factors with regard to infectious disease, this understanding is only halfway to what is required for highly sensitive patient groups. Medical care professionals risk losing patient contact when they fail to employ cultural humil- ity.39 This aspect takes competence one step further and acknowledges one’s own
culture, and the moral equivalence of that culture to another. This is a lifelong learn- ing responsibility for anyone working with a variety of people like health-care workers.
22.7 Economic Inequalities and COVID-19
The COVID-19 pandemic has highlighted the harsh reality of economic inequality within and between countries. Within countries, the chronic gap in wealth and employment surfaced as an acute problem. Those with nancially secure jobs and savings were able to work from home and maintain social distancing compared with people who were living paycheck-to-paycheck or on daily wages through the infor- mal sector found it dif cult to pay rents and buy food.40 People with money were able to create the physical distance between themselves and others, connect to oth- ers via Zoom, able to get food and other supplies delivered to their doors, and hoard necessities. But those without such af uence risked exposure through their jobs or lost their jobs altogether. The unemployment rate was higher for Black workers; 17.8% lost their jobs between February and April compared with 15.5% of white workers, with black women facing the largest losses of 18.8%.41
This scenario has played out in different parts of America prompting the US Congress to call for federally assisted income replacement, the Coronavirus AID, Relief, and Economic Security (CARES) ACT, which provides $1200 per adult for individuals whose income was less than $99,000 or up to $3,400 for a family of four with children under 17 years old.42 A total of $293.4 billion to people who had led taxes, but at the same time, the CARES Act handed out an almost equal amount, $257.9 billion in 2020, in tax breaks and corporate losses to the country’s wealthiest people and corporations.43 The underlying inequalities continue to persist, and result in poorer health outcomes for the less af uent.44
The World Bank estimates that COVID-19 will push 71 million into extreme poverty of $1.90 per day of earning.45 Sub-Saharan Africa and South Asia will be hit hardest, and see large increases in the number of poor. Equally concerning are the marginally poor, who earn less than $3.20 per day, and their numbers will increase to 176 million. The COVID-19 pandemic has laid bare the structural inequalities, inadequate health care, and the lack of social protections for the poor and exposed the social agenda that rede nes the public good as helping the rich get richer.46 The pro-growth policies, focused on GDP, have pushed aside the growing inequality, rising hunger, unaffordable health and housing costs, dismantled social safety nets, and promoted jobs that do not pay a living wage. According to Philip Alston, United Nations Special Rapporteur on extreme poverty and human rights, the coronavirus pandemic has only helped to lift the veil of a preexisting pandemic of poverty and inequality, and a political system that is designed by those in power to sustain and create wealth for themselves through an agenda of deregulation, privatization, and lower taxes for corporations and the wealth. The dismantling of social safety nets and ecological devastation directly related to neoliberal policies will most likely create more threats to peoples’ health and well-being.
COVID-19 has exacerbated the social determinants of health in the United States and around the world by creating job losses, food insecurity, housing instability, and unequal health care for communities of color, indigenous peoples, prisoners, immi- grants, and other marginal and disenfranchised groups. Given the fragility of their lives, they have not been able to exercise the self-distancing and isolation required to prevent transmission. In the United States, Black communities have been dispro- portionately hit, but the reality is that all over the world those with limited resources and zero social safety have faced, and continue to experience, the brunt of COVID-19.
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36. The White House. Proclamation suspending entry of immigrants who present risk to the U.S. Labor market during the economic recovery following the COVID-19 outbreak. April 22, 2020.
37. U.S. Immigration and Customs Enforcement. ICE guidance on COVID-19. Published July 1, 2020. https://www.ice.gov/coronavirus.
38. Loweree J, Reichlin-Melnick A, and Ewing W.A. The impact of COVID-19 on noncitizens and across the U.S. immigration system. American Immigration Council. https://www.ameri- canimmigrationcouncil.org/sites/default/ les/research/the_impact_of_covid-19_on_nonciti- zens_and_across_the_us_immigration_system.pdf. Published May 2020.
39. Stewart A. Cultural humility is critical to health equity. AAFP Home. https://www.aafp.org/ news/blogs/leadervoices/entry/20190418lv-humility.html. Published April 18, 2019. Accessed June 10, 2020.
40. Semuels A. It’s a race to the bottom. The Coronavirus is cutting into gig worker incomes as the newly jobless ood app. Time. May 18, 2020. https://time.com/5836868/ gig-economy-coronavirus/.
41. Gould E and Wilson V, Black workers face two of the most lethal pre-existing conditions for coronavirus—racism and economic inequality. Economic Policy Institute. https://www.epi. org/publication/black-workers-covid/. Published June 1, 2020.
42. The U.S. Department of Treasury. The CARES act provides assistance to workers and their families. https://home.treasury.gov/policy-issues/cares/assistance-for-american-workers- and-families#:~:text=The%20CARES%20Act%20provides%20for,for%20a%20family%20 of%20four.
43. Sloan A. The CARES Act sent you a $1,200 check but gave millionaires and billionaires far more. Propublica. https://www.propublica.org/article/the-cares-act-sent-you-a-1-200-check- but-gave-millionaires-and-billionaires-far-more. Published June 8, 2020.
44. Reeves RV, Rothwell J. Class and COVID: how the less af uent face double risks. Brookings. https://www.brookings.edu/blog/up-front/2020/03/27/class-and-covid-how-the-less-af uent- face-double-risks/. Published March 27, 2020. Accessed June 10, 2020.
45. Mahler DG, Lakner C, Aguilar RAC, et al., Updated estimates of the impact of COVID-19 on global poverty. World Bank blog. https://blogs.worldbank.org/opendata/updated-estimates- impact-covid-19-global-poverty. Published June 8, 2020.
46. Alston P. COVID-19 has revealed a pre-existing pandemic of poverty that bene ts the rich. The Guardian. Published July 11, 2020. Accessed June 8, 2020
Health-Care Policy and COVID-19
Apurv Gupta M.D., Hemant Gupta M.D.,
Andrew Cooper J.D., Sarah Zaidi Sc.D., MSc., Azwade Rahman, Rohan Iyer, and Terran Cooper
CDC Centers for Disease Control
CECC Central Epidemic Command Center COVID-19 Coronavirus disease
ICU PPE
The philanthropist Bill Gates has referred to coronavirus disease (COVID-19) as a once-in-a-century pathogen that requires global cooperation for its containment.1 With no availability of vaccines or widespread immunity among people, only public health measures can reduce transmission and control outbreaks.
Soon after the con rmation of human-to-human transmission of SARS-CoV-2, the Chinese authorities imposed a cordon sanitaire, a de ned quarantine area from which those inside were not allowed to leave, around Wuhan and then Hubei prov- ince. In addition, the authorities ordered bans on public gatherings, compulsory stay-at-home policies, mandatory closures of schools and nonessential businesses, and face mask ordinances, among others.2 Other neighboring countries had already imposed some of these measures along with testing, isolating positive cases, contact tracing, and quarantining those who had been exposed.
Nevertheless, from the time that the rst case of COVID-19 was identi ed on December 8, 2019, to the time that the Chinese central government took full control of the outbreak, a total of 47 days had passed and the virus had spread far and wide both within China and across the globe. Multiple studies modeling the epidemic pre- dicted that large overseas cities with transport links to China would become outbreak epicenters, unless substantial public health interventions at both the population and personal levels were implemented.
This chapter looks at the global spread of COVID-19 and the responses imple- mented by countries to control the pandemic. Although the world is still in the midst
Chapter 23: Health-Care Policy and COVID-19
of the COVID-19 pandemic, looking back over the early responses can provide insightful lessons about policy considerations, even as cases decline or disappear in some countries or increase and resurge in others.
23.2 East and Southeast Asian Response
The Chinese Center for Disease Control (CDC) informed the local of ces of the World Health Organization on December 31, 2019, about pneumonia of unknown etiology. But since mid-December, the information had been percolating on Chinese social media3 and Canadian-based disease tracking company, Blue Dot, had revealed news of the outbreak.4 Neighboring Taiwan, 81 miles off the coast of mainland China, once learning of the of cial declaration, started to screen incoming passengers from Wuhan.5 The Taiwanese government activated the Central Epidemic Command Center (CECC) that had been established in 2004 after the SARS epidemic. The CECC coordinated efforts by various ministries and managed the response to the entire crisis.
Since the outbreak occurred just before the Chinese Lunar New Year, a time dur- ing which millions of Chinese and Taiwanese travel for the holiday, the expectation was for Taiwan to have the second highest number of cases. However, the govern- ment’s quick response with real-time alerts to classify travelers’ infectious risks based on ight origin and travel history and case identi cation and isolation, quar- antining of high-risk individuals, and regulating the pricing and availability of masks as well as ghting misinformation minimized the number of cases.6
Taiwan announced its rst con rmed imported cases of COVID-19 on January 21, 2020.7 By then, it made use of its established national disease surveillance and reporting system, as well as new location-based monitoring programs via cell phone geolocation.8 The government also utilized a location-tracking phone-based appli- cation to monitor compliance with quarantine measures. Taiwanese citizens’ unique health ID cards enabled doctors and hospitals to access online records allowing for easier access to records of individuals with COVID-19.9 The hospitals prepared for surges, and the production of personal protective equipment was scaled up and face masks were made widely available to the public. All these measures meant that Taiwan, a country of 23 million citizens, could rely on less aggressive measures such as lockdowns and could allow the most economic activity to continue. It has reported only 480 cases and 7 deaths until today, August 10, 2020.10
Other countries in the region that had experienced the SARS outbreak of 2002 and 2003 rushed to implement nonpharmaceutical measures and active screening and quarantining of individuals entering from Wuhan. South Korea reported its rst con rmed case of COVID-19 on January 20th (the same time as the rst reported case from the United States). It had imposed screening measures on January 3 for individuals entering from Wuhan,11 yet cases began to slowly rise over the coming months. On February 17, there were only 30 reported cases, but over the next 10 days, the cases grew exponentially, and by the end of February, there were nearly 3,000 COVID-19 cases in South Korea.12
The South Koreans, learning from their criticized MERS response in 2015 (clus- ter outbreak of 186 cases and 38 deaths due to ve superspreaders),13 acted quickly
East and Southeast Asian Response
to slow down transmission by expanding testing. The government in partnership with the private sector built hundreds of high-capacity screening clinics and 600 testing centers, with testing capacity reaching 15,000 to 20,000 tests per day. The nation of 51 million people also took a big data approach with contact mapping through credit card history and location from cell phone carriers. The authorities also pushed an intense, and mostly voluntary, social distancing campaign, but left most restaurants, stores, and social venues open for operation.
The Korean strategy included snuf ng out clusters of disease outbreak through aggressive contact tracing and testing, housing positive cases in temporary isolation wards (separate from hospitals), monitoring their symptoms regularly through smartphone applications or by phone, and providing timely and accurate informa- tion to the public and health-care professionals about COVID-19.14 Experience with past outbreaks provided that people wore masks and stayed at home without requir- ing government mandates. By the end of March, the pandemic was under control with fewer than 100 new cases per day and a total of 128 deaths. An outbreak con- nected to several nightclubs on May 12 was quickly brought under control. To date (October 3, 2020), South Korea reported 24,239 cases and 422 deaths compared to the United States with over 7.7 million cases and 215,278 deaths even though both countries reported their rst case on the same day.
Post-SARS, other countries such as Thailand, Singapore, and Vietnam had also invested in their public health infrastructure. Thailand reported one of the rst cases outside China (January 16), but its early adoption of facemasks combined with a robust health-care system and enforced lockdown in March (which was lifted in May) has kept cases to a minimum.15 A popular tourist destination with millions of foreign visitors, Thailand has recorded only 3,600 cases and 59 deaths (October 3, 2020). It has imposed a strict 14-day quarantine period for all visitors. Other coun- tries such as Cambodia and Laos in the Mekong River Basin also recorded few COVID-19 infections and deaths. Myanmar, however, saw a spike in con rmed cases from 336 reported in mid-July to 10,000 in September and over 20,000 as of October 3, 2020. However, deaths remain low at 471.
Vietnam was especially proactive, moving quickly to put into place screening and testing measures, quarantine centers for passengers coming in on international ights, initiating aggressive multilevel contact tracing, and informing people about COVID- 19 through creative means such as songs and performances.16, 17 Similar to Korea, the Vietnamese employed a cluster strategy of containing outbreaks and tracing contacts to the third degree (index case to those close proximity to index and those in contact with the close contact), and quarantining those that did not test positive for the virus in government-run centers and requiring self-isolation at home for 14 days. The exten- sive tracing was supplemented by possible commune-level lockdowns, and although Vietnam did eventually introduce a nationwide lockdown, it was relatively short-lived (April 1–15, but extended to 21 days in 28 out of 63 provinces).
Although the rst con rmed case of COVID-19 was reported on January 23, Vietnam contained community transmission and has thus far (October 3, 2020) reported a total of 1,098 cases and 35 deaths until today. The majority of con rmed cases, nearly two-thirds, have been imported from China, Europe, and the United States.15
Singapore appeared initially well prepared, and established border screening and quarantine measures for all new arrivals.18 The contact tracing was an inten- sive effort between multiple agencies that used activity mapping, analytic tools, and surveillance footage. The Singaporean economy remained open, and it seemed that the worst of the pandemic had been averted. However, in April, an outbreak of COVID-19 took hold among the 300,000 foreign workers living in overcrowded dormitories. The migrant workers were not allowed to leave and relied entirely on government support for food and water, communications, and entertainment. The country went into a lockdown on April 7 for nearly 2 months, but infection rates soared despite the high quality of health care.19 Although deaths (27 in total) remained low, the paradox of high rate of COVID-19 infections (55,353 positive cases to date) highlights the vulnerabilities among migrant communities that have little control over their lives and living situation. Singapore started a phased lift- ing of restrictions on June 2, but remote working arrangements and keeping physi- cal distance orders stay in effect. Migrant workers continue to remain in lockdown.
The Japanese government was initially criticized for its management of COVID- 19 because passengers on the Diamond Princess cruise ship, oating off the coast of Yokohama city, contributed to the initial (but mild) wave of community spread. A larger surge occurred in late March, and cases were managed through 460 local public health centers (hokenjo in Japanese), which doubled as miniature centers of disease control.20 The centers were strained, and became bottlenecks for testing, while designated hospitals brimmed with mild cases. In mid-April, the government declared a national state of emergency and shifted to restructure the strained health- care system into a more expansive network that included privately owned facilities and started to house mild and asymptomatic cases in converted hotels or ordered them to stay at home.
By May, Japan had attened the curve and averted a full-blown health crisis compared to countries of similar demographics, like Italy (aging population), and economic development, like the United States.21 It had managed to bring down transmission without large-scale testing or very restrictive social distancing by focusing on clusters of infection in gyms, pubs, live music venues, karaoke rooms, and similar types of establishments where people get together for extended periods of time. Japanese citizens complied voluntarily to wear masks and avoid large gatherings.
The public health responses to COVID-19 by Indonesia and the Philippines oundered and were delayed. Both countries continued to see new infections and deaths. Indonesia reported a total of 128,776 cases, an average of roughly 1500 new cases per day since mid-June, and 5765 deaths (August 10, 2020).22 Philippines surpassed Indonesia in terms of total cases, 139,538 con rmed COVID-19 cases, and 2312 deaths. Over the past 2 weeks, new cases continued to grow exponentially with a jump from around 1500 cases at end July to over 6000 on August 9.23 The pandemic has challenged the Philippines health-care infrastructure, and the country was included in the Global Humanitarian Response Plan together with 63 of the hardest hit countries in the South.24
On January 27, the WHO European Region and the European Center for Disease Prevention and Control (ECPD) introduced a surveillance system and asked coun- tries to report con rmed and probable cases of COVID-19.25 The overall strategic aim at the time was containment with a rapid identi cation of probable cases and contact tracing. The rst case detected in France on January 19, followed by two cases on January 24, had direct links to Wuhan.26 By February 21, 47 cases of COVID-19 were reported from 9 countries that included Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1), and the United Kingdom (UK) (9). Researchers observed transmission of infection taking place in two broad contexts: sporadic cases linked to travel from China and local community transmission in Europe.27 Clustered outbreaks occurred in France/Spain (7 person cluster in Haute-Savoie and cases were detected in UK) and 14 cases from Bavaria, Germany, and the risk level of similar clusters and community transmis- sion was raised from low to moderate, and then high.28
Although the Germans initially experienced a high rate of infection, they were able to slow down the transmission of the virus. They had developed the rst diag- nostic test for COVID-1929 and started early testing for the virus, increased the capacity of hospitals to manage severe cases, and engaged in a transparent and sci- enti c communications strategy. The German government at the federal and state levels undertook several measures such as social distancing, banning gatherings, wearing facemasks, and stay-at-home orders in some states. While these restrictive measures caused anger and frustration, and even protests, and were considered to impinge on basic rights, they contained the spread of the virus. By June, the UK had over 300,000 cases, over 100,000 more than Germany. More striking was the differ- ence in the total deaths—46,526 deaths in the UK in comparison to 9268 deaths in Germany. An individual with COVID-19 was 6.5 times more likely to die in the UK than in Germany because of the delays in implementing public health policies.
The Germans were able to successfully handle the pandemic. At the forefront of medicine with a strong pharmaceutical industry, they had started early production of test kits and personal protective equipment (PPE). They introduced early lockdowns based on outbreaks, and followed up on positive cases and their contacts. As the country entered into a recession because of the lockdown, the government intro- duced an aid package of $808 billion to mitigate the damage, which included sup- port to further strengthen the health-care system, to provide help to small businesses and the self-employed, to provide state aid for companies, and to secure corporate debt at risk of defaulting.30 A fresh domestic stimulus package worth $146 billion was launched in June for 2020/202131 that included providing families with an extra $336 per child.
In contrast, COVID-19 caught the Italians wholly unprepared. By mid-February, cases began to rapidly increase in northern regions of Italy and two deaths were recorded.32 Similar to Wuhan, the Italian provinces in the northern region became the next epicenter, and cases rose from 3 to 50 to 800. On March 8, the Italian govern- ment closed public spaces and prohibited traveling to Lombardia, Emilia Romagna,
Piemonte, and Veneto. Commercial activities were closed aside from essential busi- nesses. A nationwide lockdown was declared on March 9, and all ights were sus- pended. But these measures were introduced too late as 14 other countries in Europe con rmed their rst cases seeded from travelers who visited Italy.
By March 19, the death toll in Italy surpassed that of China’s totaling 4,634, and it was eventually 7.5 times more.33 The health system was quickly saturated with cases, and faced major shortages of intensive care unit (ICU) beds, ventilators, and personal protective equipment.34 The highly competent state-run health-care sys- tem, overwhelmed with cases, especially as u season, was still ongoing, experi- enced overcrowding and disorder within and across hospitals resulting in high rates of transmission among medical personnel and patients. At one point, there were 900 deaths per day, and the horror stories of doctors being forced to choose who to treat and dramatic scenes of people lying on hospital oors circulated around the world.
A total of 35,216 deaths occurred in Italy, 87% in people over 70 years old,35 and over 150 medical doctors36 lost their lives. The crude mortality rate in Italy was 6–7%. The death rate was 58.3 per 100,000 population in Italy, almost six times that of Germany at 11.08 per 100,000 population and 10% less than the UK at 69.81 per 100,000 population.37 The Italian government, however, did take several strategic steps to contain the unfolding crisis, including social distancing, mandatory face- masks, banning large gatherings, closure of nonessential commercial and retail businesses, and closure of schools and universities, among others.
The Italian government also passed a 25 billion Euros nancial package, Cura Italia, of which 3.2 billion was used for strengthening the health-care infrastructure. New hospitals were built and the existing buildings were converted to house-infected cases. By early April, intensive care beds had doubled, and the departments for infection and respiratory disease received an in ux of funding to purchase PPE. Community nurses were recruited to intensify testing and contact tracing. Any indi- vidual who tested positive, or who had come in contact with a positive case, was placed under self-isolation and home quarantine of 14 days. After nearly 70 days, Italy loosened its restrictions on May 4. But the Italian government’s decentralized approach and bureaucratic red tape proved to be challenging in containing the out- break and minimizing the deaths.
Following the spike of cases in Italy, Austria closed its border. But soon it con- rmed two cases, tourists from Italy. Like many other countries in Europe, Austria did not shut down nonessential businesses until mid-March, and although it did not mandate wearing masks in public until April, it managed to contain the outbreak by a rigorous and punitive social distancing regime that ned people for breaking quar- antine. The government set up a hotline to dispatch medical workers to test for COVID-19 at home, and also implemented a random testing policy to nd presymp- tomatic and asymptomatic cases. As a result, there were only 22,439 infections and 724 deaths.38 The mortality rate was 8.16 per 100,000 population.
France, like Germany, has a strong central government and advanced health-care system. But its death rate was 4.5 times higher than that of Germany even though it con rmed its rst case around the same time. One reason for the difference was that the French government did not implement social distancing measures or ban large gatherings. Until early March, President Emmanuel Macron was still seen in large
gatherings, shaking hands, and kissing other colleagues, and even making public appearances in retirement homes.39
The French did not impose a lockdown until March 17, and failed to build their logistical capacity to promote mass testing.40 Only 45 public laboratories were accredited, and there was a limited availability of reagents for RT-PCR testing. Instead of scaling up testing, authorities argued that systematic testing was not needed and only reversed their position in late March as a way to end the lockdown. Although France had an expert committee for scienti c guidance, it proved ineffec- tive in informing policy. The French also faced shortages of PPE, relying on China for both masks and testing kits.
The government introduced a series of laws to protect businesses, including a 300 billion euros loan program that included the protection of workers. It intro- duced “Operation Resilience” that used the French military to provide medical and logistical help, and created checkpoints to prevent people from defying lockdown order. But while these policies appeared to be heading in the right direction, the government decided to hold the rst round of mayoral elections (a decision forced by political opponents of President Macron who wanted to take advantage of his rising unpopularity). However, the President postponed the second round given the low voter turnout and the severe losses incurred by his political party.41
On June 2, the government fully relaxed the lockdown measure. The French government, maintaining a reputation of being colorblind, refused to collect data by race, and it failed to acknowledge the disproportionate effect the pandemic had on its minority communities.42 The politicization of COVID-19 crippled France’s abil- ity to manage the public health crisis. Over 600,000 cases have been recorded in France and 32,299 deaths until October 3, 2020.
Greece has the second highest aging population in the European Union after Italy, and with years of economic hardship and austerity, it has a weak health-care system. However, the Greek government reacted swiftly to the threat of COVID-19, adopting an approach driven by science. Rather than promoting public messages that con ict with those of its own public health of cials, Prime Minister Mitsotakis consulted with specialists from the University of Athens Medical School, the National Research and Technology Centre, and other institutions, and established a specialized task force that advised on policy and communicated with the public.43 The emphasis on transparency quelled any backlash against socially disruptive mea- sures that were introduced by the government. In addition, the government through a public–private partnership effectively managed its health resources, doubling its ICU capacity by the end of March.44 It employed over 4000 new doctors and nurses, and spent an estimated $5 billion per month.45 As a result of its proactive interven- tions, Greece experienced only 6177 cases and 216 deaths.46 It has opened up its economy and resumed tourism, a major source of revenue. Tourists entering Greece are tested for the virus, and depending on their results, they are either required to self-isolate or spend 14 days in supervised quarantine.47
Sweden was an outlier in comparison to its neighboring countries and never imposed a full lockdown, keeping businesses, restaurants, and most schools open throughout the pandemic. It did not of cially prescribe policies of social distancing and the use of facemasks. Swedes naturally adopted preventative measures, such as
keeping their distances, limiting social interactions, refraining from forming crowds, and wearing masks. The approach resulted in a high death toll, nearly 6000 deaths or 567 deaths per million people compared to three times that of Denmark (166 deaths per million people) and 7 times that of Finland (59 deaths per million people) and Norway (47 deaths per million per million). The COVID-19 deaths per million in Sweden were closer to Italy than to its neighbors.1 Sweden experienced an eco- nomic recession.
23.4 Oceania—Australia and New Zealand
Australia and New Zealand with two very different governments managed to success- fully control the outbreak of SARS-CoV-2.48 New Zealand reported its rst case on February 26, and moved swiftly to shut down the country. Initially, it instigated shut- ting its borders to other nations, but a week later shut down all nonessential business and then went further implementing a level 4 lockdown, meaning that people could interact only within their household unit. The strategy was accompanied with text messages explaining what was expected from the individual, and accompanied by Facebook Live videos of the country’s prime minister explaining the situation. As a result, New Zealand reported just over 1500 cases and only 22 COVID-19 deaths. The government of Prime Minister, Jacinda Ardern, also introduced a series of tax reforms that supported small businesses and protected individuals from losing their homes. In addition, in a symbolic gesture, Ardern and her ministers took a 20% cut in salaries.
The full lockdown allowed the government to get its systems up and running and to effectively manage testing and contact tracing, as well as surveillance.49 The New Zealand response based on scienti c evidence, leadership, and careful communica- tion helped to slow down transmission and eliminate the virus.50 On June 8, the country announced that it was COVID-19 free but it remains vulnerable to future outbreaks.
Australian leadership could not be more different than New Zealand, but it also managed to contain the COVID-19 outbreak by deferring to its scientists for guid- ance. As COVID-19 spread across the vast island, federal and state leaders from across the political spectrum coordinated their response rooted in scienti c evi- dence. As early as March, Australia was possibly heading towards a public health disaster with cases rising exponentially and not enough testing.51 The passengers on the Ruby Princess cruise liner, amounting to 700 COVID-19-positive cases (10% of total cases), were allowed to disembark and self-isolate despite exposure to COVID- 19. The country also suffered from PPE shortages, with many health professionals unable to get enough materials for self-protection.52
But in the middle of March, the Australian government turned the tide and estab- lished a COVID-19 national cabinet to respond to the pandemic.53 All states and ter- ritories met to agree and implement consistent policies on testing, social gatherings, visitor restrictions to long-term facilities, and quarantine period. Listening to health experts guiding policy, political leadership remained apolitical of the COVID-19 out- break. Social distancing rules were put in place, and the government expanded access to telemedicine services to over 3 million patients.54 Changes in hospital services,
including screening staff, patients, and visitors, as well as aggressive testing of those most at risk and effective communication prevented greater transmission.55 As of October 3, a total of 27,173 cases of COVID-19 have been recorded with 895 deaths.56
23.5 The Americas
The only entry of a successful response in the Americas is Canada, which had expe- rienced a localized SARS breakout in 2003 with 44 deaths.56 This had pushed the government to invest in testing and surveillance infrastructure for any future pan- demics, but even then Canadians were initially unprepared. They did not recom- mend social distancing or ban of large gatherings, facemasks, and other interventions until the rst COVID-19 death.57 Despite some delay in their response, the Canadian government implemented social distancing and lockdowns. Listening to the advice of health professionals, cross-partisan decisions and actions served to send a mes- sage of unity to the general public and reduce transmission.
However, Canada’s public health system has three levels of jurisdiction—fed- eral, provincial (10 provinces), and regional (3 territories). In a manner similar to the United States, where individual states determine the response, in Canada prov- inces and territories have the authority to determine strategies for containment, while the federal government focuses on international border closing, managing PPE supplies, testing kits, and ventilators. There was considerable cooperation between the federal and provincial governments including on policies related to social distancing, banning public gatherings, school and university closures, and closing of public spaces and nonessential businesses.58
Long-term care facilities for elderly struggled to contain the outbreak, and 81% of deaths occurred in these facilities.59 Employees in elderly care worked in multiple facilities and were spreading the virus. The Canadian military was deployed to sup- port facilities and contain transmission. Public health agencies hired extra people for testing and contact tracing, and the government introduced a new COVID-19 exposure mobile app. Masks were recommended in June and mandated in parts of Canada. By August 12, 2020, Canada reported a total of 120,844 cases and 9006 deaths. Currently, less than 300 new cases are being reported across the country unlike its neighbor the United States that has been recording over 50,000 new cases daily and 1,000 deaths.60
The US government response to the COVID-19 outbreak has been catastrophic, and President Trump’s administration has left policymaking for the outbreak up to state governors. Often the federal government and some state governors have even downplayed the impact of the virus. As a result, the United States, which makes up 4% of the global population, has reported 26% of COVID-19 cases (5.4 million of the 20.8 million cases) and the highest number of deaths at nearly 170,000 (22% of total deaths) followed by Brazil at 104,263 (14%) deaths and India at 47,138 (6%) deaths (August 22, 2020).61 However, as numbers have gone up globally, the United States proportion of cases has declined to 21.4% and deaths to 20.4% (October 3, 2020).
The US government initially ignored any warnings regarding the virus even though the administration was made aware of the outbreak on January 3.62 The rst
known case of COVID-19 was detected on January 19, a 35-year-old man in Snohomish County, Washington.63 By February, there was evidence of person-to- person transmission,64 but the cases were downplayed and President Trump repeat- edly ignored warnings instead stating that the virus would disappear.65 The CDC botched testing efforts, further delaying the ability to detect new cases.66 State gov- ernors failed to recognize the severity of the crisis despite ample warning signs from Europe and Asia. Most of cials delayed on providing transparent guidance based on scienti c evidence and on introducing coherent public health policies of social dis- tancing; banning large gatherings; wearing facemasks; and closing of schools, uni- versities, and nonessential business. As the CDC advised and provided guidance to the Federal government and states on reducing transmission and attening the curve, the responses remained inconsistent.67
By the third week of March, COVID-19 cases increased exponentially and cities such as New York and San Francisco scrambled to manage the outbreak. The epi- center of the pandemic had once again shifted, from China to Italy and now the United States. The pandemic exposed the fragility of some of the most marginalized American communities, including racial and ethnic inequities and economic dis- parities deeply rooted in decades of structural discrimination.68 Five former CDC directors noted that America was behind the curve in containing the virus despite its considerable resources, scienti c expertise, and state-of-the-art health infrastruc- ture, and furthermore, simple behavioral interventions like wearing a mask had become far too politicized.69, 70
In March 2020, one of the earliest estimates of the impact of COVID-19 from the IHME (Institute of Health Metrics and Evaluation) projected “a total of 81,114 deaths (95% UI 38,242–162,106) from COVID-19 over the next 4 months in the US.”2 As a result of many of the policy failures noted above, the number of deaths in the United States has already far exceeded this projection (170,000 on August 20, 2020). IHME’s latest (August 7, 2020) COVID-19 forecasts indicate that “the US will reach nearly 300,000 deaths by December 1, 2020.” The IHME issued simple and stark guidance along with this latest estimate, “if mask wearing in public increases to 95%, more than 66,000 lives could be saved.”3
In Brazil, President Bolsonaro’s response was similar to the US’s President Trump’s.71 Even as cases rose, the government postponed issuing recommendations of physical distancing, wearing facemasks, banning social gatherings, closing schools and nonessential businesses, as well as regional lockdowns, and instead played down the virus, comparing it to seasonal u. Many of these aforementioned public measures had been utilized in prior health emergencies such as H1N1 and the Zika virus, but had fallen out of favor with the current administration’s decentralized approach.72
President Bolsonaro’s rigid insistence that the virus posed no danger and later his belief in using hydroxychloroquine (unproven antimalarial drug as a remedy for COVID-19) resulted in the termination of his health minister, and resignation of the second within a month of taking on the job.73 Testing remained low even as cases grew. Similar to the United States, where state governors and city mayors stepped in to mitigate the COVID-19 impact, in Brazil, the states and municipal govern- ments stepped in to take up the mantle of responsibility.74 In low-income
Conclusion: Lessons Learned
neighborhoods, known as favelas, transmission and mortality rates were higher, given that social distancing was a near impossible challenge.75 Indigenous people and people of color were most affected with rates of transmission three times greater in poor neighborhoods compared to wealthy areas.76 The rst con rmed COVID-19 case was detected on February 26, and today (August 13), Brazil has the second highest number of cases after the United States at 3.1 million and reported over 100,000 deaths. Both countries were reporting an average of 55,000 new cases per day and over 1000 deaths per day.77
The Americas account for less than 10% of the global population, but have recorded 30% of COVID-19-related deaths78 and 50% of cases (11.1 million).79 The Pan American Health Organization Director noted that the COVID-19 pandemic revealed not only the structural de ciencies in the health sector resulting from years of inadequate public investment but also the inequalities around livelihoods.80 Coupled with delayed initiatives, poor leadership, and misinformation campaigns that undermined the scienti c realities, it should not be a surprise that the COVID- 19 pandemic continues to rage in the Americas with the one exception of Canada, which manages to limit infections.81
23.6 Conclusion: Lessons Learned
While no government should be blamed for creating the COVID-19 pandemic, they should be scrutinized for how they responded in slowing down transmission and protecting the health of their people, including preventing excess mortality. The pub- lic health policies for containing the outbreak were the same, but the timing of their implementation varied across the world. Some countries imposed aggressive mea- sures early on to contain and manage outbreaks, and others reacted slowly. The effect of travel restriction modestly slowed down viral transmission, by 3–5 days in China after the Wuhan lockdown.82 But it had a marked effect at an international scale, reducing case importation by nearly 80% until mid-February. The authors concluded that travel bans and restrictions were not as effective as early detection, hand wash- ing, self-isolation, and quarantine measures in mitigating the COVID-19 pandemic.
While this chapter did not cover the situation in western Asia, Middle East, Africa, and the Paci c, the elements of a successful response with regard to infec- tions and deaths are evident in these regions as well. Listed below are the interven- tions shown to limit infection in the absence of vaccines and effective treatment.
1. Early implementation of nonpharmaceutical public health measures: Given the airborne nature of COVID-19 transmission, outbreaks could only be limited by implementing measures such as physical (social) distancing, good hand hygiene, and facemasks. Banning large gatherings, closing schools, uni- versities, public playground, and nonessential business, and mandating stay at home orders substantially reduced contact between people and helped to bring down the rate of transmission. Travel restrictions had a modest impact on reducing transmission, especially when community spread had already started.
2. Testing, testing, testing! Isolating positive cases, contact tracing, and quarantining exposed individuals: The importance of testing was central to containing COVID-19, especially clustered outbreaks that could turn into super-spreading events. Ongoing containment of viral transmission, espe- cially as the next u season approaches and restrictions are lifted, requires a robust testing strategy that includes positive individuals to self-isolate and their contacts to quarantine. A testing strategy should include both the RT-PCR and serological tests for antigens, and should focus on asymptom- atic and presymptomatic carriers and priority populations such as the elderly, health-care workers, immunocompromised individuals or those with chronic conditions. Mass serological testing can also provide a preva- lence estimate of COVID-19 in the population. The Brookings Institute and Washington University in St. Louis produced a computational simulation model to inform policy responses to COVID-19 called Testing Responses Through Agent-Based Computation Epidemiology (TRACE)82 for the United States.
3. Scienti cally accurate and transparent decision-making and public com- munications by leadership: Countries that made decisions based on medical and scienti c evidence and communicated the true facts to their citizens man- aged to control the spread of the virus and minimize deaths. Governments that denied viral spread or built mistrust of their public health and medical of – cials fared much worse, resulting in greater confusion. They experienced a higher number of cases and, as a result, many more deaths.
4. Well-resourced health infrastructure, including plans for pandemics: Countries that had experienced the SARS outbreak were better prepared, including having a pandemic response plan coordinated across various gov- ernment agencies. They were able to mobilize quickly and contain the out- break. They had stockpiled PPE, maintained their health infrastructure (or in the case of China were able to quickly build as needed), and maintained suf- cient investments in medical professionals and health-care workers. Governments who had been cutting health care and public services budgets did much worse, including those who had decimated their public health sector.
5. Prioritizing the most at risk, which includes the poorest and most mar- ginalized along with those who are vulnerable to the virus: COVID-19 has brought out the stark inequalities embedded in today’s globalized world. People with higher incomes and stable jobs were able to follow the public health recommendations, but those with lower incomes held essential jobs and were from ethnic and racial minorities. They were unable to keep physical distance, less informed about the pandemic, and often had preexisting condi- tions. As a result, they bore the brunt of exposure and mortality. Governments that prioritized a holistic approach and provided income support along with health services were able to contain the virus much quicker than those where there was an absence of universal, comprehensive health care, protection against job loss, and supplemental income.
COVID-19 has infected over 21 million people, and continues to rage in coun- tries that never contained the virus and has resurged in some countries that ended community transmission because of international travel. This coronavirus may never go away. It is much more transmissible but not as deadly as its cousins— SARS and MERS—and outbreaks are going to continue to pop up. Even if it was eliminated from circulation among humans, the pathogen has successfully made the interspecies jump and could easily transmit back into humans from its animal host. Governments around the world have learned that they need to recognize their role in supporting health care and public health infrastructure, to put aside partisan differ- ences in times of crisis in order not to sow confusion and distrust, to take care of their most disadvantaged citizenry in order to protect them as well as the population at large, and to heed the advice of experts and work in close collaboration with respective agencies in order to create coherence and consensus.
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Looking Beyond the COVID-19 Pandemic
Carey Kriz, Chirinjeev Kathuria M.D., MBA, Gary Shmorgon, and Carmina Rogelio
COVID-19 Coronavirus disease
Coronavirus disease (COVID-19) pandemic has overwhelmed countries, brought economies to a standstill, and forced people to sequester in their homes. With no vaccines or effective treatment available, interventions have focused on nonpharma- ceutical methods along with testing, contact tracing, and quarantining. Some coun- tries have managed to successfully control the initial unfolding of SARS-CoV-2 transmission, and developed strategies to mitigate the possibility of resurgence of infections. Others are still in midst of the rst wave of the pandemic. COVID-19 is now part of diseases that infect people, and this chapter looks at the potential future of our world with COVID-19.
24.2 How Might the Pandemic End?
Theoretically, there are three possible scenarios characterizing how the coronavirus pandemic might end: one that is catastrophic, one that is the best possible scenario,
and one that is in between the two.1, 2
The rst scenario is based on building up herd immunity by allowing the disease
to run its course through the population. This essentially means that few protective measures will be in place, and most people will become infected. Those who get infected and recover will begin to make up the immune population until hopefully, eventually, the virus will nd no more viable hosts and fail to infect any more peo- ple. Herd immunity would only be possible if 70–90%3 of the population became permanently immune.4 This is the fastest way for the pandemic to come to a head and effectively eradicate the virus, but of course would be unspeakably disastrous for the human population and health systems worldwide.11 Many people would die.
Chapter 24: Looking Beyond the COVID-19 Pandemic
The second scenario is based on cooperation among leaders to control the spread of the virus through precise and aggressive containment measures. Comprehensive testing would be required in order to identify any and all cases, which are then placed under immediate isolation. Strong cooperation between leadership, full com- pliance of the public, and adequate resources would be a prerequisite to enforcing this level of containment.1 This is an attractive strategy which could eventually shrink the magnitude of the coronavirus pandemic perhaps similar to the original SARS in 2003. Health policy expert Dr. Harvey Fineberg predicted it may take as little as 10 weeks to “crush the curve” with a forceful enough campaign.5 However, given the exponential upward trend of outbreaks in the United States as well as the political, sociocultural, and economic climates that the pandemic was born into, this is astronomically unlikely to happen.
Finally, the third route is a strategy of mitigation until a vaccine comes. This is generally what is occurring around the world through various degrees of public health measures and the resulting daily number of cases. The summer and remain- ing months of 2020 are still described as part of the “ rst wave” in the United States.6 The disease will remain circulating as long as containment measures are imperfect and as long as it takes for a vaccine to be made and distributed.
While there are still too many unknowns to accurately make predictions, the pat- terns of other coronaviruses and past pandemics may be considered for thinking ahead. Some researchers speculate transmission dynamics which depend on two unknown factors: immunity status after infection and seasonality of infection.
24.2.1 If Immunity is Permanent, then Covid-19 is a Relatively Brief and Intense Pandemic
Kissler et al.7 built a deterministic model of SARS-CoV-2 transmission dynamics with a focus on the United States and cross-immunity interactions between the 2019 virus and other coronaviruses.7 Their projections consistently determined that given permanent immunity to COVID-19, the virus would cause a major outbreak and then effectively disappear in 5 or more years.1 The WHO has found that most stud- ies show that people generate antibodies to the virus after recovery. However, there is no evidence yet to determine whether or not antibodies to SARS-CoV-2 confer immunity to future infections.8
24�2�2 If Immunity is Temporary and not Permanent, then Covid-19 Enters Regular Circulation of Other Respiratory Infections
In the case of temporary immunity, multiple sources point to the scenario of an initial wave of SARS-CoV-2 followed by the long-term seasonal ares much like the u.1, 4, 9 Kissler et al.7 modeled different durations of temporary immunity lead- ing to possible annual, biennial, or sporadic outbreak patterns. Based on other known coronaviruses, a duration of immunity of 40 weeks leads to an annual
The Future of COVID-19 and Dealing with the Years Ahead
pattern, while a longer 2-year immunity leads to biennial outbreaks.10 Cross- immunity with the existing coronaviruses also plays a role in the duration of immunity.11
A Swedish modeling study also simulated different scenarios using data from the existing endemic coronaviruses.12 Plausible model parameters show an initial phase in which northern and southern temperate and tropical regions see different patterns of circulation. After a few years, they predict SARS-CoV-2 will become a seasonal coronavirus with characteristic winter outbreaks. What determines seasonality? Infectious disease experts and biologists say that even for well-known diseases, it’s not exactly clear.11 Other researchers analyzed past pandemics since 1700 and did not discern any clear seasonal pattern for most. The 1968 pandemic (Hong Kong u) was the only one with seasonality characterized by more winter-dominant out- breaks. Seven other pandemics in the past had an early peak, which waned until a second peak erupted about 6 months after the rst.13
Some Russian scientists generated similar predictions when thinking from a virus–host perspective. They speculate that the virus will eventually become sea- sonal and endemic after a series of microevolutionary events during the initial wave. They paint a picture that perhaps one wintertime day in the future, a person will catch the virus, visit their doctor who will prescribe something like “covidol,” and recover in days.10 While it is not an impossible future, only the virus and our collec- tive actions will forecast how the pandemic will unfold.
24.3 The Future of COVID-19 and Dealing with the Years Ahead
24.3.1 Ongoing Mitigation
Every day of the pandemic, we learn from the mistakes and discoveries of others. It is vital that accurate information is shared widely in the public and in scienti c communities. Much information is already constantly promulgated by health experts, public of cials, and news outlets. Still, it is worth reinforcing how mitiga- tion strategies are actually proving to work due to persistent objections and politici- zation of some of these measures.
Researchers and health of cials acknowledge that an extended period of quar- antine may not be realistic for many reasons. Moreover, a one-time quarantine might merely delay an inevitable peak.7, 14, 15 Multiple sources conclude that a feasible strategy is intermittent social distancing as well as increasing critical care capacity.10, 14–16 Decisions to increase or loosen distancing restrictions should be informed by ongoing and widespread testing, contact tracing, and other data collection. A short-term goal might be to balance economic activity without exceeding health-care capacities.7 At the same time, development of vac- cines and other interventions is an urgent priority. Research on serology would also be helpful to learn more about the long-term immunology and transmission dynamics of the virus.
Ch. 21, 21.3
Vaccines, Vaccines in development for SARS-CoV-2
Ch. 18.2
Ch. 3.1, 3.2, 3.3
Transmission, Prevention, nonpharmaceutical interventions (NPIs)
Diagnostics, Testing
For more information, see the following sections:
The numbers evolve so rapidly, so it is important to keep a pulse on the local situ- ation by regular testing. This might involve the implementation of systems in com- munities to streamline testing and reopening and restriction of activities. Without comprehensive testing, a signi cant percentage of transmission may occur unknow- ingly by asymptomatic individuals. Importantly, the use of cloth masks would help reduce asymptomatic transmission.17, 18 Simple cloth masks with <30% ef cacy (compared to ≥70% ef cacy of medical-grade masks) have been proven to reduce the risk of infection and transmission of the virus.19 Other preventative measures (see Chapter 3) should also be adopted.
A study published in March 2020 revealed early transmission in China.18 Researchers used a very large pool of mobility data to build a dynamic networked population model, and subsequently made inferences about epidemiology of SARS- CoV-2. It was found that undocumented infections were the source of 79% of docu- mented infections. Another modeling study used highly detailed mobility data to describe transmission dynamics in the Boston metropolitan area.16 Aleta et al.16 sought to calculate what percentage of the population would need to be quarantined in order to follow a proposed contact tracing and isolation strategy. If 50% of symp- tomatic infections were identi ed and 40% of their contacts were traced, then about 9% of the population would need to be quarantined at any given time. Researchers at Emory University generated a similar model with partial restoration of the econ- omy based on testing.20 This group investigated the role of serological testing in allowing seropositive individuals to be free of social distancing and act as “immu-
nological shields.”
To be clear, these models were generated with limitations and imperfect param-
eters; thus, further con rmation is needed. However, the idea of selective quaran- tine alongside a semi-active economy may be worth exploring for a sustainable future.
24�3�2 Dealing with the Aftermath
This section addresses the period not only after the peak has passed, but in the event of successful eradication of the disease. The WHO has recommended actions to take on a national level in order to address the long-term health and social impact of a pandemic. These actions are multifaceted and subdivided into categories:
1. Planning and coordination: review lessons learned with the international community; replenish resources
2. Situation monitoring and assessment: evaluate the pandemic characteris- tics and situation monitoring and assessment tools for the next pandemic and other public health emergencies
3. Reducing the spread of disease: conduct a thorough evaluation of all inter- ventions implemented
4. Continuity of health-care provision: evaluate the response of the health system to the pandemic, and share the lessons learned
5. Communications: publicly acknowledge contributions of all communities and sectors, and communicate the lessons learned, incorporate lessons learned into communications activities and planning for the next major pub- lic health crisis
Even without a vaccine, signi cant changes in individual behaviors such as hand washing and masks wearing and public policies can reduce disease transmission. Preventable diseases already cause huge losses of life. For example, on average, 400,000 people die each year from malaria; 1.5 million die from tuberculosis; and 140,000 children die from measles for which there is a vaccine. Since the virus selectively impacts the elderly and those with underlying chronic diseases, it is pos- sible that with smart interventions, deaths in these groups can be averted in the future. COVID-19 unleashed an unprecedented, and rarely witnessed, rush of pub- lications to mitigate its impact, share information on treatments, and nd vaccines. In the midst of a lot of uncertainty, there is a lot that has been discovered and shared about COVID-19. As the pandemic evolves, this section and book will continue to evolve with it.
The COVID-19 pandemic has had devastating effects on people and economies. As of August 27, over 800,000 people had died. The economic effects to the world economies have also been devastating. It has resulted in one of the largest global recession in history with much of the world being locked down in quarantine.
It is expected that global contraction could reach greater than 2% in 2020. Although governments have recorded one of the largest nancial scal packages in recorded history which to date is already greater than $9 trillion, the impact of loss of jobs, livelihoods, and homes will have far-reaching consequences, including depression.
The coronavirus pandemic is also upending the US Presidential elections with conventions being held virtually to a signi cant amount of the votes to be done by mail.
It has changed the way campaigns will be conducted from limiting large cam- paign rallies to different tactics for fundraising. The COVID-19 response, deaths, and the economic effects are expected to have major impacts on the outcome of all aspects of the elections from the Presidential and control of the US Senate and House.
The COVID-19 pandemic has also changed the way patient care is delivered now and in the future. Telemedicine has grown an incredible 4000% during the pan- demic and is expected that a signi cant number of health-care visits will continue to be virtual. All that is needed is a computer, tablet, or smartphone for two-way video interaction between providers and patients. In the United States, the laws allowing for reimbursement of telemedicine continue to evolve and the Congress and advo- cacy groups are asking private insurers to make telemedicine.
The COVID-19 pandemic is unfortunate, but its occurrence provides an opportu- nity to set up a different kind of world where health care can be delivered to all in a cost-effective manner, where mental health and well-being will become mainstream and part of health services, and where people will be the priority.
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13. Moore KA, Lipsitch M, Barry JM, Osterholm MT. COVID-19: The CIDRAP viewpoint. Center for Infectious Disease Research and Policy. https://www.cidrap.umn.edu/sites/default/ les/public/downloads/cidrap-covid19-viewpoint-part1_0.pdf. Published April 30, 2020. Accessed July 3, 2020.
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Dr. Riyaz Ahmad M.D. graduated from Magadh Medical College in Gaya, India, in 1991, and Darbhanga Medical College, Darbhanga, India, in 1997. He received his MRCP from The Royal College of Physicians (Ireland) in 2012 and MRCP from The Royal College of Physicians (UK) in 2013. He is currently practicing in Dubai and contributed to Chapter 7 on COVID-19 manifestations in the central nervous system.
Dr. Syed E. Ahmad M.D. graduated medical school in 1990 from Darbhanga Medical College/Lalit Narayan Mithila University, Laheriasarai, Bihar, India. He is an Assistant Professor of Medicine and Acting Internship Director at Donald and Barbara Zucker School of Medicine, and is working at Albert Einstein College of Medicine & SUNY Downstate SOM. In 1990, he joined the staff at North Shore University Hospital. During the COVID-19 pandemic, he worked on the front line and contributed to Chapter 12 on severe COVID-19 manifestations, Chapter 17 on post-recovery and long-term complications, Chapter 20 on drug treatments, and Chapter 21 on vaccines.
Syed Imran Ahmad is currently pursuing his medical degree at the Sophie Davis/ CUNY School of Medicine. He contributed to Chapter 2 on virology and the immune response.
Shaan Ahmad M.D. is a graduate of Brown University’s combined BA/MD pro- gram and currently a PGY-2 in Internal Medicine at Columbia University Medical Center in New York City. He is interested in cardiology and hopes to pursue fellow- ship training after completing residency. He contributed to Chapter 4 on outpatient management.
Syed Muzaffar Ahsan M.D. is a nephrologist in Taylor, Michigan. He is af liated with multiple hospitals in the area and has been practicing medicine for more than 20 years. He has been a senior physician at the Department of Nephrology at the Henry Ford Hospital since 1994 and Medical Director at Green eld Taylor Dialysis since 2007. Dr. Ahsan graduated from Dow Medical College in Karachi, Pakistan, and completed his residency at the Masonic Medical Center in Chicago. He contrib- uted to Chapter 9 on renal manifestations of COVID-19.
Abena Baah-Fordjour is currently pursuing her Medical Degree at the Sophie Davis/ CUNY School of Medicine. She contributed to Chapter 4 on outpatient management.
Dr. Sudhir Bansal M.D. received his medical degree from Delhi University in India, and then attended Medicine and Endocrinology training at the University Hospital Rochester, N.Y. Since 1988, he has been running a private practice, and during the COVID-19 outbreak, he has triaged numerous numbers of patients. He contributed to Chapter 10 on the endocrine manifestations of COVID-19.
Dr. Nicholas Barresi M.D. graduated from the University of Connecticut School of Medicine and is currently a pediatric resident at the Yale New Haven Children’s Hospital. He has done a tremendous amount of research regarding the pediatric considerations of COVID-19, spreading awareness to the Yale and UCONN health systems and beyond, and contributed to Chapter 14 on COVID-19 in children.
Urmila Bharathan is currently pursuing her medical degree at Virginia Commonwealth University School of Medicine with interests in pediatrics and cardiology. She graduated with a B.A. in Biology from the University of Virginia. She contributed to Chapter 6 on cardiovascular manifestations.
Arijit Robin Chakraborty is currently a second year medical student at the University of Connecticut School of Medicine. He completed his Bachelor’s of Music with a minor in Psychology from the University of Connecticut. He contrib- uted to Chapter 3 on transmission and prevention and to Chapter 18 on personal protective equipment.
Sabbir Chowdhury is pursuing his degree of Medicine and Bachelor of Surgery degree at the University of Manchester and preparing for a degree in Health Sciences with Management at Imperial College London, UK. He contributed to Chapter 5 on the pulmonary manifestations of COVID-19.
Andrew Cooper J.D. is an experienced health-care lawyer who represents profes- sionals, practices, hospitals and health-care systems in litigation, transactional and regulatory issues, as well as emerging areas like telemedicine. He has over 30 years of experience representing companies from start-ups to established enterprises in matters involving intellectual property, commercial, compliance, and regulatory issues. Andrew has also served as counsel and trusted C-Suite advisor to companies in market segments ranging from health care and biotech to salty snacks, and food and beverage. Andrew graduated with a Juris Doctor from Hofstra University School of Law, where he was on the Editorial Board of the Hofstra Law Review and has an LLM from NYU School of Law. He is a member of the law rm of Mohen Cooper LLC and is serving as the General Counsel to First Medicine. He contrib- uted to Chapter 23 on health-care policy in the COVID-19 response.
Terran Cooper has a Bachelor of Science in Architecture and minor in Creative Writing from the Ohio State University. He is a health-care paralegal at Mohen Cooper
LLC, whose responsibilities include legal research and writing on a variety of health- care-related issues, matters, and topics. He contributed to Chapter 23 on health-care policy in the COVID-19 response.
Dr. Apurv Gupta M.D., MPH completed his Internal Medicine training at Beth Israel Deaconess Medical Center in Boston, MA. He received his M.D. and Sc.B. from Brown University, and his MPH from the Harvard School of Public Health. He is an expert in physician engagement, change management, and leadership develop- ment, and contributed to Chapter 23 on health-care policy to the COVID-19 response.
Shariq Haider Hashmi M.D. graduated from the University of Virginia with a double degree in physics and biochemistry. He is currently pursuing his medical degree at New York University School of Medicine. He contributed to Chapter 9 on endocrinology.
Dr. S. Ejaz Husain M.D. graduated from Brown University School of Medicine in 1986 and completed his ophthalmology residency at Baylor College of Medicine in Houston, Texas, where he also completed a two-year surgical fellowship program in Cornea, Cataract, and Refractive Surgery. He contributed to Chapter 12 on the oph- thalmological manifestations of COVID-19.
Eesha Imam graduated from Roanoke College with a degree in Creative Writing and a minor in Chemistry. She worked as a medical scribe and medical assistant in a family practice and internal medicine clinic and is currently preparing for a career in medicine. She contributed to Chapter 7 on the neurological manifestations and Chapter 12 on the ophthalmological manifestations of COVID-19.
Dr. Khursheed Imam M.D. is a board-certi ed radiologist who has practiced and taught in Roanoke, Virginia, since 2003. Dr. Imam is an Associate Professor of Radiology at the Virginia Tech Carilion School of Medicine. He obtained his AB in Physics with Honors at Harvard University in 1990, obtained his MD at Yale University School of Medicine in 1994, completed his residency in Diagnostic Radiology at Brown University in 1999, and completed his fellowship in Body Magnetic Resonance Imaging, including training in musculoskeletal imaging at the Johns Hopkins University School of Medicine, where he remained on staff as Instructor in Radiology until 2002. His clinical interests include neurological, tho- racic, abdominal, and musculoskeletal imaging and fetal MR imaging. He contrib- uted to Chapter 15 on radiology of COVID-19.
Dr. Naiyer Imam M.D. is a practicing radiologist. He graduated from Brown University with an M.D. and BSc in Mathematics and Computer Sciences, and MSc in Biostatistics from Harvard University. He is the President and CEO of the First Medicine Corporation, a company focused on telemedicine. Previously, he served as a Medical Director for the publicly traded corporation, NightHawk Radiology Services, and was the Chairman and Founder of American Teleradiology NightHawks
(ATN). The two companies combined in February 2006 with a market cap of over $700 million at the time of the IPO. Breaking Down COVID-19: A Living Textbook book was his idea, and he pulled together all the writers and researchers. Dr. Imam contributed to several chapters, including Chapter 1 on COVID-19 overview, Chapter 3 on COVID-19 transmission and prevention, Chapter 4 on outpatient management, Chapter 7 on COVID-19 and neurological manifestations, Chapter 15 on COVID-19 and radiology, and Chapter 19 on testing for COVID-19.
Syed Ashraf Imam Ph.D. is a licensed Clinical Psychologist in the state of California with vast experience of working with people of different culture, race, and ethnicity. He has more than 15 years of practical experience in the eld of psychology and behav- ioral health, and is trained in a range of treatment modalities. Certi ed PEARLS Therapist from University of Washington to treat depression and Mental Health America, his focus in therapy is on holistic healing by optimum blending of eastern and western philosophy, also including narrative therapy, logo therapy, reminiscence, spiri- tual, and faith-based counseling. Currently, he is a Consultant Clinical Psychologist with Lyra Behavioral Health, San Francisco; HELP Therapist, San Diego, CA; and Program Manager at UPAC Positive Solutions Program, San Diego, CA.
Rohan Iyer graduated from Washington University with a Bachelor’s degree in Global Health and Environment. He contributed to Chapter 22 on the socioeconomic factors of COVID-19.
Dr. Vineet R. Jain M.D. studied at Case Western Reserve University School of Medicine. He did his residency in Diagnostic Radiology at Northwestern Memorial Hospital and then completed his Fellowship of Thoracic Radiology at the University of Maryland. He is currently an Associate Professor of Radiology at Monte ore Medical Center and contributed to Chapter 15 on radiology and COVID-19.
Dr. Saeed Jaffer M.D. graduated from the Harvard Medical School and completed his M.S. in Computer Science from MIT. He is a Fellow at the American Academy of Dermatology and the American Society of Mohs Surgery, and currently runs a private practice in Southern California. He contributed to Chapter 11 on dermato- logical manifestations of COVID-19.
Dr. Mehran Javeed MBChB, MRCPsych, PGCert in Medical Education gradu- ated from University of Manchester Medical School in 2007 and is a Consultant Psychiatrist for older people in Salford, United Kingdom. He is also a member of the Greater Manchester, Lancashire, and South Cumbria Clinical Senate. He has co- authored book chapters on drugs in dementia as well as neuropsychiatric manifesta- tions in dementia and contributed to Chapter 13 on mental health and COVID-19.
Allen Jo graduated from the University of Virginia with a B.S in Biology. He is cur- rently pursuing his medical degree at Howard University College of Medicine. He contributed to Chapter 20 on drugs for treating COVID-19 and Chapter 21 on vaccines.
Dr. Samer Kabbani M.D. graduated from the American University of Beirut in 1994. Then, he completed his internal medicine residency at The Cleveland Clinic Foundation in Cleveland, Ohio, and his cardiology and interventional car- diology fellowship at the University of Vermont in Burlington, Vermont. He is an Associate Professor of Medicine at the Lebanese American University and inter- ventional cardiologist at Clemenceau Medical Center af liated with John Hopkins international. He contributed to Chapter 6 on cardiovascular manifesta- tions of COVID-19.
Dr. Nooshi Karim M.D. graduated medical school in 1996 from Nalanda, Medical College Bihar, India, and completed her residency, including third-year chief resi- dent in 2006 from Flushing Hospital Medical Center NY and her Fellowship in Geriatrics in 2007. She is currently an Assistant Professor of Medicine at Donald and Barbara Zucker School. She is an Attending Physician, Division of Hospital Medicine Long Island Jewish Medical Center. During this pandemic, she has been extensively involved in care of COVID-19 patients on the front line. She contributed to Chapter 4 on outpatient management and Chapter 20 on drug testing for COVID-19.
Dr. Chirinjeev Kathuria M.D., MBA graduated from Brown University with his medical degree and received his business degree from Stanford University. He is the Co-founder and Chairman of New Generation Power and also the Co-founder of American Teleradiology NightHawks, Inc., which merged with NightHawk Radiology Holdings, Inc. The combined company went public on NASDAQ. Dr. Kathuria is an entrepreneurial investor, businessperson, and philanthropist. He ran for political of ce in Illinois, becoming the rst Indian-American to run for the US Senate in US history, in a race that included eventual winner, President Barack Obama. He contributed to Chapter 24 on looking beyond the COVID-19 pandemic.
Dr. Hasmeera Kathuria M.D. graduated from the Loyola University Chicago Stritch School of Medicine and completed her Pulmonary and Critical Care fellow- ship at Boston University. Dr. Kathuria is currently a Pulmonary and Critical Care physician at Boston Medical Center, and is also an Associate Professor at Boston University Medical School. During this pandemic, Dr. Kathuria cared for COVID- 19 patients admitted to the ICU and served on a hospital committee to develop and update best practices for ICU management of COVID-19 patients. She contributed to Chapter 16 on severe COVID-19.
Joseph Kennedy is pursuing his medical degree at the CUNY School of Medicine. He is enrolled in a seven-year joint BSc/M.D. program and received his bachelor’s degree in Biomedical Sciences from the Sophie Davis School of Biomedical Education. He is interested in pursuing anesthesiology and has published several works in obstetric anesthesiology. He has also worked on research related to medical education, telemedicine, and geriatric medicine during COVID-19.
Dr. Intezam Khan M.D. graduated from Jawaharlal Nehru Medical College and completed his residency in neurology at the Albert Einstein College of Medicine. He has been in practice for more than 20 years and is af liated with multiple hospi- tals in New York. He contributed to Chapter 7 on central nervous system manifesta- tions of COVID-19.
Dr. Ruhani Doda Khera M.D. is currently a postdoctoral fellow in Radiology at Massachusetts General Hospital and Harvard Medical School, and also completing her Masters in Business Administration (MBA) from the University of Massachusetts, Amherst. Dr. Doda Khera completed her medical school and postgraduate residency training in India. She plans to use her clinical and administrative skills to improve patient experience and optimize resource utilization in radiological suites. Dr. Doda Khera contributed to Chapter 15 on radiology.
Dr. Lawrence Kogan M.D. graduated from Dartmouth Geisel School of Medicine. He is an internal medicine resident at Brown University and has treated COVID-19 patients in the ICU and general medicine oors at Rhode Island Hospital and The Miriam Hospital. He contributed to Chapter 8 on gastrointestinal manifestations of COVID-19.
Carey Kriz is the chairman of the First Medicine Holdings Corporation of New York, director of Kingdem Capital in Beijing, and founder and chairman of Templeton Energy. Previously, he was the CEO of Keystone Health Ltd of London, England/Cyprus and has held engineering and executive positions with the IBM Corporation and Johns Hopkins. Mr. Kriz was on the executive committee of Johns Hopkins Medicine, directed the Center for Biomedical Visualization and launched the institutions Medical Robotics program with IBM Research. He is also founder of Johns Hopkins International, American Radiology Services, Amcare Labs, MedBiquitous, and the Callisto TV Corporations. He has been involved in leading investment syndications with institutions including the government of Singapore, P zer, Medtronic, and others. Mr. Kriz has a degree in Economics from the University of Rochester and studied computer science/mathematics at the University of Maryland. He contributed to Chapter 1 on the overview of COVID-19, Chapter 2 on virology and the immune response, and Chapter 24 on looking beyond COVID-19.
Dr. Syed Basharath Mehdi MBBS, FRCP (Edinburgh) is currently a Consultant Chest Physician and Lung Cancer Lead at Lancashire Teaching Hospitals NHS Trust. He completed his medical schooling from M S Ramaiah Medical College and Teaching Hospital, Bangalore, India, and completed his core medical training fol- lowed by specialist registrar training in Respiratory Medicine from Northwest Deanery UK between 2010 and 2015. His specialist areas include lung cancer and interventional pulmonology. During the pandemic, he has delivered public aware- ness seminars and clinical webinars related to COVID and Contributed to Chapter 5 on pulmonary manifestations of COVID-19.
Dr. Nishat Mehdi M.D. graduated from M.N.R. Medical College in Telangana, India, in 2015 and received certi cation on maternal and child health in 2019. She has been working on raising community awareness about communicable diseases and volunteers in free medical camps for low-income people. She contributed to Chapter 5 on pulmonary manifestations of COVID-19.
Dr. Ehusn Mirza M.D. graduated from Dow Medical College in Karachi, Pakistan. He is a Critical Care Medicine Specialist in Fall River, MA, and is af liated with medical facilities at Kent Hospital and Southcoast Hospitals Group—Charlton Memorial. He has over 27 years of experience in the medical eld and contributed to Chapter 18 on personal protective equipment (PPE).
Dr. Usman Mirza M.D. is a Chief Resident at a major NY hospital system and will be starting subspecialty fellowship training in epilepsy in mid-2021. He had rst- hand exposure in managing neurological complications in patients infected with COVID-19 in the New York metropolitan area, which was the epicenter at the onset of the outbreak in the United States. He contributed to Chapter 7 on CNS manifesta- tions of COVID-19.
Sundus Nasim is currently a medical student at Dow University of Health Sciences in Karachi, Pakistan. She contributed to Chapter 9 on renal manifestations of COVID-19.
Dr. Arshad Quadri M.D. is a cardiac surgeon and began his practice in 1995 at St. Francis Hospital in Hartford, Connecticut. He has performed 100 to 150 open heart surgeries a year, and treated a range of heart diseases. His experience has given him a deep understanding of cardiovascular pathologies leading him to develop numer- ous technological solutions and over 100 patents. Dr. Quadri’s most notable patent is for the world’s rst percutaneous mitral valve delivered via a transfemoral approach. The technology was sold to Edwards Life Science over four years ago. Dr. Quadri completed his medical training in Darbhanga Medical College in Darbhanga, India. He completed his surgical residency in Berkshire Medical Center in Pitts eld, Massachusetts, and his fellowship in cardiothoracic surgery at Long Island Jewish Medical Center. Dr. Quadri contributed to Chapter 6 on cardiovascu- lar manifestations of COVID-19.
Dr. Ishrat Quadri M.D. received her medical degree from Mt Sinai (now ICAHN) School of Medicine in New York City, New York, and completed her pediatric resi- dency at Connecticut Children’s Medical Center at the University of Connecticut (UConn) Medical School. She owns a private pediatric practice in West Hartford, Connection, and is currently af liated with UConn and St Joseph’s University. Dr. Quadri has a special interest in pediatric obesity, migraines, and children with developmental issues. Dr. Quadri has a BS in biology from Columbia University, where she also minored in English Literature. She contributed to Chapter 14 on pediatrics and COVID-19.
Farhan Qureshi is currently pursuing his medical degree at the University of Miami Miller School of Medicine. He is in his second year of PhD training in the laboratory of Dr. Alejandro Caicedo, where he is studying the effects of local immune in ltration on beta cell function in the context of pre-type 1 diabetes. He contributed to Chapter 8 on gastrointestinal manifestations and Chapter 10 on endo- crine manifestations of COVID-19.
Azwade Rahman graduated from Drexel College of Arts and Sciences with a degree in Biological Sciences and is currently studying medicine at the SUNY Upstate Medical University in Syracuse, NY. He contributed to Chapter 15 on radiology, Chapter 22 on socioeconomic factors and COVID-19, and Chapter 23 on health policy.
Dr. Syed Raza M.D. graduated with his medical degree from Aligarh University, India. After completing his postgraduate degree in Medicine from the same univer- sity, he moved to the United Kingdom for higher specialist studies. He successfully completed MRCP and CCT, and later also awarded Fellow of the Royal College of Physicians of Edinburgh (FRCP). He was awarded professor John Goodwin prize for outstanding performance in Diploma Cardiology examination at Hammersmith Hospital, University of London in 2001. Dr Raza is a Fellow of American College of Cardiology and American College of Chest Physicians. He is also a Fellow of European Society of Cardiology and Fellow of European Society of Cardiovascular Imaging. He is also on the committee of Acute Cardiovascular Care, Heart Failure, and Cardiovascular Imaging (European Society of Cardiology). He is currently head- ing the Department of Medicine at Awali Hospital in Bahrain as a consultant cardi- ologist. He contributed to Chapter 6 on cardiological manifestations of COVID-19.
Carmina Rogelio graduated from Pennsylvania State University with a degree in Psychology and Neuroscience. She is currently pursuing her medical degree at Howard University College of Medicine and contributed to Chapter 17 on post- recovery and long-term complications of COVID-19, Chapter 20 on drugs for treat- ing COVID-19, and Chapter 24 on post-pandemica.
Dr. Samir A. Shah M.D., FACG graduated from the Harvard Medical School and completed his internal medicine residency and GI fellowship from Beth Israel Deaconess Medical Center in Boston, MA. He currently serves as President of the Digestive Diseases National Coalition (DDNC), Vice President of the American College of Gastroenterology (ACG), Co-chair of the Crohn’s & Colitis Foundation membership committee, and Co-chair of the IBD Circle. He has a special interest in managing IBD patients in the COVID-19 era and recently organized and co-moder- ated a national webinar on the topic. He contributed to Chapter 9 on gastrointestinal manifestations and COVID-19.
Gary Shmorgon is pursuing his medical degree at State University of New York Upstate Medical University. During the pandemic, he participated in SUNY
Upstate’s Incident Command initiative and is currently a member of Upstate Task Team. He contributed to Chapter 17 on post-recovery and long-term complications and Chapter 24 on post-pandemic.
Dr. Sanjay Saini M.D. graduated from Tufts University Medical School and received his MBA from MIT Sloan School. His research, teaching, and clinical activities have focused on computed tomographic imaging of the abdominal organs. As a former director of CT services at the Mass General Hospital, Dr. Saini oversaw performances of scanners by different manufacturers and models, which has given him a unique per- spective on evaluating and introducing newer CT methods in the realm of clinical care. He is currently the Vice Chairman for Finance, Quality, and Safety at the Department of Radiology at Mass General Hospital, and contributed to Chapter 15 on radiology.
Lilah Sanduby is in her third year of medical school at the CUNY School of Medicine, where she also mentors and prepares students for STEP 1. She is cur- rently exploring multiple specialties within her clerkship experience while she nur- tures her passion for surgery. She contributed to Chapter 15 on radiology.
Ashley Slack is currently pursuing her medical degree at Howard University College of Medicine in Washington, D.C, with interests in dermatology. She con- tributed to Chapter 11 on dermatological manifestations of COVID-19.
Bethany Sullivan graduated from UConn with degrees in Animal Science, Pathobiology, and Molecular and Cell Biology. She is currently pursuing her medi- cal degree at the University of Connecticut School of Medicine and contributed to Chapter 16 on severe COVID-19.
Dr. Chung Sang Tse M.D. is a Gastroenterology Fellow at Brown University. She received her Medical Degree from Yale University and completed internal medicine residency at the Mayo Clinic (Rochester). Dr. Tse has been treating COVID-19 patients in the intensive care unit at Rhode Island Hospital. She contributed to Chapter 8 on gastrointestinal manifestations of COVID-19.
Sarah Zaidi Sc.D., MSc. graduated from the Harvard School of Public Health and completed her undergraduate studies from Brown University. She is a public health scientist dedicated to improving health-care access for underserved and marginal- ized communities and currently working to establish Global Clinical Partners. She co-founded and served as the Science and Managing Director of the Center for Economic and Social Rights, and later headed a global network of activists working on access to HIV treatment. Dr. Zaidi was responsible for the entire book project and contributed to the following chapters: Chapter 1 on the overview of COVID-19, Chapter 3 on transmission and prevention, Chapter 17 on post-recovery and long- term complications, Chapter 19 on testing for COVID-19, Chapter 22 on socioeco- nomic factors, and Chapter 23 on health policy and the COVID-19 response.
Abdominal pain, 149
Acalabrutinib (Calquence), 222 Adenoviral Vector Vaccines, 236
Adrenal insuf ciency, 109
American Academy of Pediatrics (AAP), 147 Analgesics, 178
Angiotensin-converting enzyme 2
(ACE2), 13
Angiotensin Converting Enzyme 2
Angiotensin II (ATII), 37
Anticipate, 135
Anticoagulating, 102
Antiretroviral, 216
Antivaxxers and Vaccine Ef cacy, 241 ARB Usage in COVID-19, 101 Arrhythmia, 68
Asthma, 43
Atypical Kawasaki disease, 149 Azithromycin, 220
Baricitinib (Olumiant), 222 B-cell, 17
Blood urea nitrogen, 80 Brazil, 267
British Thoracic Society (BTS), 47 Bronchoalveolar lavage (BAL), 205 Bruton’s tyrosine kinase (BTK), 213 Budesonide/Formoterol, 225
Canakinumab (Ilaris), 221 Candidate pandemic virus, 9
Carbon monoxide diffusion capacity (DLCO), 187
Cardiovascular, 63
Case fatality rate (CFR), 1
Caste and COVID-19 in India, 249 Cell-to-cell spread, 14
(CDC), 245
Central Epidemic Command Center
(CECC), 257
Central Nervous System (CNS), 71 Cerebrospinal uid (CSF), 72
Chest X-Rays (CXR), 156
Childhood psychological, 135
Children on school break, 31
China, 259
Chloroquine, 58
Chloroquine and Hydroxychloroquine, 126 Chronic obstructive pulmonary disease
(COPD), 53
Ciclesonide, 224
Clinical Manifestations, 116 Clofazimine, 221 Community-acquired pneumonia, 72 Complete blood count (CBC), 171 Computed tomography (CT), 155 Convalescent Plasma, 215
Cordon sanitaire, 31
Coronavirus Disease 2019, 2
Cough, 157
COVID-19, 63
C-reactive protein, 64
Creatine phosphokinase (CPK), 171 CRISPR-based test, 208 Cross-immunity, 277
Cultural Considerations, 245 Cura Italia, 262
Cytokine Storm, 180
Deoxyribonucleic acid (DNA), 213 Dermatological Manifestations, 113 Dexamethasone, 224
Dexcom Clarity and Glooko, 108 Diacylyglycerol (DAG), 17 Diagnosis, 146
Diarrhea, 84
Direct Viral Infection, 99
DNA Vaccines, 238
Doing It’s Best (DIB), 195
Drugs for Treating COVID-19, 213
Headache, 80
Health-Care Policy and COVID-19, 257 Health Framework, 245
Heart Failure, 66
Hemoglobin, 104
(HLH), 171
Hemorrhagic Conjunctivitis, 128 Hepato-pancreato-biliary cancer, 89 High-altitude pulmonary edema (HAPE), 171 High- ow nasal cannula (HFNC), 171 HIV and Ebola virus, 6
Hokenjo in Japanese, 260
Home oxygen therapy, 44
Hong Kong, 3
Human immunode ciency virus (HIV), 213 Hygiene, 202
Hypoxemia and Hypercapnia, 98
IgE antibodies, 17
Immunoglobulin G (IgG), 205 Inactivated Vaccines, 239
Incarceration and COVID-19, 250 Individual Disease Prevention, 28 In ammatory Bowel Disease, 87 Inhaled Pulmonary Vasodilators, 177 Innate and adaptive immune systems, 15 Intensive care unit (ICU), 95
Interferon (IFN-𝜆), 58
Interferon-β, 219
International Society on Thrombosis and
Haemostasis (ISTH), 52 Interspecies jump is SARS-CoV-2, 6 Invasive bacterial infection (IBI), 143 Isolating, 268
Ivermectin, 225
Journal of the American College of Cardiology (JACC), 169
Keratoconjunctivitis, 128
Lancet Global Health, 32 Leronlimab, 222
Live Attenuated Vaccines, 238
Early Management of AKI, 99
East and Southeast Asian Response, 258 Eat & Drink healthy, 138
Economic Inequalities, 252
Economic Security, 252 Electrocardiogram (ECG), 131 Emergency medical services (EMS), 195 Endocrine Diseases, 107
Endocrine Manifestations, 103
Endoscopy and Risk of Transmission, 85 Epidemiology, 96, 172
Epstein–Barr virus (EBV), 121 Erythrocyte sedimentation rate (ESR), 171 Europe, 259
European Center for Disease Prevention
and Control (ECPD, 261 Eye protection, 195
Face masks, 196
Favipiravir (FPV), 213
FDA-approved drugs, 213
Food and Drug Administration (FDA), 213 Forced vital capacity (FVC), 187
Fructose consumption, 44
Gastrointestinal (GI), 83
GI Cancers, 88
Global population, 267 Guillain–Barrésyndrome, 76
Liver Diseases, 87
Liver function test (LFT), 171 Lopinavir/Ritonavir, 217
Lung Protective Ventilation, 175
Magnetic resonance imaging (MRI), 155 Management by Telemedicine, 44 Massive psychological trauma, 135 Mean arterial pressure (MAP), 171 Mechanism, 51
Media distancing, 137
Meningitis, 75
Mental Health in Patients, 133 Mental Health Manifestations, 131 Mental Illness, 133 Methylprednisolone, 224
(MERS), 7
Monoclonal Antibodies, 221 Mother-to-Child (Vertical) Transmission,
145 Myopericarditis, 69
National Institute for Occupational Safety and Health (NIOSH), 195
National Institute of Biomedical Imaging and Bioengineering (NIBIB), 208
Natural killer (NK), 15
Nausea, 157
Newborn and Infant Considerations, 145 New England Journal of Medicine, 127 New York Times article, 45 Nitazoxanide, 225
Noninvasive ventilation (NIV), 57 Northern and southern temperate, 277 Nucleic acid ampli cation test
(NAAT), 205
Oceania—Australia and New Zealand, 264 Ophthalmological Manifestations, 125 Oseltamivir (Tami u), 218
Outpatient Management, 37
Paralytics, 178
Pathogen-associated molecular patterns
(PAMPs), 16
Pathophysiology, 48, 100
Pattern recognition proteins (PRRs), 16 Pediatric Manifestations, 143
Personal protective equipment (PPE), 171 Person-to-person transmission, 26 Physical Distancing, 202
Planning and coordination, 279
(PEEP), 171
Post-Recovery and Long-Term
Complications, 187
PPE Usage Impact on Patients, 122 Predicted body weight (PBW), 171 Prescribed Antidiabetic Drugs, 106 Prime Minister Mitsotakis, 263 Prioritizing, 268
Pro-in ammatory cytokines, 23
Prone Ventilation, 176
Proton pump inhibitors (PPIs), 91 Psychological disturbances, 134 Psychological Health in Patients, 133 Psychological Impacts, 131
Public health emergency of international
concern, 3
Race and COVID-19, 247 Racial, 245
Radiation, 226
Radiological Manifestations, 155 Radiology of Chest Imaging, 155 Reduces anxiety/fatigue, 136 Renal Manifestations, 95 Respiratory Failure, 52
Reverse transcription polymerase chain reaction (RT-PCR), 71
Ribonucleic acid (RNA), 213 R-naught (R0), 27
RNA Vaccines, 238 Ruxolitinib (Jaka ), 223
Rx Health, 91
Sanitization, 136
Sarilumab (Kevzara), 221 SARS-CoV-2 Vaccines, 236
Palliative Care, 182 Pancreatic beta cells, 105
Screening, 202
Sedation, 178
Tracheostomy, 179 Triggering the gag re ex, 85 Type 2 diabetes (T2D), 103
United States (US), 259
Vaccines, 278
Vaccines for COVID-19, 235 Vascular Manifestations, 66
Venous thromboembolism (VTE), 96 Veno-venous extracorporeal
membrane oxygenation (VV ECMO),
Viral double-stranded RNA, 16 Viral-Like Particle Vaccines, 239 Viral-like particle (VLP), 235 Viral Vector Vaccines, 236 Vitamin C, 44
Vomiting, 84
Washington, 266
Washington Post article, 45 Weakness, 79
Weaning and Extubation, 179
What goes around comes around, 137 Winter-dominant outbreaks, 277 World Health Organization (WHO), 1
(SARS), 7
Severe COVID-19 and ICU, 171 Singapore, 260
Situation monitoring, 279
Skeletal Muscle Injury, 80
Smoking, 33
SNG001, 219
Social determinants of health (SdoH), 245 Society of Surgical Oncology, 89 Socioeconomic, 245
Sore throat, 157
South Koreans, 258
Steroids, 58
Stress cardiomyopathy, 69
Subacute Thyroiditis, 108
Sub-Saharan Africa, 252
Subunit Vaccines, 239
Sweden, 263
Telehealth in GI, 91
Testing for COVID-19, 205 The pathogen pyramid, 8 Tobacco, 33
Tocilizumab (Actemra), 221 Tofacitinib (Xeljanz), 223 Total lung capacity (TLC), 187
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Copyright © 2016 Hail Science
Hail Science
Mark Vogelsberger wins 2020 Buchalter Cosmology Prize for simulating a “fuzzy” universe
Ten “keys to reality” from Nobel laureate Frank Wilczek
RNA molecules are masters of their own destiny
Evelyn Hu delivers 2020 Dresselhaus Lecture on leveraging defects at the nanoscale
Pulling the secrets of dark matter out of a hat
Professor and astrophysicist Sara Seager appointed officer to the Order of Canada
3 Questions: Rona Oran and Benjamin Weiss on the ancient moon’s missing magnetism
A technique to sift out the universe’s first gravitational waves
Field geology at a distance
Lincoln Laboratory is designing a payload to integrate on Japanese satellites
Stars, brains, and enzymes: a celebration of MIT science
Scientists discover slimy microbes that may help keep coral reefs healthy
Four astronauts with ties to MIT named to NASA’s Artemis team
Portable device can quickly detect plant stress
Making smart thermostats more efficient
2020 MIT Water Summit brings international audiences together to discuss resilience
With campus as a test bed, climate action starts and continues at MIT
MIT.nano’s Immersion Lab opens for researchers and students
To the brain, reading computer code is not the same as reading language
Model could help determine quarantine measures needed to reduce Covid-19’s spread
Knight Science Journalism Program at MIT launches digital handbook for science editors, online fact-checking project
Automating material-matching for movies and video games
Scientists seek insight into Parkinson’s, addiction by tracking gene expression in the brain
Concept for a hybrid-electric plane may reduce aviation’s air pollution problem
Photos show European Mars probe crashed, may have exploded (Update)
A rendering of the Schiaparelli Space Module and of the planet Mars is displayed on a movie screen during an event organized by Italy’s Space Agency on the occasion of the insertion of the Trace Gas Orbiter into orbit around Mars, and the landing of Schiaparelli module on the surface of of the planet, in Rome, Friday, Oct. 19, 2016. (AP Photo/Gregorio Borgia) Europe’s experimental Mars probe hit the right spot—but at the wrong speed—and may have ended up in a fiery ball of rocket fuel when it struck the surface, scientists said Friday. Pictures taken by a NASA satellite show a black spot in the area where the Schiaparelli lander was meant to touch down Wednesday, the European Space Agency said. The images end two days of speculation following the probe’s unexpected radio silence less than a minute before the planned landing.
”Estimates are that Schiaparelli dropped from a height of between 2 and 4 kilometers (1.4-2.4 miles), therefore impacting at a considerable speed, greater than 300 kilometers per hour (186 mph),” the agency said.
It said the large disturbance captured in the NASA photographs may have been caused by the probe’s steep crash-landing, which would have sprayed matter around like a blast site on Earth.
”It is also possible that the lander exploded on impact, as its thruster propellant tanks were likely still full,” the agency said.
Schiaparelli was designed to test technology for a more ambitious European Mars landing in 2020. The European Space Agency said the probe’s mother ship was successfully placed into orbit Wednesday and will soon begin analyzing the Martian atmosphere in search for evidence of life.
”In my heart, of course I’m sad that we couldn’t land softly on the surface of Mars,” ESA chief Jan Woerner told The Associated Press. ”But the main part of the mission is the science that will be done by the orbiter.”
Woerner said engineers received a wealth of data from the lander before the crash that will prove valuable for the next attempt in four years’ time. He described the mission as ”a 96 percent success.” Italian Space Agency President Roberto Battiston holds a pamphlet reading in Italian ’Colonize Mars, Friday, Oct. 19, 2016, in front of a rendering showing the Schiaparelli Space Module and the planet Mars as they follow during an event organized by Italy’s Space Agency, the insertion of the Trace Gas Orbiter into orbit around Mars, and the landing of the Schiaparelli module on the surface of the planet. (AP Photo/Gregorio Borgia) Still, the crash-landing was a painful reminder of how hard it is to put a spacecraft on the surface of the red planet.
Its resting place was photographed by NASA’s Mars Reconnaissance Orbiter, which also spotted Europe’s last ill-fated mission to the surface of the planet. The Beagle 2 probe landed on Mars in 2003 but failed to deploy its solar panels properly, preventing it from functioning.
There have only been seven successful robotic landings on Mars, all by NASA. The last landing was in 2012, when the Curiosity rover touched down in a Martian crater.
Landing on Mars is notoriously difficult because of the planet’s thin, dusty atmosphere. Inbound spacecraft hit the atmosphere at 12,000 mph (19,300 kph) and have only minutes to slow down and land.
With the loss of Schiaparelli, only two spacecraft are currently roaming the Martian surface—Curiosity and Opportunity, which landed in 2004.
ESA said that, according to what its scientists have been able to piece together so far, Schiaparelli suffered problems during the last 50 seconds of its descent through the harsh Martian atmosphere.
The picture taken by NASA’s orbiter shows two features that weren’t visible on the surface when the spacecraft photographed the area in May. The first is a bright spot of about 12 meters diameter, likely to be Schiaparelli’s parachute, ESA said.
The second was described as ”a fuzzy dark patch roughly 15 by 40 meters in size and about 1 kilometer north of the parachute” and is likely to be the lander. A model of Schiaparelli· the mars landing device , is on display at the European Space Agency, ESA, in Darmstadt, Germany Wednesday Oct. 19, 2016. Schiaparelli will enter the martian atmosphere at an altitude of about 121 km and a speed of nearly 21 000 km/h. Less than six minutes later it will have landed on Mars. The probe will take images of Mars and conduct scientific measurements on the surface, but its main purpose is to test technology for a future European Mars rover. Schiaparelli’s mother ship ,TGO, will remain in orbit to analyze gases in the Martian atmosphere to help answer whether there is or was life on Mars, ( Uwe Anspach/dpa via AP) ”These preliminary interpretations will be refined following further analysis” and a high-resolution picture in the coming days, the agency said.
While Schiaparelli was able to beam back some 600 megabytes of data before the crash, scientists won’t get any of the close-up photos the probe took during its descent. Those were meant to be transmitted after the landing.
ESA said the other part of the ExoMars mission—the Trace Gas Orbiter—was ”working very well and will take science calibration data during two orbits in November.”
The spacecraft will then descend to an altitude of about 400 kilometers and begin its study of Mars next year. The orbiter is also going to act as a radio relay for the next stage of the ExoMars mission and other future attempts to land on the planet.
Explore further:Experimental European Mars probe set for landing on Mars (Update)
© 2016 The Associated Press. All rights reserved.
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The main one that actually sold was Adamantine Shirt +3. We sold 3 or 4 of those at least, priced between 45 gold and 48 gold each.
The combat armors like Crusaders Scale/Chain, which are harder to make, where priced more like 60 gold plus but I am not sure any of those actually sold. Possibly one set.
It does seem like people are more prepared to part with larger sums of gold for a crafting/gatherer armor and more wary about paying out on the combat armors. I suspect the problem is the people with 5 or 6 platinum to their name already have access to in house crafters so will only pick up a T3 armor if they see it as a "bargain".
Makes sense. Well within my available purchasing power. Thx Edam
With all due respect because I know that Paizo is seriously between a rock and a hard place trying to keep this game alive, without workable revenue, and all the while improving it enough to attract a larger population; you certainly are putting quite a bit of "stick" into a game that costs $14.95/month. Please do not get me wrong, one of the things that I like about this game is that it is not an easy guided-handholding tour from 1-20, from weak to substantially/confidently powerful. I think that is one of it's strengths.
However, we(the players) are at the same time, enduring a long drawn out experiment of a sort. Throughout we are having to adjust for periodic changes, use our XP for expensive work-arounds then end up not needing them or having something change that makes them come out differently. The game is a lot different now than it was back on day one. That is great and that is encouraging. Games should always strive to improve but this is like enduring a paid Beta. A long paid beta.
Hopefully, GW/Paizo has definitive records of how much XP each account has paid for and can eventually consider offering "Respect/Rebuilds" as a kindly reward for all of us loyal fans that have hung in so long.
@ Bob
•Ensured that the heights and centers used for mob collision models are identical between client and server. This should reduce the likelihood of mobs being able to fire over a hill or other object when the UI says you can’t fire back.
Thanks for the whole of the fixes but I hope that through iterations, this can be even further refined. Someday it would be pretty neat if a figure behind a wall, rock or some other cover can shoot at a target either also having "some" cover or none. In other words, have a working "cover" calculation mechanic.
That reads reasonably. Thank You
Now that the holiday escalation event is over, when can we start talking about EE15, a revision to the Road Map, and lots of controversial subjects we have been holding off on debating all over again?
Well, we've already started talking a fair amount about EE 15 in the crowdforging forums about Upkeep, Upgrades, DI and Taxes. Aside from my needing to distribute out the remaining structure kits (including those just rewarded), I think that covers the bulk of the topics for upgrading settlements/structures.
Of the other items originally listed for EE 15, Selectable Alignment was already delivered in EE 13, leaving the Claim Tickets and the Core Rulebook. As we've been looking into the Claim Tickets, it looks more and more like we should hold off on them until Enchanting is done (currently scheduled for EE 16), since both X's of Holding and Y's of Protection are included in that system. For the Core Rulebook, we're thinking about pushing that off for the moment in favor of tackling other features, likely including social tools, first.
Beyond that, we're still working on our own thoughts about what the schedule is for delivering EE 15 (structure upgrades are already partially working, but still more work, and particularly testing, to do), as well as revisions to the remaining Road Map. We'll post discussion threads on various topics as we're feeling the need for discussion on them, but feel free to start any discussion threads of your own at this point.
Do you guys reckon that you will put what you are still planning out as EE 15 and hold off on any social tools until EE 16+, or are you thinking of swapping out the other (rulesPDF, Tickets) and doing some social tools for EE 15?
Get rid of tokens and put some of these "Token Powers" into other things such as salvage items like relics, fragments, even "Goblin Bags"
please adjust lesser token drops to "lower lvl mobs.
harneloot
Flari-Merchant
P.S We plan to have all of our structures available to at least all that are not aggressive to us or our friends.
This is true now, or only in the *future*?
See the bold above. Right (currently) now the only thing that has changed is Caer Coedweg being fully open and accessible. Not all other "Dominion" settlements are fully or partially closed according to the settlement leader's will.
As is also "current" policy, if you find yourself unable to access any "Dominion" settlement, all that is needed is to contact that settlement's leader (through direct or proxy contact) so that he/she knows that you would like that changed. This would probably be an agreement between you and them to not be aggressive to our members and anything else that particular leader has concerns about.
Several of our Leaders are not interested in playing at workarounds with the "Blacklist" and "Unaffiliated" systems and having a big mess to edit later. That is likely why some groups or persons find themselves unable to access certain parts of The Dominion's existing facilities.
I like you and have respect for you, Xyzzy, which is why I am(once again) re-informing you of this current policy. As things change and mechanics come online, The Dominion is considering some significant changes but it is not for me to detail those yet.
It doesn't mean much that a settlement can have zero buildings because the server(in general) is willing to allow anyone to train and craft at their facilities…
Ultimately, we always expected most settlements to be pretty open in terms of letting outsiders use their facilities, since doing so will let them bring in more tax money (starting in EE 15). Going without buildings means both turning down those possible earnings, and having to pay others to use their facilities.
Yes, well I can see how that would leave the option open to structure the support mechanic the way that you have. Honestly though, I do have some concerns about future ramifications but I am aware that how people end up using mechanics rarely ends up as bad as imagined. Just look at all the years of debate about griefers. Never materialized.
You have demonstrated that you ARE blacklisted in some places. You have not demonstrated that it is a practice that the server accepts without grumbling about, making it a sort of "taboo".
but, the point is: It doesn't mean much that a settlement can have zero buildings because the server(in general) is willing to allow anyone to train and craft at their facilities…
Maxen
stretch goals…Stretch Goals…STRETCH GOALS!!!
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NewsDecember 1, 2018
KETV: Council Bluffs Location opening soon
Medical cannabidiol goes on sale on Saturday in Iowa. The products have trace amounts of THC, the active ingredient in marijuana that makes users high. Medpharm Iowa will grow it and sell products to dispensaries across the state of Iowa, including the one in Council Bluffs.
Have a Heart Compassionate Care is a Seattle-based company that has medical and recreational dispensaries in several states. It will open its Council Bluffs branch in an unassuming building at 3615 9th Ave.
“We will have all the available products in the state showcased along with educational information,” said Charley Wells, store design manager for the company.
Have a Heart Compassionate Care will sell 14 CBD products: capsules, lotion and drops.
“We’re here to help and we’re here to end the stigma when it comes to cannabis and cannabis use,”said Miguel Mendoza, who trains new employees at dispensaries.
Four people have been hired to run the Council Bluffs dispensary.
Iowa lawmakers in 2017 approved the Medical Cannabidiol Act, which allows CBD to treat certain debilitating diseases, including cancer, multiple sclerosis and Parkinson’s.
Operators said the dispensary works like a pharmacy.
“The difference is you’re going to have the ability to look at the products, ask questions and dig into information on it, prior to ever getting up to a counter,” Wells said.
You have to be an Iowa resident and registered with the State Department of Public Health, after an Iowa doctor’s approval.
The patient will be issued a medical card.
“They’ll put that in the system and once they come in, they’ll verify and cross reference that identification whether it’s driver’s license or a regular ID,” Mendoza said.
The company said it always works closely with police and has installed several layers of security, including 24/7 monitoring of surveillance cameras.
“Deterrent is a big thing and we’re creating a secure space, so we know that the product is going to remain safe,” Wells said.
A soft opening is set for Saturday and a grand opening will be Dec. 8. Operators said everyone is welcome, even those who don’t have a medical card but want to learn more information about CBD.
Article originally published by KETV 7
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Women's Soccer / August 23, 2018
Iowa Set to Take on Washington State, Indiana State
Hawkeye Fan Shop — A Black & Gold Store | 24 Hawkeyes to Watch 2018-19 | Week 2 Notes
THE MATCH-UP
The University of Iowa soccer team will travel to Minneapolis to face No. 22 Washington State in a neutral-site matchup Friday at 4 p.m. (CT) at Elizabeth Lyle Robbie Stadium. Iowa will be home Sunday, hosting Indiana State at 1 p.m. (CT) at the Iowa Soccer Complex. Admission is free.
WATCH/FOLLOW LIVE
• Both games will be streamed live on BTN Plus on BTN2GO, a paid subscription service.
• Live stats for both contests will be available on hawkeyesports.com by visiting the Iowa soccer schedule page.
• Fans can follow the Iowa soccer program on Twitter (@HawkeyeSoccer) for live game updates.
LAST TIME OUT
• Iowa opened the season with a scoreless draw in double overtime against Missouri on August 17.
• The Hawkeyes bested Creighton, 2-0, on August 19 for their first victory of the season.
• Junior Natalie Winters converted a penalty kick for her first goal of the season (and the game-winning goal), while freshman Riley Whitaker scored her first collegiate goal.
SCOUTING NO. 22 WASHINGTON STATE
• Washington State is 2-0-0 to open the 2018 season. The Cougars defeated Seattle, 3-1, on August 17 and Grand Canyon in overtime, 1-0, on August 19.
• Morgan Weaver led the Cougars last season with six goals. She has two this season.
• Head coach Todd Shulenberger is in his fifth season as the Cougars’ head coach.
• WAZZU was picked to finish seventh in the Pac-12 Women’s Soccer Preseason Coaches Poll.
SCOUTING INDIANA STATE
• Indiana State is 0-1-1 through two games, losing to Northern Kentucky, 3-0, on August 17 and tying Purdue Fort Wayne, 0-0, on August 19.
• Julie Hanley is in her third season as head coach at Indiana State after spending four seasons at Iowa as an assistant coach. Five current Hawkeyes — Kaleigh Haus, Morgan Kemerling, Jenna Kentgen, Karsen Rauch, and Rose Ripslinger — played for Hanley during her final season in 2015.
• This will be Iowa’s first meeting all-time against Washington State and Indiana State. It is the second time in three seasons the Hawkeyes have played a PAC-12 foe. Iowa dropped a 3-1 decision at Colorado during the 2016 season.
GRAVES EARNS WEEKLY HONORS
• Junior goalkeeper Claire Graves earned the inaugural Big Ten Goalkeeper of the Week honor Aug. 21 for her play against Missouri and Crieghton
• The junior posted two shutouts, running her career total to 13 shutouts — the third-most in program history.
• Graves made six saves against Missouri and five saves against Creighton. Her 11 saves are second in the Big Ten.
• Two Hawkeyes — Hannah Drkulec and Sara Wheaton — played the full 110 minutes against Missouri, while Graves and Morgan Kemerling played the full 200 minutes last weekend.
• Kemerling has played 90 or more minutes in 18 of Iowa’s last 21 games.
HAWKEYE NEWCOMERS EARLY IMPACT
• Seven Hawkeyes — Bianca Acuario, Skylar Alward, Riley Whitaker, Hailey Rydberg, Sara Wheaton, and Olivia Hellweg — made their first career starts this past weekend.
WINTERS ON THE OFFENSIVE
• Junior Natalie Winters has four shots on goal on nine shots — second-most in the Big Ten — through two games. The Plymouth, Michigan, native scored her first goal of the season against Creighton, converting a penalty kick early in the second half. It was her fifth career goal.
ON THE MEND
The Hawkeyes were without their top two returning goal scorers — juniors Devin Burns and Olivia Fiegel — during the opening weekend of the 2018 season.
• Burns is sidelined after suffering a meniscus injury during the preseason, while Fiegel is working her way back from a leg injury. Both players are expected back in the coming weeks.
RETURNEES BY NUMBERS
• Offensively, the Hawkeyes return 80 percent (25 of 31) of the team’s goals from 2017 and 68 percent (21 of 31) of the team’s assists. Iowa has two starting defenders returning, Morgan Kemerling and Leah Moss.
B1G PRESEASON HONORS
• Three Hawkeyes — juniors Devin Burns, Kaleigh Haus, and Natalie Winters — were named to the Big Ten Preseason Honors List. Burns led the team with nine goals and 23 points, Haus finished third on the team with five goals and 14 points, and Winters started all 19 games and has started all 38 games of her collegiate career.
• Iowa was picked to finish 10th in the Big Ten in the preseason coaches’ poll.
BURNS X 2 X 2
For the third straight season there will be a Burns tandem on the Iowa soccer roster. It was Corey and Devin Burns in 2016 and 2017. Corey is now playing professionally in Denmark, but the sister duo continues with freshman Riley Burns joining the Hawkeyes’ roster and her sister Devin.
FORWARD BREAKDOWN
The Hawkeyes will rely on veteran leadership with junior forwards Devin Burns, Kaleigh Haus, and Olivia Fiegel, who combined for 20 of the team’s 31 goals last season.
Senior Morgan Kemerling and redshirt junior Kaleigh Haus are Iowa’s team captains for the 2018 season.
CHALLENGING SLATE
• Iowa will play five contests against NCAA Tournament teams in 2018.
• The Hawkeyes will face three opponents who are currently ranked in the United Soccer Coaches top-25 — Penn State (3), Northwestern (19), and Washington State (22).Four more Iowa opponents are receiving votes.
COACHING STAFF CHANGES
The Hawkeyes have added Katelyn Longino as an assistant coach and Drago Ceranic as a volunteer assistant coach to the 2018 coaching staff. Longino joins Iowa following coaching stints at Valparaiso, Xavier, and Columbus State. Ceranic coached with the Cedar River Soccer Association since 2009 and has been a part of Iowa’s Olympic Development Program since 2016.
Iowa will host the four-team Hawkeye Invitational next weekend at the Iowa Soccer Complex. The Hawkeyes will face Central Michigan on Aug. 31 and VCU on Sept. 2.
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Comley/Routledge-Harder
Not much is known about the use of this barn but it is known that the property was homesteaded by the Comley family. Mr. and Mrs. William Comley arrived in Sedgewick, Alberta in June of 1910 and purchased the property the barn sits on from the Canadian Pacific Rail and Land Company. They built the barn and the house that still stand on the quarter. William was an accomplished stonemason and so he built the barn’s foundation. William and his younger brother, Frank, were known for having worked in Edmonton in the summer of 1911 on the Flatiron Building at 95th Street and Jasper Avenue. As well, William’s son, Gilbert, boasted that, as a carpenter, he hung the door and window sashes on Edmonton’s first brewery at 121 Street and and 102 Avenue.
The property was purchased by Cathy Harder in the early 2010s. Even upon purchase, the barn was in a state of disrepair; however, it is still well known in the area. The barn is frame construction with platform framing.
Routledge, John and Peggy. Personal communication. 20 Jul. 2016.
This frame is of the western face of the barn and the northern half of the barn’s roof.
This frame shows the western face and southern half of the barn’s roof. The stone foundation and wall on the south-western side of the barn has crumbled away.
This frame shows the masonry work on the western face of the barn.
This frame is a close-up of the south-western corner of the barn.
This frame shows part of the southern side of the barn. The barn is leaning to the east quite a bit.
This frame shows part of the southern side and eastern face of the barn.
The mortar and stone wall has developed many cracks over the years and has completely fallen apart in places.
Even while the building decays, the barn’s beauty and the quality of craftsmanship is undeniable.
This frame shows the eastern face of the barn.
This frame shows the eastern face of the barn and the northern half of the barn’s roof. The northern half of the barn is in a state of disrepair. Soon, the lack of support on the northern side will cause the barn to collapse.
The inside of the barn is very unsafe. The barn’s loft broke its support posts when the northern wall gave out. As a result, what appears to be artistry and architectural genius from the outside, seems dubious and decayed from within.
This barn was featured on a paper handout promoting heritage preservation. It was prepared by the Historic Sites Committee of the County of Flagstaff.
52.878621, -111.429285 SW 17-45-10 W4.
Barn Condition: Poor
Construction Date: Unknown
Features: None
Roof Shape: Gambrel
Paint: None
Decorations: None
Roof Covering: Wooden shingles
Siding: Wooden shiplap
Foundation: Mortar and field stone/brick
Additional Information on the Property
Comley Mullen, Morraine. “The Comley Story”. Metropolitan Memories. 1st ed. Sedgewick: The Community Press, 1979. Print.
Snethun
One thought on “Comley/Routledge-Harder”
Pingback: Preserving Heritage for Future Generations: Heritage Barns of Flagstaff County – RETROactive
Why Heritage?
We must not wait until scarcity elicits demand for these historic resources. We should take action now, while residents of the Flagstaff Region still have the access and the connection to historic barns in the area. We all should work to change our own perceptions on the importance of Albertan history.
This frame shows the peak of the hill. This frame was taken whilst standing on the west-southwest side of the hill looking east-northeast
This frame shows the southern side of the barn.
This frame shows the southern face and western side of the outbuilding.
This frame shows the southern half of the barn and the eastern face of the barn.
This frame shows the southern face and eastern side of the barn.
This frame shows the western side of the chicken coop in the yard.
This frame is a close-up of another concrete marker on the hill. This marker lies to the north-west of the first marker shown.
This frame shows the western side and southern side of the barn.
This frame shows a gate for a box stall and an old wagon wheel.
This frame shows a close-up of the ground floor door in the eastern side of the barn.
Please respect land and property owners. Do not enter onto land or into property without the prior consent of the owner.
Please contact Flagstaff County with your questions or concerns, 780-384-4100.
No parts of this website may be reproduced in any form without permission in writing from Flagstaff County.
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Bend the Arc: A Jewish Partnership for Justice
For Support Of FCYO’s Fundraising And Board Development Plan
Women’s Choices
330 Seventh Avenue - 19th floor
for support of the Funders' Collaborative on Youth Organizing project
This grant to Bend the Arc: A Jewish Partnership for Justice will support the Funders’ Collaborative for Youth Organizing’s program called Pipelines to Power. Pipelines to Power aims to strengthen the capacity of the youth organizing field and mobilize more young people in support of reproductive health, rights, and justice. By investing in the leadership of young people, Pipelines to Power will (a) help advocacy campaigns reach more young people; (b) increase engagement of young activists of color in issues related to reproductive rights, health, and justice; and (c) build the capacity of the youth organizing, civic engagement, and leadership field. (Substrategy: Youth)
This grant to Bend the Arc: A Jewish Partnership for Justice will support the Funders’ Collaborative for Youth Organizing’s program called Pipelines to Power. Pipelines to Power aims to strengthen the capacity of the youth organizing field and mobilize more young people in support of reproductive health, rights, and justice. By investing in the leadership of young people, Pipelines to Power will (a) help advocacy campaigns reach more young people; (b) increase engagement of young activists of color in issues related to reproductive rights, health, and justice; and (c) build the capacity of the youth organizing, civic engagement, and leadership field.
Seven things the Women’s Funds Collaborative taught me about feminist philanthropy
Evaluating our International Reproductive Health Strategy
Global nonprofit leaders on why women’s time and work must be part of future policy choices
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Hinduism Meta
Hinduism Stack Exchange is a question and answer site for followers of the Hindu religion and those interested in learning more about Hinduism. It only takes a minute to sign up.
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Believing our family ancestors
In our family,they tell us to worship our ancestors from where family have been started Is it right that we should worship them rather than worshipping God?? Please tell me in detail
gods worship ancestry
Rhythm MurgaiRhythm Murgai
Krishna says in Gita 9.25 - "Those who worship the gods go to the gods, those who worship dead ancestors go to dead ancestors, those who worship the spirits go to the spirits, and those who worship Me come to Me." – Swami Vishwananda Apr 19 '17 at 13:39
Worshipping dead ancestors doesn't mean you should worship them literally. You should not forget their date of death. You should offer libations of water during the days prescribed, do the karma kaanda when their death anniversary occurs. This pleases the dead ancestors. The food you offer on anniversary will be received by manes. This is important for the growth of your family. This is prescribed in scriptures not building temples, worshiping the images of them like we do to god and deities. – Sarvabhouma Apr 20 '17 at 4:31
@SwamiVishwananda, the original word used by Krishna - 'pitrus' is much better than simply saying 'dead ancestors'. Krishna also says, those who don't offer libations to pitrus (tarpanam, shraddham) are his drohis (traitors), are not bhaktas, nor are they vaishnavas, because this karma is all laid down in shruti/smriti, which are Krishna's own orders. – ram Apr 20 '17 at 18:06
Yes, you should worship them, and also worship God. Did your family say 'Worship only ancestors and not God' ? You love your parents right ? Similarly your parents loved your grandparents and so on. To repay the debts of their unconditional love and affection, we worship them through tarpana, shradham etc. – ram Apr 20 '17 at 18:11
@ram I think it is better to say you should honor your parents and worship God. When quoting Sri Krishna please give the scripture and verse. Too many people on this forum quote what they think is scripture. – Swami Vishwananda Apr 21 '17 at 5:32
According to Scriptures pleasing the Gods is not enough. Pleasing the Manes (Pitrus or ancestors) is also needed and is in fact even more important.
Actually, the Scriptures ordain the "Pancha Maha Yajnas" for all householders to satisfy the Rishis (Sages), Devas (Gods), Manushyas (Human Beings), Pitrus (Manes) and Bhutas (Beings). So satisfying all of them is necessary for our all round peace and prosperity. Satisfying only one or two among them is not enough.
Manu Smriti 2.176. Every day, having bathed, and being purified, he must offer libations of water to the gods, sages and manes, worship (the images of) the gods, and place fuel on (the sacred fire)
Manu smriti 5.169. (Living) according to the (preceding) rules, he must never neglect the five (great) sacrifices, and, having taken a wife, he must dwell in (his own) house during the second period of his life.
And appeasing the Manes is even more important than pleasing the Gods as said in the following verse:
Manu Smriti 3.203. For twice-born men the rite in honour of the manes is more important than the rite in honour of the gods; for the offering to the gods which precedes (the Sraddhas), has been declared to be a means of fortifying (the latter).
RickrossRickross
Yes. In addition - there are 3 runas (debts) we borrow when taking birth as a man - 1. to rishis, which is repaid by brahmacharyam and learning vedas.. 2. to devas, which is repaid by yagnas.. 3. to pitrus, which is repaid by begetting a son(or progeny in nowdayas of 1 or 2 kids policy) and doing tarpana/shraddam. – ram Apr 20 '17 at 18:09
@ram Really a son required if a couple want to satisfy ancestors? – Tat Tvam Asi Aug 21 '18 at 17:02
@TatTvamAsi, yes, at least for doing tarpana-shraddha, which many don't do nowadays anyway. women are supposed to assist their husbands in same above rituals, meaning for the family she got married into, not her birth family. – ram Aug 21 '18 at 18:43
The Vedas layout the attainment of different paths - Dharma, Artha, Kama, and Moksha. If your goal in this life is the attainment of various heavens (and consequently, rebirth) then worship of others than the Lord is prescribed. In his introduction to the Kena Upanishad, Sankara says (Swami Gambhirananda translator):
Answer: No, because in the Vajasaneyaka (Brhadaranyaka) Upanishad that (combination of rites and meditation) has been spoken of as the cause of a different result. Starting with the text, "Let me have a wife". (Br. I.iv.17), the Vajasaneyaka shows in the text, "This world of man is to be won through the son alone, and by no other rite; the world of the Manes through rites; and the world of the gods through meditation' (Br. I.v.16), how rites and duties lead to the attainment of the three worlds that are different from the Self. And there (in that Upanishad itself), again, the reason for embracing renunciation is adduced thus: "What shall we achieve through children, we to whom the Self we have attained is the goal?" (Br. IV.iv.22). The explanation of that reason is this: What shall we do with progeny, rites, and meditation combined with rites, which are the means for the attainment of worlds other than that of the Self, and are the causes for the attainment of the three worlds of men, Manes, and gods? Nor are the three worlds--transitory and attainable by means as they are--desirable for us, to whom is desirable the world that is natural, "birthless, undecaying, immortal, fearless" (Br. IV.iv.25)...
And Sri Krishna says in the Uddhava Gita XII 52-58 (Swami Madhavananda translator):
He should not get attached to his family, and, even though he is a householder, should not forget God. The wise man should consider the unseen enjoyments of future life just as perishable as the visible enjoyments of this life.
The association with one's sons, wife, relatives, and friends is like the chance meeting of travelers. They depart with the end of each body, as dreams are inextricably bound by sleep.
One who reflecting thus lives at home without attachment and egoism, like a guest, is not fettered by the home, and is free.
A devotee, worshipping Me through his household duties, may lead a householders life, may retire into the forest, or, if he has progeny, may embrace monasticism.
But he who is attached to his house, is afflicted by the desires for sons and wealth, and is henpecked--is foolish, and being beguiled, he comes under the bondage of "I and mine".
"Alas, my parents are old, my wife has got young children; and how can she in her helpless state live, with these poor children, without me?"
Thus does the foolish man, with his heart distracted by thoughts of home, continue to think of them without satisfaction. Then he dies and enters into abysmal darkness (birth in a very undesirable body).
And Sri Krishna in the Gita 9.25 (Swami Gambhirananda translator)
Votaries of the gods reach the gods; the votaries of the manes go the the manes; the worshippers of the Beings reach the Beings; and those who worship Me reach Me.
And Sankara's commentary on this verse:
...Pitr-vratah, the votaries of the manes, those who are occupied with such rites as obsequies etc., who are devoted to the manes; go pitrn, to the manes such as Agnisvatta and others...
and at the end of the commentary he says:
Although the effort (involved) is the same, still owing to ignorance they do not worship Me exclusively. Thereby they attain lesser results. This is the meaning.
Honor your ancestors, worship the Lord exclusively.
Swami VishwanandaSwami Vishwananda
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The RAF Avro Lancaster
The Avro Lancaster was the Royal Air Force’s main four-engine bomber in World War II. Its superb design, overall performance, and load-carrying capacity proved key factors in successfully prosecuting the nocturnal bombing offensive against Hitler’s industrial and military base. With its ability to carry up to 16,000 pounds in explosives and incendiaries, specialist Lancasters could also deliver the 12,000-pound “Tallboy” and 22,000-pound “Grand Slam” bombs that took out key targets. The Lancaster was also featured in the classic 1955 British film The Dam Busters, the story of the famed May 1943 low-level bombing raid in Germany’s Ruhr River valley. By the end of the war, upward of sixty squadrons operated the Lancaster, demonstrating clear proof of its preeminent presence within the RAF’s offensive. Part of the Legends of Warfare series.
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by Marco Chiappetta — Tuesday, September 20, 2011, 07:17 PM EDT
NVIDIA Reveals Kal-El's Fifth "Companion" CPU Core
Over the past seven months or so, NVIDIA has revealed a number of details regarding its upcoming mobile wonder-chip, codenamed Kal-El. According to information provided by NVIDIA dating all the way back to February, Kal-El was to be the world’s first mobile quad-core SoC, sporting an integrated 12-core GeForce GPU, with support for resolutions up to 2560x1600, and performance that’s roughly 5x that of the current Tegra 2.
News out of NVIDIA today, however, reveals that Kal-El actually has 5 CPU cores, four high-performance cores for general processing duties a low-power “companion” core that’ll only be used for background tasks, active standby, and for some music and video playback. NVIDIA is calling this approach Variable Symmetric Multiprocessing, or vSMP.
Kal-El's Low-Power Companion Core
“Our next-generation Tegra processor, codenamed “Project Kal-El,” is widely known as the world’s first quad-core mobile chip. Today, we’re unveiling Kal-El’s little-known fifth core in two new whitepapers that detail its “Variable SMP” architecture.” said NVIDIA’s Matt Wuebbling on a blog post on the company’s website. “This extra core – which we call the “companion core” – runs at a lower frequency and operates at exceptionally low power. During less power-hungry tasks like web reading, music playback and video playback, Kal-El completely powers down its four performance-tuned cores and instead uses its fifth companion core. For higher performance tasks, Kal-El disables its companion core and turns on its four performance cores, one at a time, as the work load increases.”
Core Management, Based On Workload
According to the white papers, the “Companion” core is completely OS transparent, which means the OS and applications are not aware of the core, but they are able to take advantage of it, automatically. Being able to transparently switch between the high-performance cores and low-power Companion core should result in significant power savings. The Companion core uses specialized, low-power transistors that operate at lower frequencies than the high-performance standard cores. However, all five of the cores employ the same ARM Cortex A9 CPU cores. The Companion core is said to operate between 0Mhz (gated, off) and 500MHz, while the performance optimized cores can operate between 0MHz (gated, off) and the SoC’s maximum GHz rating.
NVIDIA’s vSMP technology manages the workload distribution between the Companion and main cores based on the OS and application requirements. The actual management is handled by Kal-El’s Dynamic Voltage and Frequency Scaling (DVFS) feature and CPU Hot-Plug management software and does not require any modifications to the operating system.
(source: NVIDIA)
According to numbers released by NVIDIA, Kal-El’s unique CPU core configuration and transistor mix give it some marked advantages over competing offerings, both in terms of power and performance. The chart above (provided by NVIDIA) illustrates what we’re referring to—Kal-El is not only the lowest power solution when clocks don’t surpass 1GHz, but its performance is almost double that of current dual-core SoCs, even though Kal-El has twice of the number of CPU cores.
Tags: Nvidia, GeForce, Mobile, ARM, Cortex, cores, A-9, SoC, Kal-El
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Welcome Grace Rodriguez to the Impact Hub Houston Team!
by Grace Rodriguez | Feb 12, 2019 | Latest News
From the Houston Chronicle:
Grace Rodriguez, who spent much of her childhood in Houston and would later return as an adult in 2000, has long promoted Houston and its innovators. She strived to change the city’s perception during the six-year run of the “Houston at SXSW” promotional effort; helped Harris County Sheriff Ed Gonzalez create the first Mayor’s Innovation and Technology Advisory Committee during his tenure on the Houston City Council; and worked as a lead organizer for Women In Tech: Houston and TEDxHouston.
In 2016, she was one of four founders who started Station Houston and helped grow it to 184 startups, 139 mentors and 351 members. The organization has become a driver for the city’s efforts to become a hub for high-growth, venture capital-attracting technology companies. And Station Houston fit well with her track record of working behind the scenes to found and nurture young organizations. But this time around, Rodriguez will take the next step in her career as the CEO and face of an organization.
Impact Hub is a global network with more than 100 hubs in over 50 countries. Roughly 6,400 startups were founded at its hubs between 2012 and 2016. Starting an Impact Hub is a long process that requires approval from the global network. Shiroy Aspandiar and Natasha Azizi co-founded Impact Hub Houston in 2016 and then reached out to Rodriguez this past summer.
“Grace has the right mix of mindsets, character, experience,” Aspandiar said, “and also just a true love for helping people that I think would make her a natural fit to be able to lead the helm of an Impact Hub.”
Others in Houston’s startup community likewise saw Impact Hub as a natural fit.
“She’s had such a focus on all social issues,” said Russ Capper, executive director of Houston Exponential, a nonprofit tasked with marketing and connecting Houston’s various innovation initiatives. “She likes to integrate them deeply into innovation and startups.”
Learn more about Grace, her background working in Houston’s creative, startup and innovation communities, and her crazy path to becoming the new CEO/Executive Director of Impact Hub Houston through her interview on “Working Wisdom” podcast from the C. T. Bauer College of Business:
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Gaby and Nicolas
Almost 5 years ago, we were just two strangers trying to survive the stereotypical college-life struggles. Our paths crossed when we both, unknowingly, signed up for the same Accounting course. (Side note: Nico says we met a year prior at a house party, but I was too busy being a social butterfly to remember). Clearly, Nico being the math wiz and a finance major, he aced his first exam. Me on the other hand, let’s just say, I was really good at guessing the wrong answer. So just as any girl would do, I asked the cute boy for some tutoring sessions.
Throughout the following next 2 years, Nico and I had become close friends and shared many unforgettable moments. Our friendship was like no other. We shared and talked about everything; we would even asked each other for dating advice (crazy, huh?).
Fast forward 3 years with falling in love somewhere in-between. We’re ENGAGED!
how they asked
It started off like any other day in city. We were fortunate enough to wake up to a bright October day. Nico and I had plans to meet up with my parents in Hoboken, NJ for brunch at Malibu Diner (my family’s favorite anytime-bite-to-eat). Since the weather was absolutely gorgeous, there was no reason not to take the ferry across the river. Within a few minutes, my parents, Nico and I were all eating and discussing the plans for the rest of the day.
Before we had taken this trip to NYC, I had told Nico, it was a MUST that we go to the Brooklyn Bridge for two reasons: 1) I had never been and 2) It was the perfect spot for some “Instagram-worthy” shots.
I called up my girlfriend, Danielle, a friend from Florida, who was visiting her parents in New York (coincidently, right?), to see if she wanted to hit up the bridge with us to take some cool pictures. Obviously she said, YES. Little did I know, Danielle and Nico had been planning this for a few months now.
We finished up eating, jumped in the car and took a ride through the Holland Tunnel to get to lower manhattan. Guess what’s in lower manhattan? Ferrara! There was no way we were going to miss out on Ferrara’s while being so close. We packed up some of the best cannoli in town and picked Danielle from the station Okay, now we were officially ready to make the trip over the bridge to Brooklyn.
Naturally, Danielle and I started taking hundreds of photos. Posing this way, posing that way, you know, the usual instagramer poses. Before we knew it, 35 mins had passed and Nico and my parents were way ahead of us, just under the first arch.
We finally reached up to them and at this point, I still had no idea my life was about to change forever. Nico was there, waiting for me, right under the arch. If only I could should you how beautiful the view was right behind him. The sun was setting and blessing each building with shimmering little sparkles. It was magical.
As Nico and I began posing for some pictures, I started to hear his breath get heavy, similar to what he sounds like after playing a soccer game. It was a bit odd but I forgot about it quickly and continued posing. Danielle and my father continued to take pictures. Meanwhile, Nico was holding the ring box right behind me the whole time! You can see it in one of the photos above.
Before I knew it, he was down on one knee!
I blacked out. I was shaky. I was crying tears of true happiness. This was it!
YES! I said.
The whole bridge began clapping and cheering. Some were even taking pictures! This truly was a magical proposal.
It was perfect!
To Nicolas Coburn,
You are everything I’ve prayed for. There isn’t a single bad bone in your body. You always give 100% and keep your word. You know how to make me laugh even when I’m having my worst days and know how to listen when I’m troubled. Besides your good looks, you are kind and loving.
Thank you for making October, 7th 2017 one of the best days of my life. I can’t wait to spend the rest of my life with you.
A special thank you to family & friends who helped make this day amazing.
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Home › Culture › arts & entertainment › 2016 Hoydens: Debbie Reynolds and Carrie Fisher
2016 Hoydens: Debbie Reynolds and Carrie Fisher
When word came through of Carrie Fisher’s heart attack, and then of her death, and almost immediately after that of the death of her mother, Debbie Reynolds many of us felt we had been dealt a particularly harsh blow. No matter how many degrees of separation we were from knowing them directly (and I know some who adored them in person, but plenty of others who felt sustained by their work in so many different aspects), they brought a special kind of light into our world. It would be impossible to quantify how much joy these two women between them have given others.
Photo by Lawrence Schiller (1963) of Carrie Fisher watching Debbie Reynolds perform
Instead of doing my own inadequate round-up of commentary on Carrie in her role as General Leia in the Star Wars verse, I suggest heading over to The Mary Sue to browse through their terrific series of articles. Most people posting early footage of Debbie have chosen Good Morning from Singing in the Rain, which I freely admit is irresistible, but we must remember what a long-term, all-round star of the golden age she was, so I have put something more obscure but no less joyful below. Though people think of them both first as actresses, they also gave us a model of the possibility of a textured, mercurial yet utterly solid relationship between mother and daughter (plenty of re-watchings of Postcards From the Edge going on around the place this weekend), and Carrie was an absolute lion in the crusade to make it acceptable and understandable to live a rich life while negotiating mental illness.
Without wishing to attach Carrie too much to her fictional alter ego, I found this obituary for Leia Organa by Malcolm Sheppard to be a masterful, whimsical, real way to think about her role in the Star Wars story.
Here is a Q&A Debbie did in 2010.
And here is a dance routine she did with Bob Fosse in a movie called Give a Girl a Break.
Here are the Guardian‘s obituaries of Carrie and Debbie. Of course there has been an outpouring of personal reflective writing on their lives, careers, and what they have meant to people. I would be delighted if you would share in the comments any pieces that have meant something to you.
‹ Open Looking Forward to 2017 Thread
The 104th Down Under Feminists Carnival is up! ›
Categories: arts & entertainment, gender & feminism, media
Tags: film, hoydens
Wonder Woman movie marketing machine tied up in knots
Quick Link: the 2014 Ernies are in
Signal Boost: Wonder Women!
More of this, please
sunlessnick
RPGNet suggested three ways to honour Carrie Fisher: 1, Normalise the mentally ill; 2, Don’t take life as seriously; 3, Overthrow a fascist regime.
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Home Noticias Nacionales Mexican comic book ‘Memin Pinguin’ sold at Wal-Mart called racist
Mexican comic book ‘Memin Pinguin’ sold at Wal-Mart called racist
Mexican comic book called 'racist'
By . -
>>From KHOU staff reports
HOUSTON– Shawnedria McGinty was not sure what to think when she saw the comic book series Memin Pinguin on shelves at her local Wal-Mart. After flipping through the popular Mexican comic book, one word came to mind –racist.
OK, is it a monkey or a boy? … So, I opened the book up,” she said. “This is, you know, rude.”
Historically, Memin Pinguin has been hugely popular on newsstands in Mexico and Latin America and has sales in the millions. Originally published in the 1960s, it was recently re-issued and available in Wal-Marts north of the border.
“They are calling him names. They call him an animal in one section. His mom is spanking his butt and it looks like they are drowning him,” said McGinty, who went so far as to buy a Spanish dictionary to better understand the comic books.
She found one passage particularly offensive. In the frame, Memin Pinguin is being kicked by a light-skinned man and called “a black troublemaker.”
Activist Quanell X said the problem with the book is more than just words.
“This is poking fun at the physical features of an entire people. Making them look buffoonish (and) portraying the young (black) kid as stupid,” said Quanell. “Whenever they are beating him, they are referring to him as Negro. Even here when he is being punched, slapped (he is called) Negro.
Calls to Wal-Mart’s corporate offices were not returned.
This is not the first time Memin Pinguin has stirred up controversy. The character spurred debate in 2005 when the Mexican government issued a stamp commemorating Memin.
At the time, many U.S. activists and political figures called the character racist. The Mexican government said Americans did not understand Memin’s cultural significance in Mexico.
That debate spurred the publisher to re-issue the old comics in a collector’s series available for purchase in the United States as well as Mexico
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CONTEMPORARY ONE WORD SEVERAL WORLDS
Death of Haku Shah, eminent Gandhian artist signifies the end of an era
Source National Herald by Girish Shrivastava
With the passing away of the doyen of Indian Art, Haku Shah (1934-21 March 2019) in Ahmedabad at the age of 85, we have lost an eminent Gandhian painter belonging to the Baroda School of Art. He was also a cultural anthropologist and an author of international repute on folk and tribal art and culture. His works are considered in the line of artists who brought themes of folk or tribal art to the mainstream Indian art. In 1968, he curated the ‘Unknown India’ exhibition, organized by Art Critic Stella Kramrisch at the Philadelphia Museum of Art. He received the Rockefeller Grant in the same year and in 1971, the Nehru Fellowship Award. Over the years, he had carried out extensive field research and documentation on rural and tribal crafts, traditions and folklore. He established a tribal museum at Gujarat Vidyapith in Ahmedabad and was a curator here for several years which was to become his last legacy. Veteran artist Manu Parekh in 1963, said, “Haku knew very well about crafts and craftsmen and was in direct touch with the village craftsmen. I don’t know many people who have such deep connections with village craftsmen. In our country especially, we need these kinds of artists.”
Publié par Herve Perdriolle
$17,757 nouveau record pour une peinture sur papier de Jangarh Singh Shyam
Une peinture sur papier de Jangarh Singh Shyam 50x65 cm des années 1980 a été vendue ce 29 mars 2019 par la maison de vente indienne Saffronart pour $17,757. Exposée aux Magiciens de la terre (Centre Pompidou 1989), cette œuvre sur papier avait été vendue en 2005 à Paris par Calmels-Coehn pour 800 €, puis en 2010 chez Sotheby's New York pour 3849 €. Ce nouveau record vient après la publication récente de trois livres dédiés à cette figure légendaire de l'art contemporain vernaculaire indien né en 1962 et disparu prématurément en 2001 au Japon.
> voir la vente
Works by major Indian Modernists lead $8m sale of jailed diamond dealer's art collection
Source The Art Newspaper by Kabir Jhala
Leading the sale was an untitled 1973 work by the Indian Modernist VS Gaitonde, which sold for $3.7m, making the work the artist's fourth most expensive sold at auction. A work by Raja Ravi Varma also achieved the artist's second highest record at auction with the sale of an 1881 painting of the Maharaja of Travancore achieving $2.4m via a phone bid. Indeed, a report released earlier this year by ArtTactic says the 2018 South Asian market saw a 39.7% increase in sales of Indian Moderns (alongside a less significant increase in contemporary sales).
India auctions fugitive billionaire's art, raises $8 million
Source Reuters by Sai Sachin Ravikumar
Tax authorities who are pursuing Modi in connection with the country’s largest bank fraud appointed auction house Saffronart to carry out the sale of 68 works. The sale will be challenged in court on Wednesday by lawyers for a company controlled by Modi that owns the artwork. Auctioneers say the sale, which was originally expected to raise up to $7.3 million, was the first of its kind in a country where tax authorities have usually auctioned property, gold and luxury items, but not art. “Until a few years ago, the tax authorities really didn’t know the value of art,” said Farah Siddiqui, an art adviser who advised clients eyeing Modi’s collection.
Atul Dodiya, GR Iranna, Jitish Kallat in artist lineup to show at Venice Biennale's Indian pavilion
Source Indulge Express by JD Sen
The works of seven modern and contemporary artists, including Nandalal Bose and Atul Dodiya, will figure at the Indian pavilion in its second-ever participation at the prestigious Venice Biennale, which begins in May. The Indian artist lineup at the 58th International Art Exhibition at La Biennale di Venezia (Venice Biennale) also includes Ashim Purkayastha, GR Iranna, Jitish Kallat, Rummana Hussain and Shakuntala Kulkarni, pavilion curator, the Kiran Nadar Museum of Art (KNMA), said in a statement. The pavilion titled 'Our Time for a Future Caring' is themed around Mahatma Gandhi. It will form a part of India's ongoing programme celebrating his 150th birth anniversary.
One of India’s Most-Wanted Fugitives Is Selling Off His $5 Million Art Collection. See What’s for Sale Here
Source Artnet News by Naomi Rea
The Indian businessman and art collector Nirav Modi, who has been on the lam for his alleged connection to a multi-billion-dollar fraud, was arrested yesterday in London. Meanwhile, the fugitive’s art collection is being auctioned off on behalf of India’s tax recovery office in a bid to recover some of the $2 billion the tycoon is accused of scamming from a state-owned bank. One of India’s most-wanted men, Modi is the number one suspect sought in connection with a $2 billion fraud that rocked the Punjab National Bank last year. Modi was named Indian’s 85th richest man by Forbes in 2017, with the magazine estimating his net wealth at around $1.3 billion. The diamond mogul is known for decking out celebrities including Kate Winslet and Naomi Watts in his designs, which he has said are influenced by great works of art. His art collection, assembled over 20 years, is valued at around $5 million.
Lake turns into stage for contemporary theatre in rural Bengal
Source The Telegraph by Manasi Shah
Since 2009, Trimukhi, in association with other organisations, comes up with an annual event, known as the Night of Theatre. Every year, choreographers, intellectuals, farmers from different countries — including Spain, France, Mexico and Japan — congregate in the village of Borotalpada to create, practise and explore contemporary art such as theatre, sound and video installations. When I meet Chevallier at his south Calcutta residence, the 2019 Night of Theatre is still a month away, but he shows me some videos from the previous years.
At 82, is Arpita Singh ‘the next really big thing’ in Indian art?
Source Christies
Born in West Bengal in 1937, 10 years before the Partition of India, Arpita Singh is now widely considered one of her country’s premier contemporary artists. Her oil paintings and watercolours are renowned for the tantalising stories they tell, often from a female perspective. ‘She’s the standard-bearer for narrative art in India today — a narrative tradition that dates back centuries to miniature painting,’ explains Nishad Avari, Indian art specialist at Christie’s in New York. ‘She’s undoubtedly the standard-bearer for women artists in India, too.’ Now in her eighties, Singh is currently the subject of a major retrospective at the Kiran Nadar Museum of Art in Delhi (until June 30). Her work can also be found in the collections of institutions worldwide, including the V&A in London and Peabody Essex Museum in Salem, Massachusetts.
The rise of the performance art
Source The Hindu by Shrinkhla Sahai
A crossover genre with multiple influences, performance art continues to be intriguing, strange and full of surprises as it increasingly occupies more space in the arts arena in the country. Often immersive, amusing and rooted in radical acts, performance art is still considered relatively nascent in the Indian contemporary art scene. It eludes definition and sometimes baffles the public, leaving them wondering about what can really be called art. It also indicates the changing relationship between the spectator and artist into a participative and interactive one, going beyond gallery spaces and seeking new venues.
There's an art museum at the Mumbai airport; have you missed it?
Source The Economic Times by Vindu Goel
Mukeeta Jhaveri, who lives in Mumbai and advises companies and private collectors on art purchases and cultural philanthropy, said that the airport’s collection stood out among both India’s museums and other public art installations at airports around the world. "Even when I am rushing through the corridors, there is such a wonderful sense of both discovery and also that of meeting familiar friends.” About 25 percent of the passengers that pass through the airport are blue-collar workers travelling to and from jobs in the Middle East, and the museum very deliberately sought to include Indian crafts along with contemporary fine art.
Sheela Gowda Wins 2019 Maria Lassnig Prize
Source Art News by Annie Armstrong
Sheela Gowda has been awarded the 2019 Maria Lassnig Prize, which is given biennially by the Maria Lassnig Foundation. Gowda is the second artist to be granted this prize, which comes with €50,000 (about $56,300) as well as a solo exhibition at an affiliated institution, which for Gowda will be the Lenbachhaus museum in Munich, Germany. The prize, which is awarded to a mid-career artist, was conceived by Lassnig just before her death in 2014.
Modern India traced
Source The Telegraph by Anasuya Basu
Many would say the “modern” in India began with 1947 but Catherine David, French art historian, disagrees. “The modern would begin with the invention of Calcutta, when the Empire realised it could not function from London and that Calcutta could better operate the Empire,” said David, delivering a lecture on Rethinking the Future of Museums of Modern Art at the Victoria Memorial Hall (VMH) on Tuesday. Modern culture, literature and visual art came into being in Santiniketan with the birth of the Bengal School of Art, she said. While Vivekananda and Tagore contributed to the development of the modern in India in the spiritual context, it was the Bengal School of Art led by Abanindranath Tagore that gave a formal political and social dimension to the “modern” in India. “The development of the modern moment in India happened in Santiniketan. It was at the same moment an emancipatory, spiritual and formal project. It was a good combination of the colonial project and the more local,” David said. “Not many people went to Santiniketan. But that did not deter an artist like Benode Behari Mukherjee from working in a place where there was hardly any international visibility.”
Welcome to Mumbai Airport. Your Gate Is Past the Art Museum.
Source The New York Times by Vindu Goel
You could easily pass through the most sprawling art museum in India without realizing you had even been there. Scattered throughout the four levels of Terminal 2 of Mumbai’s international airport are more than 5,500 pieces of Indian art and handicrafts, including tribal totem poles and a 3-D map of Mumbai built from recycled chips and circuit boards. Together they make up the Jaya He, GVK New Museum. The X-shaped, ultramodern terminal handles all international and many domestic flights for the country’s commercial hub. So it is foremost a working airport, and the 50 million people who come through every year are there for one primary purpose: to get to and from their airplanes. “There is anxiety built in,” said Rekha Nair, who oversees the museum and customer experience at Chhatrapati Shivaji Maharaj International Airport. “People think, I just want to get to the gate.” As a result, the art is tucked into the hallways, baggage carousels and check-in counters so as to avoid disrupting the movement of passengers and the nearly 30,000 people who work at the airport. Angelic figures perch above the elevators. Treelike sculptures stand sentinel over the luggage belts. A mural accompanies passengers up the escalator after they step off the arrivals bus.
Souza to lead Sotheby's upcoming auction in New York
Source The Telegraph by Smita Tripathi
At Sotheby's upcoming sale of Modern and Contemporary South Asian Art to be held in New York on March 18th, 93 paintings representing 56 artists will go under the hammer. This is a major leap from last year when around 70 lots were sold. Says Anuradha Ghosh-Mazumdar, Head of Department, India and Southeast Asian Art, New York, Sotheby's, "Having 56 artists is quite a record for us as well." The artists include FN Souza, MF Husain, SH Raza, Jagdish Swaminathan, Ram Kumar, Jogen Chowdhury, Jamini Roy, Zainul Abedin, among others. An online quick guide well illustrated.
Living Outlines at Alliance Française de Delhi to exhibit violence, politics through art
Source Indulge by JD Sen
With an aim to explore the impact of French milieu on the Indian art today, Alliance Française de Delhi under the Back from France series, has announced Living Outlines, an exhibition addressing violence, politics and cultural memory in our times. The solo-exhibition titled Living Outlines, featuring seven seminal works of the Indian contemporary artist, includes Reji Arackal as the second name for the Back from France series. The series holds two solo exhibitions of two different artists every year in order to provide a platform to deserving young Indian artists who have returned from France after a stay of more than six months and now continue their practice in India.
Gandhi, Guernica, and an India pavilion at the Venice Biennale
Source Livemnint by Anindita Ghose
In 2011, India announced that it would participate in the Venice Biennale for the first time in the art event’s storied, 116-year history. Art critic and curator Ranjit Hoskote was tasked with producing a national pavilion. It was titled “Everyone Agrees: It’s About To Explode". The exhibition, like the theme, was tentative. After this late arrival to the global art party, India was a no-show in the next edition in 2013. Indian artists have been occasionally invited to participate in the Biennale’s other sections, and this continued to happen. In 2013, for instance, the German pavilion showed the works of photographic artist Dayanita Singh; the idea was to question the basis of identity. Speaking to me later, Singh said that even as she received praise for her work, she felt “a little bit ashamed". It isn’t that Singh is easily shamed. It is that countries like Angola, Azerbaijan, Georgia, Bangladesh and Maldives have all had national pavilions. Even the tiny island nation of Tuvalu, forecast to be one of the first countries to disappear due to rising sea levels, put forward its first national pavilion in 2013 to highlight the effects of global warming on the island. India was absent in the next two editions as well, although Delhi-based art patron Feroze Gujral sponsored an unofficial joint India-Pakistan pavilion in 2015. The messaging of India’s sophomore appearance is loud and clear—we’re playing Gandhi, our trump card. It is in keeping with UK-based curator Ralph Rugoff’s overall theme for the Biennale this year, “May You Live in Interesting Times", which considers the role of art in response to the current political climate, especially in the context of fake news and alternative facts. Given the theme for the India Pavilion, it is interesting that both Pakistan and Ghana will make their debuts this year—as recently as December, a statue of Gandhi was pulled down at the University of Ghana campus following protests against his racist views.
How a 35-page letter turned into a graphic novel told in Madhubani
Source The Hindu by Shivani Bhasin
The genesis of the book lies in a 35-page letter that the adult Biksu wrote to one of his sisters. It was such a powerful outflow of emotion and narrative that it gained legendary status in his family. His first cousin, the book’s creator Rajkumari, remembers reading it in a daze. She handed the letter to her husband, the Bollywood scriptwriter Grover, and he too read it one go. That’s when they decided to convert Biksu’s evocation of his childhood days into something more tangible. Somewhere along the line, as she crafted the tale, it also became Rajkumari’s tale — a product designer who trained at NIFT, Hyderabad, and her explorations as an artist. Rajkumari turned to Madhubani, an art form she had long been drawn to, as the medium for Biksu’s story. After graduation, Rajkumari had turned to folk art to express herself. By her own admission, she found the lack of control in canvas painting ‘terrifying’. Some of the earliest works she produced in Madhubani were, therefore, scenes sketched from famous Bollywood movies. “It’s not like I am an artist who decided to make a book,” she says. “I was a designer who fell in love with a letter and with an art form, and I wanted to communicate something very deeply, so I explored that.”
Lights, camera, enact
Source The Week By Sneha Bhura
How do you link photography and performance? Lithuanian-American visual artist George Maciunas scavenged prom dresses from the Salvation Army and thrift stores, and wore them to enact and photograph his own striptease performance in 1966, as a comment on gender indeterminacy. Chinese artist and activist Ai Weiwei channelled his mockery and disdain for historic monuments and nationalist pride in a photo series called "Study of Perspective" by pointing his own middle finger against a backdrop of iconic landmarks. Iranian photographer Azadeh Akhlaghi meticulously reconstructs in her images episodes of executions, assassinations, suspicious deaths and torture from Iran's modern history to portray events for which no photographs exist. For Delhi-based contemporary artist Shine Shivan the word yashtimadhu assumed the seriousness of a lived reality, a performative subject, an art project and a life's mission.
Baroda still brims with promise as an art destination of contemporary India
Source The Guardian by Bhumika Popli
Baroda’s MSU has remained one of the top choices for those looking to expand their artistic horizons. The university’s art faculty has produced veterans like Gulam Mohammed Sheikh, Nasreen Mohammedi and Laxma Goud among other stalwarts who elevated the Indian art scene to new levels. The Baroda Group—a significant collective of artists which included doyens like Jyoti Bhatt, N.S. Bendre, K.G. Subramanayan and many more—is also respected worldwide for its genre-breaking achievements. The MSU gained its university status in 1949 and its arts faculty came into being the following year. But Baroda’s history of art goes way back to 1881. In this year, the College of Science—what is now the MSU—was founded. At the same time, Maharaja Sayajirao Gaekwad III invited the well-known painter Raja Ravi Varma to Baroda. Varma produced a considerable quantity of works here, which are now on display at the Baroda Museum, located across the road from the university.
The beguiling work of Jangarh Singh Shyam, creator of his own artistic language, defies labels such as ‘tribal’, ‘folk’ and ‘Gond’
Source The New Indian Express by Pooja Pillai
The tradition that Shyam drew on, Jain says, was that of mythology and storytelling. “Women in Jangarh’s community used to make clay relief artwork, but his own work went beyond the decorative,” he says, adding, “Moreover, it wasn’t like there was a tradition of Pardhan art, like there was a tradition of Warli or Madhubani art”. Thus as creator of his own form of artistic expression — mediated by what he learnt at Bharat Bhavan and elsewhere — Shyam can’t be pushed into the “tribal” or “folk” art category. “He was, in every sense, a modern artist,” says Jain.
Home is where the art is: Art, writing residencies explore varied spectrum of disciplines
Source The New Indian Express by Ayesha Singh
The artistic bent of mind has never been so trendy in India. The bank accounts of successful artists, writers, filmmakers and photographers have never been so overflowing before either. New names and new styles are trophies in the Indian art business, which was valued at over `1,400 crore in 2017. Subsidiary stakeholders like art residencies are mushrooming across the country, inviting artists to practice their creative mantras in sylvan solitude or culturally rich environments. Indian artists are also receiving invitations from residencies abroad, both privately funded and corporate. Some of these charge a fee. There is Sangam House in Bengaluru. Khoj in Delhi. Art Ichol at Khajuraho and Kalanirvana International Art Centre in Bhubaneswar.
Death of Haku Shah, eminent Gandhian artist signif...
$17,757 nouveau record pour une peinture sur papie...
Works by major Indian Modernists lead $8m sale of ...
India auctions fugitive billionaire's art, raises ...
Atul Dodiya, GR Iranna, Jitish Kallat in artist li...
One of India’s Most-Wanted Fugitives Is Selling Of...
Lake turns into stage for contemporary theatre in ...
At 82, is Arpita Singh ‘the next really big thing’...
There's an art museum at the Mumbai airport; have ...
Welcome to Mumbai Airport. Your Gate Is Past the A...
Living Outlines at Alliance Française de Delhi to ...
Gandhi, Guernica, and an India pavilion at the Ven...
How a 35-page letter turned into a graphic novel t...
Baroda still brims with promise as an art destinat...
The beguiling work of Jangarh Singh Shyam, creator...
Home is where the art is: Art, writing residencies...
PHOTO : JIVYA SOMA MASHE FISHNET 2013 ACRYLIC AND COW DUNG ON CANVAS 160X140 CM (DETAIL).
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Cette newsletter permet de suivre l'actualité de l'art contemporain indien à travers une revue de presse internationale régulièrement mise à jour.
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Rusty Strait
AMERICA’S CHANGING LIFESTYLES – PART X
Toward the end of 2007 we ran into a boomerang with the onset of a “Great Recession.”
From which we continued to recover when Donald J. Trump became president. It became fashionable to throw out the words, “Make America Great Again.” Words I distinctly remember from the late 1930’s in Germany. But we were America at its strongest now. Nothing like that could ever happen here. No way.
It seemed like a businessman in the White House was just the right thing. I also have not so fond memories of Herbert Hoover with “Prosperity is just around the corner.” What was just around the corner was the greatest Depression this country ever had.
We are now in the 21st century with the stock market reaching the clouds, but wait, let’s fill in the blank spaces.
We were retroing back to FDR and his “Happy Days Are Here Again,” or were they?
Socializing and popular fads
It seems we just can’t escape the British influence when it comes to togs, music and almost anything else having to do with British Royalty, Prince Harry (sort of the renegade Prince of the 21st century, married an American Actress setting of canons of explosive tabloid frenzies. It soon became obvious that this young couple didn’t show any interest in stodgy old English customs. Harry and his lovely Meghan Markle accepted their role as Duke and Duchess of Sussex. But it was only a formality. You knew immediately he was different when he said, “Just call me Harry.” They lived a life more like American rich kids, not seeming to find the kind of work set out for them to their liking. Young American teens, especially took to Meghan’s casual style of dress (some parents were already wondering whatever on earth would they take off or put on next).
Harry and Meghan conducted themselves like American High School brats with more money than they might know what to do with. Not just teenagers but adults with more common sense (we would hope), became somewhat hysterical with joy that the couple would choose to move to North America. The excitement isn’t over and you can bet we’re in for a resurgence of British styles and fashions for some time to come.
The Bigger We Are, The Harder Will Fall
And fall we have. At the turn of the century, we were so busy worrying about clothes, music and do-dads that most of us failed to notice that the Stock Market started to wobble between 2000 and 2002. During that time, one of the prime market sections, the S&P 500 suffered a 49% wipeout and three years later dipped another 56%. Overall that diminished American wealth some 20-trillion dollars, which ain’t five and dime money.
Get a Bucket, Bail the Boat – We’re Sinking
Break the law, got to Jail. “Hey dad, come bail me out of this stinking joint.”
In the early 21st century, when the automobile makers, banks, housing industry and mortgage companies crashed, they asked for another relative. “Call my Uncle Sam and tell him to come down here and bail us out.” Uncle Sam, i.e., the American taxpayers. It may not have happened in your community, but it did happen, and you paid part of the bill to bail them out. That’s just the way it is done and most poor suckers have no idea what happened to them, only that the government took another healthy slice of their hard-earned wages. Before it was all over, Uncle Sap (us) bore the brunt of close to $100 trillion dollars. Talk about grandchildren paying, how about triple grandchildren, after while stuff like that becomes real money.
Why are we so Afraid
Whether we like or admit it, we have grown into a country afraid of our own shadows. Fearful of the dark like the rat is scared of daylight. Afraid of Russia, Afraid of Chinas afraid of nature, afraid of the monsters we drive every day on super concrete highways. Afraid to let our children walk to school. Beware the guy behind the bushes. Just plain old unadulterated fear itself. Are those things what we are really afraid of, or are we simply afraid of ourselves? That’s become a working model for most of us in the 21st century. Maybe FDR was right when he made his famous speech of being afraid of fear in his first inaugural address in 1933.
Abraham Lincoln made us aware in a long-forgotten speech of 1838 when he sagely advised, that no foreign country across any ocean would destroy us. He said, in part, that the greatest danger “must spring up amongst us. It cannot come from abroad. If destruction be our lot, we must ourselves be the author and finisher. As a free people, “We must live through all time, or die by suicide.” Fear of one thing or another is the cause of most suicides. So will we stop fearing everything and face the future undaunted by such childishness and emerge again as the greatest nation on earth. We do not stand alone today. Our changing lifestyles has failed to recognize just how many competitors we have today, always willing to steal away our dignity and strength, lest we first give it up without standing up.
Why are Our Parents Copying our Styles
Back to a less somber lifestyle. Have you noticed how much you try to look more like your teenager than yourself? Remember when you told the kids to “act your age.” Isn’t it getting time to look in the mirror and ask yourself, “Why am I trying to look like a teenager?” Never noticed, huh? When a teenager applies acne medication to his or her face, you notice how well it is working. “Well,” you say, “I’ll bet it will help me get rid of that zit next to my nose.” Or, “Bet that stuff they advertise for bags under the eyes and that flab under the chin would make me look years younger. It has become fashionable to look younger and younger even when you’re approaching seventy and eighty and god know how much older. It puts us in the dream world when we ogle at a lovely lady or handsome young athlete. Oh, how we dream, and now we will climb mounts of creams, etc., etc., to go back to those days when we were one of those young people even though it ends up being nothing more than kemtone and putty. We are not only afraid but we all too often fall into some kind of dreamland. No doubt those applications will help some, but you are still who you are so get used to it. It sounds like a bitter pill, but we’ve tried every pill in the drugstore, so why not an unwanted bitter one telling the truth about us. As I heard one dowager say, “But it is so trendy.”
Teenagers have such Bad Habits
Whoa there. A recent article in Best Life delineated 20 teenage bad habits that many adults have picked up or never let go of.
1. Munching on food all day and at dinner, you will say, “I simply don’t eat so much these days.
2. Biting your nails. We all do it so some degree, especially when we are nervous, but we alibi our way out when confronted. “Oh, I snagged them somewhere.”
3. Not flossing. Remember how you practically screamed at your kids for not flossing? Now, they’re doing just fine because you were on them about it. You don’t floss anymore. Too busy looking for uppers and lowers that don’t give you blisters.
4. Procrastinating. Remember when you were all over the kids to do their homework? Now many of your put off until next week that contract you need to sign or that appointment you should have kept. Excuse: “I simply had to much to do “or “I don’t like to be pressured.” Yeah.
5. Washing Dry-Clean Only clothes. “Son, I’ve told you a million times not to put that cashmere sweater in the dirty wash. It must be washed by hand,” so you say, “Oh, I’m sure this will wash,” as you stuff something into the washer that “feels washable,” but isn’t. Another one of your teenaged habits you still up to at 40.
6. Packing a lunch. You told your kid, “I don’t care if you rather eat fast food at lunch. My lunches are more nutritious.” Mother knows best? Maybe, but why do you feel embarrassed to take a nutritious lunch in a paper bag to the office every day? Oh, you’d instead grab a burger at the diner. So, instead of carrying a nutritious lunch in a bag, you’d rather carry it around the waist you try to hide with a double-breasted suit of caftan. Yeah.
7. “My goodness, will those girls ever stop gossiping on the phone all day?” What” How do you square that when you spend most of your afternoon about the girl who got pregnant and isn’t married. Probably doesn’t even know who the father is?” That little dinging you call a cell phone stays busy and very little of it is business as you leisure about in an air-conditioned home gabbing with Maisie down the street. Some change in styles or is it?
8. “You’ve got to learn how to save money or you will never grow up to amount to much.” So you dictate, but are you aware that the average American cannot come up with $400 cash in an emergency? There have been several recent studies on that. So don’t be surprised when your admonishes to your “spendthrift” teenagers fall on deaf ears.
9. TV binging. “Don’t you kids do anything but watch TV. It must get so boring.” So you can’t wait to get home from work to binge on Netflix and Prime. You think the kids are addicted to the Tube. While you sit, munch and binge, you are wasting a lot of time. Also, you may wonder, “Why am I getting so much flab?” It doesn’t take a Mensa to figure that one out.
10. Dirty dishes in the sink. “Oh, those lazy kids. I’ve told them a thousand times to clean up their dirty dishes. Was it the kids who brought cockroaches into the sink? Or was it the dinner dishes that, “I’ll wash them in the morning. I’m tired tonight.” You are not alone. You have a lot of company that aren’t anywhere near being the teenager you criticize.
The list goes on and on, but you get the gist. These things are part of our changing lifestyles, but we simply don’t catch on until we are so far down the road, and into some other gimmicky lifestyle.
Whatever Happened to the Grand Ole Opry?
Oh, it didn’t go away. As a matter of music ratings, it has once again become the rage, brought into the limelight by The American Music Awards. Grammy’s are as popular with 21st Century folks as the Oscars were in the 40’s and 50’s. Believe it or not, but it is so true. People who can’t remember a movie star’s name or what pictures they starred in can tell you all the details from the song-writer to the producer and performer in country music. It is very big in our current lifestyles because so many of us like to reminisce about the good old days down on the farm listening to WSM. Trust me folks, I grew up in a hollow and the days were not that “good ole.’ Outside wells, outhouses, wood stoves, oil lamps, Sears Roebuck Catalogs. No. But country music is back and it sounds almost like rock most of the time. Lifestyles are so retro these days.
What the Hell Happened
You’ve been waiting for it and now you’re gonna get it. The politicians have taken to hating each other for no good reason. Compromise is something you do with your kids when they tell you what their rights are. That is a never-ending negotiation and it seems that for the most part, the kids win because we are afraid of accusations (however untrue) from them that might stigmatize us for life. I had an elderly attorney tell me recently, “Rusty, I won’t even be in a room with my granddaughter unless another adult is present. Sad. School teachers are fearful of putting an arm around the shoulder of a distraught kindergartner. You think I’m joking? Fear. We are fearful of what someone might say and once it is said, right or wrong, there are those who will say, “Well, if there’s smoke there must be some kind of fire.” Changing lifestyles.
There are re-new laws that go into effect on January 1st of every year. Telling us what to do, when to do it and how to do it and they delineate the punishments in fines and incarcerations if we don’t comply. Pot is legal, but our prisons and jails are filled to the gills with addicts while the dealers and cartels go along their merry way sucking in more young and old into the dens and drugs inequity. They have expensive lawyers and they fight the system, doing whatever it takes to sustain their business, more or less telling the authorities to mind their own business. Every day you read about an elected official being charged with taking a bribe.
Our modern lifestyle hawks equality, but minorities and the poor know they are at the bottom of the barrel when it comes to any equality. Modern lifestyles. Some things are as modern at high buttoned shoes and carriages. We put on a show and everyone loves a show, so we ignore the inequities.
While we bicker over minuscule changes, we fail to see what is actually happening in the world, including the United States of America. Mother nature has a way of leveling the field when she feels she’s been mistreated too much. When she strikes back, and she always does, it is with the vengeance and anger of a riled King Cobra. Dust storms, cyclones, tornados, earthquakes and erupting volcanos. If it didn’t happen to us, so what? However, the time comes when we say, “Why us?” The scientists know why.
Case in point. In 1917-18 the Spanish flu (a product of nature) took us down a stroke and with it, some 25 to 50 million people died.
Sometime late last year and little virus crept out of somewhere (blame who you want but nobody guided it; it laid out its own road map and what a map it was). Remember back in January and February of this year? “Oh, it is just a few and will go away like magic.” Like magic, it traveled like Ali Baba on a cushion. Some say the jet stream carried it. Seems logical since it first appeared from East to West. After a short period, a few grew into a hundred and then a thousand and hundreds of thousands and we were simply caught with our masks and guards down. Remember the old butter slogan ‘” Don’t fool with mother nature?” We did, and our new lifestyle takes place not only in the hospitals, funeral homes and cemeteries but in every nook and cranny of our world. There is no escaping. Everybody is looking for a treatment or vaccine. Gotta save lives. And the powers that be continue on their way without even thinking that the real culprit is nature. That kind but wicked when it has to be, nature who has finally said enough. Face masks are in style of all colors, sizes and designs as are limited assembly and six-foot spaces between us. Maybe this is a lifestyle that will change us for the better. In that venue, I’m from Missouri. Show me. Wishing everybody the freedom that has been whisked away from us and hoping we really do change our way of living this time.
Just sayin’ rustystrait@gmail.com
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On the right with Robin Lowe
Mark Lentine - November 7, 2019
I am proud to announce that I was just elected President of the California Federation of Republican Women of Hemet-San Jacinto, this past Wednesday, October 23.
Takin’ it to the streets
Rusty Strait - October 31, 2019
Growing up "dirt poor" in the mountain communities of West Virginia during the Great Depression, “homeless” usually meant that one had no family. I was a product of “Appalachia” 30 years before John F. Kennedy discovered it.
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Doing What You Love from Home, with Kids featuring Michelle Glogovac
Released: Mar 17, 2020
Michelle Glogovac is a podcast producer, pitcher, and host who launched her business after 18 years in corporate aviation. When we recorded this podcast episode a couple of months ago, the only Corona we knew about came in a glass bottle with a twist of lime and maybe some grenadine! But it's a timeless message: transferring skills from a previous corporate job into something they love, while working from home— even with small children. We talked about:
How she made the switch from a long career in corporate aviation to podcast production How she manages working from home while also caring full-time for 2 young kids Her advice for you to get on track to do what YOU love
Show Notes - https://kickinitwithdaree.com/episode/working-from-home-with-young-kids
Doing What You Love from Home, with Kids featuring Michelle Glogovac: Kickin' It with Daree | Talking about the Things that Matter | Personal Development
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Welcome to the web: Becki Percy, Vicky Ash, & the UK SRA pushers
We’ve said this before, but the web of those who push the Satanic ritual abuse narrative within the UK is both relatively small and very close-knit.
For example, when we were looking into the story of SRA claimant Becki Percy, we learned that although she began her career of allegations by claiming that her father had sexually abused her, and later expanded that to her mother trafficking her, she didn’t really get rolling with her abuse claims until she’d discovered a woman named Victoria (Vicky) Ash.
Off to a good start
Becki contacted blogger Fenna Vlekke in early 2015, “because she wanted to raise awareness on the topic of childhood sexual abuse”. In the interview she not only claimed that she was locked into the loft at her parents’ home with “only a dog bowl filled with water for company”, but she described what happened after she allegedly told a teacher in January 2010 that her father had been sexually abusing her:
That night, a police woman and a social worker came to mums house. My dad was still at work so it was only my mum and me. They explained everything to her and she started with the crocodile tears. She pretended she had no clue this had been happening. Of course, they believed her tears. My dad came home and, for my own safety, the police woman told me to go upstairs so I did. I could still hear everything. She told my dad he would have to find somewhere else to live because he wasn’t allowed near me. He was angry. Saying that I’d made it up and that he hasn’t ever touched me. Lies. Thankfully the police made him go and he did. He left.
So…a 13-year-old girl reports sexual abuse, the police show up, and instead of arresting her father for questioning, they simply tell him he has to leave the home…and then they toodle off themselves, job done?
In this interview, Becki says she went to live with her uncle, but worse luck, guess what? He was involved in her parents’ child trafficking ring too! When she reported this in March 2010, she was sent to live in foster care, followed quickly by emergency residential care, and finally “a lovely placement” where she was living at the time of the interview.
There’s no mention of her uncle or parents ever having been arrested or prosecuted for their alleged crimes; they just fade out of the picture.
Asked whether she had help dealing with the emotional effects of her abuse, Becki’s response is telling:
In terms of social services, they don’t believe a word that comes out of my mouth. They think I’ve lied about the abuse. I’ve been referred to CAMHS countless times but they’re totally useless.
Shifting narratives
Interestingly, in a December 2016 YouTube video, the story changes somewhat:
I lived with Xxxx ([mother’s] brother) until May 7th. I disclosed to the same school teacher about him sexually abusing me. I was placed in foster care
I was in that foster care placement for around a month in which time the male foster carer was sexually abusing me. I, again, disclosed to a school teacher and was placed into an emergency children’s home
I was there for a further month then placed in a more permanent children’s home.
From July 2nd 2010 to April 21st 2015 I live in the second children’s home. In that time I went through a cycle of CPS wanting me to see Ann, I would have contact with her then she would abuse and traffick me, I would eventually tell someone. The police would ‘investigate’ but then come back and say they wasn’t going to prosecute which is when the cycle would start over.
A few things are notable here:
Becki adds an allegation of sexual abuse against her male foster carer;
She states that her social workers wanted her to see her mother, a strange choice for a teen who was allegedly being sexually abused and trafficked;
The police would investigate, but refused to prosecute—again, a strange choice if there was any evidence whatsoever that Becki was being sexually abused or trafficked; and
Nowhere in any of the above does she mention Satanic ritual abuse, nor her devotion to evangelical Christianity, which will become leitmotifs of her current internet fame.
And then along came Vicky Ash
In January 2017, however, Becki posted this video to YouTube:
We’ve discussed this video before: it’s the one in which she states, then tries to retract, that she has done a great deal of research into SRA. The main thrust of the video is that while she knew she’d been abused as a child, it wasn’t until about six months earlier that she’d come to the stunning realisation that she had been a victim of SRA.
At 05:52 she mentions that her role model in this is “a very courageous woman named Vicky Ash”. Becki expresses admiration for Vicky:
I really find her story and her courage inspiring and she was the push that I needed spiritually—she’s a Christian—to continue doing these videos….To hear from another survivor that has experienced similar things to myself speak about it with such…she was so graceful about it, and she was calm. She looked like she was at peace. And I’m thanking God that she has found God, and she is strong in her faith, and I know that God has already started healing her, which I’m thankful for also.
Unfortunately, the video Becki refers to has been removed from YouTube for violating its terms of service.
On Voat, Becki gushes about how Vicky helped her understand that the alleged abuse she’d suffered was actually SRA.
We don’t know that Becki and Vicky ever communicated directly. However, it seems quite clear that Vicky’s various online interviews helped Becki shape and hone her SRA story, as it shifted from “my parents abused me” to “my parents trafficked me and locked me in the loft with a dog bowl of water” to “my parents and other unnamed people chased me through the forest full of dead children hung from the trees like Christmas ornaments, and each time they raped me they took another item of my clothing”.
Who is Vicky Ash?
Although the specific video Becki references is no longer available, Vicky Ash has given many interviews over the years. In this undated interview with Wilfred Wong, she describes the familiar litany of “Satanic” practices:
I was also forced by my Satanist abuser to watch pornography, which included Bestiality. In addition I was forced to ‘play games‘ during which I was sexually abused and told that I was the ‘star of the show‘. Photographs were taken of this abuse.
I was drugged with a drink and taken out at night to tunnels and other locations with everyone wearing black hooded cloaks. I heard screaming and witnessed Satanist rituals with animals and children being murdered. There was lots of chanting. I was impregnated and my baby was aborted and offered as a sacrifice to Satan. Abortion is the modern form of Child Sacrifice. Bible-believing Christians ought to take careful note of this and become much more actively Pro-Life.
(Yes, she does say, “Abortion is the modern form of Child Sacrifice”. You were not imagining it. Sorry.)
With the help of her MP Geoffrey Dickens, Vicky’s case was investigated by police twice, but no one was ever charged, despite her persistence. However, she claims “there is plenty of hard evidence that SRA exists in the UK, including the several successfully prosecuted SRA cases in our nation”.
This is blatantly false: in Prof Jean La Fontaine’s 1994 study of over 200 allegations of SRA in the UK, only three cases were substantiated, and they were found to have been “pseudosatanic”—sexual abuse was the main motivation of the abusers, and the ritual elements were incidental.
However, like most SRA pushers, Vicky does not let mere facts stand in the way of her belief.
A former beauty salon operator who now describes herself as a “beauty therapist”, she runs a “Holistic Christian Ministry called ‘Christoria’. Its work includes helping other SRA survivors and warning people that some beauty treatments on offer are Occultic”.
Vicky’s ties to UK SRA pushers
In addition to Wilfred Wong, Vicky Ash is closely linked to others within the UK SRA-pushing community.
In November 2015, we find her being interviewed by Brian Gerrish, an interview which was promoted on David Icke’s website.
Interestingly, in addition to referencing Geoffrey Dickens, she talks about her affiliation with Dianne Core of Childwatch. Ms Core was an enthusiastic promoter of the SRA narrative in the 1990s, who managed to straddle the fundamentalist/evangelical Christian / radical feminist divide, and worked on The Cook Report at the time when it was pushing SRA heavily. She is probably worthy of a post on her own, but it’s interesting that Vicky Ash says she was helped by her.
We found that Sabine McNeill has featured Vicky on her National Inquiry into Organised, Orchestrated, and Historic Child Sexual Abuse blog. In a post on 8 May 2017, Sabine featured Vicky speaking at the “Perth Conference on Full Spectrum #ChildSexualAbuse”.
That event, described by our own YdychyncachuTracey as “a shitfest of complete utter fuckwittery”, turns out to have been the founding event of none other than the Scottish Fresh Start Foundation, which we’ve been tracking for the past several months. In addition to Vicky Ash, speakers included the aforementioned Wilfred Wong, Robert Green, Sandy Smith, Shirley P. Cooper, and Andrea Sadegh, with Brian Gerrish, David Icke, and Kevin Annett making video appearances. Hail, hail, the gang’s all here!
Once again, we have no idea what Vicky actually said at the event, as that particular Fresh Start Foundation YouTube channel seems to have taken down for “multiple infractions” of YouTube’s terms of service. Quelle surprise.
We find it fascinating, though, that despite being located so far from the UK, an SRA claimant like Becki Percy, looking for validation of her own stories, somehow seems to have hooked into the UK SRA-believers’ community so seamlessly.
23/06/2018 in Witch hunters. Tags: Becki Percy, Brian Gerrish, Fresh Start Foundation, Kevin Annett, Robert Green, Sabine McNeill, Satanic ritual abuse, UK Column, Wilfred Wong
Justice for Becki Percy…whether she wants it or not
Becki Percy follows a well-worn path
Dunn & Wong: More on Wong’s connections
← Angela barks up the wrong tree…again
Are SRA claimants lying, or victims of false memory? →
108 thoughts on “Welcome to the web: Becki Percy, Vicky Ash, & the UK SRA pushers”
Very interesting post EC. I see that the MP Geoffrey Dickens was mentioned and he was the MP that first bought allegations of high-level paedophiles to attention. All rubbish of course but interesting to see that he was in contact with Vicky Ash.
Yes, it’s amazing how interlinked they all seem to be. If I didn’t know better I might call it a “conspiracy”.
Perish the thought EC 😉
Here’s a link to a BBC report about Dickens and his dossier.
https://www.bbc.co.uk/news/uk-politics-28141531
Thanks, Arthur! Good thinking. 👍🏻
Geoffrey Dickens talking about SRA.
Wow, a veritable who’s who!
Sally the SENCo says:
So she’s citing referrals to a mental health service as proof that she wasn’t a lying fantasist?
Good work on finding all those inconsistencies in Becki’s ever-changing story, EC.
Thanks! This just scratches the surface, I’m afraid.
I watched the video with Vicky Ash talking to Brian Gerrish and i wondered does she really believe in what she is saying due to a mental illness or is she straight out lying?
That’s an excellent question and I’ve wondered that about all the SRA myth promoters, tbh. One could almost do a pie chart for each of them to show the differing proportions of lies to fantasy.
Can I just let people know about this comment from OMG?
https://hoaxteadresearch.wordpress.com/2018/06/22/angela-barks-up-the-wrong-tree-again/comment-page-1/#comment-110658
S/he clearly put a lot of time and effort into it but sadly it was found languishing in the spam folder and ended up in the dead zone that is the tail end of the last post.
Incredibly, the article that OMG links isn’t from a 1980s tabloid but from yesterday’s Metro!
Thanks for re-posting OMG’s comment as I may have missed it otherwise. Those sort of articles do no good at all apart from encouraging belief in such nonsense. I wonder if the journalist really did meet that woman or did she just make the story up?
Who would have thought that a man offering to massage your ‘yoni’ would turn out to be a pervert? It’s the perfect job for a pervert wanting to feel up any woman daft enough to visit him.
Thanks, Scarlet, and thanks OMG. That first story sounds as if it was written 30 years ago. I find it depressing that this nonsense is being peddled again as if it were real.
I think it’s an important question. This is worth addressing in more detail, but I believe the short answer would be “it depends”. I think that “recovered memory therapies” can make people believe that these terrible things really did happen. Then there are the fakers, who create the stories as they go, in order to gain attention, money, or both. Even they, though, can come to believe some of their own lies, as they repeat them so often they begin to feel true.
Yoni massage is featured in the film ‘The Road to Wellville’ which is hilarious.
‘ Its work includes helping other SRA survivors and warning people that some beauty treatments on offer are Occultic”.’
OMG. I’m going to be careful next time I have a pedicure. You never know do you!
OMGnotthisoldshiteagain says:
It does sound very 1980s except for the fact that the narrative has been updated to try to bypass the activism of the various posters here and on other sceptical blogs and news sites who point out there have been no actually proven cases of SRA. The article in the Metro has a section titled “What is a pseudo-cult?” that is definitely worthy of careful reading and reflection. I perceive it as evidence that this blog and other similar, sceptical blogs are making a difference and that the SRA promoters’ narratives are changing to adapt to the new scepticism.
Also re the “vagina massage” articles, the first is effectively an advertisement that recommends female readers to submit to vagina massages from a convicted sex offender, while the second article includes a multiple choice questionnaire in which readers can share their enthusiasm, or lack thereof, for spending money on vagina massages.
I was wondering what company or organisation developed the questionnaire? Given that, in the age of the internet, criminals and cults harvest compromising information from people in order to identify people vulnerable to blackmail and exploitation, I always am very careful and cautious around online multiple choice questionnaires.
It seems to me that the Metro are being extremely negligent with their readers’ safety by publishing these articles.
The only thing I can think of in their defence is that many much more reputable news sites have also published completely uncritical articles promoting dodgy cults, fake shamans and assorted new age grifters.
Actually there is another redeeming feature of the Metro and that is that, when Gwyneth Paltrow’s dodgy website Goop was advocating that women heal their sex lives by pushing jade eggs up their vaginas, Metro ridiculed the idea and actually published a lot of sane reasons why this was a potentially dangerous practice. If only they could extend the same level of sanity and scepticism to SRA / DID and vagina massages the world would be a safer place.
I call shenanigans on your use of the word “journalist”
Grobnob says:
Can’t wait for becki to get her dumb ass booted out of America and see how she settles into life in the UK without an adoptive clan of over wealthy and underwise buffoons to support her. These fakes are parasites who belittle genuine victims in their lust for attention. Maybe she’ll find a spare room in Highgate, though I feel her true spiritual home would be among the tiny tears and unicorns of golders green. Imagine those two idiots together . . . . Scented candles, my little ponies and wanky rainbows all round.
Well, you wouldn’t want to put your foot in it, Miss Camden.
Actually Vicky Ash’s narratives that some beauty treatments are “occult” is extremely interesting to me.
Many of the disgusting cults that exploit vulnerable people as human assets encourage the said vulnerable people to start their own businesses.
Some of these businesses are running workshops in “yoni massage” / “sexual awakening” etc. Some are multi-level marketing (MLM) businesses selling quack products and remedies. Some are MLM businesses selling the cuts books, workshops / retreats, DVDs etc promoting the cult and quite a lot are people selling beauty creams and other beauty products.
I think that one of the main reasons why criminals encourage people to work hard as new age entrepreneurs is that is creates a large community within which multiple revenue streams can be used as layers to obscure dirty money that can be laundered. Of course the criminals want their victims to work hard and build large, successful businesses because, at the end of the day, they will relieve people of their assets and own the businesses themselves.
I wondered why so many of the businesses include beauty products and I believe there is one very obvious answer (not the only answer though) and the obvious answer is that even corporate producers of beauty products deal in woo.
The Advertising Standards Authority is always rapping the knuckles of various corporate beauty brands for making false claims in advertisements. If you watch an advertisement for face cream or other product with the volume turned off you will see that models put animated cartoons of scientific vignettes on their faces. When a women applies a moisturiser to her face she is not applying just a moisturiser, she is applying ideas, concepts and dreams.
In fact if one considers some of the most noticeable products promoted by cults and criminals, they are the very same products that snake oil sellers have sold for millennia, quack cancer cures, cures for erectile dysfunction, weight loss remedies and face creams to make you look 10 years younger.
Back to Vicky Ash, I have not researched her particular issues with “occult” beauty treatments, but it seems to me that whenever criminals and cults do something dodgy, some conspiraloon turns up with a batshit crazy conspiracy theory that identifies the grift but that is encased in a layer of insanity that obscures the reality at the core of the narrative.
Interesting piece in the Telegraph today
“The Church of England disregarded dozens of allegations in its inquiry into child sexual abuse and then downplayed the issue to protect its reputation, a critical report has found.
A report by former Barnardo’s chief executive Sir Roger Singleton found that close to 100 cases were whittled down to just a handful for a review released in 2010.
Inconsistent and overly specific criteria reduced the number of cases they reported for the Past Cases Review, leading it to conclude after examining 40,000 files that just 13 cases of alleged child sexual abuse merited formal action.
Sir Roger, who was commissioned to complete an inquiry into the review, said he believed the Church “downplayed” the issue in public statements to avoid reputational damage.
https://www.telegraph.co.uk/news/2018/06/22/church-england-excluded-child-abuse-allegations-inquiry-downplayed/
Further down in the article it reports that:
“In a case in Exeter Diocese, there was “concern about obsessional interest in satanic ritual abuse and conduct generally” by a retired priest, which it was decided would be dealt with by the Archdeacon.”
I am detecting a theme here.
Thanks Scarlet 🙂
I sometimes get inspired to post late at night / early in the morning. I appreciate you reposting it here
Thanks for that, hadn’t seen it before, great video
Agreed 100%
We have to be very careful not to fall into binary thinking, the issue is nuanced and complex
Firstly, love the spider web photo. This is my update on the Becki Percy case.
My plan to go-fund an assistance dog for Becki Percy as an incentive to report her allegations to the police has fallen through, there are no such assistance dogs in the UK for those with PTSD except ones for emergency and military personnel. I could not therefore cost the project to launch a Go-Fund. As you might remember, the incentive was that the money would be given to police in Hull, and if they found a case to bring charges against those Becki accused of crimes, she would get her dog, otherwise the funds would go to Childline.
As these allegations by Percy have not been tested by a police investigation, I am treating it as an active crime scene until the police have come to their conclusions. It appears the personal sex abuse claims by Percy have been looked at by the police and the evidence was not strong enough to bring charges. In her own words Percy said the police and the four social workers who dealt with her case considered her an “allegation maker”.
The newest allegations that Percy makes appears to have manifested around the time she arrived in the USA in 2015. There is no mention of SRA allegations in her internet postings pre 2015. These new allegations have not been tested by a police investigation, so I have in recent days been lobbying Percy and her supporters to contact the UK police to initiate an investigation. Percy has been frustrating, despite her many internet postings about her alleged SRA experiences, plus her concerns for the dead and abused children of her alleged abusers, she did not and seems unwilling to report these latest horrific alleged murders to the police. Her response to me is block me on Twitter, and when her supporters thought my suggestion that she should contact the UK police was a good idea, her only response was “he is a Satanist.” It is beyond bizarre that Percy is posting away on her two Twitter accounts promoting her candle business, yet does not and is unwilling to put any effort or time into contacting the police to bring about justice for her alleged victims and to safeguard future children from harm. Percy has been selfish in my opinion, complaining about her own misfortunes, promoting her candle business, promoting Trump and her Gofund projects … she has no motivation to help the alleged thousands of victims in Hull … it is moments like that when I want to bang my head on my keyboard.
According to Percy, apart from one teacher, everyone she has shared her abuse claims with have not believed her. She has been passionate enough about her claims to get herself put into care for five years, and a further 14 months in jail in the USA as an illegal immigrant. It is strange that Percy has not shared all her story with the authorities, rather, it has been in bits, thus she claimed her father sexually abused her, he was asked to leave the home; she then said her mother sexually abused her, she was sent to live with an uncle; she then said her uncle sexually abused her, she was sent to live with a faster carer; she then said the foster carer sexually abused her; she was sent to a care home. Why Percy has not shared the whole abuse story right at the start rather than bits and pieces that are growing ever wilder over the years is a mystery.
Because Percy has been unwilling to bring her allegations to a conclusion through a police investigation, rather wanting a type of internet circus to emerge where she encourages her gang of supporters to fund her many gofund campaigns, buy candles, and attack her abusers, I have been very assertive to the point of harrassment in getting her to report these allegations to the UK police. I however have always been polite and encouraging to her, and my actions fall under the prevention and investigation of crime legal defense for UK harrasment legislation.
Some might be critical of my strategy, but one has to take into account I have to keep in harmony with the law on harrassment, and it is better to have an open communication with Percy and her supporters to bring about a police investigation, since there might have been crimes committed. For legal reasons I won’t be contacting the real family of Becki Percy.
Percy has currently claimed political asylum to the USA from Britain because she says her family will kill her. Her family are ordinary working class people, her mother is a pillar of her local community. They are hardly sophisticated or that well connected to be capable of killing thousands of children in Hull over ten years without someone noticing. Percy has made no efforts to involve the UK police in investigating her SRA allegations or to protect her in their witness program, which is going to be noted by Homeland Security and the courts dealing with her asylum case. She will be deported.
Such is our frustration that Percy refuses to contact the UK police, that my associate “Ajax” contacted the police in Hull and made them aware of the allegations of Becki Percy. Now that we have an official record on file “Record C732 22-06-18” we now have an anchor point to drive this matter to a police investigation and a conclusion.
As I did with the Hampstead case, I have done objective due diligence during an analysis of the Percy SRA allegations. Unlike the Hampstead case, the Percy allegations have yet to be tested with a police investigation, so this is where my goal is focused, to bring about a police investigation.
Ajax is far from happy that he has had to go to so much trouble to contact the police in Hull because of the refusal of Percy to do so. The Percy case shows that I, Ajax and others involved in cases such as this which involves contact with the police, media and other interested parties, means we have to be more formally organised. We are starting a new group called the Arachne Project. I will deal with the internet communications, Ajax deals with the police etal, others will deal with other aspects of the project. This also allows us to bring into play a technology to examine the complex eco-system or web of information that those who allege or promote SRA leave all over the internet, to output that information in a form that crime victims, lawyers and the police will find useful.
One way or another, there is going to be a police investigation, and if there is a crime, someone is going to end in court.
…aka Tony Does Yoni
For ‘Whores, the lot of them’, read ‘Why didn’t the bastards invite me?’
Well done SV. I will be paticularly interested to know where these alleged woods and tunnels were the abuse took place are. BP has been very vague so far.
From the underground crypt at St Giles
Came a scream that resounded for miles…
LOL, i was feeling generous at the time. 🙂
Except that it wasn’t all rubbish at all
As so often happens in these cases there were truthful allegations against a real, disgusting child abusing cult, the notorious Children of God
I believe that what happened was that Dickens had an initial dossier containing allegations against the Children of God, an extremely dangerous and well networked cult that was engaged in prostitution and sex trafficking, the sexual abuse of children from birth onwards, producing films and photographs depicting the sexual abuse of children and the infiltration of the military and judiciary of various territories internationally.
Dickens’ initial dossier was followed up and, to some extent obscured by, a subsequent dossier making allegations of SRA and elite paedophile rings
yet again I detect a theme
We may not see eye to eye on some things SV but, on this particular issue, I have to say that I like the cut of your jib. 🙂
I would dearly love to know what sort of mindset lies behind the fabrication and promoting of these myths.
I do know there is a huge industry out there selling such screeds to the unsuspecting public, someone came up with the term “emotional pornography” to explain why it sells so well….apparently we like to read about others’ misfortunes, perhaps it makes us feel less unlucky.
If you type “magazines which buy personal stories of abuse in UK” into your chosen search engine you’ll be given a list of rag mags willing to pay you up to 300 sterling for your ‘true story’.
I think “attention-seeking” will rank high on the list of reasons why people invent these stories. I’m not sure where “monetary gain as a motivating factor” would rank.
I do suspect that some individuals who latch onto the whole “I was abused as a child by satanists” or “I am a victim of MK Ultra programming” are trying to explain away/justify their own inadequacies and failings and want pity rather than blame.
Also the movie “Hysteria” and the TV series “Masters of Sex”, which was a partly fictionalised account of the work of Masters and Johnson.
Interestingly there is a Masters and Johnson link to a satanic panic in the US relating to multiple abuses of vulnerable people at the notorious Castlewood Treatment Centre by Mark Schwartz and Lori Galperin.
“Previous to being clinical director at Castlewood, Mark Schwartz and his wife Lori Galperin were directors of the Masters and Johnson Trauma units at Two Rivers Psychiatric Hospital in Kansas City and also at River Oaks Hospital in New Orleans.”
http://www.fmsfonline.org/?news2013update=Castlewood%20Lawsuits%20Dismissed.
Masters and Johnson were the first sexologists to use “sexual surrogates”, that is to say people who have sex with patients in order to heal them of sexual problems. Whatever the ethical issues surrounding such a controversial practice back in the days when Masters and Johnson pioneered the practice, nowadays it is difficult to find a “sexual surrogate” who is not involved with a sinister cult.
Galperin and Schwartz also have multiple personal and business links to the disgraced paedophile former rabbi Marc Gafni.
As I have said before, scratch the surface of the satanic panic and you will find a network of paedophiles, perverts, predators, pimps and traffickers all attempting to deflect the collective gaze away from their nefarious activities by pointing and screaming “oh look Satanic Ritual Abuse!”
I read your exchange with another twitterer on the tweet machine under one of Ms. Percy’s tweets and he seemed horrified that the murders of all those babies had not yet been reported to the police, that’s when Becky interjected and advised the man concerned that you are a Satanist – I laughed when I read that but an angel came to your rescue.
Ms. Percy is interesting in that she appears to apply the KISS principle quite well in her words….we are not her target audience – she knows exactly that non-believers are of no consequence to her as long as a certain number of unquestioning believers continue to support her. Has she been trained by someone?
Under Trump’s regime she may well get to remain in the USA.
Also worth reading on the subject of the Children of God is the book the Dirty Squad by Michael Hames the Detective Superintendent in the Metropolitan Police, head of the Obscene Publications Branch from 1990 until his retirement in 1994.
In the book Hames is sceptical of SRA allegations stating clearly that his team never encountered any evidence of SRA.
However Hames and his team did, as reported in the book, receive autogenic therapy (a form of self-hypnosis) from the notorious SRA promoter the late Vera Diamond and her husband Malcolm Carruthers.
Obviously this is concerning.
Towards the end of the book Hames reports receiving a dossier of information about the Children of God, a fact that I read with interest and I was very much looking forward to reading what he made of a real, as opposed to imaginary, CSA cult.
Unfortunately, pretty much immediately after receiving the dossier, Hames suffered a coronary and the book ends, with no reporting at all about the investigation into the CoG.
can my typo please be corrected
Whatever the ethical issues surrounding such a controversial practice back i note days when Masters and Johnson pioneered the practice
Whatever the ethical issues surrounding such a controversial practice back in the days when Masters and Johnson pioneered the practice
@ Fairly Sane.
I have asked Becki Percy to send to me locations and maps of the wood and where she thinks bodies are buried. Ajax will pass these onto the police. She has been given my e-mail.
What’s missing from Becky’s tale is a remembrance of a Black Magic ceremony with a black cloaked & hooded figure (with ghastly bleached blonde hair sticking out and accompanied by the pungent smell of a cigar) intoning “now then, now then, how’s about that folks ?”.
Get with the program Becky- you need a celebrity in your tale and what better than a dead one if you want to crack the Sunday newspapers (Hell, it worked for Angela Power-Disney)
On the subject of Fruit Loopery I know Hoaxtead contributors are aware of the brilliant “creator” of The Voice (bloody Dutch- known plagiarists) , The X Factor (as if Simon Cowell could come up with that idea on his own!) Star War films. Bugs Bunny cartoons, Meet the Press, Coronation Street and ‘Roseanne’ and who was the inspiration for Walt Disney’s (via a psychic seance) Mickey Mouse, one Charles Seven who won a High Court action against all these programs for plagiarism and a $Billion damages remedy award but as usual, the Rothschild Cult & Rupert Murdoch with Ted Turner’s help have bribed the judges to claim they dismissed her legal action.
Despite a TV producer claiming he recalls Ms Seven (I keep telling Mr Soros “why do you perpetuate horrendous actions like 9/11 & 7/7 -think about it- it all adds up to 7- to frighten the gallant Mizz Seven , wouldn’t it be easier to just assassinate Charles herself?”, but he rudely just says “you stick to your broom closet and just worry about emptying the bins”)…said producer says he recalls Ms Seven attending a public event at his TV network and casually saying “wouldn’t it be nice if peoiple danced on TV?” and thus Dancing With The Stars was born albeit, Seven being ripped off yet again of one of her brilliant creative ideas.
Now Charles Seven is joined in her heroic actions against the evil British Media Empire (BBC) by Rainetta Jones, the true Inventor of the iPod and Kindle. Well I have news for Rainetta. A very early paparazzi snap of me (below) with my prototype Ipod in 1957 powered by Organite & dubbed the Quantum Ear Gearbox (or QEG) and it was ME who had the idea first.
https://ascensioncorner.wordpress.com/2015/01/26/sevengate-massive-uk-intellectual-property-theft-coverup-connection-to-some-false-flags/
@ Issy T.
When I read the “he is a Satanist” statement, I had a need to start banging my head against the desk. A yellow jelly baby came to the rescue.
I am forcing Becki Percy to make choices. If she really believes in her allegations, she will contact the police in Hull, if not, then her contrary choices will work against her, since I won’t let her off the hook.
I get the impression that Trump is hostile to all non-Americans. The guys who have to enforce the borders in the USA won’t be keen to be allowing every youngster through to become an American citizen based upon a weak claim that their parents are going to kill them due to an unproven narrative. If this was the case, every kid in Britain will be heading to the USA and claiming political asylum.
This is brilliant, SV. Given that Becki Percy seems to believe so strongly in online campaigning to raise awareness of child sexual abuse, one would think she would welcome your efforts to open a police investigation to help bring justice to those she accuses.
Nor would you wish for your sole to be so exposed, which reminds me, my plan for today was to exfoliate my Achilles’ heel. So much hard skin…so little time!
You would have thought so EC rather than me having to force the issue.
“Drug-fueled orgies?”.
Christ you had me frightened there for a minute and I thought they had busted us at the Tuesday “Grandma’s Getting Frisky” Bingo session at the East Freemantle Probus Club.
# no prizes for guessing which one is moi.
The very thought of it could give one diabetes.
This is a great piece overall but I have to say that I disagree with the opening sentence
“’I’ve said this before, but the web of those who push the Satanic ritual abuse narrative within the UK is both relatively small and very close-knit.”
In my experience there is a huge network of scammers and quacks promoting SRA, including many mental health professionals working in the NHS.
Obviously dubious organisations such as the Fresh Start Foundation, Izzy’s Promise and the like are just the foetid pimple on the arse of a much larger beast.
Scamming conspiratards like Becki Percy, Angela Power Disney and the like are highly visible and easily debunked, however there is an ocean of apparently properly qualified psychotherapists, counsellors, psychiatrists and psychologists who are promoting the satanic panic amongst populations of extremely vulnerable adults. Most of these people appear to have no connection to SRA conspiracy theories unless, like me, you have had first hand experience of their bullshit.
Then you have the ocean of life coaches, yoga therapists, energy healers, past life regression therapists, hypnotherapists / NLP practitioners and the like who specialise in recovering memories of historic abuse and in separating vulnerable people from their assets and their families.
It is a terrifying situation.
There’s a lot of it about
I was very concerned by this news article and also for the welfare of the 2 teenagers involved in caring for their DID diagnosed mother
https://www.bbc.com/news/av/uk-41713725/radio-1-awards-the-teen-heroes-caring-for-mum
“I get the impression that Trump is hostile to all non-Americans.”
Well if he ain’t, all of us non-Americans are hostile to him except for Kim Jong Un so out of spite he might let her stay. To me, Trump’s politics revolve around him validating his worthiness by being the biggest bitchiest bitterest of bullies doling out punishment to all who dare question everything and anything about him.
I reckon he could decide Becky is welcome with open arms to remain in the America he has made less than great again just to put our noses out of joint….we’ll all be johnpatersonned someday soon!
I’ll be nick-naming you “Thunder Thighs” from now on
For the likes of me I cannot see what the problem is with the police not arresting Becki’s father until Becki had been formally interviewed. Teacher tells police. Police start an investigation.
According to Becki, she has a reputation with the police and social workers as an “allegation maker”.
The horrible reality is that some people who are genuine survivors of multiple real abuses and violations are likely to end up being classified as “allegation makers” amidst the SRA hysteria.
Try going to the police to report a real sexual assault or violation (or several) once one of the satan hunting quacks has control of your narrative and has dismissed your accurate and true allegations as delusional (whilst the same quack cherishes a belief in SRA) and justice becomes inverted and perverted.
Anyone subsequently deciding to scam or take advantage of such a survivor can do so with relative impunity. Should the police become involved the likelihood of a thorough investigation will be compromised if not thwarted if the survivor’s true allegations have been dismissed as delusional.
I am not talking about Becki Percy’s obviously false claims but speaking of experience of something much closer to home.
Time and time again the satan hunters not only cause misery and distress to innocent, falsely accused families but also do untold damage to real survivors.
You paint a depressing a picture to this inexperienced naive mind but also a a salutory and empowering awareness.
Much of what you write causes moments for me of the penny-dropping and jaw-dropping kind. I must have an affiliation with business minded sorts (my parents were shop-keepers), I can see from your contributions here that there is a viable opportunity …a perceived one from unscrupulous types – to exploit people for money far too easily.
Like with the “pink pound” or college students ability to spend their study grants wily-nily, it seems that women only’s expendable income is rife for rifling also and it’s been a thing for decades, centuries even but I’m just understanding now how very sinister and completely undermining of women the sales techniques, the forced direction, the dictactorial way in which women are sold products ultimately designed to rob them of their power is….
It was more obvious years ago and I thought that sexism was done and dusted already but now my feminist heckles have been raised once again – as consumers we are still enslaved!
Anyway, having studied web design I found the the subject of attention economics very interesting.
Absolutely, and this is one important reason we’re so strongly opposed to those who promote SRA hysteria. Not only does it destroy innocent lives of falsely accused people, it keeps abuse survivors who truly need help from receiving it.
TorkGirl8 says:
Yes, David Berg was a disgusting individual.
Can someone please call 999? Angie’s pants are on fire again.
The Green Gobbler says:
Angela Power Disney, if you are wearing flammable knickers, don’t play with matches.
I really like the approach you have taken with Becki Percy. I’m most impressed SV.
Aw, pity!
JakeBlake says:
LOL! Cat was streaming live from a restaurant/bar where Green was being interviewed, spewing his nonsense around the other diners until the Manager told them to stop. Then they moved out onto the street to Mercat Cross. There didn’t seem to be anyone there or interested in them. Only themselves. 😀
Uhh? I thought it was Angie who said she flogged her kids with a lump of wood?. Is she now denying it?. And why would that terrify her daughter?
I reckon they may have Skyped but were actually having a good laugh.
Perhaps it should be noted that any comment with more than two links in it will be held for moderation as well, plus wordpresses usual random glitches can cause comments to be randomly held up
Not everyone may be aware of that Scarlet, I wasn’t at first either (although I must say the ones held up usually get pushed through quite quickly in most cases)
Thumbs up from me for all the good work
I agree that is one of the worst aspects of these SRA promoters, I recently mentioned Fiona Bartlett’s recent attempts and even partial success(?) in getting her abuse claims separated from her fantasy claims in the recent investigations here. There may or may not be any truth in her allegations, but I am now of the opinion that any investigation into her claims should include her entire ‘body of work’ so that any investigators are aware of just unreliable anything she says as a ‘witness’ about her own case is not totally reliable (i.e. is she lying about an aspect of claimed abuse or not?) unfortunately in her case, it is better to say yes she is unless extremely strong evidence is present to confirm any claim she makes.
This is one of the worst aspects of the various people pushing the SRA side of things, in that it tars any survivors claims and once the various false memory experts and the like get involved, a true survivor of CSA can find their case irreversibly tainted , even to the extent that innocent people can be jailed, and guilty ones left free to continue
That has already happened (multiple times) and it is why IMHO that the hoaxers need to be stamped on much more quickly and successfully than they have been, already the newer pizzagate/pedogate type hoaxes have had notable ‘success’ in getting a following in the less stable ‘conspitards’ of the world. It wouldnt matter so much except that the more unstable/gullible have been known to start harassing innocent people, both online and in real life, and things can quickly escalate into incidents with truly tragic results
Fascinating about Dickens and the CoG cult, OMG. Would you happen to know any links I could read on this? It’s an angle I’d never heard of.
Looks like Ogilvy’s forgotten FSF weren’t wanted in Inverness either.
It’s certainly a convenient loophole for a number of people.
In Becki’s case, I noticed that early on, before she’d really got into the “my parents were evil abusers” line, she was attempting to raise awareness of mental health issues, particularly autism, on Twitter. I wondered whether she might have been diagnosed on the ASD, but from what she tweeted, it seemed that one of her friends was in that situation, and Becki was trying to support her.
This is only a hypothesis, but that did make me wonder whether she got a bit of attention for her efforts, it felt good, and so she started changing the story, a bit at a time, each time finding that she got a bit more public admiration. It’s entirely possible that the internet, in a sense, helped to shape and mould her story into what it has now become.
False memories, if you ask me.
While I agree that Berg was undoubtably a disgusting person, I think that possibly the most horrifying aspect of the cult, and there were many, was Berg’s ability to persuade apparently perfectly ordinary people that sexual activity with children, including parents with their own children, was a wonderful, divinely inspired practice. In the CoG the practice of sexual activity was euphemistically referred to as “sharing”.
In the video in the below link a couple of adult cult members enthuse about “sharing” between a young lad and his stepmother (both are in the video). Prior to that part, at 4.15 minutes in, the stepmother says she was “FFing” (flirty fishing) using sex to recruit new cult members. To anyone who doesn’t understand what “sharing” and “FFing” means the video looks fairly innocent and appears to be just a deeply religious family talking about prayer.
The “Dad” addressed in the video is David Berg
https://www.xfamily.org/index.php/Report_to_Dad_and_Maria_from_Australia
(obviously there is no illegal or sexually explicit material in the video)
Good spot, JB!
I recently moved home and have books all over the place in various locations but I think it might have been in the Dirty Squad, but I’m not entirely sure. It might also have been in a video. I’ll see what I can find and get back to you.
I wonder in what sense he means they were banned. Were they sent packing by the Jurys Inn and have to relocate to the bar, I wonder?
Cat Snot’s three videos from today’s washout can be seen here (if you fancy a snooze):
https://www.pscp.tv/calamiTcat/1mrGmnVYyLBJy
https://www.pscp.tv/calamiTcat/1YqJDQvygEkxV
https://www.pscp.tv/calamiTcat/1yNxaXjvMNRJj
Some time back this blog ran an exposé on a former CoG member called Zen Gardner. I don’t know if you’re familiar with him but he had a leadership role, I believe. Suffice to say Angela latched on to him and did one of her cringey, sycophantic Skype interviews with him.
https://hoaxteadresearch.wordpress.com/2016/08/24/angela-gives-zen-gardner-a-free-pass
According to Richard Bartholomew there was an article in the Sunday Times re Dickens and the CoG
This whole blog post is interesting and relevant to your question
It suggests that Dickens possessed and passed on a dossier re the CoG cult and some other complaints re possible grooming of young males but nothing about SRA or VIP paedophile rings. Most or all of the complaints not relating to the CoG were dismissed by the police as having insufficient evidence to proceed.
Later on in the blog post there is reporting of Dickens’ SRA allegations, I’m just too tired to read it and think about it immediately, but hopefully you can make some sense of it
http://barthsnotes.com/2015/02/01/some-notes-on-leon-brittan-geoffrey-dickens-and-the-media
I just find it very interesting that more attention was given to fraudulent accounts of SRA than to real concerns about the sexual exploitation of children by members of a real cult.
I feel your pain, OMG, having recently moved house myself. I found it a great opportunity to have a bit of a clearout and gave a load of my old books to a charity shop. (Don’t tell Debs, though. She frowns on that sort of thing.)
I remember watching a documentary about the history of comics and annual books for girls. Apparently when they were first published the comics didn’t sell well and so researchers were sent to schools to consult girls about what kind of stories they liked and why they didn’t buy the comics that had been specially created for them.
The researchers were shocked to discover that tales of happy girl guides rescuing puppies and groups of clever girls thwarting the plans of megalomaniacs planning world domination was not what girls wanted to read.
What girls really wanted to read about were stories about aspiring ballerinas who suffered appalling accidents and were left unable to follow their dreams, tales of abused step-daughters forced into domestic slavery by wicked stepmothers and the like. What the girls really wanted was to experience a reverie of vicarious misery. The story writers and comic publishers listened and adjusted their business plans accordingly and the comics sold like hot cakes.
I also recently read an article about the various true crime channels on freeview and who watches them. You can usually identify the demographic by the products advertised in the commercial breaks. In this instance Tenna Lady incontinence pads feature prominently. The main demographic of viewers for “Wives with Knives”, “Kids who Kill”, “Killer Clergy” and the like are older females of the same generation who loved to read about crippled ballerinas and Cinderella type domestic slavery.
This is the generation of women who made the book Flowers in the Attic a best seller back in the day. Misery memoirs are still massive business and it seems as though some older females especially just can’t get enough of the people’s tales of abuse and exploitation.
Aha, so they were given the heave-ho by the Jurys Inn. Go to 2:30 in the top video on Cat Snot’s Periscope page. Just after Gandalf introduces Green, he says: “Unfortunately, we’ve had a mishap with two consecutive bookings and we find ourselves out on the street.”
Her snoozefest… sorry “roadshow” videos can also be seen on her twitter page.
The restaurant/bar located in the Jurys Inn matches her videos. So I guess they never got use of the Inn’s Meeting Room.
Is that Ogilfail in the baseball cap in the Facebook video?
It doesn’t just prevent abuse survivors from getting help it puts us at increased risk of being abused repeatedly and with impunity. It takes away our voices, our power and our credibility.
One of the reasons why I have spent so much time posting here is because your blog is doing a great job educating people and long may it continue to do so.
This evil has to be exposed for what it is and it feels great to be part of the battle against it.
Janine Runny says:
So to summarise:
1. The first booking (the station Hotel) was cancelled due to (cough cough) “flooding”.
2. The second one (the Jurys Inn) barred them from using their meeting room.
3. They then tried to hold it in the bar and got chucked out of there as well.
So all in all, another successful day for the mighty FSF 😂
I thought that too. Not sure though.
@Tinribs
I remember your posts about Zen Gardner very well. The whole issue is nteresting yet disturbing and very consistent with the concept that if you scratch the surface of an SRA promoter you will find some extremely dodgy associates including paedophiles and child abusers.
(love the user name by the way 😀 )
In a nutshell! LOLOLOL!
Cat must be watching. She’s taken down the Facebook video. But fret ye not, hehe:
Green & Co-Conspirators in Aberdeen, 22.06.18
Thanks, both 🙂
So not so much a roadshow as a pavement show 😀
the documentary about comics was called Comics Brittania – episode 2 Girls and Boys
Sadly,while episodes 1 and 3 are on youtube, episode 2 is not.
There is a review here though
http://danowen.blogspot.com/2007/09/comics-britannia-girls-boys.html
includes the text
“Heading into the 1970s, I was very surprised to learn that our modern era of serious-minded “graphic novels” came about because of the girls comics! Market research revealed teenaged girls wanted to feel emotion when they read comics, so a male-dominated industry began pumping out shocking tales of home abuse, work violence and heartwrenching melodrama, in publications like Tammy.
One Tammy strip, “Slaves Of War Orphan Farm”, best encapsulated the vogue for downbeat storylines. “Cinderella Spiteful” and “Little Miss Nothing” were other examples of cruelty and misery being used as “entertainment” for girls of the period… and they lapped it up!”
I used to occasionally buy my elderly neighbour’s favourite magazine for her, Take A Break. A veritable smorgasbord of mini misery memoirs, as you can see here
https://takeabreak.co.uk
EC’s posts rather than mine. I can only dream of attaining such giddy heights 🙂
Just an idea, but I wonder whether their preference for that sort of story was at least in part because it made their own drab or limited lives seem pretty good by comparison?
I agree OMGNTOSA, I looked into the COG a few years ago.
The Story of Davidito was an awful publication and the boy who featured in it and suffered the abuse (Ricky Rodriguez) killed one his childhood abusers before committing suicide when he was 29.
Pingback: Are SRA claimants lying, or victims of false memory? | HOAXTEAD RESEARCH
Actually make up and beauty stuff is a form of witchcraft. Just study the origin of the word glamour.
She was born two or three decades too late to find a social worker to believe her hunger games of rape and forest adorned with corpses stories. The fact she had to skip of to americky to find willing supporters says it all. I’m looking forward to her return and want to see how that works out for her
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Angela & Heather videos target HR commenter with credible death threats
Regular readers are well aware that on Wednesday Angela released one of her most bizarre videos to date.
Reading from communication between herself and Heather Brown (aka Suzy Jones, aka Prudence Halliwell), who she claimed would “validate” her “testimony” by typing “yes” (or something), Angela made a record number of delusional, threatening, and/or just plain strange statements, including:
Heather admits to having stalked Steve Keys, his wife, and his parents;
Ghost of Sam, Grobnob, El Coyote, and Tinribs are all Steve Keys;
Scarlet Scoop is Steve Keys’ wife;
It’s been “forensically proven” by “anons” that Hoaxtead Research is run by (you guessed it!) Steve Keys (which apparently lets RD and Sheva off the hook, as it was “forensically proven” that they ran the blog on Angie’s last outing of this sort);
This blog has claimed responsibility for breaking Angela’s leg…via curses!;
Steve Keys’ wife stole Heather’s identity, and Heather and Angela plan to report her for identity theft;
Heather is going to get EC’s and Scarlet’s passwords, hack into this blog, and close it down, a feat she claims she could accomplish “with one click”;
Heather sent Steve Keys a private message threatening to burn down his elderly parents’ café;
Heather claims that the café runs some sort of dog-stealing operation.
And then there was a lot of gibberish about how HR and/or Steve Keys’ wife have been hacking Heather’s email and/or Facebook, and she can watch it happening in real time (and doesn’t think to turn her computer off) but that’s all right because she’s going to put a Trojan in someone else’s computer and we lost track after that because she was making no sense whatsoever.
‘But Brain…how will you get the Trojan into the computer?’
As we listened, we were torn between anger on behalf of Steve and his family, who have absolutely nothing to do with this blog other than Steve’s comments, and hysterical laughter at the stream of clangers issuing from Angela’s mouth.
Round 2: Let the death threats begin
Not content with having made a complete fool of herself, last night Angela released another video, this time consisting of a Skype conversation between herself and Heather.
While it lacked the Hilarity Quotient™ of Wednesday’s effort, this one featured Heather making credible death threats toward Steve Keys and his wife, who she believes have been hacking her email.
At about 19:00, she says,
They’ve been found in my email box, and they’ve been sending emails, and they’ve been stealing emails. Just a warning to the thief of those emails: you are in serious danger. We know who you are, and we sat and watched you do that.
And you stole emails about seriously dangerous actual gangsters who’ve been doing things for years, and they never spent a day in prison. So if you think they won’t do you, they know what you’ve got about them, and that you stole it.
Watch out. Because they will know. And how they will know is, because I will tell them. And I will show them exactly what you did. Because I wanted you to do it, because I watched you watching my email box for a long time. So I fitted you up and stitched you up like a pair of kippers.
Heather follows this with an apparent claim that she was involved in the 2005 killing of Jim Gray, a UDA brigadier, and combines this with another threat toward Steve and his wife:
If you don’t believe me, go and look at what happened to the last adversary, the last person who crossed me was a man called Jim Gray, who ran the UDA in East Belfast. You go and look at what happened to Jim Gray.
And you can phone the police and say, ‘Ooh, she said she did something to Jim Gray’ because the detective in charge of his murder inquiry spoke with me, and was laughing, and then said, ‘but we’re scuppered’.
The police know exactly what happened to Gray. And how. And who shit-stirred and caused it. Yeah, it was me.
So you can go to police. Because if you cross me again, you’ll end up just like Jim Gray, in an unmarked grave, and that’s a promise. A certified promise.
Rather than do the sensible thing—put this video on ice and pretend it never happened—Angela weakly reprimands Heather, saying maybe they shouldn’t be making death threats.
Not because it’s a terrible thing to do to another person, mind you. No, she’s just afraid she’ll get her channel taken down. Go, Angie.
Heather takes this very seriously, and refrains from issuing death threats for…oh, at least another half hour. Possibly some sort of land record for her.
At 1:05:36, however, she forgets Angela’s admonition. At this point, Angie is reading from private messages between her and Steve:
Angela: Then he says, ‘Despite me telling my wife to block her, I’m glad my wife gave back as good as she got…’
Heather: No, I blocked Lynn Keys. She’s raging about it. Because she was on his page ranting about it.
Angela: Right, then he says, ‘You and Angie since March try and target my parents’ business is shambolic—’ His English is crazy. ‘Now claiming that they are—’
Heather: It’s a Freudian slip, because if I get my way, it will be shambolic. It will be a shambles. Because they are active criminals, and I am out for them. And I am out to get them. Yes.
Heather follows this up by threatening Jimmy ‘Outlaw’ Jones, saying she knows where he lives, and challenging him to come to see her in Southeast London “and see what I will do to you”.
We sincerely hope that Steve will take Heather up on her invitation to report her to the police.
As for Angela, she ought to be ashamed of herself, publishing a video like this. She’s clearly fully aware that Heather is making death threats, since she half-heartedly asks her to stop; and surely she must be aware that in doing so, she makes herself an accessory to any charges which may be laid against Heather.
Christian, Angie? Hardly.
17/08/2018 in Angela Power-Disney. Tags: death threats, harassment, lies
Angela barks up the wrong tree…again
Angela continues attack after her enemy has left the field
Angela shares ‘abusive and threatening’ comments
← Fact-checking Jon Wedger
BREAKING: ANGELA POWER-DISNEY ‘INVITED FOR POLICE INTERVIEW’ →
71 thoughts on “Angela & Heather videos target HR commenter with credible death threats”
The hags strike back. heathers as deranged (and as grey) as Angie.
tdf says:
I assume that the reference they are making is to Jim “Doris Day” Gray, not Jim Grey.
He was notorious.
Plenty of stuff about him on the net, from reputable sources.
Jim Gray didn’t end up in an unmarked grave, but very few people attended his funeral. He was certainly a UDA commander of some type at some point, that much is true.
He was a pederast, a drug addict and drug dealer, and a violent criminal, and at the time of his death, almost everyone thought ‘good riddance’. A rare moment of agreement between the Loyalist and Republican communities in NI.
Incidentally, Jim Gray died in 2005, not 2003. They can’t even get basic facts right, when they issue their weird threats.
Peg Plunkett says:
So Heather was dressed up as a man the day he was shot. She seems to have a fascination with the UDA, she has referenced them before too.
Ah, the misspelling is mine. I’ll fix it.
^ Ah ok, yes probably for the best. We don’t want loonies running around trying to re-exhume graves of innocent parties called Jim Grey who died in 2003, just to see if APD’s claims stack up. Ireland, north and south, has enough problems as it is, frankly.
DuchessGaGa says:
This is one of the reasons why a lot of genuine, good people don’t try and help expose these hoaxers and liars because these people are dangerous and deranged.
The despicable behaviour by these two witches who think their tough and strong while believing their denchers can seriously hurt anyone they sink their teeth into is hilarious . Oh puhlease!!!
I hope these two idiots are reported to the police. Has Angela’s time finally come were she has to take accountability for her action? Karma is a bi*c*!
Everyone stay safe!
They are both a nasty pair of bitches, how dare they make videos like that! I do hope Mr. Keys that you go to the Police about it, they are really disgusting & think they are so funny!
Comment from the FB page of the couple they were slagging off last night, for unknown reasons it seems.
“The top one (Angela) looks like Peter Kay in a wig…..and the bottom one looks like she’s an inpatient in a mental hospital!)
APD lives in Ireland (south of border) IIRC. Surprised she hasn’t been arrested, mind. There ought to be some co-operation between the police forces of England and the ROI.
Exactly TDF I don’t understand why these conspiraloons along with Icke and Neelu get away with dangerous and damaging lies they spew.
@DuchessGaga
I am a bit less harsh on Icke or Neelu as I believe they are mentally ill.
APD I think is just bad.
Have you read Jon Ronson’s book “Them: Adventures with Extremists”?
He records finding no anti-Semitism in his dealings with Icke personally, but he did record over-hearing a comment from one of Icke’s followers along the lines of ‘we showed the fat Jews’.
There behavior is abhorrent cringe worthy and pathetic they are bullies and abusers. The sooner they are dealt with by legal entities the better. Keep up the great work it is empowering others.
Mental illness doesn’t excuse bad behaviour. I think its all an act so they can hurt and harm people so when its time to face the music they say diminished responsibility. Thats just my opinion.
These Truthers have done so much harm its shocking they are still allowed to lie. They shouldn’t be forgiven or let off so easily.
No, thanks for the recommendation. I will now.
THE OUTLAW (@outlawjimmycom) says:
I have spent the last few years being pursued and threatened by a few online nutters, and some in the real world too …. but being threatened by a mad old bat, who also claims to have close links to South London ‘Gangsters’, is a first, even for me.
One for the memoirs I think 😉
Yes, Heather is mad as a box of frogs.
You too, FD. I had a hearty laugh at your video yesterday…thought you did very well holding onto your temper with her, but enough was enough.
Yes agree Flo. However the legal entities seem to be dragging their feet. I hope the tide changes and these nasty, mean people who have no problem upseting and endangering innocent people, are brought to justice.
@tdf, I don’t think she is important enough in the grand scheme of things. Mind you, her local Garda/Gardaí had a few words to her before for a live she did.
Her constant claims of the ‘RA’ are bull, I reckon 75% of people living on the isle of Ireland know someone associated with paramilitary groups but would NEVER talk about that on live videos.
EC would you be so kind as to fix my bad typing this morning please. *bulk to bull* & missing parenthesis. Thank you.
Thank you! 👍
Agreed Peg Plunkett,
I really doubt if she has ever had serious connections to the Provies.
The Provies did dreadful things, but they weren’t stupid.
What a pair of actual knobheads. Do they think anyone believes their Walter Mitty bollocks that they can have people killed ? Angie can’t even afford a reconditioned pc and has to to ebeg to raise the required £100 or so.
As for me, I’m neither Steve keys nor married to scarlet scoop.
I’m so glad you publish these posts, saves me having to hold my lunch down trying to watch the crap myself.
We do it so you don’t have to. 🙂
Don’t forget, Alex Jones was recently wiped off the internet, and he didn’t make any death threats or murder claims. The time has never been better for flagging youtube videos.
I bet Alex Jones blood pressure is stable now he doesn’t need to go on a volcanic rant were his face is so red it looks like he smacked himself silly and he is about to let one rip like in the nutty professor. LMFAO
Jeez. Finally two super dingbats in one session. I thought APD was a looney but this other harridan surpasses even APD in the fruitloop bowl. I would pay good money to see these two and the Lebanese Looney “mass debating ” each other in a frenzy!! What a gob fest that would be.
Seriously though, this pair of twats don’t even realise how hilariously funny they are.
For anyone who missed it at the tail end of the last post, Maloney’s being hampgroomed by Anthony Pike:
https://www.linkedin.com/pulse/truth-transparency-all-we-people-require-from-bill-maloney-devine/?published=t
https://drive.google.com/open?id=1p9qdV-8-AwBBjQFsmhcojpADL6-kv4oY
And Guidance is hampgrooming Eddieisok:
Check this out. Angela, you really are the lowest of the fucki*g low.
Plus lest we forget that Icke’s made a fortune out of his “delusions”.
Congratulations on your “sting operation”, FD 😀
By the way, do you have a blog that we could add to our “Blogs We Like” page?
If you haven’t come across Heather before, Sam, you’re in for a treat:
https://drive.google.com/open?id=1VSV0dKUCXMWpF5v5TlLBboLSlzBkIVC_
I don't exist says:
Angie says: “God loves me the way I am”. I’ll be having a word with him tonight after supper as I believe standards have dropped lately.
I have no idea who Mr. Keys is but he has my sympathy. These two harridans really are the pits. They simply cannot accept that in the Hampstead matter there is 100s if not 1000s of locals infuriated and alarmed over the whole ghastly affair. These are innocent residents, families, and relatives caught up in the maelstrom and endless cycle of false accusations and internet gossip while just trying to get on with their lives. There just has to be a legal reckoning at some stage.
# Publishing my latest passport snap so there can be no mistaking as to my identity. People say I have a familiar face but you can see I couldn’t really be mistaken for someone else.
Another day, another bandwagon…
A nurse writes says:
He’s deranged. He tells the world he’s about to rain riches down upon them and then when obviously desperately poor people in Lebanon reach out to him he tells them to basically piss off and it will come in his own good time.
More (mini) exposés from Flo Destroyer 🙂
Steve’s an occasional poster here, as Postnein. He’s also featured in one or two of EC’s posts:
https://hoaxteadresearch.wordpress.com/2018/05/13/facebook-group-a-study-in-paranoia
https://hoaxteadresearch.wordpress.com/2018/06/22/angela-barks-up-the-wrong-tree-again
https://hoaxteadresearch.wordpress.com/2018/07/08/angela-continues-attack-after-her-enemy-has-left-the-field/
Arfur Daley says:
Seems Heather is threating to team up with John Patterson & the Sarf London Mob. I’ve put the word around the manor that they’re to be given the cold shoulder. We don’t put up with interlopers and trespassers on our patch.
In the meantime can I interest you a new range of plus 50 size gorgeous frocks that have come into my possession recently?. Meet me at the lock-up.
Oops! I think I may have touched a nerve…
Exactly Chris. Shocking really how some are so manipulated.
More tears and tantrums…
Whoa! So Abe and Ella are in Spain? So there isn’t an arrest warrant anymore?
Has Guidance changed on Hampstead? I am confused?
These conspiraloons ain’t loyal. LOL
Mark Trellis says:
I work in mental health. The GP/ local CMHT of Heather needs to be informed about her as she is becoming seriously unwell. Risk to others needs to be considered. Heather is showing marked paranoia and is delusional. Unresolved grief of the son she lost but could not mourn will be a factor to consider when it comes to her treatment in the long term..Right now she could benefit from appropriate medication…legal measures may need to be taken to protect Steven keys and his family. He seems to have taken more than his fare share of the fall out from this case, first code 2222, and now this. If someone could write a letter to Heather’s GP or the CMHT lead in her area f heather providing video evidence of death threats and stalking, harassment, etc. Proper assessment of the risk she poses needd to be carried out. Steve should also call adult safeguarding or social services in heather’s health authority and discuss his family’s safety and what support they can offer as the woman is at the very least causing a lot of stress to him and his family. The police can also alert GP and CMHT/CPE to MH issues re any person, of course.
Abe & Ella have been in Spain for about three years and the arrest warrants are still in place as far as I know.
I think she’s in one of her moods…
I still have the recording of the 5am death threat woman, who got a visit from the police, telling me anons would turn up and slit my throat if I didn’t leave Angela Power Disney, Mel Ve and Hopegirl alone. The police visited the woman, she stopped.
I left this comment, which will of course be hidden, lol….. I’ve reported twice, on others behalf mainly Stephen and his parents and of course for myself……
Apparantley I have gout ? News to me, lol 🙂 I think I’d know ! It’s not something that can be ignored, serious, I’ve met people who suffered with it.
Is the Spanish police refusing to get involved and arrest them? I can’t believe it or are they hiding out?
Someone call Dog the Bounty Hunter!
I hope your advise helps Mark. Heather seems really serious and unhinged.
I am glad the people being threatened can get help and support too and that they are not alone.
Good luck with that, John 😂 😂 😂
The saga so far:
Angie & Heather’s Bullshit Extravaganza, 15.08.18
Just posting this for no particular reason…
Thank you Scarlet Scoop the “sting” would not have been possible without the resources that have been made available on this blog and the support of others.
I appreciate the sentiment however the quality of my work would not be to a standard i would feel comfortable being associated with you fine people due to my own lack of ability . I appreciate the offer greatly though and have been humbled by the response and am glad i am on the right path.
Thank you for the kind words and treatment your work is highly respected and valued.
Check out this comment from Guidance. I had a feeling this was gonna happen – Eddieisok is not happy about the conversation being covertly recorded and posted:
The full transcript:
https://www.youtube.com/ watch?v=RUb0dlsFJIk&lc=UgwjzZDgHR-JI5CjuQ94AaABAg
It’s a long transcript but this bit looks interesting:
I get gout. A fellow sufferer told me that he wouldn’t wish it on his worst enemy. I politely declined to agree. I have a short list of people I would wish it on. APD would make a fine addition!
Generally refusing to say anything is the behaviour of someone who knows either a little or a lot. Shooting off your mouth is the sign of someone who knows absolutely nothing.
He’s only ever been in it for the money. He’ll be hurting at the loss of his monetized youtube channel.
Hey wifey, where did you hide those emails we stole ? I can’t find them anywhere.
Very true, it reminds me of someone that wants to be in the know but never will be.
I’m sorry to hear that, I can only imagine, but it looks really painful, to me. I don’t like to wish harm even on these horrible lot of scammers, liars and accusers, but am mightly glad that justice seems to be catching up and don’t feel sorry for any thing that they’ve brought on themselves……
It is excruciating. However, the pain and agony can be treated. What is more painful is the old gouty port drinker reputation, as in “it’s self-inflicted”. It’s true that too much alcohol can reduce the body’s capacity to remove excess uric acid, but it doesn’t cause gout. Gout can be caused by failing kidneys, poor diet, too much of a good diet (shellfish etc), dehydration. high blood pressure, diabetes etc. Men produce more uric acid naturally anyway. It can be caused by drinking too much orange juice! There is no one cause and can occur in almost any joint in the body.
Top tip. If you are caught off guard, the recommended dosage levels of Ibuprofen can be doubled for short periods (always befriend a pharmacist, unless it’s a super qualified one).
Oh, I havn’t actually got it, that was Heather Browns assertion, insinuating that vile myth, as she was vile about me, during the video with Angela, yesterday.
Oh yeah, south London gangsters have si much free time inbetween doing blags, running knocking shops and banging out Charlie to yuppies that they just love defending butt hurt youtubers who get their knickers in a twist. Mad frankie fraiser was often in the dock for slapping people who left contentious comments on facebook. Not.
Funny you should mention that in light of what happened next. 😂
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PVR-9200 Freeview Recorder
A couple of small issues so is it worth replacing?
Thread starter Bamboozled
I have a bit of a dilema that I would like to share with you in order to seek your experiences, knowledge and advice. Deep down, I expect that I will be told, "the choice is yours" but nonetheless, any comments would be very much welcomed!
I purchased a company refurbished Hummy 9200 11 months ago now (through the official Humax company website) and are considering an exchange under warranty before the 12 months expires as we have a couple of frustrating issues with it. Namely; the series link recording feature misses episodes approximately 10% of the time and; the box freezes in whatever mode it is currently in i.e. if it is fast-forwarding, we often cannot get it to play again at the correct speed unless we switch it off at the mains and start again (we have tried using the buttons on the front of the box but even these do not work when it freezes.
We have the latest software update installed and have re-set the box to its default factory setting as recommended by other threads on this site but all to no avail.
On the one side, we bought a PVR that advertises certain functions and we expect it to perform those well. On the other side, we bought it factory re-furbished and it cost significantly less than other makes so perhaps we should just learn to live with it.
As an aside, but another issue, I have tried installing the supplied Media elinker software only to be advised that the file MFC71.dll is missing. Again using this website, people appear to be recommending Andy Chappell's Media Controller (although I note this is dated 2007). Would anyone happen to know if downloading this software would resolve the file transfer issue and enable me to transfer the programmes from rthe PVR to the PC/DVD?
I hope you can shed some light on my issues.
Did it work correctly when you first received it ? if not then you have a faulty unit and I suggest you contact Humax without delay.
As to wheather the unit was bought as refurbished or as new it should still work correctly, refurbished to me means " as new but not new"
Because you have had the unit almost 12 months I should phone Humax support not Email them.
Hi Talos - Thank you for getting back to me so quickly.
The unit worked absolutely fine initially - it's only been the last couple of months or so bizzarely. I forgot to mention it earlier, but I get the impression from various users that the unit "isn't perfect" so didn't know whether my issues were to be expected from that model and whether I would just be swapping units for more of the same problems. Like you said in your reply, regardless whether it's refurbished or new, it should still work correctly.
You could try a "default reset" from the menu, that always seemed to work on mine, I assume it came with a 12mth G'tee, if so I suggest you contact Humax without delay to register the fault, because I have found if you are just one day out of G'tee they will not want to know.
Well-Knwοn Мember
Bamboozled said:
Namely; the series link recording feature misses episodes approximately 10% of the time and; the box freezes in whatever mode it is currently in i.e. if it is fast-forwarding, we often cannot get it to play again at the correct speed unless we switch it off at the mains and start again (we have tried using the buttons on the front of the box but even these do not work when it freezes.
Double check that you do have the latest software.
It sounds as though the Humax has been tuned so that it aware of more than one transmitter. Hopefully, someone can step in and explain or provide a link to instructions on how to correct this. Once that is done delete any channels you will never watch or listen to.
Version 2.7 of elinker does not require MFC71.dll.
Is it possible for this site to host 2.7? The Dutch Humax site which use to have it available closed down at the end of September.
Luke said:
There is an upload a file button but it says the file is too large. The zip file is 4.48MB.
Is there any way around this as I would think there are others who are having MFC71.dll issues when attempting to use elinker?
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The good, the bad, the ugly: Notre Dame vs. Michigan
By Keith ArnoldSep 8, 2013, 9:16 PM EDT
Last season, every Saturday ended with the Victory March. While it wasn’t always pretty, the Irish found a way to win, even when out-gained, and sometimes out-played. Breaking in a young quarterback, reinventing an offense, and relying on a defense that played historically stingy, it was a season to remember.
Saturday night reminded us that every year is different. The magic was coming from a team wearing a different jersey. Every loss requires inspection, and that’s likely happening in South Bend right now, as Brian Kelly and his staff examine what went into the Irish’s 41-30 defeat at the hands of Devin Gardner and the Michigan Wolverines.
Let’s do the same ourselves and take a look at the good, bad and ugly from Saturday night’s defeat in Ann Arbor.
Special Teams. So all those that were worried that the Irish special teams would cost Notre Dame a close game can breathe deep. Kyle Brindza was a veritable weapon out there on Saturday night, punting the football well on both his attempts while making all three of his field goals as well. Brindza also had four touchbacks on his seven kickoffs.
TJ Jones did a nice job on his lone punt return attempt while George Atkinson also returned a kick to midfield. After looking shaky last week, Kelly turned all the kicking duties over to Brindza and he returned the favor by playing flawlessly.
Amir Carlisle. Taking the lion’s share of carries, Carlisle ran hard both inside and out, carrying 12 times for 64 yards while chipping in two catches as well. The durability everybody worried about seems to be there, as the junior put together a nice game and appears to be the early leader for carrying the load.
TJ Jones. A gutty performance for the senior receiver, who banged up his shoulder early in the night but came back and still had nine catches for 94 yards and a touchdown.
Troy Niklas. The run of greatness at tight end looks to be continuing with Niklas, who played another excellent game, quickly becoming a weapon in the pass game with another touchdown among his six catches for 76 yards.
Running Back George Atkinson: After not looking all that explosive against Temple, Atkinson did some damage on the ground, averaging a mighty quiet 7.4 yards a carry while also making a big kickoff return.
We’ll talk about the other part of George’s game in the bad section.
The Defense. Brian Kelly can talk about the plays the offense could’ve made, but this one is on Bob Diaco’s guys. There’s no question that Devin Gardner does some things that make life hard, but the defense didn’t do themselves any favors, routinely blowing assignments and losing one-on-one battles.
You can’t expect to win a game when you give up 41 points. Period.
Coverage in the secondary. It was a tough day the office for the back-end of the Irish defense. KeiVarae Russell looked like he was being picked on at times, and Jeremy Gallon looked like Desmond Howard out there, racking up three touchdowns and 184 receiving yards.
The pass rush. They weren’t playing horseshoes or hand grenades, so one sack of Devin Gardner just isn’t going to cut it. While he made an incredibly acrobatic interception in the end zone for a touchdown, Stephon Tuitt didn’t make a tackle, given chase to Gardner often but not getting to him. Ishaq Williams tallied his first sack of his career, but Prince Shembo was kept in check again.
The Irish committed blitzers to stopping Gardner but it didn’t matter, and Gardner routinely made Notre Dame pay when it went one-on-one in coverage.
One-dimensional offense: People tend to forget that the Irish were essentially down two touchdowns for much of the second half, necessitating a passing attack, especially as time ticked away. But the Irish averaged 5.1 yards a carry on just 19 official rushing attempts, while Tommy Rees threw 53 passes. During the Irish’s final three possessions, they threw 13 times and ran it only twice, often from an empty formation.
Looked at as a whole, that kind of ratio isn’t good. It’s likely a product of a game that was on the verge of getting out of hand and forced Kelly and offensive coordinator Chuck Martin to abandon the ground game.
Pass catcher George Atkinson. Too often the football clanked out of Atkinson’s hands, with at least three drops on the ledger. Never know for his natural catching ability, Atkinson did have a nice gain out of the backfield on one pass. But if he’s going to be a guy that can play in a featured capacity, he’s got to make the plays… or let somebody else have a chance.
Slow Start. Not exactly how you want to get out of the gate. Two three and outs for the Irish, both with the Irish unable to convert running the ball. Compare that to Michigan putting up scores on their first two possessions, and that’s an easy way to get down 10-0.
THE UGLY
Giving up big plays. It’s mystifying how this defense can give up some of the big plays that it did Saturday night. When it was time to make a big play, it just kept feeling like it was only Michigan that made it.
The Irish tried multiple things to keep Devin Gardner in check– spying linebackers, safeties, keeping contain — none of it worked. Last season was defined by the defense’s flair for the dramatic. There are still ten games left, but this group needs to make some steps forward quickly.
Leaving the Big House with a L. That’s a football game that everybody wanted. Players, coaches, fans. After listening to Big Blue and company crow all offseason about Notre Dame chickening out, that the Wolverines would back up the talk with a convincing victory can’t taste too good.
Pass Interference. Sooner or later, the Irish defensive backs will figure out that they can’t get sloppy in coverage on third down and around the goal line. While you could argue until you’re blue in the face that the call against Bennett Jackson was pretty iffy, the Irish need to play smarter and better in coverage, especially with a group that’s got plenty of experience.
College GameDay Signs: If there’s a benefit to taking a break in this series, it’s that ESPN won’t give three hours of national air time to idiots with signs. While the network allegedly filters the signs allowed to be in the background, the tasteless nature of a few defied logic.
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Job Rejection Letter Speak Decoded
by Leslie Stevens-Huffman April 26, 2017 5 min read
cover letterInterviewingJob SkillsRejectionresume
Facing rejection after an interview is hard enough, but receiving a canned rejection letter can make things even worse. A standard form letter is not only impersonal, but lacks a clear explanation for why you weren’t selected for the position.
But drilling down into the language of those rejection letters might help improve your job-hunting strategy and interviewing skills. Here are a few phrases that typically appear in rejection letters, and what the hiring manager might mean when using them.
“After a comprehensive search, we’ve selected a candidate who most closely meets our current needs.”
In many ways, recruiting is like fishing. When a manager doesn’t know what they’re looking for (or several people weigh in), the hiring criteria tend to morph after every interview—resulting in a prolonged, wide-ranging search.
In other words, you may have been a good fit when you applied, but once the company finally figured out exactly what it was looking for, you didn’t meet the revised profile.
“We found someone internally to fill the position.”
Some companies like to comparison shop before extending an offer. Unbeknownst to outside candidates, they simultaneously post job openings internally and externally so they can survey the market and compare the benefits that diverse professionals bring to the table.
“Put another way, you were part of a focus group and didn’t know it,” said Jacob Share, job search expert and creator of JobMob.
Although you theoretically had a shot at the job—if the manager was looking to shake things up by bringing in an outsider—the internal candidate often has the edge because they’re budget-friendly, a known quantity, and ultimately less risky.
“You’re overqualified.”
Overqualified is employer code for “you want too much money,” or “we’re afraid that you’ll accept the job, keep looking, and bail when you find something better.”
“However, it may also mean that the manager feels inferior and is uncomfortable giving direction to someone who is older than he is, or more experienced,” noted Louise Garver, a certified job search strategist and career coach.
Garver helped junior tech managers conquer their insecurities and hire the strongest candidate when she worked in HR. But sometimes managers don’t overcome those issues.
“We’re meeting with some additional candidates over the next couple days, we’ll let you know.”
This could be true; for some companies, it really is early in the hiring process, and they don’t just want to pick the first candidate who meets the minimum requirements, explained Robert Hummel, director of Information Technology for Cheshire County, New Hampshire, who submitted comments via email.
So the company doesn’t want to leave a candidate hanging. But Hummel admits that the phrase contains a hidden message: “I haven’t rejected you yet. You have a chance. But you didn’t knock my socks off.”
“While I enjoyed our conversation, I think we need someone with more hands-on experience for this role.”
This may mean that your initial impression was positive, but the manager found a stronger candidate who offered better value. It also may mean that you rubbed a colleague or senior manager the wrong way during the final round of interviews, or that a key influencer preferred another candidate.
“The position has been cancelled or closed.”
Companies often institute a hiring freeze during management changes or when they begin M&A discussions. However, you may also get a letter containing this phrase if the manager was testing the waters and didn’t have the necessary approvals or budget to make another hire.
“We have filled the position. However, we will keep your application on file for consideration if there is a future opening that may be a fit for you.”
This means: “Please don’t submit another résumé for my next job opening and save me the trouble of having to reject you again,” Hummel noted.
“Interviewing is a skill,” he added. “There are many managers who need to hire who lack that skill. That may account for some of the terrible or awkward phrases that appear in rejection letters.”
Bouncing Back from Job Rejection
Tailoring Your Cover Letter to Fit the Job
Two Job Search Mistakes to Avoid
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Apple Stores to Hold More Swift Coding Classes
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Leslie Stevens-Huffman
Leslie Stevens-Huffman is a business and careers writer based in Southern California. She has more than 20 years’ experience in the staffing industry and has been writing blog posts, sample resumes and providing sage career advice to the IT professionals in our Dice Community since 2006. Leslie has a bachelor’s degree in English and Journalism from the University of Southern California.
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You are at:Home » Featured » Science Hill’s Hutchins wins title with historic run
Science Hill’s Hutchins wins title with historic run
By N&N Admin on November 25, 2020 Featured
Science Hill’s Jenna Hutchins, in a meet earlier this season, made history last Saturday by becoming the first high school girl in United States history to complete a 5K cross country course in under 16 minutes.
Here at the News & Neighbor, we’ve been chronicling the running exploits of Jenna Hutchins since before she got to middle school. But last Saturday morning, Hutchins accomplished something that almost defies description.
Hutchins, a junior at Science Hill, became the first high school girl in history to break the 16-minute barrier in a cross country race. Hutchins dominated a field that included several state champions from around the country at the RunningLane National Championships, laying down a time of 15:58.42 on the 5K course at John Hunt Running Park.
Her time broke the previous national record for high school girls by eight seconds as she finished nearly a full minute ahead of the runner-up. When Cory Mull with MileSplit caught up to Hutchins, she said the joy of running meant more than all the records she broke in one fell swoop last Saturday morning.
“Running has been one of my favorite things since I was little, so just having the passion for it is enough for me,” said Hutchins, the top-ranked girls high school cross country runner in the nation. “It makes it a little sweeter having those marks to hit, too.”
Unfortunately for Hutchins, she’s running out of marks to aim for. In addition to breaking the national high school record, Hutchins set a new Tennessee state record and a new record for the fastest time run by a high school girl on Alabama soil. She also shattered the course record at the demanding course at John Hunt Running Park.
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December 29, 2016 October 20, 2017 by JeanetteAbrahamsen
Fake news isn’t exactly new, but 2016 saw a historic rise in fake news as one of the most contentious presidential elections in history unfolded online and across social media platforms.
The increase is forcing journalists to shift their focus from uncovering and telling news stories to debunking fake news. The media is spending more time desperately trying to get get the public to understand what’s true and what isn’t.
So how do you separate truth from fiction? FactCheck.org explains how to spot fake news. I suggest you read the entire post, but here are the main takeaways journalists must understand:
Read beyond the headline.
Check the author.
What’s the support?
Check the date.
Is this some kind of joke?
Check your biases.
Consult the experts.
Here’s How Fake News Works
How A Partying Macedonian Teen Earns Thousands Publishing Lies
The REAL News About FAKE News
What is real news? What is fake news? How do we be smart about the media that we choose to consume? Tom Becka answers this important question in his TEDxUNO talk from February 18, 2017.
Tom Becka can be seen every night during Omaha’s Fox 42 News at 9 giving his unique views on what’s happening in Omaha and the rest of the world. His Becka’s Beat can be humorous, poignant, serious, or whimsical. But they are always informative, entertaining and on point. Becka’s Beat is also available on demand at Fox42 KPTM.com.
He is also a nationally-recognized radio talk show host currently heard Monday-Friday on legendary Kansas City radio station KCMO. Formerly of KFAB and KOIL in Omaha, Tom has been named one of the Top 100 talk show hosts in America ten times by Talkers magazine and one of the Top 25 local hosts in America by Newsmax magazine. He has also been a fill-in host for nationally-syndicated radio shows and on WLS in Chicago and many others.
He performed with such greats as Jerry Seinfeld, Lewis Black, Sam Kinnison, Darrel Hammond, Drew Carey.
This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at http://ted.com/tedx
How Fake News Grows in a Post-Fact World
As a journalist with extensive experience, Ali has had the opportunity to witness all forms of news. One type, in particular, poses a threat that has been exacerbated in our digital media society – fake news. Ali discusses the problems of fake news, how we are all affected by it, and how individuals can ensure the news they’re reading is rooted in fact, not fiction.
Ali Velshi is an anchor & correspondent with MSNBC. Most recently, he hosted “Ali Velshi On Target” on Al Jazeera America, covering the Presidential campaign, ISI, the refugee crisis, the Iran deal, Russia/NATO tensions, and Greece’s debt crisis, among other global affairs and economic issues. Before that, Velshi was CNN’s Chief Business Correspondent and authored two finance books.
Velshi has been nominated for three Emmy Awards and he holds a B.A and an honorary Doctorate from Canada’s Queen’s University. Velshi is a member of the Council on Foreign Relations and serves on the Boards of the X-Prize Foundation, Seeds of Peace, and the Chicago History Museum. He volunteers weekly with New York’s homeless outreach program.
Truth Spreads Through Transparency
Nieman Lab published an intriguing article called, “With Open Notebook, Hearken wants to help news orgs do more of their reporting in public.” I highly encourage you to skim through this article to understand the collaboration now underway between journalists and readers to increase transparency. I suggest you watch this short video that walks you through how readers can help pitch and write news stories.
Fighting For Facts
The radio program 1A created a thought provoking discussion called Fighting For The Facts: How To Tell What’s News And What’s Fiction. The 30-minute debate looks at how journalists can decode fake news by understanding why it exists and how it’s shared.
1A has since covered the topic in several shows. Here’s another interesting show called Can The Democracy Survive The Internet?
Take a look at how fake news affected politics and why people write and share fake news in the following articles:
https://www.washingtonpost.com/news/the-intersect/wp/2016/11/17/facebook-fake-news-writer-i-think-donald-trump-is-in-the-white-house-because-of-me/?utm_term=.c20f47cf15d3
http://www.nytimes.com/2016/11/25/world/europe/fake-news-donald-trump-hillary-clinton-georgia.html
http://www.journalism.org/2016/12/15/many-americans-believe-fake-news-is-sowing-confusion/
http://www.nytimes.com/2016/11/15/technology/google-will-ban-websites-that-host-fake-news-from-using-its-ad-service.html?_r=0
https://www.wired.com/2016/11/facebook-won-trump-election-not-just-fake-news/
https://www.cnet.com/news/facebook-google-fake-news-election-2016-trump-clinton/
Check out Poynter’s Fake News page dedicated to stories about fake news and resources to stop it.
Play the fake news game Factitious to test your judgment.
The American Press Institute is leading a project to improve fact-checking in journalism.
Verification online lesson: https://newslab.withgoogle.com/lesson/5710999223009280
Reverse Image Search online lesson: https://newslab.withgoogle.com/lesson/6351120209281024
Verify with Street View: https://newslab.withgoogle.com/lesson/6044738583003136
Hurricane Harvey: That shark photo is fake — and part of a bigger problem https://t.co/VLzckW3G1L via @usatoday
— Jeanette Abrahamsen (@JNetAbrahamsen) August 31, 2017
How can fact-checkers earn readers’ trust — and keep it?https://t.co/MOAudrM69t @TomRosenstiel has some ideas: pic.twitter.com/Cd04xvmpGj
— Poynter (@Poynter) July 17, 2017
Why the #factchecking company @snopes matters https://t.co/2dDNPeimnA @AmPress #FakeNews
— Jeanette Abrahamsen (@JNetAbrahamsen) July 25, 2017
Behind the unlikely success of PolitiFact and the Truth-O-Meter https://t.co/a9IzG7AW3a via @cjr
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Jerusalem Mortimer: Between the Lines
Jerusalem Mortimer wants a word
The “shameful” pudenda: there’s a shameful history behind the word
Posted on March 31, 2013 by jaime
The Greek academies had collected a lot of medical and anatomical knowledge. They had the works of Galen, the Hippocratic writings, and above all they had the anatomical works of Herophilos, an early scientist in something like the modern sense, who performed and recorded dissections of human bodies and recorded his findings in considerable detail.
The academies were the inheritors of the tradition of Plato, Aristotle and others, although the tradition was not continuous. It would be misleading to present them as purely scientific in the modern sense. Neo-Platonic doctrines were, on the whole, more mystical and dogmatic than scientific. However, free inquiry in philosophy and science was possible in the academies. Free inquiry was a dangerous thing under early Christian rule, and the academies were forcibly closed by the Christian Emperor Justinian in CE 529.
Not everything was lost, because the main Academy philosophers and scientists took asylum in Persia, under the protection of king Khosrau 1. At the time, Persia was a Zoroastrian country.
Shoot straighters, you bastards! Use bigger elephants! The fall of Persia to Arab Muslim forces, 633-644.
Some of the original group to travel to Persia ultimately returned to Greece. However, others remained, as did their books, or copies of their books. When the Muslim Arab invasion of Persia began in CE 633, the academy’s successors had been based in Tehran for nearly 100 years.
(When the invasion was completed, in CE 644, the conquest of Persia complete, the Muslim conquerors of Persia found themselves in possession of scientific texts and knowledge which Christians under Justinian had deliberately tried to destroy.
This is the most important reason why Islamic countries were for a time ahead of Christian countries in medicine and other sciences.
So this knowledge was lost to Europe. Meanwhile, the Zoroastrians of Persia, who had invited those philosophers to come with their books, began to be persecuted and killed by their Islamic conquerors.
If I had a time machine, one of the things I’d do would be to go back to Persia in 633, and encourage Persia’s archers to shoot a little straighter and their other defenders to fight a little harder.
But the consequence in the West was that, with Christian Emperors having stamped out the long Greek tradition of free enquiry, the universities that were set up were Christian-controlled, and reflected Christian attitudes such as hostility to sex.
Therefore, genitals became “pudenda”, shameful parts. Modern anatomists, following their 15th century predecessors, still use the term.
This entry was posted in Bodies, History and tagged Inter-gracile sub-pudendal fossa by jaime. Bookmark the permalink.
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Home Business Relativity Creditors to Get TV Assets for $125 Million Debt Cut
Relativity Creditors to Get TV Assets for $125 Million Debt Cut
Ryan Kavanaugh’s Relativity Media LLC, the bankrupt maker of films including The Fighter and Act of Valor, agreed to turn over its television business to a group of lenders in exchange for cutting $125 million in debt, the company said in a court filing.
Relativity reached the deal after no other bidders offered to buy the entire company at an auction, which had a starting bid of $250 million. The lenders had originally agreed to make a so-called credit bid.
Read the full story at Bloomberg, by Steven Church
bankrupt maker
Relativity Media LLC
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Statewide Poll Shows Massive Support for Governor’s Mask Mandate
Sean Gallup /Getty Images
Each morning as we sit in the control room of our radio station we field countless hundreds of phone calls. Lots of those calls are about current events and obviously the most talked-about current event at this time is COVID-19 and all things associated with it.
However, if one were to judge by the sheer volume of calls we receive, we would have told you that one of the most divisive things associated with COVID has been the mask mandates. Being told to do something is something a lot of people are just uncomfortable with and they've been vocal about it. However, in a report from the Louisiana Radio Network, we find the issue isn't nearly as divided as one would have imagined.
In the report, we discover that Louisiana House Speaker, Clay Schexnayder, commissioned Remington Research Group to poll Louisiana citizens about their feelings regarding Governor Edwards' mask mandate and, unless the poll has been tainted or done ineffectively, it shows wide and bipartisan support for the mandate and public health emergency declaration.
76 percent of those surveyed on Saturday and Sunday support a government mask mandate. UL Lafayette Poli Sci Professor Pearson Cross says it is rare to see that kind of unanimity.
“That is enormously strong and a fairly rare outcome in a poll like this, and it is a big poll, 3,600 people, so we can trust the results,” says Cross.
The poll also goes on to say that nearly two-thirds of Louisianans oppose canceling the public health emergency declaration. Professor Cross adds, “Large majorities of Democrats, non-partisan people, and nearly one half of all Republicans think that the healthcare emergency in Louisiana needs to be carried on and addressed with seriousness.”
See Full Results of the Poll Here
How to Make a No-Sew Face Mask From Leggings
Filed Under: Coronavirus (COVID-19), Mask Mandate
Categories: Health/Wellness, Louisiana News, Shreveport News
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deencs
Franz Kafka Menu >>
Oskar Pollak
Prague residences
Max Brod
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Clerkship in a law firm and in court
Assicurazioni Generali
The Workers’ Accident Insurance Institute
His works
Hedwig Weiler
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Physical and mental conditions and their causes
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Paths to recovery following the onset
Austrian hospitals
In Prague
Kafka’s close friend from their years at the high school. He was a gifted, intellectually mature and determined student, who was severe in his judgments and academically ambitious. He studied the history of art and graduated at the same time as Kafka, submitting a dissertation on the statues on Charles Bridge. They were both active in the German Student Reading and Lecture Hall. He was a major influence on Kafka’s thinking at university as can be seen from the extant correspondence. It was Pollak who introduced Kafka to the journal Kunstwart – whose style he succumbed to for a while – and most likely also to Nietzsche. The character of the ‘friend’ in Description of a Struggle is probably a projection of Pollak. Pollak soon left for Rome and his Roman studies led to valuable work on Italian baroque. His work on art during the reign of Urban VIII was published posthumously. After the outbreak of World War I, Pollak volunteered for the army and fell on the Italian front at Isonzo.
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T h e Paci f i c N o rthW est Ec onomi c R eg i on’ s
29TH ANNUAL SUMMIT July 21 - 2 5 , 2 0 1 9
COLLABORATIVE PROSPERITY: OVERCOMING CHALLENGES BY WORKING TOGETHER AS A R E G I O N
About PNWER
Host Committee Welcome
PNWER Leadership and Staff
PNWER Program Areas
Detailed Agenda
Policy Tours
Save the Date: 30th Annual Summit
Save the Date: Economic Leadership Forum 73
Summit Tracks
Border Track Energy & Environment Natural Resources Economic Diversification Agriculture Invasive Species Transportation
Sunday, July 21 10:00 - 7:00pm Registration - Bessborough Convention Foyer 12:00 - 1:00pm Executive Board Luncheon - Bess Terrace Lounge
1:00 - 5:00pm Executive Committee & Delegate Council Meeting (open to all) - Bess Salon Batoche 5:00 - 6:00pm Executive Committee & Sponsor Reception (invitation only) - Bess Terrace Lounge. Hosted by Nelson Mullins 6:00 - 8:00pm Welcome Reception featuring Mayor Charlie Clark - Bessborough Gardens Hosted by the City of Saskatoon and Tourism Saskatoon 9:00 - 11:00pm Hospitality Suite - Sheraton Top of the Inn. Hosted by CN.
Monday, July 22 7:00 - 5:30pm Registration - Sheraton Conference Foyer 7:30 - 9:00am
9:15 - 11:30am Coffee Break hosted by NorthWestern Energy
Opening Keynote Breakfast featuring former U.S. - Canada ambassadors reflecting on the U.S. - Canada Relationship - Sheraton Ballroom U.S. Ambassador David Jacobson, Canadian Ambassador Michael Kergin, U.S. Ambassador David Wilkins Moderated by Scotty Greenwood, Canadian American Business Council Hosted by Nutrien Economic Energy & Invasive Species N atural Border Track Diversification Environment Track R esources Track Track Track Trade Forestry Invasive Tourism Infrastructure Species Resilience & Energy Hosted by Innovations The Butchart Gardens Sheraton Top of the Inn
Bess Williams Pascoe
Sheraton West Room
Bess Terrace Lounge
Bess Salon Batoche
11:30 - 12:30pm Orientation on PNWER Governance, Working Group Action Plans, How PNWER works (Open to all)- Sheraton Starlight Room 11:30 - 12:30pm Networking Break - Sheraton Hamptons Room. Hosted by Shell 12:30 - 2:15pm
Coffee Break hosted by Port of Vancouver
Keynote Luncheon featuring the Honourable Scott Moe, Premier of Saskatchewan, and remarks by the Honourable Bob McLeod, Premier of the Northwest Territories - Sheraton Ballroom | Hosted by Canpotex Energy & Economic Agriculture Invasive Species Border Track Environment Diversification Track Track Track Track Border Climate Policy Agriculture Invasive University *Departs at 2:30 & Economic Species Presidents’ Hosted by SK Cattlemen’s Growth Roundtable Hosted by FortisBC
Sheraton Top of the Inn
Offsite at Ag In Motion- Western Canada’s Farm Expo
Reception at University of Saskatchewan featuring President Dr. Peter Stoicheff, Marquis Hall, Buses depart at 5:30pm | Hosted by the University of Saskatchewan
9:00 - 11:00pm Hospitality Suite - Sheraton Top of the Inn. Hosted by Cameco.
2 | Pacific Northwest Economic Region
Tuesday, July 23 7:00 - 5:30pm Registration - Sheraton Conference Foyer 7:30 - 9:00am
9:15 - 11:30am Coffee Break in Bess Williams Pascoe hosted by Washington PUD Association
Coffee Break in Bess Salon Batoche hosted by Alberta Beef Producers
Keynote Breakfast Panel “Building Infrastructure for the 21st Century: How does the region look forward to the future markets we need to serve” - Sheraton Ballroom Vee Kachroo, Senior Vice President of Operations, Canpotex Phil Lamarche, Director of Transportation Operations, FCL David Miller, Canadian National Railway Company Robin Silvester, CEO, Port of Vancouver Rep. Gael Tarleton, Washington State Legislator Jim Titsworth, General Director, Canadian Business Development, BNSF Railway Moderated by Jennifer Fox, Vice President, Int’l Trade & Canada Relations, NASCO Hosted by the Pacific Northwest Building & Resilience Coalition Transportation Track Transportation & Infrastructure I Sheraton Top of the Inn
Environment Track
Energy Resilience, Regional Reliability & Infrastructure Hosted by MDU Resources
Agriculture Track Agriculture & Cross Border Livestock Health Hosted by SK Cattlemen’s Association
Diversification Track Innovation Hosted by Microsoft
Natural Resources Track Mining Hosted by Orano
11:30 - 12:30pm Networking Break - Sheraton Hamptons Room. Hosted by BP. 12:30 - 2:15pm
2:30 - 5:00pm Coffee Break in Bess Williams Pascoe hosted by CAPP
Keynote Luncheon “Capturing Asian Markets” - Sheraton Ballroom Murad Al-Katib, President and CEO, AGT Foods John Stackhouse, Senior Vice President, Royal Bank of Canada Moderated by Victor Thomas, VP, Prairie Region, Asia Pacific Foundation of Canada Hosted by The Mosaic Company Energy & Enviro Nat. Resources Tracks Transportation GHG Reduction & & Reuse Infrastructure II Strategies
Agriculture Track
Transportation Track
Cross Border Livestock Health Hosted by SK Cattlemen’s Association
Diversification Track Workforce
Natural Resources Track Water Policy
4:30 - 5:30pm Special session: Using Public Data for Economic Development - Sheraton Starlight Room 6:00 - 9:00pm
Continued PNWER Celebration Dinner featuring Métis and First Nations performers - on next page Western Development Museum, Buses will depart at 5:45pm | Hosted by the Cement Association of Canada with entertainment hosted by K+S Potash Canada Group
9:00 - 11:00pm Hospitality Suite - Sheraton Top of the Inn
Continued on next page Pacific Northwest Economic Region
SCHEDULE AT A GLANCE Wednesday, July 24 7:00 - 3:00pm Registration - Sheraton Conference Foyer 8:00 - 9:00am
Keynote Breakfast on the U.S. - Canada Border, featuring the Honourable Ralph Goodale, Minister of Public Safety and Emergency Preparedness- Sheraton Ballroom Hosted by Federated Co-operatives Limited
9:15 - 11:30am 10:00am Executive Committee Meeting
Coffee Break hosted by Food Northwest
Agriculture Track Cross Border Livestock Health Hosted by SK Cattlemen’s Association
Economic Diversification Track Ec Dev: The Changing Dynamics of Indigenous Businesses
Disaster resilience Track Border Security Roundtable Disaster Resilience Sheraton Top of the Inn
11:30 - 12:30pm Networking Break - Sheraton Hamptons Room. Hosted by Marathon 12:30 - 2:15pm
Keynote Luncheon featuring a business roundtable on U.S. - Canadian Trade - Sheraton Ballroom Scotty Greenwood, CEO, Canadian American Business Council Goldy Hyder, President and CEO, Business Council of Canada Edward Alden, Senior Fellow, Council on Foreign Relations Moderated by Colin Robertson, Canadian Global Affairs Institute
2:30 - 5:00pm Executive Committee Meeting
Policy Tour
Meewasin Valley Authority and Wanuskewin
Gardiner Dam *Departs at 2:15
Livestock and Forage Centre of Excellence
Canadian Light Source & VIDO Intervac
Closing Reception at Remai Modern- Buses will depart at 5:55, walking directions available | hosted by the Canadian Engineering and Geoscience Regulators
9:00 - 11:00pm Hospitality Suite - Sheraton Top of the Inn. Hosted by Enbridge
Thursday, July 25 6:00 - 9:00am Optional Continental breakfast- Sheraton Ballroom 6:45am - 1:30pm
Nutrien Allan Potash Mine Tour- Legislators only; sign up during registration
Boundary Dam Power Station Unit 3 & Carbon Capture Tour- advanced registration required
LETTER FROM THE PRESIDENT On behalf of the Pacific NorthWest Economic Region (PNWER) Executive Board and Delegate Council, I am pleased to welcome you to the 29th Annual Summit. We are honoured and excited to be hosting you in Saskatoon this year. The PNWER region is comprised of 10 jurisdictions that offer natural beauty, resources and economic opportunity. Every year, the Summit brings us together to discuss our common challenges, develop innovative solutions and promote further collaboration. I hope you take full advantage of the time this week to establish new relationships, strengthen partnerships and learn from others. Over the past year, I have had the tremendous honour of serving as your PNWER President. Meeting and collaborating with colleagues from our 10 jurisdictions has been one of the many highlights of my term. During the PNWER Economic Leadership Forum in Whitehorse, Yukon, 100 delegates gathered to discuss the importance of First Nations economic development. Attendees also offered insights on the unique challenges and creative solutions in meeting the needs of consumers and industry in the North. PNWER also held successful capital visits to Helena, Montana; Boise, Idaho; Salem, Oregon; Olympia Washington; and Juneau, Alaska, which presented opportunities to testify in front of committees on invasive species, the importance of trade with Canada to each state, and innovation and economic development opportunities. Further on trade, PNWER supported the United States-Mexico-Canada Agreement (USMCA) as an important part of the United States (U.S.)-Canada relationship. PNWER engaged with various members of Congress, encouraging them to ratify the USMCA and emphasized the importance of our two countries maintaining a strong trade relationship. This crossborder region continues to work closely together everyday - which is driven by our interconnected and interdependent supply chains. PNWER has also been working actively to support the secure and efficient flow of goods and people across the border, which is critical to our shared economic competitiveness and prosperity. PNWER co-chaired and spoke at the Beyond Preclearance Transportation Border Summit in Washington, D.C. Also, I provided input to U.S. Customs and Border Protection regarding a proposed reduction of service hours at the border crossings between Montana and Saskatchewan and am pleased that the Port of Raymond will remain a 24-hour port for the time being. It was another impressive year for the Legislative Energy Horizon Institute. To date, more than 260 state and provincial legislators have graduated. This year, 25 legislators participated in the program and will meet in Washington this fall for a second three-day course. The PNWER Centre for Regional Disaster Resilience also hosted a number of significant events this spring, including the first statewide Unmanned Aerial System Drone Workshops in Washington and Idaho. The fifth statewide Idaho Cybersecurity Summit was attended by more than 300 participants. Throughout the week, you will learn more about our work on these issues. I encourage you to take full advantage of the policy sessions and contribute your expertise in finding innovative solutions. Lastly, I would like to personally invite you to the upcoming PNWER Economic Leadership Forum in Seattle this November 17-19, 2019, and next year’s 30th Annual Summit in Big Sky, Montana on July 19-23, 2020. Thank you for coming to the Summit, and for all you do for this great region we all proudly call home. Sincerely,
Larry Doke, Member of the Legislative Assembly for Cut Knife-Turtleford PNWER President 2018-2019, Legislative Assembly of Saskatchewan Pacific Northwest Economic Region
ABOUT PNWER Mis s i o n G oa l s
To increase the economic well-being and quality of life for all citizens of the region, while maintaining and enhancing our world-class natural environment. • • • • •
Coordinate provincial and state policies throughout the region Identify and promote "models of success" Serve as a conduit to exchange information Promote greater regional collaboration Enhance the competitiveness of the region in both domestic and international markets • Leverage regional influence in Ottawa and Washington D.C. • Achieve continued economic growth while maintaining the region’s natural environment
PNWER is the preeminent binational advocate for regional, state, provincial, and territorial issues Founded in 1991, the Pacific NorthWest Economic Region (PNWER) is a public-private partnership chartered by the states of Alaska, Idaho, Montana, Oregon, and Washington; the western Canadian provinces of Alberta, British Columbia, and Saskatchewan; and Yukon and the Northwest Territories. PNWER is recognized by the federal governments of both the United States and Canada as the “model” for regional and bi-national cooperation because of its proven success. PNWER is the leading forum where people in the policy world and the business world come together to figure out solutions to regional challenges
HOST COMMITTEE WELCOME Shawna Argue, APEGS (Co-Chair) Ernie Barber, U of Saskatchewan Greg Brkich, MLA David Buckingham, MLA Hon. Lori Carr, Minister of Highways and Infrastructure
Hon. Ken Cheveldayoff, Minister of Central Services/Public Service Commission/Provincial Capital Commission
Herb Cox, MLA Chris Dekker, President & CEO, STEP Larry Doke, MLA (Co-Chair) Hon. Bronwyn Eyre, Minister of Energy and Resources/SaskWater/ SaskEnergy
Muhammad Fiaz, MLA Glen Hart, MLA Everett Hindley, MLA, Legislative Secretary to the Minister of Trade and Export Development
Dear PNWER Delegates, The Pacific NorthWest Economic Region (PNWER) Summit Host Committee is honoured to welcome you to Saskatchewan and the 29th PNWER Annual Summit. We are pleased to host you again for this important event in Saskatoon, our largest city. PNWER brings together the public and private sectors to tackle our common challenges and share innovative best practices. Working together, we can accomplish common goals that will strengthen the relationships amongst our respective jurisdictions and ultimately lead to greater prosperity across the region. PNWER has a strong history of success over the years thanks to the dedication of the legislators, business leaders, academics, and policy makers that attend the Summit each year. This year’s Summit will help us build on this good work as we continue to pursue new opportunities and advance our collective interests. The agenda for this Summit includes a broad range of issues that address agriculture, technology and innovation, trade, resource development, transportation, the environment, and economic development, including a panel on the Changing Dynamics of Indigenous Businesses. It will give us the opportunity to come together and discuss subjects of mutual interest, including best practices and current challenges facing our region.
Darla Lindbjerg, President and
We hope you find the policy tours in the greater Saskatoon area a valuable
CEO, Greater Saskatoon Chamber of
experience. As well, we encourage you to explore the City of Saskatoon. There is
much to see and do that will give you a glimpse into the significant historical and
Hon. Paul Merriman, Minister of
cultural landscape of this city and our province. There is an exceptional lineup of
speakers from all over the region who will provide you with food for thought, and
Alan Migneault, President, AJM
contribute to the ongoing dialogue during and after the event.
Management Corp
Hon. Don Morgan, Minister of Justice
May you have a successful, rewarding experience at the 29th PNWER Annual
and Attorney General/Labour/GTH/
Summit.
Rob Norris, Senior Strategist, University
of Saskatchewan
Eric Olauson, MLA Brad Peters, Director of Int’l Sales, Tourism Saskatoon
Victor Thomas, Vice President, Asia Pacific Foundation of Canada
Randy Weekes, MLA Hon. Gord Wyant, QC Deputy Premier/Minister of Education
Larry Doke, MLA
Shawna Argue
Legislative Assembly of Saskatchewan
Director of Registration
PNWER President APEGS Host Committee Co-Chair
Host Committee Co-Chair Pacific Northwest Economic Region
PNWER STAFF Matt Morrison, CEO matt.morrison@pnwer.org Brandon Hardenbrook, COO brandon.hardenbrook@pnwer.org Eric Holdeman, Director, Center for Regional Disaster Resilience (CRDR) eric.holdeman@pnwer.org Steve Myers, Senior Program Manager
CONNECT WITH PNWER 206-443-7723 @pnwer #pnwer pnwer.org
steve.myers@pnwer.org Rachael Kopp, Events Program Manager rachael.kopp@pnwer.org
bitly.com/pnwerlinked @therealpnwer
Jennifer Grosman Fernรกndez, Program Manager jennifer.grosman@pnwer.org
Facebook.com/PNWER
Nate Weigel, Program Coordinator nate.weigel@pnwer.org Tara Edens, Program Coordinator tara.edens@pnwer.org
special thanks to our 2019 interns Daniel Green, University of Washington Sonora Hetrick, University of Washington
Betz Mayer, Program Coordinator
Brenton Riddle, University of Washington
betz.mayer@pnwer.org
Sarah Smiley, University of Washington
code of conduct It is the policy of the Pacific NorthWest Economic Region (PNWER) that all participants, including attendees, staff, board members, volunteers, and all other stakeholders at PNWER meetings will conduct themselves in a professional manner that is welcoming to all participants and free from any form of discrimination, harassment, or retaliation. To make it possible for true collaboration, creativity, innovation, and idea exchange to thrive we are committed to facilitating a welcoming, respectful, and professional community for all. Participants will avoid any inappropriate actions or statements based on individual characteristics such as age, race, ethnicity, sexual orientation, gender identity, gender expression, marital status, nationality, political affiliation, ability status, educational background, or any other characteristic protected by law. Disruptive or harassing behavior of any kind will not be tolerated. Harassment includes but is not limited to inappropriate or intimidating behavior and language, unwelcome jokes or comments, and unwanted touching or attention. Inappropriate behavior will not be tolerated. PNWER reserves the right to refuse entry to or remove any party from the event at any time. Sanctions may range from verbal warning, to ejection from the meeting without refund, to notifying appropriate authorities. If you witness or are subjected to inappropriate behavior or have any other concerns, notify a PNWER staff member as soon as possible.
PNWER LEADERSHIP
Hon. Larry Doke, MLA President Saskatchewan
Sen. Mike Cuffe Vice President Montana
Premier Bob McLeod Vice President Northwest Territories
Rep. Gael Tarleton Vice President Washington
Sen. Arnie Roblan Imm. Past President Oregon
Delegate council British Columbia Alaska Gov. Mike Dunleavy Premier John Horgan Lt. Gov Kevin Meyer Rick Glumac, MLA Dan Ashton, MLA Sen. Tom Begich Sen. Mia Costello Idaho Rep. Chris Tuck Gov. C.L. Butch Otter Rep. Dave Talerico Rep. Chuck Kopp (Alt). Sen. Michelle Stennett Rep. George Rauscher Sen. Chuck Winder Rep. Elaine Smith (Alt). Rep. Rick Youngblood Rep. Mat Erpelding (Alt) Alberta Premier Jason Kenney Richard Gotfried, MLA
Montana Gov. Steve Bullock Cliff Larsen Sen. Mike Cuffe Sen. Keith Reiger Sen. Jon Sesso (Alt) Rep. Derek Skees Rep. Bradley Hamlett Oregon Gov. Kate Brown Sen. Arnie Roblan Sen. Bill Hansell Rep. David Brock Smith Rep. Caddy McKeown (Alt) Rep. Greg Barreto (Alt)
Private Sector council
Private Sector Co-chairs Colin Smith, Engineers & Geoscientists BC Dan Kirschner, NWGA
Alaska John Boyle, BP Hans Neidig, ExxonMobil Cam Toohey, Shell Alberta Amanda Affonso, Enbridge Jim Donihee, CEPA Riley Georgson, Transalta Mike Simpson, Devon Energy Scott Thon, AltaLink British Columbia David Bennett, FortisBC Dave Cowen, The Butchart Gardens Don Dalik, Fasken Martineau
Hana Doubrava, Microsoft Marcia Smith, Teck Idaho Ken Dey, J.R. Simplot Patrick Kole, Idaho Potato Commission Bob Naeurbout, Idaho Dairymen’s Assn. John Revere, INL/Battelle Jesse Ronnow, Zions Bank Montana Mike Halligan, The Washington Companies Cory Fong, MDU Resources Bob Rowe, Northwestern Energy Northwest Territories Darrell Beaulieu, Denendeh Investments Pawan Chugh, NWT BDIC
Northwest Territories Premier Bob McLeod Hon. Wally Schumann, MLA Saskatchewan Premier Scott Moe Larry Doke, MLA Hon. Dustin Duncan Hon. Lori Carr Warren Steinley, MLA *Jurisdiction Leads on the PNWER Executive Committee are in bold
Oregon Curt Abbott, Oregon PUD Association Sunny Radcliffe, PGE Mark Sytsma, Portland State University Diane Warner, Northwest Cement Council Saskatchewan Shawna Argue, APEGS Chris Dekker, STEP Bob McDonald, APEGS Alan Migneault, AJM Management Corp Natashia Stinka, Canpotex Victor Thomas, Asia Pacific Foundation of Canada Washington Pam Brady, BP George Caan, WPUDA Brandon Housekeeper, PSE Nina Odell, PSE
Washington Gov. Jay Inslee Sen. Jim Honeyford Sen. Bob Hasegawa Sen. Barbara Bailey (Alt) Sen. Lisa Wellman (Alt) Rep. Bruce Chandler Rep. Gael Tarleton Rep. Cindy Ryu (Alt) Rep. Bob Sutherland (Alt) Yukon Premier Sandy Silver Paolo Gallina, MLA Hon. Ranj Pillai (Alt)
Megan Ouellette, Alaska Airlines Irene Plenefisch, Microsoft Bob Sailer, PNWLG Dennis Vermillion, Avista Courtney Wallace, BNSF Carol West, WPUDA Yukon Albert Drapeau, Yukon First Nations Chamber of Commerce Leneath Yanson, Yukon First Nations Chamber of Commerce Other David Miller, CN Amb. David Wilkins, Nelson Mullins
Pacific Northwest Economic Region
PNWER’s Legislative Energy Horizon Institute provides an extensive overview of the North American energy systems to legislators, administrators, and policy experts from around the U.S. and Canada.
10 | Pacific Northwest Economic Region
In November, 34 state and provincial legislators and policymakers graduated from the rigorous Legislative Energy Horizon Institute (LEHI) program at the Canadian Embassy in D.C.
The Economic Leadership Forum in Whitehorse, YK focused on the importance of First Nations Ec Dev. Below, Yukon First Nations Culture & Tourism, and Chief Isaac Group of Companies speak at the event.
WA Rep. Zack Hudgins speaks at the Cyber Incident Reporting workshop with the PNWER Center for Regional Disaster Resilience. The Cyber CONOPS is a model for the nation.
PNWER President: Larry Doke, MLA (SK) assumed the PNWER presidency from Sen. Arnie Roblan (OR) at the 28th Annual PNWER Summit in Spokane, WA in July 2018
PNWER spoke at the CSG National event in Kentucky on efforts supporting the USMCA and pushing for Section 232 tariff exemptions with Canada. PNWER CEO Matt Morrison spoke with Ambassador Craft.
Year in
PNWER visited Helena, Boise, Salem, Olympia, & Juneau and testified in committees on the importance of trade with Canada, innovation, and ec dev opportunities. President Doke seen testifying in MT on invasive species prevention.
Idaho Governor Brad Little provided opening remarks at the PNWER CRDR 5th Annual statewide Idaho Cybersecurity Summit attended by over 300 participants. Attendees participated in a mock data breach trial.
The 6th Annual Arctic Encounter Symposium was held in Seattle in April highlighting Innovation in the Arctic. Premier Bob McLeod of the Northwest Territories and PNWER Vice President gave a keynote speech.
PNWER attended the National Governors Association 11th Annual Meeting in D.C. to discuss key issues such as USMCA, tariffs and aquatic invasive species. SK Premier Scott Moe with PNWER CEO Matt Morrison.
PNWER’s CRDR hosted the first state-wide UAS Drone Workshops in WA and ID to connect Unmanned Aerial System users from the public and private sectors to improve awareness of damage post-disaster.
PNWER co-chairs the Beyond Preclearance Transportation Summit hosted by the U.S. and Canadian Chambers of Commerce in D.C. Pictured: Ambassador MacNaughton and Scotty Greenwood with the CABC.
Review Pacific Northwest Economic Region
CENTER FOR REGIONAL DISASTER RESILIENCE The Center for Regional Disaster Resilience (CRDR), a division of PNWER, focuses on infrastructure interdependencies and disaster resilience projects. The CRDR is committed to working with states, provinces, territories and communities to develop regional publicprivate partnerships. This is done in a very collaborative fashion to provide workable and commonsense solutions to the complex problems brought on by operating in the technology heavy 21st Century. Our collective and ultimate goal is to reduce risks and eliminate vulnerabilities while building resilience in people, organizations and institutions.
Cyber security | Drones | Critical Infrastructure | Earthquake Preparedness
2019 saw significant ransomware attacks on governments, large and small, which have highlighted the continue need to have joint public and private sector action to improve our cybersecurity resilience. The CRDR has continued its support of the State of Idaho’s cybersecurity emphasis. In April, a Cybersecurity Summit was held in Boise with more than 300 attendees. Governor Brad Little opened this event and his leadership has set the tone for a continuing effort to make cybersecurity a priority for Idaho. Additionally, the work being done in King County, Washington on cybersecurity continued with the annual workshop that had an emphasis on ransomware as a significant threat and measures that can be taken to reduce risk to public and private organizations.
New positive uses of drones continue to be found. The CRDR successfully completed a 2017 Department of Homeland Security Resilience Challenge Grant that funded research into drone inspections of bridges in a postearthquake scenario. A workshop and a webinar discussed appropriate measures to establish a drone program. Work continued with the 2019 Resilience Challenge Grant on expanding the use of drones to support the inspection of other forms of critical infrastructure. The project entails drone workshops in Oregon, Idaho, Montana and Washington to assist states in improving the situational awareness on the status of critical infrastructure following a disaster. Long-term power outages caused by solar activity, also called a Coronal Mass Ejection (CME), was addressed in CRDR workshop. This CME hazard is one of the top priorities for the Department of Homeland Security (DHS) due to a lack of planning that has not been done to-date. Experts on this subject provided briefings and the interdependencies between infrastructures were explored by the attendees.
VISIT REGIONALRESILIENCE.ORG
261 Alumni
class hours
Legislators, municipal leaders, committee staffers, executive branch officials have graduated from the program to date
Hours contributed by legislators to participate in energy training
Split into two sessions in Richland, WA and Washington, D.C.
Legislators give LEHI a rating of 4.83 out of 5 on quality, saliency and content
LEGISLATIVE ENERGY HORIZON INSTITUTE July 6 - 9, 2019 | Richland, WA
LEHI is in its 9th consecutive successful year. Formal assessments show learning increases in every course module every year
October 24 - 26, 2019 | Washington, D.C .
visit pnwer.org/energyhorizon The Legislative Energy Horizon Institute (LEHI) is a certificate program covering the North American energy system. LEHI is specifically designed to prepare emerging state and provincial leaders the ability to address the complex energy issues facing state and provincial legislatures. The comprehensive curriculum helps policymakers understand how energy systems and infrastructure work; how energy infrastructure is built and financed; and the regulation and market impacts on energy infrastructure
►► Electric Power Generation, Transmission, Distribution ►► Natural Gas Production, Transmission & Delivery ►► Petroleum 101 ►► Integrating Renewables ►► Smart Grid & Energy Storage ►► Canada’s Energy Picture ►► Future of Utilities & Ratemaking ►► Carbon Markets ►► Cyber Security ►► Outlooks for state & provincial energy regulation
“If you want to understand the complexity and significance of energy policy to our civil society, then LEHI is your premier ‘goto’ program to jump start your education” Senator Albert Olszewski, MT
University of Idaho | U.S. Department of Energy | National Conference of State Legislators (NCSL) | Government of Canada | Western Governors Association | Pacific Northwest National Laboratory | Energy Council
PNWER TRADE ADVOCACY “When markets are open and goods are transported freely across borders, the result is economic growth, new businesses, and more and better job opportunities for individuals.” - Larry Doke, MLA, Saskatchewan PNWER President 2018 - 2019
PNWER met with Congressman Earl Blumenauer (OR) and House Ways & Means Chairman Richard Neal
►► PNWER prepared and delivered letters to all of the region’s congressional delegation strongly urging them to ratify the USMCA and to encourage the Trump administration to remove the steel and aluminum tariffs. These letters reiterated the importance of free, fair, and open trade for the mutual benefit of the three economies
The U.S. - Canada trade partnership is the largest in the world Since the USMCA was signed by the leaders of the U.S., Mexico, and Canada in November of 2018, PNWER has supported the trade deal as an important part of the U.S. Canada relationship. PNWER has sent letters to and met with members of Congress to encourage them to ratify the USMCA while emphasizing the importance of maintaining a strong trade relationship with our closest neighbors.
►► PNWER applauds agreement on lifting steel and aluminum tariffs and associated retaliatory tariffs ►► PNWER drafts USMCA resolution and submitted to PNWER states ►► PNWER testified to trade committees in 5 states as part of Annual Capital Visits ►► PNWER Joined the Pass USMCA Coalition which is a group of U.S. companies and associations working to secure congressional approval of the USMCA
“Here in the Pacific Northwest we are stronger by working closely together, and our relationships are intact because of the ongoing partnerships in every major sector of the economy, and in state, provincial, territorial, and tribal governments.” - Sen. Arnie Roblan, OR
PNWER Past President 2017 - 2018
PNWER met with all 29 congressional leaders from the northwest states advocating for the USMCA and repeal of section 232 tariffs.
Letters and statements sent directly to President Trump and Ambassador Lighthizer
$673 billion
$282.3 Billion
Total value of trade between the U.S. and Canada in 2017
Canada is the largest goods export market for the United States
Two-way trade with Canada in the Pacific Northwest
KEYNOTE SPEAKERS Edward Alden Senior Fellow, Council on Foreign Relations Wed July 24 | 12:30 - 2:15pm Edward Alden is the Ross Distinguished Visiting Professor in the College of Business and Economics at Western Washington University, and a senior fellow at the Council on Foreign Relations in Washington, D.C. He is author of Failure to Adjust: How Americans Got Left Behind in the Global Economy . He was the project director for the Council’s Independent Task Force report The Work Ahead: Machines, Skills and U.S. Leadership in the 21st Century. His first book, The Closing of the American Border: Terrorism, Immigration and Security Since 9/11 was a finalist for the J. Anthony Lukas book prize. He has testified to Congress many times, written for major newspapers, and appeared on major news networks.
Murad al-katib president and Ceo, AGT foods Tue July 23 | 12:30- 2:15pm Murad Al-Katib, President and CEO of AGT Food and Ingredients Inc., is the guiding vision in all aspects of the business, also serving on the Board of Directors. A strong financial and strategic business thinker, able to anticipate and mitigate the risks in international trading and commodities, Murad earned his MBA then worked in trade promotion for the Saskatchewan government. In 2001, he founded Saskcan Pulse Trading, providing the nucleus for AGT, growing the company into a world leader in value-added pulses, staple food, and pulse ingredients for markets around the globe and building a Canadian start-up into a global billion dollar company.
Mayor Charlie Clark City of Saskatoon Sun July 21 | 6:00 - 8:00pm Mayor Clark was elected in 2016 with a mandate to make Saskatoon the city that gets it right - on planning for growth, creating economic opportunities, and improving safety and quality of life for all residents. Charlie is passionate about Saskatoon. He believes our history of innovation, problem-solving, and collaboration can position us as a leading city across Canada. His approach is centered on the belief that partnerships among groups with different perspectives can offer the best solutions to the challenges being faced by cities across the world. He is committed to building a community where people,see each other’s strengths, where families thrive, and children see a future for themselves here. Pacific Northwest Economic Region
KEYNOTE SPEAKERS Jennifer Fox, VIce president, International Trade Policy & Canada Relations, NASCO Tue July 23 | 7:30 - 9:00am Jennifer Fox is an advocate for Canada’s role in global trade and the impact the CA-U.S. relationship has on North America’s ability to compete in global trade markets. With nearly fifteen years of industry experience in supply chain logistics and trade, Jennifer has developed and maintains close relationships with both Canadian and U.S. officials to raise awareness of, and bring pragmatism to border and security issues impeding North American competitiveness. Jennifer’s experience has touched on all things trade and border related from the commercial processes of import, export, and transport to the movement of passengers, people, and cross border tourism.
Honourable Ralph Goodale Minister of Public Safety and Emergency Preparedness Wed July 24 | 8:00 - 9:00am Canada’s Minister of Public Safety and Emergency Preparedness since 2015. Ralph Goodale was raised on a family farm near Wilcox, SK, and educated at both the University of Regina and University of Saskatchewan, Goodale has practical experience in business, agriculture, law and broadcasting, as well as federal and provincial politics. He was first elected to Parliament in 1974, and has served in the Saskatchewan Legislative Assembly. He has held several cabinet positions previously serving as Minister of Agriculture, Natural Resources, Leader of the Government in the House of Commons, Public Works, and Finance. Goodale is the only M.P. to serve in both Trudeau governments.
SCOTTY GREENWOOD CEO, CANADIAN AMERICAN BUSINESS COUNCIL Mon July 22 | 7:30- 9:00am & Wed July 24 | 12:30 - 2:15pm Maryscott “Scotty” Greenwood is a Crestview Strategy Partner. A former American diplomat to Canada and a frequent media commentator and public speaker, Scotty serves as a business and public policy advocate, communications expert, and political strategist to Fortune 500 companies, trade associations, and non-profit organizations. CEO of the CanadianAmerican Business Council, she has repeatedly been recognized by Canadian newsweekly The Hill Times which has named her one of the country’s “Top 100 Lobbyists” (2017), “Top 100 People influencing Canadian Foreign Policy” (2014), and “Top 100 Most influential People in Government and Politics” (2010).
Goldy Hyder President and CEO, Business Council of Canada Wed July 24 | 12:30 - 2:15pm Goldy Hyder was appointed President and Chief Executive Officer of the Business Council of Canada in 2018. Founded in 1976, the Council is a non-profit, non-partisan organization composed of the chief executives and entrepreneurs of 150 leading Canadian companies, representing every major industry and region. From 2014 to 2018, Mr. Hyder was President and CEO of Hill+Knowlton Strategies, providing strategic communications counsel to the firm’s extensive and diverse client base. Prior to that, he served as director of policy and chief of staff to The Right Honourable Joe Clark, former prime minister and former leader of the then federal Progressive Conservative Party.
Ambassador David Jacobson Former U.S. Ambassador to Canada 2009 - 2013 Mon July 22 | 7:30 - 9:00am Mr. Jacobson became Vice Chairman of BMO Financial Group in October 2013. In that role, he is responsible for driving business across all lines, including Capital Markets, Personal and Commercial Banking, and Wealth Management. Prior to joining BMO, Mr. Jacobson served as the 22nd United States Ambassador to Canada from 2009 to 2013. As Ambassador, Mr. Jacobson worked to expand the bilateral trading relationship between the U.S. and Canada, raising it to the highest level between any two countries in history. Ambassador Jacobson led the Beyond the Border and Regulatory Cooperation efforts to improve security and efficiency of the border between the two countries.
Vee Kachroo, Senior Vice President, Operations Canpotex Tue July 23 | 7:30 - 9:00am Vee Kachroo was appointed as Senior Vice President, Operations of Canpotex in September 2017. Vee is based out of Canpotex’s head office in Saskatoon. He is a member of the Canpotex Executive Leadership Team. Prior to joining Canpotex, Vee worked for CN Rail for over 30 years, holding a variety of technical, financial, sales and marketing, commercial, and operating roles. He served as Vice President of Supply Chain Solutions from 2012 - 2017, and was responsible for subsidiaries that included Autoport, Transloads, CNWW, Great Lakes Fleet (vessels and docks), and freight optimization. Other positions at CN included Vice President Industrial Products from 2010 - 2012. Pacific Northwest Economic Region
KEYNOTE SPEAKERS AmBassador Michael Kergin Former Canadian Ambassador to the U.S. 2000 - 2005 Mon July 22 | 7:30 - 9:00am Michael Kergin is a Senior Advisor to Bennett Jones LLP. He provides advice to clients on international affairs, particularly Canada - U.S. relations. He has over 40 years of experience in the Federal Government of Canada. Michael is a former Canadian Ambassador to the U.S. (20002005), and to the Republic of Cuba (1986 - 1989). He was the foreign and defence policy advisor to Prime Minister Chretien, the equivalent of the National Security Advisor in the United States. After leaving government, Michael founded a consulting firm and was appointed as Special Advisor to the Premier of Ontario for Border Management.
Phil Lamarche, Director of Transportation operations Federated Co-Operatives Ltd Tue July 23 | 7:30 - 9:00am Phil Lamarche was recently appointed as the Director of Transportation Operations at Federated Cooperatives Ltd in May of 2019. He has been with FCL since October 2017. Prior to his arrival at FCL Phil spent over 30 years in the downstream petroleum industry, 18 of which have been in transportation and/or distribution. He has served as Chair on the Land Spill Response Committee of the Eastern Canada Response Corporation (ECRC) and has also served on the Distribution Committee with the Canadian Fuels Association. His career has taken him to every corner of the country from Halifax to St. John’s, two tours in Montreal, Mississauga, Edmonton, Calgary, and now in Saskatoon, Saskatchewan.
The Honourable bob McLeod Premier of the Northwest Territories Mon July 22 | 12:30 - 2:15pm The Honourable Bob McLeod has served as the Premier for the Northwest Territories since October 2011. Born and raised in NWT, he has been elected three times to the NWT Legislative Assembly to represent the constituents of Yellowknife South as an Independent. Mr. McLeod has over 28 years of experience in public service with both the Government of the Northwest Territories and the Government of Canada. In addition to his duties as Premier, Mr. McLeod has served in a variety of senior roles including Minister of Industry, Tourism and Investment, Minister Responsible for the Public Utilities Board, Minister of Aboriginal Affairs and Intergovernmental Relations, Minister Responsible for New Energy Initiatives.
David Miller Canadian National Railway Company Tue July 23 | 7:30 - 9:00am David Miller has worked in Canadian Government and Government Relations for the past 40 years. He recently retired as Assistant Vice President, Government Affairs at CN, a position he held for 16 years. Prior to joining CN, Mr. Miller worked in a variety of positions in government and public affairs. He served three years as Director of Operations and Senior Advisor to the Prime Minister of Canada. He also has experience in government as an assistant to three federal Ministers of Transport and spent time as Executive Assistant to the Leader of the Opposition. Mr. Miller spent ten years as a government relations consultant based in the Ottawa office of the firm Hill and Knowlton Canada.
The Honourable Scott Moe Premier of Saskatchewan Mon July 22 | 12:30 - 2:15pm Scott Moe was sworn in as Premier of Saskatchewan in 2018, after first serving in the legislature since 2011. He has previously served as Minister of Environment, Minister of Advanced Education, Minister responsible for SK Water Corporation, and Minister responsible for SK Water Security Agency. Premier Moe’s priorities include a focus on increasing Saskatchewan’s exports to create opportunities for people and further grow Saskatchewan’s economy. To this end, he created the Ministry of Trade and Export Development with a mandate to sustain and develop relationships with Saskatchewan’s current export customers and place an increased emphasis on diversifying our markets worldwide.
Colin Robertson Vice President, Canadian Global Affairs Institute Wed July 24 | 12:30 - 2:15pm A former Canadian diplomat, Colin Robertson is Vice President and Fellow at the Canadian Global Affairs Institute. He is an Executive Fellow at the University of Calgary’s School of Public Policy and a Distinguished Senior Fellow at the Norman Peterson School of International Affairs at Carleton University. Robertson sits on the advisory councils of the JohnsonShoyama School of Public Policy and the North American Research Partnership, among others. A member of the teams that negotiated the Canada-U.S. FTA and then the NAFTA, he is a member of the Deputy Minister of International Trade’s NAFTA Advisory Council and the North American Forum. He writes on foreign affairs for the Globe and Mail. Pacific Northwest Economic Region
KEYNOTE SPEAKERS Robin Silvester President and CEO, Port of Vancouver Tue July 23 | 7:30 - 9:00am Mr. Silvester was appointed president and chief executive officer of the Vancouver Fraser Port Authority in 2009, bringing to the position extensive international experience in both the port and property sectors. Mr. Silvester spent a significant portion of his career serving in senior roles internationally with P&O Ports, having served as CEO of P&O Ports Canada in Vancouver. Mr. Silvester is involved in a number of boards: the Association of Canadian Port Authorities, the Int’l Association of Ports and Harbors, the Greater Vancouver Gateway Council, the Greater Vancouver Board of Trade, the Western Transportation Advisory Council, the Canada West Foundation, and the British Columbia Business Council.
John Stackhouse Senior Vice President, royal bank of Canada Tue July 23 | 12:30 - 2:15pm As Senior Vice President, Office of the CEO at the Royal Bank of Canada, John is responsible for interpreting trends for the executive leadership team and Board of Directors with insights on how these are affecting RBC, its clients, and society at large. Prior to this, John was editor-in-chief at the Globe and Mail (2009 - 2014), editor of Report on Business, and from 1992 - 1999, a foreign correspondent based in New Delhi, India. He has authored three books: Out of Poverty, Timbit Nation, and most recently, Mass Disruption: Thirty Years on the Front Lines of a Media Revolution. John is a Senior Fellow at the C.D. Howe Institute and the University of Toronto’s Munk School of Global Affairs.
Dr. Peter Stoicheff President, University of Saskatchewan Mon July 22 | 6pm - 8pm When he was named the University of Saskatchewan’s 11th president on October 24, 2015, Peter Stoicheff promised to remain true to the university’s storied past, while enhancing its focus on the future - on the university’s commitment to being the university the world needs. Peter understands the need to connect the academy with communities. An active scholar throughout his career, he is highly regarded internationally for his work on modern literature, and his exploration of the history of the book and its future in a digital age. Peter has served in national and provincial leadership roles in research, scholarly, and artistic work. Peter has an undergraduate degree in English and a PhD in literature.
Representative Gael Tarleton Washington State Legislator Tue July 23 | 7:30 - 9:00am Gael is a former senior defense analyst for the Pentagon, a Port of Seattle Commissioner, an international business director, and most recently worked at the University of Washington for more than 8 years before joining the Washington State Legislature in 2013. As a representative for the 36th Legislative District, Gael is currently chair of the Finance Committee, and has served in a variety of leadership roles including Majority Floor Leader. She holds a master’s degree from Georgetown University and a Bachelor of Science from Georgetown’s School of Foreign Service. Gael always focuses on finding bipartisan solutions to statewide problems and providing opportunities to consensus.
Jim Titsworth, General Director, Canadian Business Development, BNSF Railway Tue July 23 | 7:30 - 9:00am Jim Titsworth joined BNSF Railway in 1989 and is currently General Director of Canadian Business Development. In this role, he oversees a broad array of business development activities in Canada across all four of BNSF’s Business Units. He has held a variety of positions with increasing responsibility within BNSF, including Agricultural Marketing, Iron and Steel Marketing, Consumer Products and Merchandise Equipment, Intermodal Equipment Operations, Interline and Franchise Development and now Canadian Business Development. In addition to development of BNSF’s Canadian franchise, Jim’s international activities have also included joint venture responsibilities in Mexico.
Victor Thomas Vice President, Prairie Region, Asia Pacific Foundation Tue July 23 | 12:30 - 2:15pm Victor Thomas is Vice-President, Prairie Region, of the Asia Pacific Foundation of Canada. He is a Past Chair of the Regina & District Chamber of Commerce and Vice Chair of SaskEnergy Inc. In Saskatchewan, he currently is Strategic Advisor to the President at the University of Regina, and Vice-Chair of Innovation Place in Regina and Saskatoon. Nationally, he serves on the Banff Forum Advisory Council, the National Executive for the 2020 Governor General’s Canadian Leadership Conference, the Directors College Alumni Advisory Board, and on the Rideau Hall Foundation Board. Globally, he is Chair of CARE International in Kenya’s Board of Directors. Pacific Northwest Economic Region
KEYNOTE SPEAKERS Ambassador David Wilkins Former U.S. Ambassador to Canada, 2005 - 2009 Mon July 22 | 7:30 - 9:00am Ambassador David Wilkins chairs the public policy and international law practice group with a special focus on U.S. - Canada interests. He proudly served as U.S. ambassador to Canada from June 2005 to January 2009, appointed by President George W. Bush. Since returning home from Canada, Ambassador Wilkins spent six years chairing the Clemson University Board of Trustees and remains as an active member of that board. He also sits on the board of United Community Bank. First elected in 1980, Wilkins served 25 years in the South Carolina House of Representatives. He was elected as speaker in 1994 - a position he held for 11 years until he resigned for his ambassadorship post.
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DETAILED AGENDA SUNDAY, JULY 21 Registration
Bess Convention Foyer
Executive Board Luncheon
Executive Committee & Delegate Council Meeting (open to all)
Executive Committee & Sponsor Reception (invitation only) Hosted by Nelson Mullins
6:00 -8:00PM
Bessborough Gardens
10:00 - 7:00PM 12:00 - 1:00PM
WELCOME RECEPTION FEATURING MAYOR CHARLIE CLARK SUNDAY, JULY 21 6:00PM - 8:00PM | BESSBOROUGH GARDENS Hosted by the City of Saskatoon and Tourism Saskatoon
9:00 - 11:00PM
Hospitality Suite - Hosted by CN
MONDAY, JULY 22 7:00 - 5:30PM 7:30 - 9:00AM
Sheraton Conference Foyer
Opening Keynote Breakfast and First Nation Welcome
Sheraton Ballroom
OPENING KEYNOTE BREAKFAST FEATURING FORMER U.S. - CANADA AMBASSADORS MONDAY, JULY 22 7:30AM - 9AM | SHERATON BALLROOM A panel of former U.S. - Canada Ambassadors will kick off the Summit reflecting on the U.S. - Canada relationship. Featured panelists include: David Wilkins, former U.S. Ambassador to Canada (top) Michael Kergin, former Canadian Ambassador to the U.S. (center right) David Jacobson, former U.S. Ambassador to Canada (center left) Moderated by Scotty Greenwood, CEO, Canadian American Business Council Hosted by Nutrien Pacific Northwest Economic Region
DETAILED AGENDA MONDAY, JULY 22 9:15 - 11:30AM Coffee Break hosted by NorthWestern Energy
Monday Morning Working Group Sessions Trade Sheraton Top of the Inn Infrastructure Bess Williams Pascoe Resilience & Energy Innovations Forestry Sheraton West Room Tourism Bess Terrace Lounge Invasive Species Bess Salon Batoche
TRADE SESSION
Monday, July 22 9:15am - 11:30am | Sheraton Top of the Inn
Katherine Dhanani U.S. Consul General Vancouver
Opening comments from Consuls General on the benefits of USMCA/CUSMA, and the path forward Katherine Dhanani, U.S. Consul General, Vancouver Brandon Lee, Consul General of Canada, Seattle A global perspective on the North American trade relationship. How is North America positioned to lead the world in trade in the 21st Century? Edward Alden, Bernard L. Schwartz senior fellow at the Council on Foreign Relations (CFR) and Ross Distinguished Visiting Professor, Center for International Business, Western Washington University
Brandon Lee Consul General of Canada Seattle
U.S. - Canada trade panel - Commentary on current events impacting trade and the path forward. Moderated by Chris Dekker, President and CEO, Saskatchewan Trade and Export Partnership Lucia Piazza, U.S. Consul General, Calgary StĂŠphane Lessard, Consul General of Canada, Denver Scotty Greenwood, CEO, Canadian American Business Council Ben Voss, President & CEO, Morris Industries Ltd. Gordon Stoner, Director, U.S. Dry Pea & Lentil Association
Action item discussion: How can PNWER work to address current trade issues?
Working Group Welcome Rick Glumac, Parliamentary Secretary for Technology, MLA, British Columbia Paul Manson, CEO, Grid Development Corp
Roadmap to Resilient, Ultra-low Energy Buildings in the Pacific Northwest PNWER is advancing the development of a “Roadmap” to improve infrastructure resilience and energy efficiency in new and existing buildings through “net zero” energy targets by 2030. Efficient buildings encourage job creation, affordability, competitiveness, and resilience. Through consultations with all levels of government and the private sector, the Roadmap will develop marketdriven strategies to promote energy efficiency including technical research; best practice sharing; promotion of innovative technologies and construction materials; industry capacity building; and workforce development. Currently, the Energy and Environment Working Group is commissioning research at the University of Victoria to examine synergies in building design and retrofit solutions that advance climate adaptation, resilience, and energy savings objectives. Join the Resilience Building Network at www.pnwer.org/energy-and-environment.
Rick Glumac, MLA Parliamentary Secretary for Technology, British Columbia
Paul Manson CEO DC Grid Development Corporation
INFRASTRUCTURE RESILIENCE & ENERGY INNOVATIONS Bess Williams Pascoe | Monday, July 22 9:15am - 11:30am
Hosted by FortisBC, Insulating Concrete Forms Manufacturers Association, Energy Trust of Oregon, RDH Building Science, Construction Center of Excellence, & BC Ministry of Municipal Affairs and Housing. The connection between infrastructure, energy innovation and resilient cities How do we prepare region to take advantage of new energy technologies, adapt to climate stresses, and foster resilient cities? Public leaders and industry experts will examine the connections and interdependencies between infrastructure, energy innovations and resiliency in this panel. Speakers will share their experience with these emerging opportunities as well as explore the role of cities, states/provinces, and the private sector in developing a resilient northwest. Rep. Beth Doglio, Washington State (via phone) Ian Loughran, Owner, Vereco Homes Inc. Mayor Roy Ludwig, City of Estevan Virginia Wittrock, MSc, Climate Research Specialist, Saskatchewan Research Council Renewable energy in Northern / Indigenous / remote communities Remote, indigenous, and northern communities face unique challenges and creative solutions in meeting energy needs for consumers and industry. Each panel participant will showcase the benefits of their project and address the technical, financing, and workforce challenges faced. Participants will discuss the best practices in energy efficiency and resiliency and how can they be applied in the rest of the PNWER jurisdictions. Moderated by Paul Manson, CEO, DC Grid Development Corporation Jenna Gall, Community Energy Project Manager, First Nations Power Authority Dr. Greg Poelzer, Professor, School of Environment and Sustainability, University of Saskatchewan Jessica Nixon, CEO, Cowessess Ventures Ltd. David Isaac, President, W Dusk Energy Group Action item discussion and looking ahead to Seattle Economic Leadership Forum Nov. 17-19 Pacific Northwest Economic Region
Monday, July 22 9:15am - 11:30am | Sheraton West Room
Mark Peck Libby County Commissioner Montana
Welcome, Introductions and Opening Remarks Travis Joseph, President, American Forest Resource Council Mark Peck, Lincoln County Commissioner, District 1, Montana Wildfire Impacts on Tourism, Public Health, and Local Economies What are the current impacts to tourism, public health, and local economies from wildfires in our region? What will be the long-term impacts on our region from evermore intense wildfire seasons?
Travis Joseph President American Forest Resource Council
Sara Morrissey, Public Affairs Manager, Travel Oregon Dr. Christopher T. Migliaccio, Research Associate Professor, College of Health Professions & Biomedical Sciences, University of Montana-Missoula Mitigation Strategies - What can we do about it? What mitigation strategies are being employed in our region? What are the challenges and successes? What is going well and what needs to be improved? Larry Fremont, Education and Prevention Coordinator, Wildfire Management Branch of the Saskatchewan Ministry of Environment Other Jurisdictions Action item discussion
TOURISM SESSION
Monday, July 22 9:15am - 11:30am | Bess Terrace Lounge Hosted by The Butchart Gardens Welcome, Introductions and Opening Remarks Dave Cowen, CEO, The Butchart Gardens
Rep. Gael Tarleton Washington
Rep. Gael Tarleton, Washington State Legislature 2019 Regional Tourism Dashboard Updates on the latest regional tourism picture, including statistics on the state of the tourism industry Matt Holme, Manager, Corporate Communications and Destination Management at Destination Greater Victoria
Dave Cowen CEO The Butchart Gardens
Industry Listening session: Indigenous Tourism Case Study of Saskatchewan Indigenous Tourism Corridor Jim Bence, President & CEO, SK Hotel & Hospitality Association
Christian Boyle, Owner, Glyph Creative Strategy Keith Henry, CEO, Indigenous Tourism Association of Canada (invited)
TOURISM SESSION CONT’D
Bess Terrace Lounge | Monday, July 22 9:15am - 11:30am
Case for regional electrification strategy & modernization of Victoria Cruise Bus Fleet David Roberts, Managing Director, Pacific NW Transportation Services Lindsay Gaunt, Director of Cruise Development, Greater Victoria Harbour Authority Roundtable for industry issues and briefings Around the room call for discussion from industry Discussion of Action items and key findings
Electrification and Modernization of Tourism and Ground Transportation How can we create a more sustainable tourism industry? And how are we able to collaborate better regionally to ensure long-term sustainable growth and become a world leader as it relates to tourism, cross-border technology; and a “Two-nation vacation” destination?
Bess Salon Batoche | Monday, July 22 9:15am - 11:30am
Update from Manitoba on Status of Invasive Mussels Mussel impacts, program, challenges, and successes. What is the latest status from a neighboring province dealing with invasive quagga and zebra mussels? Jeff Long, AIS Director & Manager, Manitoba Ministry of Sustainable Development Update on Federal Aquatic Invasive Species Funding, Program & Auditor General’s Report Fisheries & Oceans Canada to provide an overview of the federal AIS program with updates on western provincial collaboration and outcomes/findings of the Auditor General’s Report. PNWER CEO to provide update on federal funding status for AIS in the west (WRDA) Becky Cudmore, Department of Fisheries & Oceans Canada (invited) Matt Morrison, CEO, Pacific NorthWest Economic Region Legislative Panel Legislators will have an opportunity to emphasize key concerns and issues. What are key issues being dealt with in jurisdictions? Rep. Terry Gestrin, Idaho Herb Cox, MLA, Saskatchewan Sen. Jon Sesso, Montana Rep. Jeff Morris, Washington
Rep. Terry Gestrin Idaho
Kate Wilson Commission Administrator Montana Dept. of Natural Resources and Conservation
Opening Remarks & Introductions
Western Provinces priorities: Opportunity to emphasize priorities across Western Provinces Provincial program leads: Nicole Kimmel, Alberta; Manjit Kerr-Upal, British Columbia; Matt Tyree & Jeri Geiger, Saskatchewan; & Jeff Long, Manitoba Pacific Northwest Economic Region
MONDAY, JULY 22 11:30 - 12:30PM 11:30 - 12:30PM 12:30 - 2:15PM
Networking Break | Hosted by Shell
Sheraton Hamptons Room
Orientation on PNWER governance, working group action plans, how PNWER works (Open to all)
Sheraton Starlight Room
Keynote Luncheon
SUMMIT FEATURE KEYNOTE WITH PREMIER SCOTT MOE OF SASKATCHEWAN MONDAY, JULY 22 12:30PM - 2:15PM | SHERATON BALLROOM Premier Scott Moe welcomes Summit attendees to Saskatchewan, followed by remarks from Premier Bob McLeod of the Northwest Territories Hosted by Canpotex
AND REMARKS BY PREMIER BOB MCLEOD OF THE NORTHWEST TERRITORIES 2:45 - 5:00PM
Monday Afternoon Working Group Sessions Border Sheraton Top of the Inn Climate Policy & Economic Growth Bess Williams Pascoe Agriculture Offsite at Ag In Motion, Buses will depart at 2:15 Bess Terrace Lounge University Presidents’ Roundtable Bess Salon Batoche Invasive Species
BORDER SESSION
Monday, July 22 2:45pm - 5:00pm | Sheraton Top of the Inn
Sen. Mike Cuffe Montana
Laurie Trautman Border Policy Research Institute
PNWER continues to serve as a top forum for U.S. - Canada border coordination and collaboration by providing input on preclearance and recommendations for potential pilots in our region. PNWER has worked with public and private stakeholders to provide input to federal partners on specific issues to facilitate cross-border travel. Pre-Arrival Readiness Evaluation (PARE) pilot: PARE is an automated traffic management system for commercial vehicles departing Canada, which will be used to optimize traffic flow on the Peace Bridge during a planned three-year bridge resurfacing project. CBP is working with Public Bridge Authority to exchange information of commercial vehicles to determine if commercial fees have been paid and travel documentation has been properly filed to further the efficient movement of commercial vehicles and cargo
Ron Reinas, GM, Buffalo and Fort Erie Public Bridge Authority
BORDER SESSION CONT’D
Preclearance update Deborah Meyers, Director, Canadian Affairs & Senior Advisor on North America, U.S. Department of Homeland Security Beyond Preclearance Initiative- Designing the inter-modal Canada -U.S. Border processes toward using smart technology Gerry Bruno, Vice President, Federal Government Affairs, Vancouver Airport Authority; Co-Chair of the Beyond Preclearance Coalition
Sheraton Top of the Inn | Monday, July 22 2:45pm - 5:00pm
Northern border, remote ports, and the need for co-location Senator Mike Cuffe, Montana State Legislature CBP / CBSA roundtable A facilitated dialogue focused on utilizing technology at the border, addressing rural border crossings, preclearance caro pilot in the northwest and recommendations from the Beyond Preclearance Coalition. Rose Marie Davis, Director, Innovative Program Acquisitions (IPA), Office of Field Operations (OFO), Planning, Program Analysis and Evaluation (PPAE), U.S. Customs and Border Protection
CBSA Representative Action Item Discussion
Hosted by FortisBC Climate change policies can promote economic growth and job creation by investing in new and innovative industries such as clean tech, low-carbon transportation options, energy efficiency upgrades, and agricultural and forestry investments. This session will explore the linkages between environmental policies, good jobs, and economic growth.
Hon. Dustin Duncan Minister of Environment; Sask Water Security Agency; Sask Power
Welcome, introductions, and opening remarks Hon. Dustin Duncan, Minister of Environment, Saskatchewan Sen. Michael Dembrow, Co-chair, Joint Committee On Carbon Reduction, Oregon Legislative Panel: What are the economic benefits of climate action strategies? Panelists will provide an overview of climate policies in their jurisdiction with an emphasis on the economic benefits and resulting innovation resulting from climate action strategies. Discussion will focus on emerging economic opportunities from workforce developments, tech innovation and lower energy costs; designing climate policies in line with specific emission profiles; and lessons to be shared with the rest of the PNWER region.
Sen. Michael Dembrow Oregon
CLIMATE POLICY & ECONOMIC GROWTH Bess Williams Pascoe | Monday, July 22 2:45pm - 5:00pm
CLIMATE POLICY & ECONOMIC GROWTH CONT’D Monday, July 22 2:45pm - 5:00pm | Bess Williams Pascoe Panelists
Hon. Dustin Duncan, Minister of Environment, Saskatchewan Hon. Bronwyn Eyre, Minister of Energy and Resources, Saskatchewan Rick Glumac, Parliamentary Secretary for Technology, MLA, British Columbia
Senator Mike Dembrow, Oregon Representative Gael Tarleton, Washington Paolo Gallina, MLA, Yukon
Industry perspective: How have climate action strategies contributed to the economic growth in your company / industry? Panelists will share how climate policies have positively impacted their business through business certainty, creation of new markets, incentivizing tech innovation and workforce promotion. David Bennett, Director, Communications and External Relations, FortisBC Adam Auer, Vice President, Environment & Sustainability, Cement Association of Canada Bryan Buggey, Director, Strategic Initiatives and Sector Development, Vancouver Economic Commission Action Item Discussion
AGRICULTURE Monday, July 22 2:30pm - 5:00pm | Offsite at Ag in Motion Hosted by the Saskatchewan Cattlemen’s Association
Larry Doke, MLA Saskatchewan
Patrick Kole Vice President Idaho Potato Commission
This session will take place at the Ag-in-Motion site near Saskatoon. Buses will board outside of the hotel at 2:30pm. Following the demonstrations at Ag-inMotion, buses will take participants directly to the reception at the University. Participants should wear comfortable clothing and shoes since many of the demonstrations will be outdoors. Technology and Agriculture See the newest agricultural technology in the field. Ag in Motion, Western Canada’s first outdoor farm expo, is situated on 320 acres of prime agricultural land, northwest of Saskatoon. The session will feature live demonstrations of field equipment, crop plots, and interactive agribusiness exhibits showcasing the newest technology in ag. Welcoming Remarks
Hon. David Marit, Minister of Agriculture, Saskatchewan
MONDAY, JULY 22 AGRICULTURE CONT’D
How is new technology impacting agriculture across the region? What policy updates are needed to address the growing demand for new tech in ag?
• Lack of high-tech curriculum for agriculture students - we need “Techgronomists” and we need them now • Lack of broadband coverage- can’t have a Smart farm with a slow connection • There is a need to deal with regulatory issues regarding autonomous farm equipment, how can our elected leaders work with industry to address this gap? Robert Saik, CEO at DOT Ready Retail - Autonomous Robotic Broad Acre Farming Platform Tour demonstrations: 1. DOT Demo - The DOT Power Platform is a mobile diesel-powered platform designed to handle a large variety of implements commonly used in agriculture, mining, and construction. Its U-shaped frame facilitates the direct loading of implements, so that, once loaded, the implement “becomes one” with the mobile powered platform. 2. Drone Demo- Drone technology produces accurate, actionable, and affordable data. The surge in UAV (Unmanned Aerial Vehicle) technology allows for the collection and delivery of information that was, until recently, cost prohibitive or even impossible to obtain 3. Pessl/METOS technology demo. The METOS equipment is new to Western North America and it uses the LoRa network to deliver data collected by a wide range of sensors to the user in a way that is less prone to interference at a lower cost than current digital options. 4. U of S seminar ( Soil Fertility & Herbicide technology ) Using crop imagery to drive yield increases from plant breeding and crop management.
Offsite at Ag in Motion | Monday, July 22 2:30pm - 5:00pm
Please meet at the Sheraton Conference Foyer at 2:15pm for tour departure. Buses will leave the Ag-in-Motion site at 5:15pm and go directly to the reception at the University of Saskatchewan
UNIVERSITY PRESIDENTS ROUNDTABLE
Monday, July 22 2:45pm - 5:00pm | Bess Terrace Lounge Dr. Peter Stoicheff President University of Saskatchewan
Welcoming and Introductions President and Vice-Chancellor Peter Stoicheff, University of Saskatchewan The role of universities in Bridging Economic Reconciliation A moderated discussion of these questions featuring indigenous leaders, followed by responses and commentary from a panel of university presidents. The Indigenous panel discussion will be moderated by Craig Hall, Chief Operating Officer of Indigenous Works, a non-profit national organization that helps foster successful partnerships between companies and Indigenous organizations. 1. What are the roles that universities can play to help Indigenous / Native American communities and institutions achieve their self-determination and well-being goals, sustainable socio-economic outcomes, and prosperity? 2. How can university education and research opportunities be made more attainable to Indigenous students, businesses, organizations, and communities in Canada and the U.S.? 3. What do we mean when we talk about ‘innovation’ in the Indigenous context? Manley Begay, a Native American (Navajo) who earned his master’s and PhD degrees in education from Havard, is a professor of applied Indigenous studies at Northern Arizona University and is also on the faculty of the College of Social and Behavioral Sciences, with appointments to the Department of Politics and International Affairs. He is currently co-director of the Harvard Project on American Indian Economic Development. Judith Sayers, member of the Hupacasath First Nation (was chief there for 14 years), is currently a Strategic Adviser to First Nations and corporations, as well as an adjunct professor with the Peter Gustavson School of Business at the University of Victoria. Lee Ahenakew, a member of the Ahtahkakoop Cree Nation and University of Saskatchewan commerce graduate, is a management consultant who builds business opportunities with First Nations and industry, with a focus in the natural resource and utility sectors. He has served as Interim CEO for the First Nations Power Authority of Saskatchewan and is currently on the board of directors. He was formerly chair of the USask Board of Governors, and is currently a board member.
Existing & Emerging Pathways and Threats Potash Primer Potash as molluskicide. The necessity/challenges of registering products in Canada. The processes and differences between the U.S. and Canada re: registration
Nicole Kimmel, Aquatic Invasive Species Specialist, Alberta Environment and Parks Feral Swine: Overview of current distribution, research impacts, and eradication projects Ryan Brook, Associate Professor, University of Saskatchewan Firewood as a Pathway Destructive pests have wreaked unprecedented havoc on regional forests. Campaign overview of infested fireword and invasive tree pests
Dr. Rory McIntosh, Provincial Forest Entomologist and Pathologist, Government of Saskatchewan
Bess Salon Batoche | Monday, July 22 2:45pm - 5:00pm
Prussian Carp: Overview of species, impacts, distribution. Current research and control Mark Poesch, Associate Professor, University of Alberta Action Item Discussion
RECEPTION AT UNIVERSITY OF SASKATCHEWAN FEATURING PRESIDENT PETER STOICHEFF MONDAY, JULY 22 5:45PM - 7:45PM | MARQUIS HALL, USASK The University of Saskatchewan will host PNWER attendees for an evening reception with a welcome from Dr. Peter Stoicheff, University President Hosted by the University of Saskatchewan
Hospitality Suite - Hosted by Cameco
TUESDAY, JULY 23 7:00 - 5:30PM
Opening Keynote Breakfast
TUESDAY KEYNOTE BREAKFAST: BUILDING INFRASTRUCTURE FOR THE 21ST CENTURY TUESDAY, JULY 23 7:30AM - 9:00AM | SHERATON BALLROOM A panel featuring Industry, Port, and Rail will discus Building Infrastructure for the 21st Century and how the region can look forward to the future markets we need to serve. Featured panelists include: Vee Kachroo, Senior Vice President of Operations, Canpotex (top) Phil Lamarche, Director of Transportation Operations, Federated Co-Operatives Limited (top center) David Miller, CN Rail (left center) Robin Silvester, CEO, Port of Vancouver (middle) Representative Gael Tarleton, Washington State (right) Jim Titsworth, General Director, Canadian Business Development, BNSF Railway (bottom left)
Moderated by Jennifer Fox, Vice President, International Trade Policy & Canada Relations, NASCO (bottom) Hosted by the Pacific Northwest Building Resilience Coalition
9:15 - 11:30AM
Tuesday Morning Working Group Sessions
Coffee Break in Bess Williams Pascoe hosted by Washington PUD Association
Transportation & Infrastructure I
Energy Resilience, Regional Reliability and Infrastructure
Agriculture and Cross Border Livestock Health
| Tuesday, July 23
The Transportation and Infrastructure Working Group focuses on the infrastructure of our major corridors and gateways, with a special interest on border infrastructure. The PNWER Innovative Infrastructure Finance Taskforce promotes best practices for public-private infrastructure financing. P3s are innovative financing models between governments and the public sector to build public infrastructure. The Taskforce leverages public and private sector expertise to educate elected officials on the potential applications of P3s and is working with Congressional leadership to fund the Regional Infrastructure Accelerator Demonstration Program which will create a regional “Center of Excellence to assist state and municipalities access existing and new funding sources; share Canadian expertise in P3 projects; support the alignment of multi-state regulations for cross border infrastructure projects; and support the streamlining of regulatory environment. Join the Innovative Infrastructure Finance Taskforce at www.pnwer.org/ transportation.
Sen. Chuck Winder Idaho
Bruce Agnew Director Cascadia Center
Welcome and Overview Bruce Agnew, Director, Cascadia Center Infrastructure Finance Opportunities and Challenges Minister Gordon Wyant, Deputy Premier, Minister Responsible for SaskBuilds, Saskatchewan Mark Romoff, CEO, Canadian Council of Public Private Partnerships Kyle Toffan, CEO, SaskBuilds U.S. Federal Infrastructure Update on 2019 transportation and infrastructure bill in Congress and discussion on regional opportunities Regional Legislative Update Hon. Lori Carr, Minister of Highways and Infrastructure, Saskatchewan Sen. Jeff Golden, Oregon Rep. Terry Gestrin, Idaho Action item discussion
ENERGY RESILIENCE, REGIONAL RELIABILITY, AND THE IMPORTANCE OF INFRASTRUCTURE Tuesday, July 23 9:15am - 11:30am | Bess Williams Pascoe Hosted by MDU Resources
Rep. Derek Skees Montana
Welcome, Introductions and Opening Remarks Representative Derek Skees, Montana State Legislature Dan Kirschner, Executive Director, Northwest Gas Association Energy Update from Saskatchewan Hon. Bronwyn Eyre, Minister of Energy and Resources, Government of Saskatchewan
Dan Kirschner Executive Director Northwest Gas Association
Western Canada Energy Infrastructure Mega Projects What is the status and what are the issues around the large energy infrastructure projects - LNG Export on the northern BC Coast; TransMountain Expansion Pipeline project, and the KXL TransCanada Pipeline? What are the impacts that these projects have on the PNWER economy? If these go forward at approximately the same time, what might the implications be on our regional workforce? Moderated by Barry Penner, Director of B.C. International Commercial Arbitration Centre, and former B.C. Attorney General, Environment Minister, and Minister of Aboriginal Relations Bryan Cox, President and CEO, B.C. LNG Alliance Chris Montgomery, Manager, Exploration and Production Engagement, Canadian Association of Petroleum Producers Energy Interdependence and Resource Flexibility Discussion What do we need to do as a region to ensure continued reliability of both natural gas and electricity infrastructure for long term economic resilience? Resource adequacy is starting to be displaced by concept of resource flexibility. Join us for a regional discussion on defining resource flexibility, examining the nexus of where gas loads and electric generation meet. How do we address the growing interdependence of our gas and electric systems? How do we ‘backstop’ the NW Power Grid? What is being done to examine our North - South transmission capacity for long term reliability, especially given the impact of last winter’s natural gas pipeline disruption on downstream users? Representative Jeff Morris, Washington State Legislature David Bennett, Director, Communications and External Relations, FortisBC Nicolas Garcia, Policy Director, Washington PUD Association Dan Kirschner, Executive Director, Northwest Gas Association Frank Afranji, President, Northwest Power Pool Action item discussion
Bess Salon Batoche | Tuesday, July 23 9:15am - 11:30am
Hosted by the Saskatchewan Cattlemen’s Association
Welcome, Introductions and Opening Remarks
USMCA / CUSMA - How is Agriculture impacted? Global perspective on current issues impacting North American agricultural trade. What is the path forward? What is holding us back from expanding global market share? Carlo Dade, Director of the Trade & Investment Centre, Canada West Foundation Regional perspective on agriculture trade and the USMCA / CUSMA Private sector perspective roundtable: 1. How have tariffs or other trade barriers impacted Ag producers and processors? 2. How will USMCA impact the Agriculture sector? 3. How can regulatory cooperation play a positive role in Canada - U.S. trade and
AGRICULTURE AND CROSSBORDER LIVESTOCK HEALTH
Ryder Lee, CEO, Saskatchewan Cattlemen’s Association Rory McAlpine, Senior Vice President, Government & Industry Relations, Maple Leaf Foods Gordon Stoner, Director, U.S. Dry Pea & Lentil Association Public sector perspective roundtable: 1. What steps has your province/state taken to help facilitate trade and increase market access? 2. What are the biggest threats to Agriculture trade in the region and overseas? 3. What innovative practices are you most proud of in your state/province?
Dr. Amber Itle Asst. State Veterinarian WA Dept. of Agriculture
Hon. David Marit, Minister of Agriculture, Saskatchewan Richard Gotfried, MLA., Legislative Assembly of Alberta Representative Mary Dye, Washington House Rural Development, Agriculture, & Natural Resources Committee Senator Bert Brackett, Chair of the Idaho Transportation Committee
Janice Tranberg President and CEO Alberta Cattle Feeders Association
Representative Brad Hamlett, Montana State Legislature
Action item discussion David Moss General Manager Canadian Cattleman’s Association
INNOVATION Tuesday, July 23 9:15am - 11:30am | Bess Terrace Lounge Hosted by Microsoft
Welcome, Introductions and Opening Remarks Senator Mia Costello, Alaska State Legislature Nirav Desai, CEO, Moonbeam Exchange Sen. Mia Costello Alaska
Innovation ecosystems: Building a sustainable innovation ecosystem Showcase of how Saskatchewan works with local startups and fosters innovation. Learn from leading experts on how the province is building a sustainable innovation ecosystem. Jordan Dutchak, Executive Director, Co.Labs Aaron Genest, President of SaskTech, Mentor Graphics Kari Harvey, Chief Operating Officer, Innovation Saskatchewan Overview of Innovation Cluster mapping project conducted by the University of Washington Master of Arts Applied International Studies (MAAIS) project
Nirav Desai CEO Moonbeam Exchange
Innovation is crucial to the economic development of the Pacific Northwest. The project identifies recommendations for under leveraged innovation clusters in the region Nirav Desai, CEO, Moonbeam Exchange Michael Farber, Founder, Ratio Innovation Management Facilitated design thinking session and action item discussion The PNWER Innovation Co-Chairs will moderate a design thinking session on Innovation ecosystems and economic diversification with all session participants
MINING Tuesday, July 23 9:15am - 11:30am | Sheraton West Room Hosted by Orano
Welcome, Introductions and Opening Remarks Sen. Keith Regier Montana
Senator Keith Regier, Montana State Legislature Pam Schwann, President, Saskatchewan Mining Association Critical Minerals and Economic Benefit of Mining New technologies and innovations are driving demand for mined products. What are some best practices to showcase the importance of mining in the digital age. Tammy Johnson, Montana Mining Association Kathleen Benedetto, Senior Advisor, Bureau of Land Management Hilary Morgan, Director, International Affairs and Trade Division, Policy and Economics Branch, Lands and Mineral Sector, Natural Resources Canada / Government of Canada
Pamela Schwann President Saskatchewan Mining Association
Private Sector representative
MINING CONT’D Sheraton West Room | Tuesday, July 23 9:15am - 11:30am
Sen. Keith Regier Montana
Cory Hughes, Executive Director, Mineral Policy - Resource Development Ministry of Energy and Resources Government of Saskatchewan Dale Huffman, Vice President, Health, Safety, Environment & Regulatory Relations, Orano Roundtable discussion with session attendees Action item and findings discussion Pamela Schwann President Saskatchewan Mining Association
Showcasing the Institutional Control Program The Institutional Control Program (ICP) defines and implements a process for the long-term monitoring and maintenance of decommissioned mine and/or mill sites located on provincial Crown land in Saskatchewan.
Networking Break - Hosted by BP
12:30 - 2:15PM
TUESDAY KEYNOTE LUNCHEON CAPTURING ASIAN MARKETS TUESDAY, JULY 23 12:30PM - 2:15PM | SHERATON BALLROOM Murad Al-Katib, President and CEO of AGT Foods (right), with John Stackhouse, Senior Vice President, Royal Bank of Canada (left) will address the opportunities and challenges the region faces in expanding Asian markets, and how we can work together to capture the greater market share. Moderated by Victor Thomas, Vice President, Prairie Region, Asia Pacific Foundation of Canada (bottom). Hosted by The Mosaic Company
Tuesday Afternoon Working Group Sessions
Coffee Break hosted by CAPP
Transportation & Infrastructure II
GHG Reduction & Reuse Strategies
Cross Border Livestock Health
TRANSPORTATION & INFRASTRUCTURE II Tuesday, July 23 2:30pm - 5:00pm | Sheraton Top of the Inn
Potential of autonomous, electric, connected, shared vehicles Autonomous, connected, electric and shared (ACES) vehicles can potentially reduce congestion, limit traffic accidents, clean up our air and water, and enhance social equity by reducing the costs of personal mobility. ACES will also revolutionize the supply chain logistics world of marine, surface, and air transportation while electrification offers new business opportunities for our binational region’s utilities. Bruce Agnew, Director, Cascadia Center
Autonomous vehicles in agriculture Seedmaster is a Saskatchewan agriculture machinery manufacturer that has developed an autonomous seeder/farm implement platform called DOT. This cutting-edge technology is also a great example of how Saskatchewan ag machinery technology is helping to reduce GHG emission. Owen Kinch, SeedMaster Manufacturing Inc. and DOT Technology Corp Transportation and electrification in Washington State Representative Jake Fey, Washington State Legislature Connecting the inland northwest The ALCAN Highway and Highway 97 are critical transportation corridors for the PNWER region. How do we strengthen these inland connections between the Arctic jurisdictions and the rest of the region? What is their value for the region’s economic development? Paolo Gallina, MLA, Yukon Mead Treadwell, former Lieutenant Governor of Alaska, and Chief Operating Officer, Alaska - Alberta Railway Development Corporation A2A Rail was established to build, own, and operate a new railway connecting the Alaska Railroad and Alaska’s tidewater, to northern Alberta (1,500 miles or 2,400 km). A2A Rail will provide critical infrastructure connecting North America to global markets through safe and efficient transport of commodities, containers, natural resources and people.
Action Items: What are the next steps to promote the PNWER agenda looking ahead to the Economic Leadership Forum in Seattle November 17 - 19, 2019 • Smart Cities & 5G • Infrastructure Resilience • Transportation and Market Access Pacific Northwest Economic Region • Puget Sound and Spokane Autonomous Vehicles Study
Bess Williams Pascoe | Tuesday, July 23 2:30 - 5:00pm Reduction of GHG emissions is an important objective for PNWER jurisdictions. How can new technologies, such as carbon capture storage/reuse and strategies boost the carbon sink capabilities in the forestry and agricultural industries, contribute to GHG reduction strategies across the region reduce GHG emissions?
Welcome, Introductions and Opening Remarks Senator Keith Regier, Montana State Legislature Pam Schwann, President, Saskatchewan Mining Association Saskatchewan Prairie Resiliency Plan for Climate Change - Cooperation with the mining sector David Brock, Assistant Deputy Minister, Climate Change and Adaptation, Ministry of Environment Pamela Schwann President Saskatchewan Mining Association
Carbon capture and Storage Anna Stukas, Business Development Lead, Carbon Engineering
INNOVATIVE GREENHOUSE GAS REDUCTION AND RESUSE STRATEGIES
Corwyn Bruce, Vice President, Technical Services for the International CCS Knowledge Centre, SaskPower Agriculture Industry and Efforts to Reduce GHG Tristan Skolrud, Assistant Professor, University of Saskatchewan Forest Industry and Efforts to Reduce GHG Mark Johnston, Distinguished Scientist, Environment Division, Saskatchewan Research Council Concrete Industry and Efforts to Reduce GHG Jonathan Moser, Head, Environment & Public Affairs, LaFarge Canada Mining Industry and Efforts to Reduce GHG Jessica Theriault, Director, Regulatory Affairs – Potash, The Mosaic Company Comment from Canada / U.S. Federal Perspective StÊphane Lessard, Consul General of Canada, Denver Action item discussion
CROSS-BORDER LIVESTOCK HEALTH
Tuesday, July 23 2:45pm - 5:00pm | Bess Salon Batoche Hosted by the Saskatchewan Cattlemen’s Association Dr. Amber Itle Asst. State Veterinarian WA Dept. of Agriculture
Panel Session I: Towards More Seamless Border Crossings: Moderator: Dr. Amber Itle Welcome and Opening Remarks Dr. Amber Itle, Interim State Vet, WA Janice Tranberg, President & CEO, National Cattle Feeders’ Association Dave Moss, General Manager, Canadian Cattleman’s Association Brandon Hardenbrook, Deputy Director, PNWER
2019 Action items regulatory responses • Electronic certification at all livestock border port crossings • Streamline and align livestock handling procedures and standards at border ports • Allow Restricted Feeder Cattle from U.S. to enter CAN per Restricted Feeder Cattle Import Policy • USDA partner with software co. to provide carcass data to cattle breeders, backgrounders, and feedlots to incentivize EID use • Animal Disease Traceability update (U.S). Dr. Jack Shere, Deputy Administrator, VS USDA Dr.Renee Oleck, National Port Services Director, USDA Ports Dr. Jaspinder Komal, VP Science, CFIA Dr. Mohit Baxi, Director, Animal Import-Export, CFIA
David Moss General Manager Canadian Cattleman’s Association
Panel Session II Animal Disease Lessons Learned: Moderator: Ron Barker, AHEM-II project advisor Biosecurity and Emergency management In a world of global trade, the threat of animal disease spread is an ever-present danger. What biosecurity and other mitigation measures are being taken to prepare for an emergency situation? Rory McAlpine, Senior Vice President, Government & Industry Relations, Maple Leaf Foods - AHC WG Chair Dr. Danielle Bickett-Weddle, Associate Director, Center for Food Security and Public Health Matt Taylor, Canadian Animal Health Coalition, AHEM - II Panel Session III Animal Disease Reports Moderator: Casey Smit, SaskPork, Olymel • Overview of ASF and activities to get ready • Updates on Bovine Tuberculosis - U.S. and CAN perspectives Dr. Jack Shere, Deputy Administrator, VS USDA Dr.Gary Brickler, Director, Dist 6, USDA APHIS VS Surveillance Prep & Resp Service (TBC) Dr. Jaspinder Komal, VP Science, CFIA Dr. Noel Ritson-Bennett, Veterinary Program Officer, CFIA
Welcome, Introductions and Opening Remarks Senator Lisa Wellman, Washington State Legislature Shawna Argue, Association of Professional Engineers and Geoscientists of Saskatchewan (APEGS) Workforce Development is evolving across the region How is the education community engaging with industry and stakeholders on workforce development? Janet Uchacz-Hart, Saskatoon Industry Education Council, RoboX Program Lisa Shingoose, Saskatchewan Indian Institute of Technologies (SIIT) Dr. Larry Rosia, President and CEO, Saskatchewan Polytechnic Overview of Career Connect Washington, an innovative government program in Washington State focused on workforce development Senator Lisa Wellman Washington State Legislature, Career Connect WA Maddy Thompson, Senior Policy Advisor on Education, Office of Governor Inslee Future Launch: Preparing youth of today for jobs of tomorrow Andrew Schrumm, Senior Manager, Research Office of the CEO, Royal Bank of Canada (RBC)
Sen. Lisa Wellman Washington
Shawna Argue Director of Registration Association of Professional Engineers and Geoscientists of Saskatchewan
WORKFORCE DEVELOPMENT Bess Terrace Lounge | Tuesday, July 23 2:30pm - 5:00pm
Workforce immigration mobility challenges Showcase of how Saskatchewan and the region are addressing labour shortages Chad Vickers, Ministry of Immigration and Career Training, Government of Saskatchewan Roundtable Discussion: Explore how the region could move forward to address emerging challenges on workforce development. Discussion led by Co-Chairs, Panelists, and Working Group Attendees.
WATER POLICY | Tuesday, July 23 2:30pm
- 5:00pm
Welcome, Introductions and Opening Remarks Senator Bill Hansell, Oregon State Legislature David Hill, Director, Centres & Institutes & Research Advocacy University of Lethbridge Food marketers and consumers are increasingly valuing concepts of sustainability and environmental stewardship in the agri-food supply chain. Farmers and agrifood processors are becoming aware of the benefits of water stewardship practices and strategies to improve farm productivity and product marketability. However, global agri-food supply chains lack a coordinated and practical approach to take advantage of the opportunities of water stewardship. Supported by Nutrien and Alberta Innovates, the Agriculture Water Future Project began in late 2017 to develop a process to better define and prove the value of water stewardship across the agri-food supply chain in Alberta, with a view to how it could be applied globally. Mike Nemeth, BSc, MSc, P.Ag., EP, Director, Environment & Sustainability, waterSMART! Water Management Solutions Continued on next page
Sen. Bill Hansell Oregon
David Hill Director of Development Centres and Institutes, and Research and Advocacy University of Lethbridge
WATER POLICY Tuesday, July 23 2:30pm - 5:00pm | Sheraton West Room
Global view of water access Dr. Jay Famiglietti, PhD, Professor, School of Environment and Sustainability, University of Saskatchewan Water Policy Legislative Roundtable A Round Robin panel of legislators from across PNWER will showcase water policy, legislative, regulatory, and finance issues from various PNWER jurisdictions. They will also explore how they are proposing to move forward and address these emerging challenges. Herb Cox, MLA, Government of Saskatchewan Representative Mary Dye, Washington State Legislature Representative Terry Gestrin, Idaho State Legislature
Senator Bill Hansell, Oregon State Legislature Senator Jon Sesso, Montana State Legislature Action item discussion
Special Sidebar Session: Using public data for Economic Development (open to all)
PNWER Celebration Dinner
Western Development Museum
PNWER CELEBRATION DINNER FEATURING MÉTIS AND FIRST NATIONS PERFORMANCES TUESDAY, JULY 22 6:00PM - 9:00PM | WESTERN DEVELOPMENT MUSEUM Come join us by taking a journey through time at a reception in 1910 Boomtown where Saskatchewan-inspired stories from 1910 to the present unfold. Attendees will experience the culinary delights of the prairies at dinner featuring First Nations and Métis performances by Grammynominated Young Spirit, a Cree drum group, and tap their toes to the rich tradition of the high-energy Asham Stompers, which combine the richness of the Métis Red River Jig with First Nations Square Dancing Hosted by the Cement Association of Canada. Entertainment supported by K+S Potash Canada GP
7:00 - 3:00PM 7:30 - 9:00AM
Sheraton Conference Foyer Sheraton Ballroom
WEDNESDAY KEYNOTE BREAKFAST THE U.S. - CANADA BORDER WEDNESDAY, JULY 24 7:30AM - 9:00AM | SHERATON BALLROOM The Honourable Ralph Goodale, Minister of Public Safety and Emergency Preparedness Canada will share the latest on the U.S. - Canada border. Hosted by Federated Co-operatives Limited
9:15 - 11:30AM Coffee Break hosted by Food Northwest
Wednesday Morning Working Group Sessions 10am Executive Committee Meeting (open to all) Cross Border Livestock Health Ec Dev: First Nations & Indigenous Business Roundtable Border Security Roundtable 9:15 - 10:15 / Disaster Resilience
Sheraton West Room Bess Salon Batoche Bess Williams Pascoe Sheraton Top of the Inn
Panel Agri-Food Sector Emergency Planning Moderator: Dave Moss, CCA Emergency response scenario An open dialogue on what would likely unfold in a livestock emergency event; who would be involved, possible impact across a multitude of stakeholders, and overview of the steps necessary to recover from such an event • Emerging disease(s) of concern by species and coordinated cross border response and secure food supply plans • U.S. and Canadian participants cross sector of value chain discuss all perspectives • CFIA and USDA develop ‘disease zoning’ agreements that minimize trade disruptions between U.S. and CAN, as well as with other major trading partners • CFIA, USDA, and Industry continue priority national EM preparedness planning • Increase cross border USDA-CFIA collaboration regarding disease reporting by establishing/sharing reportable disease lists through secure platforms Dr. Elizabeth Parker, International and Strategic Partnerships Specialist, AgriLife Research, Texas A&M University Dr. Jaspinder Komal, VP Science, CFIA Dr. Barbara Porter-Spalding, Vet Med Officer, USDA-APHIS-VS (TBC) Dr. Jack Shere, Deputy Administrator, VS USDA Dr. Tom Smylie, Sr Staff Vet, CFIA Dr. Aline Dimitri, Executive Director Animal Health, CFIA (TBC) Dr. Danielle Bickett-Weddle Assoc. Dir, Food Security & Public Health Michael Riedy, CEM USDA ESF11 Region X Coordinator; AK, ID, OR & WA Casey Smit, SaskPork, Olymel Gabriela Guigou, Canada Pork Council Patrick Webb, Director, Foreign Animal Disease, National Pork Board
Bess Salon Batoche | Wednesday, July 24 9:15am - 11:30am
Action item discussion Pacific Northwest Economic Region
ECONOMIC DEVELOPMENT: THE CHANGING DYNAMICS OF INDIGENOUS BUSINESSES Wednesday, July 24 9:15am - 11:30am | Bess Williams Pascoe
Introduction, opening remarks and setting the stage Senator John McCoy, Washington State Legislature Sean Willy, President & CEO, Des Nedhe Development
Senator John McCoy Washington
Sean Willy President & CEO Des Nedhe Development
The changing dynamics of Indigenous businesses: How Indigenous leaders are creating world-class businesses Moderator Lee Ahenakew, CEO, Nutraponics, and Chair of the Board of Governors, University of Saskatchewan Jasper Lamouelle, CEO, Tli Cho Investments Delbert Wapass, Executive Chair and Founder, Project Reconciliation Chuck Greene, Director of Economic Development, Northwest Arctic Borough (via phone) Legislative Perspective: What are the opportunities and barriers to First Nations Businesses What are best practices in your jurisdiction? How can we remove barriers for indigenous businesses and encourage economic growth and involvement of First Nations? The Hon. Bob McLeod, Premier, The Northwest Territories Senator John McCoy, Washington State Legislature Representative Brad Hamlett, Montana State Legislature
BORDER SECURITY LISTENING SESSION & DISASTER RESILIENCE Wednesday, July 24 9:15am - 11:30am | Sheraton Top of the Inn Rep. Cindy Ryu Washington
Border Roundtable Listening Session 9:15 - 10:15am Listening session featuring public and private multi-modal key stakeholders from the U.S. and Canada. Each stakeholder will have 2 - 3 minutes for comments and/or recommendations. The PNWER Center for Regional Disaster Resilience works on emergency preparedness and disaster resilience projects across the Pacific Northwest from its Seattle office. The CRDR operates under the umbrella of PNWER and is committed to working with states, provinces, territories, and communities to create publicprivate partnerships, develop action plans, and undertake pilot projects and activities to improve regional disaster resilience cooperation
Brad Richy Director Idaho Office of Emergency Management
Mitigation and Resilience Planning Across the Region 10:30 - 11:30am 1. 2. 3. 4. 5.
Lessons from Canada How can a watershed approach work to promote disaster resilience? What roles do government and the private sector play? How do we incentivize preparedness and mitigation? The United States Government is about to launch a new effort to promote disaster mitigation and they are providing a significant increase in funding. Pacific Northwest Economic Region Learn more about this new programmatic effort at this session
Sheraton Top of the Inn | Wednesday, July 24 9:15am - 11:30am Moderated by Eric Holdeman, Director, Center for Regional Disaster Resilience Rep. Cindy Ryu Washington
Speakers: Representative Cindy Ryu, Washington State Legislature Brad Richy, Director, Idaho Office of Emergency Management Mike Nemeth, BSc, MSc, P.Ag., EP, Director, Environment & Sustainability, waterSMART! Water Management Solutions David Hill, Director, Centres & Institutes & Research Advocacy University of Lethbridge
Discussion of action items
Networking Break Hosted by Marathon
DISASTER RESILIENCE CONT’D
WEDNESDAY KEYNOTE LUNCHEON: BUSINESS ROUNDTABLE ON U.S. - CANADA TRADE WEDNESDAY, JULY 24 12:30PM - 2:15PM | SHERATON BALLROOM Hear from Business experts on U.S. - Canada Trade Featured panelists include: Goldy Hyder, President and CEO, Business Council of Canada Scotty Greenwood, CEO, Canadian American Business Council Ted Alden, Senior Fellow, Council on Foreign Relations Moderated by Colin Robertson, Canadian Global Affairs Institute
Offsite Policy Tours
See Page 52 for more info
See next page for more info
Hospitality Suite Hosted by Enbridge
WEDNESDAY, JULY 24 CLOSING RECEPTION AT REMAI MODERN ART MUSEUM WEDNESDAY, JULY 24 6:00PM - 8:00PM | REMAI MODERN Join us for the Summit’s closing reception at the Remai Modern art museum. Attendees will enjoy a wonderful reception with the chance to explore the Remai Modern with access to the Picasso exhibits and featured galleries Hosted by the Canadian Engineering and Geoscience Regulators
THURSDAY, JULY 25 6:00 - 9:00AM
Optional Continental breakfast
Nutrien Allan Potash Mine Tour - Legislators Only
Boundary Dam Power Station Unit 3 & Carbon Capture Tour
“Think of us not as two great countries, but as one great place...Innovation requires diversity. The best ideas come when you bring together people who think differently.” -Brad Smith, President of Microsoft, speaking at the 2017 PNWER Annual Summit
Achieving a safe and prosperous future through engineering and geoscience The Association of Professional Engineers and Geoscientists of Saskatchewan and Engineers and Geoscientists BC are proud to support the Pacific NorthWest Economic Region’s annual summit.
PNWER is grateful for the support of our regional partners. Our economy is strengthened by our regional connections, and it was the recognition of the need to build strong partnerships across these borders that first prompted the formation of PNWER 28 years ago. PNWER’s reach crossborder and region wide makes it a valuable organization for business and government leaders alike. Visit PNWER.org/sponsorship for opportunities to become involved
Summit Media Partner
POLICY TOURS Policy tours are a great way to see and experience more of Saskatchewan while you are in Saskatoon for the Summit. Check registration desk for availability.
Ag in Motion Western Canada’s Farm Expo Mon July 22 | 2:15pm - 5:30pm
Canadian Light Source and VIDO-Intervac Wed July 24 | 2:30pm - 5:30pm
Planting the Future: How conservation protects more than land Wed July 24 | 2:30pm - 5:30pm
PNWER attendees have a special opportunity for private access of Ag in Motion- the largest agricultural trade show in Western Canada. The expo was created to empower farmers by providing knowledge on the latest in agricultural innovations, in real time situations, in order to make informed decisions. The Ag in Motion team works with the industry to identify trends and issues that are on the minds of farmers in Western Canada.
The Canadian Light Source produces the brightest light in the country, enabling research in mine tailing remediation, food security, cancer research to drug development and cutting edge materials, like semi-conductors and future battery technology. VIDO-InterVac is dedicated to human and animal infectious disease research and vaccine development, and is home to some of the world’s most advanced vaccine research development.
Wanuskewin Heritage Park is the longest active archaeological dig site in Canada. Meewasin Valley Authority protects ecological, historical, and cultural aspects of the Saskatchewan River Valley through active conservation. There will be opportunities on the tour to learn about the importance of these areas to the economy, education, culture, and the environment. Meewasin is a conservation organization that specializes in partnerships with government, business, and public to protect natural habitat within an urban setting. Tour will include a moderate amount of walking ~1.5km/1mile.
POLICY TOURS As arguably the single most influential infrastructure project in Saskatchewan’s history, this is your chance to see up close an integrated project which dramatically shifted the Province’s destiny. Guests will tour the dam structure and spillway, followed by SaskPower’s tour of its renewable energy facility, a key ongoing component in the Province’s efforts to reduce electricity-based greenhouse gas emissions by 40% below 2005 levels by 2030 The Livestock and Forage Centre of Excellence (LFCE) brings together all aspects of beef cattle research into one entity, providing researchers, faculty, students, industry, and producers with a broad-based platform for research, teaching, and extension activities. Participants will get hands on experiences in the metabolism barn, a walking tour of the feedlot, and a presentation at the cow calf centre. The tour will conclude at the University of Saskatchewan with a tour of the Rayner Dairy Research and teaching facility. Nutrien is the world’s largest provider of crop inputs, services, and solutions, Nutrien plays a critical role in growing our world from the ground up by helping growers to increase food production in a sustainable manner. The Allan potash mine is a conventional underground mining operation. You will travel 1000 metres below the surface and observe the continuous mining machines as they cut out the ore. Next, you will tour the surface mill to see how the raw potash is processed and shipped to markets Boundary Dam 3 is the world’s first coal-fired power station with a Carbon Capture facility. The Carbon Capture facility captures carbon dioxide instead of being released into the atmosphere. This reduces carbon emissions from the coalfired power plant, while producing a reliable, clean source of energy. BD3 is renowned for its full-chain approach. It has a coal plant, capture facility, transportation infrastructure, enhanced oil recovery, and pure storage capabilities.
Gardiner Dam and the Couteau Creek Hydroelectric Project Wed July 24 | 2:15pm - 5:30pm
Livestock and Forage Centre of Excellence Wed July 24 | 2:30pm - 5:30pm
Nutrien Allan Potash Mine *For Legislators only Thu July 25 | 6:45am - 1:30pm
Boundary Dam Power Station and Carbon Capture Tour Thu July 25 | 7:00am - 2:00pm
RECEPTIONS University of Saskatchewan Mon July 22 | 5:45pm - 7:45pm The University of Saskatchewan is honored to welcome Summit attendees on Monday, July 22 for an evening reception to be held on its beautiful campus. Join us to meet fellow PNWER delegates and summit attendees at Canada's #1 water resources research facility.
Buses will depart the hotel at 5:30pm
The University of Saskatchewan also leads research in areas of global importance, such as food security, sustainability, and biodiversity. In addition to its scientific accomplishments, USask proudly sits at the heart of the Métis homeland and prioritizes the integration of Indigenous culture on campus.
The Western Development Museum Tue July 23 | 6:00pm - 9:00pm Buses will depart
The Cement Association of Canada is proud to host the 2019 PNWER Celebration Dinner embracing the stories of Saskatchewan and the prairies through local food, history and entertainment at the Western Development Museum, the largest human history museum in the province. Come join us by taking a journey through time at a reception in 1910 Boomtown where Saskatchewaninspired stories from 1910 to the present unfold. Attendees will experience the culinary delights of the prairies at dinner featuring First Nations and Métis performances by Grammy-nominated Young Spirit, a Cree drum group, and tap their toes to the rich tradition of the high-energy Asham Stompers, which combine the richness of the Métis Red River Jig with First Nations square dancing.
the hotel at
RECEPTIONS Remai Modern Art Museum Wed July 24 | 6:00pm - 8:00pm Join us for the summit’s closing reception hosted by the Canadian Engineering and Geoscience Regulators at the Remai Modern Art Museum! With values such as safety, competence, honesty, fairness, and respect, the Regulators work to ensure public safety and environmental protection by regulating the practice of engineering and geoscience in Saskatchewan. As the 2019 Annual Summit comes to a close, attendees will get the chance to explore the Remai Modern and get a glimpse into the future of 21st century art. Attendees will have private access to the Picasso and featured collection galleries. Remai Modern is a new museum of modern and contemporary art in Saskatoon. It is informed by the rich culture and history of the Prairies, including Indigenous artists and nations, distinct modernist influences, and a legacy of progressive support for the arts. The museum is a demonstration of Saskatchewan’s strong history of progressive politics and support for the arts.
Remai Modern
It is a short walk to the Remai Art Museum. We will also have a bus departing at 5:55 from the hotel Directions • Head SW on Spadina Crescent E toward 21st St E • At the roundabout, continue straight to stay on Spadina Crescent E • Slight right to stay on Spadina Crescent E • Enter the roundabout and the museum will be on your left
At Nutrien, our purpose is to grow our world from the ground up. As the world’s largest provider of crop inputs, services and solutions, Nutrien plays a critical role in feeding the future by helping growers increase food production in a sustainable manner. We’re moving the agriculture industry and the world forward – today and for generations to come.
Proud to support the Pacific NorthWest Economic Region summit in Saskatoon.
Feeding the Future … from Saskatchewan to the world
Nutrien’s Saskatchewan roots run deep, so we’re excited to welcome delegates from across the Pacific NorthWest to showcase our great city and province. The mission of PNWER is to increase the economic well-being and quality of life for all citizens of the region, while maintaining and enhancing our natural environment – and that connects powerfully with Nutrien’s Purpose of growing our world from the ground up. As the world’s largest provider of crop inputs, services and solutions, Nutrien plays a critical role in feeding the future by helping growers increase food production in a sustainable manner. With more than 20,000 employees and operations and investments in 14 countries, Nutrien’s products and solutions reach every major growing region in the world. From our corporate offices in Calgary, Alberta; Loveland, Colorado and here in Saskatoon, we support operations that produce and distribute over 27 million tonnes of potash, nitrogen and phosphate products worldwide. Combined with our 1,700 agriculture retail locations, which services over 500,000 grower accounts in seven countries, we are well positioned to meet the needs of a growing world and create value for our stakeholders. Nutrien employs over 4,000 people in Saskatchewan, and we are proud to be the largest private-sector employer in the province. We operate six world-class potash mines and also have 120 Retail farm centers around the province that work directly with growers. Our Retail footprint in the rest of the Pacific Northwest is considerable, with more than 150 Nutrien Ag Solutions locations spread across Alberta, British Columbia, Idaho, Montana, Oregon and Washington. Nutrien is the largest ag retailer in Canada, the United States and Australia, and we also have Retail operations in Argentina, Brazil, Chile and Uruguay. Nutrien is the world’s third-largest nitrogen producer, with six nitrogen facilities in central and southern Alberta, one in Kennewick, Washington, five more in other parts of the US and one in Trinidad. Our phosphate business is concentrated in the United States – we operate large integrated mining and processing facilities in North Carolina and Florida, and regional upgrading plants in Ohio, Missouri, Illinois and Nebraska. Each day, farmers across the globe are challenged to produce more nutritious food, and to do so in a manner that sustains the planet’s finite resources. The world’s population is expected to approach 10 billion by 2050 and growers will face mounting pressure to produce more and better-quality food on limited arable land, while minimizing impacts on the environment. Nutrien is working to help meet this challenge in a sustainable manner, through cutting-edge agronomic science and precision agriculture, and in partnership with other players across our industry. We’re moving the agriculture industry and the world forward – today and for generations to come. Nutrien is a strong believer in working with government, industry and community organizations across our operating regions and we are proud to support the PNWER Summit. We look forward to connecting with delegates from across the Pacific Northwest this week, to learning from each other and collaborating for the benefit of our Region as a whole. Note: This article is a submission by, and reflects the views of, 2019 Annual Summit Sponsor: Nutrien The Pacific NorthWest Economic Region (PNWER) is not responsible for the content of this piece
Resilience and Sustainability Working in Tandem Resilience and sustainability have become major themes in public policy and business planning over several past generations. In the wake of devastating climate-related disasters – hurricanes, flooding, wildfires, power outages, and extreme weather incidents – more attention is now being paid to ensuring that our buildings and related infrastructure – bridges, roadways, dams, communications facilities – are capable of withstanding and recovering from extreme climate-related incidents. With so much of our normal life spent in the built environment – homes, schools, offices, vehicles – the choices we make in how we design, build and manage the built environment are critical to ensuring sustainability and resiliency. They are also critical factors in preventing injuries or death and reducing economic, environmental and social disruption. Reducing our vulnerabilities to disaster is now part of the fabric of resilience and sustainability. The Pacific Northwest Building Resiliency Coalition (PNBRC) believes we all have a role to play in ‘Building Better Buildings’ and in ensuring that our communities not only are more sustainable but also more resilient. More than half of the world’s population now live in large metropolitan areas. This fact places enormous pressure on urban infrastructure and makes the availability of the necessities of life – food, water, and shelter – increasingly difficult for many. Overcrowding, traffic congestion, degraded air quality, unsafe water supplies, and severely constrained physical infrastructure – roads, buildings, bridges – not only affect the quality of life for residents, they also increase vulnerability to weather-related extremes such as flooding, fire, and earthquakes. PNBRC is a gathering of organizations, primarily in the cement, concrete and masonry industries, committed to furthering the planning, development, and construction of buildings and associated infrastructure better able to withstand, recover from and to adapt to the growing impacts of an ever-changing urban and physical environment. The Coalition believes that the quality of life in our cities and towns is directly related to the quality of the built environment. When the physical environment of where we live, and work is sustainable and resilient, the potential for personal and community well-being is greatly improved. That is why careful planning, responsible design, and proper construction and management of the built environment is so important, and why architects, engineers, public officials, policy advisors, and community leaders must work together to make our communities better places in which to live and work. There are so many things that contribute to making cities great places in which to live, work and learn. The quality of the physical environment, access to green spaces, safety in the streets, cultural amenities, ease of mobility, responsible management, and social and economic stability are but a few of factors cited as determinants of greatness. Perhaps the single most important consideration stems from the fact that great communities don’t just happen. They are the consequence of key decisions taken at critical times within the life of the community by people of vision and leadership. The design considerations that shape the physical layout of cities and the countless undertakings that constitute the built environment wherein we live, and work are the essential pieces of the fabric of what makes cities great. The quality of design and construction of the built environment are the key reasons why some of the world’s most vibrant cities have buildings still in use that are centuries old. Members of the Pacific Northwest Building Resilience Coalition believe the need to build better buildings/ structures is as important today as it was in ages past, and that sustainable and resilient buildings are the key to greatness. Note: This article is a submission by, and reflects the views of, 2019 Annual Summit Sponsor: the Pacific Northwest Building Resilience Coalition
Perhaps the single most important consideration stems from the fact that great communities don’t just happen. They are the consequence of key decisions taken at critical times within the life of the community by people of vision and leadership. The design considerations that shape the physical layout of cities and the countless undertakings that constitute the built environment wherein we live, and work are the essential pieces of the fabric of what makes cities great. The quality of design and construction of the built environment are the key reasons why some of the world’s most vibrant cities have buildings still in use that are centuries old. Members of the Pacific Northwest Building Resilience Coalition believe the need to build better buildings/ structures is as important today as it was in ages past, and that sustainable and resilient buildings are the key to greatness.
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“BUILDING STRONG, SUSTAINABLE and RESILIENT COMMUNITIES” www.buildingresiliencecoalition.org Pacific Northwest Economic Region
THE VOICE OF SASKATCHEWAN’S BEEF CATTLE INDUSTRY
Working on behalf of the beef industry to reduce regulation, expand markets and increase opportunities.
RESEARCH Funding a variety of projects to help improve the industry, preserve the environment and educate producers and consumers.
COMMUNICATION Connecting producers to the information they need and increasing consumer awareness of the benefits of beef to a healthy lifestyle, economy and environment.
102-2255 13th Avenue Regina, SK S4P 0V6
Sign up for our email blasts: info@saskbeef.com Like us on Facebook:
www.facebook.com/saskbeef/
Call us toll-free:
1-877-908-BEEF (2333)
@SaskCattlemens
www.saskbeef.com
www.saskbeef.com 60 | Pacific Northwest Economic Region
DEFINING OUR SHARED FUTURE We believe in creating a better future for us all. That’s why we invest in our people, communities, businesses and professional organizations to help all of us realize this vision. By honing our skills, helping develop progressive policy frameworks at all levels and being innovative, we can rise together and create stronger, thriving communities. oranocanada.com | 61
Inspiring Growth Our Cars Carry More Than Potash Every Canpotex railcar carries high-quality, Saskatchewan potash from mine to port. They also carry the best in Canadian industry and innovation. Working with our partners in transportation, manufacturing and trade, we create value for Canadian resources and we create jobs across our country.
SĂƒO PAULO
w w w. c a n p o t e x . c o m
CN is proud to support the 29th Annual PNWER Summit.
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18/06/19 infographe : CM
358, rue Beaubien Ouest, bureau 500 Montréal (Québec) H2V 4S6 t 514 285-1414
Our commitment to Saskatchewan runs deep. Through ongoing employment, local business partnerships and community investment, we’ll make sure opportunity continues to take root in our province for generations to come.
CO-OP CO-OP IS IS PROUD PROUD TO TO SUPPORT SPONSORPNWER THE PACIFIC ECONOMIC AND THENORTHWEST 2019 ANNUAL SUMMIT REGION
2019 PNWER SUMMIT GOVERNMENT
BUSINESS Harris Greenaway Communications is a full-service agency offering a unique, specialized set of skills and experience in strategic communications, public affairs, public relations and marketing across Western Canada. We develop and execute strategies to manage complex issues while protecting and building reputations and relationships with the government, public, media and stakeholders.
619 Main Street, Saskatoon, SK | 306.384.6200
harrisgreenaway.ca Pacific Northwest Economic Region |
Climate change policies must properly account for all carbon emissions The construction, operation and decommissioning of our buildings and infrastructure account for approximately 40% of all man-made greenhouse gas emissions. For those involved in climate policy, it is self-evident that building practices need to change – our buildings must become lower carbon and more resilient to our changing climate. Governments and many in the building sector are in pursuit of solutions. And, on the face of it, we’re doing a lot of things right. First, it is generally understood that retrofitting our existing stock of relatively inefficient buildings is priority number one. Second, building code processes are focused on pushing new construction toward net-zero carbon as quickly as possible. Third, there is an emerging consensus among academics, governments, procurement professionals and environmental groups that lifecycle assessment (LCA) is the best, and perhaps only tool that can objectively and transparently address the complexity of designing for low carbon and climate resilience. For all this great work, governments across Canada and the U.S. are nevertheless placing big bets on one particular strategy: building with more wood. History has taught us that governments “picking winners” is bad policy – it’s bad for the economy, it’s fiscally inefficient and when it comes to transformative challenges like climate change, it disrupts natural innovation cycles that are constantly pushing competing industries to do better. In the case of favouring wood, the underlying environmental rationale also turns out to be deeply flawed. Efforts to reduce GHGs must be informed by science Today, our understanding of real-world silvicultural success rates, carbon releases from soil disturbance and changes in carbon productivity between old growth and replanted forests has evolved, but the models that underpin how we account for a wood product’s carbon footprint have not kept pace. A new report by Canada’s renowned International Institute for Sustainable Development (IISD), titled “Emission Omissions: Carbon accounting gaps in the built environment”, should give policy makers and building professionals reason for pause. Among its most significant findings is that current lifecycle assessment models do not account for biogenic carbon losses from logging and that these carbon releases could represent up to 72% of a wood product’s carbon footprint.In this scenario, a wood building could in fact be more carbon intensive than a concrete building, and that’s not conventional wisdom. With significant low carbon advances in the cement and concrete sector and emerging evidence that concrete, over its life, re-absorbs a significant portion of the carbon emitted in its production, we believe concrete’s role as a climate solution is even clearer. This is admittedly a complex issue but today this complexity matters more than ever. The atmosphere doesn’t care about our assumptions, and with growing evidence that up to three-quarters of wood’s carbon footprint could be missing from our ledger, we need to do better. Rather than promote one building material over others, governments must get the best from all building materials. Low carbon building policies should secure a level but competitive playing field where material manufacturers and the building industry are driven toward low carbon solutions. Michael McSweeney President and CEO Cement Association of Canada Note: This article is a submission by, and reflects the views of, 2019 Annual Summit Sponsor: the Cement Association of Canada. The Pacific NorthWest Economic Region (PNWER) is not responsible for the content of this piece
Concrete is more than a material. It’s about life. When it comes to reducing carbon emissions from the places where we live, work and play, innovations in cement and concrete are leading the way. Today’s concrete is made with lower carbon cement and using lower carbon fuels recovered from wastes. Together, these innovations help reduce greenhouse gas emissions by up to 30%. Our investments in transformative carbon capture, storage and utilization technologies promise even deeper reductions. What’s more, concrete naturally absorbs GHGs throughout its life. Historic durability and resilience together with low carbon innovation means concrete plays a vital role in building a sustainable future for Canadians.
concretebuildforlife.ca
Nelson Mullins and Ambassador David Wilkins are proud sponsors of
PNWER 2019 We know Canada.
Our team understands the bilateral and the critical border issues that define the US-Canada relationship. We are experienced in the workings of both the US and Canadian governments from federal to state and provincial levels. We help clients on both sides of the border advance their government relations objectives.
800+ Attorneys & government relations professionals
Experience includes litigation, government relations, trade, energy, economics, and more.
Offices across the nation
Our firm is fast growing and includes key former lawmakers, prominent Capitol Hill staffers, and diplomats
TOP 100 Am Law ranked firm
Balanced perspectives Relationships and experience empower connected business-government relations strategies, and our team includes professionals who have called the halls of government home during their careers. We leverage strong relationships and an understanding of the political process, the law, and our communities to best serve our clients.
Nelson Mullins Riley & Scarborough LLP David H. Wilkins, Partner
101 Constitution Avenue, NW | Suite 900 Washington, D.C., 20001 | 864.373.2231 | nelsonmullins.com
@mosaicincanada
We help the world grow the food it needs.
Canadian potash GHG emissions are only 29% of the global average – leading the world in terms of low GHG output. Source: Carbon Footprint for Canadian Potash Production, Cheminfo Services Inc., 2018.
As one of the world’s largest suppliers of potash, we consider this mission one that carries a vast responsibility.
At Mosaic, we took charge of our future. Since 2012, the Potash Business Unit has achieved reductions in 3 major areas:
mosaicco.com
Decrease of freshwater used per tonne of finished product
Decrease of total energy use per tonne of product
Decrease of GHG emissions per tonne of product
OF THE GOVERNOR STATE OF MONTANA
Steve Bullock GOVERNOR
Mike Cooney LT. GOVERNOR
June 27, 2019 On behalf of the State of Montana, I would like to personally invite you to join us under Montana’s Big Sky for the 2020 Pacific NorthWest Region’s Annual Summit. Events will be taking place July 19th through the 23rd in Big Sky, MT and I know you will not want to miss this opportunity to take in the natural beauty we offer. Montana is an active member of PNWER and enthusiastically promotes collaboration in the Pacific Northwest region through the close cultural, bilateral, and multilateral links we have with our neighboring PNWER states and provinces. This will be a wonderful opportunity to meet with key business and legislative leaders from ten jurisdictions in two countries, who are interested in building innovative solutions to solve common challenges and enhance the economy and lifestyle of our communities. PNWER is a leader in fostering regional and international cooperation on priority issues such as agriculture, energy, the environment, disaster resilience, economic development, invasive species, trade, tourism, transportation, and workforce mobility. Join us in Big Sky in July of next year for what promises to be an exciting conference that will bring together over 500 legislators, private sector and government leaders, who will share innovative solutions for our great region. And while you plan your trip, make sure to plan time to take in some of Montana’s spectacular, unspoiled nature, visit our vibrant and charming small towns, and have breathtaking experiences by day and relaxing Montana hospitality at night. I look forward to welcoming you to Big Sky, Montana! Sincerely,
STATE CAPITOL • P.O. BOX 200801 • HELENA, MONTANA 59620-0801 TELEPHONE: 406-444-3111 • FAX: 406-444-5529 • WEBSITE: WWW.MT.GOV
Pacific NorthWest Economic Region Big Sky, Montana | July 19 - 23, 2020
The leading forum where people in the policy world and the business world come together to figure out solutions to regional challenges
30 PNWER Annual Summit Visit pnwer.org/2020-summit for more information
The Summit is taking place in the Sheraton
HOTEL MAPS
Cavalier Hotel and the Bessborough Hotel. The main plenary events will be at the Sheraton Ballroom, with breakout sessions located
Sheraton Cavalier Hotel
Main Level Conference Centre
between both hotels.
Top of the Inn 8th Floor
Bessborough Hotel
Convention Floor
Sheraton Cavalier
Bessborough
PNWER Economic Leadership Forum Nov 17 - 19, 2019 Grand Hyatt Seattle, Washington pnwer.org/2019pnwerforum
Strengthen regional cooperation Learn about key economic issues of the region Collaborate with U.S. & Canadian public and private sector leaders in a focused setting
The City of the Future Smart Cities 5G Edge Computing Machine Learning and AI Drones Resilient Infrastructure Autonomous and Electric Vehicles Special session for LEHI Alumni
The Economic Leadership Forum provides an opportunity for local, state, and provincial leaders in both the public and private sectors to carry out in-depth discussions on key subjects affecting our regional economy.
The Delegates
State, Provincial & Territorial Legislators Corporate CEOs or VPs NGO Executive Directors Subject Matter Experts Government Officials
Building Connections Economic Development Columbia River Treaty Border and Trade Tourism Contact Rachael Kopp rachael.kopp@pnwer.org to become involved
Pacific NorthWest Economic Region (PNWER) 2200 Alaskan Way, Suite 460 Seattle, WA 98121
pnwer.org
@pnwer #pnwer
info@pnwer.org
2019 PNWER Annual Summit Program
Welcome to PNWER's 29th Annual Summit in Saskatoon, Saskatchewan! The Annual Summit serves as a platform for delegates to explore shared cha...
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Best Of - Anthony Fauci: From Aristotle to AIDS
Da: What It Takes
0 0 9 mesi fa
Mi piace Mi piace
Chat in Diretta Commenti
Cultura e società, #aids, #covid, #disease, #doctor, #drug, #fauci, #hiv, #immunology, #medicine, #new yorker, #nih, #nina totenberg, #pandemic, #research, #science, #treatment, #white house
If Anthony Fauci was not on your radar before the Covid-19 pandemic, he certainly is now. Dr. Fauci is a lead member of the White House Coronavirus Task Force, and a trusted daily presence in the news. Many now view him as America’s MD. We told the inspiring story of Dr. Fauci’s life and career on this podcast in July of 2018. Under the circumstances, it seemed time for an encore:
This is the story of a remarkable doctor who, in 1981, became one of the first scientists to recognize that we ... Maggiori informazioni were on the verge of a new and terrible epidemic - HIV/AIDS - and then devoted his career to understanding and finding treatments for it. Dr. Fauci has been at the forefront of HIV/AIDS research ever since. Along the way, he also became the head of the National Institute of Allergy and Infectious Diseases, overseeing research into every frightening outbreak imaginable: Ebola, Plague, SARS, Zika, Anthrax, Malaria, Tuberculosis, Influenza, etc… He talks here to Nina Totenberg, for the Academy of Achievement, about growing up as the grandson of Italian immigrants, and about how an education in the classics prepared him for medical school. He recalls how he became a target of the AIDS activist movement, but turned out to be one their greatest champions. And he describes his relationship with presidents and lawmakers and the news media, throughout decades of medical crises.
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Academy of Achievement 2 followers Follow Following
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ホーム › DJチャート › Juno_Recommends_Soul ›
Juno Recommends Soul February 2019
Juno Recommends Soul
Jack JACOBS
I Believe It's Alright
Melodies International
Cat: MEL 14. Rel: 18 Feb 19
I Believe It's Alright (3:16)
I Believe It's Alright (extended) (4:11)
Shahid WHEELER
Just One Dance Before You Go
Just One Dance Before You Go (vocal) (3:48)
Just One Dance Before You Go (instrumental) (3:52)
Recipe For Love (1 per customer)
Cat: FSR 7078. Rel: 11 Feb 19
Recipe For Love (feat Jack Tyson Charles) (3:51)
Recipe For Love (instrumental) (3:52)
Judy POLLAK feat 33 1/3
In Togetherness (1 per customer)
Athens Of The North
Cat: AOTNLP 027. Rel: 25 Feb 19
Your Mine (8:38)
Come With Me (3:08)
Mr DJ (5:02)
Happiness (4:21)
Fascinating (5:48)
Billy's Coming Back (4:44)
More Than Words (4:00)
Still In Love (3:40)
Review: Second time around for "In Togetherness", a private press gem from 1977 that has recently become popular with dusty-fingered collectors of underground disco and soul. It was originally written, performed, produced and pressed by almost unknown singer Judy Pollak and Michigan-based backing band 33 1/3. This Athens of the North vinyl re-issue follows a recent CD edition by Japanese imprint P-Vine. Musically, there's much to admire throughout, from the sax-and-synths-laden disco stomp of "Mr DJ" and down low disco-funk headiness of "Fascinating", to the seductive sweetness of Pollack's breathy vocal on "Come With Me" and the sun-kissed breeziness of the brilliant "More Than Words".
Carlton JUMEL SMITH/COLD DIAMOND & MINK
This Is What Love Looks Like! (reissue) (1 per customer)
Timmion Finland
Cat: TR 725C. Rel: 04 Mar 19
This Is What Love Looks Like! (3:47)
This Is What Love Looks Like! (instrumental) (3:48)
DIPLOMATS OF SOUL
Sweet Power Your Embrace
Cat: 7DOS 2. Rel: 04 Feb 19
Sweet Power Your Embrace (feat Incognito & Vanessa Haynes) (4:42)
Brighter Tomorrow (feat Incognito & Imaani) (4:51)
Stephen Michael SCHWARTZ
Get It Up For Love
Get It Up For Love (3:30)
Get It Up For Love (album version) (4:11)
The RIGHT NOW
Star Creature US
Cat: SC 1216. Rel: 18 Nov 19
Up All Night (6:10)
Up All Night (BusCrates 16-bit Ensemble remix) (6:26)
Up All Night (Liquid Pegasus remix) (6:36)
Up All Night (Liquid Pegasus dub mix) (6:15)
Up All Night (JKriv remix) (6:59)
Shirley FINNEY
Pray Again
Rain & Shine
Cat: RSRLTD 003. Rel: 04 Mar 19
Pray Again (4:31)
Give Your Best To The Master (4:53)
Review: Shirley Finney's 1979 debut album "Pray Again" has recently become something of a sought-after set amongst collectors of disco-era gospel soul. Original copies of the LP are expensive and hard to come by, so Rain & Shine has decided to stick two of the set's most admired tracks on one 7-inch single. "Pray Again" is rather wonderful, with Finney delivering a strong, heartfelt vocal above a backing track rich in sustained organ chords, jangling pianos and clipped guitars. "Give Your Best To The Master", meanwhile, is a more up-tempo and stomping gospel-disco affair that benefits greatly from some stellar choral backing vocals. It sounds like the sort of thing that Tony Humphries may have championed at Zanzibar in New Jersey back in the day.
JASON JOSHUA & THE BEHOLDERS
Rosegold (reissue)
Mango Hill US
Cat: FMH 007BLACK. Rel: 18 Feb 19
Rosegold (5:07)
Are You Ready? (3:20)
Review: JJ and The Beholders blast the doors off with their debut single "Rosegold". A powerful bluesy lament, everything from the spacious production to the hammonds that croon behind Joshua ooze soul and sentiment. Meanwhile on the B we hit northern soul territory with a thumping beat, minimal instrumentation and stacks of room for Joshua's tones to shine through. Behold that that horn led middle-eighth. Pow!
RASPUTIN'S STASH
Make Up Your Mind
Family Groove US
Cat: FG 10001. Rel: 25 Feb 19
Make Up Your Mind (4:29)
You Are My Everything (3:22)
Review: We've had less than two years to recover from the unearthing of Hidden Stash by Athens Of The North when along comes Family Groove with the promise of another lost album from the debauched Chicago funk crew Rasputin's Stash. Entitled Stash it's due in April and the hype starts here with these two beautiful soul funk adventures. "Make Up Your Mind" rides on a sleazy fuzzy groove and peppy horns while "You Are My Everything" hits more of a classic triumphant horn and harmony led vibe not dissimilar to "I See Your Face" on their second album. April can't come soon enough.
SPACEARK
Spaceark Is
Cat: MRBLP 182. Rel: 18 Feb 19
Sweet Hitch Hiker (5:38)
Take Her Out Dancing (6:41)
Sexy Lady (5:42)
Ja More Mon A More (I Love My Love) (4:50)
Phantom Lover (4:55)
Each Song (7:39)
Barbara HOWARD
Remined US
Cat: RMND 12002LP. Rel: 18 Feb 19
Light My Fire (2:45)
My Song (3:43)
You've Made Me So Very Happy (3:38)
I Need You (3:04)
Welcome Home (2:27)
Save Your Love For Me (2:47)
Oh Me, Oh My, I'm A Fool For You (2:28)
The Man Above (2:39)
It's Not Unusual (1:50)
For Once In My Life (4:15)
Keep On Keeping On: Curtis Mayfield Studio Albums 1970-1974 (remastered)
Cat: 060349 7855797. Rel: 25 Feb 19
(Don't Worry) If There's Hell Below We're All Going To Go (LP1: Curtis) (7:46)
The Other Side Of Town (4:02)
The Makings Of You (3:43)
We The People Who Are Darker Than Blue (5:59)
Move On Up (8:53)
Miss Black America (2:57)
Wild & Free (3:17)
Give It Up (3:43)
Get Down (LP2: Roots) (5:41)
Keep On Keeping On (5:11)
Underground (5:15)
We Got To Have Peace (4:46)
Beautiful Brother Of Mine (7:30)
Now You're Gone (6:47)
Love To Keep You In My Mind (3:53)
Back To The World (LP3: Back To The World) (6:45)
Future Shock (5:18)
Right On For The Darkness (7:29)
If I Were Only A Child Again (2:48)
Can't Say Nothin' (5:12)
Keep On Trippin' (3:14)
Future Song (Love A Good Woman, Love A Good Man) (4:53)
Ain't Got Time (LP4: Sweet Exorcist) (5:09)
Sweet Exorcist (3:51)
To Be Invisible (4:12)
Power To The People (3:25)
Kung Fu (6:10)
Suffer (4:05)
Make Me Believe In You (5:33)
Nicole WILLIS/BANDA POLAMITA
My Soul Sensation
Cat: PERSE 005LP. Rel: 25 Feb 19
Save It (4:18)
Reparate (3:15)
Free (5:11)
My Soul Sensation (4:12)
I Call Your Name (4:16)
My Reflection (5:15)
LUCKY BROWN/THE SGs
Sweet Tea (With My Sweetie)
Tramp Germany
Cat: TR 1046. Rel: 04 Mar 19
Sweet Tea (With My Sweetie) (4:12)
More Sweet Tea (3:52)
Review: "Sweet Tea (With My Sweetie)" was originally destined for inclusion on Lucky Brown & The SG's 2018 album "Mesquite Suite", but for one reason or another ended up getting cut. Happily, Tramp Tapes has decided to make it available as a 7-inch single instead. As with previous Brown excursions, the title track sounds like it was recorded sometime in the late 1960s, with authentically fuzzy production, punchy horns, Meters style Hammond licks and sweet, eyes-closed guitar riffs riding a loose but punchy funk-soul groove. "More Sweet Tea" sees the assembled band offer up a jazzier, solo-heavy instrumental revision of the title track that's even dustier and heavier than the A-side.
Walk Through Fire
Farawy Look (3:10)
Shady Grove (2:42)
Ride Out In The Country (3:12)
It Ain't Easier (4:23)
Walk Through Fire (3:47)
Rock Me Gently (3:25)
Love All Night (Work All Day) (3:32)
Deep Blue Dream (2:14)
Lonely The Night (4:43)
Still Gone (2:53)
Keep Me Here (3:33)
Love Is Light (3:12)
MATADOR! SOUL SOUNDS
The Juice Ain't Worth The Squeeze
Color Red US
Cat: CRR 0037. Rel: 04 Feb 19
The Juice Ain't Worth The Squeeze (4:21)
Go On, Love (3:47)
Doing The Natural Thing: Psychedelic Country Garage Soul & Shaking R&B Obscurities
PTR Canada
Cat: PTR 053. Rel: 18 Feb 19
LA Jones - "Doing The Natural Thing" (2:10)
Ansley Fleetwood & The Surprises - "Elvira" (feat Surprises) (2:45)
Dale Mason - "She's My Baby" (1:46)
Gary Von - "I Wanna Know" (2:41)
Leo Krokos - "Kiss Of Fire" (3:08)
Wayne Richards - "Seasons" (3:50)
Obrey Wilson - "Headman" (2:16)
Chic Morrison - "Talk About Love" (2:24)
Benchmark - "Hold On I'm Coming" (2:32)
Denver Affair - "Crawdad Hole" (3:13)
Randall Gray - "They Call It The Soul" (2:24)
Oakbrook Trees - "Mustang Sally" (2:49)
The Dip Delivers
Cat: MSTRD 001LP. Rel: 11 Feb 19
Sure Don't Miss You (2:54)
Best Believe (3:56)
Advertising (feat Jimmy James & Delvon Lamarr) (3:01)
Adeline (3:33)
Atlas (3:47)
Slow Sipper (3:02)
Spiderweb (3:15)
Starcastle (2:54)
She Gave Me The Keys (2:25)
Sea Snake (3:04)
The ISLEYS
Brother Brother Brother (reissue)
T-Neck US
Cat: TNECK 3009LP. Rel: 25 Feb 19
Brother, Brother (3:17)
Put A Little Love In Your Heart (3:02)
Sweet Seasons (2:58)
Keep On Walkin' (2:17)
Work To Do (3:13)
Pop That Thang (2:53)
Lay Away (3:22)
It's Too Late (10:30)
Love Put Me On The Corner (6:30)
Hi, check out my new chart at Juno! https://jp.juno.co.uk/charts/dj/1429002-Juno_Recommends_Soul/4462407-Chart/
チャートのJuno Playerを作成するには、このコードをWebページまたはMyspaceにコピー&ペーストしてください。
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Cats in the NFL week 15 Preview
By Brent Wainscott | December 15, 2019 | 11:30am
© Philip G. Pavely | USATSI
The push for the playoff is in the air in week 15. Here’s where our Cats stand heading into the final push.
Buffalo Bills at Pittsburgh Steelers (Benny Snell, Bud Dupree)
Benny Snell football is heading to primetime! While this isn’t the first time the Steelers will be kicking things off in primetime this season, this will probably be the first time Benny Snell gets to make a statement in front of a national audience. Snell’s volume has tripled the last few weeks and Mike Tomlin makes no mistakes about it, he is all about Mr. Snell ya Later.
Mike Tomlin to Benny Snell: I watched you play Florida last year. I was sitting there in my hotel room and I wanted to draft your ass!
pic.twitter.com/jRN7VrBuQw
— Big Blue Nation (@BigBlue9ation) December 14, 2019
Bud Dupree will also try to keep playing well in his contract year. The former Cat has 42 tackles on the year and is 12th in the league with 9.5 sacks.
The Steelers will kick things off against the 9-4 Buffalo Bills on Sunday Night Football at 8:15 p.m.
Chicago Bears at Green Bay Packers (Za’Darius Smith)
Oh, what a wonderful day this can be. The Chicago Bears will head up to the Frozen Tundra today as they try to stay in the hunt for that final NFC wild-card spot. Despite the Bears taking four of their last five, it has to be near impossible for this Chicago team to beat Aaron Rodgers on his home turf. Not to mention that the ever-struggling Bears offense has to line up against Za’Darius Smith, who is tenth in the league with ten sacks. In the first game of the year, the Green Bay defense held the Bears to just three points and I’d like to see more of the same today.
Green Bay will try to end Chicago’s season today at 1:00 pm ET on FOX from Lambeau.
Tampa Bay Buccaneers (Mike Edwards) at Detroit Lions
Mike Edwards and the Tampa Bay Buccaneers were eliminated from playoff contention last week. This week they face a Detroit Lions team that has lost six straight. You either have to be a die-hard fan of both teams or live in a horrible market area to watch this one. Unless, of course, Mike Edwards has a big game…that’s about the only thing I can imagine for tuning in.
Kickoff for this monstrosity will be at 1:00 pm ET on FOX.
Houston Texans (Lonnie Johnson) at Tennesee Titans (Wesley Woodyard)
From a game that means absolutely nothing, to a game that means just about everything in the AFC South. The Titans seem to have found some life in the form of Ryan Tannehill to keep them in the hunt at 8-5 as they go up against an under-achieving Houston Texans team that also sits at 8-5. The winner will, of course, be a leg up in the AFC South and ultimately take over the playoff spot for the time being. The nation’s eyes will be set on Deshaun Watson and Derrick Henry, but the Kentucky eyes will be set on the defense as Lonnie Johnson takes on Wesely Woodyard.
Kickoff from the Music City is set for 1:00 pm ET on CBS…someone check on Drew.
Jacksonville Jaguars (Josh Allen) at Oakland Raiders
Josh Allen and the Jacksonville Jaguars head out west to take on the Oakland Raiders in the Black Hole. Josh Allen will try to continue his stellar rookie season, as he looks to close the gap between him and Nick Bosa in the rookie of the year race. But, if we’re honest, playing in Jacksonville hasn’t done him any favors this season. Regardless, he will look to remain as the Rookie sack leader.
Jags and Raiders at 4:05 pm ET on CBS.
Los Angeles Rams at Dallas Cowboys (Randall Cobb)
We love Randall Cobb and we also love watching the Cowboys struggle to get a win when it comes to playoff time. So it’s a win-win if you ask me. The Rams will try to stay in the hunt today against a Cowboy team that has been just miserable after their 3-0 start to the season. Randall Cobb will look to make a bigger impact in this one as he’s only hauled in 44 catches for three touchdowns this season.
Kickoff at Jerry World is at 4:30 pm ET on FOX.
Article written by Brent Wainscott
Twitter: @BrentWainscott_
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← SOLO IN ENEMY TERRITORY PROJECT PART 1: PIRATES VS. METS
The Pittsburgh Logos Project →
SOLO IN ENEMY TERRITORY PROJECT PART 2: PENN STATE VS. ILLINOIS
By Pat Combs
Driving across Indiana lends itself well to thinking. There’s not a lot out there to distract a driver; this shouldn’t surprise anyone.
http://www.gourmet.com/images/gmtlive/2012/100312/impact-of-2012-drought_608.jpg
( I didn’t actually take the above picture, but you get the point.)
I drove from my place in Lafayette across the border to Champaign, Ill., last Saturday to see my first Penn State football game in nearly two years. I hadn’t seen the Nittany Lions play in person since they beat Michigan in 2010.
It’s safe to say that things have changed since then.
That’s primarily what filled my mind as I made my way through metropolises like Wingate and Veedersburg. As Pete’s story from earlier this week mentioned, he and I each took in a game – or, in his case, games – in “enemy” territory. It’s always been a dream of mine to see as many different college football stadiums as possible, so at least Memorial Stadium could be checked off the list.
You’ll notice that I omit words like “hostile” from this piece. There’s a reason for that – Memorial Stadium and its fans couldn’t have been any more welcoming. Naturally, I was concerned about how Illinois fans would treat opposing fans (namely, me) of an embattled team, but Illini fans were extremely benign.
Almost sleepy.
The worst I saw was a woman sitting in front of me who constantly complained about her team’s play during the game, but she’s an Illinois football fan – how much could she expect? There was also a couple sitting a few rows behind me who seemed like they were straight out of a terrible football-themed comedy. The man yelled “BLITZ!!!” before every play of the first half. Every. Play. His wife yelled “TOUCHDOWNS!!!” only slightly less frequently (her use of the plural form of the word went for naught; Illinois scored just seven points). Other than observing their knowledge of two football words, they seemed to know nothing of the game.
The positive experiences far outnumbered the minor annoyances of BLITZ and TOUCHDOWNS. To start with, I had a terrific seat. A woman and her son had an extra ticket and sold it to me for a very reasonable price. I had gone to the game without tickets, figuring I’d gamble an hour-and-a-half drive rather than pay $50 to see Illinois football (would you?). I spent some time in the Penn State alumni tent and had a pretty good time…seven minutes in, I’d already secured a free Rice Krispies treat and orange juice. Big Ten football demands hearty breakfasts.
Not a bad view for $20.
While in the tent, I saw an older Penn State fan named Walter. I did not discuss the game with Walter, nor did I even talk to him. I didn’t even introduce myself to him. How did I know Walter’s identity? He was wearing a knitted sweater that had to have been 30 years old with his name emblazoned down the sleeve. If I weren’t a grad student living on a stipend, I would’ve offered him at least $40 for it. Sadly, the lighting in the tent combined with the obvious creepiness of taking a cell phone picture of an old guy’s arm prevented me from obtaining photographic evidence.
Everyone in Champaign (and Urbana, technically the city in which I parked) was beyond friendly. Even the Illini band waved to and cheered for the Blue Band. The parking attendant who took my money wished me luck and told me that the parking lot was full of mostly Penn State fans (she was right). As I walked into Memorial Stadium, I passed a guy selling programs who was more than accommodating with his sales pitch:
“Yinz wanna buy a program?”
Yes, even the fine people of central Illinois are at least proficient in Pittsburghese. One woman responded that she felt at home.
Memorial Stadium itself is a venue more notable for its architecture and history than its atmosphere. It’s a stadium that held many games in which the Illini were led by Red Grange and displays its age well. It would probably be a pretty cool scene should its inhabitants begin holding more meaningful games; I think the fans would be there to provide a strong environment if the stakes were higher than in the current post-Zook era. The stadium has 200 columns ringing its exterior, giving it a pretty cool look. Inside, large banners hung from the rafters display famous former players such as Grange, Dick Butkus and former Steelers legend Matt Cushing. It occurred to me that I was inside the stadium where my favorite Penn State player of all-time, Brian Milne, scored the biggest touchdown of his career to cap one of the great drives in Nittany Lion history.
The external walls of Memorial Stadium.
The game itself was a successful one for myself and other Penn State fans, but my time on the inside of Memorial Stadium wasn’t all that eventful. Aside from a convincing 35-7 Penn State win and the several perplexing chants of “OSKEE-WOW-WOW,” it was actually a pretty dull game.
In some ways, my excursion to Illinois was a bit disappointing. I went to a college football game – a Division I football game! A Big Ten football game! – completely devoid of animosity or even mild fan-inspired intensity. I obviously didn’t want to hear anything disrespectful directed at Penn State fans, but I was looking forward to at least some football-related chiding from the home fans. I wanted competitive banter. I wanted some jawing back and forth. I wanted just a little well-placed, football-specific vitriol.
I found none.
But as a Penn State fan traveling to a foreign stadium, I know how fortunate this situation was. The Illinois fans I encountered were nothing short of classy and I heard not one word from an Illini faithful regarding the events of the past 11 months. Of course, I’m glad I didn’t, because, for at least a few hours, football was about football, even for Illinois fans.
Now all they need to do is have their offense work on making TOUCHDOWN plural.
The proof of Penn State’s dominant performance.
— Pat Combs is a contributing writer for the Keystone Sports Spot. He is a Penn State alum and current Purdue grad student.
Filed under NCAA Football, Penn State Tagged with Blue Band, Brian Milne, Champaign, college football stadiums, Dick Butkus, Illinois, Illinois Fighting Illini, Illinois Football, Matt Cushing, Memorial Stadium, Penn State Football, Penn State Nittany Lions, Penn State University, Red Grange, Ron Zook, Sports, University of Illinois, Urbana
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Wynonna & the Big Noise Announce Christmas Tour Dates
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Michael Noble Jr., Getty Images
Wynonna Judd and her band the Big Noise will end 2016 with a holiday tour, kicking off just after Thanksgiving and running through mid-December.
The Wynonna & the Big Noise Christmas Tour will couple Judd's well-known hits with a healthy mix of holiday tunes. In addition to her biggest songs and holiday favorites, Judd will also be sharing some of her newer music with fans; Wynonna & the Big Noise's self-titled debut album was released in February.
"Every year, I look forward to our Christmas tour," says Judd in a press release. "It's so easy to get caught up in the perfectionism that this time of the year often brings. I love singing the music that inspires me to remember the real reason for the season. My hope is that people can come to the show, forget about their 'to-do' list and, for the time we are together, simply enjoy themselves."
The Wynonna & the Big Noise Christmas Tour will start with a bang: a free concert in Panama City Beach, Fla., on Nov. 26. From there, they'll travel to nine other cities, including Las Vegas and Nashville, and wrap up the trek in Lufkin, Texas, on Dec. 17. A full list of stops can be seen below, and more information is available on Judd's official website.
With Wynonna & the Big Noise, Judd tells The Boot that she feels as though she’s truly getting a second chance.
“It’s so vulnerable, and it’s changed my life. [My husband and bandmate] Cactus Moser has made the best record for me that I’ve ever done, and the best one of mine,” she gushes. “This record is my next chapter of what it’s like to be a 50-year-old woman and have a renewed spirit — a Stella Got Her Groove Back kind of thing. I’m sassier than ever.”
Wynonna & the Big Noise, 2016 Christmas Tour Dates:
Nov. 26 -- Panama City Beach, Fla. @ Aaron Bessant Park
Dec. 1 -- Bowling Green, Ky. @ SKyPAC
Dec. 2 -- Glen Ellyn, Ill. @ McAninch Arts Center
Dec. 3 -- Shipshewana, Ind. @ Blue Gate Theater
Dec. 8 -- Las Vegas, Nev. @ Golden Nugget
Dec. 9 -- Cerritos, Calif. @ Cerritos Center for the Performing Arts
Dec. 14 -- Nashville, Tenn. @ CMA Theater at the Country Music Hall of Fame
Dec. 15 -- El Dorado, Ark. @ El Dorado Municipal Auditorium
Dec. 16 -- Biloxi, Miss. @ IP Casino Resort & Spa Studio A
Dec. 17 -- Lufkin, Texas @ Temple Theater at Angelina College
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Source: Wynonna & the Big Noise Announce Christmas Tour Dates
Filed Under: wynonna judd
'Wagons For Veterans' Cookout Scheduled for Saturday, March 13
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Approved 3-7-19
ASEC Minutes
2:00 – 4:30 p.m. Thursday, February 28, 2019
53 Bascom Hall
Members Present: Donna Cole; Aaron Crandall; Tim Dalby; Mallory Musolf, vice chair;
Deb Shapiro; Lindsey Stoddard Cameron
Guests: Laurent Heller, Sarah Mangelsdorf, Casey Nagy, Lori Reesor, Jake Smith
The meeting was called to order at 2:07 p.m.
The minutes of February 21, 2019, were approved.
Guest: Laurent Heller, Vice Chancellor for Finance and Administration
Vice Chancellor Heller discussed the recent flooding on campus from burst pipes. In order to keep up with deferred maintenance, the campus should be spending $150-200 million. Right now, campus is spending $30 million. The state used to care take of deferred maintenance costs, but that hasn’t been the case in the past decade or so.
The capital budget is very important to campus this year. Priorities include replacing the Natatorium, Veterinary Medicine expansion and renovation, renovation in housing and utility replacement on Bascom and Linden Dr.
The Board of Regents has approved pre-planning for the project to replace the current human resources and business services systems. The new systems need to do what campus needs them to do, not be driven by technology.
Guest: Sarah Mangelsdorf, Provost
Provost Mangelsdorf gave an update on the Cooperative Extension transition to UW-Madison. The University Academic Planning Council (UAPC) was presented with a draft proposal on how Extension would be structured once they move to UW-Madison. The proposal was put together by a joint committee of UW-Madison and UW-Extension faculty. The proposal has a single department with a department chair reporting to the Dean. There would be five sections under the department with each section having its own head.
She also provided some information on the Policy Library project. This project won’t be making any changes or decisions regarding policies, but they will identify issues with current policies including conflicts. The goal of the project is to make a searchable library of campus-wide policies.
Guest: Lori Reesor, Vice Chancellor for Student Affairs
Vice Chancellor Reesor announced the hiring of a new University Health Services director, Jake Baggott, who will start in May. The Dean of Students search is under way. The search and screen committee will begin reviewing applications in March with finalist visits in April.
There will be a review of campus fraternities and sororities. This review is not prompted by any specific event. A review has not been conducted since 1999. They are bringing in consultants from different fraternity and sorority organizations to do the review. The review will look at areas including accountability, diversity and inclusion, institutional relationships, membership experience, resources and support, and student safety. The consultants will be on campus this spring and are expected to complete their report by summer.
She has also put together a Mental Health Task Force. This is a significant issue for students and the highest priority for Associated Students of Madison (ASM). The task force is made up of faculty with expertise in the areas as well as some students. A first report will be released in May to look at immediate needs. Additional work will be done in the coming year to look at this topic more in depth.
Guest: Casey Nagy, Interim Vice Provost for Extension and Public Media
Vice Provost Nagy commented on the proposal for the structure of Extension when it moves to UW-Madison. He is optimistic that the faculty and administration will reach an agreement on the structure. One of the unresolved issues is how academic staff fit into the model. This is something that doesn’t have to be worked out right now, but the proposed structure would need to set the foundation for how things could develop.
In terms of the overall transition, everything is on track and meeting benchmark dates. They are working on migrating Office 365, creating placeholders for personnel and financial functions, creating NetIDs. He expects that payroll and purchasing will switch to Madison on April 1. They are looking to accelerate the facilities transition due to loss in personnel.
He continues to work with Aaron Brower and others to review policies. The technical changes have been done, but not anything substantive. He hopes to have a fundamental policy document ready for review and comment in the next couple weeks.
Mallory Musolf, ASEC vice chair, reported on the meeting with Mark Walters and Patrick Sheehan, Office of Human Resources. Mark elaborated on the role of the OHR leadership in the new TTC Advisory Committee. He expects to see various leadership present at these meetings. A draft charter will be distributed and hopefully finalized at the first meeting.
She also asked OHR about the role and composition of the TTC Planning Committee. This committee is comprised of OHR leadership and TTC staff. They put together proposals about TTC that are then vetted by others. Mark indicated that strategies coming out of this committee will be shared with the new Advisory Committee.
Heather Daniels asked ASEC if they would like to hear from the Policy Library project team. ASEC is interested.
•March Assembly Agenda
ASEC reviewed the March Assembly agenda. There is a resolution on the agenda asking the Assembly to sponsor the worklife survey. Motion to approve the agenda (Stoddard Cameron). Seconded. Approved.
Minutes submitted by Heather Daniels, Secretary of the Academic Staff
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VIDEO: It was a monostrous fraud…it will be a bombshell…I’ve never seen anything like it, says Orengo
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“I’ve never seen such a fraud,” Lawyer James Orengo after Supreme Court submission.
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KDF pilot killed in crash months before wedding
Like many ambitious young men, Lieutenant Adams Rhova had big plans for the New Year.
Exactly 30 days from today, he was due to reveal the date he would have walked down the aisle with the love of his life Sandra Kadzo.
An inspiration, a mentor, a role model and a philanthropist, many poor families in Kulesa village, Garsen, Tana River County, also looked forward to a good year, thanks to his alms.
But the dreams were shattered on Tuesday morning when Rhova, 30, perished in a Kenya Air Force plane crash inside Tsavo East National Park, some 15 kilometres from Voi town.
The aircraft, a Harbin Y-12 model that was being flown from the Kenya Air Force Moi Air Base, Nairobi, claimed the lives of three other military personnel who were on an undisclosed mission in Taita Taveta County.
When the Nation visited Kulesa village yesterday, pain was written all over the faces of his family, neighbours, friends, local leaders and even strangers. His mother, Yunia Hadulo, who received news of her son’s sudden death, was still in shock and could not talk.
A holiday
Just 20 days ago, the lieutenant had taken his entire family for a holiday in Malindi where he announced his future plans.
READ ALSO: Uhuru is "shredding" the constitution which is disastrous for the country, says Prof Yash Pal Ghai
“He was planning to marry his fiancée, whom he introduced to the family early this year. He had many other big plans for Kulesa people and as matter of fact, he was the family’s mentor,” Alpha Rhova, Adams elder brother said.
Reached for comment, crestfallen Kadzo said she needed time to mourn her loss. “Kindly I’ve no strength to comment or say anything. The death has robbed me of my life too. He was my everything and this has happened when our relationship is at its peak,” she said amid tears.
Many remembered the lastborn in the family of three as a humble man who helped many poor families with school fees and ran campaigns against violent extremism.
In Kulesa, Rhova had a team of youth who provided him with intelligence on local security matters.
“He was [more] informed of the activities in the village than anyone else. He was a man of the people and his presence here elated many lives, both the youth and the elderly,” Alpha said.
Born on December 12, 1990, Rhova went to Kulesa Primary School before proceeding to Garsen High School.
He later joined the University of Nairobi in 2012 for a Bachelor’s degree in Education, but dropped out in his second year to join the military.
READ ALSO: Former Kenyan TV presenter Louis Otieno goes deaf
In 2016, he secured a chance to train as a cadet and was taken for aviation training in South Africa where he graduated in 2017. He had only served the Air Force for three years.
Salama location chief Peter Jilo said Rhova was the only military man in his village and surrounding areas. “His death has broken my heart into many pieces; it feels like I’ve lost my own flesh and blood. Only God knows our pain,” he said, tears welling in his eyes.
A brave and humble person
The chief eulogised Rhova as “a son and a torch” that will take a lifetime to replace.
Eric Bonny, a former schoolmate of Rhova’s and one of his best friends, is heartbroken.
Rhova carries lots of “secrets and wisdom” to the grave, he said.
“The accident has robbed us of a brave and humble person, who could create time to help anyone in time of need,” he said.
The Kenya Defence Forces is yet to release details and possible cause of the crash of a plane model that has been involved in several similar accidents in recent years.
Last August, a Harbin Y-12 craft came down at Dhobley Airstrip in Somalia.
The 10 occupants on board did not suffer any injuries but the aircraft was seriously damaged. The landing gear as well as the left-hand wing were mangled.
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In 2014, one person was killed and 11 others injured when a plane of the the same model crashed shortly after taking off from El Wak airport in Mandera County.
In 2006, another military aircraft of the same model crashed on a hill in Marsabit, killing 14 people.
Last year, KDF announced plans to acquire three Italian-manufactured Spartan aircraft to replace the aged Harbin Y-12s. The first one was delivered late last year.
by Nation.africa
Ex-Chelsea star Drogba drops his 10-year-old marriage for ‘positive’ young woman
Chelsea football legend Didier Drogba has revealed his ten-year marriage to Lalla Diakate is over, after appearing in an intimate video in bed with a mystery woman.
The two, who have three children together, have always had a discreet private life in order to shield their loved ones from the limelight.
However, Drogba was forced to confirm that he had split from wife Lalla after photos and videos went viral on social media of him with another woman.
The 42-year-old met Lalla in Paris in the 1990s and formalised their union in 2011.
In the film, according to The Sun, which a representative claimed had been hacked, Drogba was seen bare-chested in bed with the near-naked young woman, sparking headlines in his home country.
The two appear extremely playful as she jokingly bites his shoulder before he cries in French: “She’s positive! She’ll infect me by biting me!”
The scenes left tongues wagging back in Ivory Coast and the Blues’ icon was forced to respond.
“But, because of speculation in the media today, I can confirm that sadly, after 20 years together, Lalla and I took the difficult decision to separate last year.
“We remain very close, and our main priorities have been to protect our children and our family’s private life. May God bless you.”
Drogba spent an initial eight years at Chelsea, before briefly returning in 2014, scoring 104 goals in 254 Premier League games, winning four league titles and the Champions League in 2012.
The 42-year-old is also the all-time top scorer and former captain of the Ivory Coast, boasting 65 goals in 105 caps.
By NN
There is something roundly enchanting about Senior Counsel Philip Murgor: his mild manner and piercing mind. It is also his unrelenting spirit and an almost inscrutable gaze. Yet nothing quite compares to his ability to gel in different contexts, in different seasons.
As he turns 60 this year, he tells me if his life was plotted on a graph, he would be thoroughly pleased with the results.
“My career and social life have had a steady rise,” he says.
We met a day after Chief Justice David Maraga’s exit, making it difficult to skirt the subject of his scorecard and succession. How would he rate him? “CJ Maraga did his best. He was sincere in everything he did and attempted to do. I would give him 65 out of 100.”
The Senior Counsel observes though that it was Mr Maraga’s responsibility to resolve the publicly frosty relations between the Judiciary and the Executive.
At the core of the escalating tension between the two arms of government has been budgetary disputes and the appointment of judges.
I ask him how differently he would navigate the terrain if he were Chief Justice. “It’s important to avoid disputes that lead to institutional deadlocks,” he says, adding that he’d be alive to the realities that define this relationship. “I’d have handled the budgetary issue differently, by being more diplomatic but also firm.”
Is he diplomatic? Mr Murgor calls it a question of discretion. “There’s a time to shout from the rooftops and a time to be diplomatic. I’m diplomatic when I need to be and firm when the situation so demands.”
Born in Iten in 1961, he went to school in Nairobi and has worked in the city ever since. His first job was in public service as a public prosecutor. This decision was largely influenced by his background.
“My father was a provincial administrator. He worked in different stations in Kiambu, Kisumu, and later Eldoret. You feel obligated to work in the public sector,” he says.
Mr Murgor and his wife Agnes Murgor, a judge, later left public “when it became impossible to raise a family” owing to various hardships touching on pay and maternity leave.
The Murgors have two daughters and a son, aged 29, 26, and 21. “I have a wonderful wife and wonderful children,” he says of his triumphs at the social level. “We’re a simple family. My daughter was stuck in the UK for almost a year. She just returned home. That was the longest time we had to wait.” His eldest daughter is a lawyer. That makes three lawyers in the same household. Do they talk shop at home? “No. But sometimes we discuss topical legal news stories in the country.”
On his contribution to the country, Mr Murgor, a Master of Law holder from the University of Nairobi, cites major cases, including the Goldenberg, where he represented the government and the Central Bank of Kenya.
READ ALSO: Kenyan law allows Cabinet Secretaries to campaign
In these cases, Kenya recovered billions of shillings that had been stolen while the perpetrators were also brought to book. I’m curious to know what kind of feeling such roles and feats inspire in him.
“I had hoped this would give me a measure of satisfaction. But it didn’t,” he says.
First, because he feels he did not finish his work, and secondly because he thinks a lot more needs to be done “to make the country better.”
But it is his stint as Director Public Prosecutions ( DPP) that he is proudest about. “That’s where I made a mark in my career. I took over at a time when public prosecution in Kenya was considered dead,” he says.
He likens his tenure to fighting a war without shoes. “As DPP, I received instructions from the Attorney-General who was [technically] the public prosecutor.”
Even without constitutional protection, Mr Murgor took the difficult assignment in his stride and with zeal.
But he would soon take a bullet for asserting himself in sensitive matters. “The President (Mwai Kibaki) couldn’t remove the AG because he was constitutionally protected,” he says.
Mr Murgor left the stage in a cloud of confusion over who was responsible for his boot. Does he think the country owes him? “Not really,” he says with a chuckle, reclining in his chair. “I think I owe the country more service.”
Is public service thankless? “Public service shouldn’t be thankless. Doctors and teachers were respected members of the society in the past,” he says. He blames the change of attitude on capitalism. “We’ve become a very commercial society. [That’s why] we look at public servants [with disdain].”
“Public service can be more, should be more. It’s what drives a country. It should be facilitated for that purpose.”
In the coming weeks, the Judicial Service Commission (JSC) will start to recruit Mr Maraga’s successor. What should the JSC look for in a candidate and what should Kenyans expect?
“Someone who can bridge the gap between the Judiciary and the other two arms of government to facilitate service delivery to the people,” he says, noting that the candidate must also inspire investor confidence.
“No investor will place his money in a country where the dispute resolution mechanisms or Judiciary do not function or are underfunded,” he adds. That person must also project independence, be level-headed, and experienced. Would he go for the post? In a measured tone, Mr Murgor replies: “Obviously, I’ve considered it.”
Will he? “I’m leaving it open. I’m also consulting.” For him, turning 60 is a milestone that comes with more responsibilities. It is time to evaluate his career and contribution to the country. “I hope to be in my prime between now and 70. I could do this in either private practice or the public service,” he says with effusive composure.
Away from the law, Mr Murgor has interests in animal and crop farming, which keeps him going during weekends. He rears dairy cows on his farm in Moiben in Uasin Gishu County and also grows fodder, maize, and barley.
Does he know how to milk? “Yes,” he replies emphatically. “I grew up on a farm. Milking was one of the lessons. But a machine does that now.”
From his frame, it is evident he likes to keep fit. Did he attain his fitness goals in 2020? He hesitates. “I did,” he says after a momentary pause. “I have moments when I exercise more than others. During the lockdown, I ventilated a lot, working out and taking long walks.”
He is a teetotaller and has no indulgences. “I avoid consumption of red meat. I enjoy vegetables and white meat.”
Whereas his family has travelled twice every year before, for work, to take time off and to meet friends abroad, the pandemic disrupted such travel plans in 2020.
A stickler to discipline, Mr Murgor does not camouflage his impatience for incompetence. “Some people have no interest to serve the country, which comes at a great cost. When one gets a public job, they should truly commit to service.”
For many years, he has advocated for the rights of the disadvantaged in society, including special-interest groups and women. He says the two-thirds gender rule in public service is not enough.
“I believe in gender parity. The two-thirds rule is a minimum. Kenya should strive to do better.” His office, he tells me, has more women employees than men. “Even my children, I teach them in that manner.”
I ask him when he has felt most vulnerable. He scowls almost imperceptibly, before steadying himself. “I’ve been threatened in my line of work,” he says, adding, “but that comes with the territory. Even as an advocate sometimes you take a position on a matter and it will come back to haunt you.”
Mr Murgor interned at the Superior Court of the US in Washington as part of a student exchange programme. His scope of practice covers criminal, constitutional, civil, and commercial litigations.
Throughout his career, he has represented clients in criminal cases, including murder. He says a lawyer’s job is like a doctor’s.
“By the time a client consults a lawyer, they’re in a very vulnerable position. They will confide in you. It’s your responsibility to comfort and assure them.”
Trust, he adds, is paramount. “A client has to be sincere to be helped. The truth eventually comes out, and as a lawyer, I don’t want to be ambushed when that happens,” says the lawyer who has been in legal practice for 28 years.
Winning and losing cases is part of the job. When I ask him how he prepares for rulings in cases he feels he stands little chance, he goes for a cracker: honest lawyers do not promise a particular outcome to their clients.
“When a client’s case is weak, you tell them as much, but you assure them that you’ll fight it nonetheless. Or you advise them to settle it in another way to avoid incurring costs in legal fees and a possible loss.” So, who inspires his work? Mr Murgor points at one of the many portraits hanging in his office of him with former US President Barack Obama. He met him in 2006 when, then Senator for Illinois, Obama had visited Kenya.
“Obama is the epitome of servant leadership. He remains the standard by which you judge the performance of a president.”
Chalk and cheese is his phrase for the difference between Obama and outgoing US President Donald Trump. “Trump has been a total international disaster. Unfortunately, there are political leaders and professionals in Kenya who embrace Trumpism as a means to rule.”
At this level in his career, are there things he feels he has outgrown? “As a professional, you’ll never outgrow any legal problem. But as a human being, as you mature, you realise you have less time for useless exchanges. At 60, you’ve seen it all and you know when to say something and when not to,” he says. In recent years, Twitter has become an arena for sometimes embarrassing exchanges and even personal attacks between lawyers. This conduct, he laments, puts legal practice to ridicule and disrepute.
“Lawyers who are worth their salt should conduct themselves on social media in a manner that reflects seriousness. Think about how you portray yourself and the profession. Weigh your words before you speak. Speak only when you must.”
With a sluggish economy, Mr Murgor says it is become harder to remain in legal practice. “I don’t have any personal struggles, but it’s a difficult time to work in Kenya.”
The best way to visualise him is to imagine him in a pinstripe suit. He tells me his sense of fashion is conservative.
He used to play golf which he had “easily mastered” but the interest soon petered out as he found he “could not continue doing the same thing every day, without a specific objective.” He now concerns himself more with farming.
Strip him of his career, reputation, and family, and he says a decent and fair man is what would remain. “I tend to attract victims; people who have been wronged and not those who have wronged others,” he says.
In 2017, he vied for the presidency on a United Democratic Movement ticket. Is his political ambition still alive? “That moment passed,” he says with finality.
He adds that he was driven by “the need to unite the country” and “to give Kenyans another option” away from the predominantly ethnic-fuelled politics. His months-long incarceration as a first-year student at the University of Nairobi in the aftermath of the attempted coup of 1982 hardened him even as it broke some of his fellow detainees. “It shaped my career. I’m extremely resilient now.”
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CHECK YOUR LUCK: Results for Green Card Lottery 2020 are out! Good luck
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USCIS Announces Citizenship and Assimilation Grant Opportunities
Here are the various different ways to obtain a US Green Card (Permanent Residency)
Shock as Kenyan woman found dead in her car in Atlanta
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Announcement to DV-2019 Winners: You have until September 30th to secure a Green Card Interview and Visa
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KXEO Sports Report 12/10/20
December 10, 2020 By KXEO
The Mexico Girls Basketball Team are back on the road tonight (Thursday) to face the Columbia Battle Spartans.
The Mexico Girls are 2-1 while Battle is 1-2.
JV tips at 6 with Varsity to follow at 7:30.
The North Callaway Thunderbirds Girls Basketball Team lost 46-42 to Salisbury in the Centralia Tournament last (Wednesday) night.
The Thunderbirds Girls will not be in action again until next Thursday, December 17th when they host Louisiana.
The Missouri Tigers Men’s Basketball Team kept their undefeated streak in tact last (Wednesday) night with a 69-60 win over Liberty.
Mizzou senior guard Mark Smith led all scorers with 17 points.
Dru Smith chipped in 14 points and Xavier Pinson added 12 points, seven boards and three assists.
The Tigers improved to 4-0 and will play the annual Braggin’ Rights game against Illinois on Saturday night with no fans in attendance at Mizzou Arena.
Hockey legend Brett Hull is being named the top St. Louis sports personality of the last 50 years.
In October St. Louis sports fans submitted their online votes for the Top 50 St. Louis Sports Personalities of the last 50 years.
On Tuesday night during the Jack Buck Awards banquet, Hull finished ahead of St. Louis sports legends Ozzie Smith, Lou Brock, Albert Pujols and Kurt Warner.
Over 11 years and 744 regular-season games, Hull recorded 527 goals as a Blue.
Local Sportssports
← COVID-19 Vaccine Coming To Audrain County Soon
Mexico Public Safety Report 12/10/20 →
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Regina Jennings - książki
Malcolm X and the Poetics of Haki Madhubuti
Regina Jennings
Illustrating the power of oratory in the 1960s and its successful merging with the art of that era, this text examines the significance of Malcolm X as a literary muse for Haki Madhubuti, one of America's premiere poets and essayists. Long after the death of Malcolm X, Haki Mudhubuti continued to expound on X's major oratorical themes, including the effort to destroy the racial appellation "Negro" and to create new definitions for words that relate to Africa. X's persistence in oratory during the 1960s influenced an art movement that changed the psychology and behavior of American Blacks....
Illustrating the power of oratory in the 1960s and its successful merging with the art of that era, this text examines the significance of Malcolm X a...
Race, Rage, and Roses
Featuring poems, this work reveals the beauty and tragedy of women in the Black Panther Party. It explores the reality of growing up Black and female during the spirited, tumultuous 1960s and 1970s.
Featuring poems, this work reveals the beauty and tragedy of women in the Black Panther Party. It explores the reality of growing up Black and female ...
She Wants the Freedom of the Open Plains.
He Wants the Prestige of a Successful Career.
Neither is Ready for What Comes Instead.
The train to Garber, Texas, is supposed to bring life's next victory to Nicholas Lovelace. Instead, it gets held up by robbers who are thwarted by the last person Nick ever expected--Anne Tillerton from back home in Prairie Lea.
Anne's been hiding away as a buffalo hunter. She's only in town to find their runaway cook, but the woman flees--leaving Anne with her infant son. With Nick the only person Anne knows in town, the two form an...
A Most Inconvenient Marriage
Abigail Stuart Thought She was Jeremiah Calhoun's Widow.
But Jeremiah Calhoun Is Very Handsome, Very Alive, and Very Perplexed.
Most Inconvenient Indeed.
With few options of her own, nurse Abigail Stuart agrees to marry her patient, a gravely wounded soldier calling himself Jeremiah Calhoun. They arrange a quick ceremony before he dies, giving Abigail the rights to his Ozark farm and giving Jeremiah the peace of knowing someone will care for his ailing sister after he's gone--a practical solution for both of them.
After the war, Abigail fulfills her side of the...
Most Inconven...
At Love's Bidding
Regina Jennings Is a Rising Voice
in Humorous Historical Romance
After helping her grandfather at their Boston auction house, Miranda Wimplegate discovers she's accidentally sold a powerful family's prized portrait to an anonymous bidder. Desperate to appease the furious family, her grandfather tracks it to the Missouri Ozarks and makes an outlandish offer to buy the local auction house if they promise not to sell anything until he arrives.
Upon their arrival, however, they discover their new business doesn't deal in fine antiques, but in livestock. And its manager, ruggedly...
After helping her grandfather at their Boston auction house, Miranda Wimplega...
With This Ring?
Karen Witemeyer Mary Connealy Regina Jennings
Humorous Historical Romance Novella
Collection Offers Love and Laughs
Four top historical romance novelists team up in this new collection to offer stories of love and romance with a twist of humor. In Karen Witemeyer's "The Husband Maneuver," Marietta Hawkins decides to grab the reins when the ranch foreman she loves seems to be leaving forever. Regina Jennings offers "Her Dearly Unintended," where friends stranded by a rising river pretend to be newlyweds when a dangerous stranger arrives.
Mary Connealy's "Runaway Bride" finds a Texas ranger getting more than he...
Four top historical romance novelists team up in this new coll...
Jennings Offers Another Delightful Blend of History and Romance
Betsy Huckabee might be a small-town girl, but she has big-city dreams. Writing for her uncle's newspaper will never lead to independence, and the bigger newspapers don't seem interested in the Hart County news. Trying a new approach, Betsy pens a romanticized serial for the ladies' pages, and the new deputy provides the perfect inspiration for her submissions. She'd be horrified if he read her breathless descriptions of him, but these articles are for a newspaper far away. No one in Pine Gap will ever know....
Betsy Huckabee might be a small-town girl, but she has big-city dreams. ...
Holding the Fort
Jennings Winningly Combines Humor, History, and Romance
Louisa Bell never wanted to be a dance-hall singer, but dire circumstances force her hand. With a little help from her brother in the cavalry, she's able to make ends meet, but lately he's run afoul of his commanding officer, so she undertakes a visit to straighten him out.
Major Daniel Adams has his hands full at Fort Reno. He can barely control his rowdy troops, much less his two adolescent daughters. If Daniel doesn't find someone respectable to guide his children, his mother-in-law insists she'll take them.
Louisa Bell never wanted to be a dance-hall singer, but dire circumstances force...
Hearts Entwined: A Historical Romance
Four top historical romance novelists team up in this new collection to offer stories of love and romance with a twist of humor. In Karen Witemeyer's "The Love Knot," Claire Nevin gets the surprise of her life awaiting her sister's arrival by train. Mary Connealy's "The Tangled Ties That Bind" offers the story of two former best friends who are reunited while escaping a stampede. Regina Jennings offers "Bound and Determined," where a most unusual trip across barren Oklahoma plains is filled with adventure, romance, and . . . camels? And Melissa Jagears' "Tied and True" entertains with a tale...
Four top historical romance novelists team up in this new collection to offer stories of love and romance with a twist of humor. In Karen Witemeyer's ...
ilość książek w kategorii: 22
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Death an educational experience
Do you use food delivery services such as Skip The Dishes or Uber Eats?
By Lethbridge Herald on April 1, 2019.
Al Beeber
abeeber@lethbridgeherald.com
Death isn’t entertaining. It’s heartbreaking, soul-destroying and spirit-crushing. For those who are entrusted to be executors of a loved one’s will, it’s also demanding and exhausting.
I’m learning that with an exclamation mark. I knew before my dad died, I was the one he entrusted to take care of business. He’d told me multiple times; what he didn’t say was last year he added my brother as co-executor which meant two signatures on every form that needed to be signed. With him up north and me closer to dad’s residence in Calgary, it made sense for me to take on the whole job.
And it’s become an experience that is something to write about. Dad thought he was going to get out of hospital alive after he was admitted on Feb. 26 but he didn’t and starting on March 9, I began the arduous process of dealing with the aftermath.
Dad told me where his will was — what he didn’t say, or leave any information about, was financial information. Bank cards in his wallet and a few dated statements I found after poring through box after box of material we took out of drawers, provided me with clues.
But the search for investments and debts has been much akin to an Easter egg hunt. I’ve been making multiple phone calls and visiting various institutions to glean information for the accountant and his estate lawyer.
Only because the company name was on his TV boxes did I learn who to contact about closing his cable account. An old bill from 2016 told me who his utility provider was.
I knew driving home from Calgary one night with his ashes and the can of bear spray he accidentally used on himself in Ontario, this was going to be challenging. I also had to laugh that dad and the bear spray and I were still together. Humour comes in handy during times like these, trust me.
And I’ve learned an important lesson — we all need to be ready for the inevitable. As I go through this process, I’m planning to make sure my family knows what they need to make the process smoother.
And what we need to do is be organized. Store current bank statements in an envelope or file folder. Ditto with investment updates.
One thing I desperately need to do is update my will which hasn’t been done since my son was young. My lawyer long ago retired and I kind of think I’ve forgotten what law office he was even with.
This is the type of thing none of us can afford to do. All I can remember about my lawyer, and it’s embarrassing, is his name was Garry. I know that’s bad but life gets busy and we get distracted.
Since dad’s demise, I’m realizing distraction isn’t a good thing unless you’re a dog and even then it can be dangerous. We need to be focused and prepared and make life easier for those we leave behind.
When I last saw dad, he looked good, was alert and laughing. I thought he dodged a bullet and we’d be back having lunch soon at his favourite Calgary restaurant. But the next day, he started slipping. And each day got worse.
I’m glad we had our time last summer together in Ontario; it was a bonding experience of a lifetime.
I saw him as often as I could and when my son was working as an emergency medical technician in the oilpatch, it was regularly because I would drive Dylan to, and pick him up at, the Calgary airport every three weeks. And I always stopped to have coffee with dad and his wife.
For years, dad and his friend Mel Ray of Strathmore joined my local crew, who dad knew from Raymond when we were kids, at the motorcycle and boat shows in Calgary.
Those exhibitions were regular rituals that were always entertaining since dad was not only a motorcyclist unti his early 80s but a fisherman until the end. And as he aged, he became a truly fun guy to hang around with, more like friend than father.
On that Ontario trip, he told me time and again, he trusted me to do the right thing when he was gone.
He wanted assurance that his affairs would be handled professionally and timely and when I think about it, I’m wondering if he knew that trip was going to be his last.
I’ve since learned dad kept a stone face after his wife died but he confided to a couple of people that he was lonely beyond words. His reason for living perhaps died last February when his long-time wife took her last breath. So maybe his 87-year-old heart finally just completely broke.
Wherever dad is now — OK, he’s in a closet but you know what I mean — he doesn’t have to worry about that happening again because I’ll put in whatever time and energy it takes to make sure his final testament is handled the way he wanted.
Rest in peace, buddy. And don’t touch bear spray if you come across any. Please. Don’t. Touch.
THE DIRT: I managed last weekend to catch the new Netflix film called “The Dirt,” which is based upon the autobiography of glam metal band Motley Crüe.
This film isn’t for everyone given the wild life that the band lived but to me, it was fantastic. The casting was brilliant, with all four actors capturing the essence of the band members they portrayed.
I doubt it will get any Oscar buzz given that it tends to be X-rated but I was far more impressed with “The Dirt” than the Queen biography.
It was fun and completely over-the-top — just like the Crüe.
Follow @albeebHerald on Twitter.
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Minding Middle School
Ideas and Advice for Families
Minding Middle School: Ideas and Advice for Families
This guide is intended to assist families in understanding the challenges and opportunities their children will encounter when transitioning for elementary to middle school.
Preparing for Middle School
Middle school is an exciting, yet challenging, milestone for students and their families. As children transition from a self-contained classroom with one teacher to multiple teachers and a larger school environment, family guidance and support is more important than ever. This guide provides information and tips on how families can help with a successful transition middle school.
Making the Move to Middle School
It's your child's biggest transition since kindergarten: Leaving the cozy nest of elementary school for the wide-open spaces of middle school can be daunting for the whole family, so start your preparations now. These resources can help you smooth the way, both socially and academically.
Helping Children Transition from Elementary to Middle School
Families can do a great deal to help with the transition when kids enter a new environment. With some sense of what to expect, children are more likely to be successful and less likely to be overwhelmed. Help them manage by taking some steps before school starts.
Family involvement in a child's education during the middle school years is just as important as it is in earlier grades.
Here are 10 ways to keep your child on track for academic success in middle school.
Motivating Middle Schoolers: A Parent’s Guide to Navigating Academics
Here are some ideas for ways you can make the transition to middle school more successful for both you and your child.
Helping Your Teen With Homework
How to Motivate a Middle School Reader
How to Create a College-Going Mindet for your Middle School Studentollege
Social Emotional Changes
Families play an important role in teaching and assisting middle schoolers to manage emotions, make responsible decisions and resolve conflicts in a positive manner. Here are some resources you can use to learn more about social emotional learning:
Be actively engaged in your child's new school
Attend school meetings
Join the school PTO
Attend conferences
Communicate with your child's teachers, counselors and administrators
Establish communications early in the year either in person, by email, or by phone
Get to know other families
Review expectations with your child
Go over the school handbook
Review classroom expectations by visiting the teachers' web page with your student
Tips on a Successful Transition to Middle School
Guiding Our Children Through School Transitions: Middle School
Ensuring Your Child is Supported at School
Teaching Middle Schoolers to Take Responsibility
Media Use
6–12 Family Tips: Media Balance & Well-Being
Here are a few tips from Common Sense Education to help parents keep media and tech use in check.
Common Sense Media (CSM) is a non-profit organization that "provides education and advocacy to families to promote safe technology and media for children."
Common Sense Media reviews books, movies, TV shows, video games, apps, music, and websites and rates them in terms of age-appropriate educational content, positive messages/role models, violence, and more. Common Sense provides parents, educators, health organizations, and policymakers with reliable, independent data on children's use of media and technology and the impact it has on their physical, emotional, social, and intellectual development.
Omaha Public Schools Tech Hub
Here you will find links to technology training and support for students, staff and families.
The middle years are sometimes referred to as the "awkward stage" in human growth. Beyond the physical changes, there is a large amount of brain development that accompanies the onset of adolescence. Middle schoolers may be more prone to risk-taking, may have exaggerated emotional responses to events or friends, or may find new friendships or interests. To help them use these developmental changes to their advantage, families can
Encourage development of new friendships and pursuit of new activities or interests
Show them that failure as a natural part of the growing and changing
Be alert to signs of anxiety or depression and seek assistance if necessary
Support them in becoming increasingly independent
Understanding Your Teen's Brain
URL: https://libguides.ops.org/middle
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Watch LRTV Online!
LIVE and Archived
Webcasts on Vimeo
History of Lake Region Television
Lake Region Television (LRTV) was founded in the summer of 1992 by Wesley Wolcott, a resident of Harrison who had considerable experience in television production and who saw the need of a local television access channel serving Bridgton, Harrison and Naples. With a small group of volunteers and a Board of Directors of like-minded citizens, he was able to obtain initial funding from several sources including area businesses and acquire some of the equipment from a former M.S.A.D. 61 educational access channel which was no longer being operated. The Town of Bridgton offered space in a 10'x16' office in the lower level of the Municipal Complex and helped arrange for an upstream audio/video connection to the United Cablevision system that was serving the three communities. LRTV began cablecasting on Channel 4 in October of 1992 with coverage of the Bridgton and Naples selectmen's meetings, in-studio talk shows including Legal Issues with Bob Kimball, Direct Line with Price Hutchins, and Sports Talk with Wayne Rivet plus coverage of a few area events. These were the days of recording video in the field on one of two comsumer grade VHS camcorders with one handheld microphone for picking up sound, adding limited graphics generated from an Amiga computer, and manually inserting the edited tapes into one of two VHS playback decks and hitting "play" at the appropriate time. In between tapes a message board of community events and underwriter spots was generated by a second Amiga computer. As the station lacked a video monitor for this computer, updates to the message board could only be done "live" during the daytime hours by watching the return video feed from the cable company on a regular TV. This actually worked to the stations advantage as it gained several volunteers who had become interested in watching the mouse cursor move around as message board editing was being done.
In late November of 1992, Bill Severance of Stoneham, Maine became interested in the channel through a desire to film the upcoming Christmas Cantata at the Bridgton Alliance Church. Wes Wolcott suggested that this could be done as a multi-camera (2) production using the two studio cameras and the semi-portable video switcher. Wes then trained Bill and two other church members how to help set up the equipment and a few basic camera techniques. With Wes as technical director, the stations first multi-camera field taping was done in December of 1992. Weekly (single-camera) tapings of the services of the Alliance Church began in January and were soon joined in the program lineup by regular tapings at St. Joseph Catholic Church and Windham Assembly of God. Bill Severance became more and more involved with the growing station helping out with editing, message board updates and some field tapings.
At about this same time Peter Lake and Wayne Rivet - both from Bridgton and Don Jacobson from Harrison began videotaping high school and rec league sports and producing the weekly Sports Talk panel discussion. Tux Burke of Naples began taping Naples Selectmen's Meetings and other Naples events. Dick Dunlap and Phil McLean of Bridgton took over coverage of the Bridgton Selectmen's Meetings and both became heavily involved in the operation of the channel with Phil McLean serving for several years as its Treasurer.
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Low End Mac
Tech Spectrum
There’s No ‘i’ in Apple Anymore
Simon Royal - 2015.04.12
The late 90s saw Apple take on it’s iconic range of devices beginning with i – starting a whole era of products. Has this era ended?
Apple created one of the most instantly recognisable brands ever – which spilled over in to millions of third party companies, products, and accessories – and society in general.
With Apple nearly on its knees in the mid 90s, Steve Jobs returned as CEO and in 1998 launched one of the most iconic computers in history, the iMac G3 – and the first product to feature the i prefix in it’s name. It saved Apple and began their rise to glory.
The i stood for internet – as in internet Mac – embracing the new internet and digital age.
In 1999, the colorful iBook was released, as well as the revised, slot-loading iMac G3, both ushering in Apples wireless AirPort networking standard. In 2001, the iPod – Apple’s large capacity music player – was released. It was to bring with it the so called ‘iPod halo effect’, switching more users to the Mac computing platform.
The music and media centric Apple were riding high on their iProducts, and 2003 saw the launch of the iTunes Store offering downloadable music for use on their computers and iPod.
In 2003, Apple took a side step, introducing the eMac – the e this time standing for education, as it was originally launched for the educational market only, but later released to retail stores.
The Mac mini, initially a G4 based device, was released in 2005 and switched to Intel in 2006. It was the first new Mac model to feature the ‘Mac’ prefix – with a whole range to follow. With the switch to Intel, they ditched the entire i and Power naming schemes, going with MacBook, MacBook Pro, and Mac Pro in 2006 and the MacBook Air in 2008. The one exception to the new naming patter is the iMac, which is still in production, but I could see this being rebranded as just Mac to fall in line.
The AppleTV, the media streaming device, was released in 2007 – codenamed iTV in production – was a completely new product and marked a change in Apple’s naming direction.
The iPhone, launched in 2007, was essentially an extension of the iPod – adding phone capability, touch screen and apps and the iPad released in 2010 was a large scale iPod touch/iPhone and the last new device to have the i prefix.
The Power Mac (1994) and PowerBook (1991) ranges had been around a long time before Steve Jobs introduced the consumer aimed iMac and iBook range in 1998 and 1999 – and continued the Power prefix until 2006, when Apple switched from the PowerPC platform to Intel.
Even their software packages have undergone serious changes. iDVD and iWeb have been discontinued. iPhoto was rebranded as Photos, and iCal was renamed to Calendar. iMovie and iTunes – some of their oldest modern pieces of software – are still going strong, and Apple would find it hard to lose the iTunes branding in particular because of the iTunes Store.
But with rumours about Apple launching a watch stretching back years, it was always thought it would be called the iWatch – especially as it is a companion for the iPhone. So it was a great surprise that it was named the Apple Watch.
The Apple Watch, released in 2015, is the first new product in five years. Other releases have just been extenuations of current lines, so it makes sense to leave the long since dead PPC and i era behind.
This sent ripples through the Apple community and inspired me to write this article. Apple named the iPhone and iPad after the iPod, cementing them as extensions of each other – but what does the future bring for new Apple products.
Could we be about to see a whole new range of Apple products? Have the Apple Watch and AppleTV have set a new prefix for future consumer products?
Could the much talked about MacBook Touch (a.k.a. iPad Pro) – a high powered OS X based tablet – be around the corner? Are Apple about to do the one thing they swore they would never do and merge iOS and OS X, producing one synonymous OS across all future devices, just as Microsoft are planning with Windows 10?
Could it mean the iPhone is due a massive change – and perhaps a new Apple Phone will revolutionize Apple’s mobile market and give the lift that a lot of iPhone users and non-iPhone owners claim is needed.
Or perhaps they will keep the iPod, iPhone, and iPad names for their media range, the AppleTV and AppleWatch for its add-on devices, and Mac for its computing range.
Who knows. Apple have been coasting off of the iPod, iPhone, and iPad for a while. To maintain their lead in the world of technology they, need to come up with something more than just a new watch.
Follow Simon Royal on Twitter or send him an Email.
Like what you have read? Send Simon a donation via Tip Jar.
keywords: #applewatch #iphone #ipod #macbook #imac #techspectrum #simonroyal
short link: http://goo.gl/TcJF9c
searchwords: noiinapple
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Faculty Hiring
Hire a Ph.D.
Keyword Search of polisci
Honors Major
Prospective Majors
Current Majors
Undergraduate Student Conferences
Virtual Commencement Spring 2020
James Morrow Selected by College to Receive a Collegiate Chair
This award confirms Professor Morrow's excellence in teaching, scholarship and service.
James Morrow, Professor of Political Science, has been selected by the College to receive a Collegiate Chair, one of the highest honors that the University of Michigan bestows upon a member of the faculty. This award confirms Professor Morrow's excellence in teaching, scholarship and service. Recipients of these prestigious positions can name them after faculty members who were formerly affiliated with the University. Professor Morrow has decided to name his chair after Ken Organski, author of many books including World Politics. James Morrow is now the A.F.K. Organski Professor of Political Science. Congratulations!
5700 Haven Hall
polisci@umich.edu
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← Jewish History: A Very Short Introduction
The Faith of Fallen Jews: Yosef Hayim Yerushalmi and the Writing of Jewish History →
My Kitchen Wars: A Memoir by Betty Fussell
Posted on January 5, 2021 by Luke Ford
She was married to Paul Fussell.
She writes in this 2015 book:
* We began to give dinner parties in the slab house, enticing the Princeton literary set up Route 27 with lavish displays of food and drink. In Germany we’d made friends with a Fulbright couple who lived in Princeton and were part of a circle that sat at the feet of R. P. Blackmur, a poet and critic who was a maverick in the academy—no Ph.D.—and the smartest man I’ve ever met. Like Dr. Johnson, he had absorbed a great deal of the world’s learning and expounded it best in conversation. There was reason to sit at his feet and pay attention to his words. Although he could be ruthlessly cruel, he was also a sage, and I was flattered when he took a shine to Paul and me. He invited us to join not only the elect at the invitation-only Gauss Seminars, which sponsored guest lecturers of renown, but also the super-elect for drinks at his house afterward. This was a world I’d been missing at Rutgers, a world I wanted to join. Paul’s ticket of entrance was his own sharp wit and literary acumen. Mine was as a well-packaged and intelligent sex object who gave good value as a hostess.
One night when Paul couldn’t go to the Gauss, I went without him, and afterward went on to drinks at Blackmur’s. It was a heady crowd of writers and aesthetes and intellectuals, including Kingsley Amis, Al Alvarez, R. W. B. Lewis, Eric Kahler. Paul had asked me to come home early because he wanted to make love. I said I’d try, but I got home late. Paul was angry. “We had a date,” he said. To me it felt like blackmail. I felt a constant current of hostility from him and, for the first time, thought seriously of packing my bags, bundling up the children, and leaving. But I could already hear him asking, “Where would you go?” I certainly couldn’t run home to Mother. Without a cent of my own, I certainly couldn’t take off for New York or some other city and expect to land a job that would pay for an apartment and care for the kids. No, the thing to do was to have another child.
* We picnickers were mostly young academics in our thirties, from Princeton and Rutgers, some with young children, some without, all of us frolicsome. R. P. Blackmur was our rubicund Lord of the Revels, our Bacchus, with vine leaves in his white hair. The respectables of the Princeton English Department scorned him as a mere writer, a poet-critic with no scholarly credentials at all. And of course they scorned anyone from Rutgers, a state university. But we saw ourselves as outsiders because we cared about Art, in contrast to the philistine Establishment.
* Curiously, our picnics were not a rebellion against kitchen work. The woman who cooked indoors cooked outdoors as well. I don’t know if blue-collar men were grilling hot dogs and hamburgers in their backyards in the early sixties, but I do know that white-collar academics were not, any more than they were going bowling, hunting, or to the Elks. It was women who toted the bags of charcoal and loaded up the Weber grills and squirted kerosene and watched the flames explode and then subside and the gray ash grow while they manipulated six pounds of ground chuck into thick patties and laid out giant wooden bowls of chopped iceberg lettuce and tomatoes and grated red cabbage slathered with blue cheese dressing and shooed the kids away from the grill as they chased fireflies and each other, while the men stood around and drank. Heavily.
Princeton was an outpost of Cheever territory, where you could drink your way across town from party to party in one long moveable feast. While the women tended the grill, the men tended the thermoses of iced martinis and wrestled with the corkscrews that opened the wine and dispensed the brandy and cigars that finished off the meal. Drinking was men’s work, and the men went at it manfully. The women drank too, of course, and not just to keep up with the men. Drinking was vital to our picnics, loosening tongues and lips and hearts and kidneys. Men could turn their backs and pee openly in the bushes. Women had to choose their coverts more carefully. But the unspoken rule was that you could do things on a picnic that you couldn’t or wouldn’t do in a parlor. Such license was sanctified by a host of pastoral forms, literary and cinematic…
* Sex was in the air and on our lips and in the pressure of our bodies when we kissed each other hello and goodbye, a social custom that had infiltrated America’s upper bourgeoisie in the fifties and lingered on, putting a full-mouthed American twist on the Continental habit of kissing both cheeks in greeting. Women rubbed cheeks so as not to leave lipstick behind, but women and men rubbed bodies together like Boy Scouts starting a fire, and the prolonged good-night kiss that began as ritual courtesy might end as rendezvous. Or not. It was an era good for kissing and flirting without anything happening at all.
Except, of course, it did. It had to, the way the Cold War eventually had to hot up after the prolonged foreplay of threats and counterthreats, simulated and real. With Ike and Khrushchev flashing their missiles, Russia was bound to fire off a Sputnik and a Lunik just as we were bound to counter with a Jupiter and an Apollo. Nationally we believed we were in control of our fears, just as privately we believed we were in control of our lusts. Self-delusion clotted the air like sex, and it took but a small charge to blow it sky-high.
Our Princeton pals had already been primed by a quartet of Brits, writers and their wives, who’d revived the days just after the war when a crew of bacchants had danced across the quad—John Berryman, Delmore Schwartz, Randall Jarrell, Allen Tate, Robert Lowell. But the Eisenhower years had lulled the Establishment into a false sense of security, so when Lucky Jim arrived at Princeton in the person of Kingsley Amis, few were prepared. Kingsley cut a swath a mile wide through the faculty wives, literally laying them low with his charm, celebrity, curly blond hair, and bad-boy antics. He’d propositioned me once in the bathroom of our house in Piscataway while I washed out baby Sam’s diaper. “Not quite my idea of a romantic setting,” I said. “Oh,” he said, as if surprised, “would you prefer a bed?”
The Amises had inspired a whole year of husband- and wife-swapping in Princeton before we moved there, and I didn’t know whether to be sorry I’d missed it or glad. There was no scandal left in who had slept with Kingsley. Who hadn’t? The Amises were so very English, and yet not at all like the English revered by the English Department and mocked for all time by Lucky Jim . I tried to imagine resisting Kingsley’s irresistible combination of comedy and sex, as he single-mindedly put one in the service of the other, and I longed to be put to the test. Laughter is the most powerful seduction of all, and for these English, America, with her straitlaced Puritans, was one big laugh-in. They would as soon fuck as say the word; they seemed to have no verbal or sexual inhibitions at all.
In Princeton the Amises lived out scenes Kingsley had already written in Lucky Jim . They accidentally burned a bed-sheet in their rented house and tried to cover it up by cutting a hole in the sheet; Kingsley went off to Yale to deliver a lecture and forgot his briefcase with his speech inside. They were also living out scenes that would appear shortly in One Fat Englishman , like the infamous barge party on the Delaware River by New Hope, in which drunken revelers who’d been screwing in dark corners of the barge kept falling off the boat and having to be fished out of the water half naked. A lot of the time Kingsley couldn’t remember whom he’d screwed, it meant so little and he drank so much.
Another pair of Brits doubled the charge the Amises had ignited. Al Alvarez was an explosive nonfiction writer and his wife, Ursula, distantly connected to D. H. Lawrence, was a ripe raven-haired beauty who wore her hair long and her bosom full. Men flocked to Ursula the way women flocked to Kingsley, but for sex in the opposite mode. Ursula was pure romanticism La Belle Dame sans Merci, silent to the point of being sullen. When she placed a white rose in her bosom, you could hear the room heave a sigh. Not much later, she ran off with an Irish poet. The poet’s wife committed suicide and Al later attempted the same, then wrote a book about it. The Alvarezes played out tragedy while the Amises played out comedy in our small university town of Anglophiliacs.
Adultery was in the air like wood smoke, only no one called it adultery. It was called Letting Go, and Letting It All Hang Out, in the jargon of that prefeminist era. Now that Freud and Kinsey and Joyce Brothers had told us that women were as sexual as men, now that Marx and Marcuse and Norman O. Brown had told us that sexual morality was the opiate of the masses, it was a liberated woman’s duty not to go out there and get a job, but to go out there and fuck. We were not at war with men. Men were our heroes, and we wanted to love them all, in the high style of Simone de Beauvoir. French women of a certain class had always had lovers, just as their husbands had. So had the English. Why shouldn’t we?
In food as in sex, America was slipping behind us as Europe beckoned. The moment classes were over, we all hopped boats for Europe, often the same boat so that we could continue partying at sea…
* On one climactic occasion it all came together—food, literature, sex, and art. Paul and I staged a dinner to honor Muriel Spark, who was giving a lecture series at Rutgers she called “L’Amour de Voyage.” She appeared at our little cottage in a chauffeured limo, which impressed us and our neighbors neighbors no end. She wore a bright red wig and fake eyelashes that nearly swept her plate and entertained us with bawdy stories while we stoked her with course after course…
* last. From now on, I’d be sexy. I made my own clothes, because that way I could afford expensive fabrics and make a good show. I cut the tops of my dresses lower and made the waists tighter. I put tissue in the bottom half of my bras to push my cleavage up. I could feel men buzz around me like drones to the honey pot, and I liked that feeling.
I discovered that all I had to do was ask intelligent questions, and men of all ages would find me intelligent. I could wrap my arm in the arm of the distinguished Eric Kahler, a fellow émigré and friend of Thomas Mann, and while we strolled across campus feel his pleasure as he discoursed learnedly on the relation between Klimt and Freud in the Vienna Circle. I could feel the drama theorist Francis Fergusson glow when I sat at his feet by the fireplace in his Victorian parlor and asked questions about Sophocles. I was only half aware that I was adding new weaponry to my arsenal, the weaponry of flattery and adoration and argument, not as an intellectual exercise but as a form of sex.
If I couldn’t use logic professionally, I’d use it for fun. With the lights on, I would engage one or another young male instructor in heated argument over the superiority of Whitman to Milton, say—the more outrageous the thesis, the better, because it required more skill to defend. It was a fencing match, the thrust oblique and the parry direct, designed to challenge, provoke, and parry other thrusts when, lights out, we danced close and closer to old recordings of “Sunrise Serenade” and “How High the Moon.” So blatantly sexual was argument to us that the wife of one instructor, a trained nurse, rose from her chair one night and said, “I know I can’t discuss la-de-da poetry or the works of Emerson, but I can do this … and this … and this ,” and she executed a couple of bumps and a grind that put my mental gyrations to shame.
Dancing, we made love standing up and swaying slow, the way we had in high school and college, teased by the same urges and the same prohibitions, only now it was not virginity we were protecting but marriage. In effect, these were licensed petting parties and there were subtle, unspoken rules about what was and was not permitted. Sitting on laps was okay, dancing so close you could feel each other’s body parts was okay. Fondling in public was not, nor was disappearing into bedrooms, but disappearing outside into nature was. Once I sat on our picnic table out back, huddled under a blanket with a vet who’d seen a lot of action in both military and marital wars, a man whose heroism I much admired and whose horniness when drunk was commanding. He got drunk compulsively, as we all did, and when I indicated kissing was fine but that was it, he didn’t argue, he simply masturbated while we kissed.
Decades before Bill Clinton’s equivocations, we were looking for a presidential solution to the semantics of sex. One evening after a great deal of brandy in front of the fire, Paul and I traded partners with this same vet and his wife. Paul was delighted when we took off clothes, because the vet’s wife had unusually large breasts. I hated to be naked because mine had diminished to nonpregnancy flatness, and I was ashamed of them. I was not surprised when the vet proved to be less interested in kissing them than in kissing parts further south, at which point his wife came alive and hit him on the head with her shoe to make him stop. Nudity was permitted, kissing below the belly was not.
* Only years later did Paul confess that during that time he’d been screwing one of his single colleagues at Rutgers for real.
Another visiting writer and his wife became the catalyst for further explosion. Philip Roth’s breakup with his first wife, Maggie, left a wild and hungry girl on the loose. She was, as we used to say, dynamite. Roth had not yet written Portnoy’s Complaint , but he clearly had sex on the brain just as Maggie had it on the body. Maggie, born into the hardscrabble poor of the Midwest, had been a teenage mother and bride in that order. She’d left her children with relatives in order to work and get herself educated, and at the University of Chicago she’d had the good and bad fortune to team up with a manic young writer on the rise.
As a couple, the Roths were far too absorbed in each other to bother with any genteel hanky-panky with the rest of us. They seemed to make war and love simultaneously and with equal violence. But when Roth abruptly left his wife and moved to New York, Maggie was a loose cannon. She was less restrained, repressed, or undamaged than the rest of us, and in her language as in her actions she called a spade a spade. “Come on, I’ve seen the way you dance with Dave, why don’t you fuck him, for chrissake?” she’d ask me. “Who do you think you are, the Great White Ice Queen?” She called me IQ for short. She loved to spar with Paul and me, pitting her energy and despair against our underdeveloped emotions and overeducated brains. The three of us became close, and when Kennedy was assassinated, we took her in to share that long Thanksgiving week glued to our TV, bonded by popcorn and tears.
* Maggie too appeared one night in the doorway of our bedroom, naked. Paul was away and Maggie had come over for supper but was too drunk to drive home, so I opened the sofa bed in the living room for her. It had been an emotional night as the drink took hold, with her trying to call “that fucker” in New York, leaving alternately tearful and threatening messages on his answering machine. I was exhausted when she finally went to bed. But before I could get to sleep upstairs, there she was. “Can I come in?” she whispered. She was crying. Oh Lord, I thought. But I was a mother after all, so I took her in. She immediately took my hand and put it between her legs. “Oh no, Maggie, no, I can’t do that,” I said. “Please,” she begged. I sat up, feeling desperate because I couldn’t do what she wanted, but my instinct for survival was as strong as hers. “Go back to bed, Maggie,” I said. By that time she’d finished what she came for without any help from me. She thanked me for “being there” and tottered back through the doorway, down the stairs, and into bed.
For a long time, that was my image of Maggie, a long, thick torso on short but sturdy legs, silhouetted against a backlight of trouble. When she tried to kill herself with sleeping pills in New York, I was heart-struck but not surprised. Someone found her in time, but a couple of years later a car she was in plowed into a tree in Central Park. The driver was unhurt, but Maggie was dead.
* Dave was taken aback by my passion. So was I—I who was always in public cool and self-controlled. I knew he had had many affairs in Europe, so I was not surprised by his skill, even as I relished it. This was an unknown world. Paul and I had been married for nearly a decade before we’d learned about The Clitoris and then only from a book, which Paul read first and then passed on to me. All that time I’d wondered exactly what a female orgasm was and whether I’d ever had one.
* Knowledge was not virtue, because I knew what I was doing, and I knew it was wrong.
I began to understand people who had eating disorders. They were as obsessed with food and its image as I was with sex. I understood people who tried to give up smoking and couldn’t. I was one of those myself. I understood people who tried to give up drugs and couldn’t, even though the only drug we knew, nicotine aside, was booze, and we weren’t about to give that up. I played tug-of-war with Dave and myself, swearing and forswearing, for a biblical seven years.
* Dave and Vittoria went off to Tuscany every summer, where Vittoria’s family had a villa, and where Dave picked up where he had left off with one village girl or another. “It has nothing to do with you and me,” he’d say. “I’m like a father to them.” An incestuous father, I muttered, jealous as hell. He was constantly falling in love with their innocence, their swelling bosoms, their budding knowledge, and it burned me up that I knew this about him and still couldn’t stop.
* After we separated, he finally went to see a shrink for a few weeks, just long enough to discover, as he related with disbelief, that he’d always connected sex with shame, with dirtiness, which he’d gotten from his mother—of course. A mastoid operation as an adolescent had kept him home for six months and he’d become a mama’s boy, learning to knit and sew while his older brother went out for sports and girls. “The shrink says I’m a permanent adolescent,” he said. “I never grew up and that’s what makes getting old such a shock. Adolescents aren’t supposed to be old.” He was attracted to students who were straight, he said, because he got a charge from their youth. “I don’t want to be with old people like me.”
* In the end, he [Paul Fussell] took each child to lunch separately in New York and told them he was a pederast and I an adulteress. For a civilized person, it was a brutal way of putting it. Sam cried. Tucky took it on the chin, and exploded later.
* Paul sat opposite me on a chair and ticked off items on a list he held in his hand. One, a tax bill of $1,309.40, due February 1, must be paid on time or the borough would charge interest. Two, living alone in England, he’d found out how much he loved me and how much he hated living alone. Even if we got divorced, he wondered if we might not live together. Three, he’d discovered he was not homosexual. He didn’t want to touch young boys, he just wanted to look at them. Four, he’d done what he’d done to punish me, because I didn’t like his students, because I was jealous of them. It could have been a girl just as easily.
About Luke Ford
I've written five books (see Amazon.com). My work has been followed by the New York Times, the Los Angeles Times, and 60 Minutes. I teach Alexander Technique in Beverly Hills (Alexander90210.com).
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Liverpool FC HQ
Home News LFC Fight For Top Four, Lallana and Emre Close to Fitness? Gerrard...
LFC Fight For Top Four, Lallana and Emre Close to Fitness? Gerrard Departs For Rangers
Following their Champions League success against Roma on Wednesday, the reds now turn their attention to Chelsea on Sunday. A point against the blues will be enough to secure Champions League qualification for next season regardless of whether they win the trophy or not in Kiev.
Ahead of the game, Jurgen Klopp has provided an update on the fitness levels of Adam Lallana and Emre Can:
“We are in contact with Emre. An important day is next Monday and then we can make the decision if he starts training with us or not immediately. It would only be good news for the final, probably not for the last game of the season.”
On Lallana:
“Adam trained his first real football session in Rome in the morning after the game. How Adam is, he looked good, so that’s OK. I have no idea if we will use that or not, but I have to think about it. I don’t know, but it’s good.”
Joe Gomez is also a doubt for the fixture against Chelsea after suffering an injury.
Klopp was also quick to praise keeper Loris Karius after a difficult start to his Liverpool career. Karius took over the number one role from Simon Mignolet midway through the season.
“He progressed a lot. I’m really happy with his progress. [There is] still a lot to come, I’m sure. He really took the chance that we gave him a few months ago and was a big part of us being more stable in that period. It’s cool.”
Youth News:
Steven Gerrard has been confirmed as the new Rangers manager. Gerrard has signed a four-year contract with Scottish side who look to win their first title since 2011. Gerrard will be joined by ex-teammate Gary McAllister who joins as assistant manager.
Elsewhere, Liverpool’s U23 battle Chelsea on Tuesday in the final game of the season. A win for the Reds will take them up to second in the league.
Previous articleRoma v Liverpool: Klopp set up in familiar shape while Roma learned from first defeat
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Guide to Online Football Betting in 2020!
Chris Darwen - November 26, 2020
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It’s time for AAP to answer – BJP to confront Delhi Government on policies
Opposition leader Vijendar Gupta said that the strategy for the forthcoming Assembly Session would be to confront the ruling party for its “unconstitutional actions” leading to a piquant situation in running the government.
“The government has taken many illegal and anti-poor measures which need to be raised in the Vidhan Sabha Session for rectification,” said Gupta.
Hinting on the mismanagement of funds he confirmed that “The government which boasts of increasing the minimum wages of workers, has committed the illegal act of diverting Rs 1,150 crore out of Rs 1,700 crore of cess fund contributed by building and other workers since 2002 has been diverted by AAP government for non-permissible heads such as construction of schools, colleges, aganwaris, canteens, etc.
The fund can only be used for the listed 18 welfare schemes for construction and other workers.”
He also pointed that opposition seeks to revert on 40 burning issues for which notices have been issued to the secretary, Vidhan Sabha. All of this will affect the way drugs in Punjab problem is concerned and dealt with.
Pointing out the AAP Government for its hypocrisy on drug and drinking addiction. Lakhs of poor and homeless people are taking to drugs because of the government inaction and lack of convincing rehabilitation policy, said the BJP leader. But AAP is worried about drug addiction in Punjab and is least bothered about the fast spreading drug addiction in Delhi.
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maidstone.gov.uk
National Lockdown - Stay Home restrictions apply in Maidstone | Visit our Coronavirus section for support for residents and businesses.
Contact your Parish Council
Borough Boundary Map
Cabinet Member Decisions
Decision Digest
Decisions Due to be Made
Officer Decisions
Council - Wednesday 15th July, 2020 6.30 pm
Agenda frontsheet PDF 76 KB View agenda as HTML
Agenda reports pack PDF 4 MB
Printed draft minutes PDF 95 KB View draft minutes as HTML
Venue: Remote Meeting - The public proceedings of the meeting will be broadcast live and recorded for playback on the Maidstone Borough Council website
Contact: Debbie Snook 01622 602030
Link: clickhere for webcast channel
Minute's Silence
The Council observed a minute’s silence in memory of all those in the Borough and surrounding area who had lost their lives due to COVID-19, including Mr Mark Radford, Chief Executive of Swale Borough Council.
Prayers were said by the Reverend Steve Price, Vicar of All Saints, Loose.
Recording of Proceedings
Councillor McKay reserved his right to record the proceedings.
Apologies for Absence
It was noted that apologies for absence had been received from Councillors Harwood, Newton, D Rose and Wilby.
There were no applications for dispensations.
Disclosures by Members and Officers
There were no disclosures by Members or Officers.
Disclosures of Lobbying
There were no disclosures of lobbying.
Exempt Items
RESOLVED: That the items on the agenda be taken in public as proposed.
Minutes of the meeting of the Borough Council held on 26 February 2020 PDF 104 KB
View item 128. as HTML 84 KB
Appendix B - Schedule of Council Tax Base and Additional Council Tax in Parts of the Area with Parish Precepts 2020-21 , item 128. PDF 92 KB
Appendix C - Schedule of Council Tax levels for all Bands and all Parts of the area , item 128. PDF 71 KB
RESOLVED: That the Minutes of the meeting of the Borough Council held on 26 February 2020 be approved as a correct record and signed.
Mayor's Announcements
Referring to the Coronavirus lockdown restrictions, the Mayor said that she hoped things would return to normal soon so that Members could start meeting again in the usual way.
There were no petitions.
Question and Answer Session for Members of the Public
Question to the Chairman of Strategic Planning and Infrastructure Committee from Mr Stuart Jeffery
Given the Council’s stated ‘Anti-Idling Campaign’, has the Council adopted the powers provided by Regulation 12 of The Road Traffic (Vehicle Emissions) (Fixed Penalty) (England) Regulations 2002 to enforce the switching off of engines when vehicles are stationary on the road?
The Chairman of the Strategic Planning and Infrastructure Committee responded to the question.
Mr Jeffery asked the following supplementary question of the Chairman of the Strategic Planning and Infrastructure Committee:
Given that over one thousand people have died since the legislation was introduced in 2002 and the implication of air pollution in exacerbating COVID infections, does the Council agree that it should have done more including enacting its powers as other English Councils have now done?
Councillor Adkinson, on behalf of the Leader of the Labour Group, responded to the questions.
Question to the Chairman of Policy and Resources Committee from Ms Kate Hammond
In January you told us you had written to the Secretary of State for Housing, Communities and Local Government about Maidstone's housing numbers. You made various press releases about the efforts Maidstone are doing challenging the National Government’s housing numbers. You then took nearly six months to write again because your first letter never arrived. How can we have confidence in your ability to negotiate housing numbers if we don't have confidence in you being able to deliver a letter?
The Chairman of the Policy and Resources Committee responded to the question.
Councillor Mrs Gooch, the Leader of the Independent Group, Councillor Powell, the Leader of the Independent Maidstone Group, and Councillor Perry, the Leader of the Conservative Group, responded to the question.
Ms Hammond asked the following supplementary question of the Chairman of the Policy and Resources Committee:
We made a request under the Freedom of Information Act to the Ministry of Housing, Communities and Local Government and they told us that they have no paper or electronic records of correspondence with the Council on housing matters in the first five months of the year. How can we believe Maidstone is serious in reducing the numbers given that, from what we have seen so far, they have not been very active in the last six months?
Question to the Chairman of Policy and Resources Committee from Mr Steve Heeley
We were pleased to note that your second letter to the Secretary of State for Housing, Communities and Local Government about Maidstone's housing numbers was sent on 3rd June by post as well as by email this time. In that letter you asked for a 'sensible conversation' with civil servants about housing numbers to take place no later than 30th June. Can you update residents please on how this conversation went?
Councillor McKay, the ... view the full minutes text for item 131.
Questions from Members of the Council to the Chairmen of Committees
There were no questions from Members of the Council to the Chairmen of Committees.
Current Issues - Report of the Leader of the Council, Response of the Group Leaders and Questions from Council Members
Councillor Cox, the Leader of the Council, submitted his report on current issues. Councillor Cox expressed his sympathy with the families of those who had lost their lives due to COVID-19 and other ailments and his thanks to all those who were supporting their communities during the pandemic.
After the Leader of the Council had submitted his report, Councillor Perry, the Leader of the Conservative Group, Councillor Mrs Gooch, the Leader of the Independent Group, Councillor Harper, on behalf of the Leader of the Labour Group, and Councillor Powell, the Leader of the Independent Maidstone Group, responded to the issues raised echoing the sentiments expressed.
A number of Members then asked questions of the Leader of the Council on the issues raised in his speech.
Report of the Strategic Planning and Infrastructure Committee held on 10 March 2020 - Local Development Scheme 2020-22 PDF 100 KB
Appendix 1 Local Development Scheme 2020-2022 FINAL , item 134. PDF 501 KB
Prior to moving the recommendation of the Strategic Planning and Infrastructure Committee relating to the Local Development Scheme (LDS) 2020-2022, Councillor D Burton, the Chairman of the Committee, advised the Council that he wished to amend Table 3.1 contained within the LDS (Project Plan for the Maidstone Borough Local Plan Review) as follows:
Preferred approaches consultation (Regulation 18) (with emphasis on detailed topic areas) – February 2020 2021
Referring to the report of the Strategic Planning and Infrastructure Committee, Councillor Burton said that it was stated within the reasons for the recommendation that “The Maidstone Borough Local Plan includes a commitment to review the Plan by April 2021 (Policy LPR1)”. He wished to add the following sentence to the reasons for the recommendation as he believed it to be material to the adoption of the LDS by the Council:
The April 2021 commitment was superseded by the NPPF update in 2018 requiring Local Authorities to review their Local Plans every five years; therefore, the end date for the review is October 2022.
It was moved by Councillor D Burton, seconded by Councillor English, that the recommendation of the Strategic Planning and Infrastructure Committee relating to the Local Development Scheme (LDS) 2020-2022 be approved subject to the amendment of Table 3.1 contained within the LDS (Project Plan for the Maidstone Borough Local Plan Review) as follows:
RESOLVED: That the Local Development Scheme 2020-2022, attached as Appendix 1 to the report of the Strategic Planning and Infrastructure Committee, be approved subject to the amendment of Table 3.1 contained within the LDS (Project Plan for the Maidstone Borough Local Plan Review) as follows:
Report of the Democracy and General Purposes Committee held on 11 March 2020 - Consultation Response on the Motion - Membership of Committees PDF 130 KB
It was moved by Councillor Mrs Gooch, seconded by Councillor Perry, that the recommendations of the Democracy and General Purposes Committee relating to the membership of Committees be approved.
1. That the motion concerning the membership of Committees be approved.
2. That the amendments to the Constitution arising from the motion be approved.
Report of the Democracy and General Purposes Committee held on 11 March 2020 - Amended Constitution 2020/21 - Reformatting, Minor Amendments and Member and Public Questions at Committees PDF 98 KB
Proposed Amendments to the Constitution , item 136. PDF 333 KB
It was moved by Councillor Mrs Gooch, seconded by Councillor Purle, that the recommendations of the Democracy and General Purposes Committee relating to the amended Constitution 2020/21 be approved.
Amendment moved by Councillor McKay, seconded by Councillor Powell, that the recommendations of the Democracy and General Purposes Committee relating to the amended Constitution 2020/21 be approved subject to the amendment of recommendation one as follows:
That the amendments to the Constitution in Appendix 1 to the report of the Democracy and General Purposes Committee, including the additional recommendations arising from further corrections to the document, as set out in Appendix 1, be agreed subject to the amendment of the fourth column on page 2 of the Appendix relating to Questions by Members of the Public to read:
At ordinary meetings of the Council members of the public may ask questions of the Chairman of any Committee provided written notice has been given in advance as set out below.
The question and answer session will be limited to one hour.
With the following stated below:
After the Chairman of any Committee has spoken, the Mayor will ask if any Group Leader/Representative present would also like to respond.
At Committee meetings members of the public may ask questions of the Chairman provided written notice has been given in advance as set out below.
This question and answersession will be limited to half an hour.
AMENDMENT LOST
The original motion was then put to the vote and carried.
1. That the amendments to the Constitution in Appendix 1 to the report of the Democracy and General Purposes Committee, including the additional recommendations arising from further corrections to the document, as set out in Appendix 1, be agreed.
2. That the reformatted and amended Constitution be adopted.
Report of the Strategic Planning and Infrastructure Committee held on 9 June 2020 - Marden Neighbourhood Plan (Regulation 19) PDF 100 KB
Before moving the recommendation of the Strategic Planning and Infrastructure Committee relating to the Marden Neighbourhood Plan (Regulation 19), Councillor D Burton, the Chairman of the Committee, took the opportunity to congratulate and thank everyone that had been involved in producing the document.
It was moved by Councillor D Burton, seconded by Councillor Mrs Grigg, that the recommendation of the Strategic Planning and Infrastructure Committee relating to the Marden Neighbourhood Plan be approved.
RESOLVED: That the Marden Neighbourhood Plan be made (adopted).
Report of the Communities, Housing and Environment Committee acting as the Crime and Disorder Committee held on 30 June 2020 - 2019/2020 Strategic Assessment and Revised Community Safety Plan PDF 93 KB
MaidstoneCommunitySafetyPartnershipPlan2020refreshUPDATED , item 138. PDF 2 MB
Before moving the recommendation of the Communities, Housing and Environment Committee acting as the Crime and Disorder Committee relating to the revised Community Safety Partnership Plan, Councillor Mortimer, the Chairman of the Committee, said that Members might have noticed that there was no reference to COVID-19 in the Plan.
Councillor Mortimer explained that:
· The Plan was prepared prior to the outbreak and was based on trends and data from the previous twelve months. It was known that COVID-19 had an impact on the five priority areas and this would be considered in the delivery of the Plan in the coming months.
· There had been quite a large increase in domestic abuse and the various Partners had been adapting to support victims and empower survivors through the trauma.
· The Partnership also continued to work throughout the lockdown to support and protect young people and to engage with those at risk and was responding to increased levels of anti-social behaviour and nuisance.
· As with any emergency, the recovery phase was often longer than the crisis itself because of its broader impacts. The Safer Maidstone Partnership through the Community Safety Partnership Plan would remain agile to the pressures created by the Coronavirus and ensure that Maidstone remains a safe place to live, learn, work and visit. He would like to thank the Officers and the outreach teams for their work at this time.
It was moved by Councillor Mortimer, seconded by Councillor Kimmance, that the recommendation of the Communities, Housing and Environment Committee acting as the Crime and Disorder Committee relating to the revised Community Safety Partnership Plan be approved.
RESOLVED: That the April 2020 revision of the Community Safety Partnership Plan 2019-22, attached as an Appendix to the report of the Communities, Housing and Environment Committee acting as the Crime and Disorder Committee, be adopted.
Report of the Democracy and General Purposes Committee held on 1 July 2020 - Extension of the Appointment of the Independent Person PDF 89 KB
It was moved by Councillor Mrs Gooch, seconded by Councillor Webb, that the recommendations of the Democracy and General Purposes Committee relating to the extension of the appointment of the current Independent Person be approved.
1. That the term for the current Independent Person be extended for one year from 1 August 2020 to 31 July 2021.
2. That the role of the Independent Person and a reserve position be advertised for appointment in 2021.
Oral report of the Strategic Planning and Infrastructure Committee held on 7 July 2020
There was no report arising from the meeting of the Strategic Planning and Infrastructure Committee held on 7 July 2020.
Oral Report of the Economic Regeneration and Leisure Committee held on 14 July 2020
There was no report arising from the meeting of the Economic Regeneration and Leisure Committee held on 14 July 2020.
Appointment of Deputy Mayor
It was moved by Councillor Munford, seconded by Councillor Cox, supported by Councillors Perry, McKay and Powell, and
RESOLVED: That Councillor Fay Lynette Gooch be duly appointed Deputy Mayor for the Borough of Maidstone until the next Annual Meeting of the Council.
The Deputy Mayor then made her Declaration of Acceptance of Office and thanked the Council for her appointment.
Report of the Head of Policy, Communications and Governance - Review of Allocation of Seats on Committees Following a Vacancy PDF 51 KB
SeatReview_Allocations of Seats_July2020_APPENDIX1 , item 143. PDF 26 KB View as HTML (143./2) 42 KB
SeatReview_CtteeSubMembership_APPENDIX2 , item 143. PDF 26 KB View as HTML (143./3) 203 KB
It was moved by Councillor Cox, seconded by Councillor Perry, that the recommendations set out in the report of the Head of Policy, Communications and Governance be approved.
In seconding the motion, Councillor Perry said that he wished to add Councillor Brindle as a Member of the Licensing Committee.
1. That the allocation of seats on Committees be as set out in Appendix 1 to the report of the Head of Policy, Communications and Governance.
2. That the wishes of the Group Leaders with regard to the membership of Committees as set out in Appendix 2 to the report of the Head of Policy, Communications and Governance be accepted with the addition of Councillor Brindle as a Member of the Licensing Committee.
MAIDSTONE BOROUGH COUNCIL ACTING AS CORPORATE TRUSTEE OF THE CHARITY KNOWN AS THE COBTREE MANOR ESTATE
CMET_QORWK_Review_Comm_Membership_APPENDIX1 , item 144. PDF 14 KB View as HTML (144./2) 34 KB
In seconding the motion, Councillor Perry said that he wished to add Councillor Springett as a Member of the Cobtree Manor Estate Charity Committee.
1. That it be noted that there is no impact on the allocation of seats on the Cobtree Manor Estate Charity Committee as a result of the vacancy on the Council.
2. That the wishes of the Group Leaders with regard to the membership of the Cobtree Manor Estate Charity Committee as set out in Appendix 1 to the report of the Head of Policy, Communications and Governance be accepted with the addition of Councillor Springett as a Member of the Committee.
MAIDSTONE BOROUGH COUNCIL ACTING AS CORPORATE TRUSTEE OF THE QUEEN'S OWN ROYAL WEST KENT REGIMENT MUSEUM TRUST
RESOLVED: That it be noted that there is no impact on the allocation of seats on the Queen’s Own Royal West Kent Regiment Museum Trust Committee as a result of the vacancy on the Council.
Duration of Meeting
6.40 p.m. to 8.50 p.m.
View our A to Z of services
© Maidstone Borough Council 2020
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Chinese embassy says Australia 'misread' offending social media post
By Kirsty Needham
Chinese Foreign Ministry spokesman Zhao Lijian attends a news conference in Beijing
SYDNEY (Reuters) - China's embassy in Australia said politicians there had "misread" a tweet showing a digitally-altered image of an Australian soldier holding a bloodied knife to the throat of an Afghan child, and were trying to stoke nationalism.
Australia's Prime Minister Scott Morrison on Monday called the tweet posted by China's foreign ministry spokesman, Zhao Lijian, "truly repugnant", and called for an apology.
On Tuesday the tweet was pinned to the top of Zhao's social media account, and China's Global Times newspaper, known for nationalistic views, interviewed the Chinese artist who created the image.
"The rage and roar of some Australian politicians and media is nothing but misreading of and overreaction to Mr Zhao's tweet," the Chinese embassy in Canberra said in a statement on Tuesday.
Australia's Foreign Affairs and Trade secretary had called ambassador Cheng Jingye on Monday to complain about the social media post, it confirmed, adding that Cheng had "refuted the unwarranted accusations as absolutely unacceptable".
Australia was seeking to "stoke domestic nationalism", and "deflect public attention from the horrible atrocities by certain Australian soldiers", it said.
New Zealand's Prime Minister Jacinda Ardern said earlier on Tuesday that New Zealand has registered its concern with Chinese authorities over the use of the "unfactual" image of the soldier.
An independent investigation into allegations of war crimes by Australian special forces in Afghanistan found 39 unarmed prisoners and civilians were killed, and Australia has said 19 soldiers will be referred for potential criminal prosecution.
Morrison apologised to Afghan president Ashraf Ghani before the public release of the investigation report a fortnight ago.
The inflammatory tweet came just days after China effectively blocked an A$1.2 billion ($883.44 million) wine export industry by imposing dumping tariffs of up to 200% on Australian wine.
Australia has said there looks to be a pattern of Chinese trade sanctions against Australian products this year, linked to Beijing's diplomatic grievances over Australia's national security, human rights and foreign policy decisions.
(Reporting by Kirsty Needham; Editing by Raju Gopalakrishnan)
This MCO, some confusion about what is ‘essential’ as retail outlets selling jewellery and even perfumes allowed to open in Klang Valley malls
What Moving Day at The White House Is Really Like, According to Designer Michael S. Smith
The Obamas' "decorator in chief" offers insight on Inauguration Day, and how the White House is prepped for the incoming President of the United States.
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True Buddha Dharma Factually Manifests Realization Power, False Buddha Dharma is Only Empty Theoretical Talk
Feb 12, 2020 | World
H.H. Dorje Chang Buddha III was Compelled and Could Not Decline
LOS ANGELES, CA, February 12, 2020 /24-7PressRelease/ — In the Great Hall of Shakyamuni Buddha at the Holy Miracles Temple, a Dharma Assembly about the true realization power of Buddha Dharma was held: The Exam of Lifting the Pestle onto the Platform. The purpose of this exam is to verify how the true realization power of Buddhist cultivators learning from Buddha to cultivate themselves changed the degree of the physical conditions of their bodies. Unexpectedly, this Exam inadvertently required the involvement of H.H. Dorje Chang Buddha III was compelled and could not decline the request to resolve a difficult situation.
What is meant by Lifting the Pestle onto the Platform? Vajra pestles are commonly found in shops selling cultural relics and antiques. These pestles range from 10 to 400 jins, equivalent to approximately 11 to 440 pounds. This kind of huge pestle is from Tibet; they are called Platform Pestles. They come in different styles such as the Phurba Pestle, Five-pronged Pestle, Nine-pronged Pestle, Kalachakra Vajra Pestle, Yamataka Vajra Pestle, Guhyasamâja Vajra Pestle, and more. Some Platform Pestles were made during the Era of Sutra, Illusion and Mind at the Early Propagation Period. Some Platform Pestles of correct standard were made based on the system revamped by Guru Padmasambhava during the Later Propagation Period. People commonly regard these as art objects. Rarely do people know that the pestles were in fact used for directly testing practitioners’ realization power from practicing true or false Buddha Dharma in ancient time. Those who were tested were required to lift the vajra pestle off the ground, hold it for a required duration of time and then place the pestle onto the platform. This kind of test is called Lifting the Pestle onto the Platform.
Proven by real practice, using one hand to lift a Platform Pestle is extremely difficult. Someone who can lift 1,000 jins (approximately 1,100 pounds) with two hands cannot even lift 300 jins (approximately 330 pounds) off the ground with one hand. According to the Dharma rules, each person has a weight standard that they have to reach based on their respective age and body weight. One who reaches their standard is called a Healthy Physique Man. Exceeding the level of Healthy Physique Man is surpassing the standard. Going below the level of Healthy Physique Man is subpar. There are a total of 30 levels above, and five levels below.
Lifting the Pestle onto the Platform is the most scientific testing mechanism for verifying whether a person is of ordinary physical condition or possesses the composition of a holy person. The physical composition and condition of a holy person is completely different from that of an ordinary person. Both have the appearance of a person. However, their inner properties are completely different. Just like a pigeon and an eagle. They have the same appearance of a bird, but their inner properties and their strength are vastly different. Such differences naturally exist. A professional strong man trains himself every day, and only after 10 or up to 20 years is he able to become a strong man of exceptionally strong physique. However, his physique is strengthened due to cumulative practices. The essential quality of his physique has not changed. He is unable to transform the physique or functions of an ordinary person and cannot become liberated from the ordinary to become holy. A holy one who has learned and practiced true Buddha Dharma can surpass the physical condition and strength of a strong man of great strength by many times.
One who surpasses their weight standard by 12 to 19 levels is an elementary level Holy Guru, by 20 to 25 levels is a mid-level Holy Guru and surpassing 26 to 29 levels is a Great Holy Guru. When one surpasses the maximum level of 30, one is a Tremendously Great Holy Guru and a Vajra King of Great Strength. Normally, it is very difficult for an ordinary man of good strength to surpass two to three levels. A national level strong man can surpass up to nine levels. A world-class strong man can surpass 10 levels, but not beyond that. The holy strength generated by the body of a holy person is absolutely not something anyone with the physique of an ordinary person can hope to attain. This is especially true for lifting the Supreme Holy Vajra Pestle “Onto the Golden Step,” or “Off the Holy Seat.” Lifting the weight of such a level will cause the bones, tendons, and muscles of an ordinary person to break down and their joints to break apart. One must have the physique and strength of a Tremendously Great Holy Guru in order to lift the Supreme Holy Vajra Pestle. We have personally seen the strongest man in Asia Long Wu perform Lifting the Pestle onto the Platform. Although he broke his fingers and bled while doing so, he did eventually surpass 10 levels and was awarded the golden belt of Grand Master of Strength, World’s Strongest Man for Lifting the Pestle onto the Platform. That was terrific.
On February 9, there was a huge vajra pestle of 420 pounds inside the Hall of Shakyamuni Buddha at the Holy Miracles Temple. That was the Supreme Holy Vajra Pestle that was placed on the Golden Step during a Dharma Assembly held two days earlier by Holy Gurus. Other than Tremendously Great Holy Gurus, no one in this world has ever been able to lift it one bit. Since the Supreme Holy Vajra Pestle was already placed onto the Golden Step, the Exam of Lifting the Pestle onto the Platform could not be conducted. This was because according to the Dharma rules, when this Pestle is on the Golden Step, the Vajra Hook cannot be used to lift any pestle. Otherwise, it is against the rules. Everyone was very worried and all those who have good physical strength came forward, but no one was able to lift that Pestle off the Holy Seat with one hand. They used their utmost effort to lift this Pestle off the Golden Step, but the Pestle did not move one bit. The Dharma Assembly could not proceed. It happened that H.H. Dorje Chang Buddha III had accepted a respectful request to make His presence at this Dharma Assembly to observe the proceedings. Everyone then beseeched H.H. Dorje Chang Buddha III to resolve this difficult situation.
H.H. Dorje Chang Buddha III said: “From the beginning, I have disagreed with your conducting this exam. After all this time, all those who were tested were but ordinary people. How many of them are elementary level Holy Gurus? They are not Holy Gurus, they could not surpass more than 10 levels! Let whoever put this pestle onto the Golden Step take it down.” The Dharma masters replied that it was placed up there by a Holy Monk. H.H. Dorje Chang Buddha III said: “This is absolutely a mischief. Isn’t this a deliberate intention to make things difficult? He clearly knew that you have to take the Exam today, yet He deliberately set up such a difficult barrier here! Let Him take it down!” The Dharma masters said that this Holy Monk had already left yesterday to propagate Dharma in another state. Reluctantly, H.H. Dorje Chang Buddha III ascended to the Dharma platform and said: “I did not come to take part in your activities here to lift the pestle, I am just helping you. I will give it a try. I don’t know yet whether I am able to help you bring the pestle down.
After saying that, H.H. Dorje Chang Buddha III went in front of the Supreme Holy Vajra Pestle, and lifted the Vajra Pestle off the Holy Seat with one hand, the Golden Step was removed in accordance with the Dharma rules. At that time, the disciples were tremendously shocked. H.H. Dorje Chang Buddha III, who only weighs between 100 and 200 pounds, could have lifted a Vajra Pestle of 420 pounds that even the World’s Strongest Man with a body weight of more than 300 pounds could not lift, surpassing 56 levels. The holy physique and holy strength of H.H. Dorje Chang Buddha III stuns the world!
Although the Supreme Holy Vajra Pestle was lifted off the Golden Step, there was another 280-pound exam pestle on another Golden Step on the floor. This pestle also had to be lifted off the Golden Step before the Exam could go forward. In fact, everyone knew that no one on site could lift this pestle with one hand off the Golden Step. Even the Strongest Man in Asia Lu Xiao could only lift the weight of 226 pounds at his maximum limit the prior December. Today, all the strong men on site enthusiastically came forward to lift this Vajra Pestle. Among these people were some who could lift 700-800 pounds with two hands in a normal weightlifting competition. Surprisingly, they could not lift 280 pounds with one hand today. In the end, only H.H. Dorje Chang Buddha III was able to lift this pestle off the Golden Step with one hand. The Dharma Assembly of the Exam was finally able to proceed.
This unexpected incident that happened before the exam has brought a mysterious and surprisingly joyful discovery. In turns out the rejuvenation achieved by H.H. Dorje Chang Buddha III was not limited to the physical appearance, but also included the inner properties. The youthful qualities of His Holiness the Buddha are very many times more than that of young people.
Kaichu Jiaozun of the World Buddhism Association Headquarters, a disciple of H.H. Dorje Chang Buddha III, said, “I dare say for certain here, except for H.H. Dorje Chang Buddha III who has such holy power, any Dharma king, great rinpoche or Dharma master in this world cannot even think about lifting the Supreme Holy Vajra Pestle one bit!” Kaichu Jiaozun has never practiced any kind of exercises or strength training to improve His physical well-being or learned any martial arts. He is simply a scholarly person who cultivates His conduct, practices meditation and Dharma. This elderly Holy Guru is only two years from 90 years old, and His body weight is less than 190 pounds. Three of His fingers are deformed due to an old injury. Yet surprisingly, He was able to use his crippled hand to lift an Elementary Level Holy Person Pestle onto the Platform according to the Dharma rules, surpassing 16 levels. It is proven that a holy person who has attained a high level of realization does possess supernormal physical condition and strength. Ten years ago, this elderly Holy Guru publicly demonstrated His inner strength from practicing Corpse Pose Tummo Concentration Dharma transmitted by H.H. Dorje Chang Buddha III. His abdomen emits heat reaching 92 degrees Celsius and an egg that was placed on His abdomen was cooked. Surprisingly, at the age of 88 now, He was able to lift the Vajra Pestle with one hand and surpassed the strongest man in Asia Lu Xiao by 14 levels. Can this be done by a human being? It can only be said that this is a god!
People attending the Dharma Assembly unanimously recognized that Lifting the Pestle onto the Platform is the most direct testing mechanism to distinguish between true and false Buddha Dharma, or true and false holy ones. It can be clearly seen who is an ordinary person and who is a holy one simply by means of Lifting the Pestle onto the Platform. What is most incomprehensible is why the physique and strength of professional strong men, who do strength training every day, would be incomparable to that of someone who does none of that strength training but only cultivates His conduct and practices meditation?
For example, Lu Xiao represented China in the World’s Strongest Man Competition in Malaysia and won the Championship in November 2014. In 2017, he pulled a 184-ton train forward for 20 meters in a New Year’s Gala that was broadcast on TV in Liaoning. On December 27, 2019, at the age of 36 and with the body weight of 350 pounds, he lifted the Pestle onto the Platform in Shenyang, and successfully surpassed his standard by two levels. Yet an elderly Holy Buddhist Guru who is almost 90 years old, and with a body weight between 180 and 190 pounds, was able to surpass Lu Xiao by 14 levels! His Master, H.H. Dorje Chang Buddha III, is even more inconceivable. Except for one with the innate quality of a Buddha, who could have achieved that? Believe it or not, the fact is right there. No tricks could be used. That was a direct lift of an actual weight. Other than marveling at and recognizing the profundity of Buddha Dharma power, what else can we say? Through this event, the fulcrum supporting all that ambiguous, mystical and empty talks throughout Buddhist history is finally broken. The truth has been revealed through the real fact!
By Younian, senior media writer; photos by Christine Yang, senior teacher in Mass Communications; validated on site by Jennifer HW Tsai, Esquire
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Nick Brandt : This Empty World
J.G. Ballard, arch-connoisseur of shifting ontologies, remarked more than once how he came to see reality as ‘a stage set … that could be dismantled overnight’. If reality can be dismantled, it can also be constructed and this is what Nick Brandt accomplishes in his latest project, as seen in the splendid book of that title, This Empty World, published by Thames & Hudson. The photographs are composites of two scenes occupying the same physical space – a small area of Maasai land in Kenya – but ones which never existed at the same moment in time.
The work followed three stages, beginning with the rigging up of pre-set cameras and lighting in a designated spot where animals might be expected to visit. The site is left unattended but wildlife entering the frame of the cameras are captured on film. The second stage is the erection of a stage set, utilising space around the site and featuring, for instance, an artificial gas station, highway construction or bus depot. Then, to complete the scene, people are hired to take up positions relevant to the nature of the site – construction workers, say, or passengers around a bus station. A photograph from this third stage is then combined with one from the first stage. The final results are hugely dramatic and emotional mis-en-scènes that ask what is to be done in a world where humans and animals now have to share earth’s space and resources.
This Empty World is a logical development of his earlier black-and-white project, as seen to impressive effect in Inherit the Dust, published by Edwynn Houk Editions. Brandt photographed his own staged installations, ones created by positioning panels depicting life-size images of wildlife in African locations which once constituted the animals’ territory. Brandt’s ecological message was explicit: ‘Keep going at this pace, and the unique megafauna of Africa will be rapidly gone the way of the megafauna of America and Europe’.
Brandt’s phantasmagorias in a Kenyan landscape reveal a truth hidden by quotidian reality. The ordinary Africans that populate Brandt’s pictures are seen to be as much victims of modernity as the animals that inhabit the land now shared with them.
Sean Sheehan
Nick Brandt: This Empty World
Size:33.0 x 38.1 cm
Extent:128 pp
Illustrations:84
www.thamesandhudson.com
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Shout Out: Meg Schmitz, business franchise counselor
In the Press, Press
Meg Schmitz, 56, is a senior franchise consultant for FranChoice, where she has worked for 16 years. Before working at FranChoice, she owned five Great Clips throughout the northwest suburbs for 11 years. She received a bachelor’s degree in counseling from Northwestern University. Schmitz jokes that she received a master of business administration degree after owning the Great Clips locations. She is married to Peter Layton, and they have three children. Schmitz lives in Glenview and grew up in Wilmette.
Q: What inspired you to become a business owner?
A: I didn’t really have the desire to get into it, but it didn’t take very long for me to find my attitude, find my voice, and really take over the business and work with my employees. That’s the counseling side of me. I like to know what makes people tick and makes them do better. I enjoyed engaging with my employees.
Q: What do you enjoy about working at FranChoice?
A: Everyday is different. I work with people who have an aspiration to own a business. Sometimes it’s the first time. They don’t want to work for the man, they want to be the man. Other people have done this before either as an entrepreneur or as a franchise owner. What I enjoy about it is everyone has a different journey and, like counseling, I get to go on that journey with them and help them make a decision that is the right decision for them. These people have a desire to own a business that is already fleshed out. There’s already a playbook. They already understand the marketing and who the customer is. They don’t want to recreate the wheel. They want something that they can execute now and start making money sooner.
Q: What advice would you give someone who would like to get into business?
A: People don’t realize that consultants like me are out there. Work with me. I’ve got 27 years of experience in business ownership. I’ve helped entrepreneurs launch, and I’ve helped entrepreneurs turn their business into a franchise. Leverage my knowledge base and I’ll help you find the thing that suites you best.
Q: Why should more women purse careers in business?
A: Women do well in franchising because we’re used to spinning a lot of plates and prioritizing things. Give us a recipe, we can execute it. Give us an operations manual, we can execute it. Women do well in franchising all over the world, it’s a documented fact.
Read the article online here.
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Erephisia Cast
(Redirected from Ecast)
The Erephisia Cast
Billy Neil, Kuri Kabanov
Billy Neil, Kuri Kabanov, Samuel Azehtyla
Billy, Kuri Kabanov, Samuel Azehtyla, Various
Theme music composer
André Sammut
Technological Federation of Erephisia
Executive Producers(s)
60–120 minutes
ECRAB
Original channel
Original run
September 2012 - October 2013
The Erephisia Cast was a podcast created by and starring Billy Neil, Kuri Kabanov and, most recently Samuel Azehtyla.
5 Special Guests
The Erephisia Cast was originally thought up around May 2012 as a radio show with Billy Neil as the host and Kuri Kabanov as the first special guest, with different guests with each show and Kabanov only as a guest in oppose to a co-host. However, on the day that the first show was to be recorded, Kabanov suffered severe technical difficulty, and the recording couldn't go ahead. The project was put aside until the September of 2012, when 1. Pilot was recorded. Originally, Neil had intended to record a podcast with Alex Bennett. The podcast had one episode recorded, named 1. Atari 2600, but didn't develop beyond this. Said episode is now lost. Due to internet porblems on Neil's part, production of the Erephisia Cast had to be halted until April 2013 after 2. Wikia, making this the longest gap between episodes. Because of this, all episodes after 3 and until the first episode of 2014 are considered as being different "series", with each year henceforth being a new series. I.e., 2014 being Series 3, 2015 being Series 4 and so on. Series number will have no effect on the production of the Erephisia Cast, with changes to the series being based primarily on other stimuli.
After Series 1, the Erephisia Cast was allotted to a set date, being recorded on a Friday and released on a Saturday. Due to internet complications, the first episode of Series 2 wasn't recorded until April 2013. Other set rules for the podcast include having special guests every other episode (with a maximum of 2 special guests per episode to avoid the potential of guests talking over each other), with single word (and in some cases, monosyllabic) names, and being no longer than 2 hours, but no shorter than an hour. Also, 2 features appear in the episodes, "Makarov Says", wherein Kabanov impersonates Vladimir Makarov (a character from the video games Call of Duty: Modern Warfare 2 and 3) and "Wikiatrocity", wherein all guests trawl all different micronational wikis for ridiculous, bad and laughable articles to point out. It has been observed repeatedly by Neil that any content considered offensive is in fact a joke, and should not be taken seriously. There are plans to create a Let's Play series hosted by the same hosts as and concurrent with the Erephisia Cast.
The Erephisia Cast is met with mixed reception throughout the micronational communities. Some episodes are met with particular disdain from members of the MicroWikia community as they feel that it makes them look worse than they are. The episode 2. Wikia was a particular example of this, being widely panned by MicroWikians who felt greatly victimized by the hosts and guests for their depiction of the way they act.
The Erephisa Cast gained a third Permanent Member, Samuel Azehtyla on May 25 of 2013.
Samuel Azehtyla did not sleep for 37H:43M:21S before the recording of E10, his first episode as a Permanent Member.
Episode 8's original theme was "indie games," but that it was deleted and re-recorded due to the malfunction of new recording software, a similar event occured with the original version of 13. Trial, which was originally going to star Andre Sammut, the shows composer.
Beyond the introductory theme, a few songs by Andre Sammut including "Inpt", Sammut's remix of Autechre's "Outpt" and "Velliety" have appeared in the casts, as intermissionary music.
Episodes 14. Radio and 15. Title didn't include Kabanov due to Kabanov being on holiday, in episode 14 he was replaced by Ciprian of Juclandia as co-host and in episode 15 Pierre D'Egtavie and Jacob Tierney (both making their second appearance on the show) shared the role somewhat, with Sebastian Linden taking the role of special guest.
The show follows a strict set of rules during production, said rules including haviing special guests every other episode, said episode being recorded at 9PM on a Friday and being uploaded on a Saturday, and each episode being longer than an hour and shorter than two hours. Some of the rules have been slackened somewhat in more recent episodes, however the length per episode will indefinitely remain between an hour and two hours. All episodes have since been lost.
Pierre d'Égtavie (4 appearances)
Richard Cunningham (3 appearances)
Jacob Tierney (2 appearances)
Sebastian Linden (2 appearance)
Arthur Lobão (1 appearance)
Alex Ulbricht (1 appearance)
Ruby Azehtyla (1 appearance)
Kuri's Sister (1 appearance)
Daniel Anderson (1 appearance)
Andrew Perrea (1 appearance)
Sovetus (1 appearance)
Ciprian of Juclandia (1 appearance)
Joseph Kennedy (1 appearance)
Carl Miller (1 appearance)
Teaglan I Nihilus (1 appearance)
Daniel Morris (1 appearance)
James H Whittle (1 appearance)
Markus "Akkusky" (1 appearance)
Andre Sammut (1 appearance)
Bradley of Dullahan (1 appearance)
Retrieved from "https://micronations.wiki/index.php?title=Erephisia_Cast&oldid=693193"
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United Democratic Republic of Mackinac
(Redirected from United Republic of Mackinac)
This article is of poor quality. Based on the last time it was edited, the future of this article is yet to be determined. The discussion page may contain suggestions.
The United Democratic Republic of Mackinac is a micronation in North America. It is bordered by the United States, Lake Superior, Lake Michigan, and Lake Huron.
Motto: "Stand strong, live free"
Anthems: "Imagine", "Working Class Hero"
Engadine, Capital District
Largest Collectivity
Chippewa Terrirory
English,German
Democratic Socialist Republic
John Kaloz (L)
Jack Mixter (L)
Last Election
5 703 square miles
US Dollar (USD, $)
Mackinac Dollar (RMD, $)
-6 UTC (DRM does not use daylight savings time)
Internet domain
1.1 Formation
1.2 Expansion
1.3 Population
2 National Symbols
2.1 National Flower
2.2 National Food
2.3 National Bird
2.4 National Beverage
2.5 National Condiment
2.6 National Tree
2.7 National Metal
3 National Holidays
5 Relations
6 Flags
6.1 Flags Through Mackinac History
In 2016, Governor Kaloz formed the United Democratic Republic of Mackinac as a peace seeking nation, and a country where the citizens can have all their rights, equality, and live what was supposed to be the American dream. He first declared independence on May 12, 2016, and wrote the declaration of independence. He then joined forces with Deputy Governor Mixter, and they signed the declaration, sealing the independence. They then proceeded to fly the first national flag on the date of full independence, July 16, 2016, and declared that date to be flag day, as Independence day was marked already as May 12. Kaloz declared himself as governor of the nation, and Mixter as the deputy governor.
When the United Democratic Republic of Mackinac was originally formed, it only contained the Engadine Capital District, and went by the name of the Engadine Republic. Soon, President Kaloz decided to expand his territory, claiming the Townships of Garfield, Hudson, and Hendricks for the nation (merged as Garfield), on June 13, 2016. The current townships were referred to as districts of the nation, then.
He soon decided to claim the west half of Michigan's Mackinac County, and then declared the country's second name, the Republic of West Mackinac. This contained the districts of Garfield, Portage, and Newton. He then declared the nation to contain all of Mackinac County, and granted Vice President Mixter the eastern half of the country. They soon decided to merge the country as one and not have it split up between halves of the government.
When Vice President Mixter declared his previously dormant nation as active again, and he decided to expand his territory to take the northwestern part of Michigan's upper peninsula, but then decided to cede Houghton County back to the United States. They decided they wanted to border each other, and that Mackinac should border Canada, for help with refugees. Because of this decision, President Kaloz declared Luce and Chippewa counties as territories of Mackinac.
National Flower
National Food
National Bird
National Beverage
National Condiment
National Metal
Thanksgiving - March 20
Independence Day - May 12
Flag Day - July 16
Negaunee Independence Day - July 17
Negaunee Remembrance Day - September 17
Governor's Day - July 28
The United Democratic Republic of Mackinac has 9 townships (acting the same as states do in the United States), 2 territories, and a capital district.
Engadine Capital District
Brevort
Bois Blanc
Luce Territory
Chippewa Territory
Formerly allied with the Negaunee Republic
The Flag of the United Democratic Republic of Mackinac
The Mackinac Naval Ensign
The Mackinac Air Force Ensign
The Mackinac Army Ensign
The Mackinac Coast Guard Ensign
The Mackinac Marine Corps Ensign
The Mackinac Space Corps Ensign
The Flag of the Liberty Party, also known as the MNSP (Mackinac Nationalist Socialist Party)
Flags Through Mackinac History
The first Mackinac Flag, with blue for the lakes and sky, with a green stripe in the middle for the Mackinac Bridge and the land. (December 2015-May 2016)
The second flag of the United Democratic Republic of Mackinac. (May–July 2016)
A previously suggested design for a Mackinac Flag, the 11 red and white stripes representing the 11 townships the country was formed from, the people, and their blood, with the canton resembling the second national flag. Now used as the Mackinac Ambassador's Ensign (June–July 2016)
The third flag of the United Democratic Republic of Mackinac. The Fleur De Lis stands for the history of the nation, and the 11 stars for the 11 townships the country was formed from. (July 2016-September 2017)
An updated design for the Mackinac Ambassador's Ensign, with the canton resembling the third national flag. (June 2016-September 2017)
The Former Mackinac Naval Ensign
The Former Mackinac Air Force Ensign
The Former Mackinac Army Ensign
The Former Mackinac Coast Guard Ensign
The Former Mackinac Marine Corps Ensign
The Former Mackinac Space Corps Ensign
Obverse of the current flag of the United Democrcatic Republic of Mackinac, a slightly different version of the first flag, with darker colors, and a longer, 1x2 ratio, rather than a 3x5 ratio. Chosen for its simplicity, proving it a much better flag by the codes of the FIAV, ICV, and the NAVA. (September 2017 – Present)
Reverse of the current flag of the United Democrcatic Republic of Mackinac, with a gold star in the canton, to represent the 5 supports of the country; the people, the nature, the past, the present, and the future. (September 2017 – Present)
Retrieved from "https://micronations.wiki/index.php?title=United_Democratic_Republic_of_Mackinac&oldid=716327"
North American micronations
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Handy guide for recognizing trolls in the Richard Armitage fandom
[This was my original planned topic for today, but I’ve modified it somewhat to deal with today’s events.]
The Beta XII-A entity from ST: TOS: The Day of the Dove. You can read the story here if you don’t know it already.
We had another incident of fan-directed trolling in our fandom on Friday evening. Trolling usually escalates in frequency when Richard Armitage is doing something fans are excited about, because a troll loves nothing more than sucking up our energy. (For Star Trek fans, think of the energy creature who splits the Klingons and the Enterprise crew in ST:TOS The Day of the Dove). Since I personally find reading the drama around trolling exhausting, I thought I’d drop a few suggestions about the topic here. Your mileage may vary, and of course, you may have good reasons for responding to a troll. I have done so from time to time myself. However, one must always keep in mind that doing so means giving a malicious total stranger who is laughing at you a chunk of your positive energy for free.
In my opinion, there are two key principles in understanding how to respond to problematic fandom content on the Internet.
First, ask (a) to whom am I speaking? and (b) is that a person I really want to speak to? and (c) are they listening?
Second, ask (a) what am I accomplishing by speaking here? What is at stake? and (b) what really needs defending?
I’m not telling anyone not to respond to a troll, even though I wish we wouldn’t, but here are some things I try to keep in mind when I’m debating a response.
What a troll is (and isn’t) and how to recognize one
A troll prepares to cook Bombur in The Hobbit: An Unexpected Journey. Screencap.
[I’m using “they” as a neutral pronoun in this post, incidentally, even though it bugs me grammatically.]
Here’s a definition. Paraphrasing that article, a troll is someone who intentionally puts something down in a discussion stream that they know will be highly controversial or inflammatory, solely for the purpose of provoking an emotional response from the normal audience for that topic in that medium. A troll in Armitageworld is usually either an outsider to the superfan community, or if not, uses a sockpuppet. These features are important because there’s a difference between trolling and controversy in discussion between known entities (intense controversy in fan discussion can causing flaming, but flaming usually has an object of contention — it doesn’t happen solely for the purpose of upsetting people), and a fan who says something controversial with their normal pseudonym is typically not a troll. Although some of us enjoy drama, there’s a different pattern to that behavior than that of a troll. (The lady in your church who is always the first to cry wolf about bomb threats is different from the person who calls your church phone anonymously with a bomb threat.) Similarly, and I can’t emphasize this enough, a fellow fan who disagrees with you about something or says something you find troubling and does not change their position even after you raise the issue with them about it is not a troll (or, as I read all too often these days, a bully). Reasoned disagreement, even if it doesn’t result in agreement, is a normal and acceptable part of fan discourse.
In contrast to controversial discussion, trolling is a specific behavior conducted for the purpose of the uproar it generates, which the troll enjoys. Its only goal is the fostering of bad feeling. The troll doesn’t care about the topic they are trolling about — they count on the fan to do that. Indeed, trolling only works because the fan cares about whatever the issue is more than the troll does. This frees the troll to say whatever they like, in order to see the fan squirm in response. The point of trolling is to make fans look silly, crazy, prejudiced, or worse. The troll enjoys seeing this reaction and knows that fans are regularly ready to provide it, which reinforces the troll’s feeling that fans are silly, crazy, prejudiced or worse.
Today we saw the manifestation of something which is not technically trolling, but many tweeps find disturbing — the penetration of non-fans into the stream of responses to Armitage’s tweets because he used the hashtag #Orlando. Some of this disagreement is legitimate. However, some of it is also conducted for the purpose of creating bad feeling. Such tweeps concentrate on specific issues and assemble to discipline people who are tweeting things they don’t like. While some fans were disagreeing with Armitage, non-fan accounts are generally recognizable as such. Whenever we’re talking about a political opinion (guns, immigration, whatever) there are people organized on Twitter to jump on tweets they disagree with and challenge the tweeter. Nothing can be done about this other than making one’s own tweets private, or blocking the people in question when they appear. If their words are particularly abusive, they can and should be reported to Twitter.
Trolls discuss their dinner in The Hobbit: An Unexpected Journey. Screencap.
But back to the fandom. While every principle about recognizing a troll is a generalization to which there will be exceptions, most casual trolls on Twitter are not very well constructed. A little clicking around makes it easy to identify a likely troll simply by their Internet trail.
For instance, a frequent feature of a troll account is that it is often not very old. In the troll incident we experienced this weekend, the account was created in June 2016. I noticed its appearance on June 2. Additionally, a troll account is usually not well-integrated in the fandom. Most Armitage tweeps follow one or more friends who are also fans, or they follow a fan-related account. They like or retweet pictures or tweets about Armitage. In contrast, a troll is typically not following many other fans or fan-related accounts, if at all, and they are not followed by other fans. They may follow Armitage, but they don’t have a trail of content related to him among their tweets. So it’s always important to check the tweets a troll has made, as well as the following and followed — including not only how many followers, but who they are, because it’s easy to follow fake accounts on Twitter and make oneself look larger than one is. Another way you can check on a troll is to google the handle or pseudonym they are using. Although it’s not a hard-and-fast rule, most fans use variations on their pseuds all over the place on different platforms and social media (I use “Servetus,” “Michaela Servetus,” “@ServetusRA,” “Servetus_Armitage,” and so on. A troll, in contrast, doesn’t want to reveal their real identity or put such poisonous comments on well-established social media accounts, so they tend to use either a very nondescript pseudonym (increases anonymity) or one that appears practically nowhere else.
Another good way to recognize a troll is by the shape of their comments, which often seek to triangulate. Loosely understood. Triangulation is the attempt to bring other people into conflict who are not central to it for the purpose of redirecting emotion in ways that suit the triangulator. (Example: I ask my mom for ice cream. She says “no.” So I ask my dad, who says “yes.” If my mom sees me eating, I tell her “dad said yes,” ensuring that I get what I want, appear innocent, and deflecting her negative response to my father and away from me.) The effectiveness of triangulation relies on a very exact knowledge of the matter that is likely to disturb the person who is being targeted to provide the emotional response. This is not difficult with celebrity fans, who tend to get exercised about a series of not-very-well-hidden matters, no matter the celebrity. In the case of the troll, triangulation allows trolls themselves to magnify the conflict, without ever feeling the brunt of the negative emotion they generate and enjoy.
The triangular role can be played by other fans. So, for example, a troll might say something about a controversial issue in the fandom that will making differing segments of fans fight with each other in order to enjoy the spectacle. The conflict is between the fan and the troll, but other groups of fans are drawn into the fray as rescuers. A typical axis for this is any issue that relates to Armitage’s personal life. One group of fans will disagree with the content of the troll’s statement; a second will disagree that the matter should be discussed at all; soon the fans are fighting with each other as the troll — the actual source of the conflict — watches with pleasure. This effect relies on the fact that fans almost always identify more with their individual pictures of Richard Armitage than we do with each other.
Most often, though, the triangular role in our fandom is played by the notional Richard Armitage. The troll says something I don’t like about Armitage — not to me directly. These comments are often phrased in a way that makes the need to respond appear necessary in order to defend myself against the allegation that I am bigoted or that Armitage is not worthy of fan admiration. As a result, I confront the troll on behalf of Armitage but also on behalf of my own good name, rescuing both him and myself (victims). We saw this this morning when fans began defending Armitage for the way he treats his fans. Or, a classic case of this occurred in the summer of 2014, when a well organized group of three twitter accounts started tweeting that they wanted refunds on their Crucible tickets because they claimed to have learned something they didn’t like about him. (I say well organized, because although the attack was clearly coordinated by a troll or trolls, they had taken care to organize it far enough ahead of time that it took more digging than usual to discover the evidence.) Naturally, fans jumped in to defend Armitage. This defense had the effect of amplifying the matter that the fans didn’t want to discuss. The triangulation here provokes the response from the non-involved party, i.e., the troll attacks Armitage, and that is where the conflict should lie, between persecutor and victim. However, the technically non-involved fan defender of Armitage is drawn in as the rescuer and provides the predictable emotional thrill for the troll. This strategy is most effective if the issue gets lots of play and lots of fans pile on for the defense, which proves to the troll that they are crazy defenders of their crush. If the first effect above also occurs (fans fight with each other), that is an added bonus.
What to do about this? The only one I can change is me
Thorin Oakenshield (Richard Armitage) prepares to engage with a troll, in The Hobbit: An Unexpected Journey. Screencap.
I said above that I think there are two key issues in contemplating a response to a troll. The first — who am I speaking to? — is important for behavior; the second — what is at stake / what needs defending? — is important for one’s state of mind.
First, the question of who is speaking to one, and to whom one is speaking. To me, this is one of the most pernicious problems of social media and it’s taken me years of facebooking to understand it. My college bestie posts an article on Facebook, and I respond. I don’t have to — she’s just throwing it out there and not directly asking for my comment. A total stranger who is friends with her in some other context foreign to me responds to me charging me with being a homophobe. The first question is: am I actually being spoken to? Maybe or maybe not. Then: who is this person to me? No one. So why do I care what she thinks about me? The second is: am I a homophobe? I would say on the whole, no, although no doubt I have prejudices that might be examined, my life shows that I am not. She has no way of knowing this because she has no information about me beyond her interpretation of a single comment. The correct response is clearly not to get into it with her, because why do I care at all about what an uninformed stranger thinks of me?
Applying this to trolls, a troll is a total stranger who knows only one thing about me — that I’m crushed on Richard Armitage and likely to react negatively on certain issues related to him. That’s enough to provoke me, certainly. A total stranger says something to me about something I’ve said something about that could be a vulnerable point. I check them out and they are not identifiable as a fellow fan and I don’t know them from any other context. Why would they be speaking to me if not to provoke? This is someone I need not to respond to. Block or mute if necessary. I would argue this also goes for people who join on a discussion on the basis of a popular tag. No one is required to speak to total strangers who say mean things. Why would I? This essentially constitutes a refusal to respond to manipulated attempts to triangulate.
Bilbo (Martin Freeman) decides to intervene to defend Thorin against the wargs, in The Hobbit: An Unexpected Journey. Screencap.
Which gets me to the second issue: the defense of Armitage.
This has been an issue in the fandom as long as I’ve been a fan and probably longer — the need we feel to defend Richard Armitage. In fact, I read an hour or so ago that Armitage’s reason for deleting his tweets was to keep fans who were defending him from being bullied by trolls. I don’t see everything, so I didn’t see any evidence of this, and I find that explanation implausible, but if it’s true, it would be a bit disturbing. Years ago we coined the term Armitage Protection Mode (APM) to delineate a behavior that all of us fall into from time to time. Because the thing is — the man has been living independently for three decades and he doesn’t need us to defend his words, his career, his actions, his role choices, his relationships, or anything about his life. He makes his own decisions about deleting tweets and they should not be about us. If Richard Armitage needs me to defend anything about him, he’s really in much worse shape than I think. And the odds that he has time to defend me rhetorically against against Internet trolls are really low. In short, he’s a grown up guy with a life in which his fandom is not central and he doesn’t have time any longer to be concerned with individual fans. He has a mum and doesn’t need thousands of mothers; he has an agent and a successful career and friends who actually know what is happening in his life (as opposed to us; we’re just guessing), and I don’t know how many professionals watching out for his interests. In that light, this is one of my all-time favorite blog posts in the fandom, ever, one that has grown more valuable in retrospect. So I’d ask myself, before deciding to respond to a troll — if I think I have to respond to a total stranger who is provoking me on purpose in order defend Richard Armitage, why do I think that?
There was a classic case of this last summer when someone who felt spurned for an autograph in the Vancouver airport began a malicious twitter campaign and, although the actual conflict was between the tweep and Armitage, successfully triangulated fans rose to the bait. My position on that: Richard Armitage knew what he was doing, he was in enough contact with the person to be able to speak to her, if he had wanted to say anything more than he did publicly, he certainly could have. If he didn’t think he needed to justify himself — so why did we? Instead, and predictably, fans jumped up to defend him and gave that troll all the attention and emotion she needed to feed off for weeks. I think the answer to that was not that we needed to prove that Richard Armitage is a good person to someone who claimed to have had an unsatisfactory experience (he is who he is, however that is, and my argumentation won’t change that), but rather we needed to bolster our own beliefs that Richard Armitage is a good person.
And if it’s down to that — if my defense of Armitage is down to having to state what I need to believe about him and thus providing the outrage that makes a total stranger happy — then I can go back to point one. Why do I need to justify my attitude to a complete stranger who knows nothing about me? Especially if the point of their attack is to get me to respond for their pleasure?
Please feel free to share your own experiences with dealing with Internet trolls.
Tags: fandom, Richard Armitage, trolls, Twitter
58 Responses to “Handy guide for recognizing trolls in the Richard Armitage fandom”
In German we use the phrase “troll dich” which means “shove off”. Nothing more to say.
CraMERRY said this on June 13, 2016 at 6:04 am | Reply
Interesting — some more German slang to add to my vocabulary!
Awesome essay. Clearly well thought through and brilliantly executed. I am sorry for whoever was on the end of any vitriol or mischief making. I realise I am naive and am always hopeful for a world where we can all just get on, despite our differences. I would hate to think I had upset anyone so to do it for kicks is just very sad and something I really struggle to understand. Thanks for speaking out and giving some tips. I’m just so sorry that you had to.
Evie Arl said this on June 13, 2016 at 6:56 am | Reply
I think this is what is insidious about a lot of trolling — the person who is being attacked is implied and that drives troll targets crazy.
I wasn’t hassled this time — and the level of direct hassle to me has dropped quite a bit recently. I think trolls think the tweeps are a better target.
Thank you for this. I have always been somewhat in the dark about trolls, because my presence on social media is very minuscule to say the least.
As a novice – still – to twitter, I have come across something odd very recently; not only yesterday when it apparently peaked, although I wasn’t aware at the time, but in the past week or so.
I have a twitter account which I opened some five years ago, but never really began using until a certain gentleman began tweeting.
My twitter account is a compilation of many things that interest me, a sort of archive if you like, and it isn’t apparent that I follow RA. I have tweeted him directly only a few times (twice), when something was entertaining, and that’s it.
My twitter account hasn’t got many followers; I don’t seek to have many followers, but I follow quite a number of accounts, primarily news, food and travel related. In the course of the years, a few RA-fans have followed me, and I’ve followed them back.
The past week – the time span eludes me, but it’s not longer than that – I have gained seven(7) followers. Actually, it’s more than seven, because I’ve already blocked about five accounts, all of a sexual nature (then I changed my profile picture ;-)) One account is clearly related to an illness that I’m interested in. Another account is seemingly interested in photography. The last four ‘arrived’ on the same day or night, somewhere in between Saturday and yesterday, Sunday. I find this odd, highly unusual, and apparently their accounts show no signs of being interested in RA or anything I’m interested in. Their accounts hold real names and pictures, but that could just fake. Could they be trolls? Are they on my account for a certain purpose? Can trolls hide behind others’ accounts? Perhaps I should block them, just to be on the safe side.
I know I shouldn’t conjure up conspiratorial theories, but is some ‘attack’ under way? You can’t possible know the answer to this. Needless to say, I’m highly suspicious at this point.
Mermaid said this on June 13, 2016 at 7:17 am | Reply
Hello Mermaid, don’t worry. Twitter suggests who you should follow. Those suggestions often don’t make sense but people who are just interested in collecting new followers often act on those suggestions. I also think there is software out there which “collects and suggests”twitter accounts for others to follow automatically.
If you feel uncomfortable with an account: block and immediately unblock. This makes the account disappear. Trust your instincts 😊
suse3 said this on June 13, 2016 at 8:16 am | Reply
I am sorry to hear that you have been harassed by some losers.
I don’t follow or have too many followers, too. Nor, do I care. I like to just creep on people and see what they are up to. Sometimes I’ll engage, but most of the time I just read and have a chuckle at what might be happening on Twitter.
When it comes to trolls, I like to have a little fun with them until they end up blocking me. In the past, I noticed some annoyingly mean tweets to me and some people I followed. Instead of blocking them, I just started tweeting back at them about what I thought of them. lol I guess that makes me a troll.
I personally don’t believe in blocking people, because it make them win in my book. It’s only words and they can’t really hurt me. Besides, I like seeing if they’ll block me after what I say and do to them.😈
The last psychological pain I had to endure was going to concert with my horrible sister to listen to Mahler’s Symphony No. 6 ( “Tragic” ). Unfortunately, the only thing tragic about it was that I had endure the emotional torture of being told how underdressed I was and how uncouth I was. I could even crack a joke after the concert because she was my only ride home.
Duke said this on June 13, 2016 at 8:25 am | Reply
Don’t worry about that, Mermaid. Those are bots that automatically follow accounts in the hope that you will follow them back. It’s related to marketing rather than trolling. If they annoy you, block and mute. But I don’t think you will receive any hassle from them. They do not engage.
Guylty said this on June 13, 2016 at 8:36 am | Reply
Thanks for your advice, Guylty, Duke, suse3. I have blocked the four of them (their profiles were very similar). Hopefully, that’s the end to that.
Mermaid said this on June 13, 2016 at 12:33 pm | Reply
There are also accounts that “sell follows” that might follow you. These can be blocked as well.
hm , interesting i might need to look into the followers since i don’t really notice the ones who never talk to me… do they have to be blocked or do they drop off when you don’t interact? Or do they gather information by following and it is safer to block? (sheesh… as if cleaning the flat was not enough of a pain now i better worry about who follows borin’ ol’ me on twitter and what they want if they never say a thing)
Hariclea said this on June 14, 2016 at 2:30 am | Reply
As long as you don’t follow them back, you’re pretty safe. If you follow them back they can DM you which may set you up to be at risk of phishing, viruses, etc. Usually they are trying to get you to follow to generate a statistic that can be sold (here’s an account with so and so many followers, etc.) rather than gathering information.
Servetus said this on June 14, 2016 at 4:43 am | Reply
thanks v much that’s very helpful, will have a look at the lot and do a bit of long overdue clean up
Hariclea said this on June 14, 2016 at 10:42 am | Reply
Thanks to everyone who explained this feature of Twitter.
Did you ever have anon memes in Richard Armitage fandom?
Trolling experience – not too long ago in the Richlee fandom there was an incident where a well known Richlee blogger kinda went haywire. First, passively aggressively saying they no longer will ship Richlee because they their heart broke with the whole Robsten debacle but that will keep their tumblr up for their Richlee posts. Of course, everybody asked why. Then apparently they went off on Twitter against Lee. Then they deleted their tumblr. But throughout all this you could feel a palpable sense of sadness going through the fandom. I felt it too. There were posts actually defending Lee against these accusations as if Lee somehow owed an explanation to some kid in China (where apparently these rumours originated). While recognizing the absurdity of the situation, it actually felt good to see the posts because they did reinforce my ship, and all the reasons I shipped it. Yes, it fed into the troll but it also felt that those posts needed to be made to address the larger feeling of uncertainty within that fandom. Sightings of the two together had been rare. No obvious clothes sharing incidents. Really somestimes it had come down to looking at the timing of their tweets to justify a reason to keep shipping them beyond the obvious reason of them being hot together.
In my experience, trolling always picks up on some undercurrent in fandom. The good trolls (yes, I do believe some trolling is good) take the piss out of the issue. The bad trolls sow discord for the sake of discord but they are picking up on a larger issue.
Maybe the troll did enjoy feeding off the responses for a couple of days, but after a while it ceased to be about them, but more a meditation of the ship which in some ways backfired on the troll.
mimreckoner said this on June 13, 2016 at 7:38 am | Reply
I still ship them together.
It was funny that they tweeted about #Orlando around the same time as Servetus had mention in an earlier blog. This just makes one wonder more about those two.😉
anon memes: not yet; everything hits us eventually, just later and in smaller proportion.
RichLee rumors are older than Pace’s visit to China.
I do think combatting a troll does enhance certain kinds of group solidarity because there is a common enemy.
I don’t think there are good trolls. I am not centrally involved with the RichLee shippers but my observation of the phenomenon of trolling them suggests that they have malicious motivation, they say mean things, and then enjoy the blowups afterward. I have frequently been exposed to the argument that it is good for these fandoms to be trolled because it supposedly corrects the craziness, but I am skeptical of that argument.
that is a strange argument indeed, especially since it starts with the prejudice that something is ‘wrong’/’off’ in being a fan and then justifies negative/aggressive action against fans on that basis.
As a fan i find it infinitely more satisfying to join with others in talking about the work, forever puzzling (up/down/up/down) about the person/personality of the person than fighting some nasty external commentator.
Probably not the best place for this discussion but I do not like it when people refer to Richard and Lee together as “shipping” or a “ship”. I feel like it’s dehumanizing somehow. They are real people, not fictional characters. I think the world “ship” belonges to fiction. At this point the majority of us knows (or strongly suspects) that Armitage and Pace are an actual, real life couple. (Or were. I have no idea if they are still together.)
Alice said this on June 13, 2016 at 5:50 pm | Reply
I think the word is used in a lot of senses. I have trouble with the insistence that the word not be used to apply to talking about whatever their real life relationship is, because all fans involved in this particular discussion are speculating based on how we apply our fantasies to any evidence that appears. As far as I know, none of us has decisive evidence. The fantasy about real life persons is also a fantasy.
I agree to some extent, Alice. But I like fictional Richlee, too. Sometimes I almost like them better than their RL counterparts! One of my favourite Lee’s is tattoo artist Lee. Fictional Richard tends still to be an actor or high powered business man. But somehow people feel more free reimagining Lee – which I love.
I think you can like the fictional version of each man while still respecting the RL Richard and Lee, together and also separate.
There’s some RichLee fanfic that I have just adored.
“In short, he’s a grown up guy with a life in which his fandom is not central and he doesn’t have time any longer to be concerned with individual fans. He has a mum and doesn’t need thousands of mothers; he has an agent and a successful career and friends who actually know what is happening in his life (as opposed to us; we’re just guessing), and I don’t know how many professionals watching out for his interests.”
Thanks Servetus for explaining things the way you did. I could not have said it any better. It is kind of annoying seeing people fawn all over him like a baby or small child, which he is not.
Yes, I am an admirer of the man’s work, but it doesn’t mean I think he’s a god or ethereal being that some people in his fandom think. He is fallible like any other human being.
On aside note, I think it’s stupid when some fans decide to jump the gun at getting tickets for a play he may or may not actually be doing and booking plane tickets before RA has actually confirmed it. This scenario reminds me of the story of Henny Penny or Chicken Little. Could you imagine how many people with egg on their faces if RA is not in this play?
Please be aware of the comments policy regarding remarks about fans who are not present here / policing. Your comment is on the line, although I will let it stay.
Duke said this on June 13, 2016 at 4:47 pm | Reply
I have not attracted trolls because I am not a force to be reckoned with. Not a blip on a troll’s radar. However, when I think of trolling, I think of trailing a lure behind a boat to catch a big fish. In a way, Serv, you should be flattered that your lure (blog) has attracted some mighty big mouthed fish from time to time. Sometimes they provide a good fish dinner. And they never sink the boat.
Kathy Jones said this on June 13, 2016 at 8:47 am | Reply
Yeah, I actually assumed that was the origin of the word when I started being a fan. Too much time spent around fishermen? The word origin is apparently disputed.
This is a brilliant and really helpful post – thank you for explaining so well some of the weird things going on. It leaves me quite bewildered as to what motivates trolls, though. I guess they genuinely have nothing better to do, which must mean they are very sad and inadequate people.
Love the commentary on RA (as quoted above by Duke), too. Spot on.
Helen said this on June 13, 2016 at 9:01 am | Reply
There are emotional constellations in real life that create this need to suck up other people’s negative emotions or simply to live on other people’s feelings. I can’t venture to say what they might be in individual cases. I tend to experience a metaphorical allergy to passive aggression myself — this is a known bug of being an ACOA. I try to tamp down on it but am rarely successful.
Very interesting article with some wonderful explanations of what goes around and around, and the only thing I can think of is so many need to get a life, thank goodness the only trolls I have to worry about are the ones that live under the bridge near my house 🙂
Irish Witch said this on June 13, 2016 at 9:54 am | Reply
Yes, watch out for the ones closest to you. It’s a good policy 🙂
I’ve had a few nasty anon asks, but none I’ve given the time of day to. I think being in the RA and RichLee fandoms has thickened my skin considerably. I used to be so bothered (and I do still get riled up now and then), but my tolerance for BS has had a massive overhaul in the past few years. Really different experience from all my past other fandoms, which I find pretty interesting.
Fruity said this on June 13, 2016 at 12:09 pm | Reply
This brings up a great issue (that is not typically a situation one encounters on WP because it doesn’t have the anon ask feature). I feel like if one is very vulnerable to this problem, one should turn off anon asks. I regularly read people saying that their anon asks are so upsetting and my response is usually, well, then turn them off. It will cut way down on the number of people who are poking you to see if they can get a response.
This is still my only fandom but my response to certain behaviors has also changed. I feel like it’s a consequence of mid-life. I have much less time for nonsense.
Terrific article, Serv. It really is a good guide for recognizing trolls and determining what one’s response should be, if any.
Experiences with Internet trolls … ahhhh, memories! (Please note the heavy sarcasm.) In a fandom far, far away, a million years ago (at least in Internet terms), I used to moderate an email list dedicated to news and discussion about a certain musician. Let’s call him George. The name of the list was The George List. It had about 200 subscribers who were a bit of a crossover — most started out as fans of one artist (we’ll call him Zeb) who was actually quite famous. These folks became fans of George because the two of them had performed together quite often back then. I was one of them. I should state here that a few of the subscribers were hard-core Zeb fans. (I was not.) In fact, George was a subscriber and loved to join the discussions with us. There were only two rules I asked folks to follow, both stated in the welcome letter: 1) no flaming and 2) limit discussion about Zeb to stuff that George and Zeb did together.
On this one occasion, George had told the group the previous day that he was headed out on a brief road trip doing a few solo gigs and he’d be back on a certain date. The next morning, a new “fan” subscribed, someone none of us recognized from previous fandom interactions,and their very first post was, “Zeb is going to be performing blah blah blah.” Being ListMom, I privately emailed this person, off list, welcoming them and asking them politely to follow the rules stated in their welcome letter. Instead of responding to me privately, they took it to the list, saying things like how I had told them they weren’t allowed to talk about Zeb and asking if they all agreed with that and calling me names I won’t repeat here.
Several of the long-time subscribers tried to explain the intent of the list to the new person, which fell on deaf ears. They continued spouting off about how they should be able to post whatever and whenever they wanted about Zeb. And calling me more names (some of which I had to look up). The first person to agree with this troll (and sock puppet, as I later found out) was the fiercest hard-core Zeb fan on list. She started in and rallied the other hard-core Zebophiles … and voila, flame war.
Over the next 8 hours or so, each time a solution to end the fighting was suggested, the troll/sock puppet would fire back with more vitriol. Enough was enough, and I decided to desubscribe and ban this entity. As I was doing so, they unsubscribed. Oh, and so did Fierce Hard-Core Fan.
While I had gone into mediator/firefighter mode, a few of my assistant mods and friends went into investigator mode. They found out that the email account had been set up that morning. And the account was deactivated immediately after the address had unsubscribed from the list. It seemed as though it had been set up for the sole purpose starting the flame war. But why?
The list quieted down and went about its course. We did lose a few other subscribers over the following week or so. But we added far more in the coming months. George came back and was appalled at what had transpired. He wrote a glorious piece about respect and caring directed at the troll, even though they were long gone. There didn’t seem to be any other huge fights after that, just the usual family squabbles. The list continued in full swing for another 10 good years.
About that why? Good things come to those who wait. That Fierce Hard-Core Fan? She outed herself as the troll/sock puppet when she tried to start another attack against me on another media, where I wasn’t even subscribed, but one of my friends was. Friend sent me the exchange. It was gratifying to see the troll put in her place by the other posters. Karma …
zan said this on June 13, 2016 at 2:21 pm | Reply
Great story, Zan! (or at least it ended well). Glad you survived this!
i started to write about sockpuppets here (because we have had as many of them over the years as trolls) but decided it would complicate the issue too much. I think it’s a really interesting phenomenon, but in my experience it frequently falls apart because (as you say) either is a tell somewhere or the fan / sockpuppet feels a need to be recognized on some level. The only really successful sockpuppets are those who rigorously control clues about their identity and it’s very hard to do that.
it took me awhile to realize that when I defend Richard it’s not really about Richard, it’s about me. in defending his character, I’m also defending my own character, justifying my judgment for choosing him. I identify with Richard in various ways, so when I’m defending him, I’m also defending myself in the process. he doesn’t need me to defend him, I need to defend me. it’s still hard to differentiate that sometimes but it makes it much easier for me to not take things that are said about him so personally.
as for trolls, I think the biggest problem fans have is that they feel they must correct the inaccuracies for others who may be following along, they don’t want misinformation to influence newbies or non-fans and give them the wrong impression about Richard. but that is what the trolls are counting on, they give us a good length of rope and just sit back and watch us hang ourselves. we’re so passionate about the way we feel, what a good actor/person we think Richard is and how that makes us want to shout it from the rooftops, which makes it so easy for them to tap into that passion and then make fun of it, our fanaticism. so for me, I’ve put aside the need to be right. if someone who is just passing through is going to believe the petty lies the trolls spread about Richard, so be it, they’re not the type of fan that would have stuck around that long anyway. I feel that when it comes to crushes, you either get struck by lightening or it comes to you softly. if it’s the first, nothing anyone says is going to influence you into seeing your new crush in a negative way, nothing. if it’s the second, then you’ll scope out the lay of the land, investigate the claims and the character of the crush thoroughly, which will eventually bring you back. but the real question I had to ask myself was, why did I care? what’s it to me if Richard loses fans or gains them? why did it matter what fans said about him on public message boards/blogs? was I afraid he was going to see it and it would influence the way he felt about fans, about me? and that question slapped me in the face. this whole thing was supposed to be one-sided, it was supposed to be about me watching Richard, not Richard watching me. I don’t mean that I shouldn’t take responsibility for the way I act, but rather I shouldn’t be modifying my actions to suit Richard. it’s something I’m still digesting.
KellyDS said this on June 13, 2016 at 2:52 pm | Reply
Well said. I am glad you realized that.
He is an actor and not a personal acquaintance nor boyfriend to any of his fans. It’s simple to get easily to swept up in the fandom with accessibility his fans have of him through social media. Plus, stories of fan meetings of him after The Crucible at Stage Door where he took the time to sign autographs and take pictures don’t help.
With the speculation of RA being in a new play, some fans who have booked tickets. They will be shocked and have the same reaction you have experienced if this play doesn’t actual happen or if this play actual happens and there are no Stage Door meetings to be had.
I think people have to step away from their perfect imagine RA and realize that version of him does not exist. He is human, you know. I think being an admirer of his work is enough for me.
Duke, I’m not sure why you are so focused on this issue of fans buying tickets, but I think you should consider, since their activities have no bearing on you, why you feel the need to raise the issue. In any case it’s not the topic here and I have just warned you about policing fans. This is the last warning.
That’s an excellent point (fans needing to correct inaccuracies) and it was something that I did a fair amount of when I was a a new fan, although not with trolls. There probably should have been a paragraph about that in the original post. In my case, as my knowledge of the actor, his career, and his fandom has grown, I’ve felt the need to correct mistakes when others make them less and less (although I will still write about them here).
The second point is a really great question — why do I need Armitage to have fans, why do I care about the numbers beyond the certain good will that one has for someone one wants to do well? and the whole question of me seeing him vs him seeing me is one that has really bedeviled this fandom over the years. Everyone’s switch on that issue is set differently and it causes a lot of conflict.
I’ve been on Twitter a long time. I used it rarely – it was my mean girl place. (Mean, nasty, gun-loving Conservative that I am) however that seems to have become a bit more diversified since He began to post. Don’t ask me why. I still don’t use it very often.
Over the 15 years I’ve been involved in online fandom, I’ve seen so much drama and while most times I’m willing to sit on the side, eat cheetos and drink cokes and just watch, (and yes, point and snicker at) on occasion, I’ve been sucked into it – whether it be my writing being flamed or mocked (why do people hate hetters so much?) or me not writing what someone thought I should write (go write your own stuff!) or the fact I speak my mind and some people don’t like that. If you don’t want my opinion, don’t ask me, k? I especially hate when tragedy occurs and people use it to push their political agenda. There is a time and place and taking it to someone else’s abode or garden ain’t it. If you’re on your soapbox in your own arena, that’s fine. If you bring your hateful plants and ugly weeds into my garden, you best believe, I’m going to soak you with weed b gone.
Trolls are attention seeking and the internet makes it easier for people to hide. Richard is welcome to his opinion, even if it’s different from mine. I’ve not walked in his shoes and he’s not walked in mine.
What was the question? I think I’ve wandered…
zeesmuse said this on June 13, 2016 at 5:12 pm | Reply
I disagree strongly that moments of tragedy are not opportunities for talking about political issues. In the US in particular, we are told that we can’t talk about these things when the issues are acute, but no one cares about them when they aren’t. In my opinion, saying “don’t use this moment to talk about the actual issue” is a way of suppressing discourse and insuring that nothing will ever change. That means, of course, that we have to tolerate opinions we don’t like, but that is pretty standard.
I respect that. There is a time and a place for everything, and i’m such a passionate (hot-head) that for me, it’s best to step back. (hence why I decided to address something elsewhere a day late)
The issue here is already a hot topic. It’s really a push-button topic and is currently being beat to death in our political arena. The weapon wasn’t the cause, in my minuscule, personal opinion. We’ve suffered a tragedy and it’s easy to say things and insinuate things and blame things and issues in the heat of the moment. I recall vividly 9/11 when it FIRST happened and 2 radio personalities were angrily blaming someone whose fault it wasn’t. And when it came down they were wrong…
But now I’m so far off topic. Sigh.
Trolls are still attention seekers. Most times I think it’s someone simply creating and manufacturing imaginary support and friendships they lack in real life. It gives them a sense of importance, I guess.
It’s not much of a hot topic, if this keeps happening and we continue not to act, I’m afraid. I think it’s pretty much business as usual and our leadership showed us that this weekend.
re: trolls — I think the trolls I’m talking about don’t use the troll identity for friendships (although they may make friendships in other ways). I think it’s different with tumblr and anon asks — anon asks allow anyone to become a troll instantly. The other thing is that I am starting to see that function used for a different kind of trolling, e.g., to express sympathy with the blogger in order to see what kind of potentially ridiculous thing they will say.
To Morgana: thanks for your kind words about the blog and thank you for reading it for so long. I am declining to publish your comment because everything except the first sentence violates the comments policy. You are welcome to leave a comment that falls within the rules. Thanks.
Servetus said this on June 14, 2016 at 12:10 am | Reply
I think these are very good questions to ask and not only before interacting with a suspected troll, but generally. It would probably often to good to the discussion in general to think about who we are talking to and what we are talking about and what point we really want to make and why? I find it is a constant exercise in patience to count to 10 before i jump 😉 It’s easiest when i am least in APM mode 😉 Sometimes i actually find it harder to resist the case of ‘defense of another fan’ than APM. Because he is sort of remote and can remove himself easier from the debate or isn’t there to begin with whereas the fans are more exposed in certain ways.
I still often doubt if it was a good idea to say what i said but i do try to ponder a bit before i jump. I think in time and through repeated ‘fires’ one learns what one’s triggers are. Sometimes maybe we absolutely feel we must say something, for our own sanity and then we just stop there.
I know i’ve jumped in total fan reaction at times but i just had to say it and i don’t have to engage further. But that’s probably true more for press or public figure statements about fans in derogatory terms than trolls. The ones you clearly categorized above are easier to ignore i find. Media and public figure derogatory statements about fans are my downfall, so far even against my better judgment i’ve not been able to keep stumm to that:-)
The one thing that i am conflicted about is the tone of responses to non-fans… do i try to keep a cool head to make a better argument? Do i try to disprove their argument about the ‘crazy’ fan by appearing/being rational? is a passionate response necessarily a bad thing or am i embarrassed about being so passionate? I always wonder where the truth lies, i’d like to think i can combine passion and reason, but i’m sure it is all those answers at the same time although i wish it were not.
I am totally with you on the trigger regarding celebrities criticizing their fans. Obviously it’s not an either / or situation, but Cumberbatch’s statements about fans in the fall two years ago were a serious turnoff for me. One of the things that I’ve appreciated about Armitage is that until relatively recently (November/December 2014) he never said anything at all negative about fans.
re: tone of response — I try to stay cool / superior / detached. But that’s me.
You always get to the point! Thanks. I wish I could follow you more often and read all the comments here, but my eyes and lack of time don’t allow that frequently! I know too a lot about trolls and I think you painted the whole frightful scene perfectly! I had years of experience but in other places and for other issues. And I must say that they actually existed in real life, too, they were not born on social media — whenever I was in a public place speaking about things I was campaigning for, there was always someone in the audience or stopping by wherever my group and I were speaking who would just throw a word and try to inflame the audience or us. They were less, they had probably less chances to remain anonymous, but they did exist. I fought a lot against them even on social media, but for the same issues as in RL. This is probably the reason why I try to stay away from all this concerning Richard Armitage. I’ll openly confess: he’s my safe place in the world. When RL is really bad, RA is my healthy thought, my nice escape. So, I voluntarily stay away from any debate and don’t read responses to his tweets – except from those I already follow or know personally – and only write in some selected forums. Of course, sometimes it is impossible not to get wind of the fact that something is going on among the fans and that some issue is inflaming people or that trolls are doing their job as usual. But I try to just skip quickly and go on. As you perfectly say in your article: the real Mr. Armitage needs no defending and I certainly don’t need to defend myself, either. Thanks Servetus, though, because this article is important beyond RA’s question and has a lot to do with how we human beings use that feral weapon which is communication!
P.S.: it’s nice to see that my profile is fully int he “no-troll” zone 😀 My nick name has always been Lookaround or Lookie ever since I got in the first forum about RA and still is in anything RA-related 😀
Sara Lookaround said this on June 14, 2016 at 8:13 am | Reply
I think a lot of people feel that way (avoid controversy to enhance sanity) and I have nothing but respect for it. For whatever reason, it hasn’t worked out that way for me — although one of my most serious priorities in fandom has been to avoid most political discussion, because I have a lot of it in other settings.
Weighing in a little late on this one – I searched late Sunday pm on his @ tag for bullying tweets toward fans who had commented, and only found 1 that could even be considered borderline. And that one actually had a short convo which appeared basically cordial.
Has anyone found or experienced any that were “off-tag” bullying on twitter?
I think possible chivalry on his part to “defend” us as fans creates a nice warm feeling for a lot of us, but 1) I’d like to see actual evidence of bullying tweets toward fans (not just him, I saw the one that called him an idiot but did not see that person bully those who defended him) and 2) I’m actually a little concerned about him if he’s going to delete in order to defend his followers. That seems unsustainable and over-responsible to me. Lots of heart, but unsustainable. His active tweeps should know his statements about not feeding trolls unless you’re prepared for the risk. And I think those active tweeps also know to block/report as needed. So I’m skeptical without further evidence of need for it- anyone got? DM to me on twitter if you’d prefer.
SHeRA said this on June 14, 2016 at 3:58 pm | Reply
Yeah, I watch that tag fairly closely and I didn’t see any, which is why I find that article implausible. I always feel like it’s a game of percentages anyway. I hear someone say “Richard Armitage got bullied after such and such a post” and I see that there are 90 positive comments, 8 critical ones and 2 cranks. To me, that is a pretty good result. You won’t get that response in a classroom, that’s for sure 🙂
Absolutely! I find it surprising that anyone would expect to never see a negative response directed toward him, that’s part of public life, really! Or to your point, anything where you receive formal evaluation.
SHeRA said this on June 19, 2016 at 1:58 am | Reply
I’m coming out of lurker-mode again to say “Thank you, Servetus.” I really appreciate the way you explain complex matters with such clarity and patience and without ever condescending to your readers. I’ve learned so much about modern communication and the online world by reading your blog these past few years. You even deepened my understanding of myself!
Shalini said this on June 16, 2016 at 8:16 pm | Reply
Wow, thanks for the very kind words! I’m learning too as this goes along, just trying to distill the results.
Thanks for this, Serv! Excellently explained!
Methinks Cybersmile could use you as an ambassador, you have more insights and experience than some people on Twitter we know… 😉
Esther said this on June 16, 2016 at 9:35 pm | Reply
ah, but I don’t look so sexy in a leather jacket as some people, either 🙂
[…] is that it sparks healthy, critical discussion but that it does not turn to vitriol and trolling (so brilliantly explained by Servetus in her recent post). I expect his message to be empathicalist (yay! I’ve connected Richard Armitage to Audrey […]
Empathicalism | The Book of Esther said this on June 17, 2016 at 4:13 pm | Reply
[…] my own rule about dealing with potential trolls to this situation, I’d suggest first trying to learn something about the speaker whose speech is bothering me […]
Homophobia in the Richard Armitage fandom, or: what I’d like to say on #SCD2016 | Me + Richard Armitage said this on June 17, 2016 at 5:59 pm | Reply
[…] shouldn’t amplify this, if I were following my own rules, but this is an example of me being concern trolled. This account was created in order to RT […]
Concern trolling in the Richard Armitage fandom #SCD2016 | Me + Richard Armitage said this on June 17, 2016 at 6:23 pm | Reply
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DC Public Safety (Video)
Welcome to DC Public Safety.Brief video programs for the public on crime, criminal offenders and the criminal justice system.
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Successful Reentry from Prison – DC Public Safety Television
December 9, 2014 by CSOSA
The topic for the 30th TV show produced by the Court Services and Offender Supervision Agency and the Office of Cable Television is “Successful Reentry from Prison.”
The program provides an overview of the lives of four people who have successfully reentered society after spending time in prison. What are the lessons learned? What should society understand about their experiences that will lead to greater support of programs and resources for successful reentry?
The host is Nancy M. Ware, Director, Court Services and Offender Supervision Agency.
Participants-first segment:
•Eddie Ellis, Activist
•Lashonia Etheridge-Bey of the Mayor’s Office on Returning Citizen’s Affairs
Participants-second segment:
•Lamont Carey, President/CEO, LaCarey Enterprises, LLC
•Petrina Williams, Chief Operating Officer, Clean & Sober Streets
Court Services and Offender Supervision Agency:
We welcome your comments or suggestions at mailto:leonard.sipes@csosa.gov .
The website for the Court Services and Offender Supervision Agency is http://www.csosa.gov . The social media site is http://media.csosa.gov .
Television and radio programs are produced by Leonard Sipes and Timothy Barnes.
Comments offered on “DC Public Safety” television and radio programs are the opinions of participants and do not necessarily represent the policies of CSOSA or other government agencies.
Podcast Video Play Now | Play in Popup | Download
Filed Under: Corrections-Prisons, Drug Treatment, Education and Vocational Assistance, Employment, Mental Health, Parole and Probation, Reentry, What Works Tagged With: offender reentry, Reentry, reentry from prison
Synthetic Drugs – DC Public Safety Television
April 25, 2014 by CSOSA
The topic for the twenty-ninth TV show produced by the Court Services and Offender Supervision Agency (CSOSA) and the Office of Cable Television is “Synthetic Drugs.”
Television Program:
The program provides an overview of efforts to address synthetic drugs in Washington, D.C. and throughout the country.
Adrienne Poteat, Deputy Director, Court Services and Offender Supervision Agency
Ryan R. Springer, MPH, Deputy Director, Addiction Prevention and Recovery Administration
Jonathon Fox and Anthony Pickett, two individuals supervised by the Court Services and Offender Supervision Agency.
Transcript available at http://media.csosa.gov/podcast/transcripts/2015/04/synthetic-drugs-dc-public-safety-television/
Special Announcements:
A top priority for Attorney General Eric Holder’s Department of Justice is to invest in scientific research to ensure that the Department is both tough and smart on crime. The Office of Justice Programs’ CrimeSolutions.gov website shapes rigorous research into a central, reliable, and credible resource to inform practitioners and policy makers about what works in criminal justice.
A new website lists and evaluates prisoner re-entry programs nationwide. Launched by the Urban Institute, the Council of State Governments, and the John Jay College of Criminal Justice Prisoner Reentry Institute, the “What Works Clearinghouse” can be seen at http://nationalreentryresourcecenter.org/what_works.
The National Reentry Resource Center is a project of the Bureau of Justice Assistance, Office of Justice Programs, US Department of Justice. Please see the Center’s website at http://www.nationalreentryresourcecenter.org/. Please see “Federal Interagency Reentry Council Launches Website, Releases Myth-Buster Series” on the front page of the site (see announcements). CSOSA is a member of the Council.
Several requesters have asked for national research on reentry. The Office of Justice Program’s National Institute of Justice reentry research portfolio supports the evaluation of innovative reentry programs. To access these studies and NIJ’s entire reentry research portfolio visit www.nij.gov/nij/topics/corrections/reentry/welcome.htm .
The Office of Violence Against Women offers stalking response tips for corrections, prosecutors, judges, law enforcement, victims and victim advocates. They are posted on OVW’s website at www.ovw.usdoj.gov .
Correctional Social Media:
The Pew Center on the State’s Public Safety Performance Project offers a video on research to reduce recidivism as well as brief but powerful overviews of reentry and sentencing research. See http://www.pewstates.org/projects/public-safety-performance-project-328068 .
The U.S. DOJ Center for Faith-Based & Neighborhood Partnerships held two successful webinars on Faith and Community Based approaches to Reentry and Responsible Fatherhood Initiatives. Click the links below to watch/listen to these informative webinars.
Faith and Community Based Approaches to Responsible Fatherhood and its Impact on Delinquency Prevention, seehttps://bjatraining.org/media/webinar/faith-and-community-based-approaches-responsible-fatherhood-and-its-impact-delinquency
A Look at Faith & Community-Based Approaches to Offender Reentry, see httpshttps://bjatraining.org/media/webinar/look-faith-community-based-approaches-offender-reentry
The Louisiana Department of Corrections/Division of Probation and Parole is offering radio shows on offender reentry. Please visit their website at http://www.doc.la.gov/pages/reentry-initiatives/reentry-radio/.
The New York State Division of Criminal Justice Services offers podcasts at http://www.criminaljustice.ny.gov/pio/podcasts.html.
The Minnesota Department of Corrections offers a YouTube channel at http://m.youtube.com/user/minnesotadoc .
The Facebook page for the Rhode Island Department of Corrections is https://www.facebook.com/pages/Rhode-Island-Department-of-Corrections/400377866663063 .
The California Department of Corrections and Rehabilitation Facebook Page is http://www.facebook.com/cacorrections.
The Twitter page is http://twitter.com/cacorrections .
The website for the Court Services and Offender Supervision Agency ishttp://www.csosa.gov . The social media site is http://media.csosa.gov
Television and radio programs are hosted by Leonard Sipes. The producer is Timothy Barnes.
Filed Under: Criminal Justice, Drug Treatment, Synthetic Drugs, Youthful Offender Tagged With: synthetic drugs
Coordinating Justice-CJCC-DC Public Safety Television
August 20, 2013 by CSOSA
The topic for the twenty-sixth TV show produced by the Court Services and Offender Supervision Agency and the Office of Cable Television is “Coordinating Justice-The District of Columbia Criminal Justice Coordinating Council.”
The program provides an overview of cooperative efforts of federal and local criminal justice and government agencies and how they interact to protect public safety in the nation’s capital.
As an independent agency, the Criminal Justice Coordinating Council (CJCC) for the District of Columbia is dedicated to continually improving the administration of criminal justice in the city.
The mission of the CJCC is to serve as the forum for identifying issues and their solutions, proposing actions and facilitating cooperation that will improve public safety and the related criminal and juvenile justice services for District of Columbia residents, visitors, victims and offenders.
The Goals for the Program are:
Discuss systemic changes across the District’s juvenile and criminal justice systems through shared commitment and collaboration.
Evaluate and promote continuous improvements within the juvenile and criminal justice agencies in the District of Columbia.
Address communication among criminal juvenile and criminal justice agencies to eliminate duplication and maximize available resources
Nancy Ware, Director, Court Services and Offender Supervision Agency
Mannone A. Butler, Executive Director, Criminal Justice Coordinating Council
Paul A. Quander, Jr., Deputy Mayor, Public Safety and Justice
Transcript available at http://media.csosa.gov/podcast/transcripts/2015/04/coordinating-justice-cjcc-dc-public-safety-television/
The website for the Court Services and Offender Supervision Agency ishttp://www.csosa.gov . The social media site is http://media.csosa.gov .
Filed Under: Criminal Justice, Drug Treatment, Education and Vocational Assistance, Interagency Cooperation, Interviews with Policy Makers, Parole and Probation, Reentry, What Works Tagged With: CJCC, coordinating justice, Criminal Justice Coordinating Council
Corrections Monitoring and Reentry-DC Corrections Information Council-DC Public Safety Television
June 21, 2013 by CSOSA
The topic for the twenty-fifth television show produced by the Court Services and Offender Supervision Agency is “Corrections Monitoring and Reentry.” The program is a combined effort of the D.C. Corrections Information Council and the Court Services and Offender Supervision Agency.
The portal site for “DC Public Safety” television, radio, blog and transcripts is http://media.csosa.gov.
Transcript available at http://media.csosa.gov/podcast/transcripts/2013/06/corrections-monitoring-and-re-entry-dc-public-safety-television/
Current Television Program:
The program provides an overview of the DC Corrections Information Council: It:
Discusses the formation and history of the CIC.
Addresses the legislative mandate of the CIC.
Discusses outreach and interaction with the D.C. community about the work of the CIC and D.C. residents who are incarcerated in the Federal Bureau of Prisons and the D.C Department of Corrections DOC.
Michelle R. Bonner, Esq., Chair, CIC
Rev. Samuel Whittaker, Board Member, CIC
Cara Compani, Esq., Program Analyst, CIC
Courtney Stewart, Chairman, The Reentry Network for Returning Citizens
A Look at Faith & Community-Based Approaches to Offender Reentry, seehttps://bjatraining.org/media/webinar/look-faith-community-based-approaches-offender-reentry
The Facebook page for the Rhode Island Department of Corrections ishttps://www.facebook.com/pages/Rhode-Island-Department-of-Corrections/400377866663063 .
Filed Under: Corrections-Prisons, Drug Treatment, Education and Vocational Assistance, Employment, Interviews with Policy Makers, Reentry Tagged With: Corrections Information Council, DC, reentery, Washington
Supervision of High-Risk Offenders-DC Public Safety Television
February 16, 2012 by CSOSA
The topic for the twentieth television show produced by the Court Services and Offender Supervision Agency is “Supervision of High Risk Offenders”.
There is extensive research that parole and probation agencies should focus their efforts on offenders who pose an obvious risk to public safety. CSOSA embarked on two reorganizations in 2011, one focusing on women offenders (TV show filmed on February 16, 2011) and the other on high risk offenders; the focus of this production.
Multiple national research centers, such as The Urban Institute, Pew, and the US Department of Justice, suggest that parole and probation agencies focus their supervision and treatment resources on high risk offenders, as identified through objective, validated risk and needs instruments, while placing less emphasis on lower risk offenders through alternative methods of supervision.
The program intends to provide an overview of CSOSA high risk offender supervision and treatment efforts based on national best practice standards. The program will:
Discuss the findings of national best practices research.
Discuss how CSOSA chooses high-risk offenders with a focus on violence, weapons, sex offenses, drug use and previous violations while under community supervision.
Another focus will be on younger offenders in the 18-25 age bracket. CSOSA makes its judgments on the totality of an offender’s violent criminal history, and not just on the offender’s current conviction. It is estimated that approximately one-third of CSOSA offenders will fall into the high risk category.
Discuss CSOSA efforts and programs created to focus on the treatment of high risk offenders.
Discuss CSOSA efforts and programs created to focus on the supervision of high risk offenders. These include identifying the right offenders to participate in existing efforts such as Accountability Tours, intelligence exchanges with law enforcement, GPS and curfews, services provided to offenders at our day reporting centers, and the reallocation of staff. Part of the reallocation of staff includes a new seven person warrant unit.
Discuss alternative methods of supervising lower risk offenders to include kiosks.
The first segment will be an overview of the national research findings pertaining to the high risk offender.
The second segment will focus on CSOSA practices as they pertain to the implementation of the high risk offender reorganization.
Jesse Jannetta, Research Associate, The Urban Institute
William Burrell, Independent Community Corrections Consultant.
Valerie Collins, Branch Chief, Domestic Violence, CSOSA
Gregory Harrison, Branch Chief, General Supervision, CSOSA
DC Public Safety:
Subscribe to “DC Public Safety” through iTunes at http://itunes.apple.com/us/podcast/dc-public-safety-video/id211867321?ign-mpt=uo%3D4 for video and http://itunes.apple.com/us/podcast/dc-public-safety-audio/id211598412?ign-mpt=uo%3D4 for audio.
See http://media.csosa.gov for our radio shows, blog and transcripts.
Transcript available at http://media.csosa.gov/podcast/transcripts/.
We welcome your comments or suggestions at leonard.sipes@csosa.gov or at Twitter at http://twitter.com/lensipes.
The host is Leonard Sipes. The CSOSA producer is Timothy Barnes.
Podcast Video [ 29:31 ] Play Now | Play in Popup | Download
Filed Under: Drug Treatment, Education and Vocational Assistance, GPS, High Risk Drug Offenders, Interagency Cooperation, Interviews with Policy Makers, Parole and Probation, Reentry, What Works Tagged With: crime, criminals, dangerous offenders, high risk offenders, high volume offenders, kiosks, parole and probation
Successful Reentry Through Employment
Successful Parole and Probation Practices
Mental Health and Recovery in Criminal Justice
The Justice Experience of Black Men and Boys: A Congressional Perspective
Family Reunification and Reentry
American Jail Association
American Parole and Probation Asociation
Court Services and Offender Supervision Agency–Blog
Court Services and Offender Supervision Agency–Transcripts
Criminal Justice Journalists
CSOSA Audio Podcast
CSOSA Homepage
International Association of Chiefs of Police
International Community Corrections Association
National Association for State Courts
National Criminal Justice Association
National Criminal Justice Reference Service
National Organization for Victim Assistance
National Sheriff’s Association
Police Forum
Reentry Policy Council
US Immigrations and Customs Enforcement
Corrections-Prisons
Day Reporting
Education and Vocational Assistance
Fugitive Safe Surrender
High Risk Drug Offenders
Interagency Cooperation
Interviews with Offenders
Interviews with Policy Makers
Interviews with Staff
Parole and Probation
Women Offenders
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The 2020 Ford GT will have two awesome limited-edition versions
Earlier this year, the Chevrolet Corvette C8 Stingray was on everybody’s lips. After years of fans begging the American automaker for a mid-engine sports model, it is finally here. Not to be outdone, The Blue Oval has something up their sleeves. At the recent Chicago Auto Show, the 2020 Ford GT was in attendance with a lot more in tow. It seems the sleek and dynamic design of the base model is not enough for more discerning buyers. Thus, the company indulges them with the Liquid Carbon edition and Gulf Racing Heritage edition.
We love it when car companies cater to gearheads like us who long for limited-edition versions of awesome rides. According to industry insiders, the company wanted to build a street-legal machine with a race-ready pedigree on board. Thus, taking all the good stuff from the track-only GT MK II, it’s giving us the 2020 Ford GT with two variants on the side.
Going Beyond The Threshold
The base model of this iconic series already flaunts impressive numbers, to begin with. Nevertheless, this is where the engineers get to play around and tweak it even further. Tinkering around with the engine provides a notable boost from 647 to 660 horsepower.
Moreover, the 3.5-litre twin-turbo V6 power plant receives gallery-cooled pistons and high-energy ignition coils as well. Rounding off the powertrain is the dual-clutch 7-speed automatic transmission.
With an engine like this, it will need some serious cooling. Thankfully, its aerodynamic form and air ducts work in tandem with the intercoolers to keep everything running smoothly. Likewise, the buttress design apparently helps improve handling in Track mode.
2020 Ford GT Liquid Carbon Edition
Now it’s on to the good stuff as the 2020 Ford GT teases two exclusive versions for those who don’t mind throwing money around. Starting off with the Liquid Carbon edition, every surface on the exterior showcases the carbon fibre weave in its full glory. With nothing but a clear coat to give it a glossy finish, the mesmerizing pattern will draw anyone in. Then there’s the option to ditch the alloys for carbon fibre wheels and titanium lug nuts.
2020 Ford GT Gulf Racing Heritage Edition
This one is our personal favourite as it boasts the iconic colours that remind of the marque’s 24 Hours of Le Mans victory. The 2020 Ford GT Gulf Racing Heritage Edition touts a coat of powder blue and orange. Additionally, the number 6 — in carbon fibre — sits proudly on the hood and on the doors of the supercar. Carbon fibre wheels are also on the menu should the owner want it.
The 2020 Ford GT will have a production run until 2022 only. As for the Liquid Carbon and Gulf Racing Heritage versions, only a few will be available every year. The base model starts at $500,000, but those who want the special editions should be ready to fork over an estimated $750,000 and $615,000 respectively.
Discover what Ford brings to the table here
Images courtesy of Ford
URWERK’s UR-220 Watch & More
The UR-220 is a different type of watch. Reading the watch takes time as you learn how URWERK builds their pieces.
Fleetwood Sound Co.’s DeVille Speaker Is A Classic Beauty
Thee Fleetwood Sound Co. DeVille Speaker turns your home into a mini-concert hall. It comes with a 6" thick solid wood conical horn and rubbed with beeswax and linseed oil for an "heirloom finish."
Audi pulls off another stealthy number with the 2021 R8 Panther Edition
From a performance standpoint, the 2021 Audi R8 Panther Edition does not deviate from the regular model, but it does so with an exclusive colorway and RWD.
Bang & Olufsen is adding wireless charging support to the Beolit 20 speaker
the Beolit 20 now comes with a 5W wireless charging area on the top section -- a welcome addition that a modern smartphone user will surely appreciate.
Enjoy top-notch acoustics with the premium Beoplay H95 from Bang & Olufsen
Bang & Olufsen even throws in a sleek aluminum carrying case to protect your Beoplay H95 during transport.
RM Sotheby’s is offering this 2019 Porsche 911 Heritage Edition in a charity auction
RM Sotheby’s is doing its part in the fight against COVID-19 by auctioning off a 2019 Porsche 911 Heritage Design with proceeds going to charity.
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Appalachian Headwaters & Appalachian Beekeeping Collective
Economic Development, Food and Farm, Small Batch Makers
Packaging Design,
Share this project on facebook
Share this project on Pintrest
Share this project on Twitter
Oregon Farmers Markets Association
Community Development, Food and Farm, Tourism
This project is award winning
ArtPlace America: Creativity Lives Here Campaign
Art & Design, Community Development
Campaign Design,
Content Strategy,
Print Design,
Wheeling Heritage: Here To Stay Campaign
Book Design,
Skin Spa New York
E-Commerce,
Social Media Strategy,
Hernshaw Farms
Entrepreneurship, Food and Farm
GLG Social Impact
Advocacy, Community Development, Entrepreneurship
Citizens Housing & Planning Council
Infographic Design,
Love Your Birth Control Campaign
Education, Health
WVFREE
Advocacy, Community Development, Education, Health, Social Justice
Every Mother Counts
Advocacy, Community Development, Economic Development, Education, Health, Social Justice
Flatbush Caton Market
Community Development, Economic Development, Entrepreneurship, Food and Farm, Small Batch Makers, Social Entrepreneurship
NYC DCA Office of Financial Empowerment
Community Development, Economic Development, Health, Social Justice
Bronx Bodegas
Advocacy, Education, Health
RideLocal Campaign
Vandalia Donut Co.
Entrepreneurship, Food and Farm, Small Batch Makers
Hardy County
Community Development, Tourism
Clay Center for the Arts and Sciences
Art & Design, Community Development, Education, Sciences
Green Bank Observatory
Advocacy, Education, Sciences, Tourism
Environmental Design,
Tamarack Foundation for the Arts
Advocacy, Art & Design, Community Development, Economic Development, Education
West Virginia Farmers Market Association
Advocacy, Education, Environmental Justice, Food and Farm, Small Batch Makers
J.Q. Dickinson Salt-Works
Entrepreneurship, Transportation
Global Dignity
Advocacy, Community Development, Education, Social Entrepreneurship, Social Justice
Economic Analysis of the Detroit Food System
Advocacy, Community Development, Education, Food and Farm, Social Justice
Huairou Commission
Advocacy, Community Development, Economic Development, Education, Environmental Justice, Social Justice
ACAP: Association for Community Affiliated Plans
Vessel Brooklyn
Art & Design, Entrepreneurship
Big Switch Farm
Community Development, Entrepreneurship, Food and Farm, Social Justice
Mission Savvy Juices
Environmental Justice, Food and Farm, Small Batch Makers, Social Entrepreneurship
Advocacy, Education, Social Justice
Project Code Nodes
Art & Design, Education, Sciences
Bedstuy Credit Landscape
Community Development, Economic Development, Education
Sprout’s Adventure: The School Gardens Game
Education, Food and Farm, Health
America’s Essential Hospitals
Advocacy, Community Development, Education, Health
People Building Better Cities
Center for Community Progress
Center for Social Impact Strategy at UPENN
Advocacy, Education, Social Entrepreneurship
Wanda Petunia
The Wild Ones: Adventures on the Gorge
Children’s Museum of the Arts New York
Art & Design, Community Development, Education
Mountain State Justice
Advocacy, Law, Social Justice
Edward Tucker Architects
Architecture, Art & Design
Persinger & Associates
Architecture, Art & Design, Entrepreneurship
Rebel Crumbles
Food and Farm, Small Batch Makers, Social Entrepreneurship, Social Justice
Kanawha County Public Libraries
Advocacy, Community Development, Education
CUNY Urban Food Policy Institute
Advocacy, Community Development, Education, Food and Farm, Health, Social Justice
White Horse Wines and Spirits
Education, Entrepreneurship, Health
Pamela Hanson Photography
Bloomfield School of Jewelry Makers
Art & Design, Education, Entrepreneurship
Appalachian Mountain Speciality Foods
Food and Farm, Small Batch Makers
Own It: You Have Options Toolkit
Economic Development, Education, Social Justice
Center for Urban Pedagogy: Pay Dirt (CUP)
Advocacy, Art & Design, Community Development, Education, Social Justice
Center for Urban Pedagogy: Happy Meals (CUP)
Advocacy, Art & Design, Community Development, Education, Food and Farm, Law, Social Justice
Holly Corey Activewear
Community Development, Economic Development, Social Entrepreneurship
Center for Urban Pedagogy: Funky Fresh (CUP)
Advocacy, Art & Design, Community Development, Education, Food and Farm
United Nations University
Advocacy, Architecture, Education, Health
Advocacy, Health
Robin McClintock
Providence CityArts
Art & Design, Community Development, Economic Development, Education
Love Letter to the West Side
Mariem Shoes
Kayi & Wilkes Immigration Attorneys
WV International Film Festival
Center for Hearing and Communication: New York
Two Moon Shortbreads
Food and Farm, Small Batch Makers, Social Entrepreneurship
Smooth Ambler Distillery
West Virginia Head Start
Friends of the Cheat
Advocacy, Environmental Justice, Health, Sciences, Social Justice
Capitol Business Interiors
Public Art GuideBook: Arts Council of Kanawha Valley
Art & Design, Community Development, Economic Development
Ogonek Custom Hardwoods
Art & Design, Entrepreneurship, Small Batch Makers
TechConnect West Virginia
Advocacy, Economic Development, Education, Sciences
West Side Main Street
Community Development, Economic Development
Sustainability Institute
Advocacy, Education, Environmental Justice
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We created a custom brand and website for both the Appalachian Headwaters organization and their sister company, the Appalachian Beekeeping Collective. These small-batch entrepreneurs work with the community to support the economy and restore the forests. A full website, custom packaging, flexible logos, and print collateral were designed to support their mission, highlight the unique operation, and celebrate the tradition and land.
www.appheadwaters.org
Branding, Packaging Design, Web Design, Web Development
We worked with the Oregan Farmers Market Association (OFMA) to re-brand their look into something fresh, bright, and full of life to match the energy of the farmers and markets they represent. A series of flexible logos were created for various applications across their many outreach platforms and custom illustrations showcasing the bounty of Oregon create playful patterns. The cherry on top is a full-color palette derived from all corners of the state, feeling both vibrant and natural.
#CREATIVITYLIVESHERE is a year-long digital storytelling campaign showcasing the people and places behind creative community development.
Campaign Design, Content Strategy, Print Design, Social Media Strategy
Here To Stay is a city-wide campaign celebrating the town of Wheeling, West Virginia as a vibrant place to life, work and play to both local and international audiences.
Book Design, Branding, Campaign Design
All things skin and body care that can fit in the span of your lunch break. That was the key concept in developing a bold, modern, and striking brand identity and campaign for Skin Spa New York. From an updated Website to social media to custom packaging for their brand new skincare line, we worked to push the effortlessly cool and chic appeal of the spa. Utilizing bold images and zoomed-in shots of texture allowed them to communicate with clients a fresh and less-than-standard way. skinspanewyork.com
Branding, Content Strategy, E-Commerce, Packaging Design, Print Design, Social Media Strategy, Web Design
Hernshaw Farms is a mushroom farm in Hernshaw, West Virginia, working to create an economically sustainable market operating on top of a former mountain top removal mine site. We created a custom illustrated logo communicating their moto “Mine Land to Farm Land” and a series of colorful labels for their packaged mushrooms that take a playful approach to a heritage brand.
Branding, Packaging Design
GLG’s Social Impact works to connect organizations with the power of knowledge working to solve society’s most urgent challenges. In the fall of 2019, we worked together with them to bring the impact they help achieve come to life in a beautiful, full-color, and oversized magazine. The magazine showcased the work of their fellows alongside their mission to provide social innovators with free access to their platform.
Book Design, Print Design
We’ve worked collaboratively with the Citizens Housing & Planning Council (CHPC) in New York City to bring a bright and bold approach to addressing housing concerns, answering questions about what’s next for New York’s residents, and showcasing the impact of their research. Together, we’ve created reports, logos, event graphics, illustrations, and marketing materials. Our relationship is just at it’s beginning as we continue to build upon the research work that CHPC is doing and sharing the information with the policy makers, architects, and engineers of NYC. chpcny.org
Book Design, Branding, Infographic Design, Print Design
The Love Your Birth Control campaign aims to inform women in West Virginia about their reproductive choices. Historically, advisement on birth control has been subjective—and at times coercive. MESH, in collaboration with WVFREE, created an informational tool and website designed to give patients the power to discuss birth control options with their healthcare providers and make the best choice for their bodies. loveyourbirthcontrol.org
Campaign Design, Content Strategy, Print Design, Web Design, Web Development
WVFREE is advocating for the lives and autonomy of women all over West Virginia. After over 20 years as a policy changemaker and advocacy group, MESH rebranded WVFREE with a flexible logo system and gradient package that can be used anywhere from official legislative letters to Pride Month movie screenings and peaceful protests. We also worked with WVFREE to bring awareness to Crisis Pregnancy Centers (“fake pregnancy clinics”) throughout West Virginia, creating billboards and a digital campaign.
Branding, Campaign Design, Print Design
Every Mother Counts works to advocate for mothers around the world. We worked closely with their team to develop a flexible brand; their logo appearing in several languages spoken in the countries they work in. A series of custom illustrations were created to bring awareness to the sensitive nature of the issues mothers face while bringing in a human touch. To tie it all together, we redesigned their website with the updated brand and a new strategic approach to their vision, their grantee partners, and helping community members find ways to take action. everymothercounts.org
We continually work with Every Mother Counts to develop annual collateral for events and promotional materials.
Book Design, Branding, Campaign Design, Content Strategy, Infographic Design, Print Design, Web Design, Web Development
Founded in 2000, Flatbush Caton Market (FCM) is New York City’s only Caribbean open marketplace. In 2017, it was announced that the market would transition from Flatbush Ave. to a temporary space while the city renovates their building. MESH was in charge of their rebranding, signage and marketing materials that would translate from their temporary space to their renovated space. flatbushcatonmarket.com
Branding, Photography, Print Design, Social Media Strategy, Web Design, Web Development
Neighborhood Financial Health Indicators is a series of infographics painting a picture of the economic health of two neighborhoods in New York City. The Department of Consumer Affairs (DCA) researched Bedford-Stuyvesant and East Harlem for five financial indicators: the ability to access financial services; the ability to access high-quality goods and services; job and income support; the ability to limit the impact of financial shocks, and the opportunity to build assets. MESH took a look at this raw data and created a strong visual system for DCA to use as they expand their research.
Book Design, Branding, Content Strategy, Infographic Design, Print Design
Bronx, NY is considered the hungriest borough in New York City with the lack of grocery stores. Bodegas have become a staple in the Bronx community. The Fresh Bronx Bodegas campaign highlights simple nutritious options that bodega owners are making accessible in the Bronx. This campaign was co-designed through our participatory design process with the kids of Bronx Health Reach and the young professionals of BronxWorks, who worked with us to brainstorm concepts, write slogans and gave us feedback throughout the process to assure this campaign was made by the Bronx, for the Bronx.
Campaign Design, Content Strategy, Print Design
MESH, in partnership with the Taxi, Limousine & Paratransit Association (TLPA), designed a campaign encouraging the use of local taxi companies. We focused on the positive aspects of using a local taxi, which include having someone who lives in and is familiar with the area, and boosting local economy, as taxi companies tend to give back to the community.
Branding, Campaign Design, Content Strategy, Print Design
Vandalia Donut Co. is a family-run, Donut-making 1970s restored camper with deep Appalachian roots. They hand-craft all donut recipes from local farms around the area.
We developed a comprehensive website for Hard County West Virginia to promote tourism in the state. From research to strategy to design to art directing a photoshoot in the region, we did it all. visithardywv.com
Content Strategy, Photography, Social Media Strategy, Web Design, Web Development
MESH developed a comprehensive brand identity system for the Clay Center and it’s four branches, a children’s museum, an art museum, a planetarium, and a music hall. We focused on the children’s art and science museum, Avampato Discovery Museum, to re-envision the entire Center’s communication system. Through multi-media design pieces, we maintained the equity of the original Clay Center logo. Every piece of the brand is inspired by play and imagination, for both kids and adults alike.
Green Bank Observatory, nestled in the mountains of the only National Quiet Zone, is the home of the trailblazers of radio astronomy. When the observatory broke away from it’s parent organization, NRAO, they worked with MESH to create a space-inspired brand identity that speaks to the down-to-earth quirkiness of Green Bank. MESH designed a flexible logo and graphic language, wrote all content, and communicated the brand in multi-media, which included a custom website for their public outreach programs.
Branding, Campaign Design, Content Strategy, Environmental Design, Print Design, Web Design, Web Development
MESH worked with the Tamarack Foundation for the Arts, the leading Arts Foundation in West Virginia, through renaming, rebranding, a re-design of programming, and a new website design, to reintroduce themselves as the leaders and voice of artists in the creative economy. Their logo is a simple container; their brand is made up of the vibrancy and colors of the artists and creatives they support. tamarackfoundation.org
Book Design, Branding, Content Strategy, Print Design, Web Design, Web Development
MESH designed the West Virginia Farmer’s Market Association brand, brand tools, and marketing toolkit, to be used by the association and all it’s member markets throughout the state. The WFMA works to promote sustainability, farm-to-table culture, community collaboration, and locally sourced foods. This brand is a visual identity that is regional and references the history of agriculture of WV but also can stand alongside bigger grocery stores.
Branding, Content Strategy, Environmental Design, Print Design
We partnered with the founders of J. Q. Dickinson Salt-Works from their inception, working through a naming, branding, communication strategy and art direction of their organic, locally produced salt and provisions lines. Every aspect of the brand was inspired by their 200-year-old family farm. Each jar is refillable, to maintain the sustainable practices pursued in the hand-harvesting of the salt. The website won a 2016 WV Tourism Gold Star. jqdsalt.com
Branding, Content Strategy, E-Commerce, Packaging Design, Photography, Print Design, Social Media Strategy, Web Design, Web Development
Metro Taxi made the transition to M7 in 2017 with a youthful and fun approach to local transportation. We developed a comprehensive brand system for their logo, typography, and illustrations to allow for flexible use across platforms.
Along with M7 we developed the logo for URide, their sister company focused on helping college students reach their destinations.
We created Link, a new, playful transportation model brand for taxi companies nationally. ridewithlink.com
Branding, Content Strategy, Print Design, Web Design, Web Development
Global Dignity has one goal: unite everyone with the belief that we all deserve to live a life of dignity. Global Dignity was started in 2006 with the hope to teach dignity all over the world. In 2017, over 680,000 young people and civil society leaders, volunteer facilitators, parents, and teachers were engaged with Global Dignity workshops, forums, and assemblies. MESH collaborated with Global Dignity in early 2018 to design an easy-to-follow, standardized teaching curriculum to be shared all over the world.
Content Strategy, Print Design
Localizing food systems in our American cities could dramatically grow our economies. We shared a new vision of Detroit’s food economy through our information design, infographics, and layout design work in the Economic Analysis of Detroit’s Food System report, powerpoint presentation, and posters, made with Urbane Development for Detroit Food and Fitness Collaborative with support from Kellogg Foundation. View the full book for download here.
Book Design, Infographic Design, Print Design
Huairou Commission is empowering grassroots women leaders globally. MESH re-envisioned Huairou Commission’s communication campaign, launching their new brand at the 2016 UN Habitat World Urban Forum. We concepted, designed, print produced, and supported managing over 30 different print pieces for Huairou Commission, and created a new website, new social media strategy, and new e-newsletter campaign to re-engage Huairou’s patrons with their work.
Book Design, Branding, Campaign Design, Content Strategy, Environmental Design, Infographic Design, Print Design, Social Media Strategy, Web Design, Web Development
MESH designed and built an entirely new web eco-system for DC-based healthcare association ACAP to make their information more accessible to their membership. We designed a user-centered information architecture through an intensive discovery and content strategy process. In this process we ran content audits, user surveys and interviews, user persona and story development, and user testing, and designed a custom publishing process for ACAP.
Content Strategy, Web Design, Web Development
Vessel Brooklyn is a custom curated gift and event planning company in Brooklyn, New York. We built an full-scale brand identity, gold-embossed notecard sets, and full scale e-commerce website for this start-up company creating memories and sharing kindness. vesselbrooklyn.com
Branding, Content Strategy, E-Commerce, Print Design, Web Design, Web Development
Big Switch Farm based in Egypt, Kentucky, is run by a young, back-to-the-land family living out their principles. MESH created a logo and brand identity inspired by nature, traditional Farmers Almanac farming-by-the-moon phases, and Big Switch Farm’s rural hometown.
Nomad is the first off-the-grid, on-the-road truck shop in New York. We hand-illustrated Nomad’s logo to reinforce the nomadic, on-the-road, wandering and wayfaring spirit of the brand. Our work with the brand has since followed suit, and all materials, from labels to business cards, are printed on recycled paper. Her truck bears the brand across its side, and her e-commerce website has the same clean, but organic feel. thenomadtruck.com
Branding, Campaign Design, Content Strategy, E-Commerce, Environmental Design, Packaging Design, Print Design, Social Media Strategy, Web Design, Web Development
MESH worked with Mission Savvy through eco-clothing company, juice bar, Organic-To-Go pop-up vegan truck, and Food Lab. We developed an illustrated brand system, print materials, truck graphics, and a website. The brand was designed to feel personal and handmade down to its very typography–the hand-illustrated typeface inspired by the fruits and vegetables served daily. The Vegan Alphabet was featured in the 2013 Print Magazine Regional Design Annual.
Branding, Campaign Design, Content Strategy, E-Commerce, Environmental Design, Packaging Design, Print Design, Web Design, Web Development
American Civil Liberties Union is ensuring every citizen in our country has justice, freedom of speech, and basic rights for all. MESH worked with the national chapter, in collaboration with PEN American Center, to develop the website for Reckoning With Torture. The website was built to crowdsource user-generated video content for an upcoming documentary film by Doug Liman. reckoningwithtorture.org
Print Design, Web Design, Web Development
Project Code Nodes is hosting the first Girls Who Code Clubs in West Virginia. We designed a program logo and mini website to recruit more teen girls to get involved!
Branding, Web Design, Web Development
In collaboration with Urbane Development, we designed the infographic poster for the City of New York Office of Financial Empowerment and Urban Development on the “BedStuy Alternative Credit Project.” The poster examines alternate underground forms of credit in the Brooklyn neighborhood of Bedstuy.
We made Sprout’s Adventure, an in-school interactive healthy food education and assessment tool packaged in the form of a healthy plate game for kids. Sprout was made in collaboration with teachers, data specialists, healthy eating specialists, and user-tested with K-8 students. It includes audio features for younger age groups, and a full backend reporting system for admin to create surveys and run reports. In this project MESH conceptualized the entire game, the name and narrative, and character illustrations.
Branding, Content Strategy, Web Design, Web Development
We’re helping to raise a new voice in healthcare, supported by a strong brand identity and a dynamic news-based website. MESH developed the brand strategy and web ecosystem for America’s Essential Hospitals. The brand launched with a documentary photography series in hospitals across the U.S., by Jennifer Judkins. MESH continually creates guidebooks, annual reports, digital zines, conference materials and online tools. essentialhospitals.org
Book Design, Branding, Campaign Design, Content Strategy, Environmental Design, Infographic Design, Photography, Print Design, Social Media Strategy, Web Design, Web Development
We partnered with Columbia University’s Global Studio to create a 24 poster, modular, open-source exhibition sharing ideas on inclusive urban design and the global problems surrounding informal housing settlements. It has traveled to 13 cities on 5 continents since opening in 2013, and is translated into 6 languages. It’s shown at AIA Center for Architecture in New York and the World Urban Forum in Medellin, Colombia, and was featured in ArchitectureAU and HOW Design. peoplebuildingbettercities.org
Environmental Design, Print Design, Web Design, Web Development
Do tax laws contribute to the decay of American houses? The Center for Community Progress (CCP) specializes in nurturing strong leadership and supporting systemic reforms at a national and local level. In collaboration with the WV Hub, another community organization, CCP sought us out to help visualize the detrimental effect property tax laws have on the public.
The Center for Social Impact Strategy is a research and action center at UPENN. MESH worked through a participatory, collaborative design process with the Center to build their online brand identity, devoting substantial time to content auditing, information architecture, and user personas. We worked closely with the Center’s team on content writing and brand imagery to create an online brand focused on engagement and conversion.
Book Design, Content Strategy, Print Design, Web Design, Web Development
Wanda Petunia is an educational, mental health focused book series and plush toy set company. We built an illustrated, animated, interactive website and e-commerce company to share Wanda’s stories and goods digitally.
E-Commerce, Web Design, Web Development
MESH designed and developed a campaign website for Adventures on the Gorge to house stories and gather new contact leads.
Branding, Campaign Design, Web Design, Web Development
Children’s Museum of New York is cultivating the creative problem-solvers of tomorrow. CMANY has one of the most amazing new spaces for kids in the city — and they needed a website to match. We redesigned their site to reflect the playful but clean aesthetic of the museum, keeping in mind the need for flexibility of daily in-house updates. We redeveloped the site with these two audiences in mind, and the project remains an ongoing evolution as we continue to improve the site with new features.
Mountain State Justice is a non-profit law firm providing legal advocacy and aggressive litigation on behalf of low-income West Virginians. MESH worked with Mountain State Justice to create a brand that directly echoes the state’s mountainous landscape. Their website uses imagery to showcase the organization’s impact on real people. We created print collateral, including legal letterhead, envelopes and business cards, as well as their website. mountainstatejustice.org
Branding, Print Design, Web Design, Web Development
MESH designed a fresh, responsive website, to match Edward Tucker Architects innovative, modern architecture. etarch.com
MESH worked with the young construction company, Persinger and Associates, to build a website with the same simplicity and structural integrity of Persinger’s buildings. persingerandassociates.com
We worked with the high-school kids of Rebel Ventures, a Philadelphia healthy snacks company and educational initiative run by kids for kids, to develop and design their latest snack product and packaging, Rebel Crumble cake. Rebel Crumble is a healthy alternative to sugary breakfasts, and was just made free to every Philadelphia public school student for morning breakfasts!
Through an extensive discovery process, MESH built a new digital brand and website for Kanawha County Public Libraries. This public library system serves a population of nearly 200,000, with 50,000+ web visitors each month. MESH ran online user surveys, focus groups, and public listening tours to understand the needs of the community. We developed user personas to inform an engaging, fresh and new online experience for these libraries. kanawhalibrary.org
We worked with City University of New York School of Public Health’s Urban Food Policy Institute to design a flexible logo and brand system. We designed the print and interactive pdf report, a micro-website, and an interactive Powerpoint presentation for Eating in East Harlem, to share with the New York neighborhood community members and academics.
Book Design, Branding, Web Design, Web Development
White Horse Wines and Spirits is a third generation family-run New Jersey beverage and organic food shop. MESH worked with White Horse to rebuild a custom, modern, responsive e-commerce platform to hold and sell over 5,000 of their wares. We integrated custom shopping options to include online sales and shipping, delivery, or in-store pick-up for the locals. whitehorsewine.com
MESH worked with career coach Lisa Podel, to create Better, the coaching workshop sessions designed to help entrepreneurs work, live, and learn better. MESH worked with this start-up through a naming process to develop the entire visual, verbal and experiential brand identity. We designed print materials and a website for Better to help people be their best possible selves at work and in their day-to-day lives. bettersessions.com
MESH developed a new, responsive portfolio website for the iconic fashion photography, Pamela Hanson. pamelahanson.com
Web Design, Web Development
Bloomfield School teaches jewelry and metalsmith classes in Gowanus, Brooklyn, by artists, for artists. MESH designed a logo, brand identity, and custom typography poster series inspired by their functional & directional mentality, and by their most precious studio items…the tools of their trade.
Appalachian Mountain Speciality Foods is carrying on decades of Appalachian Mountain cooking and sauce making. MESH worked with this family-run business in Spencer, West Virginia to reinvent their online brand. We styled and art-directed their new product with lifestyle photography (shot by Lauren Stonestreet), and designed and developed a custom e-commerce Shopify website to tell their story and sell their goods.
E-Commerce, Photography, Web Design, Web Development
OWN IT: YOU HAVE OPTIONS is an open-source, downloadable toolkit for teachers to educate high school kids on alternatives to college. The toolkit that includes 15 poster set, tiled hallway billboard, stickers, social media image shares, and toolkit guide book. The toolkit was made for Charleston Area Alliance’s Educator Industry Institute and is available to download for teachers anywhere on the Charleston Area Alliance website.
Book Design, Campaign Design, Content Strategy, Environmental Design, Print Design, Social Media Strategy
PAY DIRT explores the gender wage gap through the eyes of a group of high school girls with CUP, the Center for Urban Pedagogy. MESH adapted artwork inspired by America’s gender wage gap from the senior economics class at the Urban Assembly School for Criminal Justice in Boro Park, Brooklyn. The students’ artwork was utilized to create a print fold-out about the gender wage gap…for high school girls, by high school girls. CUP: Pay Dirt
CUP, the Center for Urban Pedagogy, looks into workers rights in the fast food industry. MESH worked with artwork from two ESL classes at the Academy of Urban Planning in Bushwick, Brooklyn on fast food, to create a print fold-out CUP: Happy Meals.
Holly Corey designs fun, fresh gymnastics, dance and activewear inspired by movement and a playful spirit. We created a brand that communicates the Holly Corey spirit with colorful graphic watercolor patterns, and her classic ‘H’ logo, embroidered and bedazzled on all her clothes. Her custom e-commerce website includes a vendor only section who wholesale. hollycorey.com
Charleston is redefining itself with Vision2030, a strategy bringing people together to improve quality of living in this beautiful southern town.
Campaign Design, Print Design
Local Bronx high school kids investigated supermarket access and food security in their neighborhoods with CUP, the Center for Urban Pedagogy. MESH adapted artwork created by Hostos Community College (an extension of City University of New York) public high school students to create a book about the Bronx food systems: CUP: Funky Fresh.
The Humanities Council enables the stories, projects, and gatherings that remind us of the beauty of our Appalachian American past. MESH built a custom website, with resource platforms, event listing, and third party integrations, to share the stories, programs, and events of the Humanities Council with the engaged public. wvhumanities.org
United Nations University International Institute for Global Health is starting human health-centered conversations. MESH designed the marketing materials for their Global Health and Wellbeing In the Changing Urban Environment events in Xiamen, China.
American Foundation for the Blind works with people with vision loss to live happy, healthy, fulfilling lives. MESH worked with AFB to design and illustrate for the Helen Keller Achievement Awards event identity, invitations, donation packet, and catalog. All pieces were gold print embossed for an extra tactile sensibility.
Robin McClintock paints her way through textures, terrains, letterforms, and memories. We made her portfolio website simple and structured to contain the organic work within. robinmcclintock.com
Providence CityArts is a community-based arts center celebrating the arts as a means to youth empowerment.
MESH installed a love letter on the side of our studio building during the week of Charleston’s annual art festival, FestivALL. We collaborated with writer Stephanie Busby to tell all the people and small businesses in our neighborhood what we love so much about them; the greatest things about being a part of a community.
Environmental Design, Print Design
Mariem hand-makes footwear in her Brooklyn-based studio, using traditional Italian processes with a modern look and feel. MESH developed this e-commerce website for Mariem.
E-Commerce, Web Development
Kayi and Wilkes Immigration Attorneys are working to secure safety, family, and futures for asylum seekers in Washington, D.C. MESH designed this start-up firm’s brand, business cards and website to put their first professional foot forward to their client base. kayiandwilkes.com
WV International Film Festival has been encouraging, supporting, and promoting the film arts since 1985. MESH designed custom typography and a custom website to host the latest and greatest classic and modern films on their rosters.
The New York Center for Hearing and Communication is transforming accessibility for the hearing impaired. MESH designed and developed a new website to communicate the organization’s variety of services, programs, and facilities available to people across New York. chchearing.com
Two Moon Shortbreads are lovingly hand-made in Brooklyn, New York and sold fresh throughout the city! MESH designed their logo, menus, and packaging to have the light, hand-crafted touch of a writer. The colors of their branding are inspired by the different lavender, thyme, and other herbal ingredients in their shortbreads.
Branding, Packaging Design, Print Design
Smooth Ambler are small-batch spirits distilled in the heart of the Appalachian Mountains. MESH worked with Smooth Ambler to redesign their website, build a Store Locator online tool, and run a social campaign. The social campaign targeted six major cities they wanted to grow their market share in, reaching 320K people. After the web launch, the website saw a dramatic increase in user engagement, with page views up 65%. The Store Locator became the highest trafficked page on the website (other than the homepage) leading to sales for Smooth Ambler.
Photography, Social Media Strategy, Web Design, Web Development
Headstart believes every child deserves a healthy life, access to care, and a strong education. MESH worked with Headstart to develop a digital brand and web platform packed with impact stories and resources for families considering the extra help they need.
Friends of the Cheat, a river conservation organization for the Cheat River, needed to update their aesthetic and redesign their online information architecture. We celebrated their collection of artist photography of the river from over the years to feature on their website and their e-newsletter, paired with graphics inspired by their staff’s field notebooks.
The purest form — a cube — a project perimeter. Capitol Business Interiors dissects space by considering our relationships with the objects around us and looking at everything from multiple perspectives. MESH designed a flexible, shifting logo to represent the heart of CBI’s design methodology. Alongside the logo and brand identity, we designed and developed a website and various promotional materials. cbiwv.com
MESH designed and art directed the 80 page Public Art: Charleston guidebook, given out free during the annual city arts festival. MESH also design the communication campaign for the Arts Council of Kanawha Valley to expand perceptions on what art really can mean to different people. The campaign included a pop-up gallery, an online poster generator, and a print series using crowd-sourced definitions of art and portraits of locals. The campaign exhibited at the AIGA Pittsburgh Context Exhibition.
Book Design, Campaign Design, Print Design, Web Design, Web Development
Ogonek is a third generation family business building A-frame houses in the woods of Ohio. Ogonek wanted a flexible mark that could work to represent both the timber side of their company as well as the building side. They asked for a seal reminiscent of their strong family history in the Boy Scouts. The final marks were inspired by Boy Scout badges, simple enough to brand into wood, and drawn based on the pine trees in their local forest and their favorite mallet.
TechConnect connects new, innovative industries to the West Virginia economy. MESH designed the brand and website based around ideas of interconnectivity. techconnectwv.org
West Side Main Street asked us to reinvent their brand to reflect the vibrant livelihood of their community. MESH worked with the local community to illustrate the neighborhood. We created a brand and website that pays homage to the rich history of the place but still feels current, to reflect the diversity of the neighborhood and appeal to all ages.
Sustainability Institute at BridgeValley works to connect our notion of sustainability with living more simply, introducing sustainability in the heart of Coal Country. MESH designed the brand, print booklets, website, and online resource library.
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Copyright MESH Design & Development 2021
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“”If you love baseball, you loved Ron Santo”
By Craig CalcaterraDec 10, 2010, 5:30 PM EST
They held Ron Santo’s memorial service in Chicago today. Bud Selig spoke. Tom Haudricort transcribed his remarks. In addition to the words in that headline, he included a great anecdote about the man:
“The move of the Milwaukee Braves to Atlanta in the mid-1960s left a void in the lives of everyone in my family. We filled that void with the Chicago Cubs, and no player embodied Cubs’ baseball more than their great fielding, power-hitting third baseman, Ron Santo. He played with unbridled enthusiasm, relentless energy and a tremendous heart.
“My daughter, Wendy, was a youngster then and she, like many young Cub fans, instantly identified Ron as her favorite player.
“One day, my mother, who was a great baseball fan and also a Ron Santo fan, bumped into Ron at a golf course in Arizona. She told Ron her granddaughter just loved him. Ron smiled, took the cap off his head, signed it and asked my mother to give it to her granddaughter. To Wendy, Ron Santo was elevated from favorite player to hero. In turn, over the years, Ron never failed to ask me about Wendy, and, to this day, Ron’s cap remains one of Wendy’s most prized possessions.”
I slam Selig for his rhetoric quite often, but good on the Commissioner for telling that story. Bud Selig is a lot of things, but I don’t think there’s any denying that he’s a real baseball fan.
Rest in peace, Ron Santo.
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Travis Scott Announces New Album
Travis Scott just plugged his new merch line and also announced a new album.
On Friday (Nov. 29), Travis urged fans to check out his new Black Jack line via his website. While doing so, he mentioned the name of what is believed to be his upcoming JackBoys compilation album.
"BLACK JACK COLLECTION LIVE ON http://JACKBOYS.TRAVISSCOTT.COM GANG GANG: JACK BOYS SOON," he wrote.
A visit to the site reveals a pre-order link for a digital download of an album titled Jack Boys. The page notes: "YOU WILL RECEIVE DIGITAL DOWNLOAD OF JACK BOYS UPON RELEASE DATE." It also shows a mock cover for the LP.
The new album will be a compilation project for Travis' Cactus Jack label and feature Sheck Wes, Don Toliver and artist/DJ Chase B. It is slated to be released before the end of the year.
jackboys.travisscott.com
Travis first mentioned dropping something called JackBoys last month during an interview with Zane Lowe. During their conversation, La Flame commented, "I'm gearing up for something special. All I can say is JackBoys on the way."
The Texas native recently released his latest single, "Highest in the Room." The new banger peaked at No. 1 on the Billboard Hot 100.
It's been over a year since he put out the critically-acclaimed album Astroworld, which was led by the singles "Sicko Mode" and "Butterfly Effect." Earlier this month, Travis' 2019 Astroworld Festival took place in Houston. It featured performances from Migos, Marilyn Manson, Pharrell, Rosalía, Young Thug, Playboi Carti, Gucci Mane, DaBaby, Megan Thee Stallion, Houston All Stars, Young Dolph, Key Glock, Sheck Wes, Pop Smoke, Don Toliver and Tay Keith.
See Every XXL Freshman Who's Been Nominated For a Grammy
Source: Travis Scott Announces New Album
Filed Under: Travis Scott
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Evolving Ourselves: How Unnatural Selection and Nonrandom Mutation are Changing Life on Earth
"We are the primary drivers of change. We will directly and indirectly determine what lives, what dies, where, and when. We are in a different phase of evolution; the future of life is now in our hands."
Why are rates of conditions like autism, asthma, obesity, and allergies exploding at an unprecedented pace? Why are humans living longer, getting smarter, and having far fewer kids? How might your lifestyle affect your unborn children and grandchildren? How will gene-editing technologies like CRISPR steer the course of human evolution? If Darwin were alive today, how would he explain this new world? Could our progeny eventually become a different species - or several?
In Evolving Ourselves, futurist Juan Enriquez and scientist Steve Gullans conduct a sweeping tour of how humans are changing the course of evolution - sometimes intentionally, sometimes not. For example:
• Globally, rates of obesity in humans nearly doubled between 1980 and 2014. What's more, there's evidence that other species, from pasture-fed horses to lab animals to house cats, are also getting fatter.
• As reported by U.S. government agencies, the rate of autism rose by 131 percent from 2001 to 2010, an increase that cannot be attributed simply to increases in diagnosis rates.
• Three hundred years ago, almost no one with a serious nut allergy lived long enough to reproduce. Today, despite an environment in which food allergies have increased by 50 percent in just over a decade, 17 million Americans who suffer from food allergies survive, thrive, and pass their genes and behaviors on to the next generation.
• In the pre-Twinkie era, early humans had quite healthy mouths. As we began cooking, bathing, and using antibiotics, the bacteria in our bodies changed dramatically and became far less diverse. Today the consequences are evident not only in our teeth but throughout our bodies and minds.
Though these harbingers of change are deeply unsettling, the authors argue that we are also in an epoch of tremendous opportunity. New advances in biotechnology help us mitigate the cruel forces of natural selection, from saving prematurely born babies to gene therapies for sickle cell anemia and other conditions. As technology like CRISPR enables us to take control of our genes, we will be able to alter our own species and many others - a good thing, given that our eventual survival will require space travel and colonization, enabled by a fundamental redesign of our bodies.
Future humans could become great caretakers of the planet, as well as a more diverse, more resilient, gentler, and more intelligent species - but only if we make the right choices now.
Intelligent, provocative, and optimistic, Evolving Ourselves is the ultimate guide to the next phase of life on Earth.
Evolving Ourselves - Part 1
The Heir (The Selection #4)
The Elite (The Selection #2)
Lisa De Jong - Changing Forever
Smarter Than You Think: How Technology is Changing Our Minds for the Better
The Crown (The Selection #5)
Changing Forever (Rains #2)
Heartland: A Memoir of Working Hard and Being Broke in the Richest Country on Earth
Children of Earth and Sky - Guy Gavriel Kay
Life After Life
Earth Abides
The Hobbit (Middle-Earth Universe)
A Journey to the Interior of the Earth
Venomous: How Earth's Deadliest Creatures Mastered Biochemistry - Christie Wilcox
Earth: A Visitor's Guide to the Human Race
The Faithful Executioner: Life and Death, Honor and Shame in the Turbulent Sixteenth Century
Love, Life, and the List
Brain Maker: The Power of Gut Microbes to Heal and Protect Your Brain for Life
Jeremy Fink and the Meaning of Life
Hot Lights, Cold Steel: Life, Death and Sleepless Nights in a Surgeon's First Years - Michael J. Collins
Life, the Universe, and Everything
Smarter Faster Better: The Secrets of Being Productive in Life and Business - Charles Duhigg
The Facts of Life and Death
Life: The Leading Edge of Evolutionary Biology, Genetics, Anthropology, and Environmental Science - John Brockman
The Big Picture: On the Origins of Life, Meaning, and the Universe Itself - Sean Carroll
The Modern Scholar - The Life and Times of Mark Twain
The Death and Life of Great American Cities:
BBC: Life and Fate (Dramatised)
The Young and the Submissive (The Doms of Her Life #2)
The Selection (The Selection #1)
Earth & Sky (Earth & Sky #1)
What the F: What Swearing Reveals About Our Language, Our Brains, and Ourselves - Benjamin K. Bergen
Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer
Big History -The Big Bang, Life on Earth, and the Rise of Humanity
Sex in the Sea: Our Intimate Connection with Sex-Changing Fish, Romantic Lobsters, Kinky Squid, and Other Salty Erotica of the Deep
The Purpose Driven Life: What on Earth Am I Here For? - Rick Warren
Life's Engines: How Microbes Made Earth Habitable - Paul G. Falkowski
The Guard (The Selection #2.5)
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Reviews, Wii
Fire Emblem: Radiant Dawn [Wii] – Review
March 9, 2018 John 2 Comments
Exactly one year ago, I struck while the iron was hot. Browsing GameStop with a friend, I spotted a pristine copy of Fire Emblem: Radiant Dawn that I couldn’t pass up. We’d see copies every so often but they’d be missing their manual or in poor shape otherwise not meriting the hefty asking price. Little did I know that this acquisition would solidify the schedule of our weekly get-togethers for the next year and that we’d eventually clock more than eighty hours in order to complete one of the hardest entries in the tactical RPG series.
First released in Japan on February 22, 2007, Nintendo published it in North America on November 5, 2007. Like the Game Boy Advance entries I’ve previously reviewed, Radiant Dawn’s narrative unfolded from multiple perspectives in a chapter-based format. Set on the continent of Tellius, three years after The Mad King’s War chronicled in Path of Radiance, the rebuilding nations once again found themselves drifting apart and closer to all-out war. Racism against the half-human, half-beast Laguz proliferated many countries fueling much of the strife, but it was the actions of power-hungry political leaders and their manipulation of the public in the name of the divine that bent the continent backwards. Rebel insurgencies rose up, their forces coalescing with fair rulers and good-hearted mercenaries as the war evolved from survival against neighbor to survival against god.
Especially late in the game, special attention had to be paid to tiles and any bonuses they granted.
In the first section, roughly ten chapters, I controlled the Dawn Brigade, a rebel force led by Micaiah, the Silver-Haired Maiden. They successfully rose up against an occupational army thanks to her mystical prescience, foreshadowing both impending trouble and her importance to the story. Consisting of five or so chapters, the second part of the game was quite brief but shone a light on the impact of the Dawn Brigade’s triumph and the tense peace that was dissipating across Tellius. Returning protagonist Ike took the spotlight in the third and lengthiest part. During the next fifteen chapters, his Greil Mercenaries aided the Laguz Alliance in their fight against the subjugation and eradication of their kind. The conflict throughout Tellius consequently resulted in the return of dueling goddesses and the unification of forces I’d separately controlled up to this point, closing the game in a grueling ten chapter run.
Amidst the calamity, subplots played out, advancing the narrative and allowing opportunities for character development. With such a large cast of characters – more than seventy playable units and numerous antagonists – it’s unsurprising that most fell into stereotypical roles. A limited support system where nearly everyone could buddy up but only engage in boilerplate conversations mid-battle didn’t help matters. In light of the par-for-the-course convoluted storyline however, predictable characters helped me to remain informed of current goings-on during our yearlong playthrough. In contrast, my enthusiasm rarely dwindled in regards to the robust and rewarding gameplay.
Objectives and maps varied widely throughout the game, providing many different challenges.
I’d long heard that this entry was one of the toughest in the series and having played through the brutal endgame gauntlet for myself, I can see why. Battles, all throughout the game, were on a larger scale than any I’ve previously played. It wasn’t uncommon for enemy reinforcements to continue pouring in for a dozen turns, becoming a running joke for my friend and I. Often, victory required the elimination of more than one hundred enemy units. The endgame in particular had us going toe-to-toe against the toughest enemies on three fronts using armies of mixed strength units and limited access to resources. The volume differential alone was staggering, especially in consideration of the need to “babysit” units who couldn’t take a hit while simultaneously lining them up to pick off units and gain experience.
To accommodate the game’s length, units could upgrade classes twice, extending their statistical growth another twenty levels compared to the handheld entries I’ve played. Latent and assignable in-battle skills furthered their strength and abilities, plus those of their enemies, adding another wrinkle to combat matchups. The shape-shifting Laguz characters were new to me although I wasn’t smitten with them. Though powerful in their beast form, they remained so only temporarily. A recharging gauge dictated when they could transform and when they’d revert to their susceptible human form. One exception was the Hawk King Tibarn who, through his Formshift skill, allowed him to remain in his beast form permanently. In conjunction with his Canto skill, allowing any unused movement to be used after an action, and the refreshing abilities of the Heron Laguz, he could be granted two actions per turn and wreak havoc on his opposition.
Though powerful, Laguz could be unreliable.
Playing as we did, alternating control on odd and even chapters, we grew attached to individual units like Tibarn. We’d use our turns to “lobby” on the behalf of personal favorites, improving their abilities and devising strategies for their universal inclusion in skirmishes. As I’ve found to be the case with these games, success required meticulous preparation, in the lead up to and during confrontations. Managing the skills and inventory of each unit, deciding who to bring into battle, examining enemies intently, positioning allies to disburse experience smartly and prepare for the enemy turn, it was mentally strenuous. However, considering one teensy-tiny overlooked detail could spoil an otherwise well thought-out strategy, it was necessary.
The inclusion of a battle save feature was a blessing, frequently allowing us to test out a strategy or attack without fear of permanently losing a unit. Truthfully, despite this game being more difficult than Fire Emblem, the battle save feature made it far less frustrating; rarely did we lose an hour of progress or forsake a fallen unit. It did not, however, alleviate the immense frustration I encountered in the penultimate chapter of the game’s first part. Controlling two units, in a small forest plagued by fog of war, I needed to rout the enemy while protecting a weaker unit who could barely withstand an attack. It must’ve taken me two-dozen attempts to overcome and rekindled my previously held impression that the genre’s difficulty stemmed from battles devolving to a point where there was a single “right way” to victory. Happily, this was the sole time this notion popped into my head.
Extensive dialogue propelled the narrative and fleshed out characters.
With another Fire Emblem in the books, I’m further convinced of the unassailable talent at Intelligent Systems. Radiant Dawn, like the entries I’ve played before it, was built upon a well-worn foundation; yet it was enhanced by unique features differentiating it from its predecessors. The challenge it offered required intense, dogged analysis. Any missteps were dire, costing the permanent loss of a character or simply the time put into a skirmish. So fulfilling was success, however, especially when a battle plan was successfully executed the first time! Though their specialty lies not in crafting a dynamic narrative, I still enjoyed the broad story and varied cast of characters Intelligent Systems produced. Of the three I’ve played, this entry reigns as my favorite in the series (and one of the favorite games I played last year). Now, which do I play next?
2007fire emblemfire emblem: path of radiancefire emblem: radiant dawngamestopintelligent systemsnintendorpgtactical role-playing gamevideo gamesWii
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Gear Daddies - My Space
1988 Boys Will Be Boys (full song)
1988 Cut Me Off (full song)
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1990 Zamboni (full song)
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Gear Daddies - 2008
The Gear Daddies is a band from Austin, Minnesota that enjoyed regional success in the late 1980s and early 1990s. Its members were Randy Broughten (electric and steel guitar), Nick Ciola (bass), Billy Dankert (drums and vocals), and Martin Zellar (guitar and vocals).
Their most mainstream success was when they played Late Night with David Letterman in 1991. Ciola and Dankert did not play on the show because many bands simply sat in with Paul Shaffer and The World's Most Dangerous Band when playing the show. Zellar had this to say of the experience: "I was so nervous, and it happened so quick. I couldn't tell you what the hell happened. I got done, and I was walking back and said to Randy (Broughton), 'Did I sing all the words? Did I do that?' When I watched it that night in the hotel room ( the Omni in New York), I had no recollection of having lived it."
The band broke up in 1992 but has since performed reunion concerts. In an interview on Minnesota Public Radio on February 10, 2005 Martin Zellar said that he hoped the Gear Daddies will regroup for a concert in the near future. Most recently, the band appeared at the Minnesota State Fair in August, 2006 along with another popular late 80s/early 90s band from neighboring Wisconsin, the BoDeans.
"Zamboni" is their best-known song, having been featured in a few movies and played at various hockey games.
Singer Martin Zellar is currently active, playing shows in Minneapolis/St. Paul area, usually with his band the Hardways. Along with their own songs, the band plays some of the Gear Daddies songs as well. The Martin Zellar and the Hardways live album "Two Guitars, Drum and Bass" features the Gear Daddies' songs "Wear Your Crown", "She's Happy", "and "Drank So Much."
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Tag: Literary Festival
Last day to enter the Chipping Norton Lit Fest critique competition 2015
The Chip Lit Agent Pitch event is back!
Carole Blake (photo by Jack Ladenburg)
Seeking a way around the slush pile? Brave enough to have your manuscript critiqued in front of an audience? Whether you’re ready to throw your hat in the ring, or just want to pick up tips for your own writing, this event is one for aspiring authors everywhere.
Literary agent Carole Blake (pictured right) teams up with author of Wannabe a Writer?’s Jane Wenham-Jones (pictured below) – and me! – for this interactive ‘reality show’ event. Submit the first 1,000 words of your novel in the form listed here by 20th March 2015 (entries over the 1,000 words excluding title will be disqualified) together with a strict 250-word maximum third-person biography (as if someone else is describing you) and strict 250-word maximum synopsis of your novel including the ending.
Submission confirms agreement with, and acceptance of, the terms and conditions listed here (with entry form).
Advice Carole gave to successful entrants in previous years includes…
not having unrealistic (or too many!) coincidences in your plot where it helps solve a problem (e.g. your character has no money but then wins the lottery); and
do make sure that your synopsis includes your ending!
We’ll invite five shortlisted writers to pitch their work to Carole. The audience will listen as Carole critiques each piece, before opening it up for audience question and answers. Based on the planned TV show Wannabe a Writer, this promises to be the Dragons’ Den of the literary world. Join in, if you dare.
Chipping Norton Literary Festival is a four-day celebration of books, reading and writing, with a host of author talks, signings, discussions and workshops.
Tickets on sale via 01608 642350, visit www.chiplitfest.com for the full programme or click here for the event itself.
Before you submit, if you’d like some tips on writing take a look at my Writing Tips page.
You can sign up to receive these blog posts daily or weekly so you don’t miss anything. You can contact me and find me on the internet, view my Books (including my debut novel The Serial Dater’s Shopping List, various short story collections and writer’s block workbooks) and If you like this blog, you can help me keep it running by donating. Thank you.
For anyone looking for an editor and general feedback on your writing at a very reasonable rate, do take a look at Editing and Critique.
Chipping Norton Literature Festival critique competition 2015
Literary agent Carole Blake (pictured right) teams up with author of Wannabe a Writer?’s Jane Wenham-Jones (pictured below) – and me! – for this interactive ‘reality show’ event. Submit the first 1,000 words of your novel in the form below by 20th March 2015 (entries over the 1,000 words excluding title will be disqualified) together with a strict 250-word maximum third-person biography (as if someone else is describing you) and strict 250-word maximum synopsis of your novel including the ending.
Wantage (Oxfordshire) Literary Festival 25 Oct – 2 Nov
October 19, 2014 October 19, 2014 6 Comments
If you’re in the Oxfordshire area of UK in the next few days, do take a look at the Wantage Literary Festival, which runs from 25th October to 2nd November.
Events include the following, taking place on Saturday 1st November:
Screenwriter Charles Harris talking about how to screenwriter: http://www.wantagebetjeman.com/from-script-to-screen-a-complete-introduction-to-screenwriting.
Literary agent Jacq Burns about how to write a bestseller: http://www.wantagebetjeman.com/write-a-bestseller.
Guardian Masterclass tutors MR Hall and William Ryan running a crime writing workshop: http://www.wantagebetjeman.com/learn-to-be-a-crime-writer.
“Definitely not to be missed by writers, and with a whole host of other events for book lovers and readers across the rest of the week.”
Other speakers include Katie Adie, Nikky Arding, Ciaran Murtagh, Andy McNab and Jenny Lewis. Links to the specific events above and the main page is www.wantagebetjeman.com.
Author Spotlight no.337 – Jim Sellers
Complementing my interviews, today’s Author Spotlight, the three hundred and thirty-seventh, is of multi-genre author and interviewee Jim Sellers. If you would like to take part in an author spotlight, take a look at author-spotlights.
Jim Sellers is the author of the newly released YA book “Jacky the Brave”. Although he had written works in most genres, he was surprised and happy to see his first publishing success was in YA. His writing in that genre is based mostly on events in his own life with some inspiration from friends and other family members. “Jacky the Brave” is just such a collection of his experiences.
Born in Edmonton in north-west Canada, Jim spent a lot of time reading and imagining exciting adventures as a kid. That was the favourite pastime of boys who didn’t play hockey and lived before the age of video games. Like most writers, he has been creating stories since his teen years and found the pen and paper to be a regular companion on long trips and quiet days. He also doubted that any of his work would be published – it seemed unlikely after watching other writers he knew trying so hard. So he set his sights on film and TV. During his 20 years in that business he learned the process of writing screenplays for drama and documentaries as well as advertising and corporate communications before retiring from that industry. For the last 10 years he has been working in communications management for non-profits groups and universities.
He continued to write screenplays as show pilots or spec film scripts, most ending up in the rejection files. It was after he decided to get his Bachelor’s degree (at 50) that he learned to appreciate the sheer joy and freedom of writing fiction. It was this appreciation for fictional writing that caused him to re-evaluate all the abandoned stories he had filed away and all the adventures he had logged in his notes. In 2004, he made a project of writing a series of YA stories based on his previous writing. Each of these stories (4 in all) received different levels of interest from publishers and agents, with results ranging from boilerplate rejections to requests for full manuscripts (followed eventually by rejections). During this time he established a variety of websites about writing, posted his short stories and wrote a serial novel.
After repeated rewrites and editing, his first Young Adult novel was accepted for publication in 2013. He is working on a sequel for the book, a short story collection and a novel.
5PM Fiction 285: The photo that no-one else can get
Welcome to the two hundred and eighty-fifth in this series that is ‘5pm Fiction’.
Late April 2011 I discovered StoryADay.org and the project that is to write 31 stories in 31 days. Anyone who knows me or follows this blog, knows how passionate I am about short stories so my clichéd eyes lit up at this new marvel. And just a few days later there I was, breathing life into new characters. This went on to become (with some editing of course) my 31-story collection eBook Story A Day May 2011. I have since published (as eBooks) the 2012 and 2013 collections, detailed on https://morgenbailey.wordpress.com/books-mine/short-stories/story-a-day-may.
I was nearing completion of the 2012 project when I decided that I didn’t want to stop at the end of May so 5PM Fiction was born. I put a load of prompts on the 5PM Fiction page and today’s was to write a story in second person-viewpoint from the keyword prompt of ‘chase’. Here is my 356-worder.
The photo that no-one else can get
You’ve been chasing her for days, to get the photo that no-one else can get. She knows you’re there. There’s always someone there.
It’s a lifestyle she’s had to become accustomed to, only you don’t think she ever will. It’s not one you’d want, except she’s become your job, your life.
When she emerges out of the building, you reach over to your camera, on its dashboard tripod, and set it to continuous.
You follow her car through narrow streets, wide streets – her executive to your jalopy, the only thing you could get at short notice. You’re used to this place, she’s been here a lot.
Most of the shots are of the back of her head but you know she could look round. She has before.
As her car gathers speed so does yours. It complains but it’s not yours so you’re not bothered.
As she heads into the tunnel, she edges forward and you floor the accelerator, a little too close for comfort but you decide to go alongside, get level, no other cars in sight, so you swivel round your camera in anticipation, a momentary lapse in concentration.
Flash Fiction Friday 109: Watcher by Angela Sturm
Welcome to Flash Fiction Friday and the one hundred and ninth piece in this series. This week’s is a 467-worder by freelance writer, blogger and book reviewer Angela Sturm. This story will be podcasted in episode 34 (with two other stories and some 6-worders) on Sunday 1st December.
I can see him making his way up the stairs. No one else appeared to notice. I called to him and he smiled. I took his outstretched hand and in an instant we were walking through the cornfield, talking laughing, knowing. I suspect this will be our last outing together. I want to cry but for some reason I can’t. I am strangely happy, content to say nothing.
I know what he is doing and why he’s doing it. He loves me. He wants me to be the first to know. I can hear crying in the background and people talking in hushed tones, moving about, but I can’t see anyone. “Can you see them?” I ask. “Yes, I can,” he said. You will see them soon enough.”
We continued to walk and although our lips weren’t moving, our conversation carried on. I am having trouble remembering much of anything said, I only know how peaceful this is and I never want to leave. I held tightly to his hand. Memories of early morning fishing expeditions, milk toast and that awful smell of head cheese he loved to make, filled my mind and made us both laugh. I remember him clothing and feeding the homeless and that silly dance he did every morning while singing the wake up song, pulling at his hair and making it stick up. I was laughing so hard I barely noticed that we’ve stopped walking. He is looking at me now, time standing still. He looks so serious, gently placing his hands on my cheeks, searching deep into my eyes. I think I saw a tear trickle down his face. I have only ever seen him cry once, and it was when he told me stories about the war and how no man should have to endure what he witnessed. War killed his spirit. I can feel my tears now. Our journey has come to an end.
The fields have disappeared. He’s not holding my face anymore. Desperate, I call out his name. “I am right here princess, do not be afraid.” I can barely see him. I call out again, “Why are you so far away?” “It is time,” he said. “I am going home.” Then a soft white light… well, more like a white cloud, appeared. He drew closer and smiled at me for the last time, then disappeared into the white fog.
A door opened somewhere, more crying. I hear my name. Something has my shoulder. “Ava, Ava, wake up, honey.” I turn to look at the clock. It’s after midnight. “Dad and I need to talk to you.” My room is filled with family. They are staring at me. “Grandpa died in his sleep,” they said, “in heaven now,” but I already knew this.
I watched him go.
I asked Angela what prompted this piece and she said…
My grandfather and I were very close. I remember like it was yesterday when he passed. I was sixteen, eating a tuna sandwich watching the wheel of fortune. My grandma called and simply said, “I think Grandpa is dead. Can I talk to your dad please?” Calm as could be. I know now she was in shock, but back then, I kept wondering how she remained so composed.
The flash fiction piece I wrote is based on actual events, but fictionalized. I miss my grandpa as much today as I did those many years ago when he died. I think about him often, the impact he had, and continues to have, on me, so I decided to memorialize him. “Watcher” was written with him in mind.
Thank you, Angela. It was very moving, and having lost my father September 2001, I feel just the same.
Angela Sturm is a freelance writer, blogger and book reviewer currently working on a novel.
Angela lives in Minnesota, is mother to three children and one grandchild, and blogs at http://insideasanemind.com.
If you’d like to submit your 6-word or 500-word max. stories for consideration for Flash Fiction Friday take a look here, or up to 1,000 words for critique on my Online Short Story Writing Group (links below).
** NEW!! You can now subscribe to this blog on your Kindle / Kindle app via Amazon.co.uk or Amazon.com **
You can sign up to receive these blog posts daily or weekly so you don’t miss anything. You can contact me and find me on the internet, view my Books (including my debut novel The Serial Dater’s Shopping List, various short story collections and writer’s block workbooks) and I also have a blog creation / maintenance service especially for, but not limited to, writers. If you like this blog, you can help me keep it running by donating and choose an optional free eBook.
As I post a spotlight or interview a day (amongst other things) I can’t unfortunately review books but I have a list of those who do. If there’s anything you’d like to take part in, take a look at Opportunities on this blog.
I welcome items for critique directly (see Editing & Critique) or for posting on the online writing groups listed below:
nonfictionwritinggroup.wordpress.com
novelwritinggroup.wordpress.com
poetrywritinggroup.wordpress.com
scriptwritinggroup.wordpress.com
shortstorywritinggroup.wordpress.com
5PM Fiction 284: Once A Month
October 17, 2013 October 5, 2013 Leave a comment
Welcome to the two hundred and eighty-fourth in this series that is ‘5pm Fiction’.
I was nearing completion of the 2012 project when I decided that I didn’t want to stop at the end of May so 5PM Fiction was born. I put a load of prompts on the 5PM Fiction page and today’s was to write a story from the one-word prompt of ‘yellow’. Here is my 163-worder.
She’d been on before. Dan recognised her brooch, yellow like the bus, but it wasn’t until she handed over the £2 coin, that he spotted the bandages round each wrist.
He handed over the change. He wasn’t supposed to – the rules were exact money only and it was only 40p, but it gave him an excuse to speak. “I like your sunflower,” he said, but felt it a lame thing to say.
“Thanks,” she said, looking down at the coins and blushing.
“Nice to see you again,” he continued.
“You remembered?”
Dan nodded.
“Once a month,” she said, tears forming.
Unsure of what to say, Dan felt as if he’d been let into a secret.
A man behind the woman coughed and as she put the change into her purse, Dan was sure he spotted a hint of a smile.
He watched her walk towards the back of the bus and hoped he didn’t have to wait another month before they spoke again.
Photograph above courtesy of morguefile.com.
November-deadline Writing Competitions
October 17, 2013 October 17, 2013 1 Comment
I still don’t have any guest bloggers (where are you all?) booked in until November, so I thought I’d bring you the competitions early (taken from this blog’s Competitions page) so you can prepare early, followed by regular (repeated) competitions and competition websites…
Auto/biography: The New England Book Festival Competition – see below.
Children’s: The New England Book Festival Competition – see below.
Flash Fiction: Weekly challenge on theironwriter.com.
Flash Fiction: Each month the Scottish Book Trust provides a prompt to get you started, but where the <50-word story goes from there is entirely up to you. Their favourite story will be published on their page and the writer will receive a lovely Novel Poster from The Literary Gift Company. You can submit your story in the body of an email or as an attachment and remember to include your full name with your entry. They also welcome entries in Gaelic or Scots.
Flash Fiction: The New Writer 17th Annual Prose & Poetry Prizes launched April 2013. £2,000 in prizes. Closing date 30th November. Short stories, flash fiction and poetry.
Flash Fiction: Indies Unlimited hosts a weekly 250-word max. prompt competition – see Indies Unlimited. Also see ‘Short stories’ below.
Flash Fiction: Writer Austin Briggs runs a monthly 55-word competition (different theme each month). It’s free to enter and you can win $55 (of his own money!).
Flash Fiction: Empirical Magazine started a monthly flash fiction (<1000-word) competition.
Flash Fiction: The Writing Competition is a short story competition hosted by Jeni Durlston-Powell. This writing contest offers writers the chance to win cash and publication, and is currently run quarterly (late Feb, late May, late Aug, late Nov). Short Stories up to 500 words. Titles to be limited to 10 words. Open theme and genre. Entry fee: £4. Prizes: £100, £75, £50. See http://www.writingcompetition.org.uk and http://www.shortstorycompetitionhq.com/the-writing-competition-writing-competition for details.
Mixed (novels & short story collections): iWriteReadRate and Cornerstones Literary Consultancy (voteformyebook.com) are offering a monthly social competition to members of the community – see ‘Monthly’ towards the end of this page.
Mixed: Words for the Wounded (W4W) launching its first writing prize on Armistice Day, November 11, with a March deadline – see below.
Mixed: The New England Book Festival Competition – see below.
Mixed: Christian magazine Pockets has a different theme per month.
Mixed: hud.ac.uk/mh/english/grist/competitions/index.htm (shorts & poetry).
Mixed: The annual The New Writer Prose & Poetry Prizes: Short Story / MicroFiction / Non-Fiction / Single Poem / Poetry Collection. Closing date 30th November. You can enter at: thenewwriter.com/entryform.htm.
Non-fiction: The New England Book Festival Competition – see below.
Novels: societyofauthors.org/betty-trask.
Novels: The New England Book Festival has issued a call for entries to its annual program honoring the best books of the holiday season. The competition is currently accepting entries in the following categories: non-fiction, fiction, biography / autobiography, children’s books, young adult, how-to, cookbooks, science fiction, photography / art, poetry, spiritual works, compilations / anthologies, gay, unpublished stories and wild card (for books that don’t neatly fit elsewhere). All entries must be in English. Books published on or after January 1, 2010 are eligible. Deadline submissions in each category must be received by Tuesday 25 November 2013.
Playwriting: livetheatre.com.au/html/cms/35/one-act-playwriting-competition-noosa has an AS$6,000 prize pot and a mid-November deadline.
Playwriting: Almost Random Theatre is running two competitions – 1. Wellbeing Playwriting Competition: We are seeking one outstanding 20 minute play to be put on in Oxford, England in January 2014. The play must be no more than 20 minutes long and require no more than three actors. CLOSING DATE 10th October 2013. 2. Retreats Playwriting Competition: We are seeking one outstanding 10 minute play to be put on in Oxford, England in January 2014. The play must be no more than 10 minutes long and require no more than three actors. CLOSING DATE 10th November 2013. See http://www.almostrandomtheatre.co.uk/competitions. My thanks go to Margaret Taylor for the info.
Poetry: The Writers’ Forum Poetry Competition is a monthly contest for poems of up to 40 lines. Closing: Monthly. Entries arriving too late (after the 15th) for one month go forward to the next. Prizes: 1st – £100. Runners-up – A Brewer’s Dictionary of Phrase and Fable. Entry Fee: £5 each, £3 each thereafter. Includes a critique (sae required if entering by post). Comp Page: writers-forum.com/poetrycomp.html.
Poetry: The New Writer 17th Annual Prose & Poetry Prizes launched April 2013. £2,000 in prizes. Closing date 30th November. Short stories, flash fiction and poetry.
Poetry: other November deadline poetry competitions include Cafe Writers, Countryside Tales, Cinnamon Press Writing Awards, The New Writer, Writing Magazine (WM: open to all theme: nostalgia), theploughprize.co.uk.
Science-fiction: Aeon Award (quarterly), Writing Magazine.
Screenwriting: Canada-based Wildsound run monthly screenwriting competitions.
Short stories: The Erewash Writers’ Group competition website is running two free entry competitions and these close early November. One of our competitions has two categories of entry ie two age groups. We recently held our first competition open to entries from outside the group. It attracted all levels of writer from complete newbies to the professional. One of the successful entrants, their story chosen by our judge Keith ‘Carrot Nappers’ Large, told me they’d never even entered a writing competition before. I think it’s a good thing any writer will want to join in with a competition, whatever their experience and ability. In my opinion that’s what competitions are there for, to encourage us all to write and to give everyone an outlet for our short stories and other works. They’re also fun as they provide deadlines to work to and in some cases, themes to challenge us. Although one of our current competitions is already categorised so that entries from children will not be judged in competition with adult entries, we will consider this point you have raised when organising our future competitions. If I may add, we are in the process of putting a call out to seek a judge for an open competition we intend to hold in 2013. We are also seeking judges for mini competitions. At present, we are delighted Rosalie Warren author of ‘Coping with Chloe’ is judging one of our free entry competitions. If anyone reading this knows of anyone suitably qualified, please will they email Debbie at erewashwriterscomps@hotmail.co.uk to register their interest.
Short stories: The Writers’ Forum Short Story Competition is a monthly no-theme contest for stories between 1,000 and 3,000 words. Closing: Monthly. Entries arriving too late (after the 15th) for one month go forward to the next. Prizes: £350, £150, £100 and publication in Writers’ Forum magazine (and possible anthology). Entry Fee: £3 per story for subscribers, £6 each non-subscribers. £5 extra for a critique (sae required if entering by post). Comp Page: http://writers-forum.com/storycomp.html.
Short stories: The New Writer 17th Annual Prose & Poetry Prizes launched April 2013. £2,000 in prizes. Closing date 30th November. Short stories, flash fiction and poetry.
Short stories: Short Sentences is a free-to-enter 1,000-word max competition run by Bloomsbury and has a different theme every two months (deadlines 30th September then 30th November) . Seehttp://www.shortstorycompetitionhq.com/short-sentences-crime-fiction-short-story-competitionand http://shortsentencecompetition.wordpress.com/rules-and-submissions for details.
Short stories: Hayley Sherman runs a monthly short story competition for submissions on any subject up to 2,000 words. The winners are published on the website, promoted online and receive a £10 First Writer voucher. All entrants are also considered for publication in The New Short Story Annual at the end of the year. Deadline 25th of the month. Heather Marie Schuldt runs a similar contest, although 500-750 words max., but with the same deadline.
Short stories: The Roy B Giv competition seeks 2,000-4,000 words on a colour. 🙂
Short stories: The FREE 2014 Commonwealth Short Story Prize is being run by Commonwealth Writers, a cultural initiative from the Commonwealth Foundation. Cash prizes are on offer for the winning writers, and prizes for translation are also available. Short stories 2000 – 5000 words. Genre, theme and setting is open. Writers must be citizens of a Commonwealth country. Writers do not need to currently reside in that country. Entries must be original and unpublished with the exception of personal blogs and personal websites. English entires only. Translations of short stories written in languages other than English are eligible if submitted by the writer (not the translator) and provided the translator is a citizen of a Commonwealth country. One entry per writer. Opens 1 October 2013, closes 30 November 2013. Free entry. One winner is chosen from each regional category – 1. Africa, 2. Asia, 3. Canada and Europe, 4. Caribbean and 5. Pacific. One regional winner will be selected as the overall winner with four runners up from remaining regions. Overall winner will receive £5,000. Remaining four regional winners £2,500. If the winning short story is a translation into English, the translator will receive additional prize money: £2,000 for the overall winning story and £1,000 for a regional winning story. Details on: http://www.commonwealthwriters.org/prizes/commonwealth-short-story-prize/entry-rules.
Short stories: The Bath Short Story Award opened October for entries – see ‘March’.
Short stories: other competitions include Ashby Writers Club (Mary Gornell Memorial), Bridgehouse Publishing, Emerald Flash Fiction, Glimmer Train (different category each month), The New Writer, Writing Magazine (WM: open to all theme: flash fiction <500 words / subscribers only).
NB. Don’t forget to check out the ongoing competition websites listed at the end of this page.
Flash Fiction: Indies Unlimited hosts a weekly 250-word max. prompt competition – see Indies Unlimited. Co-run by interviewee Kat ‘K.S.’ Brooks. Also see ‘Short stories’ below.
Flash Fiction: Each week on theironwriter.com, four writers agree to compose a five hundred word story involving the same four elements. Please remember to give your story a title. The stories can be in any genre except erotica. The writers will not know what the four elements are prior to committing to the challenge. There is a four day time limit to complete the story. I email the elements early Thursday morning, my time. The story is due at midnight, Sunday, your time. Each author retains full and complete copyright of their story submitted to The Iron Writer for this competition. However, it is understood each story will remain on this website indefinitely. The Iron Writer will not publish any submission outside this website without express permission from the author. So, if you are up to the challenge, please email me at HERE and we can schedule when you are willing to participate. Please include your main blog or website. I will link your story to your site. You may participate as often as you want.
Mixed: Needle in the Hay runs weekly and monthly competitions (“awards”). See needleinthehay.net/submission-guidelines for their guidelines. Thanks to Jason Fink for pointing me in that direction.
Poetry: Buxton’s Word Wizards slam poetry competition runs in the coffee lounge at the Grove Hotel, Buxton, Derbyshire, UK at 7:30pm on the last Tuesday of every month. Entry is £2.50. More info can be obtained by e-mailing Rob at: poetryslamUK@aol.com.
Poetry: Well Versed is the weekly poetry column of daily UK newspaper the Morning Star, published every Thursday, in print and online. Poetry editor Jody Porter. Under the stewardship of the late and esteemed John Rety, Well Versed developed into a widely-read forum for new and established writers. Send submissions, with biographical information, to: wveditor@gmail.com. Poems need not be overtly political, but space is limited so they must be short to medium in length.
Short stories: Flash Fiction Online occasionally closes to submissions (I guess because they’re overwhelmed), but they are currently open.
Flash Fiction: Empirical Magazine runs a monthly flash fiction (<1000-word) competition.
Mixed: iWriteReadRate and Cornerstones Literary Consultancy (voteformyebook.com) are offering a monthly social competition to members of the community; it’s a great opportunity to receive professional feedback as well as contribute to developing your profile and platform. The prize is a fantastic Cornerstones masterclass mini-critique on the winning writer’s first pages of their story, up to 2000 words. This is designed to give the writer a professional critique on how to improve the opening as well as hints to consider throughout their writing. Simply upload an ebook (novels or collections of short stories) to iWriteReadRate. Every month we’ll select five to take part in the competition. All the writer needs to do is promote it with their networks and aim to get as many votes for their ebook as possible. At the end of each month the ebook with the most votes wins the prize.
Mixed: Pockets and Creative Print Publishing (both have different themes each month), Opening Editions (free).
Novels: novelrocket.com/p/launch-pad-contest.html has monthly competitions (April-Sept) with a different genre each month.
Scriptwriting: Scripped has a variety of script contests including a monthly one.
Short stories: Hayley Sherman has a monthly short story competition.
Short stories: Brighton COW (currently on hiatus), Coast to Coast, Glimmer Train (different category each month), Writing / Writers’ News magazines and Opening Editions.
Short stories: Bound Off now take submissions via Submishmash.
Short stories: Darker Times Fiction is a monthly short story competition for stories of 3,000 words and less in the horror genre or on the subject of ‘darker times’. It’s open to UK and international writers and ends on the last day of each month and costs £5 / $8 a time.
Short stories: The Global Short Story Competition is a monthly event hosted by Inscribe Media. There is no theme or set genre. 2000 word maximum word count. Writers must be 16 years or over. Maximum 4 submissions per month. Closing Date: The last day of every month. Prize: Monthly first prize – £100, Monthly runner up – £25, Annual Grand Prize – £250. Entry Fee: £5 per story (up to 4 per month). Details from http://www.inscribemedia.co.uk/global-short-story-competition.html.
Short stories: Hayley Sherman runs a monthly short story competition for submissions on any subject up to 2,000 words. The winners are published on the website, promoted online and receive a £10 First Writer voucher. All entrants are also considered for publication in The New Short Story Annual at the end of the year. Deadline 25th of the month.
Short stories: Heather Marie Schuldt runs a short story contest, 500-750 words max., on her blog, with the same deadline (25th of the month).
Short stories: fivestopstory.com/write: competitions cost £4 per entry (2 for £7, 3 for £8, optional feedback £5) and have monthly prizes of £50. There is also a £150 prize for the overall winner of their 2013 league table and you can become a member for £25 which entitles you to 3 free entries per month (2013).
Short stories: LinkedIn’s Aspiring Writers Group runs a monthly short story competition. You do have to be a member of LinkedIn (free) and the writing group itself (a closed group but you can ask to join) to enter the competition.
Flash fiction: Wow Women on Writing and writingcompetition.org.uk.
Poetry: Flash 500 Fiction Competition.
Short stories: Aeon Award, Cheer Reader, Dark Tales, Emerald Flash Fiction, Five Stop Story, Flash 500 Fiction Competition, and Writers’ Village.
Children’s: Dal Burns‘ children’s writing competition ‘Write Across America‘.
Children’s: Little Star Writing is a site where you can “get published, enter competitions, win prizes, play games, improve literacy skills, receive certificates and HAVE FUN!”.
Flash fiction: One Forty Fiction and Wow Women on Writing.
Mixed: What The Dickens magazine lists “competitions and give-aways which are all free to enter”.
Mixed: sterlingmag and sundayat6mag.wordpress.com
Mixed: You can apply for a three-month residency on the Mslexia blog (women only).
Non-fiction: tales2inspire.com/HOME.html (free 🙂 )
Novels: Novel Rocket runs an annual Launch Pad Contest: Boosting You Out of the Slush Pile. Entries will be accepted in all genres beginning mid-January. The deadline for submission is different for genre categories according to the following schedule. In each case, entries must be received by 11:59 PM EST on the 10th day of the month (April to September) listed on novelrocket.com/p/launch-pad-contest.html. They also post a new writing-related article seven days a week, from author interviews to marketing discussions to articles about the craft of writing.
Poetry: Poetic Republic is an ongoing online poetry competition in which the entrants are also the judges.
Scriptwriting: bbc.co.uk/writersroom/links5.shtml.
Short stories: Creative Writers’ Circle competitions are open to all and are free.
Short stories: Flash Fiction Online is a 500-1000 word site that is free to subscribe / read, free to submitto. Payment is via donations with 60% going to the author and 40% going to the site so there’s no way of knowing how much (if anything) you’d earn but another opportunity perhaps.
Short stories: Author and columnist Lorraine Mace runs the Flash 500 flash fiction and humorous verse competitions.
Short stories: on-going competition for submissions of 500 words or fewer on any theme. First prize is £100 plus publication on our website and promotion via our social media sites (twitter, google+ and facebook). Second prize is £75 and publication on the website, third prize is £50 and publication on the website. The judge changes quarterly and is currently BAFTA and OSCAR nominee, screenwriter, playwright and novelist William Nicholson. Entry is just £4. William Nicholson will be judging until 28th August when the competition will then continue with another judge.Entries would be very welcome and please tell your members that we just launched yesterday! (June 1, 2013) Thank you, Jeni. writingcompetition.org.uk Find us on Facebook: facebook.com/TheWritingCompetition?ref=hl Tweet us on Twitter: twitter.com/writing_comp.
Short stories: Short Funny Story wants humorous short stories or true-life events and pay $15 for every story published online with $25 extra for any story chosen for inclusion in their anthologies.
Short stories: Penny Dreadfuls 21 commissions short stories.
Short stories: Words Magazine short story competition guidelines.
COMPETITION WEBSITES
Flash Fiction: Creative Times has a list of their top 10 paying flash fiction competition sites. There are also some listed on nationalflashfictionday.co.uk/competitions.html.
Flash Fiction: @ShortStoryCompHQ has great list of flash fiction and short story competitions on shortstorycompetitionhq.com/directory.
Mixed: Be a Better Writer has a list of (mostly American) current and future competitions.
Mixed: Book Marketing Maven has a list of a few.
Mixed: Duotrope is a great resource for competition and submission opportunities.
Mixed: FanStory lists a variety of ongoing competitions and is a site where you can “share your writing and learn from the feedback that you will receive on everything you write. That includes poetry, stories, book chapters and scripts. When you post your writing you will get feedback that will determine your place in the rankings. FanStory.com is a popular writing site for writers of all skill levels”.
Mixed: Fiction Addiction lists a few competition sites.
Mixed: firstwriter.com/competitions has a great list of competitions but you have to subscribe (not free) to the site to access the full details.
Mixed: Ideas Tap has a great list of allsorts.
Mixed: Jacqui Burnett’s Writer’s Bureau has a list of a variety of forthcoming and ongoing competitions.
Mixed: Carole Burdock’s bi-monthly magazine Kudos.
Mixed: Loquax.com lists thousands of competitions including writing comps.
Mixed: The National Association of Writers Groups (based in the UK) lists their competitions on nawg.co.uk/competitions/open-competitions.
Mixed: West Country Writers has a bijoux collection of competitions. 🙂
Mixed: Words Magazine has a variety of competition information.
Mixed: The Poets & Writers website include contests, grants and awards.
Mixed: prizemagic.co.uk has a variety of competitions.
Mixed: Sally Quilford‘s competition calendar.
Mixed: Trafford Publishing lists them a month per page.
Mixed: free literary monthly magazine Words with Jam have regular competitions.
Mixed: Write Link also lists forthcoming competitions.
Mixed: Writers Reign lists short story, poetry, non-fiction, performing arts, rolling competitions, children’s writing competitions and book writing awards.
Mixed: writingcontests.wordpress.com lists various competitions.
Novels: apostrophebooks.com/fictionfasttrack.
Poetry: Poetry Kit, poetrylibrary.org.uk/competitions, Writers Reign.
Poetry: You might also like to take a look at Poet Laureate Alice Shapiro’s website. Alice kindly provided some poetry tips for this blog in August 2011. 🙂 Poet Scott E Green dropped by and left a comment on my me page to say that his blog has multi-genre competition and submission info. I checked it out and it looks really useful.
Poetry: The Writers’ Forum Poetry Competition is a monthly contest for poems of up to 40 lines. Closing: Monthly. Entries arriving too late (after the 15th) for one month go forward to the next. Prizes: 1st: £100. Runners-up: A Brewer’s Dictionary of Phrase and Fable. Entry Fee: £5 each, £3 each thereafter. Includes a critique (sae required if entering by post). Comp Page: writers-forum.com/poetrycomp.html.
Scriptwriting: hollywoodscriptexpress.com/screenplay_contests.html, scriptfactory.co.uk/go/Default.html, writesofluid.co.uk/screenwriting-competitions.html, and thespiannet.com/writing_contests.shtml.
Short stories: BookTrust has a wonderful list of over 50 short story competitions.
Short stories: Christopher Fielden has a great list of multi-national short story competitions.
Short stories: @ShortStoryCompHQ has great list of flash fiction and short story competitions on shortstorycompetitionhq.com/directory.
Short stories: Writers Reign‘s short stories competitions page lists by deadline date.
Short stories: other sites include Poetry Kit (“shorts & other comps”) and Words Magazine.
Short story collections: apostrophebooks.com/fictionfasttrack.
If you discover any broken links, closed competitions or know of ones that I haven’t listed here, please do email me with details.
5PM Fiction 283: The Reason Why
Welcome to the two hundred and eighty-third in this series that is ‘5pm Fiction’.
I was nearing completion of the 2012 project when I decided that I didn’t want to stop at the end of May so 5PM Fiction was born. I put a load of prompts on the 5PM Fiction page and today’s was to write a monologue from the prompt of ‘loveable rogue’. Here is my 496-worder.
Like a dog with a bone. I’d always been like that. Take after my father. My mum’s the pushover. No, that’s not fair. Just softer, nicer really. On the inside and out. I’m just nice on the outside, when I feel like it… which is what got me in this position in the first place. I got greedy.
One of the seven deadly sins. I’m working my way through them, not on purpose but just how life’s turned out. Adultery. Been there, a few times on both sides. Black eyes – given and taken.
You don’t like me, I can tell. There’s not a lot to like, but you’ll get there. I do have some redeeming features, no black eyes at present. I’m fairly good looking without them. With them, the women feel sorry for me… like having a baby in a shopping trolley; I just put on my ‘not my fault’ face and they flock.
So, you’ll want to know why I’m here. Or maybe you won’t, but you’re curious. Determined not to like me. But want to know why you might by the end of this one-sided conversation. Reserving judgement is a good thing. I’m a guns-blazing kind of guy, act before I think and suffer the consequences.
OK, go back a couple of months, yeah, only just got here so it’s new to me too.
I hit someone… in a van. They weren’t in the van, just me, but they were in the way so I kept going. Normally, I’d have stopped, but when you’re being chased, you don’t think straight, and the guy I hit – I’d have stopped for a woman, swerved at least, I’m not that bad. I knew him. Tommy Sandford, bad as me, worse, although you won’t believe me. I’m emotional bad, not really breaking the law, he’s a big-time crook… medium-time anyway. So far over the line, he can’t remember what it looks like.
Didn’t take them long to find me, after hitting Tommy. I’d stolen the van. A publicity van – one that the council owns and a guy drives around the county changing their posters. Stupid git left the engine running. I hear an engine noise, no one in the driver’s seat, no one inside at all, I’m going to take it. Who wouldn’t? Invalidates their insurance, so it was his fault not mine. It was like a test, see who takes it first. I wasn’t the nearest, there were others but they were busy, or not paying attention. I pay attention so I thought, why not? How was I to know it had a tracking device?
I did the world a favour, if you ask me. Tommy had always been on the wrong side; of the law growing up, of the road when I hit him. Made a mess of the van, as you would expect. I am sorry for that, I’m a taxpayer too. And now for the reason why you will come to like me…
Book review – for readers and writers – no.16: Beryl Belsky reviews The Elegance of the Hedgehog by Muriel Barbery
October 16, 2013 December 12, 2014 3 Comments
Today’s book review is brought to you by Beryl Belsky of The Writer’s Drawer.
If you’d like your book reviewed or to send me a book review of another author’s book, see book-reviews for the guidelines. Other options listed on opportunities-on-this-blog.
Synopsis of Muriel Barbery’s The Elegance of the Hedgehog (Europa Editions, 2008)
Renee is the concierge of a grand Parisian apartment building, home to members of the great and the good. Over the years she has maintained her carefully constructed persona as someone reliable but totally uncultivated, in keeping, she feels, with society’s expectations of what a concierge should be. But beneath this facade lies the real Renee: passionate about culture and the arts, and more knowledgeable in many ways than her employers with their outwardly successful but emotionally void lives. Down in her lodge, apart from weekly visits by her one friend Manuela, Renee lives resigned to her lonely lot with only her cat for company. Meanwhile, several floors up, twelve-year-old Paloma Josse is determined to avoid the pampered and vacuous future laid out for her, and decides to end her life on her thirteenth birthday. But unknown to them both, the sudden death of one of their privileged neighbours will dramatically alter their lives forever. By turn moving and hilarious, this unusual novel became the top-selling book in France in 2007 with sales of over 900,000 copies to-date
Among the first things I learnt about Muriel Barbery were that she lived in Kyoto, Japan, in the years 2008-9, and that she and her husband Stéfane Barbery have been captivated by Japanese culture for well over a decade. As she said in an April 2009 interview with Times Union freelance writer Elizabeth Floyd Mair:
Our fascination began mostly as an aesthetic one, and has remained so: we are fascinated by the ability to create pure beauty, at the same time refined and pure; the kind of thing you see in the slow, sweet sumptuousness of [Yasijiro] Ozu’s films, in the splendor of the Japanese gardens, in the discreet sophistication of ikebana …
This intrigue is woven both subtly and directly into her book The Elegance of the Hedgehog,[i] which she dedicates to Stéfane, and who, it turns out, also cooperated in writing it.
Both Renée Michel and Paloma Josse, the two main characters in the book, have a “Japanese side.” Renée is the concierge in a luxury apartment block in Paris. Superficially, she is the typical concierge, a drab, dour widow who lives alone in the small lodge allotted to such French “institutions” in the building. Underneath, however, she is an autodidact, a lover of Tolstoy and of Japanese aesthetics, which she has absorbed from watching numerous Ozu films.
Paloma, a 12-year-old girl living with her upper middle class, socialist parents on the fifth floor, is also hiding a secret: her super-intelligence and her decision to kill herself when she reaches her 13th birthday. In the meantime, she searches for meaning to life by keeping two journals, one of “Profound Thoughts,” with each “thought” prefaced by a verse in Japanese haiku (3 lines) or tanka (5 lines), and the other of “the Movement of the World,” about “masterpieces of matter.” For light entertainment, she reads Japanese manga comics (she is studying Japanese at school).
The thread that connects these two complex characters is Kakuro Ozu, who purchases an apartment in the building. (Interestingly, the apartment is sold to him after the death of Monsieur Arthens, the food critic, who appears in Barbery’s first novel, Gourmet Rhapsody.) Ozu suspects that Renée is not the uncultured person she pretends to be and shares his suspicions with Paloma. In her journal of “Profound Thoughts,” Paloma writes:
I’ve had my own suspicions on the matter for a while now too… I’ve been watching her. .. Madame Michel has the elegance of the hedgehog: on the outside she’s covered in quills… but my gut feeling is that on the inside, she has the same simple refinement as the hedgehog: a deceptively indolent little creature, fiercely solitary ‒ and terribly elegant.
Renée is equally, but cautiously fascinated by Kakuro, and learns from him that he is distantly related to the filmmaker Yasijiro Ozu. When she discusses her feelings about life with the reader (her thoughts and Paloma’s journals are typeset in different fonts), you can see the extent to which she has been influenced by Ozu’s films. When drinking tea with her friend Manuela, the cleaner, for example, she ruminates:
Today, because our ritual has been transgressed, it suddenly acquires all its power; we are tasting the splendid gift of this unexpected morning as if it were some precious nectar; ordinary gestures have an extraordinary resonance, as we breathe in the fragrance of the tea, savour it, lower our cups, serve more and sip again: every gestures has the bright aura of rebirth.
Later, she discusses the Japanese use of space, which impressed her from the first Ozu film she saw, Flavour of Green Tea over Rice. She compares the closed or open door, which “disrupts continuity of movement, without offering anything in exchange other than freedom of movement,” with Japanese sliding doors, “which avoid such pitfalls and enhance space.”
Her first visit to Kakuro’s apartment she compares to summer rain following a lifetime of daily toil:
… pure beauty striking the summer sky, awe-filled respect absconding with your heart, a feeling of significance at the very heart of the sublime, so fragile and swollen with the majesty of things, trapped, ravished, amazed by the bounty of the world.
In her struggles to find some meaning to life, at least intellectually, Paloma, too, is an observer and a philosopher. Her thoughts about cats, for example, she introduces with the haiku,
The cat here on earth
Modern Totem
And intermittently decorative
Following an incident at the dinner table in which she corrects one of her parents’ guests about the origins of the game go, which he attributes to Japan instead of China, she writes angrily ‒ referring to her own imminent death ‒ the tanka:
To build
You live
These are
A conversation with Kakuro about the works of Tolstoy, a love of which he shares with Renée, inspires her to write a haiku about the birch trees he describes in War and Peace:
Teach me that I am nothing
And that I am deserving of life.
This precocious child, who understands that others see her as a brat, also wonders whether she is not turning into a “contemplative aesthete, with “major Zen tendencies.” Having witnessed the fall of a rosebud from a broken stem onto the kitchen counter, she observes:
In that split second, while seeing the stem and the bud drop onto the counter, I intuited the essence of Beauty… a calm mind, lovely roses, a rosebud dropping… It’s the ephemeral configuration of things in the moment when you see both their beauty and their death.
I will not give too much away about this book, which deserves a second and possibly even a third reading to appreciate its multiple layers and views of life, not to mention its biting humor. And despite all the philosophizing, there is a story line. There is no doubt in my mind that Muriel Barbery, who is herself a professor of philosophy, wrote this book partly as a way to set down, in essay form, her own thoughts, which are strongly influenced by Japanese aesthetics, as well as to mock “high” bourgeois intellectualism and academic pretentions. Renée and Paloma are the ideal vehicles for this task; Kakuro is the catalyst who discerns their “Japanese side,” draws them out and leads them to understand that they are not alone in the world, but three kindred spirits. Whether the book ends on a tragic note because Barbery understands that Kakuro’s and Renée’s feelings for one another cannot go any further in a society where class boundaries continue to constrict, only she can say. But Paloma has the final word and in it there is hope and redemption.
Finally, a word should be said about the translation. Translation is an art in itself, and credit should be given to Alison Anderson for her excellent and nuanced work. A novelist herself, she deserves a place among lauded translators such as Maureen Freely, who interpreted the complex works of Turkish author Orhan Pamuk so brilliantly, and Nicholas de Lange, who has produced from the Hebrew wonderfully fluent English renditions of several of the classic works of Israeli author Amos Oz.
[i] Originally, L’élégance du hérisson (Paris: Editions Gallimard, 2006).
This review was originally posted on http://www.thewritersdrawer.net/barbery.html.
A fascinating book. Thank you, Beryl.
Beryl Belsky is a graduate in East Asian studies (Japanese) and political science from the Australian National University, and works as an academic editor.
She was born in Eire, grew up in Australia, and currently lives in Israel.
If you would like to send me a book review, see book-reviews for the guidelines. Other options listed on opportunities-on-this-blog.
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Trial for 3 ex-cops opens in Pa. immigrant death
Three police officers in a Pennsylvania town obstructed a federal investigation into the fatal beating of an illegal Mexican immigrant to protect white football players to whom they had close pe...
WILKES-BARRE, Pa. – Three police officers in a Pennsylvania town obstructed a federal investigation into the fatal beating of an illegal Mexican immigrant to protect white football players to whom they had close personal ties, a prosecutor said Thursday.
Former Shenandoah Police Chief Matthew Nestor and two subordinates orchestrated a cover-up in the July 2008 beating death of 25-year-old Luis Ramirez in an effort to shield the teenage perpetrators, Justice Department prosecutor Myesha Braden said in her opening statement. One officer was dating the mother of one of the teens at the time, she said.
"Relationships are at the heart of why these three defendants covered up a malicious crime," she said. "Relationships combined with privilege to overthrow the rule of law."
Nestor, Lt. William Moyer and Patrolman Jason Hayes are charged with falsifying police reports and tampering with witnesses. Moyer is additionally charged with evidence tampering and lying to the FBI. They have pleaded not guilty.
Defense attorneys rejected the government's allegations, calling their clients honest small-town officers doing the best they could under difficult circumstances.
"From the get-go, they had the right suspects," said Enid Harris, Moyer's attorney. "Nobody was hiding anything under a rock or behind a tree."
Two men who took part in the assault were convicted in October of a federal hate crime. Derrick Donchak, 20, and Brandon Piekarsky, 19, face a maximum of life in prison when they are sentenced later this month.
Braden told jurors that Hayes and Piekarsky's mother were dating at the time of the assault; the couple are now engaged. She said Moyer was an avid fan of the high school football team, even attending practices while on duty. Their commanding officer, Nestor, was a close friend of Hayes and Tammy Piekarsky and vacationed with them.
So "they covered up the beating, a racially motivated beating," Braden said.
Nestor's attorney, Joseph Nahas, said the chief called the district attorney's office immediately after learning the seriousness of Ramirez's injuries, and had little to do with the investigation thereafter.
Nahas acknowledged that Nestor traded phone calls with Tammy Piekarsky the night of the attack, but urged the jury not to read anything into them. Nahas said it's not unusual for a police chief, especially one in a small town like Shenandoah where everyone knows everyone else, to talk to the parents of teens in trouble.
"Here's what the government doesn't get," he said. "What they view as corruption, collusion and conspiracy, I view as community, caring and consideration."
The confrontation began late in the evening of July 12, 2008, when a group of drunken athletes walking home from a block party came across Ramirez and his girlfriend in a park. The teens hurled ethnic slurs at Ramirez, then fought with him. Piekarsky was accused of delivering a fatal kick to Ramirez's head after he'd been knocked unconscious by another teen, Colin Walsh, who has already pleaded guilty in federal court and awaits sentencing.
The teens gathered at Donchak's home shortly after the fight, Braden told jurors, and Piekarsky's mother showed up and told them that she had been in contact with her boyfriend, Hayes — and that they needed to "get their stories straight" because Hayes had told her that Ramirez's condition was deteriorating.
The teens subsequently hatched a plan in which they falsely told authorities that no one was drunk, did any kicking or used any racial slurs.
Walsh, the first witness in the officers' trial, testified Thursday that Moyer showed up at his home a day after the fight.
"He asked me if I talked to the other guys," Walsh testified. "He said, 'Do you know what I mean?' He said, 'Good luck.'"
Moyer also tried to get the parents of a fourth teen, Brian Scully, to take the fall for the others, Braden told jurors. Scully has pleaded guilty in juvenile court for his role in the attack and is expected to testify against the officers.
Harris painted her client as ill-equipped to handle a big investigation, saying he had written only one police report in his entire 12-year career. Moyer issued traffic tickets, investigated minor crimes like public drunkenness, and spoke to crime-watch groups, she said.
"He was the Barney Fife of the Shenandoah police department," Harris said, referring to the bumbling deputy played by Don Knotts on "The Andy Griffith Show." Harris said she didn't mean it pejoratively, but the allusion brought a grimace from Moyer.
The government must not only prove that Nestor, Moyer and Hayes took steps to shield the perpetrators, but that they did so to obstruct a federal investigation. Defense attorneys say that's impossible, because the FBI didn't even get involved in the case until several weeks later.
Hayes' attorney, Philip Gelso, denied that Hayes falsified his police report, and told jurors the officer had limited involvement in the case due to his relationship with Tammy Piekarsky.
It's the third trial stemming from the fatal assault. Piekarsky and Donchak were acquitted of serious charges in Schuykill County Court in May 2009, including third-degree murder in Piekarsky's case, bringing an outcry from Hispanic activists. The pair were subsequently tried in federal court.
MSHA proposes new rules for mine safety violations
Treasury: Financial bailout income at $35 billion
Senate blocks bill repealing $2B in oil tax breaks
Texas schools sue state, saying funding is unfair
John Edwards indicted in $925K mistress cover-up
Minnesota Man Convicted of Aiding Suicides Faces Sentencing
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Shortwave Radio: Reaching Dissidents in China? Good theory, but…
August 28, 2019 December 11, 2020 ~ Matt Armstrong ~ 9 Comments
Shortwave radio was a mainstay of international news and information programs. It was the “new media” embraced to bypass and overcome the censorship of cables, the “old media.” This was particularly true in the United States. Radio broadcasting was seen as such an important and critical element to our national security a century ago that the Secretary of the Navy, a newspaper owner interested in the psychological defense of the nation, tried several times to nationalize wireless transmitters. He may have failed, but he contributed to forcing a British firm to sell their U.S. broadcasting assets which became the Radio Corporation of America. Indicative of the importance of the medium, RCA voting stock could only be owned by U.S. citizens, a restriction that was not removed until the 1980s.
Continue reading “Shortwave Radio: Reaching Dissidents in China? Good theory, but… “ →
The Under Secretary for Public Diplomacy and Public Affairs: an updated incumbency chart and some background
August 26, 2019 December 2, 2020 ~ Matt Armstrong ~ 1 Comment
The Under Secretary for Public Diplomacy and Public Affairs was created in 1999 to lead the State Department’s existing public affairs operations and the reintegration of most of the global public affairs activities previously based in the department. These global activities had been removed in 1953 and rebranded in the late 1960s as “public diplomacy.” (Edmund Gullion is often credited with this rebranding, but proper attribution should go to Rep. Dante Fascell (D-FL), but that’s for another post.)
Since the office was established and the first Under Secretary was sworn-in on October 1, 1999, the office has been vacant 36% of the time. To be more precise, the office has been “unencumbered” with a confirmed Under Secretary for 35.8% of the days since October 1, 1999, with an average gap between appointments of 289 days (over 9.5 months). In December 2011, the Advisory Commission on Public Diplomacy released a report about this vacancy issue (at the time, I served as the Executive Director of the commission) and the next month I published a less restrained commentary on the topic, R we there yet? A look at the Under Secretary for Public Diplomacy (and Public Affairs). Above is an updated chart showing the tenure and vacancies of the office as of August 26, 2019.
Continue reading “The Under Secretary for Public Diplomacy and Public Affairs: an updated incumbency chart and some background “ →
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“Facing situation where it is better to be closed than to be open,” says Cineworld/Regal CEO – Could be 1-2+ months before they reopen
October 5, 2020 ~ Todd Russell
As mentioned Saturday (see: Cineworld To Close All 543 Regal Cinemas After No Time To Die delay, says Variety sources), Cinemark is closing all Regal Cinemas. This has been confirmed by the company and is scheduled at the end of business this Thursday 10/8/2020.
“Might be a month, might be two months (before we’ll reopen),” says Cineworld CEO Mooky Greidinger in CNBC interview (see video interview for full context below).
Mooky gave an interview this morning explaining why they chose to close all the theaters in the United States and James Bond being delayed is only one of the problems. It’s not being able to open theaters completely in the two biggest movie theater states: New York and California. This is a main driver in the decision because studios want those major markets more fully open before they release their biggest budget movies (Black Widow, No Time To Die, Wonder Woman 1984, etc). California is about 50% open and New York is still shuttered, despite indoor dining, bowling alleys, casinos being allowed to open.
After hearing what Cineworld main man Mooky has to say, credit two state government for not determining it’s safe enough to allow them to reopen. Maybe it’s not safe enough in those two states, but we’ve made the same observation before that casinos clearly are at least equally as high risk as movie theaters — and yet they’ve reopened.
On the subject of new movies, this is more complex and deserved some better interview question than the interviewer was informed enough to ask. I mean, talk about lobbing clueless softballs.
Yes, they aren’t getting the big budget movies because studios are delaying those titles. We’ve pointed out specific movies Cineworld/Regal should have shown recently while they were open like Bill and Ted Face The Music, but chose not to do so because it was a day and date release. I wish more news articles and reporting would highlight this important detail, but it’s continually left out as if it’s almost completely the fault of the studios and government for why movie theaters don’t have more new movies playing.
It’s not. It’s part of the theater chain’s fault, too, why they don’t have more new movies.
What about Mulan? Why wouldn’t Mooky and his team talk with Disney about Mulan? It was released internationally, but only on Disney+ plus an additional $30 in America. A few weeks later, it doesn’t require the Disney+, it can be watched on PVOD. This should have had a US release as well. Doesn’t sound like the movie performed that well, but certainly Regal could have worked out a deal with Disney to screen that movie. Somehow, some way — and I’m betting it’s because it was day and date release — that they didn’t.
I just wish somebody else in all this reporting and interviewing would ask the logical question, “if you temporarily ignore the theatrical window and embrace more direct to streaming titles you can show plenty of new movies, so why won’t you try that?”
Maybe some day someone with a microphone will ask execs like Mooky these hardball questions. Cineworld/Regal is the same company who has vowed never to show movies that don’t respect the theatrical window and yet he is whining about being like a grocery store without groceries? Terrible analogy for those who deep dive the facts.
Again, they don’t have to stick by whatever the temporary decision they make with the theatrical window once the pandemic is over. They seem to feel if they violate their principles, if they make an exception during these times they won’t be able to put the toothpaste back in the tube.
Putting all that aside, it seems like Cineworld/Regal might have hung in there, if they could have gotten New York theaters open and more like the 90%+ theaters they wanted in California. That would have given studios more incentive to stick with the November releases. That’s all spilled milk we can’t cry over. Now we’re looking at them more realistically reopening around Christmas.
Stick a fork in 2020 at the movie theaters in the United States. It’s game, set and match — for you know what.
Posted in news cineworldcoronaviruscovid-19regal cinemastheatrical window
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3 thoughts on ““Facing situation where it is better to be closed than to be open,” says Cineworld/Regal CEO – Could be 1-2+ months before they reopen”
Pingback: Word on the Street: Regal Cinemas to Temporarily Close Their Doors + 2019’s ‘The Lion King’ Will Receive a Second Film – 18 Cinema Lane
Pingback: Dune postponed to 2021, The Batman to 2022, AMC doubles down on their theaters staying open – Movies, Movies, Movies
Pingback: AMC Reopening More Theaters – Shortened Theatrical Window Cited as Key Competitive Advantage – Movies, Movies, Movies
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The Mindy Project - Season 3
Episode 01: We're a Couple Now Haters Episode 02: Annette Castellano Is My Nemesis Episode 03: Crimes & Misdemeanors & Ex-Boyfriends Episode 04: I Slipped Episode 05: The Devil Wears Lands' End Episode 06: Caramel Princess Time Episode 07: We Need to Talk About Annette Episode 08: Diary of a Mad Indian Woman Episode 09: How to Lose a Mom in 10 Days Episode 10: What About Peter Episode 11: Christmas Episode 12: Stanford Episode 13: San Francisco Bae Episode 14: No More Mr. Noishe Guy Episode 15: Dinner at the Castellanos Episode 16: Lahiri Family Values Episode 17: Danny Castellano Is My Nutritionist Episode 18: Fertility Bites Episode 19: Confessions of a Catho-holic Episode 20: What to Expect When You're Expanding Episode 21: Best Man
The series follows obstetrician gynecologist Mindy Lahiri as she tries to balance her personal and professional life, surrounded by quirky co-workers in a small medical practice in New York City. Mindy begins Season 3 of this comedy in unfamiliar territory: she's in a steady relationship with Danny, a fellow ob-gyn at Shulman & Associates, but as coworkers, she wants to keep their romance a secret.
Actors: Mindy Kaling,
Mindy Kaling 24 June 1979, Cambridge, Massachusetts, USA
Chris Messina,
Chris Messina 11 August 1974, New York City, New York, USA
Ed Weeks,
Ed Weeks
Ike Barinholtz,
Ike Barinholtz 18 February 1977, Chicago, Illinois, USA
Adam Pally,
Adam Pally 18 March 1982, New York City, New York, USA
Beth Grant,
Xosha Roquemore,
Xosha Roquemore 11 December 1984, Los Angeles, California, USA
Tracey Wigfield,
Tracey Wigfield 19 June 1983, Wayne, New Jersey, USA
Rob McElhenney,
Rob McElhenney 14 April 1977, Philadelphia, Pennsylvania, USA
Enrique Taylor,
Enrique Taylor
Natasha Key,
Natasha Key
Director: Mindy Kaling
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