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A silent epidemic

first_img ‘Worry about 4 weeks from now,’ epidemiologist warns Feeling more anxious and stressed? You’re not alone Related Chan School’s Koenen discusses rising mental health concerns in the coronavirus era Harvard’s Lipsitch urges public to ramp up social distancing, increase coronavirus tests center_img HMS:  Can anything even be done to prevent delirium if someone’s on a ventilator?Inouye:  There’s a lot you can do. Getting people up and walking reduces the risk of delirium, and there are protocols for walking people even when they’e on a ventilator. Some ICUs are doing that because studies show that walking raises oxygen saturation and gets patients off ventilators faster, which frees up the machines for other patients. It takes three staff members to help with the walking, but it can be done.In the ICU, you can lower delirium risk by preserving the sleep/wake cycle, such as by making the room dark and quiet at night and providing earplugs and eye masks. You can play soothing music. You can cycle medications (when medications are available). For those who are sedated, you can lighten the sedation periodically. You can have orientation boards up in the room to help patients remember where they are. You can help them communicate through writing or pointing. Some ICUs have developed therapeutic activities like fun games to keep the mind active. It’s not ideal when someone can’t be in the room regularly because of isolation precautions, but there still is a lot that can be done.And for COVID-19 patients who are not in the ICU, the regular delirium prevention checklist still applies. Other considerations include facilitating remote visits with family members, minimizing drugs associated with confusion, avoiding physical restraints, providing vision and hearing aids as needed and attending to nutrition and hydration.HMS:  What resources are available?Inouye:  Our Hospital Elder Life Program, or HELP, has created a website about COVID-19 and delirium. It includes a patient toolkit, delirium screening and management guidance, tools for advance care planning during the pandemic, help with social isolation and more. Within a week, people had translated the toolkit materials into Spanish and Portuguese.It’s also been wonderful to see new ways hospitals have devised to connect patients with family members and the outside world in secure ways. People are so creative in times of crisis. Everybody is reaching out and helping one another. HMS:  What information is emerging about how many COVID-19 patients experience delirium?Inouye:  The two best pieces of evidence I’ve found are a JAMA Neurology paper from April 10 on the neurologic manifestations of COVID-19 in China and an NEJM paper from April 15 on neurologic features in severe COVID-19. The JAMA study reported mental status change in 30 percent of patients, and the NEJM study found an even higher rate, with mental status change in 65 percent of patients and agitation in 69 percent. Both of those probably represent delirium. And that’s in all ages, not only older adults.HMS:  Is it too early to tell to what extent delirium may arise from the coronavirus itself versus the hospital environment?Inouye:  It’s not clear yet, but it’s likely a combination.There’s some evidence of direct invasion of the brain by the coronavirus. The loss of smell is probably from a direct invasion of the olfactory nerve, and that connects directly to the frontal lobes. The NEJM article showed some light-up of the meningeal space, which could be another sign of viral encroachment into the brain. In addition, there appears to be some vascular involvement, where the coronavirus increases people’s risk of stroke. That could be another etiology for delirium. And as you may have seen in the news, the virus can instigate a cytokine storm — a severe amount of inflammation — and a lot of those patients do very poorly.On top of those, you have all the sedatives and other drugs that can contribute to delirium.Then, as a result of delirium, people become immobilized and deconditioned, which in turn causes a cascade of consequences like pressure ulcers, falls, urinary tract infections, increased risk of dementia … That’s my fear: that it’s not just delirium, it’s all these really bad long-term outcomes.HMS:  Can the worst outcomes be avoided?Inouye:  I’m hoping we can change it. We need to get on a better path with the management of delirium. We need to minimize the use of these sedating medications when possible. We need to advocate for caregivers to be allowed back at the bedside. Some facilities are letting family members into rooms where patients have both COVID-19 and dementia to reduce risk of delirium, but there are still no-visitor policies in a lot of places. We need to be aware of the damage of social isolation in older adults as well. As human beings, we need connection. It’s so important for our survival.HMS:  What else gives you hope?Inouye:  If there is a silver lining to this pandemic, it’s that people are seeing how important delirium is. There may never have been this much delirium all at one time. I think it’ll raise awareness. And when we can let our breath out and have time to educate everyone again, at least we will have strategies and resources and training in place for the future.This interview was edited for length and clarity.To hear more about delirium and Inouye’s life and career, listen to our podcast, recorded several months before the SARS-CoV-2 pandemic emerged. This is part of our Coronavirus Update series in which Harvard specialists in epidemiology, infectious disease, economics, politics, and other disciplines offer insights into what the latest developments in the COVID-19 outbreak may bring.Only a few decades ago, medical professionals believed they couldn’t do anything to stop a subset of elderly patients in the hospital from sliding into delirium — an acute state of confusion that can arise from illness or surgery and that raises risk of serious health complications and death.Then Sharon Inouye proved that delirium is preventable. She created the world’s most widely used checklist to identify delirium and developed a program that hundreds of hospitals have used to reduce cases of the condition by an estimated 40 percent. Inouye is a professor of medicine at Harvard Medical School (HMS) and director of the Aging Brain Center in the Marcus Institute for Aging Research at Hebrew SeniorLife.Now, after years of progress, Inouye worries that hard-won best practices for reducing delirium risk are getting lost in the turmoil of COVID-19 care.Early data from peer-reviewed studies suggest that one-third of hospitalized COVID-19 patients of all ages, and two-thirds of those with severe disease, show signs of delirium, said Inouye. For a variety of reasons, some potentially avoidable, delirium management is falling behind, she said. Indeed, the pandemic has led to conditions almost perfectly designed to cause delirium, she said.That’s concerning to Inouye and colleagues because, as the American Delirium Society explains, patients who experience delirium in the hospital remain hospitalized longer than their peers, have more complications and are more likely to die during their hospital stay or in the following year, need long-term care or develop cognitive impairment, including dementia.Inouye spoke with Harvard Medicine News about why cases of delirium have risen during the coronavirus pandemic and what clinicians and caregivers can do about it.Q&ASharon InouyeHMS:  What worries you most about elderly populations’ increased susceptibility to the new coronavirus?Inouye:  I have so many worries. If I had to narrow it to my two major concerns, one is what social isolation is doing to all older people, even those who don’t have COVID-19. Older adults who are sheltering at home are not getting exercise, they’re not socializing, a lot are falling into depression, they’re getting weak and frail, and as a consequence there are more falls, more fractures, all kinds of things, such that they need to be hospitalized for non-COVID-19 reasons.The other issue is that we’re seeing an epidemic of delirium in COVID-19 patients globally, and it’s getting very mismanaged. A lot of that may be unavoidable — when you’re trying to keep someone alive, you may not follow the best practices for delirium prevention, so we can understand that — but I do think from talking to colleagues that some of it is avoidable.HMS: What may be avoidable and what may not?Inouye:  Reports from around the world indicate a pattern of overuse of chemical restraints such as antipsychotics and other sedating drugs. I think health care providers are feeling very anxious and pressured, so when a patient starts to get agitated, providers get scared for the patient’s safety and their own safety and feel they have to sedate the patient. But sedating them is not always needed and leads to many complications.I always try to put myself in other people’s shoes. Let’s say your patient has cognitive impairment so it’s hard to explain things to them, they have hearing impairment, they’re fearful, and you’re coming in there all gowned up like a person from outer space and your voice is muffled behind two masks and a face shield and you have to stay six feet away. They can’t see or hear you, they can’t read your lips. They’re confused and frightened. They can’t have a family member there to translate for them or calm them down. It’s like a setup to be a nightmare for an older adult. So your reaction is to reach for the drugs so you can quickly get the IV in, get a COVID-19 swab or a chest X-ray.I understand why it’s happening, and yet I really believe that if you could just take the extra minute to come close, hold their hand, look in their eyes … Some doctors are taping pictures of themselves to their gowns so patients can see them. Talk to patients and say, “Listen, I know how scary this is. We need to make sure you don’t have this infection, or if you do, that you get the right treatment. So here’s what I’m going to do right now.”It doesn’t take much extra time. But it’s still time, and doctors and nurses are just not able to do that right now because the volume is so high and the patients are so sick and health care workers are frightened. It’s a perfect storm of not-good things.And then, if patients do have to be sedated, a lot of the short-acting medications we would normally use have run out, so doctors are having to use drips of benzodiazepines, which under normal circumstances you would never give to older patients, or they’re using general anesthesia because there aren’t any other options. It’s not how anyone would want to practice. “We need to be aware of the damage of social isolation in older adults as well. As human beings, we need connection. It’s so important for our survival.”last_img read more

Women on the Verge, Starring Tamsin Greig, Set for London Run

first_img Women on the Verge played its final performance at the Belasco Theatre on January 2, 2011. It officially opened on November 4, 2010 with a cast filled with Broadway heavyweights including Tony Award winners Patti LuPone, Brian Stokes Mitchell and Laura Benanti, as well as Danny Burstein and Justin Guarini.  Women on the Verge of a Nervous Breakdown is set in 1980s Madrid and tells the story of the intertwining lives of a group of women whose relationships with men lead to a tumultuous 48 hours of love, confusion and passion. The musical features a book by Lane, with music and lyrics by Yazbek. Greig will star as Pepa. She won the Olivier for Much Ado About Nothing and received an Olivier nod for The Little Dog Laughed. Other stage credits include Jumpy, The God of Carnage and King John. Her screen credits include Green Wing, Black Books, Episodes, Shaun of the Dead, White Heat, The Guilty and Emma. View Comments Jeffrey Lane and David Yazbek’s Women on the Verge of a Nervous Breakdown, which closed early on Broadway in 2011, is set to open in London. The tuner, based on the Spanish movie of the same name by Pedro Almodovar, will star Olivier winner Tamsin Greig and begin previews on December 20. Opening night is scheduled for January 12, 2015 at The Playhouse Theatre. Bartlett Sher, who directed the Great White Way incarnation, will helm the reworked, scaled down, U.K. production.last_img read more

Two Seymour Police Officers Arrested After Lengthy Investigation

first_imgSeymour, IN—Wednesday, detectives from the Indiana State Police-Versailles Post arrested two officers with the Seymour Police Department on charges of official misconduct, ghost employment, and theft.The investigation into the officers began in October 2019 when allegations of ghost employment were made against former Chief William “Bill” Abbott, and current Captain Carl Lamb. Detectives with the Indiana State Police-Versailles Post were requested to conduct the investigation.During the four-month investigation, detectives determined that Abbott was employed by Schneck Medical Center to schedule off duty officers to provide security at the hospital. The investigation indicated that he allegedly performed his duties for Schneck Medical Center while he was also working in his official capacity with the Seymour Police Department.The investigation also determined that Lamb, while on duty as a member of the Seymour Police Department, allegedly worked outside employment for K4 Security out of Jeffersonville, Indiana. K4 Security had a contract to provide off duty police officers for work in the construction zone on I-65. Lamb coordinated and scheduled off duty Seymour Police Officers to work the security job while he was on duty with the Seymour Police Department. He was paid by K4 Security for those hours while also being paid by the Seymour Police Department.Lamb also was a part-owner and employee of BSafe Tactical, Seymour, Indiana. BSafe provided training to area schools, churches, and businesses. The investigation determined that Lamb allegedly worked for BSafe Tactical and received payment while also on duty in his official capacity with the Seymour Police Department.At the conclusion of the investigation, the case was turned over to a special prosecutor for review. This resulted in felony charges on allegations of Official Misconduct, Ghost Employment, and Theft being filed on Abbott and Lamb.Both Abbott and Lamb have remained on administrative leave from the Seymour Police Department during the investigation.last_img read more

Update on the latest in sports:

first_imgUpdate on the latest in sports: Golf returns to TV with charity skins matchUNDATED (AP) — Rory McIlroy and Dustin Johnson headline a $3 million charity match on May 17 that marks the return of televised golf. They will be partners against Rickie Fowler and Matthew Wolff in a skins match called “TaylorMade Driving Relief.” All the money goes to COVID-19 relief.McIlroy and Johnson will be playing for the American Nurses Foundation, while the Oklahoma State alumni team will be playing for the CDC Foundation.The match will be played at Seminole Golf Club in Juno Beach, Florida. It will be the club’s first event to be shown on TV.VIRUS OUTBREAK-REAL HEROES PROJECT Share This StoryFacebookTwitteremailPrintLinkedinRedditNFL-OBIT-SHULAWinningest NFL coach Don Shula dead at 90MIAMI (AP) — Pro Football Hall of Fame coach Don Shula has died at his home in South Florida. He was 90. May 4, 2020 BOSTON (AP) — New Red Sox outfielder Alex Verdugo said on Monday that he is fully healthy and he will be ready for the season — if there is one.Verdugo has used the delay caused by the coronavirus pandemic to rehab a stress fracture in his spine he already had when Boston acquired him from the Dodgers in the deal that sent Mookie Betts to Los Angeles on the eve of spring training. At the time, the Red Sox said he was not expected to break camp with the rest of the ballclub; Verdugo had said he may be ready “slightly after” opening day.Verdugo said he remained active at home after the Red Sox complex in Fort Myers, Florida, was shut down. But things have been easier since he was allowed to return to the ballpark last week, and he is now working out four days a week. Because of social distancing mandates, the only other player he has seen there is pitcher Chris Sale.COLLEGE BASKETBALL-LOUISVILLENCAA accuses Louisville basketball of recruiting violations The Miami Dolphins say Shula died Monday morning.He won the most games of any NFL coach and led the Dolphins to the only perfect season in league history.Shula surpassed George Halas’ league-record 324 victories in 1993. He retired following the 1995 season with 347 wins, 173 losses and six ties, and was inducted into the Pro Football Hall of Fame in 1997.Shula became the only coach to guide an NFL team through a perfect season when the 1972 Dolphins went 17-0. Dolphins owner Stephen Ross says that if there were a Mount Rushmore for the NFL, Don Shula would be chiseled into the granite. NEW YORK (AP) — Mike Trout and Gerrit Cole aren’t the only major leaguers with a big financial incentive to get back on the field.While they head a starry quartet that would take in more than $200,000 per game, 65 players would earn at least $100,000 each time their team wins or loses.That’s according to an Associated Press analysis of their contracts.Most rookies and those making the minimum would get nearly $3,500 each from a major league payroll of about $24 million per game. Clubs would benefit, too, with huge revenue streams flowing from regional sports networks and national broadcast contracts.GOLF-SEMINOLE MATCHcenter_img In other NFL moves:— The Dallas Cowboys have made room for new backup quarterback Andy Dalton by waiving the player who sat behind Dak Prescott for most of the past three seasons. Cooper Rush saw mop-up duty in five games. Prescott hasn’t missed a game in his four seasons. Dalton, a former Cincinnati starter, is guaranteed at least $3 million in his one-year contract.— Former third-round pick Nazair Jones was one of four players waived by the Seattle Seahawks as the team reached its 90-man roster limit. Jones, running back Adam Choice, defensive tackle Shakir Soto and linebacker Pita Taumoepenu were all released Monday. Jones was the only one to have played in a game for Seattle.MLB-RED SOX-VERDUGORed Sox OF Verdugo says he’ll be ready for start of season Sports greats celebrate health care workersUNDATED (AP) — New Orleans Saints quarterback Drew Brees, Hockey Hall of Famer Wayne Gretzky and U.S. women’s soccer star Carli Lloyd are among the athletes who are participating in a project which will recognize and celebrate health care workers for their efforts during the coronavirus pandemic.“The Real Heroes Project” is a collaborative initiative among 15 leagues, including Major League Baseball, the National Football League, National Basketball Association, National Hockey League and Major League Soccer.Participating athletes will share a personal thank you message on social media utilizing #TheRealHeroes from today. Athletes will cover their name on their jerseys or uniforms and replace it with the name of the health care worker they are honoring.Public service announcements will debut on Wednesday across league and team platforms. Other leagues also are participating.,Tampa Bay Lightning advance to face Dallas Stars in Stanley Cup finals, beating New York Islanders 2-1 in OT in Game 6 LOUISVILLE, Ky. (AP) — Louisville has received a notice of allegations from the NCAA that accuses its men’s basketball program of committing a Level I violation with an improper recruiting offer and extra benefits and several Level II violations that accuse former Cardinals coach Rick Pitino of failing to promote an atmosphere of compliance.The notice is the completion of a nearly two-year NCAA investigation.Louisville acknowledged its involvement in federal corruption investigation of college basketball related to the recruitment of former player Brian Bowen II, which led to the ousters of Pitino and athletic director Tom Jurich in October 2017.VIRUS OUTBREAK-BASEBALL SALARIESAP Exclusive: Trout, Cole top 65 to earn $100,000 per game NFL-BEARS-GINNBears sign Ted Ginn Jr. to one-year dealLAKE FOREST, Ill. (AP) — The Chicago Bears have signed wide receiver Ted Ginn Jr. to a one-year contract.A 13-year veteran who has played in Super Bowls with San Francisco and Carolina, Ginn caught 30 passes for 421 yards and two touchdowns with New Orleans last season. He has 409 receptions for 5,702 yards and 33 touchdowns for Miami, San Francisco, Arizona, Carolina and New Orleans.Ginn has returned 257 punts for 2,600 yards with four touchdowns and 307 kickoffs for 6,899 yards and three TDs. He is one of 10 players to return two kickoffs for touchdowns in the same game. In 2009 he became the first to run back two for 100 yards in the same game. Associated Press last_img read more