Saturday, April 18, 2020

Covid-19 is now a leading cause of death in the U.S.

The Washington Post has the story:

Covid-19 is rapidly becoming America’s leading cause of death
By Dan Keating and Chiqui Esteban



Kidney disease is moved down to number 10.

Of course, "cause of death" is a squishy kind of data, since a given death can be recorded in different ways. See yesterday's post on how Covid-19 also contributes to kidney failure, (and how dialysis in crowded clinics can expose kidney failure patients to infections of all sorts, including corona virus).

Friday, April 17, 2020

Covid-19, kidney failure, and dialysis

Corona virus and kidney failure are a bad combination, whichever way you look at it. On the one hand, Covid-19 is causing kidney failure. On the other, if you are already on dialysis, you are exposed to Covid-19 infection whenever you go to spend a few hours at a crowded dialysis clinic.

Frank McCormick points me to this story from Politico:
U.S. races to stock up on dialysis supplies as kidney failure ravages virus patients
Approximately 20 percent of coronavirus patients in intensive care around the city need the kidney treatment, often for weeks.

"Hospitals in New York City are running out of dialysis fluids as thousands of coronavirus patients develop kidney failure, an unexpected development that could presage the next critical supply shortage nationwide.

"Approximately 20 percent of coronavirus patients in intensive care around the city need the kidney treatment, often for weeks, a development that many providers did not see coming. FEMA held a call Monday with FDA and CMS to discuss the possibility of issuing emergency use authorizations to import more dialysis fluids, according to a document obtained by POLITICO.
...
"Gov. Andrew Cuomo recently said that New York’s ventilator needs are beginning to plateau, and he has begun diverting the equipment to states in greater need. But hospital staff say that the extended nature of dialysis treatment means that shortages of fluids, trained personnel and even equipment there could just be starting."
**********

And here's a NY Times story on dialysis patients and clinics:

 Dialysis Patients Face Close-Up Risk From Coronavirus
As the pandemic sweeps the United States, patients needing kidney dialysis and employees of the clinics worry about keeping the virus at bay in such tight spaces.

"As the coronavirus rages from state to state, the 500,000 people whose failing kidneys require them to get dialysis are among the most vulnerable. Each clinic may have dozens of patients during a single shift, often sitting less than the recommended six feet apart for hours.
...
"Infection has traditionally been one of the industry’s biggest problems.

“The second leading cause of death among hemodialysis patients is infections,” said Dr. Alan Kliger, a Yale nephrologist who is leading efforts to control the spread of coronavirus among dialysis patients. As many as one in 10 patients die from complications from an infection, often at the site where a patient has a catheter.


Thursday, April 16, 2020

Corona lockdown, and the food supply chain in India, by Matt Lowe and Ben Roth

Matt Lowe and Ben Roth look at the effect of India's corona virus lockdown on the food arriving at the big wholesale produce market in Delhi.  They describe breakdowns in the supply chains.

Arrivals Dropped 50% Post Lockdown. When Will Azadpur Mandi’s Supply Return to Normal?
Since the lockdown has been extended till May 3, it has become all the more crucial for the government to intervene and ensure that the broader food supply chain operates smoothly. 

"The disruption can already be seen in Delhi’s (and Asia’s) largest wholesale fruit and vegetable market – the Azadpur mandi – which has seen a precipitous decline in the volume of fruits and vegetables flowing through the market.

"Relative to the three prior years, the volume of produce arriving at Azadpur fell by about half on March 24, and has hovered at around that level since (Figure 1).


Wednesday, April 15, 2020

Coronavirus information, mis-information, conspiracy theories, web search, and social media

The coronavirus / Covid-19 pandemic is constantly generating new information, and misinformation.  How to separate them?

A number of social media sites, and Google, have decided not to rely on their organic recommender systems. So e.g. if you search for "coronavirus" in Google, you get what appear to be all curated sites (e.g. government and University sources, and major newspapers), and if you google "coronavirus conspiracy theories" you get news stories about some of the craziness out there, but not the first hand insanity.

The Guardian has this story:

Tech giants struggle to stem 'infodemic' of false coronavirus claims

"Click over to Google, type in “coronavirus”, and press enter.

"The results you see will bear little resemblance to any other search.

"There are no ads, no product recommendations, and no links to websites that have figured out how to win the search engine optimisation game. Government, NGO and mainstream media sources dominate.

"Algorithms and user-generated content are out; gatekeepers and fact checking are in.
...
"Across the social web – on Facebook, Twitter, YouTube, Reddit, Instagram and Pinterest – search results related to Covid-19 are similarly predetermined.

"Instagram delivers a pop-up urging US users to go to the website for the Centers for Disease Control and Prevention (CDC) – or UK users to the NHS – rather than look at the memes and pictures tagged with #coronavirus.

"On Facebook, a dedicated “Information Center” includes a mix of curated information and official medical advice. On Pinterest, the only infographics and memes to be found on topics such as “Covid-19” or “hydroxychloroquine” are those made by internationally recognised health organisations, such as the WHO.
...
"Another complicating factor is that normally trustworthy sources are not providing reliable information.

“We’ve seen the US government, particularly the White House, becoming a significant purveyor of misinformation around the virus,” Bergstrom said.

Facebook and Twitter have removed posts by prominent and powerful people over coronavirus misinformation, including the Brazilian president, Jair Bolsonaro, but the real test of their resolve will be whether they ever take action against misinformation by Trump."
*********

Here's another story, concerning a particular conspiracy theory:

Facebook acts to halt far-right groups linking Covid-19 to 5G

"Facebook has stepped up efforts to stop the promotion of baseless conspiracy theories linking Covid-19 to 5G, after research highlighted a “toxic cocktail” of far-right-influenced groups pushing the idea alongside incitement to attack telecommunications infrastructure.

"Groups in the UK promoting the conspiracy theory on Facebook – often linking it to explicitly antisemitic messages – have been growing at a significant rate, warned the campaign group Hope not Hate.

"The largest group in the UK, Stop 5G UK, added almost 3,000 members in just 24 hours from 6-7 April while another, Direct Action Against 5G, gained more than 1,400 members in its first week after it was created on 31 March"

Tuesday, April 14, 2020

John Horton Conway (1937-2020)

John Horton Conway, the  John von Neumann Professor in Applied and Computation Mathematics, Emeritus, at Princeton, passed away on April 11, while suffering from corona virus Covid-19.

Readers of this blog likely know him for his theorem that, in Gale and Shapley's marriage model with strict preferences, the set of stable matchings is a lattice with respect to the partial order of the men's common preferences, or the women's, and that these two lattices are the dual of one another. This helped us understand the observation already made by Gale and Shapley that the set of stable matchings included a man-optimal stable matching that every man likes at least as much as any stable matching, and similarly  a woman-optimal stable matching that is  (weakly) preferred by all the women to any other stable matching (and that the best stable matching for the men is the worst for the women and vice versa).

He was a man of wide interests and many theorems. (When I met him once and told him that he was famous in the market design community for his lattice theorem about stable matching, he pretended not to know which theorem I meant.)

Here are some obituaries (which focus on some of his more widely famous accomplishments):

COVID-19 Kills Renowned Princeton Mathematician, 'Game Of Life' Inventor John Conway In 3 Days

""I am sorry to confirm the passing of my colleague John Conway. An incomparable mathematician, a pleasant neighbor, and an excellent coffee acquaintance," Wang tweeted.
...
"Conway's most notable contribution to his field may have been his invention of the Game of Life, leading to the popularization of cellular automaton."
*********

John Conway Dies From Coronavirus

"According to Princeton University Conway's proudest achievement was the invention of new system of numbers, the surreal numbers—a continuum of numbers that include not only real numbers but also the infinitesimal and the infinite numbers, noting:

"When he discovered them in 1970, the surreals had John wandering around in a white-hot daydream for weeks.

"His surreal numbers inspired a mathematical novel by Donald Knuth, which includes the line:

“Conway said to the numbers, ‘Be fruitful and multiply.’”

"He also invented a naming system for exceedingly large numbers, the Conway chained arrow notation."
*******
And this, from Scott Aaronson:

John Horton Conway (1937-2020)
"His The Book of Numbers (coauthored with Richard Guy, who himself recently passed away at age 103) made a huge impression on me as a teenager. I worked through every page, gasping at gems like eĎ€√163 (“no, you can’t be serious…”), embarrassed to be learning so much from a “fun, popular” book but grateful that my ignorance of such basic matters was finally being remedied."


Monday, April 13, 2020

Teaching online: Singapore, NYC react to Zoombombing of online classes

Some of us are old enough to remember when email didn't come with security concerns.  Things are moving faster these days, so it's no surprise that there are Zoom trolls and scammers.  Singapore and NYC schools have decided not to use Zoom to conduct their online classes any more.

Here's the Singapore story from the Guardian:

Singapore bans teachers using Zoom after hackers post obscene images on screens
‘Very serious incidents’ have forced suspension from online schools as conferencing app faces renewed questions over security

"Singapore has suspended the use of video-conferencing tool Zoom by teachers after “very serious incidents” in the first week of a coronavirus lockdown that has seen schools move to home-based learning.

"One incident involved obscene images appearing on screens and male strangers making lewd comments during the streaming of a geography lesson with teenage girls, media reports said."
**********
Here's the NYC story from CNN:

New York City schools won't be using Zoom anymore because of security concerns
By Nicole Chavez and Sarah Jorgensen

"Schools in New York City are moving away from using the video conference app Zoom after a review of security concerns.
...
"The department does not have a central contract with Zoom, Filson said, and students and staff will be transitioning to Microsoft Teams, which has "the same capabilities with appropriate security measures in place."

"Earlier this week, federal officials began warning of a new potential privacy and security concern called "Zoombombing."
...
"Eric Yuan, the founder and CEO of Zoom, apologized to the video conferencing app's users for the privacy issues earlier this week, saying his team will stop adding new features for the next 90 days and instead focus solely on addressing privacy issues.
...
"Yuan said over 90,000 schools across 20 countries have been using the platform for online teaching since the company offered its services free of charge to schools because of the Covid-19 pandemic."

Sunday, April 12, 2020

Behavioral Economics, Computation, and Game Theory, all in Budapest in July, or online...

Here's the (appropriately cautious) announcement:

Behavioral EC '20
2nd Workshop on Behavioral Economics and Computation

The 2nd Workshop on Behavioral EC will be held in conjunction with the 21st ACM Conference on Economics and Computation (ACM EC '20) and will be co-located with the 6th World Congress of the Game Theory Society (GAMES 2020), on July 17, 2020, in Budapest, Hungary. The goal of the workshop is to bring together researchers from diverse subareas of EC who are interested in the intersection of human economic behavior and computation, to share new results and to discuss future directions for behavioral research related to economics and computation. It will be a full-day workshop, and will feature invited speakers, contributed paper presentations and a panel discussion.

...
Submission deadline: May 18, 2020, 11:59pm PDT.
Notification: June 11, 2020
The workshop: July 17, 2020
COVID-19 Updates: We are aware of the severe restrictions across the globe due to the COVID-19 pandemic. The SIGecom board will update with the final plans for the EC 2020 conference on or by May 6. In the event the in-person conference does not happen, we will hold the workshop virtually.  

Saturday, April 11, 2020

Market design seminars on Zoom, Monday afternoons in Paris

For those of you missing your local market design seminars, here's a convenient substitute, Monday afternoons if you're in Europe, or before breakfast if you're in California... (The first one was this past Thursday.)

Virtual MD Seminar Series
The Virtual Market Design Seminar is an open online alternative to seminars cancelled due to the COVID-19. Seminars will cover all fields from market design. Talks usually take place bi-weekly on Monday at 4:00-5:00pm (Paris UTC) on Zoom. Please check the schedule below, different days and times are possible.
Registration
If you would like to participate and to stay up to date about upcoming presentations, please join our mailing list. You will receive the Zoom link for each talk. 

Upcoming Presentations
Thursday, April 9, 2:00pm (Paris UTC).
Maarten Janssen (University of Vienna): "Regulating Product Communication". (with S. Roy). [slides]
Monday, April 20, 4:00pm (Paris UTC).
Scott Duke Kominers (Harvard Business School): "Redistribution through Markets" (with P. Dworczak and M. Akbarpour).
Monday, May 4, 4:00pm (Paris UTC).
Renato Gomes (Toulouse School of Economics): "Regulating Platform Fees under Price Parity" (with A. Mantovani).
Monday, May 18, 4:00pm (Paris UTC).
Benny Moldovanu (University of Bonn):"tba".

Organizers
Olivier Bos (Paris II), Nicolas Fugger (Cologne), Vitali Gretschko (ZEW), Helene Mass (Bonn), Marion Ott (ZEW), Martin Pollrich (Bonn), Nora Szech (KIT).

Friday, April 10, 2020

Clearinghouses are hard to organize in a hurry: volunteer medical workers in NYC

Many healthcare workers are willing and able to come to New York to help with the shortages that Covid-19 has created there.  But existing staffing marketplaces seem to be the avenue by which many of them are in fact matched.

The NY Times has the story:

Volunteers Rushed to Help New York Hospitals. They Found a Bottleneck.
When New York called for volunteers to help fight the coronavirus, 90,000 people responded. The hard part? Getting them into hospitals.

"Ms. Strickland, a former pediatric intensive care unit nurse in High Point, N.C., spent hours trying to submit her volunteer application online, and then emailed city and state representatives. She never heard back.

"Frustrated, she reached out directly to Mount Sinai Queens hospital in New York City. A manager told her to use a private recruiting agency, which the hospital had used for years to bring in temporary staff.

"Within two days, Ms. Strickland, 47, received her assignment. She started this week in the hospital’s emergency department, making about $3,800 a week for three 12-hour shifts instead of doing it for free, as she had initially wanted.
...
"As of Wednesday, more than 90,000 retired and active health care workers had signed up online to volunteer at the epicenter of the pandemic, including 25,000 from outside New York, the governor’s office said.
...
"New York City hospitals have only deployed 908 volunteers as of Wednesday, according to city health officials.

"The urgent need for medical personnel is colliding head-on with the immovable bureaucracy of hospital regulations
...
"State officials said the volunteer portal, which was built from scratch, was initially overwhelmed by the response, but has since connected about 10,000 volunteers to hospitals in New York State within two weeks.
...
"The challenge of screening so many medical workers has opened an opportunity for the dozens of established private agencies that place temporary nurses and doctors at hospitals nationwide
...
"The staffing agencies, an $18 billion industry, say that unlike the state, they already have the technology and infrastructure in place to quickly check credentials for health professionals. In normal times, hospitals hire them to fill short-term staffing needs, such as during a regular flu season.

“As great as it is that the state is trying to help, it’s a very complex process to staff a clinician,” said Alexi Nazem, chief executive of Nomad Health, a health recruiting agency based in New York. “There are dozens of documents to verify. Our company has spent years building those systems.”
...
"New York City’s public hospitals had used private recruiters to bring in about 3,600 new medical workers as of late last week and were seeking to hire 3,600 more, according to the mayor and a city spokesman.

"One of those recruiting agencies, NuWest Group, began contracting with the city less than two weeks ago. Since then, the agency has secured hundreds of nurses and respiratory therapists for city hospitals, with some positions paying more than $10,000 a week, a spokeswoman for the agency said.

"Agencies, who negotiate the rates with hospitals, say that without the high pay, there would not be enough qualified clinicians willing to take jobs at the front lines
...
"Hospital staff members say they are grateful for any reinforcements, but some residents and nurses have expressed frustration over the pay disparities."

Thursday, April 9, 2020

Medical triage for Covid-19: if/when it comes to that, how should it be organized?

So far I haven't heard of any actual medical triage in the U.S. in which life-saving treatment for Covid-19 is rationed.  There has been a good deal of discussion of how to avoid this, and of the short supply of masks, gowns, sedatives for intubation, and health care personnel.  Much of that discussion  has focused on reallocating scarce resources to where they are needed (from where they are not so scarce (e.g. California Ventilators En Route to New York, Other States), so that rationing of e.g. ventilators doesn't become necessary.  But if the infection curve doesn't flatten enough, triage may well be coming, at least in some places. (Here's an up to date account of a hard hit rural hospital near New Orleans that hasn't yet had to triage, but might be getting close if nearby hospitals were to stop taking transfers of patients.)  

Already in Italy there was a period (maybe still) when patients over age 70 (and later over 65) were not being given ventilators because of an actual shortage of ventilators compared to the number of patients who needed them. So it makes sense that, along with the discussion of how to prevent the need for triage, there is an ongoing discussion of how to manage it, if  there comes a time and place where there aren't enough vents to go around. (I have already heard a somewhat related discussion in the U.S. about whether patients on vents should be resuscitated--given the small chance of recovery, and the exposure of health care workers to Covid-19 during a resuscitation attempt.)

As in discussions of repugnant transactions, discussing allocation of scarce resources provokes lots of debate about who should get what, and what kind of distinctions should and should not be made. 

Here are longish excerpts from several interesting contemporary accounts:

Here's an article in the March 23 New England Journal of Medicine:

by Ezekiel J. Emanuel, M.D., Ph.D., Govind Persad, J.D., Ph.D., Ross Upshur, M.D., Beatriz Thome, M.D., M.P.H., Ph.D., Michael Parker, Ph.D., Aaron Glickman, B.A., Cathy Zhang, B.A., Connor Boyle, B.A., Maxwell Smith, Ph.D., and James P. Phillips, M.D.

"Rationing is already here. In the United States, perhaps the earliest example was the near-immediate recognition that there were not enough high-filtration N-95 masks for health care workers, prompting contingency guidance on how to reuse masks designed for single use.2 Physicians in Italy have proposed directing crucial resources such as intensive care beds and ventilators to patients who can benefit most from treatment.3,4 Daegu, South Korea — home to most of that country’s Covid-19 cases — faced a hospital bed shortage, with some patients dying at home while awaiting admission.5 In the United Kingdom, protective gear requirements for health workers have been downgraded, causing condemnation among providers.6 The rapidly growing imbalance between supply and demand for medical resources in many countries presents an inherently normative question: How can medical resources be allocated fairly during a Covid-19 pandemic?
...
"According to the American Hospital Association, there were 5198 community hospitals and 209 federal hospitals in the United States in 2018. In the community hospitals, there were 792,417 beds, with 3532 emergency departments and 96,500 ICU beds, of which 23,000 were neonatal and 5100 pediatric, leaving just under 68,400 ICU beds of all types for the adult population.12 Other estimates of ICU bed capacity, which try to account for purported undercounting in the American Hospital Association data, show a total of 85,000 adult ICU beds of all types.13

"There are approximately 62,000 full-featured ventilators (the type needed to adequately treat the most severe complications of Covid-19) available in the United States.14 Approximately 10,000 to 20,000 more are estimated to be on call in our Strategic National Stockpile,15 and 98,000 ventilators that are not full-featured but can provide basic function in an emergency during crisis standards of care also exist.14 Supply limitations constrain the rapid production of more ventilators; manufacturers are unsure of how many they can make in the next year.16 However, in the Covid-19 pandemic, the limiting factor for ventilator use will most likely not be ventilators but healthy respiratory therapists and trained critical care staff to operate them safely over three shifts every day. In 2018, community hospitals employed about 76,000 full-time respiratory therapists,12 and there are about 512,000 critical care nurses — of which ICU nurses are a subset.17 California law requires one respiratory therapist for every four ventilated patients; thus, this number of respiratory therapists could care for a maximum of 100,000 patients daily (25,000 respiratory therapists per shift).
...
"Previous proposals for allocation of resources in pandemics and other settings of absolute scarcity, including our own prior research and analysis, converge on four fundamental values: maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.24-29 Consensus exists that an individual person’s wealth should not determine who lives or dies.24-33 Although medical treatment in the United States outside pandemic contexts is often restricted to those able to pay, no proposal endorses ability-to-pay allocation in a pandemic.24-33
...
"These ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients."


**********
Here's a Washington Post story with a good summary of much of the discussion and disagreement about how different patients (and groups of patients) might be prioritized if ventilators have to be rationed:

By Ariana Eunjung Cha and Laurie McGinley April 7, 2020 

"Pregnant women would get extra priority “points” in most if not all plans, U.S. hospital officials and ethicists say. This is not controversial. There also has been some discussion about whether high-ranking politicians, police and other leaders should be considered critical workers at a time when the country is facing an unprecedented threat.
...
"Catholic groups have called on hospitals to treat pregnant women as two lives instead of one. AARP, formerly the American Association of Retired Persons, has decried age cutoffs for ventilator access in some plans. Last month, the Arc, a disability rights group, filed multiple complaints with the Department of Health and Human Services objecting to plans that disadvantage those with “severe or profound mental retardation” or dementia.
...
"Bioethicist Brendan Parent, who served on a New York state task force that developed a highly regarded framework for rationing, sees hospitals and states following two paths.

"One group takes a utilitarian view of doing “the greatest good for the greatest number,” giving preference to those with the best chance of surviving the longest. Others are more focused on ensuring social justice and ensuring vulnerable groups have an equal chance.
...
"UCLA’s plan goes to great lengths to avoid possible discrimination, stating that medical teams may not consider a long list of criteria for ventilator allocation including gender, disability, race, immigration status, personal relationship with hospital staff or “VIP status” — an important reminder given the medical center’s proximity to Hollywood.
...
"In UCLA’s plan, front-line health-care workers and administrators may be given priority access to lifesaving treatment, when their return to work means more people are likely to survive the crisis. If all the allocation criteria are applied and there’s still a shortage of medical resources, then care should be allocated on the basis of a lottery, the document says.
...
"One of the most striking differences among plans is how they deal with the elderly and disabled. Some have strict age cutoffs, or explicit criteria that disadvantage those with certain conditions.
...
"Using life expectancy or remaining life years can also be problematic for those with disabilities, civil rights groups say. The typical life expectancy for a person with Down syndrome, for example, is 60 years, as compared to about 78 years for someone without the condition.
...
"Inova’s Motew said ethical principles allow for prioritizing “some individuals who provide more lifesaving opportunities if they could live” — and that this could include “government leaders.” He compared it to military medicine, in which those who are in a position to go back to help win the war are treated first."

***********
And here are some thoughts on what we might learn about medical triage from considerations that come up in allocating school places among different populations for whom some positions are reserved.  The idea is that different groups of patients would have places reserved for them, through the kind of political process that reserves places in schools for different demographic groups, with priorities within groups, and ordering of reservations among groups. Once those issues are settled by some political process, the problem starts to look like school choice with affirmative action, and in the model proposed by these authors (who are well acquainted with school choice), deferred acceptance algorithms emerge:

Triage Protocol Design for Ventilator Rationing in a Pandemic:
A Proposal to Integrate Multiple Ethical Values through Reserves
Parag A. Pathak, Tayfun Sonmez, M. Utku Unver, M. Bumin Yenmez
April 2020

Abstract: In the wake of the Covid-19 pandemic, the rationing of medical resources has become a critical issue. Nearly all existing triage protocols are based on a priority point system, in which an explicit formula specifies the order in which the total supply of a particular resource, such as a ventilator, is to be rationed for eligible patients. A priority point system generates the same priority ranking to ration all the units. Triage protocols in some states (e.g. Michigan) prioritize frontline health workers giving heavier weight to the ethical principle of instrumental valuation. Others (e.g. New York) do not, reasoning that if medical workers obtain high enough priority, there is a risk that they obtain all units and none remain for the general community. This debate is particularly pressing given substantial Covid-19 related health risks for frontline medical workers. In this paper, we propose that medical resources be rationed through a reserve system. In a reserve system, ventilators are placed into multiple categories. Priorities guiding allocation of units can reflect different ethical values between these categories. For example, while a reserve category for essential personnel can emphasize the reciprocity and instrumental value, a reserve category for general community can give higher weight to the values of utility and distributive justice. A reserve system provides additional flexibility over a priority point system because it does not dictate a single priority order for the allocation of all units. It offers a middle-ground approach that balances competing objectives. However, this flexibility requires careful attention to implementation, most notably the processing order of reserve categories, given that transparency is essential for triage protocol design. In this paper, we describe our mathematical model of a reserve system, characterize its potential outcomes, and examine distributional implications of particular reserve systems. We also discuss several practical considerations with triage protocol design.

And from the conclusion:

"In our formal analysis, we characterize the entire class of reservation policies that satisfy three minimal principles though implementation of the deferred-acceptance algorithm. As such, we also provide a full characterization of affirmative action policies."
************

There are of course other models of triage than school choice. In transplantation, there's a shortage of both deceased and living donors, to the extent that many people who need transplants will never get them. The allocation of deceased donor organs is handled not entirely differently than generalized school choice of a particularly dynamic sort (potential recipients of a deceased donor kidney that suddenly becomes available are categorized into groups, not just by blood and tissue types which have immediate feasibility implications, but also by age and by how difficult it will be to find them a feasible match, and prioritized within groups mostly by waiting time and health status, differently for different organs).  Living donors (almost all are donating a kidney) are much less regulated, and through kidney exchange are mostly allocated through an exchange system that is fairly blind to group membership, although the statistics that are collected pay attention to people in a variety of categories.  The point of kidney exchange of course is not just to allocate scarce resources, but to make them less scarce.  That is a goal to think about whenever triage becomes necessary, or starts to look like it might.

Wednesday, April 8, 2020

Plasma donation, "convalescent plasma" and Covid-19 antibodies

Blood plasma is a big source of antibodies for people who don't make their own, and in these days of Covid-19 pandemic, antibodies are again in the news. As the number of recovering patients grows, can the antibodies they produce be of help in stemming the spread of the disease, or in curbing its intensity?

Here's a just published report of a quite preliminary study from China, in the PNAS:

Effectiveness of convalescent plasma therapy in severe COVID-19 patients
by Kai Duan, ... Xiaoming Yang (46 authors)
PNAS first published April 6, 2020 https://doi.org/10.1073/pnas.2004168117
Contributed by Zhu Chen, March 18, 2020 (sent for review March 5, 2020; reviewed by W. Ian Lipkin and Fusheng Wang)


"Significance: COVID-19 is currently a big threat to global health. However, no specific antiviral agents are available for its treatment. In this work, we explore the feasibility of convalescent plasma (CP) transfusion to rescue severe patients. The results from 10 severe adult cases showed that one dose (200 mL) of CP was well tolerated and could significantly increase or maintain the neutralizing antibodies at a high level, leading to disappearance of viremia in 7 d. Meanwhile, clinical symptoms and paraclinical criteria rapidly improved within 3 d. Radiological examination showed varying degrees of absorption of lung lesions within 7 d. These results indicate that CP can serve as a promising rescue option for severe COVID-19, while the randomized trial is warranted."
**********

Here's a story from the WSJ:

Coronavirus Survivors Keep Up the Fight, Donate Blood Plasma to Others
National Covid-19 project seeks volunteers to aid the seriously ill; ‘I feel obligated to help’
By Amy Dockser Marcus

"The Mount Sinai Hospital in New York, where Mr. Sherman volunteered to donate plasma, is one of 34 institutions around the country participating in the National Covid-19 Convalescent Plasma Project, which is seeking blood-plasma donations from recovered patients who have a confirmed Covid-positive test and are at least 21 days out from the onset of symptoms.
...
“The biggest problem is not the lack of donors,” said Arturo Casadevall, a professor at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, and one of the organizers of the national project. “It is the logistics of figuring out how people who want to participate can actually donate.”

*********************

And here's a plasma industry press release:

Global Plasma Leaders Collaborate to Accelerate Development of Potential COVID-19 Hyperimmune Therapy

"Osaka, JAPAN, and King of Prussia, PA, USA – April 6, 2020 –  Biotest, BPL, LFB, and Octapharma have joined an alliance formed by CSL Behring (ASX:CSL/USOTC:CSLLY) and Takeda Pharmaceutical Company Limited (TSE:4502/NYSE:TAK) to develop a potential plasma-derived therapy for treating COVID-19. The alliance will begin immediately with the investigational development of one, unbranded anti-SARS-CoV-2 polyclonal hyperimmune immunoglobulin medicine with the potential to treat individuals with serious complications from COVID-19.
...
"Developing a hyperimmune will require plasma donation from many individuals who have fully recovered from COVID-19, and whose blood contains antibodies that can fight the novel coronavirus. Once collected, the “convalescent” plasma would then be transported to manufacturing facilities where it undergoes proprietary processing, including effective virus inactivation and removal processes, and then is purified into the product."

********
My other posts on plasma, mostly focused on repugnance to compensation for donors. Here's one that explains some of the underlying medical issues:

Thursday, July 11, 2019

Tuesday, April 7, 2020

Allocating and reallocating scarce medical supplies

An op-ed in USA today points out that shortages of critical hospital supplies are occurring and will continue to occur at different times in different states, allowing for increased efficiencies in sharing (which is hampered by a vacuum in leadership at the Federal level).

One of the authors, Dr. Deborah Proctor, is in fact an experienced market designer, who led the (re-)adoption of a fellowship match for gastroenterology fellows.*

National redistribution of hospital supplies could save lives
Taking supplies from less stressed hospitals and sharing them with overwhelmed ones, we could maximize the use of equipment and save more lives.
Diane R. M. Somlo, Dr. Howard P. Forman and Dr. Deborah D. Proctor

"Since we now know more about the predicted peaks in COVID-19 across the U.S., we can see that peak demand will likely occur at different times in different states and cities, starting in early April and extending through May. While some hospitals are already starting to drown, other hospitals that are further from their peak demand have stockpiles of unused equipment lying in wait. 

"What if there was a nation-wide system that allowed hospitals that have equipment but have lower present and predicted demand to lend some reusable (ventilator) and non-reusable equipment (PPE, testing kits) to hospitals that are currently being overwhelmed? Then, as demand in one area rises and the other falls, freed up ventilators could be re-distributed, and manufacturers will have had more time to generate non-reusable equipment for hospitals that lent their equipment. By taking from stockpiles of less stressed hospitals and sharing it with currently overwhelmed ones, we could maximize the use of our national inventory of equipment and save more lives.
...
" redistribution approaches in other settings have enabled vast functional expansions of limited supplies, including kidney transplants and donated food for food pantries across the U.S. Bottom line: Redistribution has the potential to improve the trajectory of COVID-19 mortality in the U.S. Our country is already on track to employ these measures at a state level or voluntarily, so delaying set up of cross-state exchange only means missing out on the maximal benefit of redistribution. In fact, as of this writing, New York’s Governor Andrew Cuomo has just signed an executive order enabling redistribution of medical supplies to struggling hospitals within New York state and Oregon has sent ventilators to New York.
"In these coming trying times, our healthcare system is facing an unprecedented, deadly burden, and we need to make supplies available where they are needed most —independent of state lines. Now is the time to start making the changes, to call on the federal government, national leaders, and private partnerships to coordinate our efforts as a nation, so we can provide the best care possible with our limited supplies. Lives depend on it."
****************
Niederle, Muriel, Deborah D. Proctor and Alvin E. Roth, ''The Gastroenterology Fellowship Match: The First Two Years,'' Gastroenterology , 135, 2 (August), 344-346, 2008.

Monday, April 6, 2020

Transplantation slows in Canada, too...

Ventilators in short supply may be part of the problem (since most deceased donations involve ventilators), but there's also a general risk aversion at play...

Donated organs not being used as hospitals scale back transplants for COVID-19

"OTTAWA — Transplant centres across the country have massively scaled back organ transplants as hospitals try to make sure they are able to accommodate COVID-19 cases.

"Living-donor surgeries have largely shut down across the country, and deceased-donor transplants are happening only when the case is urgent.

"Dr. Atul Humar, past president of the Canadian Society of Transplantation, said that means many organs are not going to good use.

“There’s some donors, deceased organ donors, and we’re not sending teams to procure those organs,” said Humar, who is also the director of the transplant program at Toronto General Hospital.

“It’s quite tragic.”

"Patients who go through certain types of organ donation often require time in the intensive care unit on a ventilator — resources desperately needed by patients with serious cases of COVID-19.

"At Humar’s hospital, organ transplant surgeries have decreased by about 80 per cent, though the numbers vary from province to province."

Sunday, April 5, 2020

Eating cats and dogs banned in Shenzhen

The distinction between pets and pet food just became a little clearer in Shenzhen.

The BBC has the story:

Shenzhen becomes first Chinese city to ban eating cats and dogs  

"The new law will come into force on 1 May.

"Thirty million dogs a year are killed across Asia for meat, says Humane Society International (HSI).

"However, the practice of eating dog meat in China is not that common - the majority of Chinese people have never done so and say they don't want to.

"Dogs and cats as pets have established a much closer relationship with humans than all other animals, and banning the consumption of dogs and cats and other pets is a common practice in developed countries and in Hong Kong and Taiwan," the Shenzhen city government said, according to a Reuters report."

Saturday, April 4, 2020

Sheltering in place (or maybe someplace else), repugnantly

Many fewer things would be regarded as repugnant were it not for underlying inequality. So it shouldn't surprise us to see new repugnances emerge as  we are all--rich and poor and in between-- asked to shelter in place to halt the spread of the COVID-19 corona virus.

Here's an example from the Guardian:


"A luxurious southern California retreat for wealthy participants to wait out the coronavirus pandemic has folded before the program could even open its doors.

"As millions of Americans face strict social distancing orders amid the pandemic, the “Harbor” proposed the opposite for those who could afford it: a two-month retreat in an exclusive villa where guests could “meet, mingle and collaborate with some of the brightest, forward-thinking individuals – no facemask required”.
*********

Frankly, it sounded like a cruise ship to me...

Friday, April 3, 2020

Choosing who to interview in the sports medicine fellowship match

Little is known about what goes on between application to fellowship (or residency) programs, and rank-ordering for the relevant medical Match.  Here's an attempt at looking into the black box of choosing who to interview, and combining interview information with other information to determine rank order lists:

Factors Used by Program Directors in the Orthopedic Sports Medicine Fellowship Match
Travis Menge, Ashley Nord, Kendall Hamilton, Monica LaPointe and Peter J.L. Jebson
Journal of Surgery [Jurnalul de chirurgie], Volume 16:2, 2020

Abstract
Background: Obtaining an orthopedic sports medicine fellowship position is becoming more difficult, as the number of residents seeking post-graduate training continues to increase.
Objective: To identify factors that orthopedic surgery sports medicine fellowship program directors deem valuable in selecting applicants.
Methods: A web-based questionnaire was sent to all ACGME accredited sports medicine fellowship program directors in the United States in 2016. The questionnaire was designed to identify the most important criteria in selecting applicants for an interview, and ranking candidates to match into their program.
Results: Thirty-five of ninety-one program directors responded. The criteria for offering an applicant an interview were quality of recommendation letter, technical competence, and residency program reputation. Letters of recommendation that held the highest value were from the chief of sports medicine and another sports medicine surgeon in the department. The most important features of the interview were the applicant’s ability to articulate thoughts, the maturity of the applicant, and the ability of the applicant to listen well. The attributes deemed most important in high ranking a candidate included the applicant’s commitment to hard work, quality of the interview, and quality of letters of recommendation.

Thursday, April 2, 2020

Bikes and guns while sheltering in place in Santa Clara County (bikes are essential, guns are not)

From the Santa Clara County Department of Public Health, a new shelter in place order that defines, among other things, "essential businesses" which are those that can keep operating from their traditional premises (as opposed to only making home deliveries):


Coronavirus Frequently Asked Questions
MARCH 31, 2020 SUPERSEDING SHELTER-IN-PLACE ORDER 

"This new Order requires that most people continue sheltering in their place of residence until May 3, 2020.  This new Order replaces the prior Shelter-in-Place Order, which was set to expire on April 7, 2020.  It also adds to the list of restrictions to slow the spread of the COVID-19 disease.

"You are still allowed to participate in “essential activities” or to work for an “essential business” if it is not possible for you to work from home."

There follows a long list of essential businesses, and a long set of Q's and A's to guide the perplexed.

Among the Essential businesses:

"Bicycle repair and supply shops"
********************

and there's this Q&A:

"Can gun shops selling firearms and ammunition continue to keep their storefronts open? 

"No.  Gun shops are not essential businesses under the Order.  The Order allows delivery of inventory directly to customers at their residences in compliance with applicable laws and regulations, but gun shops may not make sales from their storefronts. "
*********
I imagine the situation is different in Texas.

Expect a case to reach the Supreme Court in a few years...

Wednesday, April 1, 2020

Headlines that could be dated April 1

Something was in the air this year: many headlines in serious outlets struck me as appropriate for April Fools Day.

Non-political ones come first:

Coffee beans not vital for human survival, Switzerland decides

Dairy Queen burgers are not made of human flesh, county coroner is forced to confirm

The Ohio State University wants to trademark its favorite word: ‘The’
"officials filed Application No. 88571984 with the U.S. Patent and Trademark Office last week, seeking a trademark for the word “THE” to use it on items including T-shirts, caps and hats."



Bodyguard to Saudi king reportedly shot dead by friend
...with friends like these...

A Prisoner Who Briefly Died Argues That He’s Served His Life Sentence
A court in Iowa found that a murderer who was revived “is either still alive, in which case he must remain in prison, or he is actually dead, in which case this appeal is moot.”

Investors who lost $190m demand exhumation of cryptocurrency mogul
Canadian company founder took crucial password to the grave

Are vegetables vegan?

Wisconsin town to legalize snowball fights after 50-year ban

Judge blocks California’s alligator ban after Louisiana sues

Why is Gwyneth Paltrow selling a candle that smells like her vagina?

‘Mad’ Mike Hughes, who vowed to prove the flat-Earth theory, dies in homemade-rocket disaster

Alabama bill may lift yoga ban in public schools but prohibit 'namaste' greeting

Nevada Brothels Requiring Customers To Wear Masks

Astrophysicist gets magnets stuck up nose while inventing coronavirus device

Turkmenistan Has Banned Use Of The Word 'Coronavirus'


And a special section of (American) politics, if you can call it that:

Donald Trump’s interest in buying Greenland stuns Denmark
‘Greenland is not for sale, and can’t be sold,’ says island’s government

Trump cancels Denmark trip after PM says Greenland is not for sale
President says he is postponing meeting with Mette Frederiksen because she was not interested in discussing transaction

Trump blasts report claiming he wanted to nuke hurricanes

Trump border wall between US and Mexico blows over in high winds

Trump’s border wall, vulnerable to flash floods, needs large storm gates left open for months

Sarah Palin stuns TV viewers by rapping Baby Got Back dressed as a bear


Tuesday, March 31, 2020

Monday, March 30, 2020

How to efficiently (re)distribute ventilators (and masks, gowns, test kits...)?

How to allocate scarce medical goods, when all signals indicate shortages of everything, everywhere (but some needs are more immediate and urgent than others)?

Market mechanisms that work well when the situation evolves slowly are struggling under big swings in demand and supply.

I've received many emails on this and related subjects in the last week. (If the predictions of future need were precise, things would be easier...).  Here are two thoughts on providing market-wide information that isn't emerging naturally from the functioning of existing markets.

From the WSJ:

Manufacturers Seek U.S. Help in Deciding Where to Ship Scarce Medical Goods
To address coronavirus-related shortages, companies want the federal government to provide strategic guidance
By Rebecca Ballhaus and Andrew Restuccia, March 29, 2020

"Producers and distributors of medical supplies across the country are raising red flags about what they say is a lack of guidance from the federal government about where to send their products, as hospitals compete for desperately needed masks and ventilators to combat the spread of the novel coronavirus.
...
"Company executives say they are ill-equipped to make decisions about which hospitals and states should first receive their medical supplies and are calling on the government to step in.

“It’s really the allocation piece that’s most important to us right now because we just cannot and never will have a window into what the most urgent need is,” said Scott Whitaker, chief executive of the Advanced Medical Technology Association, a trade association that represents producers of medical devices.

"Charlie Mills, chief executive of Medline Industries Inc., a large privately held manufacturer and distributor of medical supplies, said as the company works to ramp up its production of supplies, it is being inundated with orders. He said he would welcome the government having a “strong say” in how to respond.

“All of our customers are wanting more,” Mr. Mills said. “The federal government might be in a better position to decide where it would go.”
**************

And here's an op-ed in The Hill by Loertscher and Marx:

A national ventilator exchange could address critical shortages
BY SIMON LOERTSCHER AND LESLIE M. MARX

"With elective procedures on hold indefinitely, we know there are ventilators sitting unused across the country right now — we just don’t know where and how many, so we need a nationwide registry. Every hospital in the country can document the quantity, makes and models of their machines, how many are available to treat COVID-19, and which are reserved to treat other conditions.

"There is ample evidence, for example, from reallocating land or spectrum licenses, that such registries improve the efficiency and volume of transactions.
...
"Of course, if there are not enough ventilators to go around, we face terrible ethical dilemmas, either with or without a rental market. But if we have enough, and they are just in the wrong places, then a short-term rental market is exactly the thing that could get us out of such dilemmas.

"For this model to be effective, it’s imperative to act now. If our government moves quickly to pool our resources and combine the best ideas of health care professionals, market design economists, and logistics specialists, we could do a lot of good in this time of unprecedented challenges."