The Dimming of the Shining City

By Jason Terk, MD

Published by KevinMD.com on October 20, 2021. You can read the original article here.

In March 1630, John Winthrop delivered the treatise “A Model of Christian Charity” at Holyrood Church in Southampton, England, prior to leading the first settlers of the Massachusetts Bay colony on their to journey to the New World. In his address, he referred to the new community they would found as a city upon a hill with the eyes of all people upon them. This reference to a portion of Jesus’ Sermon on the Mount underscored the importance of committing the colonists to brotherly love and unity, setting the needs of others and the community above one’s own needs.

I first heard this reference to a shining city on a hill at the moment of my political awakening and at the close of Ronald Reagan’s presidency in his farewell address in January 1989:

I’ve spoken of the shining city all my political life, but I don’t know if I ever quite communicated what I saw when I said it. But in my mind, it was a tall, proud city built on rocks stronger than oceans, wind-swept, God-blessed, and teeming with people of all kinds living in harmony and peace; a city with free ports that hummed with commerce and creativity. And if there had to be city walls, the walls had doors, and the doors were open to anyone with the will and the heart to get here. That’s how I saw it and see it still.

I was never much a fan of Reagan but did recognize his desire to lead all of us as a nation of different people who had unique talents to share and whose commonality of purpose exceeded partisan divisions. I also recognized that this vision was as aspirational as the source that inspired it. North stars have their role if only we faithfully chart our course by them.

As Reagan’s farewell words washed over me, I looked ahead at my immediate future and recalled my recent past. I would graduate from college a few months later and start medical school. I had just completed an idyllic nine months of study in Hamilton, New Zealand, an experience that still influences me today. I witnessed a nation of diverse people that cared about each other meaningfully. The Kiwi culture is exemplified in their national sport, rugby, emphasizing the team over the individual.

That promise of the shining city seemed more tangible as we witnessed the close of the 1980s and experienced the bliss of the 1990s. I and my contemporaries moved through those years, getting married, starting families, starting jobs, and acquiring mortgages. The demons of our nation still seemed to be suppressed by our angels for the most part. We could not know that the seeds of the cataclysm that was 9/11 and the divisions that would follow were germinating beneath us.

The number of years since that horrible day has verily seen the transformation of who we are and how we are. No longer do we have a presumption of goodwill toward those who are politically, religiously, or philosophically different from us. Yes, we have always borne the demons of racism and intolerance through our nation’s shared history, but there was almost always the patina of unity among us save for the years of the Civil War. Rather, we are now in a season of distrust and tribalism where each partisan seeks to win leverage for the sake of power alone only for those of like mind and mission.

The most insidious part of this darkening of our nation is the democratization of truth and the obfuscation of our understanding of reality. A lie told a million times on social media becomes fact. No longer can we count upon rationality, logic, and evidence to be the measures we employ to discern truth. Truth has been abducted to serve the mission of elevating influence, gaining advantage, and exercising power. It is a rot that is destroying us and creating many victims. The internet, formerly and quaintly referred to as the information superhighway, has become our road to perdition and the chief means of the purveyance of agenda-driven disinformation coming from both extremes of the political spectrum. The algorithms move us into our demagogic poles and obliterate the common ground where consensus suffocates from lack of oxygen.

This organized perpetration of deception has taken on more meaning as we have faced the last century’s most critical public health threat. Freedom which was once defined as something that required a personal sacrifice of individual concerns in deference to the needs of others and the community has now become rebranded as solely within the province of individual liberty. The simple acts of individuals wearing masks or getting vaccinated to protect all of us and ending the pandemic for our towns, cities, states, nations is too much for many among us who have distilled their catalyzed grievances into refusals to sacrifice their “personal freedom.”

Indeed, as I write these words, state legislatures, including our own in my state, are codifying this movement into law with bans on companies including hospitals, nursing homes, and medical facilities from requiring COVID-19 vaccination for their employees. And, those legislators are doing it not because of some sincerely held principles, but because they know which way the wind blows and cynicism Trumps all other considerations in getting reelected.

The victims of this now distorted concept of liberty are ones that we physicians encounter every day. The one that inspired this essay for me is an 11-year-old boy that I saw three weeks ago. He is a patient of mine in my pediatric practice who came to see me with typical respiratory symptoms that led to a diagnosis of COVID-19. While he recovered uneventfully, his father got sick the next day and died from the same illness five days later. Like the vast majority of people who die from COVID-19 now, he was unvaccinated, believing that getting vaccinated was unnecessary and part of a greater effort to undermine his personal liberty. His son is now dealing with the unimaginable grief of losing a parent at such a tender age and asking his mother if he killed his father by getting sick and causing his death. This happens every day now in our communities across our nation. These are wounds that will never heal for this generation of kids.

We have no hope of exiting this pathway to darkness unless we can collectively rise above our manufactured grievances and reductive individualism to truly witness and love each other. We must recognize and reconcile the real harms done to each other in the evil pursuit of purely selfish interests. Only then can we renew and rekindle the true light of a successful community and our city on the hill.

Tarrant County COVID-19 Activity – 01/18/22

COVID-19 Positive cases: 454,638

COVID-19 related deaths: 5122

Recovered COVID-19 cases: 374,926

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County updated Tuesday, January 18, 2o22. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Volunteers Needed for Arlington COVID-19 Testing Site

Tarrant County will be activating a COVID-19 surge testing site in Arlington. The Tarrant County Office of Emergency Management requests volunteers to assist with line management and other miscellaneous duties.

Volunteers will work 3.5-hour shifts with three volunteers per shift. This work will be outside and require standing for long periods. Volunteers will not be involved with the testing procedure. Water will be provided. Face coverings are recommended.

Dates:  January 20, 2022 – February 10, 2022

Time:     9:00 a.m. to 7:00 p.m.

Location: Globe Life Field, Parking Lot M 1205 Pennant Dr, Arlington, TX 76011

Volunteer Sign-up:

  1. Link: https://www.signupgenius.com/go/4090E4FA4A728A1F58-tarrant.
  2. Select one or more shifts and then click the Submit and Sign Up button at the bottom of the screen.
  3. Fill in your information. Please include your phone or email address. We will use this information to keep you informed of updates.
  4. Click the Sign Up Now button.
  5. You will receive a confirmation email with more information.

If you have any questions, please contact:

So-Called “Mild” Omicron Still a Serious Threat, Physicians Warn

By Brent Annear

Published by the Texas Medical Association on January 14, 2022. Read the original article here.

As the massive spike of COVID-19 cases continues, the degree of infectiousness and lack of the best and most available treatment worries Texas Medical Association leaders about what the next few weeks will bring. They say important medical advice bears repeating with patients

The omicron variant’s illness has been described by some people as “less severe,” but physicians urge their colleagues to help patients keep their guard up. In addition to making people sick enough to miss several days of work and school, the virus remains a serious threat to people at high risk for severe illness. Some physician practices have had to close due to COVID-19-related staff shortages or have gone to 100% telehealth visits.

“This illness may seem mild to some, but right now we don’t have enough effective treatment if too many high-risk patients get sick all at the same time,” said John Carlo, MD, a TMA COVID-19 Task Force member.

So far, only a single monoclonal antibody treatment (sotrovimab) is effective against the omicron variant. Supplies are extremely limited.

“On top of this, the omicron variant is incredibly infectious, even more so than previous variants,” Dr. Carlo added.

The Texas Department of State Health Services has reported more than half a million cases since Jan. 1.

“The good news is we know how to protect ourselves,” Dr. Carlo said. “Vaccination with a booster, diligent and effective mask-wearing, and avoiding poorly ventilated indoor settings are effective.”

Physicians also worry about Texas hospital beds filling up too quickly, as area hospitals already face staffing shortages due to sick workers. “We want to make sure we have the space for every patient who needs care,” Dr. Carlo said.

TMA’s COVID-19 Task Force recommends reiterating to patients the following protective measures:

  • Get vaccinated against COVID-19: Get the booster shot as soon as eligible, too.
  • If you must leave your home: Physically distance yourself, wash your hands frequently, and wear your mask anytime you need to be near someone when outside your home. Wear the best mask you can get: N95 masks are best, followed by KN95 masks, then surgical masks, then multi-ply cloth masks that fit snugly around your face. Wear masks if you can’t socially distance, even if outside, and even if everyone attending is vaccinated and boosted.
  • If you must gather with others from outside your home: Choose an outdoor or well-ventilated space.
  • If exposed to someone who has tested positive for COVID-19 (you were within 6 feet of him or her for at least 15 minutes in 24 hours): Quarantine away from others for at least five days and get tested after five days even if you do not develop symptoms. 
    • Watch for symptoms. If you have no symptoms after five days, wear a well-fitted mask for the next five days anytime you’re near anyone and avoid being around people who are at high risk.
    • If fully vaccinated or you have had a confirmed case of COVID-19 within the past 90 days, it is not necessary to quarantine, but you still should wear a well-fitted mask when around others for 10 days and get tested after five days even if symptoms do not develop. 
  • If you test positive for COVID-19 or have mild symptoms, regardless of vaccination status: Isolate for at least five days and until you are fever-free and your symptoms improve (stay away from other people, including people in your own household). (This applies to mild-symptom or zero-symptom cases.) After five days’ isolation, wear a well-fitted mask for five more days whenever you’re around others, avoid travel, and avoid being around those who are at high risk.
  • If you have severe symptoms: Isolate for at least 10 days and consult your doctor before ending your isolation. If you develop any serious symptoms, such as trouble breathing, seek emergency medical care immediately. 

“This current wave is spreading faster than ever before, and the only way to slow this down is for everyone – not just some people, but everyone – to be vigilant,” said Dr. Carlo.

Tarrant County COVID-19 Activity – 01/13/22

COVID-19 Positive cases: 441,134

COVID-19 related deaths: 5111

Recovered COVID-19 cases: 373,903

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County updated Thursday, January 13, 2o22. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Mask Protections & COVID-19 Transmission

Are you using the best mask to limit your exposure to the coronavirus?

As the number of COVID-19 cases continue to rise in North Texas, the importance of protective measures also increases.

In the below North Texas Medical Society Coalition video, Fort Worth physician Dr. Robert Rogers, who is also part of the Tarrant County Medical Society, explains the different levels of protection provided by cloth, surgical, and KN95 masks, and how those differences impact his own decisions.

For more information on the transmission rates/mask types Dr. Rogers mentions in the video, please refer to the below chart:

Returning to School in the Midst of the Rising Omicron Variant

Pediatrician Dr. Jason Terk recommends making careful choices as we begin a new school year while the Omicron COVID-19 variant rises in North Texas.

“Make sure you make your choices wisely about who you are gathering with,” he said. “And make sure you are gathering in safe ways.”

For more information, see the below video from WFAA:

Read WFAA’s full update on North Texas schools here.

Dr. Gregory Phillips on Safe Practices with Rising COVID Numbers

Have questions about socializing in light of the rising COVID numbers that have impacted holiday plans for many, including several local restaurants who had to temporarily close their doors? Check out Fort Worth physician Dr. Gregory Phillips’ interview with Lili Zheng of NBC5 to see what he has to say on the topic:

You can read the full article here.

Where Do SARS-CoV-2 Monoclonal Antibody Therapies Fit in COVID-19 Management?

by Catherine Colquitt, MD
Tarrant County Public Health Medical Director

This article was originally published in the November/December issue of the Tarrant County Physician. You can read find the full magazine here.

With local hospitals and emergency responders struggling to meet the space and staffing challenges brought on by the COVID-19 Delta variant, monoclonal antibody infusions (and subcutaneous injections when applicable for REGEN-COV) are being used to treat early COVID-19 infections. These are effective options in persons who don’t require hospitalization for COVID-19, aren’t hypoxic (or, if chronically O2-dependent, aren’t needing to augment their percentage of supplemental O2), or even as postexposure prophylaxis for persons at high risk for severe disease and poor outcome if they contract COVID-19 after an exposure. 

The science underlying the development of the three monoclonal products granted Emergency Use Authorization (EUA) by the FDA capitalizes on the importance of the COVID-19 spike protein as a means of host cell entry. When viral particles are tagged by SARS-CoV-2 monoclonal antibody therapies, the monoclonal antibody-tagged viruses can’t enter host cells and replicate.  

The mRNA vaccines, encoded for the COVID-19 spike protein and currently in wide usage, target the same essential viral spike protein by stimulating the host to transcribe the spike protein mRNA. They mount an immune response to that transcribed viral spike protein which the host’s immune system will then remember and repeat (anamnestic response) when COVID-19 viral particles present the spike protein to the now-vaccinated host’s primed immune system.1 

Three SARS-CoV-2 monoclonal antibody formulations have been granted EUA by the FDA, though the first monoclonal SARS-CoV2 product (the coformulation bamlanivimab and etesevimab) is no longer authorized in the U.S. because of the decreased susceptibility of Beta and Gamma COVID-19 variants to it.2 Two combinations remain in use— the coformulation monoclonal casirivimab and imdevimab (REGEN-COV), which binds to nonoverlapping epitopes of the spike protein, and sotrovimab (XeVudy).  Both are given under EUA’s for mild to moderate COVID-19 infections in persons 12 years or older weighing at least 40 kg and at high risk for severe COVID-19 infection.   REGEN-COV use in postexposure prophylaxis is also granted under its EUA for COVID-19-exposed persons not yet fully vaccinated and for persons who are vaccinated but regarded as unlikely to respond well to COVID-19 vaccinations.3 Locally, only REGEN-COV is in use at present.   

Comorbidities to consider in deciding who to refer for SARS-CoV-2 monoclonal therapy after onset of mild to moderate illness (early is best but both products are approved through day 10 after symptom onset) include:

  • Age 65 and older
  • BMI over 25kg/meter squared 
  • For 12 to 17 years old, BMI over 85th percentile for height and age
  • Pregnancy
  • Chronic kidney disease
  • Diabetes mellitus
  • Immunosuppressive disorder or treatment
  • Cardiovascular disease, including hypertension and congenital heart disease
  • Chronic lung disease, including COPD
  • Moderate to severe asthma
  • Interstitial lung disease
  • Cystic fibrosis
  • Pulmonary hypertension
  • Sickle cell disease
  • Neurodevelopmental disorders such as cerebral palsy or other conditions “conferring medical complexity such as congenital abnormalities and genetic or metabolic syndromes, and medical-related technology dependence such as tracheostomy, gastrostomy or feeding jejunostomy, mechanical ventilation, etc.”4

Data supporting the use of both SARS-CoV-2 monoclonal products currently in use is persuasive if primary outcomes of all deaths and hospitalizations through day 29 after administration of the products is the measure. For REGEN-COV there was an absolute reduction in death and hospitalization of 2.2 percent and a relative reduction of 70 percent in the treatment group versus placebo. For XeVudy, using the same primary outcome measures of all-cause mortality and hospitalization through day 29, the treatment group experienced a 6 percent absolute reduction and an 85 percent relative risk reduction compared with the placebo group.5

Some special considerations for the use of SAR-CoV-2 monoclonal products: 

Variants: So far both products are rated as efficacious against variants available to test, including Delta and Mu, though this is a rapidly changing field of study. 

Vaccinations Against COVID-19: Contraindicated in the 90 days following monoclonal administration due to theoretical concerns regarding a blunted immune response to COVID-19 vaccination.

Monitoring After Infusion: For one hour in a health care setting. 

Drug Interactions: None so far identified.

Pregnancy: Monoclonals can be used in pregnancy and should certainly be considered when a pregnant woman has additional risk factors (beyond pregnancy alone) for severe COVID-19 disease.

Reactions to SARS-CoV-2 Monoclonal Products: Injection site reactions (pain, redness, swelling, pruritus, injection site ecchymosis) in approximately 1 percent and infusion related reactions such as urticaria, pruritus, flushing, pyrexia, shortness of breath, chest tightness, nausea, vomiting, and, rarely, anaphylaxis. In general, the REGEN-COV current dose of 600mg of casirivimab and 600mg of imdevimab is significantly better tolerated than the previously higher dosed formulations. 

Lactation: No data yet available.

Hepatic impairment: No dose adjustment needed.

And please remember – COVID-19 monoclonal therapeutics are not a substitute for COVID-19 vaccination! 

Locations of Tarrant County Infusion Centers: 

JPS Urgent Care Center   

1500 S. Main Street, Fort Worth , Texas 76104

Call 817-702 1451 for appt.
          
North Central Texas COVID-19 Regional Infusion Center 

815 8th Avenue, Fort Worth, Texas 76104 

Call 800-742-5990 for appt 

Medical City Healthcare
(https://medicalcityhealthcare.com/covid-19

Additional Infusion Center resources are available at www.tarrantcounty.com or by phone at HHS Protect Public Data Hub
(1-877-332-6585 in English and 1-877-366-0310 in Spanish). 

Sources

1. http://www.covid19treatmentguidelines@nih.gov, updated 8/4/2021 

2. Fact Sheet for Health Care Providers and Emergency USE Authorization (EUA) of Bamlanivmab and Etesevimab (REVOKED) 

3. https://www.fda.gov/drugs/drug-safety-and-availability/fda-authrozies-regen-cov-monoclona-antibody-therapy-post-exposure-prophylaxis-prevention-covid-19 

4. Fact Sheet for Health Care Providers and Emergency Use Authorization (EUA) of REGEN-COV 

5. Fact Sheet for Health Care Providers and Emergency Use Authorization (EUA) of Sotrolivumab

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