Tuesday, March 31, 2020
2:53 AM (Daseinsanalysis)
瘟疫social distancing之際方見Van Life可貴
非常瘋狂的德國人才能讓普通瘋狂的法國人折服
湖口休息站的懷舊便當每個七十九元
尼采屬極端異人傳統這件事說明地下音樂的重要
也說明瘋狂的上限是十年
或懷舊的上限是十年
尼采參戰兩次第一次新訓一月就從馬上摔下來退役
第二次開救護車看著滿車屍塊和悲劇的誕生
這件事說明救護車對於哲學有多麼重要
維根斯坦和貝克特也知此事
我希望有光線有風有view不遠處有水有林
這件事說明人生有多麼將就
和Van Life有多麼可貴
和Van Life有多麼可貴
Monday, March 30, 2020
8 (Daseinsanalysis)
3/30, 5:58 AM, cloudy, birds chirping, in the woods, out there; 1:00 PM, one ER, bipolar, depressed, with multiple somatic complaints; 5:00 PM, one ER, transferred to VGH last Friday, transferred back from VGH today, conscious change last week, Brain CT r/o subarachnoid cyst (?), transferred back around 5 PM, should consult NS first, before readm;
Sunday, March 29, 2020
3:40 AM (Daseinsanalysis)
近幾個月作夢有進步
其中有些像espionage的thriller
有些甚至還有點哲理
當然這是夢中的對話的片刻
這個進步我認為說明了
睡在一個不會塌陷
的床墊的重要
回到自然的定義是
人算不如天算
所以盡人事聽天命是人
唯一的必須
我先前說過大陸的連續劇
有一重複出現的角色類型 (prototype)
就是缺心眼的傻缺
這個傢伙熱心腸不斷
被誣陷不斷
吃虧倒楣不斷
但終成正果
寫這種劇本的人
顯然相信
人算不如天算
或人算不如劇作者算
所以回到自然的關鍵是天
是劇作者作了甚麼夢
是人還見得到天
聽得到天
這有點哲理
難道你不認為
這不是作夢
雖然很像作夢
Saturday, March 28, 2020
The World on Edge (Studies in Continental Thought) (Edward S. Casey, Indiana University Press, 2017)
From one of continental philosophy's most distinctive voices comes a creative contribution to spatial studies, environmental philosophy, and phenomenology. Edward S. Casey identifies how important edges are to us, not only in terms of how we perceive our world, but in our cognitive, artistic, and sociopolitical attentions to it. We live in a world that is constantly on edge, yet edges as such are rarely explored. Casey systematically describes the major and minor edges that configure the human and other-than-human realms, including our everyday experience. He also explores edges in high- stakes situations, such as those that emerge in natural disasters, moments of political and economic upheaval, and encroaching climate change. Casey’s work enables a more lucid understanding of the edge-world that is a necessary part of living in a shared global environment. (amazon) (accessible via questia)
The World on Edge is a sequel to his book The World at a Glance (2007),
The World on Edge is a sequel to his book The World at a Glance (2007),
The World at a Glance (Studies in Continental Thought) (Edward S. Casey, Indiana University Press, 2007)
What happens when we glance around a room? How do we trust what we see in fleeting moments? In The World at a Glance, Edward S. Casey describes how glancing counts for more of human perception than previously imagined. An entire universe is perceived in a glance, but our quick and uncommitted attention prevents examination of these rapid acts and processes. While breaking down this paradox, Casey surveys the glance as an essential way by which we acquaint ourselves with the world. This experiential tour-de-force reveals what happens in a blink of an eye. It will become a landmark study in phenomenology, philosophy, environmental philosophy, and the philosophy of mind. (amazon)
Eugene Gendlin (1926-2017) (Daseinsanalysis)
https://en.wikipedia.org/wiki/Eugene_Gendlin
https://focusing.org/
Greg Madison and Eugene Gendlin (2014) Chapter 6: Palpable existentialism: An
interview with Eugene Gendlin, In Existential Therapy: Legacy, Vibrancy and Dialogue,
https://drive.google.com/drive/folders/1EWXDjkaECXtIPx6iAU3DrawzZMSPyP-l?usp=sharing
https://focusing.org/
Greg Madison and Eugene Gendlin (2014) Chapter 6: Palpable existentialism: An
interview with Eugene Gendlin, In Existential Therapy: Legacy, Vibrancy and Dialogue,
Edited by Laura Barnett and Greg Madison, Routledge, pp. 81-97 (accessible via questia)
Friday, March 27, 2020
Early and combined interventions crucial in tackling Covid-19 spread in China (2020-3-11)
https://www.southampton.ac.uk/news/2020/03/covid-19-china.page
https://www.hindustantimes.com/india-news/delay-in-lockdown-could-have-led-to-threefold-jump-in-coronavirus-cases-in-china/story-whYZGrQ3OEmGP1tI8vpVVN.html
The research also found that if interventions in the country could have been conducted one week, two weeks, or three weeks earlier, cases could have been reduced by 66 percent, 86 percent and 95 percent respectively – significantly limiting the geographical spread of the disease. However, if NPIs were conducted one week, two weeks, or three weeks later than they were, the number of cases may have shown a 3-fold, 7-fold, or 18-fold increase, respectively.
https://www.hindustantimes.com/india-news/delay-in-lockdown-could-have-led-to-threefold-jump-in-coronavirus-cases-in-china/story-whYZGrQ3OEmGP1tI8vpVVN.html
The research also found that if interventions in the country could have been conducted one week, two weeks, or three weeks earlier, cases could have been reduced by 66 percent, 86 percent and 95 percent respectively – significantly limiting the geographical spread of the disease. However, if NPIs were conducted one week, two weeks, or three weeks later than they were, the number of cases may have shown a 3-fold, 7-fold, or 18-fold increase, respectively.
粗工零工散工 (Daseinsanalysis)
送補給品去中壢
我先前說過你無法安身立命於尼采
他是一個失聯的遠房的傳奇的表哥
不憂鬱不瘋狂的藝術家是假的假的
就像不吃人不殺人的中共是假的假的
當然你說我們的世界本來就是假的
這件事柏拉圖在山洞裡講過
記住他不是在小區十八樓裡講過
雖然這兩個都是洞
我知道正常的人生是有洞就鑽就窩就假
但我說過尼采是我失聯的遠房的傳奇的表哥
意思是說他是偵探小說的Exile on Main Street
和Down These Mean Streets的角色
他沒有洞
我先前說過你無法安身立命於尼采
他是一個失聯的遠房的傳奇的表哥
不憂鬱不瘋狂的藝術家是假的假的
就像不吃人不殺人的中共是假的假的
當然你說我們的世界本來就是假的
這件事柏拉圖在山洞裡講過
記住他不是在小區十八樓裡講過
雖然這兩個都是洞
我知道正常的人生是有洞就鑽就窩就假
但我說過尼采是我失聯的遠房的傳奇的表哥
意思是說他是偵探小說的Exile on Main Street
和Down These Mean Streets的角色
他沒有洞
Thursday, March 26, 2020
Wednesday, March 25, 2020
经济问题不是下跌，而是停摆
https://www.youtube.com/watch?v=66ATBxaQFRo
歐洲和北美的疫情會持續多久
歐洲和北美的疫情對經濟的影響會有多大
中國會不會有第二波疫情不管他們怎麼遮掩否認
兩大泡沫美國股市中國房市破滅的後果是甚麼
歐洲和北美的疫情會持續多久
歐洲和北美的疫情對經濟的影響會有多大
中國會不會有第二波疫情不管他們怎麼遮掩否認
兩大泡沫美國股市中國房市破滅的後果是甚麼
The Wanderer and His Shadow (Pantheon, 2007)
https://en.wikipedia.org/wiki/The_Wanderer_and_His_Shadow_(album)
https://www.youtube.com/watch?v=oeBaABWuTx8&list=OLAK5uy_lubgNj9KwqnjrGXKt3UH_8hnxQwC3DtgY
http://www.lexido.com/EBOOK_TEXTS/THE_WANDERER_AND_HIS_SHADOW_.aspx?S=0
(the second supplement to Human, All Too Human, Nietzsche, 1880)
The Shadow: It is so long since I heard you speak that I should like to give you an opportunity of talking.
The Wanderer: I hear a voice — where? whose? I almost fancied that I heard myself speaking, but with a voice yet weaker than my own.
https://www.youtube.com/watch?v=oeBaABWuTx8&list=OLAK5uy_lubgNj9KwqnjrGXKt3UH_8hnxQwC3DtgY
http://www.lexido.com/EBOOK_TEXTS/THE_WANDERER_AND_HIS_SHADOW_.aspx?S=0
(the second supplement to Human, All Too Human, Nietzsche, 1880)
The Shadow: It is so long since I heard you speak that I should like to give you an opportunity of talking.
The Wanderer: I hear a voice — where? whose? I almost fancied that I heard myself speaking, but with a voice yet weaker than my own.
The History of Continental Philosophy (set of 8 volumes) (Alan D Schrift (Author, Editor), Acumen Publishing, 2013)
This major work of reference is an indispensable resource for anyone conducting research or teaching in philosophy. An international team of over 100 leading scholars has been brought together under the general editorship of Alan Schrift and the volume editors to provide authoritative analyses of the continental tradition of philosophy from Kant to the present day.
Divided, chronologically, into eight volumes, "The History of Continental Philosophy" is designed to be accessible to a wide range of readers, from the scholar looking for original insight and the latest thinking to the student wishing for a masterly encapsulation of a particular thinker's views. By placing continental philosophy within a historical context, "The History of Continental Philosophy" helps define what the continental tradition has been and where it is moving. It will become a landmark publication in its field.
Volume 1 covers the period from 1780 until 1848, focusing primarily on the main philosophical figures and developments in Germany during that period, but also including a description of economic and social theories in France that set the stage for the philosophical and social movements that predominated in Germany and France during the second half of the nineteenth century.
Volume 2 examines what is often referred to as the 'Age of Revolution' as various responses to Hegel, while also attending to developments in science, mathematics, sociology and aesthetics during the second half of the nineteenth century that would set the stage for the twentieth century.
Volume 3 examines the earliest developments in the twentieth century: while attending to a number of key thinkers (Bergson, Husserl, Heidegger, Freud, Jaspers, Scheler), it also discusses the emergence of French sociology in the Durkheim school, developments in modern science, the philosophical response to evolution, and the schools of phenomenology and neo-Kantianism.
Volume 4, as the title indicates, charts the various responses to phenomenology that appeared in the years following Husserl, with particular attention to the emergence of existentialism and existential theology, as well as its relations with philosophy of science, aesthetics and ethics.
Volume 5 surveys some of the main continental movements and philosophers associated with social and political philosophy and philosophy of the human sciences (notably history, linguistics, and social and political science) during the period from 1940 through to 1968.
Volume 6 looks at the major figures associated with the two dominant movements that emerge in the 1960s - poststructuralism and critical theory - while also attending to the emergence of philosophical feminism and some influential figures in those years not easily situated in the "standard" histories of the period (Serres, Bourdieu).
Volume 7 examines the developments in Continental philosophy in the years, roughly, 1980-95, the period immediately after the hegemony of poststructuralism in France and of Habermas in Germany.
Volume 8 attempts to situate the present scene in continental philosophy in terms of various new developments that are framed as attempts to rethink some of the classic themes with which the history of continental philosophy has been more or less consistently engaged. (amazon)
come across this one, due to Alan Schrift's lucidity (2020-3-25)
Divided, chronologically, into eight volumes, "The History of Continental Philosophy" is designed to be accessible to a wide range of readers, from the scholar looking for original insight and the latest thinking to the student wishing for a masterly encapsulation of a particular thinker's views. By placing continental philosophy within a historical context, "The History of Continental Philosophy" helps define what the continental tradition has been and where it is moving. It will become a landmark publication in its field.
Volume 1 covers the period from 1780 until 1848, focusing primarily on the main philosophical figures and developments in Germany during that period, but also including a description of economic and social theories in France that set the stage for the philosophical and social movements that predominated in Germany and France during the second half of the nineteenth century.
Volume 2 examines what is often referred to as the 'Age of Revolution' as various responses to Hegel, while also attending to developments in science, mathematics, sociology and aesthetics during the second half of the nineteenth century that would set the stage for the twentieth century.
Volume 3 examines the earliest developments in the twentieth century: while attending to a number of key thinkers (Bergson, Husserl, Heidegger, Freud, Jaspers, Scheler), it also discusses the emergence of French sociology in the Durkheim school, developments in modern science, the philosophical response to evolution, and the schools of phenomenology and neo-Kantianism.
Volume 4, as the title indicates, charts the various responses to phenomenology that appeared in the years following Husserl, with particular attention to the emergence of existentialism and existential theology, as well as its relations with philosophy of science, aesthetics and ethics.
Volume 5 surveys some of the main continental movements and philosophers associated with social and political philosophy and philosophy of the human sciences (notably history, linguistics, and social and political science) during the period from 1940 through to 1968.
Volume 6 looks at the major figures associated with the two dominant movements that emerge in the 1960s - poststructuralism and critical theory - while also attending to the emergence of philosophical feminism and some influential figures in those years not easily situated in the "standard" histories of the period (Serres, Bourdieu).
Volume 7 examines the developments in Continental philosophy in the years, roughly, 1980-95, the period immediately after the hegemony of poststructuralism in France and of Habermas in Germany.
Volume 8 attempts to situate the present scene in continental philosophy in terms of various new developments that are framed as attempts to rethink some of the classic themes with which the history of continental philosophy has been more or less consistently engaged. (amazon)
come across this one, due to Alan Schrift's lucidity (2020-3-25)
Tuesday, March 24, 2020
4:09 AM (Daseinsanalysis)
近日讀尼采發現一個問題
此君的生命力迸發在三十五至四十五那十年
當然三十五之前那十年已蓄勢待發
這種命格是藝術家的命格
不是正常的哲學家的命格
這種命格的作者對讀者的要求是生命力強盛
意思是說四十五歲以後的讀者往往力有未逮
豬哥亮說四十以後男人只剩一張嘴
就是這個意思
當然你可以想像
那張有名的嘴
可以舔可以吞可以品嘗人奶紅酒可以編造謊言教訓別人
以上基本上都跟吃或吃人有關
的確和瘋狂漂泊抱著被鞭打的馬哭泣的尼采無關
此君的生命力迸發在三十五至四十五那十年
當然三十五之前那十年已蓄勢待發
這種命格是藝術家的命格
不是正常的哲學家的命格
這種命格的作者對讀者的要求是生命力強盛
意思是說四十五歲以後的讀者往往力有未逮
豬哥亮說四十以後男人只剩一張嘴
就是這個意思
當然你可以想像
那張有名的嘴
可以舔可以吞可以品嘗人奶紅酒可以編造謊言教訓別人
以上基本上都跟吃或吃人有關
的確和瘋狂漂泊抱著被鞭打的馬哭泣的尼采無關
Monday, March 23, 2020
Gilles Deleuze (1962, 1965) (Daseinsanalysis)
https://en.wikipedia.org/wiki/Nietzsche_and_Philosophy
https://en.wikipedia.org/wiki/Gilles_Deleuze#Bibliography (1925-1995)
Nietzsche et la philosophie (1962). Trans. Nietzsche and Philosophy (1983)
Nietzsche (1965). Trans. in Pure Immanence (2001)
https://en.wikipedia.org/wiki/Gilles_Deleuze#Bibliography (1925-1995)
Nietzsche et la philosophie (1962). Trans. Nietzsche and Philosophy (1983)
Nietzsche (1965). Trans. in Pure Immanence (2001)
9 (Daseinsanalysis)
3/23 4:20 AM, nine days to go; working on Nietzsche and Psychotherapy (Manu Bazzano, 2019) slowly, recursively, eternal return alike; 11:00 AM, one ER, bipolar disorder, euthymic, with psychosocial stressors; epilepsy, poor control; asthma, ER obs; 8:30 PM, 3 consults, CM
Sunday, March 22, 2020
Pink Cadillac (1989)
https://en.wikipedia.org/wiki/Pink_Cadillac_(film)
https://www.youtube.com/watch?v=fjnB33yD8V4
those were dear CE's best years, when he could mock at himself; this one is the one for tomorrow
https://www.youtube.com/watch?v=fjnB33yD8V4
those were dear CE's best years, when he could mock at himself; this one is the one for tomorrow
Exile on Main St. (The Rolling Stones, 1972)
https://en.wikipedia.org/wiki/Exile_on_Main_St.
https://www.youtube.com/watch?v=Sqk1kdjk5o0&list=PLm-UOpuHGjdXP4P5ezSgy94YcZtbowvPY
Exile on Main Street: Towards a Counter-existential Therapy, by Manu Bazzano, Existential Analysis, 2016, 28(1): 48-64
http://www.manubazzano.com/uploads/Exile%20on%20Main%20Street.pdf
https://www.youtube.com/watch?v=Sqk1kdjk5o0&list=PLm-UOpuHGjdXP4P5ezSgy94YcZtbowvPY
Exile on Main Street: Towards a Counter-existential Therapy, by Manu Bazzano, Existential Analysis, 2016, 28(1): 48-64
http://www.manubazzano.com/uploads/Exile%20on%20Main%20Street.pdf
Saturday, March 21, 2020
Don’t blame ‘China’ for the coronavirus — blame the Chinese Communist Party (Josh Rogin, The Washington Post, 2020-3-20) --- CCP Virus 中共病毒
https://www.washingtonpost.com/opinions/global-opinions/dont-blame-china-for-the-coronavirus--blame-the-chinese-communist-party/2020/03/19/343153ac-6a12-11ea-abef-020f086a3fab_story.html
President Trump insists on calling coronavirus “the Chinese virus.” His rationale for doing so is simplistic but technically accurate: Chinese officials are intentionally spreading the lie the virus may have originated in the United States to deflect blame from their own early failings. “It’s not racist at all, not at all. It comes from China, that’s why. I want to be accurate,” Trump said Wednesday.
As many have noted, accuracy is not the only consideration the president should take into account. Trump is ignoring the history of racism against Asians and Asian Americans in this country and neglecting vital context: a real rise in racist incidents against ethnically Asian people in this country since the crisis began.
An Asian American reporter said a White House official used the term “Kung-Flu” in her presence. That’s unacceptable. The Asian American Journalists Association asked news organizations not to use the term “Wuhan virus,” in accordance with World Health Organization guidelines warning that referring to the geographical origin of an illness in the name stigmatizes the people there.
Surely, many who are using “Chinese virus” or “Wuhan virus” are not racist. And surely, some are. For the person on the receiving end, there’s no difference. But there’s a well-founded way to honor the truth about the virus and hold those responsible to account without causing undue offense.
We must all be specific in blaming the Chinese Communist Party for its actions. It was the CCP that hid the virus outbreak for weeks, silencing doctors, jailing journalists and thwarting science — most notably by shutting down the Shanghai lab that publicly released the first coronavirus genome sequence.
The Chinese people are heroes in this story. Chinese doctors, researchers and journalists risked their lives and even died fighting the virus and warning the world. The Chinese public’s community solidarity holds lessons for us as our own situation worsens. The Chinese are also victims of their own government’s draconian measures, which caused massive extra suffering.
“It is critical to remember that the Chinese people have no meaningful say in the measures taken by their government,” said Christopher Walker, vice president for studies and analysis at the National Endowment for Democracy. “In the haze of authoritarian information curation and disinformation now coming from Beijing, we can’t lose sight of the massive authoritarian governance failure at the global pandemic’s point of origin.”
This is not just about the coronavirus; it’s a crucial point relative to our whole approach toward China. Our beef is not with the Chinese people; our problem is with the CCP — its internal repression, its external aggression, and its malign influence in free and open societies.
Part of the CCP’s strategy is to divide us along political, ethnic and racial lines. Chinese officials routinely toss out the racism accusation to rebut criticism of their government. They also accuse the United States of racism to distract from their own horrendously racist policies, such as interning millions of innocent people in Xinjiang on the basis of ethnicity.
In the United States, most people aren’t attuned to this dynamic. In Australia, the political class has been debating CCP influence operations for several years. One report put out by the Australian Strategic Policy Institute suggested some clear guidelines on how to avoid the trap. The report states that we should avoid generalizations, clearly distinguish between the Chinese government and the Chinese people, and take care not to alienate ethnically Chinese citizens at home. In turn, we must also be careful not to attribute racist motives (unless justified) to those who criticize the Chinese authorities.
“Above all, the CCP has engaged in wedge politics to undermine legitimate public debate on Chinese Government policy and conduct within Australia,” wrote John Fitzgerald in the report. That’s happening in the United States as well.
This is not political correctness run amok. This is about recognizing when an authoritarian regime is using our sensitivity to racism against us. We must avoid making accusations against the Chinese government unless supported by evidence. We must continue to press Beijing for more transparency and truth, which are crucial to stopping the spread.
Have we learned nothing from the Russian interference in 2016? We must not aid and abet the CCP’s efforts to stoke internal divisions and spread disinformation. Have we learned nothing from the post-9/11 demonization of Muslims? Chinese and Chinese Americans need our support during this crisis and bring great strength to our response.
Let’s stop saying “Chinese virus” — not because everyone who uses it is racist, but because it needlessly plays into the Chinese Communist Party’s attempts to divide us and deflect our attention from their bad actions. Let’s just call it the “CCP virus.” That’s more accurate and offends only those who deserve it.
回到自然 (Daseinsanalysis)
是素樸的堅持
其實說起來很具體
自然就是你素面相對的
你面對的是甚麼
你告訴我
人為造作可以是抽象的
也可以是具體的
前者通常被褒為文化
後者通常被褒為文明
所以回到自然
必須被貶為
沒有文化
沒有文明
你不必驚訝
昨晚我在浴室
看到一隻小蟑螂
逃命到牆縫
隱身在與其身軀相似的顏色
依此你可以想像
那隻中共病毒
現在隱身在哪裡
這兩個例子
蟑螂是自然
病毒不是自然
不自然的源頭是製造病毒
把病毒當成生化武器的人
他們製造了新物種
改變了演化
然後隱身在焚化爐萬人塚
宣稱自己就是掌管生命的神
回到回到自然
我相信自然有它的法則
我相信元素性的力量讓人敬畏
我希望我相信惡人終有報應
我希望那隻病毒
聽得懂我的話
其實說起來很具體
自然就是你素面相對的
你面對的是甚麼
你告訴我
人為造作可以是抽象的
也可以是具體的
前者通常被褒為文化
後者通常被褒為文明
所以回到自然
必須被貶為
沒有文化
沒有文明
你不必驚訝
昨晚我在浴室
看到一隻小蟑螂
逃命到牆縫
隱身在與其身軀相似的顏色
依此你可以想像
那隻中共病毒
現在隱身在哪裡
這兩個例子
蟑螂是自然
病毒不是自然
不自然的源頭是製造病毒
把病毒當成生化武器的人
他們製造了新物種
改變了演化
然後隱身在焚化爐萬人塚
宣稱自己就是掌管生命的神
回到回到自然
我相信自然有它的法則
我相信元素性的力量讓人敬畏
我希望我相信惡人終有報應
我希望那隻病毒
聽得懂我的話
James Hillman (1926-2011)
https://en.wikipedia.org/wiki/James_Hillman
https://en.wikipedia.org/wiki/Archetypal_psychology
https://en.wikipedia.org/wiki/We%27ve_Had_a_Hundred_Years_of_Psychotherapy_%E2%80%93_And_the_World%27s_Getting_Worse
https://www.psychotherapy.net/video/hillman-archetypal-psychotherapy
http://www.springpublications.com/ue.html
https://drive.google.com/drive/folders/1p7IpXO2A85buss6FrVSO1tazZxQGi-ku?usp=sharing
https://archive.org/details/soulscodeinsearc00hill/page/n355
https://en.wikipedia.org/wiki/James_Hillman#The_Soul's_Code
https://en.wikipedia.org/wiki/Archetypal_psychology
https://en.wikipedia.org/wiki/We%27ve_Had_a_Hundred_Years_of_Psychotherapy_%E2%80%93_And_the_World%27s_Getting_Worse
https://www.psychotherapy.net/video/hillman-archetypal-psychotherapy
http://www.springpublications.com/ue.html
https://drive.google.com/drive/folders/1p7IpXO2A85buss6FrVSO1tazZxQGi-ku?usp=sharing
https://archive.org/details/soulscodeinsearc00hill/page/n355
https://en.wikipedia.org/wiki/James_Hillman#The_Soul's_Code
The Soul's Code[edit]
Hillman's 1997 book, The Soul's Code: In Search of Character and Calling, outlines what he calls the "acorn theory" of the soul. This theory states that all people already hold the potential for the unique possibilities inside themselves, much as an acorn holds the pattern for an oak tree. The book describes how a unique, individual energy of the soul is contained within each human being, displayed throughout their lifetime and shown in their calling and life's work when it is fully actualized.
Hillman argues against the "nature and nurture" explanations of individual growth, suggesting a third kind of energy, the individual soul which is responsible for much of individual character, aspiration and achievement. He also argues against other environmental and external factors as being the sole determinants of individual growth, including the parental fallacy, dominant in psychoanalysis, whereby our parents are seen as crucial in determining who we are by supplying us with genetic material, conditioning, and behavioral patterns.[8] While acknowledging the importance of external factors in the blossoming of the seed, he argues against attributing all of human individuality, character and achievement to these factors. The book suggests reconnection with the third, superior factor, in discovering our individual nature and in determining who we are and our life's calling.[9]
Hillman suggests a reappraisal for each individual of their own childhood and present life to try to find their particular calling, the seed of their own acorn. He has written that he is to help precipitate a re-souling of the world in the space between rationality and psychology. He complements the notion of growing up, with the notion of growing down, or 'rooting in the earth' and becoming grounded, in order for the individual to further grow. Hillman incorporates logic and rational thought, as well as reference to case histories of well known people in society, whose daimons are considered to be clearly displayed and actualized, in the discussion of the daimon. His arguments are also considered to be in line with the puer aeternus or eternal youth whose brief burning existence could be seen in the work of romantic poets like Keats and Byron and in recently deceased young rock stars like Jeff Buckley or Kurt Cobain. Hillman also rejects causality as a defining framework and suggests in its place a shifting form of fate whereby events are not inevitable but bound to be expressed in some way dependent on the character of the soul of the individual. He also talked about the bad seed using Hitler, Charles Manson and other serial killers as examples.
The Unrestricted Warfare of The Chinese Communist VIrus Pandemic
你必須用生化武器超限戰的觀點來沙盤推演才能理解中共所布局設套作所為比如說2020-1-21中共軍方就申請Redemsivir使用專利比如說這兩天就提出疫苗你必須想像那堆人工合成病毒在實驗室問世後一系列研究已經進行到甚麼地步比如說黃奇帆說趁美國受創打金融戰讓人民幣變成普世貨幣比如說前天十一艘中共快艇攻擊台灣海巡艦比如說接下來鋌而走險發動武統比如說疫情迄今數據維穩但從一個多月前開始數據消失比如說大外宣系統收買WHO完美成功比如說這幾天假冒救世主援助被肆虐的國家上述是已經發生的你可以想像還有多少陰謀等著一步步發生尼采說看著深淵者必為深淵吞噬意思是說用懷疑的詮釋學看著世界必為懷疑的詮釋學吞噬但我們沒有別的辦法因為你看著的是無底線的邪惡你要對抗那個邪惡只能犧牲自己那個邪惡是用吞噬億萬中國人民的精血生命維持運作的絞肉機只有殺光九千萬中共黨員中國人乃至世界方得救贖
Downtempo (Trip Hop) (Daseinsanalysis)
https://en.wikipedia.org/wiki/Downtempo
https://en.wikipedia.org/wiki/Trip_hop
https://www.youtube.com/watch?v=5NVa4w-UXwA
在那裡又似乎不在那裡
治療者最好的狀態類此
你窗外的山
當你抬頭的時候
在那裡
或正確的說
還在那裡
當你忘記抬頭的時候
它仍在那裡
意思是說
它是外於你的客觀的存在
但在那裡
等(這是我的想像)著
被你遺忘和
找到
Sun in an Empty Room (Edward Hopper, 1963)
Hopper曾說這幅畫的構圖
本來要放一個人
在那個空空蕩蕩的陽光灑進來的房間
後來作罷的原因是
這樣會傷害到
那個房間的光影內外的
某種不可言說的完整和平衡
意思是說人
對於那個空空蕩蕩的陽光灑進來的房間
是一個不可挽回的打擾
人類跟大自然的關係
失去上述這個平衡已久
這個平衡
就是回到自然的本意
https://en.wikipedia.org/wiki/Trip_hop
https://www.youtube.com/watch?v=5NVa4w-UXwA
在那裡又似乎不在那裡
治療者最好的狀態類此
你窗外的山
當你抬頭的時候
在那裡
或正確的說
還在那裡
當你忘記抬頭的時候
它仍在那裡
意思是說
它是外於你的客觀的存在
但在那裡
等(這是我的想像)著
被你遺忘和
找到
Sun in an Empty Room (Edward Hopper, 1963)
Hopper曾說這幅畫的構圖
本來要放一個人
在那個空空蕩蕩的陽光灑進來的房間
後來作罷的原因是
這樣會傷害到
那個房間的光影內外的
某種不可言說的完整和平衡
意思是說人
對於那個空空蕩蕩的陽光灑進來的房間
是一個不可挽回的打擾
人類跟大自然的關係
失去上述這個平衡已久
這個平衡
就是回到自然的本意
Friday, March 20, 2020
The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder - 2020 Focused Update
https://www.asam.org/Quality-Science/quality/2020-national-practice-guideline?utm_source=Referral&utm_medium=Email&utm_campaign=Infomz-%20Google%20analytics&_zs=6cv3a&_zl=EP622
https://www.asam.org/docs/default-source/quality-science/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2
https://www.asam.org/docs/default-source/quality-science/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2
The ASAM National Practice Guideline 2020 focused update is intended to inform and empower clinicians, health system administrators, criminal justice system administrators, and policymakers who are interested in implementing evidence-based practices to improve outcomes for individuals with OUD. This is especially critical in the context of the ongoing COVID-19 emergency, which threatens to curtail patient access to evidence-based treatment.
The document is an update to the previous NPG released in 2015 and includes major revisions to 35 existing recommendations, along with the addition of 13 new recommendations.
This focused update was developed over the course of 14 months with consensus from an independent committee of experts and the use of a rigorous RAND/RAM methodology facilitated by researchers from Research Triangle Institute (RTI).
Coronavirus disease 2019 (COVID-19) (UpToDate, 2020-3-19)
INTRODUCTIONCoronaviruses are important human and animal pathogens. At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. It rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of cases in other countries throughout the world. In February 2020, the World Health Organization designated the disease COVID-19, which stands for coronavirus disease 2019 [1]. The virus that causes COVID-19 is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); previously, it was referred to as 2019-nCoV.
Understanding of COVID-19 is evolving. Interim guidance has been issued by the World Health Organization and by the United States Centers for Disease Control and Prevention [2,3]. Links to these and other related society guidelines are found elsewhere. (See 'Society guideline links' below.)
This topic will discuss the epidemiology, clinical features, diagnosis, management, and prevention of COVID-19. Community-acquired coronaviruses, severe acute respiratory syndrome (SARS) coronavirus, and Middle East respiratory syndrome (MERS) coronavirus are discussed separately. (See "Coronaviruses" and "Severe acute respiratory syndrome (SARS)" and "Middle East respiratory syndrome coronavirus: Virology, pathogenesis, and epidemiology".)
EPIDEMIOLOGY
Geographic distribution — Globally, more than 190,000 cases of COVID-19 have been reported. Updated case counts in English can be found on the World Health Organization and European Centre for Disease Prevention and Control websites.
Since the first reports of cases from Wuhan, a city in the Hubei Province of China, at the end of 2019, more than 80,000 COVID-19 cases have been reported in China; these include all laboratory-confirmed cases as well as clinically diagnosed cases in the Hubei Province. A joint World Health Organization (WHO)-China fact-finding mission estimated that the epidemic in China peaked between late January and early February 2020 [4]. The majority of reports have been from Hubei and surrounding provinces, but numerous cases have been reported in other provinces and municipalities throughout China [5,6].
Increasing numbers of cases have also been reported in other countries across all continents except Antarctica, and the rate of new cases outside of China has outpaced the rate in China. These cases initially occurred mainly among travelers from China and those who have had contact with travelers from China [7-11]. However, ongoing local transmission has driven smaller outbreaks in some locations outside of China, including South Korea, Italy, Iran, and Japan, and infections elsewhere have been identified in travelers from those countries [12].
In the United States, clusters of COVID-19 with local transmission have been identified throughout most of the country.
Transmission — Understanding of the transmission risk is incomplete. Epidemiologic investigation in Wuhan at the beginning of the outbreak identified an initial association with a seafood market that sold live animals, where most patients had worked or visited and which was subsequently closed for disinfection [13]. However, as the outbreak progressed, person-to-person spread became the main mode of transmission.
Person-to-person spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is thought to occur mainly via respiratory droplets, resembling the spread of influenza. With droplet transmission, virus released in the respiratory secretions when a person with infection coughs, sneezes, or talks can infect another person if it makes direct contact with the mucous membranes; infection can also occur if a person touches an infected surface and then touches his or her eyes, nose, or mouth. Droplets typically do not travel more than six feet (about two meters) and do not linger in the air; however, in one letter to the editor, SARS-CoV-2 remained viable in aerosols under experimental conditions for at least three hours [14]. Given the current uncertainty regarding transmission mechanisms, airborne precautions are recommended routinely in some countries and in the setting of certain high-risk procedures in others. (See 'Infection control for suspected or confirmed cases' below.)
Viral RNA levels appear to be higher soon after symptom onset compared with later in the illness [15]; this raises the possibility that transmission might be more likely in the earlier stage of infection, but additional data are needed to confirm this hypothesis.
The reported rates of transmission from an individual with symptomatic infection vary by location and infection control interventions. According to a joint WHO-China report, the rate of secondary COVID-19 ranged from 1 to 5 percent among tens of thousands of close contacts of confirmed patients in China [16]. In the United States, the symptomatic secondary attack rate was 0.45 percent among 445 close contacts of 10 confirmed patients [17].
Transmission of SARS-CoV-2 from asymptomatic individuals (or individuals within the incubation period) has also been described [18-22]. However, the extent to which this occurs remains unknown. Large-scale serologic screening may be able to provide a better sense of the scope of asymptomatic infections and inform epidemiologic analysis; several serologic tests for SARS-CoV-2 are under development [23].
SARS-CoV-2 RNA has been detected in blood and stool specimens [24,25]. Live virus has been cultured from stool in some cases [26], but according to a joint WHO-China report, fecal-oral transmission did not appear to be a significant factor in the spread of infection [16].
VIROLOGYFull-genome sequencing and phylogenic analysis indicated that the coronavirus that causes COVID-19 is a betacoronavirus in the same subgenus as the severe acute respiratory syndrome (SARS) virus (as well as several bat coronaviruses), but in a different clade. The structure of the receptor-binding gene region is very similar to that of the SARS coronavirus, and the virus has been shown to use the same receptor, the angiotensin-converting enzyme 2 (ACE2), for cell entry [27]. The Coronavirus Study Group of the International Committee on Taxonomy of Viruses has proposed that this virus be designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [28].
The Middle East respiratory syndrome (MERS) virus, another betacoronavirus, appears more distantly related [29,30]. The closest RNA sequence similarity is to two bat coronaviruses, and it appears likely that bats are the primary source; whether COVID-19 virus is transmitted directly from bats or through some other mechanism (eg, through an intermediate host) is unknown [31]. (See "Coronaviruses", section on 'Viral serotypes'.)
In a phylogenetic analysis of 103 strains of SARS-CoV-2 from China, two different types of SARS-CoV-2 were identified, designated type L (accounting for 70 percent of the strains) and type S (accounting for 30 percent) [32]. The L type predominated during the early days of the epidemic in China, but accounted for a lower proportion of strains outside of Wuhan than in Wuhan. The clinical implications of these findings are uncertain.
CLINICAL FEATURES
Incubation period — The incubation period for COVID-19 is thought to be within 14 days following exposure, with most cases occurring approximately four to five days after exposure [33-35].
In a study of 1099 patients with confirmed symptomatic COVID-19, the median incubation period was four days (interquartile range two to seven days) [34].
Using data from 181 publicly reported, confirmed cases in China with identifiable exposure, one modeling study estimated that symptoms would develop in 2.5 percent of infected individuals within 2.2 days and in 97.5 percent of infected individuals within 11.5 days [36]. The median incubation period in this study was 5.1 days.
Spectrum of illness severity — The spectrum of symptomatic infection ranges from mild to critical; most infections are not severe [35,37-42]. Specifically, in a report from the Chinese Center for Disease Control and Prevention that included approximately 44,500 confirmed infections with an estimation of disease severity [43]:
●Mild (no or mild pneumonia) was reported in 81 percent.
●Severe disease (eg, with dyspnea, hypoxia, or >50 percent lung involvement on imaging within 24 to 48 hours) was reported in 14 percent.
●Critical disease (eg, with respiratory failure, shock, or multiorgan dysfunction) was reported in 5 percent.
●The overall case fatality rate was 2.3 percent; no deaths were reported among noncritical cases.
According to a joint World Health Organization (WHO)-China fact-finding mission, the case-fatality rate ranged from 5.8 percent in Wuhan to 0.7 percent in the rest of China [16]. Most of the fatal cases have occurred in patients with advanced age or underlying medical comorbidities (including cardiovascular disease, diabetes mellitus, chronic lung disease, hypertension, and cancer) [43,44].
The proportion of severe or fatal infections may vary by location. As an example, in Italy, 12 percent of all detected COVID-19 cases and 16 percent of all hospitalized patients were admitted to the intensive care unit; the estimated case fatality rate was 5.8 percent in mid-March [45]. In contrast, the estimated case fatality rate in mid-March in South Korea was 0.9 percent [46]. This may be related to distinct demographics of infection; in Italy, the median age of patients with infection was 64 years, whereas in Korea the median age was in the 40s. (See 'Impact of age' below.)
Impact of age — Individuals of any age can acquire severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, although adults of middle age and older are most commonly affected.
In several cohorts of hospitalized patients with confirmed COVID-19, the median age ranged from 49 to 56 years [38-40]. In a report from the Chinese Center for Disease Control and Prevention that included approximately 44,500 confirmed infections, 87 percent of patients were between 30 and 79 years old [43]. Older age was also associated with increased mortality, with a case fatality rate of 8 and 15 percent among those aged 70 to 79 years and 80 years or older, respectively.
In the United States, 2449 patients diagnosed with COVID-19 between February 12 and March 16, 2020 had age, hospitalization, and intensive care unit (ICU) information available [47]; 67 percent of cases were diagnosed in those aged ≥45 years [47], and, similar to findings from China, mortality was highest among older individuals, with 80 percent of deaths occurring in those aged ≥65 years.
Symptomatic infection in children appears to be uncommon; when it occurs, it is usually mild, although severe cases have been reported [48]. In the large Chinese report described above, only 2 percent of infections were in individuals younger than 20 years old [43]. Similarly, in South Korea, only 6.3 percent of nearly 8000 infections were in those younger than 20 years old [46]. In a small study of 10 children in China, clinical illness was mild; 8 had fever, which resolved within 24 hours, 6 had cough, 4 had sore throat, 4 had evidence of focal pneumonia on CT, and none required supplemental oxygen [49]. In another study of six children aged 1 to 7 years who were hospitalized in Wuhan with COVID-19, all had fever >102.2°F/39°C and cough, four had imaging evidence of viral pneumonia, and one was admitted to the intensive care unit; all children recovered [50].
Asymptomatic infections — Asymptomatic infections have also been described [35,51-53], but their frequency is unknown.
In a COVID-19 outbreak on a cruise ship where nearly all passengers and staff were screened for SARS-CoV-2, approximately 17 percent of the population on board tested positive as of February 20; about half of the 619 confirmed COVID-19 cases were asymptomatic at the time of diagnosis [54].
Even patients with asymptomatic infection may have objective clinical abnormalities [22,55]. As an example, in a study of 24 patients with asymptomatic infection who all underwent chest computed tomography (CT), 50 percent had typical ground-glass opacities or patchy shadowing, and another 20 percent had atypical imaging abnormalities [22]. Five patients developed low-grade fever, with or without other typical symptoms, a few days after diagnosis.
Clinical manifestations
Initial presentation — Pneumonia appears to be the most frequent serious manifestation of infection, characterized primarily by fever, cough, dyspnea, and bilateral infiltrates on chest imaging [34,38-40]. There are no specific clinical features that can yet reliably distinguish COVID-19 from other viral respiratory infections.
In a study describing 138 patients with COVID-19 pneumonia in Wuhan, the most common clinical features at the onset of illness were [40]:
●Fever in 99 percent
●Fatigue in 70 percent
●Dry cough in 59 percent
●Anorexia in 40 percent
●Myalgias in 35 percent
●Dyspnea in 31 percent
●Sputum production in 27 percent
Other cohort studies of patients from Wuhan with confirmed COVID-19 have reported a similar range of clinical findings [38,40,56,57]. However, fever might not be a universal finding. In one study, fever was reported in almost all patients, but approximately 20 percent had a very low grade fever <100.4°F/38°C [38]. In another study of 1099 patients from Wuhan and other areas in China, fever (defined as an axillary temperature over 99.5°F/37.5°C) was present in only 44 percent on admission but was ultimately noted in 89 percent during the hospitalization [34].
Other, less common symptoms have included headache, sore throat, and rhinorrhea. In addition to respiratory symptoms, gastrointestinal symptoms (eg, nausea and diarrhea) have also been reported in some patients, but these are relatively uncommon [38,40].
Reports of cohorts in locations outside of Wuhan have described similar clinical findings, although some have suggested that milder illness may be more common [58-60]. As an example, in a study of 62 patients with COVID-19 in the Zhejiang province of China, all but one had pneumonia, but only two developed dyspnea, and only one warranted mechanical ventilation [59].
Course and complications — As above, symptomatic infection can range from mild to critical. (See 'Spectrum of illness severity' above.)
Some patients with initially mild symptoms may progress over the course of a week. In one study of 138 patients hospitalized in Wuhan for pneumonia due to SARS-CoV-2, dyspnea developed after a median of five days since the onset of symptoms, and hospital admission occurred after a median of seven days of symptoms [40]. In another study, the median time to dyspnea was eight days [38].
Acute respiratory distress syndrome (ARDS) is a major complication in patients with severe disease. In the study of 138 patients described above, ARDS developed in 20 percent after a median of eight days, and mechanical ventilation was implemented in 12.3 percent [40]. In another study of 201 hospitalized patients with COVID-19 in Wuhan, 41 percent developed ARDS; age greater than 65 years, diabetes mellitus, and hypertension were each associated with ARDS [61].
Other complications have included arrhythmias, acute cardiac injury, and shock. In one study, these were reported in 17, 7, and 9 percent, respectively [40].
According to the WHO, recovery time appears to be around two weeks for mild infections and three to six weeks for severe disease [4].
Laboratory findings — In patients with COVID-19, the white blood cell count can vary. Leukopenia, leukocytosis, and lymphopenia have been reported, although lymphopenia appears most common [24,38-40]. Elevated lactate dehydrogenase and ferritin levels are common, and elevated aminotransferase levels have also been described. On admission, many patients with pneumonia have normal serum procalcitonin levels; however, in those requiring ICU care, they are more likely to be elevated [38-40].
High D-dimer levels and more severe lymphopenia have been associated with mortality [39].
Imaging findings — Chest CT in patients with COVID-19 most commonly demonstrates ground-glass opacification with or without consolidative abnormalities, consistent with viral pneumonia [57,62]. Case series have suggested that chest CT abnormalities are more likely to be bilateral, have a peripheral distribution, and involve the lower lobes. Less common findings include pleural thickening, pleural effusion, and lymphadenopathy.
Chest CT may be helpful in making the diagnosis, but no finding can completely rule in or rule out the possibility of COVID-19. In a study of 1014 patients in Wuhan who underwent both reverse-transcription polymerase chain reaction (RT-PCR) testing and chest CT for evaluation of COVID-19, a "positive" chest CT for COVID-19 (as determined by a consensus of two radiologists) had a sensitivity of 97 percent, using the PCR tests as a reference; however, specificity was only 25 percent [63]. The low specificity may be related to other etiologies causing similar CT findings. In another study comparing chest CTs from 219 patients with COVID-19 in China and 205 patients with other causes of viral pneumonia in the United States, COVID-19 cases were more likely to have a peripheral distribution (80 versus 57 percent), ground-glass opacities (91 versus 68 percent), fine reticular opacities (56 versus 22 percent), vascular thickening (59 versus 22 percent), and reverse halo sign (11 versus 1 percent), but less likely to have a central and peripheral distribution (14 versus 35 percent), air bronchogram (14 versus 23 percent), pleural thickening (15 versus 33 percent), pleural effusion (4 versus 39 percent), and lymphadenopathy (2.7 versus 10 percent) [64]. A group of radiologists in that study was able to distinguish COVID-19 with high specificity but moderate sensitivity.
In one report of 21 patients with laboratory-confirmed COVID-19 who did not develop severe respiratory distress, lung abnormalities on chest imaging were most severe approximately 10 days after symptom onset [56]. However, chest CT abnormalities have also been identified in patients prior to the development of symptoms and even prior to the detection of viral RNA from upper respiratory specimens [57,65].
EVALUATION AND DIAGNOSIS
Clinical suspicion and criteria for testing — The approach to initial management should focus on early recognition of suspect cases, immediate isolation, and institution of infection control measures. At present, the possibility of COVID-19 should be considered primarily in patients with fever and/or respiratory tract symptoms (eg, cough, dyspnea) who have had any of the following in the prior 14 days:
●Close contact with a confirmed or suspected case of COVID-19, including through work in health care settings. Close contact includes being within approximately six feet (about two meters) of a patient for a prolonged period of time while not wearing personal protective equipment or having direct contact with infectious secretions while not wearing personal protective equipment.
●Residence in or travel to areas where widespread community transmission has been reported (eg, China, South Korea, most of Europe [including Italy], Iran, Japan). (See 'Geographic distribution' above.)
●Potential exposure through attendance at events or spending time in specific settings where COVID-19 cases have been reported.
The possibility of COVID-19 should also be considered in patients with severe lower respiratory tract illness when an alternative etiology cannot be identified, even if there has been no clear exposure.
When COVID-19 is suspected, infection control measures should be implemented and public health officials notified. Patients who do not need emergent care should be encouraged to call prior to presenting to a health care facility for evaluation. Many patients can be evaluated regarding the need for testing over the phone. Infection control precautions are discussed elsewhere. (See 'Infection control for suspected or confirmed cases' below.)
The specific case definitions and clinical criteria for pursuing diagnostic evaluation differ slightly between expert groups.
●The United States Centers for Disease Control and Prevention (CDC) notes that the decision to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) should be based on clinical judgment and reminds clinicians that most patients with confirmed COVID-19 have fever (subjective or confirmed) and/or symptoms of acute respiratory illness (eg cough, dyspnea). This guidance expands its previous criteria to potentially include a wider group of symptomatic patients. In areas where testing capacity is limited, public health officials can guide prioritization of testing. The CDC suggests prioritizing hospitalized patients to inform infection control decisions, symptomatic individuals who have a higher risk of poor outcomes (eg, age ≥65 years, chronic medical condition, immunocompromising conditions), and those with high exposure risk (eg, recent travel to specific locations, contact with patients with COVID-19, or being a health care worker) [66]. Details can be found on the CDC website. An approach to suspected cases when testing is not available is discussed elsewhere. (See 'COVID-19 testing not readily available' below.)
●Case definitions from the World Health Organization are found in its technical guidance online.
●Case definitions from the European Centre for Disease Prevention and Control are found on its website.
Laboratory testing — Patients who meet the criteria for suspect cases, as discussed above, should undergo testing for SARS-CoV-2 (the virus that causes COVID-19), in addition to testing for other respiratory pathogens (eg, influenza, respiratory syncytial virus). (See "Diagnostic approach to community-acquired pneumonia in adults", section on 'Diagnostic testing for microbial etiology'.)
In the United States, the CDC recommends collection of a nasopharyngeal swab specimen to test for SARS-CoV-2 [67]. An oropharyngeal swab can be collected but is not essential; if collected, it should be placed in the same container as the nasopharyngeal specimen. Sputum should only be collected from patients with productive cough; induction of sputum is not indicated.
SARS-CoV-2 RNA is detected by reverse-transcription polymerase chain reaction (RT-PCR); in the United States, testing is performed by the CDC or a CDC-qualified lab [68]. A positive test for SARS-CoV-2 confirms the diagnosis of COVID-19. If initial testing is negative but the suspicion for COVID-19 remains, the WHO recommends resampling and testing from multiple respiratory tract sites [69]. The accuracy and predictive values of SARS-CoV-2 testing have not been systematically evaluated. Negative RT-PCR tests on oropharyngeal swabs despite CT findings suggestive of viral pneumonia have been reported in some patients who ultimately tested positive for SARS-CoV-2 [65].
For safety reasons, specimens from a patient with suspected or documented COVID-19 should not be submitted for viral culture.
The importance of testing for other pathogens was highlighted in a report of 210 symptomatic patients with suspected COVID-19; 30 tested positive for another respiratory viral pathogen, and 11 tested positive for SARS-CoV-2 [37].
MANAGEMENT
Site of care
Home care — Home management is appropriate for patients with mild infection who can be adequately isolated in the outpatient setting [24,70,71]. Management of such patients should focus on prevention of transmission to others and monitoring for clinical deterioration, which should prompt hospitalization.
Outpatients with COVID-19 should stay at home and try to separate themselves from other people and animals in the household. They should wear a facemask when in the same room (or vehicle) as other people and when presenting to health care settings. Disinfection of frequently touched surfaces is also important, as discussed elsewhere. (See 'Environmental disinfection' below.)
The United States Centers for Disease Control and Prevention (CDC) has issued recommendations on discontinuation of home isolation, which include both test-based and non-test-based strategies [72,73]. The choice of strategy depends upon the patient population (eg, immunocompromised versus nonimmunocompromised), the availability of testing supplies, and access to testing.
●When a test-based strategy is used, patients may discontinue home isolation when there is:
•Resolution of fever without the use of fever-reducing medications AND
•Improvement in respiratory symptoms (eg, cough, shortness of breath) AND
•Negative results of a US Food and Drug Administration (FDA) Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens)
●When a non-test-based strategy is used, patients may discontinue home isolation when the following criteria are met:
•At least seven days have passed since symptoms first appeared AND
•At least three days (72 hours) have passed since recovery of symptoms (defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms [eg, cough, shortness of breath])
In some cases, patients may have had laboratory-confirmed COVID-19, but they did not have any symptoms when they were tested. In such patients, home isolation may be discontinued when at least seven days have passed since the date of their first positive COVID-19 test so long as there was no evidence of subsequent illness.
The use of non-test-based strategies that use time since illness onset and time since recovery as the criteria for discontinuing precautions is based upon findings that transmission is most likely to occur in the early stage of infection. However, data are limited, particularly in immunocompromised patients, and this strategy may not prevent all instances of secondary spread [72,73]. (See 'Transmission' above.)
More detailed interim recommendations on home management of patients with COVID-19 can be found on the World Health Organization (WHO) and CDC websites [71,74,75].
Hospital care — Some patients with suspected or documented COVID-19 have severe disease that warrants hospital care. Management of such patients consists of ensuring appropriate infection control, as below (see 'Infection control for suspected or confirmed cases' below), and supportive care. Clinical guidance can be found on the WHO and CDC websites [24,70].
Patients with severe disease often need oxygenation support. High-flow oxygen and noninvasive positive pressure ventilation have been used, but the safety of these measures is uncertain, and they should be considered aerosol-generating procedures that warrant specific isolation precautions. (See 'Infection control for suspected or confirmed cases' below.)
Some patients may develop acute respiratory distress syndrome and warrant intubation with mechanical ventilation; extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia. Management of acute respiratory distress syndrome is discussed in detail elsewhere. (See "Acute respiratory distress syndrome: Supportive care and oxygenation in adults" and "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults" and "Ventilator management strategies for adults with acute respiratory distress syndrome" and "Prone ventilation for adult patients with acute respiratory distress syndrome" and "Extracorporeal membrane oxygenation (ECMO) in adults".)
Limited role of glucocorticoids — The WHO and CDC recommend glucocorticoids not be used in patients with COVID-19 pneumonia unless there are other indications (eg, exacerbation of chronic obstructive pulmonary disease) [24,70]. Glucocorticoids have been associated with an increased risk for mortality in patients with influenza and delayed viral clearance in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Although they were widely used in management of severe acute respiratory syndrome (SARS), there was no good evidence for benefit, and there was persuasive evidence of adverse short- and long-term harm [76]. (See "Treatment of seasonal influenza in adults", section on 'Adjunctive therapies' and "Middle East respiratory syndrome coronavirus: Treatment and prevention", section on 'Treatment'.)
Use of NSAIDs — Some clinicians have suggested the use of non-steroidal anti-inflammatory drugs (NSAIDs) early in the course of disease may have a negative impact on disease outcome [77,78]. These concerns are based on anecdotal reports of a few young patients who received NSAIDs early in the course of infection and experienced severe disease, as well as the theoretic concern that the anti-inflammatory properties associated with NSAIDs could have a negative impact on the patient's immune response. In light of these concerns, some providers are using acetaminophen in place of NSAIDs for reduction of fever; however, the European Medicines Agency (EMA) and the WHO do not recommend that NSAIDs be avoided when clinically indicated [79,80].
Investigational agents — A number of investigational agents are being explored for antiviral treatment of COVID-19, and enrollment in clinical trials should be discussed with patients or their proxies. A registry of international clinical trials can be found on the WHO website and at clinicaltrials.gov.
Certain investigational agents have been described in observational series or are being used anecdotally based on in vitro or extrapolated evidence. It is important to acknowledge that there are no controlled data supporting the use of any of these agents, and their efficacy for COVID-19 is unknown.
●Remdesivir – Several randomized trials are underway to evaluate the efficacy of remdesivir for moderate or severe COVID-19 [81]. Remdesivir is a novel nucleotide analogue that has activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro and related coronaviruses (including SARS and MERS-CoV) both in vitro and in animal studies [82,83]. The compassionate use of remdesivir through an investigational new drug application was described in a case report of one of the first patients with COVID-19 in the United States [84]. Any clinical impact of remdesivir on COVID-19 remains unknown.
●Chloroquine/hydroxychloroquine – Both chloroquine and hydroxychloroquine inhibit SARS-CoV-2 in vitro, although hydroxychloroquine appears to have more potent antiviral activity [85]. A number of clinical trials are underway in China to evaluate the use of chloroquine or hydroxychloroquine for COVID-19 [86].
●Lopinavir-ritonavir – This combined protease inhibitor, which has primarily been used for HIV infection, has in vitro activity against the SARS-CoV [87] and appears to have some activity against MERS-CoV in animal studies [88]. Although the use of this agent for treatment of COVID-19 has been described in case reports [89-91], there was no difference in time to clinical improvement or mortality at 28 days in a randomized trial of 199 patients with severe COVID-19 given lopinavir-ritonavir (400/100 mg) twice daily for 14 days in addition to standard care versus those who received standard of care alone [92].
●Tocilizumab – Treatment guidelines from China's National Health Commission include the IL-6 inhibitor tocilizumab for patients with severe COVID-19 and elevated IL-6 levels; the agent is being evaluated in a clinical trial [93].
Other interventions of interest but with limited or no clinical data include interferon beta and convalescent serum.
PREVENTION
In the health care setting
Screening and precautions for fever or respiratory symptoms — Screening patients for clinical manifestations consistent with COVID-19 (eg, fever, cough, dyspnea) prior to entry into a health care facility can help identify those who may warrant additional infection control precautions. This can be done over the phone before the patient actually presents to a facility. Any individual with these manifestations should be advised to wear a facemask. Separate waiting areas for patients with respiratory symptoms should be designated, if possible, at least six feet away from the regular waiting areas.
Symptomatic patients should also be asked about recent travel or potential COVID-19 exposure in the prior 14 days to determine the need for evaluation for COVID-19. (See 'Clinical suspicion and criteria for testing' above.)
In some settings, such as long-term care facilities, the United States Centers for Disease Control and Prevention (CDC) recommends that standard, contact, and droplet precautions in addition to eye protection be used for any patient with an undiagnosed respiratory infection who is not under consideration for COVID-19 [94]. This may help reduce the risk of spread from unsuspected COVID-19 cases. Infection control precautions for suspect COVID-19 cases are discussed below.
In locations where community transmission is ongoing, postponing elective procedures or non-urgent visits and using virtual (eg, through video communication) visits may be useful strategies to reduce the risk of exposure [95].
Infection control for suspected or confirmed cases — Infection control to limit transmission is an essential component of care in patients with suspected or documented COVID-19. In one report of 138 patients with COVID-19 in China, it was estimated that 43 percent acquired infection in the hospital setting [40].
Individuals with suspected infection in the community should be advised to wear a medical mask to contain their respiratory secretions prior to seeking medical attention. (See 'Evaluation and diagnosis' above.)
In the health care setting, the World Health Organization (WHO) and CDC recommendations for infection control for suspected or confirmed infections differ slightly:
●The WHO recommends standard, contact, and droplet precautions (ie, gown, gloves, and mask), with eye or face protection [96]. The addition of airborne precautions (ie, respirator) is warranted during aerosol-generating procedures (as detailed below).
The CDC recommends that patients with suspected or confirmed COVID-19 be placed in a single-occupancy room with a closed door and dedicated bathroom [95]. The patient should wear a facemask if being transported out of the room (eg, for studies that cannot be performed in the room). An airborne infection isolation room (ie, a single-patient negative pressure room) should be reserved for patients undergoing aerosol-generating procedures (as detailed below).
Any personnel entering the room of a patient with suspected or confirmed COVID-19 should wear the appropriate personal protection equipment: gown, gloves, eye protection, and a respirator (eg, an N95 respirator). If supply of respirators is limited, the CDC acknowledges that facemasks are an acceptable alternative (in addition to contact precautions and eye protection), but respirators should be worn during aerosol-generating procedures [95].
Aerosol-generating procedures include tracheal intubation, noninvasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, upper endoscopy, and bronchoscopy. Nasopharyngeal or oropharyngeal specimen collection is not considered an aerosol-generating procedure.
For health care workers who have had a potential exposure to COVID-19, the CDC has provided guidelines for work restriction and monitoring. The approach depends upon the duration of exposure, the patient's symptoms, whether the patient was wearing a facemask, the type of personal protective equipment used by the provider, and whether an aerosol-generating procedure was performed.
Links to additional infection control guidelines are found below. (See 'Society guideline links' below.)
Discontinuation of precautions — The decision to discontinue infection control precautions for patients with COVID-19 should be made on a case-by-case basis in consultation with experts in infection prevention and control and public health officials. Factors to inform this decision include resolution of clinical signs and symptoms and negative results of reverse-transcription polymerase chain reaction (RT-PCR) testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on two sequential paired nasopharyngeal and throat specimens (ie, four specimens total, each handled separately), with each pair collected ≥24 hours apart [97].
Positive RT-PCR tests for SARS-CoV-2 were reported in four laboratory-confirmed COVID-19 patients after they had clinically improved and tested negative on two consecutive tests [98]. The clinical significance of this finding is uncertain; it is unknown whether these individuals continued to shed infectious virus.
Environmental disinfection — To help reduce the spread of COVID-19 virus, environmental infection control procedures should also be implemented [71,75,95,96,99]. In United States health care settings, the CDC states routine cleaning and disinfection procedures are appropriate for COVID-19 virus [95].
Products approved by the Environmental Protection Agency (EPA) for emerging viral pathogens should be used; a list of EPA-registered products can be found here. Specific guidance on environmental measures, including those used in the home setting, is available on the CDC and WHO websites. Additional information is also found in a separate topic review. (See "Coronaviruses", section on 'Treatment and prevention'.)
The importance of environmental disinfection was illustrated in a study from Singapore, in which viral RNA was detected on nearly all surfaces tested (handles, light switches, bed and handrails, interior doors and windows, toilet bowl, sink basin) in the airborne infection isolation room of a patient with symptomatic mild COVID-19 prior to routine cleaning [100]. Viral RNA was not detected on similar surfaces in the rooms of two other symptomatic patients following routine cleaning (with sodium dichloroisocyanurate). Of note, viral RNA detection does not necessarily indicate the presence of infectious virus.
It is unknown how long SARS-CoV-2 can persist on surfaces [14,99,101]; other coronaviruses have been tested and may survive on inanimate surfaces for up to six to nine days without disinfection. In a study evaluating the survival of viruses dried on a plastic surface at room temperature, a specimen containing SARS-CoV (a virus closely related to SARS-CoV-2) had detectable infectivity at six but not nine days [101]. However, in a systematic review of similar studies, various disinfectants (including ethanol at concentrations between 62 and 71 percent) inactivated a number of coronaviruses related to SARS-CoV-2 within one minute [99].
Preventing exposure in the community — The following general measures are recommended to reduce transmission of infection:
●Diligent hand washing, particularly after touching surfaces in public. Use of hand sanitizer that contains at least 60 percent alcohol is a reasonable alternative if the hands are not visibly dirty.
●Respiratory hygiene (eg, covering the cough or sneeze).
●Avoiding touching the face (in particular eyes, nose, and mouth).
●Avoiding crowds (particularly in poorly ventilated spaces) if possible and avoiding close contact with ill individuals.
●Cleaning and disinfecting objects and surfaces that are frequently touched. The CDC has issued guidance on disinfection in the home setting; a list of EPA-registered products can be found here.
In particular, older adults and individuals with chronic medical conditions should be encouraged to follow these measures.
If SARS-CoV-2 is prevalent in the community, residents should be encouraged to practice social distancing by staying home as much as possible. In the United States, the CDC has provided guidance for cancelling and postponing gatherings [102].
For people without respiratory symptoms, wearing a medical mask in the community is not recommended, even if COVID-19 is prevalent in the area [2]; wearing a mask does not decrease the importance of other general measures to prevent infection, and it may result in unnecessary cost and supply problems [103].
Individuals who are caring for patients with suspected or documented COVID-19 at home, however, should wear a tightly fitting medical mask when in the same room as that patient.
Individuals who develop an acute respiratory illness (eg, with fever and/or respiratory symptoms) should be encouraged to stay home from school or work for the duration of the illness. Some may warrant evaluation for COVID-19. (See 'Clinical suspicion and criteria for testing' above.)
The CDC has included recommended measures to prevent spread in the community on its website.
Managing asymptomatic individuals with potential exposure — Individuals who have had travel to high-risk areas or are contacts of patients with suspected or confirmed COVID-19 should be monitored for development of consistent symptoms and signs (fever, cough, or dyspnea). Such clinical manifestations should prompt at least self-isolation with social distancing and clinician assessment for the need for medical evaluation. (See 'Clinical suspicion and criteria for testing' above.)
In the United States, the level of risk (based on the travel location or the type of contact) informs whether monitoring and isolation are done by the individual or with the involvement of public health personnel. Categories of risk and the suggested monitoring and isolation strategies can be found on the CDC website.
Global public health measures — On January 30, 2020, the WHO declared the COVID-19 outbreak a public health emergency of international concern and, in March 2020, began to characterize it as a pandemic in order to emphasize the gravity of the situation and urge all countries to take action in detecting infection and preventing spread. The WHO has indicated three priorities for countries: protecting health workers, engaging communities to protect those at highest risk of severe disease (eg, older adults and those with medical comorbidities), and supporting vulnerable countries in containing infection [4].
The WHO does not recommend international travel restrictions but does acknowledge that movement restriction may be temporarily useful in some settings. The WHO advises exit screening for international travelers from areas with ongoing transmission of COVID-19 virus to identify individuals with fever, cough, or potential high-risk exposure [104,105]. Many countries also perform entry screening (eg, temperature, assessment for signs and symptoms). More detailed travel information is available on the WHO website.
In the United States, the CDC currently recommends that individuals avoid all nonessential travel to mainland China, Iran, most European countries (including Italy), and South Korea [106]. Because risk of travel changes rapidly, those coming from other countries should check United States government web sites for possible restrictions on arrival. The CDC has released travel advisories regarding other locations where community transmission has been reported [106]. The CDC website provides updated guidance on travel restrictions as well as risk assessment and management of persons with a suspected exposure to COVID-19.
Although many cases of COVID-19 can be detected through entry screening, some may be missed. As an example, in Germany, 114 travellers returning from Wuhan were considered to be asymptomatic during entry screening but, when tested for COVID-19 virus by RT-PCR, two tested positive [107]. However, the role of asymptomatic patients in transmitting infection to others, and thus the value of PCR testing of asymptomatic individuals on entry, remains unclear. (See 'Transmission' above.)
SPECIAL SITUATIONS
Pregnant and breastfeeding women — Minimal information is available regarding COVID-19 during pregnancy. Intrauterine or perinatal transmission has not been identified [108-111]. In two reports including a total of 18 pregnant women with suspected or confirmed COVID-19 pneumonia, there was no laboratory evidence of transmission of the virus to the neonate [108,109]. However, neonatal cases of infection have been documented [112,113]. In one case, the diagnosis was made at day 17 of life after close contact with the infant's mother and a maternity matron who were both infected with the virus. The other case was diagnosed 36 hours after birth; the source and time of transmission in that case were unclear.
The approach to prevention, evaluation, diagnosis, and treatment of pregnant women with suspected COVID-19 should be similar to that in nonpregnant individuals (as described above), with consideration that pregnant women with other potentially severe respiratory infections, such as influenza, severe acute respiratory syndrome (SARS)-CoV, or Middle East respiratory syndrome (MERS)-CoV, appear to be more vulnerable to developing severe disease.
Cesarean delivery is performed for standard obstetric indications. In symptomatic women with suspected or confirmed COVID-19, one expert group suggested leaving the vernix caseosa in place for 24 hours after birth, since it contains antimicrobial peptides [114]. Additionally, the American College of Obstetricians and Gynecologists (ACOG) specifies that infants born to mothers with confirmed COVID-19 should be considered a patient under investigation and appropriately isolated and evaluated [115]. (See 'Evaluation and diagnosis' above.)
It is unknown whether the virus can be transmitted through breast milk. The only report of testing found no virus in the maternal milk of six patients [108]. However, droplet transmission could occur through close contact during breastfeeding. Thus, mothers with confirmed COVID-19 or symptomatic mothers with suspected COVID-19 should take precautions to prevent transmission to the infant during breastfeeding (including assiduous hand hygiene and use of a facemask) [71,115]. Alternatively, to minimize direct contact, the infant can be fed expressed breastmilk by another caregiver until the mother has recovered, provided that the other caregiver is healthy and follows hygiene precautions.
Women who choose not to breastfeed must take similar precautions to prevent transmission through close contact when formula is used.
COVID-19 testing not readily available — In some cases, testing for COVID-19 may not be accessible, particularly for individuals who have a compatible but mild illness that does not warrant hospitalization and do not have a known COVID-19 exposure or high-risk travel history.
In the United States, there is limited official guidance for this situation, and the approach may depend on the prevalence of COVID-19 in the area. If the clinician has sufficient concern for possible COVID-19 (eg, there is community transmission), it is reasonable to advise the patient to self-isolate at home (if hospitalization is not warranted) and alert the clinician about worsening symptoms. The optimal duration of home isolation in such cases is uncertain. A discussion of when home isolation can be discontinued in patients with confirmed COVID-19 can be found above. (See 'Home care' above.)
Managing chronic medications
Patients receiving ACE inhibitors/ARBs — Patients receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should continue treatment with these agents. This approach is supported by multiple guideline panels [116-120].
There has been speculation that patients with COVID-19 who are receiving these agents may be at increased risk for adverse outcomes [121,122]. Angiotensin-converting enzyme 2 (ACE2) is a receptor for SARS-CoV-2 [123], and renin-angiotensin-aldosterone system inhibitors can increase ACE2 levels. Although patients with cardiovascular disease, hypertension, and diabetes may have a more severe clinical course in the setting of infection with SARS-CoV-2, there is no evidence to support an association with these agents. In addition, stopping these agents in some patients may exacerbate comorbid cardiovascular or kidney disease and lead to increased mortality [124].
Patients receiving immunomodulatory agents — Immunocompromised patients with COVID-19 are at increased risk for severe disease, and the decision to discontinue prednisone, biologics, or other immunosuppressive drugs in the setting of infection must be determined on a case-by-case basis. (See 'Management' above.)
For individuals with underlying conditions who require treatment with these agents and are without evidence of COVID-19, there is no evidence that routinely discontinuing treatment is of any benefit. In addition, discontinuing these medications may result in loss of response when the agent is reintroduced. This approach is supported by statements from American and other dermatology, rheumatology, and gastroenterology societies [125-128].
SOCIETY GUIDELINE LINKSLinks to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Coronavirus disease 2019 (COVID-19)".)
INFORMATION FOR PATIENTSUpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Coronavirus disease 2019 (COVID-19) (The Basics)")
SUMMARY AND RECOMMENDATIONS
●In late 2019, a novel coronavirus, now designated SARS-CoV-2, was identified as the cause of an outbreak of acute respiratory illness in Wuhan, a city in China. In February 2020, the World Health Organization (WHO) designated the disease COVID-19, which stands for coronavirus disease 2019. (See 'Introduction' above.)
●Since the first reports of COVID-19, infection has spread to include more than 80,000 cases in China and increasing cases worldwide, prompting the WHO to declare a public health emergency in late January 2020 and characterize it as a pandemic in March 2020. The rate of new infections outside of China has surpassed that within China as epidemics have grown in other countries. (See 'Epidemiology' above.)
●The possibility of COVID-19 should be considered primarily in patients with fever and/or respiratory tract symptoms who have had recent close contact with a confirmed or suspected case of COVID-19, who reside in or have recently (within the prior 14 days) traveled to areas where community transmission has been reported (eg, China, South Korea, most of Europe [including Italy], Iran, Japan) or who have had potential exposure from specific settings where COVID-19 cases have been reported. Clinicians should also be aware of the possibility of COVID-19 in patients with severe respiratory illness when no other etiology can be identified. (See 'Clinical features' above and 'Evaluation and diagnosis' above.)
●Upon suspicion of COVID-19, infection control measures should be implemented and public health officials notified. In health care settings in the United States, the Centers for Disease Control and Prevention (CDC) recommends a single-occupancy room for patients and gown, gloves, eye protection, and a respirator (or facemask as an alternative) for health care personnel. (See 'Infection control for suspected or confirmed cases' above.)
●In addition to testing for other respiratory pathogens, a nasopharyngeal swab specimen should be collected for reverse-transcription polymerase chain reaction (RT-PCR) testing for SARS-CoV-2. (See 'Evaluation and diagnosis' above.)
●Management consists of supportive care. Home management may be possible for patients with mild illness who can be adequately isolated in the outpatient setting. (See 'Management' above.)
●To reduce the risk of transmission in the community, individuals should be advised to wash hands diligently, practice respiratory hygiene (eg, cover their cough), and avoid crowds and close contact with ill individuals, if possible. Facemasks are not routinely recommended for asymptomatic individuals to prevent exposure in the community. Social distancing is advised, particularly in locations that have community transmission. (See 'Preventing exposure in the community' above.)
●Interim guidance has been issued by the WHO and by the CDC. These are updated on an ongoing basis. (See 'Society guideline links' above.)
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