Chinese media ups the ante, asks India to withdraw with dignity

Washington, Apr 28: After nearly three weeks in an intensive care unit in Los Angeles, doctors treating 41-year-old Broadway actor Nick Cordero for COVID-19 were forced to amputate his right leg.

The flow of blood had been impeded by a blood clot: yet another dangerous complication of the disease that has been bubbling up in frontline reports from China, Europe and the United States.

To be sure, so-called "thrombotic events" occur for a variety of reasons among intensive care patients, but the rates among COVID-19 patients are far higher than would be otherwise expected.

"I have had 40-year-olds in my ICU who have clots in their fingers that look like they'll lose the finger, but there's no other reason to lose the finger than the virus," Shari Brosnahan, a critical care doctor at NYU Langone said.

One of these patients is suffering from a lack of blood flow to both feet and both hands, and she predicts an amputation may be necessary, or the blood vessels may get so damaged that an extremity could drop off by itself.

Blood clots aren't just dangerous for our limbs, but can make their way to the lungs, heart or brain, where they may cause lethal pulmonary embolisms, heart attacks, and strokes.

A recent paper from the Netherlands in the journal Thrombosis Research found that 31 percent of 184 patients suffered thrombotic complications, a figure that the researchers called "remarkably high" -- even if extreme consequences like amputation are rare.

Behnood Bikdeli, a doctor at New York-Presbyterian Hospital, assembled an international consortium of experts to study the issue. Their findings were published in the Journal of The American College of Cardiology.

The experts found the risks were so great that COVID-19 patients "may need to receive blood thinners, preventively, prophylactically," even before imaging tests are ordered, said Bikdeli.

What exactly is causing it? The reasons aren't fully understood, but he offered several possible explanations.

People with severe forms of COVID-19 often have underlying medical conditions like heart or lung disease -- which are themselves linked to higher rates of clotting.

Next, being in intensive care makes a person likelier to develop a clot because they are staying still for so long. That's why for example people are encouraged to stretch and move around on long haul flights.

It's also now clear the COVID-19 illness is associated with an abnormal immune reaction called "cytokine storm" -- and some research has indicated this too is linked to higher rates of clotting.

There could also be something about the virus itself that is causing coagulation, which has some precedent in other viral illnesses.

A paper in the journal The Lancet last week showed that the virus can infect the inner cell layer of organs and of blood vessels, called the endothelium. This, in theory, could interfere with the clotting process.

According to Brosnahan, while thinners like Heparin are effective in some patients, they don't work for all patients because the clots are at times too small.

"There are too many microclots," she said. "We're not sure exactly where they are."

Autopsies have in fact shown some people's lungs filled with hundreds of microclots.

The arrival of a new mystery however helps solve a slightly older one.

Cecilia Mirant-Borde, an intensive care doctor at a military veterans hospital in Manhattan, told AFP that lungs filled with microclots helped explain why ventilators work poorly for patients with low blood oxygen.

Earlier in the pandemic doctors were treating these patients according to protocols developed for acute respiratory distress syndrome, sometimes known as "wet lung."

But in some cases, "it's not because the lungs are occupied with water" -- rather, it's that the microclotting is blocking circulation and blood is leaving the lungs with less oxygen than it should.

It has just been a little under five months since the virus emerged in Wuhan, China, and researchers are learning more about its impact every day.

"While we react surprised, we shouldn't be as surprised as we were. Viruses tend to do weird things," said Brosnahan.

While the dizzying array of complications may seem daunting, "it's possible there'll be one or a couple of unifying mechanisms that describe how this damage happens," she said.

"It's possible it's all the same thing, and that there'll be the same solution."

Six months since the new coronavirus outbreak, the pandemic is still far from over, the World Health Organization said Monday, warning that "the worst is yet to come".

Reaching the half-year milestone just as the death toll surpassed 500,000 and the number of confirmed infections topped 10 million, the WHO said it was a moment to recommit to the fight to save lives.

"Six months ago, none of us could have imagined how our world -- and our lives -- would be thrown into turmoil by this new virus," WHO chief Tedros Adhanom Ghebreyesus told a virtual briefing.

"We all want this to be over. We all want to get on with our lives. But the hard reality is this is not even close to being over.

"Although many countries have made some progress, globally the pandemic is actually speeding up.

"We're all in this together, and we're all in this for the long haul.

"We will need even greater stores of resilience, patience, humility and generosity in the months ahead.

"We have already lost so much -- but we cannot lose hope."

Tedros also said that the pandemic had brought out the best and worst humanity, citing acts of kindness and solidarity, but also misinformation and the politicisation of the virus.

In an atmosphere of global political division and fractures on a national level, "the worst is yet to come. I'm sorry to say that," he said.

"With this kind of environment and condition, we fear the worst."

Feb 4: Americans on Monday kicked off the first vote of the 2020 presidential race as the midwestern state of Iowa began its caucuses, the closely-watched first step in deciding which Democrat will face incumbent Donald Trump in November's election.

The two frontrunners, left-wing Senator Bernie Sanders and former Vice President Joe Biden face a key test in the sparsely populated state, with a handful of others looking to make their mark to give their campaigns momentum.

The Iowa vote is a critical early look at the viability of the 11 Democratic candidates still in the race - even though just 41 Iowa delegates are up for grabs, a fraction of the 1,991 needed to secure the party nomination in July.

Iowa Democrats filed into nearly 1,700 caucus sites - schools, libraries, churches, mosques and meeting halls with Sanders and Biden in the lead in the state, followed by former South Bend, Indiana mayor Pete Buttigieg and Senator Elizabeth Warren, who is also on the left of the party.

But polling has fluctuated and Iowa's quirky caucus system - where voting is not by secret ballot but by public declaration for a candidate - makes the night hard to predict.

Luke Elzinga, a volunteer for Sanders, appeared early at Lincoln High School in Des Moines which was converted into a caucus location.

"I think he really inspires a lot of young people, a lot of disaffected voters who might not otherwise turn out," Elzinga, 28, told AFP news agency shortly before the caucusing began.

"And so I think he's the best candidate to beat Trump."

Three candidates - Sanders, Warren and Amy Klobuchar - have faced the unprecedented scenario of spending much of the past two weeks tethered to Washington for the impeachment trial of Trump instead of on the campaign trail in Iowa.

Even as candidates sought to make 11th-hour impressions on undecided voters, the senators were obligated to return to Washington for the trial's closing arguments on Monday.

Defeating Trump

In a vote scheduled for Wednesday, Trump is almost certain to be acquitted by the Republican-led upper house on charges of abuse of power and obstruction of Congress.

For Democrats, second-tier hopefuls Klobuchar and tech entrepreneur Andrew Yang look to outpace expectations and seize momentum heading into the next contest in New Hampshire on February 11.

Earlier on Monday Biden - who still holds the lead in national polls - brought pizza to a field office in a strip mall near Des Moines to thank volunteers.

"I'm feeling good about today," he said.

Like many candidates, Biden spent the weekend crisscrossing Iowa in a final push to convince undecided voters he is best placed to accomplish Democrats' number one goal: defeating Trump.

The president has not stood idly by. On Sunday he branded Biden "Sleepy Joe" and described Sanders as "a communist," previewing a likely line of attack were Sanders to win the nomination.

Unlike secret ballot voting, caucus-goers publicly declare their presidential choice by standing together with other supporters of a candidate.

Candidates who reach 15 percent support earn delegates for the nomination race while supporters of candidates who fall short can shift their allegiance to others.

Turnout is critical, and candidates and their representatives will seek to persuade voters on issues including healthcare, taxes and ending Washington corruption.

One key candidate who has opted not to contest in Iowa is billionaire businessman Michael Bloomberg, who entered the race in November but has surged into fourth place in RealClearPolitics' national polling average.

The former New York mayor, who has spent more than $300m on advertising, according to Advertising Analytics, is focused on running a national campaign with particular emphasis on states that vote on "Super Tuesday," on March 3.