How many cases of coronavirus disease 2019 (COVID-19) have been confirmed in the US?

, as of today, September 25, 2020 at 10:23 AM, EDT, there have been:

The 5 states with the highest total confirmed cases are:

 with 33 095 reported fatalities, followed by 

 with 642 169 people who have recovered, followed by 

 California leads in number of persons tested

 with 13 952 857 people tested, followed by 

How many cases of COVID-19 have been confirmed globally?

For more COVID-19 coverage for primary care, visit our

Articles

Global confirmed cases of COVID-19 have surpassed 32 million. We summarize more of today's data from the Johns Hopkins COVID-19 interactive map.

COVID-19 Update: US and Global Cases, Deaths, and Recoveries as of September 25, 2020

The increased risk for dementia associated with type 2 diabetes (T2D) is strongest for vascular dementia, according to 

 presented this week at the virtual European Association for the Study of Diabetes Meeting.

A link between T2D and elevated risk for dementia has been observed for some time but the association with different subtypes of dementia has been unclear. Study authors, led by Carlos Celis-Morales, DrPH, of the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, examined to what extent T2D is associated with Alzheimer, vascular and nonvascular dementia and whether the associations differed by level of glycemic control.

Participants were from the Swedish National Diabetes Register study and included 378 299 patients with T2D and 1 886 022 age- and sex-matched controls. At follow-up (median 6.8 years) 5.7% (21 651) patients with T2D and 5.2% (


The strongest association was observed for vascular dementia

Hazard ratio (HR) for patients with T2D, 1.36 [95% CI 1.03, 1.09] vs matched controls. For nonvascular dementia, the association with T2D was somewhat lower: HR, 1.08 [95% CI 1.04, 1.12]). The risk of Alzheimer dementia for patients with T2D was lower than for controls: HR, 0.92 [95% CI 0.87, 0.98]).

 after stratifying analyses by A1c level. When T2D patients with A1c <7%(52 mmol/mol)were compared to those with A1c >10% (87 mmol/mol) , risk was higher for Alzheimer (HR: 1.34 [95% IC 1.03, 1.75]), vascular dementia (HR: 1.93 [95% IC 1.53, 2.42]) and non-vascular dementia (HR: 1.67 [95% IC 1.45, 1.91]).

 at 3 years found that the associations remained similar for vascular and non-vascular dementia but disappeared for Alzheimer.

 that the association of T2D with neurodegenerative diseases differs by dementia type with the largest effect seen for vascular dementia. Based on analyses stratified by level of A1c, poor glycemic control is associated with an increased risk of developing vascular and non-vascular dementia.

The association of vascular dementia with T2D is stronger than that of nonvascular or Alzheimer dementia, according to a study presented at EASD. 

Patients with T2D at Greater Risk for Vascular than Other Dementias 

In his decision on a 1964 landmark obscenity case, Supreme Court Justice Potter Stewart famously said he couldn’t define pornography “but I know it when I see it.”

Anyone trying to define pain may have a similar response. We know when we suffer pain but trying to put into words what the actual sensation is beyond simply saying “if it hurts, it’s pain” is a major challenge.

A task force formed by The International Association for Study of Pain (IASP), the major international organization for medical professionals involved in the study and treatment of pain, recently released a revised definition of pain.

The revision replaces the definition first developed by the IASP Subcommittee on Taxonomy and adopted by the IASP in 1979. Pain was defined as:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” 

Accompanying the definition was a note that read in part: 

“Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life….Many people report pain in the absence of tissue damage or any likely patholophysiological cause; usually this happens for psychological reasons…Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate cause.”

This IASP definition has been widely accepted by many medical and governmental organizations including the World Health Organization.

What has always been a great curiosity to me is how many times medical professionals would choose to present just the definition and exclude any mention of the note. I’ve always felt that one of the reasons for the choice was that a majority of doctors in this country who have specialized in pain management are anesthesiologists and it might be a bit uncomfortable for them to try to explain why they should be the leaders in treating something which is “always a psychological state.”

Having served for several years on the IASP Subcommittee on Taxonomy, I know that ever since the above definition was presented, there have been many discussions on its accuracy and whether a revision was required. Although over the years, the IASP has made changes to a number of terms related to pain based on new research, there was little to suggest that another definition of pain itself would prove to be marked improvement.

In 2018, an IASP task force was formed to specifically focus on the definition of pain and to recommend whether the definition and the accompanying note “should be retained or changed based on current evidence-based knowledge.” (p.1977)

The task force decided that the definition should meet several requirements. It should:

Apply to both acute and chronic pain and to all forms of pain no matter what the pathophysiology;

Be defined whenever possible from the perspective of the person experiencing the pain and not an external observer.

Signaling just how many factors are considered to be involved in pain, the task force sought input from not only healthcare professionals but also ethicists and philosophers.

The task force noted that it received several key comments on its proposals including that the definition

its reference to tissue injury should be better aligned with modern conceptualizations of pain

should better capture the personal experience of pain

should provide more specificity regarding the various components of pain

The task force initially recommended that the definition be changed to: 

“An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury.”

However, there were concerns about use of the word “aversive” regarding the clarity of its meaning and the difficulty of its translation into many languages. It was also noted that in certain situations while pain may be unpleasant it may not be avoided such as with athletes. The task force decided to retain the word “unpleasant” from the previous definition.

There were also concerns about the indication of emphasis on tissue injury by the words “resembling that caused by” and it was decided to retain the words “association with.”

“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential damage.”

The changes from the previous definition were to add the words “or resembling that associated with” and to eliminate the words “described in terms of such damage.” 

The latter change was made to deemphasize tissue damage as the cause of pain; in many types of pain and especially of chronic pain, there is often no clear correlation between the presence or severity of tissue damage and the presence or severity of pain.

There are more significant changes in the notes accompanying the definition and clarifying how we should view pain. The new notes were put into bullet form: 

There were several goals for the revision of the notes the most important of which is the recognition that pain is an individual experience and that because of its multifactorial nature we must understand that when it comes to pain, everyone is different.

I believe this is very important point as healthcare professionals often determine what level of pain they may expect a patient to experience and treat it based on that reported by other patients with the same physical health problems. Unfortunately, this often results as the pain being dismissed or undertreated if the patient reports a greater level than others.

Also important is inclusion of the statement that we need to recognize that the inability of a person to verbally express that he or she is experiencing pain does not mean an absence of pain. Although this certainly applies to animals, it also applies to many humans, most notably those who cannot verbally convey their pain, eg, cognitively impaired geriatric patients and pediatric patients too young to be able to describe their pain. 

Repeated studies have demonstrated that these two groups are among those whose pain is most poorly managed by healthcare professionals.

As to the difference between pain and nociception, the task force noted that the latter refers to “activity that occurs in the nervous system in response to a noxious stimulus.”

Although little change was made in the definition itself, revisions to the accompanying notes do help clarify our current understanding of pain and they are now presented in more accessible format. In running prose, the notes were often ignored when the definition of pain was discussed. The simple bulleted list will no doubt make them both more understandable and more useful.

And for those interested in words, the notes also include a brief discussion of the etymology of the word “pain.”

No doubt this is not the final version of either the definition or the notes as our knowledge of what pain is continues to evolve as new research highlights both what we now know about it and, perhaps of even greater importance, the many mysteries about it that remain to be solved.

_______________________________________________________

The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises.

To redefine the word "pain," the IASP invited ethicists and philosophers to assist in the process. A one-time IASP taxonomy task force member highlights the process. 


A New Definition for "Pain" 

Reported cases of sexually transmitted diseases (STDs) in the US have decreased since the coronavirus disease 2019 (COVID-19) pandemic started, according to new data reported during a Centers for Disease Control and Prevention 

 at the agency’s 2020 STD Prevention Conference.

US cases of STDs had been on the rise before the pandemic hit, but according to the CDC, the current decline was not unexpected and may be attributed to sexual distancing caused by shelter-in-place orders and decreases in testing due to pandemic-related clinic closures.

“STD increases are not a new issue,” said Gail Bolan, MD, director of the CDC’s Division of STD Prevention, at the roundtable discussion held September 14, 2020. “Even before COVID-19, the United States was already battling steep, sustained increases in syphilis, gonorrhea, and chlamydia.”

New preliminary data from 2019 presented at the roundtable discussion showed there were approximately 1.76 million cases of chlamydia, 602 000 cases of gonorrhea, and 123 000 cases of syphilis, with a 20% increase in syphilis cases among newborns. Although this data is not yet final, it represents increases across each reported STD compared with

Also, reported STD cases in the first 2 months of the year were above 2019 levels but that changed once COVID-19 hit and most Americans were living under some form of shelter-in-place order.

“Compared to the same period in 2019, weekly reported chlamydia cases were 53% below 2019 levels. Weekly reported gonorrhea cases were 33% below 2019 levels, and weekly reported primary and secondary syphilis cases were 33% below the equivalent period to 2019,” said Hillard Weinstock, MD, MPH, chief of the surveillance and data management branch for the CDC’s Division of STD Prevention.

Weinstock stressed, however, that this decrease, “may be an underestimate.” For example, the CDC noted that during the height of COVID-19 restrictions, 28% of STD and HIV testing sites in the St. Louis region were closed, 63% operated with modified services, and 8% operated with no changes. Overall, as a result, chlamydia and gonorrhea testing decreased 45% and an estimated 5000 HIV tests were missed.

“Despite our challenges, I believe it is possible to mitigate the current STD increases, even in the midst of a pandemic. It will require new commitments and continued innovation on the ground,” said Bolan.

Sexually distancing and declines in STD testing due to COVID-19 may have caused the recent decline in reported cases of syphilis, gonorrhea, and chlamydia in the US.

Pandemic-related “Sexual Distancing,” Declines in Testing Cause Drop in Reported STDs

, as of today, September 24, 2020 at 10:23 AM, EDT, there have been:

 with 33 090 reported fatalities, followed by 

 with 618 054 people who have recovered, followed by 

 with 13 879 423 people tested, followed by 

US confirmed cases of COVID-19 number nearly 7 million; global recoveries have surpassed 22 million. We summarize more of today's data from the Johns Hopkins COVID-19 interactive map.

COVID-19 Update: US and Global Cases, Deaths, and Recoveries as of September 24, 2020

Nonpharmacologic intervention is recommended for most US adults who have hypertension as defined by the 2017 American College of Cardiology/American Heart Association hypertension detection and treatment 

According to the ACC/AHA guideline, the interventions in the slide show below may be sufficient to 

hypertension as well as to help individuals with stage 1 hypertension meet blood pressure goals; they are integral to management of stage 2 hypertension in tandem with medication and recommended as the foundation of individual and population approaches to reducing risk of BP-related cardiovascular disease. 

Each slide presents the type of intervention, recommended dose, and expected reduction in BP in adults with hypertension and those with normotension. 

Slideshows

Find out how effective each of 8 ACC/AHA-recommended non-drug interventions is at reducing BP (in mm Hg) in adults with hypertension and normal BP. 

Nonpharmacologic Interventions to Prevent & Treat Hypertension At-a-Glance 

______________________________________________________

Gretchen Ames, PhD 


Bariatric Surgery and Medicine Program 
Mayo Clinic Bariatric Center 
Jacksonville, FL

in Jacksonville, FL. Her clinical practice focuses on patients seeking treatment for obesity. This includes bariatric surgery, very low calorie diets, and cognitive behavioral therapy. She also has wide-ranging research interests including cognitive behavioral therapy for weight regain and metabolic adaptation to weight change with large weight loss. 

Videos

A clinical psychologist from the Mayo Clinic Bariatric Center in Jacksonville, FL, explains and corrects key misperceptions that inhibit open discussion of the therapy. 

Bariatric Surgery: Clinician and Patient Barriers to the First Conversation

, as of today, September 23, 2020 at 9:23 AM, EDT, there have been:

 with 613 896 people who have recovered, followed by 

 with 13 804 055 people tested, followed by 

How many cases of COVID-19 have been confirmed in the US? How many people have been tested? Get your daily COVID-19 update here.

COVID-19 Update: US and Global Cases, Deaths, and Recoveries as of September 23, 2020

Weight and health is a fraught subject for primary care providers. It’s intensely personal for the patient. On top of that, popular culture bombards a person living with obesity on this subject almost endlessly. Well-meaning friends and family offer unsolicited advice and non-verbal cues about their weight status. Though Al Roker lost more than 100 pounds after gastric bypass surgery in 2002, 

 that offering unsolicited advice about weight is a really bad idea:

"Look, here's the deal. If someone asks you, then that's fair game. People who are overweight  don't  want unsolicited advice. Guess what? We know we're fat. We live in homes with mirrors."

So the best place to start a conversation with a patient about weight and health is to ask and listen first. Is this something they want to talk about? If not, a conversation is likely to do more harm than good for the patient-provider relationship. But if so, the provider can start on solid ground with a patient who may be ready to address an important health risk.

This approach is grounded in the framework of 

, which evolved from guidance for patient counseling on smoking cessation: 

Ask -> Assess -> Advise -> Agree -> Assist.

New research continues to support the health benefits to people with obesity when they achieve and maintain at least a modest reduction in body weight. Depending on a patient's health status and receptivity to this type of information, it could help support the decision process. 

Recently, a team of health researchers examined more than half a million UK patient records. These were all records of people living with various degrees of obesity. Also, they had evidence in their records that they were trying to lose weight. After 4 years, roughly 10% of these patients had indeed lost weight and maintained a weight that was 10% to 25% lower than their initial weight.

The results are not surprising. The biggest risk reductions came in type 2 diabetes, blood pressure, and cholesterol. For sleep apnea, the data suggested some reductions, but some risks remained. The story was similar for osteoarthritis. In the case of unstable angina and heart attacks, these data provided no evidence for a benefit.

, presented in September at the European and International Congress on Obesity (ECOICO 2020), confirm 

 that supports the health benefits of sound obesity care. Even 

 with behavioral support can reduce the risks of type 2 diabetes. More aggressive treatment with bariatric surgery may prevent 

The benefits of managing the risks of obesity can be important. But remember that any clinical  conversation about the subject must begin with respect for a patient’s needs and preferences. To do otherwise can eliminate the possibility of any real benefit to the patient and increase the harm they experience from obesity.

The health benefits of sustained weight loss for persons with obesity could be a valuable topic when a discussion is opened. 

How Do Health Risks Improve After Weight Loss?

Bariatric surgery is the most effective therapy for patients with severe obesity and yet the surgery is performed annually in <1% of those who meet criteria for the treatment. 

There are insurance, financial, and healthcare acccess barriers to candidacy for bariatric surgery but there are also deeply seeded cultural beliefs and misperceptions among patients and clinicians alike that prevent even the first exploratory conversation in a clinical encounter about weight loss surgery. 

The slide show below highlights a recent paper published in 

Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment. 

In it the authors present research that identifies a range of implicit beliefs and inaccurate perceptions about obesity, wieght loss, weight regain, and the surgery itself that keep patients and their physicians from talking about bariatric surgery. 

Why wouldn't a person with severe obesity want to talk about bariatric surgery? Why wouldn't the patient's physician want to do it? Find the reasons for hesitation.  