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Hancock IV CV-19 - History

Hancock IV CV-19 - History


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Hancock IV

(CV-19: dp. 27,100- 1. 888': b. 93', ew. 147'6", dr. 28'7"; s. 33 k.; cpl. 3,448; a. 12 5", 44 40mm., 59 20mm., ac 80 plus; cl. Essex)

The fourth Hancock (CV-19) was laid down as Ticonderoga 28 January 1943 by the Bethlehem Steel Co. Quincy, Mass.; renamed Hancock 1 May 1943; launched 24 January 1944; sponsored by Mrs. DeWitt C. Ramsey, wife of Rear Admiral Ramsey, Chief of the Bureau of Aeronautics, and commissioned 15 April 1944, Captain Fred C. Dickey in command.

After fitting out in the Boston Navy Yard and shakedown training off Trinidad and Venezuela, Hancock returned to Boston for alterations 9 July. She departed Boston 31 July en route to Pearl Harbor via the Panama Canal and San Diego, and from there sailed 24 September to join Admiral W. F. Halsey's 3d Fleet at Ulithi 5 October. She was assigned to Rear Admiral Bogan's Carrier Task Group 38.2.

Hancock got underway the following afternoon for a rendezvous point 375 miles west of the Marianas where units of Vice Admiral Mitscher's Fast Carrier Task Force 38 were assembling in preparation for the daring cruise to raid Japanese air and sea bases in the Ryukyus, Formosa, and the Philippines. Thus enemy air power was paralyzed during General MacArthur's invasion of Leyte.
When the armada arrived off the Ryulyu Islands 10 October 1944, Hancock's planes rose off her deck to wreak destruction Okinawan airfields and shipping. Her planes destroyed 7 enemy aircraft on the ground and assisted in the destruction of a submarine tender, 12 torpedo boats, 2 midget submarines, 4 cargo ships, and a number of sampans. Next on the agenda were Formosan
air bases where 12 October Hancock's pilots downed six enemy planes and destroyed nine more on the ground.
She also reported one cargo ship definitely sunk, three probably destroyed, and several others damaged.As they repelled an enemy air raid that evening, Hancock's gunners accounted for a Japanese plane and drove countless others off during 7 hours of uninterrupted general quarters. The following morning her planes resumed their assault, knocking out ammunition dumps, hangars,barracks, and industrial plants ashore and damaging an enemy transport. As Japanese planes again attacked the Americans during their second night off Formosa, Hancock's antiaircraft are brought down another raider l
which splashed about 500 yards off her flight deck. On the morning of' the third day of' operations against this |enemy stronghold Hancock lashed out again at airfields and shipping before retiring to the southeast with her 3 task force. As the American ships withdrew a heavy force of' Japanese aircraft roared in for a parting crack.
One drooped a bomb off Hancock's port bow a few seconds before the carrier's guns splashed her into the sea. Another bomb penetrated a gun platform but exploded harmlessly in the water. The surviving attackers then turned
tail, and the task force was thereafter unmolested as they sailed toward the Philippines to support the landings at Leyte.
On 18 October she launched planes against airfields and shipping at Laoag, Aparri, and Camiguin Island in Northern Luzon. Her planes struck the islands offence, Panay, Negros, and Masbate, pounding enemy airfields and ship.
ping The next day she retired toward Ulithi with Vice Admiral John S. McCain's Carrier Task Group 38.1. She received orders 28 October to turn back to the area off Samar to assist in the search for units of the Japanese fleet reportedly closing Leyte to challenge the American fleet and to destroy amphibious forces which were struggling to take the island from Japan. Hancock did not reach Samar in time to assist the heroic escort carriers
and destroyers of' "Taffy 3" during the main action of
the Battle off Samar but her planes did manage to lash
the fleeing Japanese Center Force as it passed through the
San Bernardino Straits. Hancock then rejoined Rear
Admiral Bogan's Task Group with which she struck air
fields and shipping in the vicinity of Manila 29 October
1944. During operations through 19 November, her planes
gave direct support to advancing Army troops and at
tacked Japanese shipping over a 35mile area. She be
came flagship of Fast Carrier Task Force 38, 17 November
1944 when Vice Admiral McCain came on board.
Unfavorable weather prevented operations until 25 November when an energy aircraft roared toward Hancock in a suicide dive out of the sun. Antiaircraft fire exploded the plane some 300 feet above the ship but a sec
tion of its fuselage landed amidships and a part of the
wring hit the flight deck and burst into flames. Prompt
and skillful teamwork quickly extinguished the blaze and
prevented serious damage Hancock returned to Ulithi 27 November and departed from that island with her task group to maintain air pa trol over enemy airfields on Luzon to prevent enemy suicide attacks on amphibious vessels of the landing force in Mindoro. The first strikes were launched 14 December against Clark and Angeles Airfields as well as enemy ground targets on Salvador Island. The next day her planes struck installations at Maginot, San Fernando, and Cabatuan, while fighter patrols kept the Japanese airmen down. Her planes also attacked shipping in Manila Bay.

Hancock encountered a severe typhoon 17 December and rode out the storm in waves which broke over her flight deck, some 55 feet above her waterline. She put into Ulithi 24 December and got underway 6 day,s later to attack airfields and shipping around the South China Sea. Her planes struck hard blows at Luzon airfields 7 and 8 January and turned their attention back to Formosa 9 January hitting fiercely at airfields and the Tokyo Seaplane Station. An enemy convoy north of Camranh Bay, IndoChina, was the next victim with 2 ships sunk and 11 damaged. That afternoon Hancock launched strikes against airfields at Saigon and shipping on the northeastern bulge of French IndoChina. Strikes by the fast and mobile carrier force continued through 16 January, hitting Hainan Island in the Gulf of Tonkin, the Pescadores Islands, and shipping in the harbor of Hong Kong. Raids against Formosa were resumed 20 January 1945. The next afternoon one of her planes returning from a sortie made a normal landing, taxied to a point abreast of the island, and disintegrated in a ~blinding explosion which killed 50 men and injured 75 others. Again outstanding work quickly brought the fires under control in time to land other planes which were still aloft. She returned to formation and launched strikes against Okinawa the next snorkeling.

Hancock reached Ulithi 25 January where Vice Admiral MCcain left the ship and relinquished command of the 5th Fleet. She sortied with the ships Of her task group 10 February and launched strikes against airfields in the vicinity of Tokyo 16 February. During that day her air group downed 71 enemy planes, and accounted for 12 more the next. Her planes hit the enemy naval bases at Chichi Jima and Haha Jima 19 February. These raids were conducted to isolate Iwo Jima from air and sea support when marines hit the beaches of that island to begin one Of the most bloody and fierce campaigns of the war. Hancock took station oft this island to provide tactical support through 22 February, hitting enemy airfields and strafing Japanese troops ashore.

Returning to waters off the enemy home islands, Hancock launched her planes against targets on northern Honshu, making a diversionary raid on the Nansei-Shoto islands 1 March before returning to Ulithi 4 March.

Back in Japanese waters Hancock Joined other carriers in strikes against Kyushu airfields, southwestern Honshu, and shipping in the Inland Sea of Japan, 18 March 1945. Hancock was refueling destroyer Halsey Powell 20 March when suicide planes attacked the task force. One plane dove for the two chips but was disintegrated by gunfire when about 700 feet overhead. Fragments of the plane hit Hancock's deck while its engine and bomb crashed the fantail of the destroyer. Hancock s gunners shot down another plane as it neared the release point of its bombing run on the carrier.

Hancock was reassigned to Carrier Task Group 58.3 with which she struck the Nansei-Shoto islands 23 through 27 March and Minami Daito Jima and Kyushu at the end of the month.

When the 10th Army landed on the western coast of Okinawa 1 April Hancock was on hand to provide close air support. ~ suicide plane cartwheeled near~ her flight deck 7 April and crashed into a group of planes while its bomb hit the port catapult to cause a tremendous explosion. Although 62 men were killed and 71 wounded, heroic efforts doused the fares within half an hour enabling her to be back in action before an hour had passed.

Hancock was detached from her task group 9 April and steamed to Pearl Harbor for repairs. She sailed back into action 13 June and leaving lethal calling cards at Wake Island 20 June en route to the Philippines. Hancock sailed from San Pedro Bay with the other carriers 1 July and attacked Tokyo airfields 10 July. She continued to operate in Japanese waters until she received confirmation of Japan's capitulation 15 August 1945 when she recalled her planes from their deadly missions before they reached their targets. However planes of her photo division were attacked by seven enemy aircraft over Sagami Wan. Three were shot down and a fourth escaped in a trail of smoke. Later that afternoon planes of Hancock's air patrol shot down a Japanese torpedo plane as it dived on a British task force. - Her planes flew missions over Japan in search of prison camps, dropping supplies and medicine, 25 August. Information collected during these flights led to landings under command of Commodore R. W. Simpson which brought doctors and supplies to all Allied prisoner of war encampments.

When the formal surrender of the Japanese Imperial Government was signed on board battleship Missouri Hancock's planes flew overhead. The carrier entered Tokyo Bay 10 September 1945 and sailed 30 September, embarking 1,500 passengers at Okinawa for transportation to San Pedro, California, where she arrived 21 October. Hancock was fitted out for "Magic Carpet" duty at San Pedro and sailed for Seeadler Harbor, Manus Admiralty Islands, 2 November. On her return voyage she carried 4,000 passengers who were debarked at San Diego 4 December. A week later Hancock departed for her second "Magic Carpet" voyage, embarking 3,773 passengers at Manila for return to Alameda, Calif., 20 January 1946 She embarked Air Group 7 at San Diego 18 February for air operations off the coast of California. She sailed from San Diego 11 March to embark men of two air groups and aircraft at Pearl Harbor for transportation to Saipan, arriving 1 April 1946. After receiving two other air groups on board at Saipan, she loaded a cargo of aircraft at Guam and steamed by way of Pearl Harbor to Alameda, Calif., arriving 23 April 1946. She then steamed to Seattle, Wash., 29 April to await inactivation. The proud ship decommissioned and entered the reserve fleet at Bremerton, Wash.

Hancock commenced conversion and modernization to an attack aircraft carrier in Puget Sound 15 December 1951 and was reclassified CVA-19, 1 October 1962. She recommissioned 15 February 1954, Captain W. S. Putts in command. She was the first carrier of the United States Fleet with steam catapults capable of launching high performance jets

She was oft San Diego 7 May 1954 for operations along the coast of California that included the launching 17 June of the first aircraft to take off a United States carrier by means of a steam catapult. After a year of operations along the Pacific coast that included testing of Sparrow I and Regulus missiles and Cutlass jet aircraft, she sailed 10 August 1955 for 7th Fleet operations ranging from the shores of Japan to the Philippines and Okinawa. She returned to San Diego 15 March 1956 and decommissioned 13 April for conversion that included the installation of an angled flight deck.

Hancock recommissioned 15 November 1956 for training out of San Diego until 6 April 1957 when she again sailed for Hawaii and the Far East. She returned to San Diego 18 September 1957 and again departed for Japan 15 February 1958. She was a unit of powerful carrier task groups taking station off Taiwan when the Nationalist Chinese islands of Quemoy and Matsu were threatened with Communist invasion in August 1958. The carrier returned to San Diego 2 October 1958 for overhaul in the San Francisco Naval Shipyard, followed by rigorous at sea training out of San Diego. On 1 August 1969, she sailed to reinforce the 7th Fleet as troubles in Laos demanded the watchful presence of powerful American forces in water off southeast Asia. She returned to San Francisco 18 January 1960 and put to sea early in February to participate in a new demonstration of communications by reflecting ultra-high frequency waves oft the moon. She again departed in August to steam with the 7th Fleet in waters off Laos until lessening of tension in that area permitted operations ranging from Japan to the Philippines.

Hancock returned to San Francisco in March 1961, then entered the Puget Sound Naval Shipyard for an overhaul that gave her new electronics gear and many other improvements. She again set sail for Far Eastern waters 2 February 1962, patrolling in the South China Sea as crisis and strife mounted both in Laos and in South Vietnam. She again appeared off Quemoy and Matsu in June 1962 to stem a threatened Communist invasion there, then trained along the coast of Japan and in waters reaching to Okinawa. She returned to San Francisco 7 October 1962, made a brief cruise to the coast of Hawaii while qualifying pilots then again sailed 7 June 1963 for the Far East.

Hancock joined in combined defense exercises along the coast of South Korea, then deployed off the coast of South Vietnam after the coup which resulted in the death of President Diem. She entered the Hunter's Point Naval Shipyard 16 January 1964 for modernization that included installation of a new ordnance system, hull repairs, and aluminum decking for her flight deck. She celebrated her 20th birthday 2 June 1964 while visiting San Diego. The carrier made a training cruise to Hawaii, then departed Alameda 21 October 1964 for another tour of duty with the 7th Fleet in the Far East.

Hancock reached Japan 19 November and soon was on patrol at Yankee Station in the Gulf of Tonkin. She remained active in Vietnamese waters fighting to thwart Communist aggression until heading for home early in the spring of 1966.

November found the carrier steaming back to the war zone. She was on patrol off Vietnam 16 December; and, but for brief respites at Hong Kong, the Philippines, or Japan, Hancock remained on station launching her planes for strikes at enemy positions ashore until returning to Alameda, Calif., 1 August, 1966. Her outstanding record during this combat tour won her the Navy Unit Commendation.

Following operations off the West Coast, Hancock returned to Vietnam early in 1967 and resumed her strikes against Communist positions. After fighting during most of the first half of 1967, she returned to Alameda 22 July and promptly began preparations for returning to battle.

Hancock was awarded the Navy Unit Commendation and reCeived four battle stars for service in World War II.


12 Things People With Lupus Should Know About the COVID-19 Vaccine

When the vaccine will be available for people with lupus, guidance on delaying medications before vaccination, and more.

In a recent Lupus Research Alliance survey of 703 Americans with lupus and 63 of their relatives and friends, 64 percent said they’d be willing to get the COVID-19 vaccine when it’s available and determined to be safe for them by scientists.

Lupus itself and the immune-suppressing medications used to treat it may increase risk for severe COVID-19 infections, says Jeffrey R. Curtis, MD, MPH, professor of rheumatology and immunology at the University of Alabama at Birmingham and chair of the American College of Rheumatology (ACR) COVID-19 Vaccine Clinical Guidance Task Force. So the vaccine could be an important tool in reducing the risk of getting very sick from COVID-19 for the 1.5 million Americans with lupus.

But if you or a loved one have the chronic autoimmune condition, you likely still have a lot of questions. Here’s what we know right now.


2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

The following are key perspectives from the 2019 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Primary Prevention of Cardiovascular Disease (CVD):

Scope of Guideline

  1. The guideline is a compilation of the most important studies and guidelines for atherosclerotic CVD (ASCVD) outcomes related to nine topic areas. The focus is primary prevention in adults to reduce the risk of ASCVD (acute coronary syndromes, myocardial infarction, stable or unstable angina, arterial revascularization, stroke/transient ischemic attack, peripheral arterial disease), as well as heart failure and atrial fibrillation. The guideline emphasizes patient-physician shared decisions with a multidisciplinary team-based approach to the implementation of recommended preventive strategies with sensitivities to the social determinants of health that may include specific barriers to care, limited health literacy, financial distress, cultural influences, education level, and other socioeconomic risk factors related to short- and long-term health goals.

Assessment of ASCVD Risk

  1. Assessment of ASCVD risk is the foundation of primary prevention. For those aged 20-39 years, it is reasonable to measure traditional risk factors every 4-6 years to identify major factors (e.g., tobacco, dyslipidemia, family history of premature ASCVD, chronic inflammatory diseases, hypertension, or type 2 diabetes mellitus [T2DM]) that provide rationale for optimizing lifestyle and tracking risk factor progression and need for treatment. For adults aged 20-39 years and those aged 40-59 years who are not already at elevated (≥7.5%) 10-year risk, estimating a lifetime or 30-year risk for ASCVD may be considered (ASCVD Risk Estimator Plus). For those aged 20-59 years not at high short-term risk, the 30-year and lifetime risk would be reasons for a communication strategy for reinforcing adherence to lifestyle recommendations and for some drug therapy (e.g., familial hypercholesterolemia, hypertension, prediabetes, family history of premature ASCVD with dyslipidemia or elevated lipoprotein [a] Lp[a]).

Estimating Risk of ASCVD

    Electronic and paper chart risk estimators are available that utilize population-based and clinical trial outcomes with the goal of matching need and intensity of preventive therapies to absolute risk (generally 10 years) for ASCVD events. The guideline suggests the race- and sex-specific Pooled Cohort Equation (PCE) (ASCVD Risk Estimator Plus) to estimate 10-year ASCVD risk for asymptomatic adults aged 40-79 years. Adults should be categorized into low (<5%), borderline (5 to <7.5%), intermediate (≥7.5 to <20%), or high (≥20%) 10-year risk. The PCEs are best validated among non-Hispanic whites and non-Hispanic blacks living in the United States. In other race/ethnic groups and some non-US populations, the PCE may over- or under-estimate risk (e.g., HIV infection, chronic inflammatory or autoimmune disease, and low socioeconomic levels). Consideration should be given to use of other risk prediction tools if validated in a population with similar characteristics. Examples include the general Framingham CVD risk score, Reynolds risk score, SCORE, and QRISK/JBS3 tools. Among borderline and intermediate-risk adults, one may consider additional individual "risk-enhancing" clinical factors that can be used to revise the 10-year ASCVD risk estimate. For initiating or intensifying statin therapy, include: family history of premature ASCVD (men <55 years, women <65 years) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dl or non-high-density lipoprotein cholesterol (non-HDL-C) ≥190 mg/dl chronic kidney disease (estimated glomerular filtration rate [eGFR] <60 ml/min/1.73 m 2 ) metabolic syndrome pre-eclampsia and premature menopause (<40 years) inflammatory diseases including rheumatoid arthritis, lupus, psoriasis, HIV South Asian ancestry biomarkers including fasting triglycerides ≥175 mg/dl, Lp(a) ≥50 mg/dl, high-sensitivity C-reactive protein ≥2 mg/L, apolipoprotein B >130 mg/dl, and ankle-brachial index (ABI) <0.9. After considering these clinically available risk-enhancing factors, if there is still uncertainty about the reliability of the risk estimate for individuals in the borderline or intermediate-risk categories, further testing to document subclinical coronary atherosclerosis with computed tomography-derived coronary artery calcium score (CACs) is reasonable to more accurately reclassify the risk estimate upward or downward.

  1. Dietary patterns associated with CVD mortality include—sugar, low-calorie sweeteners, high-carbohydrate diets, low-carbohydrate diets, refined grains, trans fat, saturated fat, sodium, red meat, and processed red meat (such as bacon, salami, ham, hot dogs, and sausage). All adults should consume a healthy plant-based or Mediterranean-like diet high in vegetables, fruits, nuts, whole grains, lean vegetable or animal protein (preferably fish), and vegetable fiber, which has been shown to lower the risk of all-cause mortality compared to control or standard diet. Longstanding dietary patterns that focus on low intake of carbohydrates and a high intake of animal fat and protein as well as high carbohydrate diets are associated with increased cardiac and noncardiac mortality. The increased availability of affordable, palatable, and high-calorie foods along with decreased physical demands of many jobs have fueled the epidemic of obesity and the consequent increases in hypertension and T2DM.
  1. Adults diagnosed as obese (body mass index [BMI] ≥30 kg/m 2 ) or overweight (BMI 25-29.9 kg/m 2 ) are at increased risk of ASCVD, heart failure, and atrial fibrillation compared with those of a normal weight. Obese and overweight adults are advised to participate in comprehensive lifestyle programs for 6 months that assist participants in adhering to a low-calorie diet (decrease by 500 kcal or 800-1500 kcal/day) and high levels of physical activity (200-300 minutes/week). Clinically meaningful weight loss (≥5% initial weight) is associated with improvement in blood pressure (BP), LDL-C, triglycerides, and glucose levels among obese or overweight individuals, and delays the development of T2DM. In addition to diet and exercise, FDA-approved pharmacologic therapies and bariatric surgery may have a role for weight loss in select patients.

Physical Activity

  1. Despite the public health emphasis for regular exercise based on extensive observational data that aerobic physical activity lowers ASCVD, approximately 50% of adults in the United States do not meet minimum recommendations. There is a strong inverse dose-response relationship between the amount of moderate-to-vigorous physical activity and incident ASCVD events and mortality. Adults should engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous-intensity physical activity including resistance exercise.

    T2DM, defined as a hemoglobin A1c (HbA1c) >6.5%, is a metabolic disorder characterized by insulin resistance leading to hyperglycemia. The development and progression are heavily influenced by dietary pattern, physical activity, and body weight. All with T2DM should undergo dietary counseling for a heart-healthy diet that in T2DM lowers CVD events and CVD mortality. Among options include the Mediterranean, DASH, and vegetarian/vegan diets that achieve weight loss and improve glycemic control. At least 150 minutes/week of moderate to vigorous physical activity (aerobic and resistance) in T2DM lowers HbA1c about 0.7% with an additional similar decrease by weight loss. Other risk factors should be identified and treated aggressively. For younger individuals, or those with a mildly elevated HbA1c at the time of diagnosis of T2DM, clinicians can consider a trial of lifestyle therapies for 3-6 months before drug therapy.

  1. Primary ASCVD prevention requires assessing risk factors beginning in childhood. For those <19 years of age with familial hypercholesterolemia, a statin is indicated. For young adults (ages 20-39 years), priority should be given to estimating lifetime risk and promoting a healthy lifestyle. Statin should be considered in those with a family history of premature ASCVD and LDL-C ≥160 mg/dl. ASCVD risk-enhancing factors, (see risk estimate section), should be considered in all patients.

Statin Treatment Recommendations

  1. The following are guideline recommendations for statin treatment:
    • Patients ages 20-75 years and LDL-C ≥190 mg/dl, use high-intensity statin without risk assessment.
    • T2DM and age 40-75 years, use moderate-intensity statin and risk estimate to consider high-intensity statins. Risk-enhancers in diabetics include ≥10 years for T2DM and 20 years for type 1 DM, ≥30 mcg albumin/mg creatinine, eGFR <60 ml/min/1.73 m 2 , retinopathy, neuropathy, ABI <0.9. In those with multiple ASCVD risk factors, consider high-intensity statin with aim of lowering LDL-C by 50% or more.
    • Age >75 years, clinical assessment and risk discussion.
    • Age 40-75 years and LDL-C ≥70 mg/dl and <190 mg/dl without diabetes, use the risk estimator that best fits the patient and risk-enhancing factors to decide intensity of statin.
      • Risk 5% to <7.5% (borderline risk). Risk discussion: if risk-enhancing factors are present, discuss moderate-intensity statin and consider coronary CACs in select cases.
      • Risk ≥7.5-20% (intermediate risk). Risk discussion: use moderate-intensity statins and increase to high-intensity with risk enhancers. Option of CACs to risk stratify if there is uncertainty about risk. If CAC = 0, can avoid statins and repeat CAC in the future (5-10 years), the exceptions being high-risk conditions such as diabetes, family history of premature CHD, and smoking. If CACs 1-100, it is reasonable to initiate moderate-intensity statin for persons ≥55 years. If CAC >100 or 75th percentile or higher, use statin at any age.
      • Risk ≥20% (high risk). Risk discussion to initiate high-intensity statin to reduce LDL-C by ≥50%.
    Both moderate- and high-intensity statin therapy reduce ASCVD risk, but a greater reduction in LDL-C is associated with a greater reduction in ASCVD outcomes. The dose response and tolerance should be assessed in about 6-8 weeks. If LDL-C reduction is adequate (≥30% reduction with intermediate- and 50% with high-intensity statins), regular interval monitoring of risk factors and compliance with statin therapy are necessary to determine adherence and adequacy of effect (about 1 year). For patients aged >75 years, assessment of risk status and a clinician-patient risk discussion are needed to decide whether to continue or initiate statin treatment. The CACs may help refine ASCVD risk estimates among lower-risk women (<7.5%) and younger adults (<45 years), particularly in the setting of risk enhancers.

Hypertension

    In the United States, hypertension accounts for more ASCVD deaths than any other modifiable risk factor. The prevalence of stage I hypertension defined as systolic BP (SBP) ≥130 or diastolic BP (DBP) ≥80 mm Hg among US adults is 46%, higher in blacks, Asians, and Hispanic Americans, and increases dramatically with increasing age. A meta-analysis of 61 prospective studies observed a log-linear association between SBP levels <115 to >180 mm Hg and DBP levels <75 to 105 mm Hg and risk of ASCVD. In that analysis, 20 mm Hg higher SBP and 10 mm Hg higher DBP were each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. An increased risk of ASCVD is associated with higher SBP and SBP has been reported across a broad age spectrum, from 30 to >80 years of age.

    Tobacco use is the leading preventable cause of disease, disability, and death in the United States. Smoking and smokeless tobacco (e.g., chewing tobacco) increases the risk for all-cause mortality and causal for ASCVD. Secondhand smoke is a cause of ASCVD and stroke, and almost one third of CHD deaths are attributable to smoking and exposure to secondhand smoke. Even low levels of smoking increase risks of acute myocardial infarction thus, reducing the number of cigarettes per day does not totally eliminate risk. Electronic Nicotine Delivery Systems (ENDS), known as e-cigarettes and vaping, are a new class of tobacco products that emit aerosol containing fine and ultrafine particulates, nicotine, and toxic gases that may increase risk for CV and pulmonary diseases. Arrhythmias and hypertension with e-cigarette use have been reported. Chronic use is associated with persistent increases in oxidative stress and sympathetic stimulation in the healthy young.

  1. For decades, low-dose aspirin (75-100 mg with US 81 mg/day) has been widely administered for ASCVD prevention. By irreversibly inhibiting platelet function, aspirin reduces risk of atherothrombosis but at the risk of bleeding, particularly in the gastrointestinal (GI) tract. Aspirin is well established for secondary prevention of ASCVD and is widely recommended for this indication, but recent studies have shown that in the modern era, aspirin should not be used in the routine primary prevention of ASCVD due to lack of net benefit. Most important is to avoid aspirin in persons with increased risk of bleeding including a history of GI bleeding or peptic ulcer disease, bleeding from other sites, age >70 years, thrombocytopenia, coagulopathy, chronic kidney disease, and concurrent use of nonsteroidal anti-inflammatory drugs, steroids, and anticoagulants. The following are recommendations based on meta-analysis and three recent trials:
    • Low-dose aspirin might be considered for primary prevention of ASCVD in select higher ASCVD adults aged 40-70 years who are not at increased bleeding risk.
    • Low-dose aspirin should not be administered on a routine basis for primary prevention of ASCVD among adults >70 years.
    • Low-dose aspirin should not be administered for primary prevention among adults at any age who are at increased bleeding risk.

Keywords: ACC Annual Scientific Session, ACC19, Aspirin, Atherosclerosis, Atrial Fibrillation, Bariatric Surgery, Blood Pressure, Cholesterol, LDL, Coronary Disease, Diabetes Mellitus, Type 2, Diet, Dyslipidemias, Exercise, Heart Failure, HIV, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypercholesterolemia, Hyperglycemia, Hypertension, Inflammation, Kidney Failure, Chronic, Lipids, Lipoproteins, Metabolic Syndrome X, Metformin, Myocardial Infarction, Obesity, Plaque, Atherosclerotic, Pre-Eclampsia, Primary Prevention, Risk Factors, Smoking, Stroke, Tobacco, Triglycerides, Weight Loss


Moderna Covid-19 Vaccine: Here Is The Risk Of Severe Allergic Reactions

What are your chances of suffering anaphylaxis, a severe allergic reaction, from the Covid-19 vaccine? Well, it may be significantly lower than your odds of getting badly injured by a toilet this year.

A new publication in the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) indicates that the rate of anaphylaxis among those getting the Moderna Covid-19 vaccine has been approximately 2.5 cases per million doses administered. That is even lower than the rate reported so far for the Pfizer/BioNTech Covid-19 vaccine, which, as I described a week ago for Forbes, has been been around 11.1 per million doses administered.

Compare these numbers to 225 per million, which according to another CDC MMWR is the rate at which people suffered injuries from toilets in 2008. These were not just any injury from a toilet such as “I can’t feel my legs momentarily because I spent 15 minutes straight texting from the throne” toilet injuries. Instead, these were injuries that were bad enough to land people in the emergency room. This is a reminder that nothing is 100% safe and risk free, even something as comforting as the Porcelain Throne, the Poopatorium, the Oval Office, the House of Ease, or whatever you call that thing that you go to for all number one and number two occasions.

Even going to a toilet has its risks. (Photo: Getty)

Now this toilet injury number may not seem directly comparable to the vaccine anaphylaxis numbers. After all, you may use the toilet or the texting throne anywhere from one to 50 times a day. (Note: if you are using the toilet closer to 50 times a day, contact your doctor.) This probably adds up to a much greater number than the number of Covid-19 vaccine doses that you will get over the course of a year. The Moderna Covid-19 vaccine, for example, is a two dose series, not a 365-dose series.

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So perhaps, other numbers will help offer better perspective. According to a publication in the American Journal of Roentgenology, the risk for serious or severe reactions when getting contrast material used for imaging studies like a CT scan is between 0.02% (which 200 per million) and 0.4% (which is 4000 per million), depending on the type of contrast material. In a publication in the British Medical Bulletin, Hugh A Sampson, MD, a Professor of Pediatrics and Biomedical Sciences at The Mount Sinai School of Medicine, wrote that around 10.8 cases of anaphylaxis to food occur every 100,000 person-years. Oh, and by the way, if you are a run-of-the-mill-non-Leonardo-DiCaprio-dude your odds of dating a supermodel may be 11.3 out of one million, based on a article by Matt Rocheleau in the Boston Globe.

All of this further shows that two to 11 out of a million shouldn’t necessarily make you say “wow,” in the way Owen Wilson has said it in practically all of his movies. If someone were to tell you that you have a 2.5 out of a million chance of dating him or her, you probably wouldn’t respond by saying, “OK, so are you free this weekend?” Therefore, to date, the risk of anaphylaxis for either Covid-19 mRNA vaccine doesn’t seem to be high enough to raise alarms.

The reported odds of suffering anaphylaxis to the Moderna Covid-19 vaccine are based on the 10 cases of anaphylaxis that occurred after 4,041,396 first doses of the Moderna Covid-19 vaccine were administered from December 21, 2020 through January 10, 2021. The report was an analyses of data from the VAERS. VAERS is not what they called Captain Marvel before they found out her real name. Rather it stands for Vaccine Adverse Event Reporting System.

The CDC and the U.S. Food and Drug Administration (FDA) co-manage VAERS, which was established in 1990. Anyone who suffers or witnesses an adverse event after vaccination can report it to VAERS. Both healthcare professionals and vaccine manufacturers are required to report all such adverse events that come to their attention. Of course, you must report an adverse event to VAERS for it to be registered. VAERS is not like Facebook. It doesn’t watch what you do and collect information. Moreover, the adverse event needs to be legitimately connected to the vaccination. For example, feeling kind of nauseous after watching Keeping Up with Kardashians a week after getting vaccinated probably shouldn’t count as a vaccine-related adverse event.

Anaphylaxis, which rhymes with Anna Kendrick prophylaxis, is a severe allergic reaction that is potentially life-threatening. It results when your immune system overreacts to something like peanuts, bee stings, latex, or some type of medication, triggering the release of chemicals in your body. These then lead to typical signs of anaphylaxis such as a rash, rapid pulse, nausea, vomiting, the feeling that your throat is closing up, and difficulty breathing. This may throw you into shock with a major drop in your blood pressure. Anaphylaxis is a medical emergency. Usually, you’ll need something like epinephrine to reverse the reaction or risk dying, which is not a good thing.

Anaphylaxis is like a reaction to Justin Bieber’s song “Baby.” It tends to happen fairly soon after exposure or not at all. In fact, 9 of the 10 reported cases of anaphylaxis after the Moderna Covid-19 vaccine happened fairly quickly, within 15 minutes of vaccination, which is typical for anaphylaxis.

Keep in mind that just because anaphylaxis is life threatening doesn’t mean that it isn’t treatable. In fact, everyone who suffered anaphylaxis from the Moderna Covid-19 vaccine seemed to survive. Like Bieber’s “Baby” and Bieber fever in general, anaphylaxis is treatable. The key is to recognize and treat anaphylaxis quickly.

Those who are at greater risk for allergic reactions often carry EpiPens, used to treat anaphylactic . [+] shock. (Photo by: Newscast/Universal Images Group via Getty Images)

Newscast/Universal Images Group via Getty Images)

Also, the risk of anaphylaxis is not like Bernie Sanders’s mittens. One size does not fit all. Different people may have different risks of anaphylaxis. All but one of the people who had suffered anaphylaxis after the Moderna Covid-19 vaccine had had a history of allergies or allergic reactions to other drugs, radiographic contrast media, or food. In fact, five had suffered anaphylaxis previously to other things. So if you do have a history of allergies, you may want to talk to your doctor before getting the Covid-19 vaccine.

Of course, not all allergic reactions are anaphylaxis. The CDC MMWR did report 43 allergic reactions that didn’t qualify as anaphylaxis and occurred within a day of receiving the Moderna Covid-19 vaccine. Of these over half (60%) were considered non-serious and consisted of symptoms such as itchiness, rashes, scratchiness in the mouth and throat, feeling that the throat is closing a bit, and respiratory symptoms. Most (73%) happened within 30 minutes of vaccination. Sixty percent of the people who had such reactions already had a history of allergies or allergic reactions to other foods or drugs.

Does all of this mean that the Moderna Covid-19 vaccine is safer than the Pfizer/BioNTech one? No, not necessarily. Overall, the number of reported anaphylaxis cases for both vaccines has been fairly small, 10 for the Moderna vaccine and 21 for the Pfizer/BioNTech vaccine so far. Thus, an 11 case difference in this case is not really that substantial and may not represent an actual difference between the vaccines. So allergic reactions is not a reason to choose one vaccine over another, if you do have the choice.

As I have written before, individual cases of anaphylaxis may sound alarming and make for striking headlines. Certainly such a case requires immediate attention. Don’t just say something like, “oh, there Brad goes again. Doing the whole anaphylaxis thing.” Nevertheless, cases here and there shouldn’t alone deter you from getting vaccination. Look at the actual overall risk based on the total number of doses that have been administered. And take proper precautions such as talking to your doctor if you do have a history of allergies and waiting while being observed by health care professionals for at least 15 minutes after getting vaccinated. But don’t fear the vaccine just because there’s a risk of something happening. After all, you don’t eye the toilet suspiciously every time you have to go to the bathroom, do you?


Early life and marriage

Louis was the son of Louis XIII and his Spanish queen, Anne of Austria. He succeeded his father on May 14, 1643. At the age of four years and eight months, he was, according to the laws of the kingdom, not only the master but the owner of the bodies and property of 19 million subjects. Although he was saluted as “a visible divinity,” he was, nonetheless, a neglected child given over to the care of servants. He once narrowly escaped drowning in a pond because no one was watching him. Anne of Austria, who was to blame for this negligence, inspired him with a lasting fear of “crimes committed against God.”

Louis was nine years old when the nobles and the Paris Parlement (a powerful law court), driven by hatred of the prime minister Jules Cardinal Mazarin, rose against the crown in 1648. This marked the beginning of the long civil war known as the Fronde, in the course of which Louis suffered poverty, misfortune, fear, humiliation, cold, and hunger. These trials shaped the future character, behaviour, and mode of thought of the young king. He would never forgive either Paris, the nobles, or the common people.

In 1653 Mazarin was victorious over the rebels and then proceeded to construct an extraordinary administrative apparatus with Louis as his pupil. The young king also acquired Mazarin’s partiality for the arts, elegance, and display. Although he had been proclaimed of age, the king did not dream of disputing the cardinal’s absolute power.

The war begun in 1635 between France and Spain was then entering its last phase. The outcome of the war would transfer European hegemony from the Habsburgs to the Bourbons. A French king had to be a soldier, and so Louis served his apprenticeship on the battlefield.

In 1658 Louis faced the great conflict between love and duty, a familiar one for princes of that period. He struggled with himself for two years over his love for Mazarin’s niece, Marie Mancini. He finally submitted to the exigencies of politics and in 1660 married Marie-Thérèse of Austria, daughter of King Philip IV of Spain, in order to ratify peace between their two countries.

The childhood of Louis XIV was at an end, but no one believed him capable of seizing the reins of power. No one suspected his thoughts. He wrote in his Mémoires:

In my heart I prefer fame above all else, even life itself.…Love of glory has the same subtleties as the most tender passions.…In exercising a totally divine function here on earth, we must appear incapable of turmoils which could debase it.


Infection Control

Given the need for often extensive and close contact between patients and healthcare personnel, a 14-day quarantine period continues to be recommended for patients receiving healthcare and healthcare personnel with exposures to SARS-CoV-2 warranting quarantine 1 or work restrictions, respectively. This option maximally reduces post-quarantine transmission risk and is the strategy with the greatest collective experience at present.

Alternatives to the 14-day quarantine period are described in the Options to Reduce Quarantine for Contacts of Persons with SARS-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing. Healthcare facilities could consider these alternatives as a measure to mitigate staffing shortages, space limitations, or PPE supply shortages but, due to the special nature of healthcare settings (e.g., patients at risk for worse outcomes, critical nature of healthcare personnel, challenges with social distancing), not as a preferred option.

Healthcare facilities should understand that shortening the duration of work restriction or patient quarantine might pose additional transmission risk. They should also counsel patients and healthcare personnel about the need to monitor for and immediately self-isolate if symptoms occur during the 14 days after their exposure and the importance of adhering to all recommended non-pharmaceutical interventions.

1 In healthcare settings, patients under quarantine are typically isolated in a single-person room and cared for by healthcare personnel using all PPE recommended for a patient with suspected or confirmed SARS-CoV-2 infection. However, these patients should not be cohorted with patients with SARS-CoV-2 infection unless they are also confirmed to have SARS-CoV-2 infection through testing.

CDC currently recommends that asymptomatic patients and residents who have recovered and are within 3 months of a positive test for SARS-CoV-2 infection may not need to be quarantined or tested following re-exposure to SARS-CoV-2. However, there might be clinical scenarios in which the certainty about a prior infection or the durability of the immune response exist, for which providers could consider testing for SARS-CoV-2 and recommending quarantine following an exposure that occurs less than 3 months after their initial infection. Examples could include:

  • Patients or residents with underlying immunocompromising conditions (e.g., patient after organ transplantation) or who become immune compromised (e.g., receive chemotherapy) in the 3 months following SARS-CoV-2 infection and who might have an increased risk for reinfection. However, data on which specific conditions may lead to higher risk and the magnitude of risk are not available.
  • Patients or residents for whom there is concern that their initial diagnosis of SARS-CoV-2 infection might have been based on a false positive test result (e.g., resident was asymptomatic, antigen test positive, and a confirmatory nucleic acid amplification test (NAAT) was not performed).
  • Patients or residents for whom there is evidence that they were exposed to a novel SARS-CoV-2 variant (e.g., exposed to a person known to be infected with a novel variant) for which the risk of reinfection might be higher

CDC continues to actively investigate the frequency of reinfection and the circumstances surrounding these episodes, including the role that new variants might play in reinfection, and will adjust guidance as necessary as more information becomes available.

Yes. To keep patients and healthcare personnel (HCP) healthy and safe, CDC&rsquos infection prevention and control guidance applies to all settings where healthcare is delivered. However, as with any guidance, facilities can tailor certain recommendations to their setting. For example, inpatient psychiatric care includes communal experiences and group activities that may need to continue. If so, these activities might need to be adapted to align with social distancing recommendations. Other recommended infection control measures (for example, ensuring access to alcohol-based hand sanitizer, cohorting patients with COVID-19 and assigning dedicated staff, or implementing universal source control measures) might not be safe or appropriate to implement in all locations or for all patients due to security and behavioral concerns.

Challenges and potential solutions specific to behavioral health settings might include:

  • Cohorting
    • Challenge: To prevent transmission, it is generally recommended that patients with COVID-19 be transferred to a separate area of the facility where they can be cared for by dedicated HCP. Because of security concerns or specialized care needs, it might not be possible to cohort certain patients together or change HCP assigned to their care.
    • Potential Solutions: When cohorting is not possible, implement measures to maintain social distancing (at least 6 feet) between patients with COVID-19 and others on the unit. Ideally, this would include a separate bathroom for COVID-19 patients. Ensure HCP wear all recommended personal protective equipment (PPE) when caring for patients with suspected or confirmed COVID-19.
    • Challenge: Group counseling, therapy, and discussion sessions are a critical component of psychiatric treatment and care plans, but the traditional set-up for these activities is not compatible with social distancing recommendations.
    • Potential Solutions: When possible, use virtual methods, or decrease group size so social distancing can be maintained. In the event that COVID-19 is transmitted in the facility, sessions should stop or move to a video discussion forum until additional infection prevention measures are in place to stop the spread.
    • Challenge: For some patients, the use of cloth face coverings or facemasks might pose an additional danger or may cause distress. Some patients may be unable or unwilling to use them as intended. Elastic and cloth straps can be used for strangling oneself or others, and metal nasal bridges can be used for self-harm or as a weapon.
    • Potential Solutions: Consider allowing patients at low risk for misuse to wear cloth face coverings or facemasks, with a preference for those with short ear-loops rather than longer ties. Consider use of cloth face coverings or facemasks during supervised group activities. Ensure that HCP interacting with patients who cannot wear a cloth face covering or facemask are wearing eye protection and a facemask (or a respirator if the patient is suspected to have COVID-19 and respirators are available).
    • Challenge: While alcohol-based hand sanitizer (ABHS) containing 60-95% alcohol is an important tool to increase adherence to hand hygiene recommendations, ABHS must be used carefully in psychiatric facilities to ensure it is not ingested by patients.
    • Potential Solutions: Consider not placing ABHS in patients&rsquo rooms in psychiatric facilities, nor in locations where the patients have unsupervised access. Encourage frequent hand washing with soap and water for patients and HCP. Consider providing personal, pocket-sized ABHS dispensers for HCP.
    • Challenge: As part of social distancing, communal dining is generally not recommended. However, eating needs to remain supervised due to the potential for self-harm with eating utensils and because commonly used psychiatric medications may cause side effects (e.g., tardive dyskinesia, dysphagia, hypo- and hypersalivation) that increase choking risk for patients.
    • Potential Solutions: One option is to position staff in patients&rsquo rooms to monitor their dining. Another option is to allow communal dining in shifts so that staff can monitor patients while ensuring they remain at least 6 feet apart. A third option is to have patients sit in appropriately spaced chairs in the hallway outside their rooms so they can be monitored while they eat.
    • Challenge: A higher proportion of psychiatric patients smoke cigarettes compared to the general population. Patients might congregate in outdoor smoking spaces without practicing appropriate social distancing.
    • Potential Solutions: Limit the number of patients allowed to access smoking spaces at the same time, and position staff to observe and ensure patients are practicing appropriate physical distancing.

    Facilities should follow the reporting requirements of their state or jurisdiction. Those regulated by the Centers for Medicare and Medicaid Services (CMS) (e.g., nursing homes) should also follow all CMS requirements external icon , which are being updated to include new requirements for reporting to CDC and to residents and their representatives.

    In addition, CDC recommends that health departments be promptly notified about:

    • Residents or healthcare personnel (HCP) with suspected or confirmed COVID-19,
    • Residents with severe respiratory infection resulting in hospitalization or death, and
    • &ge 3 residents or HCP with new-onset respiratory symptoms within 72 hours of each other.

    These could signal an outbreak of COVID-19 or other respiratory disease in the facility. The health department can provide important guidance to assist with case finding and halting transmission.

    The facility should also have a plan and mechanism to regularly communicate with residents, family members, and HCP, including if cases of COVID-19 are identified in the facility. Often, information in nursing homes is communicated through town hall meetings and staff meetings, along with letters or emails. However, during the COVID-19 pandemic, in-person gatherings should not occur. Instead, communication should occur through virtual meetings over phone or web platforms. These should be supplemented with written communications that provide contact information for a staff member who can respond to questions or concerns. Communications should include information describing the current situation, plans for limiting spread within the facility, and recommended actions they can take to protect themselves and others. Facilities should make this information available in a timely manner and offer periodic updates as the situation develops and more information becomes available.

    No. For patients hospitalized with SARS-CoV-2 infection, decisions about discharge from the hospital should be based on their clinical status and the ability of an accepting facility to meet their care needs and adhere to recommended infection prevention and control practices. Decisions about hospital discharge are distinct from decisions about discontinuation of Transmission-Based Precautions.

    For patients with suspected or confirmed SARS-CoV-2 infection, decisions about discontinuing Transmission-Based Precautions should be based on the strategies outlined here. The test-based strategy is recommended only for use in limited circumstances.

    If a patient with suspected or confirmed SARS-CoV-2 infection has not met criteria for discontinuing Transmission-Based Precautions, they should be transferred to a facility with the ability to adhere to infection prevention and control recommendations for the care of residents with SARS-CoV-2 infection, including placement in a unit or area of the facility designated to care for residents with SARS-CoV-2 infection and provision of recommended personal protective equipment to healthcare personnel.

    If the patient has met the criteria for discontinuing Transmission-Based Precautions, they do not require additional restrictions.

    A patient hospitalized for non-COVID-related illnesses who is not known to have SARS-CoV-2 infection can be transferred to a nursing home without testing. To ensure a patient was not exposed and might subsequently develop SARS-CoV-2 infection, nursing homes should place the patient in Transmission-based Precautions in a separate observation area or in a single-person room for 14 days after admission.

    As part of universal source control measures, all residents (including those described in the scenarios above) should wear a cloth face covering or facemask (if tolerated) whenever they leave their room.

    As part of routine practices, healthcare personnel (HCP) should be applying Standard Precautions. HCP should always deliberately assess potential risks of exposure to infectious material before engaging in activities and procedures in healthcare delivery. Based on their risk assessment, safe work practices, including engineering controls that reduce the release of infectious material, administrative controls, and use of personal protective equipment (PPE) should be implemented at the point of care according to CDC guidelines and standards of practice for the activity performed.

    To reduce SARS-CoV-2 exposure during the COVID-19 pandemic, CDC recommends that facilities:

    • consider nonoperative approaches when feasible
    • minimize the use of procedures or techniques that might produce infectious aerosols when feasible
    • minimize the number of people in the operating or procedure room to reduce exposures
    • use the extent of community transmission and an assessment of the likelihood for patient harm if care is delayed to make decisions about cancelling or postponing elective surgeries and procedures and
    • implement universal source control measures, which includes having patients wear a cloth face covering (as tolerated) and having HCP wear a facemask at all times while they are in the healthcare facility.

    If surgery or procedures cannot be postponed, HCP caring for patients with suspected or confirmed COVID-19 should adhere to all recommended infection prevention and control practices for COVID-19. This includes:

    • Using all recommended PPE: an N95 or equivalent or higher-level respirator (or facemask if respirators are not available), eye protection, gloves, and a gown.
      • Respirators with exhalation valves should not be used during surgical procedures as unfiltered exhaled breath would compromise the sterile field.
      • If shortages exist, N95 or equivalent or higher-level respirators should be prioritized for procedures involving higher risk techniques (e.g., that generate potentially infectious aerosols) or that involve anatomic regions where viral loads might be higher (e.g., nose and throat, oropharynx, respiratory tract).

      Because SARS-CoV-2 can be transmitted by individuals who are infected but do not have symptoms, some infected individuals will not be identified by screening for clinical signs and symptoms. HCP providing surgical or procedural care to patients not suspected of having SARS-CoV-2 infection should use a tiered approach based on the level of community transmission to inform the need for universal eye protection and respirator use. HCP should continue to use eye protection or an N95 or equivalent or higher-level respirator whenever recommended for patient care as a part of Standard or Transmission-Based Precautions.

      In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure diagnostic testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.
      Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.

      CDC&rsquos guidance to use NIOSH-approved N95 disposable filtering facepiece or higher level respirators when providing care for patients with suspected or known COVID-19 is based on the current understanding of SARS-CoV-2 and related respiratory viruses.

      Current data suggest that close-range aerosol transmission by droplet and inhalation, and contact followed by self-delivery to the eyes, nose, or mouth are likely routes of transmission. Long-range aerosol transmission, such as is seen with measles, has not been a feature of SARS-CoV-2.

      Potential routes of close-range transmission include splashes and sprays of infectious material onto mucous membranes and inhalation of infectious virions exhaled by an infected person. The relative contribution of each of these is not known for SARS-Co-V-2.

      Facemasks commonly used during surgical procedures will provide barrier protection against droplet sprays contacting mucous membranes of the nose and mouth, but they are not designed to protect wearers from inhaling small particles. N95 and higher level respirators, such as other disposable filtering facepiece respirators, powered air-purifying respirators (PAPRs), and elastomeric respirators, provide both barrier and respiratory protection because of their tight fit and filtration characteristics.

      Respirators should be used as part of a respiratory protection program that provides staff with medical evaluations, training, and fit testing.

      Although facemasks are routinely used for the care of patients with common viral respiratory infections, N95 or higher level respirators are routinely recommended for emerging pathogens like SARS CoV-2, which have the potential for transmission via small particles, the ability to cause severe infections, and no specific treatments or vaccines.

      CDC recommendations acknowledge the current challenges with limited supplies of N95s and other respirators. Facilities that do not have sufficient supplies of N95s and other respirators for all patient care should prioritize their use for activities and procedures that pose high risks of generating infectious aerosols and use facemasks for care that does not involve those activities or procedures. Detailed strategies for optimizing the supply of N95 respirators are available on the CDC website. Once availability of supplies is reestablished, the guidance states that the use of N95 and higher level respirators should resume.

      In general, transport and movement of a patient with suspected or confirmed SARS-CoV-2 infection outside of their room should be limited to medically essential purposes. If being transported outside of the room, such as to radiology, healthcare personnel (HCP) in the receiving area should be notified in advance of transporting the patient. For transport, the patient should wear a facemask or cloth face covering (if tolerated) to contain secretions and be covered with a clean sheet.

      If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), transport personnel should wear all recommended PPE (gloves, a gown, respiratory protection that is at least as protective as a fit tested NIOSH-certified disposable N95 filtering facepiece respirator or facemask&mdashif a respirator is not available&mdashand eye protection [i.e., goggles or disposable face shield that covers the front and sides of the face]). This recommendation is needed because these interactions typically involve close, often face-to-face, contact with the patient in an enclosed space (e.g., patient room). Once the patient has been transferred to the wheelchair or gurney (and prior to exiting the room), transporters should remove their gown and gloves and perform hand hygiene.

      The transporter should continue to wear a respirator or facemask. The continued use of eye protection by the transporter is also recommended if there is potential that the patient might not be able to tolerate their facemask or cloth face covering for the duration of transport. Additional PPE should not be required unless there is an anticipated need to provide medical assistance during transport (e.g., helping the patient replace a dislodged facemask).

      After arrival at their destination, receiving personnel (e.g., in radiology) and the transporter (if assisting with transfer) should perform hand hygiene and wear all recommended PPE. If still wearing their original respirator or facemask and eye protection, the transporter should take care to avoid self-contamination when donning the remainder of the recommended PPE. This cautious approach will be refined and updated as more information becomes available and as response needs change in the United States.

      Interim guidance for EMS personnel transporting patients with confirmed or suspected SARS-CoV-2 infection is available here. EMS personnel should wear all recommended PPE because they are providing direct medical care and in close contact with the patient for longer periods of time.

      In general, only essential personnel should enter the room of patients with SARS-CoV-2 infection. Healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to EVS personnel, they should wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene.

      After discharge, terminal cleaning can be performed by EVS personnel. They should delay entry into the room until time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, EVS personnel can enter the room and should wear a facemask (for source control) along with a gown and gloves when performing terminal cleaning. Eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products. Shoe covers are not recommended at this time for personnel caring for patients with SARS-CoV-2 infection.

      Some procedures performed on patients are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These aerosol generating procedures (AGPs) potentially put healthcare personnel and others at an increased risk for pathogen exposure and infection.

      Development of a comprehensive list of AGPs for healthcare settings has not been possible, due to limitations in available data on which procedures may generate potentially infectious aerosols and the challenges in determining if reported transmissions during AGPs are due to aerosols or other exposures.

      There is neither expert consensus, nor sufficient supporting data, to create a definitive and comprehensive list of AGPs for healthcare settings.

      Commonly performed medical procedures that are often considered AGPs, or that create uncontrolled respiratory secretions, include:

      • open suctioning of airways
      • sputum induction
      • cardiopulmonary resuscitation
      • endotracheal intubation and extubation
      • non-invasive ventilation (e.g., BiPAP, CPAP)
      • bronchoscopy
      • manual ventilation

      Based on limited available data, it is uncertain whether aerosols generated from some procedures may be infectious, such as:

      *Aerosols generated by nebulizers are derived from medication in the nebulizer. It is uncertain whether potential associations between performing this common procedure and increased risk of infection might be due to aerosols generated by the procedure or due to increased contact between those administering the nebulized medication and infected patients.

      References related to aerosol generating procedures:

      Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J (2012) Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review. PLoS ONE 7(4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3338532/#!po=72.2222external iconexternal icon external icon ).

      Although spread of SARS-CoV-2 is believed to be primarily via respiratory droplets, the contribution of small respirable particles to close proximity transmission is currently uncertain. Airborne transmission from person-to-person over long distances is unlikely.

      The amount of time that the air inside an examination room remains potentially infectious is not known and may depend on a number of factors including the size of the room, the number of air changes per hour, how long the patient was in the room, if the patient was coughing or sneezing, and if an aerosol-generating procedure was performed. Facilities will need to consider these factors when deciding when the vacated room can be entered by someone who is not wearing PPE.

      For a patient who was not coughing or sneezing, did not undergo an aerosol-generating procedure, and occupied the room for a short period of time (e.g., a few minutes), any risk to HCP and subsequent patients likely dissipates over a matter of minutes. However, for a patient who was coughing and remained in the room for a longer period of time or underwent an aerosol-generating procedure, the risk period is likely longer.

      For these higher risk scenarios, it is reasonable to apply a similar time period as that used for pathogens spread by the airborne route (e.g., measles, tuberculosis) and to restrict HCP and patients without PPE from entering the room until sufficient time has elapsed for enough air changes to remove potentially infectious particles.

      In addition to ensuring sufficient time for enough air changes to remove potentially infectious particles, HCP should clean and disinfect environmental surfaces and shared equipment before the room is used for another patient.

      CDC has released information about strategies to optimize the supply of isolation gowns. Healthcare facilities should refer to that guidance and implement the recommended strategies to optimize their current supply of gowns. This includes shifting toward the use of washable cloth gowns, if feasible.

      The use of gowns as part of Contact Precautions in the context of MDROs has been implemented primarily to reduce the risk of transmission to other patients rather than to protect healthcare personnel (HCP). Facilities with shortages could consider suspending the use of gowns for the care of patients with endemic MDROs, such as MRSA, VRE, and ESBL-producing Gram-negative bacilli except as required for Standard Precautions. Facilities should assess their local epidemiology to determine which MDROs are considered endemic. Regardless of the use of gowns, HCP at facilities should continue to wear gloves for contact with these patients and their environment. Hand hygiene should continue to be emphasized. Facilities should also attempt to place patients colonized or infected with an MDRO in a private room, if available.

      • Caring for patients who have highly resistant Gram-negative organisms (e.g., carbapenem-resistant Enterobacteriacae) and other MDROs (e.g.,Candida auris) that are not considered endemic: Rather than gowns being donned for every room entry, they should be reserved for use as part of Standard Precautions and also prioritized for high-contact patient care activities that pose highest risk for transfer of pathogens from the patient to HCP. Examples of such high-contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care. To further preserve gowns, HCP are recommended to bundle high-contact care activities as part of individual care encounters. Regardless of the use of gowns, HCP at facilities should continue to wear gloves for contact with these patients and their environment. Hand hygiene should continue to be emphasized. Facilities should also attempt to place patients colonized or infected with an MDRO in a private room, if available.
      • Caring for patients withClostridioides difficileinfections (CDI): Facilities should continue using Contact Precautions (putting on a gown and gloves upon entry into the patient&rsquos room and placing the patient in a private room) for the care of symptomatic patients with CDI. As part of a supplemental strategy to prevent transmission of CDI, some facilities have implemented Contact Precautions for the care of patients at high risk for CDI who have asymptomatic carriage of Clostridioides difficile. There are limited data about the role of asymptomatic carriage in transmission of CDI. In this setting of a critical national shortage of gowns, facilities should consider suspending this approach until the shortage is addressed. Gowns should still be used as part of Standard Precautions.

      Anyone who had prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with the infected healthcare provider might have been exposed.

      • If the provider had COVID-19 symptoms, the provider is considered potentially infectious beginning 2 days before symptoms first appeared until the provider meets criteria to discontinue Transmission-Based Precautions or Home Isolation.
      • If the provider did not have symptoms, collecting information about when the provider may have been exposed could help inform the period when they were infectious.
        • If an exposure is identified. The provider should be considered potentially infectious beginning 2 days after the exposure until criteria to discontinue Transmission-Based Precautions or Home Isolation are met.
        • If the date of exposure cannot be determined. For the purposes of contact tracing, it is reasonable to use a cutoff of 2 days before the specimen testing positive for SARS-CoV-2 was collected as the starting point, continuing until the criteria to discontinue Transmission-Based Precautions or Home Isolation are met. Although the infectious period is generally accepted to be 10 days after onset of infection, eliciting contacts during the entire 10 days before obtaining the specimen that tested positive for SARS-CoV-2 is likely inefficient. In most situations an exposed provider cannot recall all contacts over the preceding 10 days. Also, because recent data suggest that asymptomatic persons may have a lower viral burden at diagnosis than symptomatic persons, the additional resources required may divert case investigation and contact tracing resources away from activities most likely to interrupt ongoing transmission.

        Contact tracing is generally recommended for anyone who had prolonged close contact with the person with SARS-CoV-2 infection during these time periods. While this question addresses exposure to a potentially infectious provider, the following actions are also recommended if the potentially infectious individual is a patient or visitor.

        Recommended actions for HCP, patients, and visitors:

        • Perform a risk assessment and apply work restrictions for other HCP who were exposed to the infected provider based on whether these HCP had prolonged, close contact and what PPE they were wearing. More detailed information is available in the Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19.
        • Place exposed patients who are currently admitted to the healthcare facility in appropriate Transmission-Based Precautions and monitor them for onset of SARS-CoV-2 infection until 14 days after their last exposure. .
        • Perform contact tracing of exposed patients who are not currently admitted to the healthcare facility and for visitors as described in Health Departments: Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Plan.

        Healthcare facilities should have a process for notifying the health department about known or suspected cases of SARS-CoV-2 infection, and should establish a plan, in consultation with local public health authorities, for how exposures in a healthcare facility will be investigated and how contact tracing will be performed. The plan should address the following:

        • Who is responsible for identifying contacts and notifying potentially exposed individuals?
        • How will such notifications occur?
        • What actions and follow-up are recommended for those who were exposed?

        Contact tracing should be carried out in a way that protects the confidentiality of affected individuals to the extent possible and is consistent with applicable laws and regulations. HCP and patients who are currently admitted to the facility or were transferred to another healthcare facility should be prioritized for notification. These groups, if infected, have the potential to expose a large number of individuals at higher risk for severe disease, or in the situation of admitted patients, be at higher risk for severe illness themselves.

        Information for health departments about case investigation and contact tracing is available in the Health Departments: Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Plan. This guidance could also be helpful to healthcare facilities performing such activities.

        Anyone who had prolonged close contact (within 6 feet for at least 15 minutes) should be considered potentially exposed. The use of a facemask for source control and adherence to other recommended infection prevention and control (IPC) measures (e.g., hand hygiene) by the provider help to reduce the risk of transmission or severe illness. In areas with moderate to substantial community transmission, patients are already at risk for exposure to SARS-CoV-2 due to exposures outside their home and should be alert to the development of signs or symptoms consistent with COVID-19.

        The following should be considered when determining which patients are at higher risk for transmission and might be prioritized for evaluation and testing:

          use by the patient &ndash Mirroring the risk assessment guidance for healthcare personnel, patients not wearing a facemask would likely be at higher risk for infection compared to those that were wearing a facemask.
      • Type of interaction that occurred between the patient and infected provider &ndash An interaction involving manipulation or prolonged close contact with the patient&rsquos eyes, nose, or mouth (e.g., dental cleaning) likely poses higher risk of transmission to the patient compared to other interactions (e.g., blood pressure check).
      • PPE used by infected HCP &ndash HCP wearing a facemask (or respirator) and face shield that extends down below the chin might have had better source control than wearing only a facemask. Note that respirators with exhalation valves might not provide source control.
      • Current status of patient &ndash Is the patient currently admitted to a hospital or long-term care facility? These individuals, if infected, can be at higher risk for severe illness and have the potential to expose large numbers of individuals at risk for severe disease.
      • 1. If HCP have recovered from SARS-CoV-2 infection but have a high-risk exposure within 3 months of their initial infection to a patient with SARS-CoV-2 infection, should they be restricted from work for 14 days after the exposure?

        CDC has posted interim guidance for risk assessment and work restrictions for HCP with potential exposure to SARS-CoV-2. Because of their often extensive and close contact with people who are at high risk for severe illness, this guidance recommends a conservative approach to HCP monitoring and applying work restrictions to prevent transmission from potentially contagious HCP to patients, other HCP, and visitors. Review of currently available evidence suggests that most people do not become re-infected in the 3 months after SARS-CoV-2 infection. Testing of asymptomatic people during this 3-month period is complicated by the fact that some people have detectable virus from their prior infection during this period a positive test during this period may more likely result from a prior infection rather than a new infection that poses risk for transmission.

        In light of this, exposed HCP who are within 3 months of their initial infection, could continue to work, while monitoring for symptoms consistent with COVID-19 and following all recommended infection prevention and control practices (e.g., universal use of well-fitting source control). If symptoms develop, exposed HCP should be assessed and potentially tested for SARS-CoV-2, if an alternate etiology is not identified. Some facilities might still choose to institute work restrictions for asymptomatic HCP following a higher risk exposure, particularly if there is uncertainty about a prior infection or the durability of the person&rsquos immune response. Examples could include:

        • HCP with underlying immunocompromising conditions (e.g., after organ transplantation) or who become immune compromised (e.g., receive chemotherapy) in the 3 months following SARS-Cov-2 infection who might be at increased risk for reinfection. However, data on which specific conditions may lead to higher risk and the magnitude of risk are not available.
        • HCP for whom there is concern that their initial diagnosis of SARS-CoV-2 infection might have been based on a false positive test result (e.g., individual was asymptomatic, antigen test positive, and a confirmatory nucleic acid amplification test (NAAT) was not performed).
        • HCP for whom there is evidence that they were exposed to a novel SARS-CoV-2 variant for which the risk of reinfection might be higher (e.g., exposed to a person known to be infected with a novel variant).

        CDC continues to actively investigate the frequency of reinfection and the circumstances surrounding these episodes, including the role that new variants might play in reinfection, and will adjust guidance as necessary as more information becomes available.

        2. If HCP within 3 months of their initial infection develop symptoms consistent with COVID-19, should they be excluded from work and retested?

        HCP within 3 months of a confirmed SARS-CoV-2 infection who develop symptoms consistent with COVID-19 should be evaluated to identify potential alternative etiologies for their symptoms. If an alternate etiology for the symptoms cannot be identified, they may need to be retested for SARS-CoV-2 infection with the understanding that a positive viral test could represent residual viral particles from the previous infection, rather than new infection. Decisions about the need for and duration of work exclusion should be based upon their suspected diagnosis (e.g., influenza, SARS-CoV-2 infection).

        3. Do HCP within 3 months of their initial infection need to wear all recommended personal protective equipment (PPE) when caring for patients with suspected or confirmed SARS-CoV-2 infection? For example, if there are limited respirators, should respirators be prioritized for HCP who have not been previously infected?

        Regardless of suspected or confirmed immunity, healthcare personnel should always wear all recommended PPE when caring for patients. In situations of PPE shortages, facilities should refer to CDC strategies for optimizing PPE supply. However, as with other infectious diseases (e.g., measles), allocation of available PPE should not be based on whether HCP have been previously infected or have evidence of immunity.

        4. Should HCP within 3 months of their initial infection be preferentially assigned to care for patients with suspected or confirmed SARS-CoV-2 infection?

        While individuals who have recovered from SARS-CoV-2 infection might develop some protective immunity, the duration and extent of such immunity are not known. Staffing decisions should be based on usual facility practices. Any HCP assigned to care for patients with suspected or confirmed SARS-CoV-2 infection, regardless of history of infection, should follow all recommended infection prevention and control practices when providing care. Guidance on mitigating staff shortages is also available.

        Yes. HCP who have any kind of exposure for which home quarantine is recommended should be excluded from work:

        • If HCP are able to quarantine away from the infected individual living with them, they should quarantine at home and not come into work for 14 days following their last exposure to the infected individual.
        • If HCP are not able to quarantine away from the infected individual living with them and have ongoing unprotected exposure throughout the duration of the individual&rsquos illness, they should remain in home quarantine and be excluded from work until 14 days after the infected individual meets criteria for discontinuation of home isolation.
        • If HCP develop SARS-CoV-2 infection while they are in quarantine, they should be excluded from work until they meet all return to work criteria for HCP with SARS-CoV-2 infection.

        Home quarantine and work exclusion of asymptomatic exposed HCP who have recovered from SARS-CoV-2 infection in the prior 3 months might not be necessary. Additional information about this scenario is available here.

        When confirmatory testing is performed on a person with a potential false-positive antigen test result, IPC measures should be maintained pending the result. Additional testing of close contacts can be delayed until results of confirmatory testing are available unless symptomatic individuals are identified.

        • For asymptomatic healthcare personnel (HCP), this includes continuing exclusion from work pending confirmatory testing.
        • For asymptomatic patients or residents, this includes placement on Transmission-Based Precautions in a single room or, if single rooms are not available, remaining in their current room pending results of confirmatory testing. They should not be transferred to a COVID-19 unit or placed in another shared room with new roommates.

        Given the generally lower sensitivity of antigen tests, people with COVID-19&ndashlike symptoms who have a negative antigen test result should have a confirmatory nucleic acid amplification test (NAAT), such as reverse transcriptase polymerase chain reaction (RT-PCR), in most situations. Pending the results of confirmatory testing, maintain the following IPC measures:

        • Patients and residents with COVID-19&ndashlike symptoms should be placed on Transmission-Based Precautions in a single room (not on the COVID-19 unit)
        • HCP with COVID-19&ndashlike symptoms should be excluded from work until the confirmatory test results are available.

        Despite the potential need for confirmatory testing of negative results, the initial use of antigen tests for symptomatic people is still preferred if turnaround time for a NAAT is >2 days because a positive antigen test would initiate contact tracing and implementation of IPC measures.

        CDC has recommended several ways to improve the fit and filtration of masks, including covering a medical facemask with a cloth mask. However, layering masks requires special care in healthcare settings.

        • Although a cloth mask can be used over a medical facemask to improve fit, there may be better alternatives such as framed &ldquofitters&rdquo or using a knot-and-tuck approach to achieve a good fit. If a good fit is achieved using a single medical facemask, additional approaches like adding layers to achieve a better fit might not be necessary.
        • Cloth masks are not personal protective equipment (PPE). They should not be used in place of medical facemasks or NIOSH-approved respirators as part of Standard or Transmission-based Precautions.
        • Wearing a medical facemask or cloth mask over an N95 respirator is not recommended for healthcare personnel in healthcare settings except as a contingency or crisis strategy during extended use of N95 respirators to protect the respirator from contamination during aerosol-generating procedures or procedures that might generate splashes and sprays.
        • Wearing a medical facemask or cloth mask under an N95 respirator is never recommended as it will interfere with the seal.

        In healthcare settings, medical facemasks are used by healthcare personnel for two general purposes.

        • First, as PPE to protect a healthcare worker&rsquos nose and mouth from exposure to splashes, sprays, splatter, and respiratory secretions, such as when treating patients on Droplet Precautions. When used as PPE, medical facemasks should be removed and discarded after each patient encounter unless extended use is being practiced as part of a crisis or contingency capacity strategy.
          • If a cloth mask is used over the medical facemask, it should be removed and laundered after each patient encounter.
          • Cloth masks are not PPE and should not be used alone to protect against splashes and sprays, such as when used while treating patients on Droplet Precautions.

          Once put on, healthcare personnel should not touch their medical facemask or cloth mask. If they touch or adjust their medical facemask or cloth mask, they must perform hand hygiene before and after contact.

          If laundering at the intervals described above cannot be performed, then cloth masks should not be used by healthcare personnel in healthcare settings.

          *Medical facemasks are personal protective equipment (PPE) and are often referred to as surgical masks or procedure masks. Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.


          COVID-19 and Blood Clots

          Mohammed Haneefa Nizamudeen/iStock/Getty Images Plus

          This article is part of Harvard Medical School’s continuing coverage of medicine, biomedical research, medical education and policy related to the SARS-CoV-2 pandemic and the disease COVID-19.

          Patients hospitalized with severe COVID-19 infections who have high levels of the blood clotting protein factor V are at elevated risk for serious injury from blood clots such as deep vein thrombosis or pulmonary embolism, according to a new study by Harvard Medical School investigators at Massachusetts General Hospital.

          On the other hand, critically ill patients with COVID-19 and low levels of factor V appear to be at increased risk for death from a form of coagulopathy that resembles disseminated intravascular coagulation (DIC)—a devastating, often fatal abnormality in which blood clots form in small vessels throughout the body, leading to exhaustion of clotting factors and proteins that control coagulation.

          Their findings, based on studies of patients with COVID-19 in Mass General intensive care units, point to disturbances in factor V activity as both a potential cause of blood clotting disorders with COVID-19 and potential methods for identifying at-risk patients with the goal of selecting the proper anticoagulation therapy.

          The study results are published online Aug. 24 in the American Journal of Hematology.

          “Aside from COVID-19, I’ve never seen anything else cause markedly elevated factor V, and I’ve been doing this for 25 years,” said senior study author Elizabeth Van Cott, HMS professor of pathology at Mass General.

          Patients with severe COVID-19 caused by the SARS-CoV-2 virus can develop blood clots in medical lines, such as intravenous lines and catheters, and in arteries, lungs and extremities, including the toes. Yet the mechanisms underlying coagulation disorders in patients with COVID-19 are still unknown.

          Surprising case

          In March 2020, in the early days of the COVID-19 pandemic in Massachusetts, Van Cott and colleagues found that a blood sample from a patient with severe COVID-19 on a ventilator contained factor V levels high above the normal reference range. Four days later, this patient developed a saddle pulmonary embolism, a potentially fatal blood clot occurring at the junction of the left and right pulmonary arteries.

          This pointed the investigators to activity of factor V as well as factor VIII and factor X, two other major blood clotting protein factors. They studied the levels of these clotting factors and other parameters in a group of 102 consecutive patients with COVID-19 and compared the results with those of current critically ill patients without COVID-19, as well as against historical controls.

          The researchers found that factor V levels were significantly elevated among patients with COVID-19 compared with controls, and they found the association between high factor V activity and COVID-19 was the strongest among all clinical parameters studied.

          In all, 33 percent of patients with factor V activity well above the reference range had either deep vein thrombosis or a pulmonary embolism, compared with only 13 percent of patients with lower levels. Death rates were significantly higher for patients with lower levels of factor V, with evidence suggesting that this was due to a clinical decline toward a DIC-like state.

          Van Cott and colleagues also found that the clinical decline toward DIC was foreshadowed by a measurable change in the shape, or waveform, of a plot charting light absorbance against the time it takes blood to coagulate.

          “The waveform can actually be a useful tool to help assess patients as to whether their clinical course is declining toward DIC or not,” Van Cott said. “The lab tests that usually diagnose DIC were not helpful in these cases.”

          Importantly, the investigators note that factor V elevation in COVID-19 could cause misdiagnosis of some patients, because under normal circumstances factor V levels are low in the presence of liver dysfunction or DIC. Physicians might therefore mistakenly assume that patients instead have a deficiency in vitamin K.

          “This investigation was spurred by the surprising case we encountered and was conducted rapidly by an interdisciplinary pathology team at Mass General during the peak of the pandemic,” said study co-author Jonathan Stefely, HMS clinical fellow in pathology at Mass General.


          Improving the Breed


          In the wake of the war-built Essex-class ships were three aircraft carriers that served as crucial testbeds for the technology and operations of their huge Cold War–era progeny.

          The three large, or battle, carriers of the Midway (CVB-41) class were the largest warships built by the United States in World War II, had an important role in the Cold War, and were the first U.S. Navy ships to embark nuclear weapons. The Battle of Midway in early June 1942 is generally cited as the event that illuminated the need for the three ships. The battle was in many respects the turning point of the Pacific war, when Japanese naval forces were decisively defeated, opening the way for an American offensive in the Pacific.

          Based on the lessons of the battles of the Coral Sea (May 1942) and Midway, the Navy proposed a 45,000-ton large carrier, that would—appropriately—be named the Midway, as well as additional fleet carriers of the Essex (CV-9) class. The CVB actually originated with a proposal from the Navy's General Board for a large carrier that would have an armored flight deck and be particularly well compartmented below decks to help resist battle damage. The board held hearings on the proposed battle carrier as early as March 1942, and Congress approved construction of the lead CVB (as well as nine additional Essex-class ships) in July.

          In early August, Secretary of the Navy Frank Knox approved contract awards in the fiscal 1943-44 authorization for 690 new ships, including four large carriers, the CVB-41 through -44. On 12 August, however, President Franklin D. Roosevelt wrote to the secretary approving the entire program except for the four 45,000-ton carriers. The President disapproved the CVBs because of their long construction time in comparison to the 27,100-ton Essex-class ships, which he believed were a better investment of resources. At the same time, U.S. fleet commanders showed no enthusiasm for the larger ships.


          Roosevelt confidant Captain Edward L. Cochrane, however, believed that shifting two of the planned CVBs to the New York Navy Yard, which had excess drafting capacity because of the cancellation of the large battleships of the Montana (BB-67) class, would interfere little with other carrier construction.1 Both Newport News Shipbuilding in Virginia and the New York yard would construct CVBs, with the drafting work done at New York.

          Cochrane, who would become chief of the Bureau of Ships in November 1942, apparently had a major influence on the President, and Roosevelt agreed to CVB construction. A memorandum from Secretary Knox on 29 December 1942, approved the construction of two ships (CVB-41 and -42) and on 26 May 1943, the President approved building a third ship (CVB-43). The fourth ship—CVB-44—was formally cancelled on 11 January 1943.

          Bigger in Every Way


          After several design iterations by the Bureau of Ships, the CVB design evolved as one of the world's largest warships, with a standard displacement of 45,000 tons and an overall length of 968 feet.2 With a beam of 113 feet, the carrier would be the first U.S. ship designed from the outset that was too large to transit the 110-foot-wide locks of the Panama Canal. (The Essex-class carriers could transit the canal locks only with their 40-mm starboard gun sponson removed and the port-side elevator in the vertical position. Also, three World War I–era battleships that were modernized after Pearl Harbor had bulges that increased their beam from 108 to 114 feet.)

          The CVBs were the U.S. Navy's first armored-deck carriers. They were also distinctive, with a massive starboard island structure and funnel somewhat reminiscent of the old Lexington (CV-2) and Saratoga (CV-3), built in the 1920s. The new ships were to have the heaviest antiaircraft battery of any warship, with 18 single 5-inch/54-caliber guns of a new, long-range design, plus 84 40-mm and 28 20-mm guns.


          The ships were designed to operate up to 144 contemporary aircraft. With an estimated optimum aircraft takeoff and landing interval of some 30 seconds, it would—in perfect circumstances—take more than an hour to launch or recover its air group.3 The aircraft would be moved between the hangar and flight deck by one deck-edge and two centerline elevators. Two hydraulic flight-deck catapults would launch the heaviest aircraft.

          Carved in Steel


          The keel for the CVB-41 was laid down on 27 October 1943 at the Newport News Shipbuilding and Dry Dock Company. During the war and afterward reports circulated that the CVBs were converted from unfinished Iowa-class battleship hulls. That was a shipyard myth. The two unfinished Iowa hulls were scrapped. During the war, consideration was given to converting the six Iowa-class battleships when still under construction to aircraft carriers. Undersecretary of the Navy James Forrestal was a prime advocate of such conversions, declaring, "I think the conversion of the BB-63 and BB-64 would be very wise indeed."4 But the Bureau of Ships demurred, arguing that it was more efficient to simply build more Essex-class carriers, and undertook no battleship conversions.

          When the CVB-41 was launched on 20 March 1945, the U.S. Navy had 88 aircraft carriers of all types and sizes in commission. Another 25 were under construction, and an additional 31 were on order. Although more than two-thirds of the flattops in service were escort carriers, 26 fast carriers were in service with 16 more in various stages of construction.

          The CVB-41 was christened the Midway by Mrs. Bradford William Ripley II, widow of a naval aviator killed during training. The first USS Midway had been a small fleet auxiliary (AG-41), renamed Panay in April 1943 so that the escort carrier CVE-63 could have the appellation. That ship, in turn, was renamed the Saint Lô in September 1944.


          The Midway was placed in commission on 10 September 1945, eight days after Japan's formal surrender on board the battleship Missouri (BB-63). Subsequently, the Midway carried out trials and air group workup for the next few months.

          On 1 March 1946, the carrier, with portions of air group CVG-74 embarked, departed Norfolk, Virginia, with three destroyers to conduct cold-weather tests. Operating off the coast of Labrador and above the Arctic Circle, this evaluation of carrier operations in arctic waters was called Operation Frostbite. It demonstrated that cold-weather carrier operations were feasible, although at a reduced tempo. The task force returned to Norfolk on 22 March.


          A more historic operation occurred in September 1947. After the war, both the United States and the Soviet Union exploited German missile technology and test-fired a large number of V-2s.5 That month at Norfolk, the Midway took aboard two operational V-2s (without warheads) and a dummy training missile. The carrier went to sea with U.S. and German rocket scientists and engineers—among them Wernher von Braun, "father" of the V-2—on board. On 6 September, one of the rockets was launched from the carrier's flight deck in Operation Sandy. The 46-foot, 14-ton missile lifted off and immediately began to tilt to starboard. Within seconds, the missile's control vanes corrected its attitude to the vertical, and the only launch of a V-2 missile from a moving platform was a success.

          Cold War Deployments


          When World War II ended in Europe in the spring of 1945, the Soviets were in firm control of Eastern Europe, mostly by military occupation. Communists also threatened Turkey and Greece and won control of Bulgaria and Soviet troops refused to withdraw from Iran.6 As a countermove, in April 1946 the United States sent the battleship Missouri, a light cruiser, and a destroyer into the eastern Mediterranean. Officially the ships were there to return the remains of a Turkish diplomat who had died in the United States in November 1944 in reality, they were sent to warn the Soviet Union of U.S. interest in Turkey remaining noncommunist.

          No aircraft carrier accompanied the Missouri. At one stage of planning for the operation, the large carriers Midway and Franklin D. Roosevelt (CVB-42) were to have accompanied the dreadnought. The carriers, however, were dropped from the operation when the State Department concluded that the Soviets might consider so large a force a provocation. But the Missouri's visit initiated the practice of sending major fleet units into the Mediterranean. The Roosevelt did operate in the Mediterranean from 8 August to 4 October 1946 with the 123 aircraft of Battle Carrier Air Group 75 (CVBG-75). The aircraft on this single carrier possessed more striking power than the combined air forces of all Mediterranean nations.

          During the 1946 cruise, the FDR visited Athens to bolster the government of Greece in its fight against communists. At other Mediterranean port calls, the Roosevelt opened her decks to thousands of visitors, starting a custom of goodwill visits by U.S. warships. This show of naval force, begun with the Missouri visit, was a major milestone in the development of U.S. foreign policy in the postwar era.

          From late 1947, on a continuous basis, at least one U.S. carrier operated in the Mediterranean, and from mid-1951 at least two attack carriers normally sailed that sea until the end of the Cold War. The Midway's first Med deployment was from November 1947 to March 1948, with carrier air group CVBG-1. She made port calls in Gibraltar, Algeria, Malta, Italy, and France.

          Finding a Nuclear-Strike Carrier Plane


          The U.S. Navy's most significant effort in carrier development in the immediate postwar years was the drive to achieve a nuclear-strike capability. When World War II ended, the United States had a very limited nuclear capability because of the few atomic bombs available, which could only be delivered to a target up to 1,500 miles away by a small number of modified B-29 Superfortress bombers. The Navy had no nuclear capability. The atomic bomb had been developed as an Army project with only a few Navy officers involved, albeit serving in key positions.

          During the war, the Navy had begun developing a large, three-engine attack aircraft—the North American AJ Savage—intended specifically to operate from the three Midway-class carriers as well as future, larger flattops. It was to be powered by twin piston engines and an auxiliary J33 turbojet. The first XAJ-1 prototype flew on 3 July 1948. But the Savage would not be ready for fleet operations until the fall of 1949, and the Navy was not willing to lose time in the development of a carrier-based nuclear-strike capability. The only naval aircraft that could carry a 10,000-pound bomb and stood any possibility of taking off from a carrier deck was the Lockheed P2V Neptune, a new twin-engine, land-based patrol aircraft. It had a wing span of 100 feet, a length of 78 feet, height of 28 feet, and take-off weight of some 60,000 pounds.

          Extensive tests with the Neptunes were conducted ashore at Patuxent River Naval Air Station in Maryland before two P2V-2s, loaded aboard the Coral Sea (CVB-43) by crane, took off from the carrier's deck with the aid of rocket boosters on 28 April 1948. A dozen of the planes were modified to carry nuclear weapons. Designated P2V-3C, they were to be loaded aboard the Midway-class carriers by crane to fly atomic strikes. On 7 March 1949, three Neptunes launched from the Coral Sea, which was then off the East Coast. Two flew to a nearby airfield while the third, weighing 74,000 pounds on takeoff, with a five-ton dummy bomb on board, flew across the country, dropped its "bomb" on the West Coast, and then returned east to land at Patuxent River—a round-trip of nearly 23 hours and 4,500 miles. Despite the demonstration, the Navy was still far from having a practical carrier-based nuclear-strike capability.

          All three of the Midways had their flight decks strengthened to operate the loaded Neptunes and were modified to store and assemble nuclear weapons. The Coral Sea was the first to be fitted to handle "nukes." Completed in March 1950, its special weapon spaces were installed at the Norfolk Naval Shipyard. The ship then moved to the nearby Norfolk naval base, where a crane deposited a P2V-3C on board. On the night of 20-21 April 1950, a gun-type (uranium) MK VIII atomic bomb was assembled on board ship, albeit without certain critical components, and loaded into the Neptune. At 0730 the aircraft, weighing 74,668 pounds, took off amid a cloud of JATO (jet assisted take-off) exhaust in the first launch of a nuclear weapon from an aircraft carrier.

          Deliveries of AJ-1 Savages to fleet squadrons began in September 1949, although the first carrier takeoff was not made until April 1950 from the Coral Sea. The Savage was the first true carrier-based heavy-attack aircraft. With a gross weight of 47,630 pounds, the AJ-1 could carry a MK III or a MK IV atomic bomb or an equal weight of conventional weapons to targets 750 miles from the carrier and return.

          Special Weapons at Sea


          On 14 June 1950, President Harry S. Truman released 90 nuclear bomb assemblies—without the plutonium core—from the Atomic Energy Commission to permanent military control a small number were placed aboard Midway-class carriers as they departed Norfolk for operations in the North Atlantic and Mediterranean. While, in theory, this gave the carriers a nuclear-strike capability, the Savages were awkward to operate on straight-deck carriers, while the Neptunes had to be loaded aboard by crane. Still, the three CVBs were the world's first warships to be armed with nuclear weapons.

          The nuclear components for atomic bombs were not placed aboard aircraft carriers until at least 1953. In the interim, under a program code-named Daisy Chain, an elaborate scheme was developed to fly the plutonium cores from Savannah, Georgia, to a NATO-controlled airfield in the Mediterranean area where modified TBM-3R Avenger aircraft would be waiting to fly the components out to the carriers.

          The Midway-class CVBs initially served with the Atlantic Fleet, making periodic deployments to the Mediterranean and other NATO areas during the early phases of the Cold War. They did not participate in the Korean War, as many U.S. political leaders feared that Korea was the first step in a process that would escalate to war in Europe.


          The Midway became the first of her class to enter the Pacific Ocean when she departed Norfolk on 27 December 1954. Sailing by way of the Cape of Good Hope, she joined the U.S. Seventh Fleet off Taiwan in February 1955. In late June she sailed to Washington's Puget Sound Naval Shipyard for an extensive modernization. In the yard through September 1957, she received an enclosed hurricane bow, angled flight deck, three steam catapults, and other updates. The Coral Sea followed into the Pacific in September 1960 the Roosevelt remained in the Atlantic. The availability of larger carriers of the Forrestal and later classes in the Atlantic beginning in 1955 permitted the shift.7

          Carriers at War


          Subsequently deploying to the Western Pacific on a regular basis, the Midway was in the South China Sea during the Laotian crisis in the spring of 1961, but no shots were fired by U.S. carrier planes. The first Midway-class carrier to launch aircraft in combat was the Coral Sea. In response to a Vietcong attack on a U.S. military compound in the Central Highlands of South Vietnam, on 7 February 1965, the Coral Sea, Hancock (CV-19), and Ranger (CV-61) launched strikes against military targets in North Vietnam. The only U.S. loss was an A-4E Skyhawk and its pilot from the Coral Sea.

          All three Midway-class ships subsequently carried out operations against Vietcong and North Vietnamese targets. From 1965 to 1975, the Midway made nine deployments to the war zone, the Coral Sea eight, and the Roosevelt—still an Atlantic Fleet carrier—one. The Midway and Coral Sea also had important roles in the evacuation of military personnel and civilians from Saigon when South Vietnam fell in April 1975.

          On 11 September 1973, in a historic move, the Midway became the first U.S. aircraft carrier based overseas when Yokosuka, Japan, became her home port. From there, with air wing CVW-5 embarked, she operated in the Western Pacific and Indian Ocean areas for 18 years. On 2 November 1990, she arrived in the North Arabian Sea to provide air support for Operation Desert Shield. And, with five other U.S. carriers, the Midway flew missions in support of Desert Storm in 1991. Keeping pace with the larger carriers, her aircraft flew 3,339 combat sorties—an average of 121 per day—during the conflict.

          Desert Storm marked the end of the Midway-class carriers in the Fleet. The Roosevelt, which had undergone the least modernization because of scheduling and cost issues during the Vietnam War, had been the first decommissioned—after 32 years of service on 30 September 1977—and scrapped. The Coral Sea hauled down her commission pennant on 30 April 1990, after 42 years in the Fleet she, too, was scrapped.

          The Midway departed Yokosuka in August 1991, relieved as the overseas-based carrier by the Kitty Hawk (CV-63). She was decommissioned at Naval Air Station North Island in San Diego on 17 March 1997 after serving in the Fleet for almost 46 years. The ship was stored at Bremerton, Washington, but was under way again on 30 September 2003, when she was towed south to Oakland, California, for restoration work.

          Finally, she was taken in tow on the last day of 2003, en route for San Diego. There, in June 2004, she officially opened as the San Diego Aircraft Carrier Museum. Today from her flight deck can be seen the site of what was the Glenn Curtiss training camp on North Island where, on 23 December 1910, the U.S. Navy accepted an offer by Curtiss to teach a naval officer to fly without charge. Lieutenant Theodore G. Ellyson reported to the Curtiss camp for flight training. He became Naval Aviator No. 1.

          Mr. Polmar, a Naval History contributing editor and frequent contributor to and columnist of Proceedings, is the author of Aircraft Carriers: A History of Carrier Aviation and Its Influence on World Events, vol. 1 and 2 (Dulles, VA: Potomac Books, 2006, 2007.)


          Development Timeline for REGEN-COV

          DateArticle
          Jun 4, 2021FDA Authorizes Lower 1,200 mg Intravenous and Subcutaneous Dose of REGEN-COV™ (casirivimab and imdevimab) Antibody Cocktail to Treat Patients with COVID-19
          May 17, 2021Phase 3 Data Presented at ATS 2021 Show REGEN-COV™ (casirivimab with imdevimab) Reduced Risk of Hospitalization or Death by 70% in Non-hospitalized COVID-19 Patients
          Apr 12, 2021Phase 3 Treatment Trial in Recently Infected Asymptomatic Patients Showed REGEN-COV™ (casirivimab with imdevimab) Significantly Reduced Progression to Symptomatic COVID-19
          Apr 12, 2021Phase 3 Prevention Trial Showed 81% Reduced Risk of Symptomatic SARS-CoV-2 Infections with Subcutaneous Administration of REGEN-COV™ (casirivimab with imdevimab)
          Apr 9, 2021NIH COVID-19 Treatment Guidelines Strongly Recommend Use of REGEN-COV™ (casirivimab with imdevimab) in Outpatients at High Risk of Clinical Progression
          Mar 23, 2021Phase 3 Trial Shows REGEN-COV™ (casirivimab with imdevimab) Antibody Cocktail Reduced Hospitalization or Death by 70% in Non-hospitalized COVID-19 Patient
          Feb 25, 2021Independent Data Monitoring Committee Finds Clear Efficacy for REGEN-COV™ (casirivimab with imdevimab) in Phase 3 COVID-19 Outpatient Outcomes Trial
          Jan 27, 2021REGEN-COV™ Antibody Cocktail Is Active Against SARS-CoV-2 Variants First Identified in the UK and South Africa
          Jan 26, 2021Regeneron Reports Positive Interim Data with REGEN-COV Antibody Cocktail used as Passive Vaccine to Prevent COVID-19
          Jan 12, 2021Regeneron Announces U.S. Government Agreement to Purchase Additional COVID-19 Antibody Cocktail Doses
          Dec 17, 2020New England Journal of Medicine Publishes Positive Initial Regeneron Antibody Cocktail Results in Non-hospitalized Patients with COVID-19
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          Oct 28, 2020Regeneron's COVID-19 Outpatient Trial Prospectively Demonstrates that REGN-COV2 Antibody Cocktail Significantly Reduced Virus Levels and Need for Further Medical Attention
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          Aug 18, 2020Genentech and Regeneron Collaborate to Significantly Increase Global Supply of REGN-COV2 Investigational Antibody Combination for COVID-19
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          Mar 17, 2020Regeneron Announces Important Advances in Novel COVID-19 Antibody Program
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          Don't Do This Until a Month After Your COVID Vaccine, Experts Warn

          New guidelines suggest waiting to do this for at least four to six weeks after your shot.

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          While the COVID vaccine has been proven to be safe, it doesn't come without warnings: You shouldn't take over-the-counter painkillers before getting the shot, and you shouldn't share a photo of your vaccination card after. Now, experts are warning people to avoid another routine activity for at least a month after getting the vaccine. Keep reading to find out what you should hold off doing post-vaccination, and for things you can do, Dr. Fauci Just Confirmed You Can Do This After Getting Vaccinated.

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          The Society of Breast Imaging just released a statement saying people who recently got a COVID vaccine may present axillary [in the armpit] lymph node swelling, which could mimic a sign of breast cancer. Since the axillary lymph nodes are near the outer breast, the sight of them swollen during a breast exam could easily raise concern. The statement detailed how professionals should document such an occurrence, and suggested people wait to schedule their appointment to prevent unnecessary worry.

          According to the Centers for Disease Control and Prevention (CDC), axillary lymph node swelling was found in both men and women during the Pfizer and Moderna vaccine trials. Swollen lymph nodes are a common immune response that occurs with various vaccines, including the flu vaccine, hepatitis vaccines, polio vaccine, and the tetanus vaccine, according to Forbes.

          "The lymph system is your drainage system, and they respond to inflammation," explained hormone expert and founder of Revitalize Medical Group Tara Scott, MD. "Your underarm (or axillary lymph nodes) nodes are the ones closest to the arm—and to the breast—so they would be visible on a mammogram." And for more vaccine reactions to be aware of, The CDC Says These 3 Side Effects Mean Your Vaccine Is Working.

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          "The recommendation is to wait at least one month after the second shot and to not get the mammogram in between shots," Scott said. In its statement, the Society of Breast Imaging also said that it would be wise to schedule a mammogram in advance of your vaccine. Doing this could also help put your mind at ease if a lump does form near your armpit after receiving the shot.

          If you can't get a mammogram appointment before your vaccine, the Society of Breast Imaging suggests waiting "four to six weeks following the second dose of a COVID-19 vaccination." And for more up-to-date information, sign up for our daily newsletter.

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          If you have a reason for concern or want to get something checked as soon as possible, don't delay your test. Jeffrey Hawley, MD, breast imaging radiologist at the Ohio State University Comprehensive Cancer Center, said patients "shouldn't put off getting their mammograms or COVID-19 vaccine—especially if it leads to a long delay or not getting screened at all."

          If you get a mammogram, just keep in mind that your COVID vaccine could impact the findings and alert your doctor that you recently got the shot. And for more on when you'll be able to get the vaccine, Biden Says This Is When You'll Easily Be Able to Get a Vaccine Appointment.

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          A mammogram isn't the only test that can catch a swollen axillary lymph node. "We are seeing unilateral axillary adenopathy on breast imaging, [such as] mammogram, ultrasound, and breast MRI after COVID-19 vaccinations are administered," Sunny Mitchell, MD, medical director of breast and women's services and director of breast surgery at Montefiore Nyack Hospital, told Forbes. "This is presenting in individuals with a history of breast cancer as well as no history of breast cancer." Mitchell said breast radiologists are using short-term follow-ups and repeated imaging to assess the situation before recommending a biopsy, in case the lump is related to the COVID vaccine.

          Rebecca Gamms, MD, breast radiologist at Hackensack Radiology Group/Hackensack University Medical Center, told Forbes they are "recommending a follow-up exam in 2-3 months to allow for the lymph nodes to return to normal." Additionally, to prevent this situation from occurring frequently, Gamms said they're adhering to the Society of Breast Imaging's recommendation to schedule mammograms either before or four to six weeks after a COVID vaccine. And for more on vaccine availability, This Is Who Can Get the Leftover Vaccine at Walgreens, CVS, & Walmart.


          Watch the video: Hancock 2008 - Your Head is Going Up His A Scene 510. Movieclips (May 2022).