Post-COVID Clinics / Long Haulers

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trader32176
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Re: Post-COVID Clinics / Long Haulers

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Long covid: Damage to multiple organs presents in young, low risk patients

11/17/20


https://www.bmj.com/content/371/bmj.m4470


Young, low risk patients with ongoing symptoms of covid-19 had signs of damage to multiple organs four months after initially being infected, a preprint study has suggested.1

Initial data from 201 patients suggest that almost 70% had impairments in one or more organs four months after their initial symptoms of SARS-CoV-2 infection.

The results emerged as the NHS announced plans to establish a network of more than 40 long covid specialist clinics across England this month to help patients with long term symptoms of infection.

The prospective Coverscan study examined the impact of long covid (persistent symptoms three months post infection) across multiple organs in low risk people who are relatively young and had no major underlying health problems. Assessment was done using results from magnetic resonance image scans, blood tests, and online questionnaires.

The research has not yet been peer reviewed and could not establish a causal link between organ impairment and infection. But the authors said the results had “implications not only for [the] burden of long covid but also public health approaches which have assumed low risk in young people with no comorbidities.”

The study enrolled participants at two UK sites in Oxford and London between April and August 2020. Two hundred and one individuals (mean age 44 (standard deviation 11.0) years) completed assessments after SARS-CoV-2 infection a median of 140 days after initial symptoms.

Participants were eligible if they tested positive for SARS-CoV-2 by random polymerase chain reaction swab (n=62), a positive antibody test (n=63), or had typical symptoms and were determined to have covid-19 by two independent clinicians (n=73).

The prevalence of pre-existing conditions was low (obesity: 20%, hypertension: 6%, diabetes: 2%, heart disease: 4%), and less than a fifth (18%) of individuals had been hospitalised with covid-19.

The most commonly reported ongoing symptoms—regardless of hospitalisation status—were fatigue (98%), muscle ache (88%), shortness of breath (87%), and headache (83%). There was evidence of mild organ impairment in the heart (32% of patients), lungs (33%), kidneys (12%), liver (10%), pancreas (17%), and spleen (6%).

Two thirds (66%) of participants had impairment in one or more organ systems and there was evidence of multiorgan impairment in a quarter (25%) of individuals, with varying degrees of overlap across multiple organs.

Multiorgan impairment was significantly associated with risk of prior covid-19 hospitalisation (P<0.05). Measures of inflammation in the kidneys and pancreas, and ectopic fat in the pancreas and liver, were also higher in hospitalised individuals (P<0.05).

The results “signal the need for monitoring and follow-up in at least the medium and longer term, especially for extrapulmonary sequelae” and demonstrate that long covid requires management across clinical specialties, the authors said.

The authors observed that neither symptoms nor blood investigations were predictive of organ impairment.

“Causality of the relationship between organ impairment and infection cannot be deduced, but may be addressed by longitudinal follow-up of individuals with organ impairment,” the authors said.

Other limitations of the study included that diagnosis of covid-19 was by multiple methods, partly due to limited access to laboratory testing during the pandemic.

The research was funded by the UK’s National Consortium of Intelligent Medical Imaging through the Industry Strategy Challenge Fund, Innovate UK, and the European Union’s Horizon 2020 research and innovation programme.
trader32176
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Re: Post-COVID Clinics / Long Haulers

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Troublesome COVID-19 symptoms could last more than 6 weeks

12/8/20


https://www.news-medical.net/news/20201 ... weeks.aspx


Physicians in Geneva have shown that some of the troublesome symptoms of COVID-19 could last more than 6 weeks, even in patients without underlying risk factors.

Since its appearance in early 2020, COVID-19 has been unpredictable for both physicians and affected individuals given the variety and duration of its symptoms. Notably, it appears to have the potential to cause an unusually long-lasting illness, and the term "long COVID" describes the disease in people who continue to report symptoms several weeks following the infection.

To better understand this phenomenon, a team of physicians and epidemiologists from the University of Geneva (UNIGE) the University Hospitals of Geneva (HUG) and the General Health Directorate of the State of Geneva followed nearly 700 people who tested positive for SARS-COV2 but did not require hospitalization. Six weeks after diagnosis, 33% of them still reported suffering from fatigue, loss of smell or taste, shortness of breath or cough. These results, which can be seen in the Annals of Internal Medicine, call for better communication, particularly with patients and with the physicians who follow them, and for ongoing messages to the general public, reminding them that SARS-CoV-2 infection is not trivial.

Even if in just a few months medical and scientific knowledge about SARS-COV2 has considerably improved, several aspects of this disease remain unknown. In particular, many people are wondering about the evolution and long-term consequences of this novel virus.

" As soon as the pandemic arrived in our country, we were confronted with these questions. In March, the COVICARE program was set up to offer remote monitoring to patients who can be followed on an outpatient basis, when this follow-up could not be carried out by the primary care physician. This has enabled us to better understand the evolution of the disease in people who generally suffer neither from specific risk factors nor from a serious form of the disease."

- Professor Idris Guessous, physician epidemiologist at the Department of Community Health and Medicine of the UNIGE Faculty of Medicine and Chief Physician of the Division of Primary Care at HUG

Some very tired patients


A total of 669 people were followed (mean age 43 years, 60% female, 25% of healthcare professionals and 69% without underlying risk factors that could be related to complications from COVID-19). At 6 weeks from diagnosis, nearly a third of participants still had one or more symptoms related to COVID-19, mainly fatigue (14%), shortness of breath (9%) and loss of taste or smell (12%). In addition, 6% reported a persistent cough and 3% reported headaches. Dr. Mayssam Nehme, Senior Resident in Professor Guessous's team and first author of this work, also explains how these patients felt: "In addition to the physical distress of their symptoms, many were very worried: how much longer would it last? Were some after-effects irrecoverable? Even without a clear medical answer, in the current state of knowledge, it is important to accompany concerned patients and to listen to them," she adds. With this in mind, the HUG has set up a specific consultation for long COVID patients in order to improve their care and guide them through the health system.

Better understanding for better information


The persistence of symptoms must be recognized in order to legitimize the concerns of patients faced with a new and unknown disease, and to optimize their management. "This requires an information campaign towards the general public and healthcare workers, but also, more broadly, among employers, insurance companies and society in general. Everyone should realize that previously healthy people can also be affected by COVID-19, weeks or even months following the infection. Prevention is therefore of the utmost importance," add the authors, who are continuing their studies to understand the long-term evolution of these patients. Indeed, a follow-up of the same cohort 3 months, 7 months and 12 months following the infection is in progress.

Source:

University of Geneva

Journal reference:

Nehme, M., et al. (2020) COVID-19 Symptoms: Longitudinal Evolution and Persistence in Outpatient Settings. Annals of Internal Medicine. doi.org/10.7326/M20-5926.
trader32176
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Re: Post-COVID Clinics / Long Haulers

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Researchers investigate whether tailored online exercise benefits ‘long Covid’ patients

12/11/20


https://www.news-medical.net/news/20201 ... ients.aspx


Researchers at the University of Warwick and University Hospitals Coventry and Warwickshire (UHCW) NHS Trust are to investigate whether a tailored online exercise and support programme would benefit those experiencing long-term symptoms of Covid-19 - what has been dubbed 'long Covid'.

The results of the Rehabilitation Exercise and psycholoGical support After covid-19 InfectioN (REGAIN) trial will help to guide recommendations for treatment of people with long Covid, for whom there is currently only limited advice and guidelines available.

Funding of £1.19 million for the trial from the National Institute for Health Research is announced today (11 December). This study is one of a number of COVID-19 studies that have been funded by the National Institute for Health Research (NIHR) as part of its Recovery and Learning call, totaling £5.5m in funding, to help better manage current and future waves of the COVID-19 pandemic and investigate its long-term impacts on the health and care system beyond the acute phase.

Little is currently known about the long-term effects of Covid-19. While most people will gradually get better on their own, others will have persistent mental and physical health problems. When the trial was first proposed there was no term for these long-term effects. This post-COVID syndrome has since been informally dubbed 'long Covid', but there is no specific definition for the term.

The REGAIN trial will focus on people who have had a hospital admission for Covid-19 and who are still suffering with any physical or mental health problems more than three months after their discharge from hospital. They are specifically looking for those people who are still experiencing the following symptoms:

Breathlessness
Low fitness/energy
Fatigue
Sleeping problems
Worry or anxiety
Low mood or frustration
Shoulder or back pain
Memory or concentration problems
A persistent cough

REGAIN is a randomized control trial aiming to recruit 535 people. Participants will be randomized to one of two groups: one group will take part in an eight-week program of online group exercise and support sessions, the other will receive a single on-line session of exercise advice and support.

Due to social distancing restrictions, the trial will be conducted entirely online. For those undertaking the exercise and support program, they will have a live video exercise session once a week with an instructor in groups of up to ten. These sessions will be tailored to suit the abilities and fitness levels of those taking part, using a range of different cardiovascular and muscle strength exercises without equipment. They will also take part in an online 45-minute group support session once a week with their exercise group and specialist.

In addition, participants will be encouraged to undertake two optional on-demand sessions per week, ranging from activities as gentle as breathing exercises and Pilates up to more moderate intensity sessions. Rather than aiming to challenge themselves, participants will be directed to activities that they are comfortable with.

Participants will be surveyed when they begin the trial on aspects of their quality of life, anxiety, depression, breathlessness, cognitive function, physical activity, PTSD, as well as details of their personal and work lives. Follow up surveys at 3 months, 6 months and 12 months after beginning the program will allow the researchers to determine whether there is any difference between the 8-week program or single session of advice and support, in how people feel. There will also be an economic analysis of the program to determine whether the treatments are cost-effective.

Dr Gordon McGregor, a Clinical Exercise Physiologist, is Chief Investigator for the REGAIN trial at Warwick Clinical Trials Unit and UHCW NHS Trust.


" At a critical time in the treatment and recovery of patients with Covid-19 we are proud to be at the forefront of research into providing world class long term care."

= Dr Gordon McGregor, Clinical Exercise Physiologist, Chief Investigator for the REGAIN trial, Warwick Clinical Trials Unit, UHCW NHS Trust

"The main aim of the REGAIN trial is to find out if we can improve people's quality of life with a single session of advice and support or an 8-week exercise and support program. It's not just about improving fitness. It's about improving any aspect of people's lives; whatever they feel is important to them, or getting back what they may have lost after having Covid-19. For some people, that might be physical, for others it might be mental, or it could be a bit of both.

"The sessions are very much geared towards encouraging people to engage in all kinds of activities. Our exercise specialists are very skilled and experienced and will be able to deliver sessions for a wide range of abilities. It's very likely that we will have participants with very different capabilities, so we will be carefully tailoring the exercise and the specialist will coach them accordingly."

While there is limited research into the long-term effects of Covid-19, there is some previous evidence from similar diseases such as SARS that patients can benefit from structured exercise rehabilitation. Other conditions where patients experience breathlessness can also benefit from exercise rehabilitation.

Little previous research has examined an exercise program delivered entirely online, where participants are also remotely supervised. While the format is similar to popular exercise programs that many gyms, leisure center and fitness trainers have been live-streaming since the start of the pandemic, the REGAIN program will be specifically tailored to the requirements of those with the symptoms of long Covid with direct supervision by exercise specialists. General advice on exercising when recovering from Covid-19 at https://www.yourcovidrecovery.nhs.uk/

Dr McGregor added: "There's some evidence to suggest exercise rehabilitation may help this group of patients, but we need to properly test this as it's still uncharted territory. With so many unknowns about Covid-19, it's important that we robustly investigate potential treatments so we can know with confidence whether they have a benefit for patients, or not.

"'Long Covid' has had a huge impact on society in the UK and that's becoming more apparent. We don't really know how many people are suffering with this but it is likely to be in the thousands and there is no formal, structured support in place at the moment. We hope that a program of exercise and support will help people improve their quality of life, but it may not. We need to test this first to see if it is beneficial."

Lord Bethell, Minister for Innovation, said:

"COVID-19 is an awful disease and we are determined to beat it. That's why I am so excited that NIHR is investing a further £5.5m to unlock the mysteries of this dreadful contagion."

Source:


University of Warwick
trader32176
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Re: Post-COVID Clinics / Long Haulers

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The many strange long-term symptoms of Covid-19, explained

Long Covid “is a phenomenon that is really quite real and quite extensive,” Anthony Fauci said earlier this month.

12/15/20

https://www.vox.com/22166236/long-term- ... rt-fatigue


When Heather-Elizabeth Brown spiked a fever in April in Detroit, the only reason she was able to get a coronavirus test was because she was volunteering as a police chaplain and was therefore considered an essential worker. Her results came back negative, and she was relieved. But then, she says, “I just got sicker and sicker.”

After being turned away from overcrowded ERs twice, Brown was eventually admitted on her third try. She finally tested positive, and by that point, she was severely ill. She was put on a ventilator and spent the next 31 days in a medically induced coma.

Before Covid-19, Brown was a healthy, active Black woman in her 30s. “But when I came off the ventilator, they had to coach me how to breathe.” The smallest pleasures — like eating a sliver of ice after her feeding tube was removed — became something to treasure.

Six months later, Brown is still very ill. She has been hospitalized for blood clots and has lingering heart problems, nerve pain, and extreme fatigue. “Even making breakfast is now out of the question,” she says. Most troublingly, she’s still experiencing severe brain fog, which makes it hard for her to return to work.

Brown is just one of many previously healthy people whose life has been derailed after a Covid-19 infection. While early research on Covid-19 focused on its respiratory symptoms, we now know its impacts — both direct and indirect — can be much more extensive and relentless.

On December 3, the National Institutes of Health held a two-day seminar on what has come to be called long Covid, or long-haul Covid — cases of lingering symptoms that can last for weeks or months after an initial infection. The Centers for Disease Control and Prevention (CDC) recently created a list of some of the persistent symptoms patients are experiencing, which include chest pain, brain fog, fatigue, and hair loss — with patients reporting many others as well.

Because these patients don’t all have the same symptoms, they will need different kinds of post-Covid care. And the NIH made clear that there are still many more questions than answers — including whose symptoms might linger for months, and how to treat them.

Almost a year into the pandemic, there have not yet been thorough, large-scale studies to determine the true prevalence of long Covid. But preliminary research suggests that somewhere between 10 percent and 88 percent of Covid-19 patients will experience at least one symptom for many weeks or months. Some of these can be life-altering; one study found that 50 percent of non-ICU patients reported a significant change to their cognitive functioning.

Doctors at the seminar said they were surprised by the scope of long Covid and its potential socioeconomic impacts. “This is a phenomenon that is really quite real and quite extensive,” said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, who spoke at the event.

Even if the prevalence ends up being on the lower end of the 10 to 88 percent range, the sheer volume of people getting sick means there are already millions of Americans who have, and will soon have, long Covid. Despite the staggering numbers, “we’re a hidden group of people,” Brown says. This can make getting treatment from skeptical physicians challenging. Long-Covid patient Anthony Campbell, for example, had a doctor refuse to sign a work disability form unless he was treated for anxiety rather than for his persistent symptoms.

Interviews with dozens of patients like Brown and Campbell provide a closer look at long Covid’s devastating impact — and the clues the latest research offers into what might be causing all these symptoms, including erectile dysfunction, hormonal imbalances, hallucinations, and dementia-like effects that can severely impact daily life.

Menstrual changes and erectile dysfunction

One of the most surprising new findings about long Covid’s effects is that both women and men have reported sexual and reproductive system symptoms following a Covid-19 infection.

The Patient-Led Research Group, a team of researchers who are also Covid-19 patients, conducted a survey of 640 long-Covid patients and recorded more than 200 total symptoms, including testicular pain, urinary problems, and menstrual changes.

“A lot of people with long Covid notice that their symptoms get worse just before their period happens,” when estrogen levels are lowest, says Louise Newson, a general practitioner and menopause specialist. She says an additional sign hormones may be involved are long-Covid symptoms like “brain fog, fatigue, dizziness, joint pain — these are also symptoms of menopause.”

Newson has 842 patient responses so far to a pilot survey, and she says the results “confirm my thoughts that long Covid is likely to be related to low hormone levels (estrogen and testosterone), which so far have been neglected with research.” Estrogen plays a key role in women’s health, and having abnormally low levels can lead to infertility, osteoporosis, lack of sex drive, and depression.

Newson says that anecdotally, patients with long Covid from her menopause clinic have improved with the right dose and type of hormone replacement therapy. “They all had low oestradiol and low testosterone results before treatment,” she says.

Long Covid can also significantly impact male reproductive systems and testosterone levels. “Absolutely, reproductive systems have been overlooked during the pandemic,” says Geoff Hackett, a professor of sexual medicine at Aston University in Birmingham, UK. He explains that during acute illness, the testes can be attacked by the virus directly.

“The testes are one of the highest sites of ACE2 expression,” writes the British Society of Sexual Medicine (BSSM) in its position paper on Covid-19. (This ACE2 enzyme is the primary way SARS-CoV-2 enters cells.) The BSSM adds that SARS-CoV-2 also damages cells on the inner surface of blood vessels called endothelial cells, a condition which is “frequently present in men with erectile dysfunction and testosterone deficiency.”

Several recent studies have pointed to testosterone, which in men is produced in the testes, as playing an important role in coronavirus patients: A study in Germany found that the majority of men admitted to the hospital with Covid-19 had low testosterone levels and high inflammatory markers. (This study was unable to determine if these low testosterone levels predated their coronavirus infection.)

A similar study in Italy found low testosterone levels predicted worse outcomes in hospitalized patients. A third study, in Wuhan, China, also found low testosterone levels in coronavirus patients, which they said required “more attention to gonadal function evaluation among patients recovered from SARS-CoV-2 infection, especially the reproductive-aged men.”

Hypogonadism, when sex organs don’t produce sufficient hormones, affects both the production of testosterone and sperm. Another recent paper, published in The Lancet, found the production of sperm was impaired in Covid-19 patients, which they said might be explained by an immune response in the testes. In some patients, they also found auto-immune orchitis, or inflammation of the testis with specific anti-sperm antibodies. “There does seem to be some evidence for relative infertility afterward,” Hackett says, though he cautions it’s too early to say if it would be permanent.

In general, “attacking the cells of the testes will have an adverse effect on erections,” Hackett says. Even beyond a direct effect, endothelial disorder and inflammation may affect the arteries in the penis, making erections more difficult. “Erectile dysfunction is going to be highly prevalent, particularly if you look at the groups at high risk of Covid-19,” Hackett says. “Seventy-five percent of diabetics have erectile dysfunction anyway.” Based on anecdotal evidence, the next Patient-Led Research Group survey will include questions on shrinkage, erectile dysfunction, and testicular pain.

Erectile function is a sign of overall health, and urologist Ryan Berglund of the Cleveland Clinic recently made a statement that for young and healthy people who develop this problem after having Covid-19, “this can be a sign of something more serious going on.”

The BSSM is concerned that these reproductive effects may have lasting implications, warning that low testosterone levels in men “are associated with increased mortality,” and that those “who may have survived the current pandemic ... may be at considerable risk from second and third wave infection, or future viral pandemics.”

Beyond Covid-19, research suggested a connection between viral infections of the central nervous system and pituitary dysfunction. A significant number of viruses have previously been associated with the onset of Type 1 diabetes, and it appears there may have been an increase in diabetes diagnoses during the pandemic.

Recognizing these impacts may help doctors find effective treatments; Hackett says a common erectile dysfunction treatment, Tadalafil, improves all markers of endothelial disease. “If it didn’t give men an erection, it would be treated as a serious cardiovascular drug,” he says. He notes that mountain climbers often take Tadalafil before big climbs to avoid altitude sickness, as it lowers pulmonary artery pressure and improves the endothelium of arteries — effects that might significantly help Covid-19 patients.

But Hackett says even as the UK National Health System rolls out long-Covid clinics, he’s been disappointed to see these symptoms overlooked. “Their strategies include things like eating healthy, hydrating, and mindfulness,” he says. “How is this going to go down with seriously ill people? All they’re offering is platitudes.”

Pulmonary problems

Long-Covid symptoms can be very diverse and are often not limited to one part of the body, making them hard to understand. One of the reasons long-Covid patients are struggling to do high-quality research through their illnesses, says Hannah Davis, a long-Covid patient and a member of the Patient-Led Research Group who helped design the survey, “is that we need answers.”

She’s tired of being told that no one knows how to help treat her symptoms, or how many others might be experiencing something similar. “We’re going to get answers faster than anyone else because we’re living this experience,” Davis says. One recent study of 201 long-Covid patients in the UK found that even in a young, low-risk population, 66 percent had impairments to one or more organs four months after their initial symptoms.

Being sick enough to be ventilated, like Brown was, often comes with its own complications; one study found that 81 percent of ventilated patients develop delirium, and one in five patients with acute respiratory distress syndrome — a common lung condition in ICU patients — experience long-term cognitive impairment. But even coronavirus patients with milder symptoms or no initial symptoms at all can develop long Covid.

Long-term lung problems are perhaps the most straightforward long-Covid symptom, as the virus can directly inflame the lung tissue, filling air sacs with fluid and making them less elastic and harder to expand as you breathe. Even at the beginning of the pandemic, it was known that previous coronavirus epidemics had caused lung scarring in some patients. One 15-year study of 71 SARS patients from a 2003 outbreak found a third had reduced lung capacity; a third of MERS survivors in a 2017 study also had long-term lung damage.

New research suggests that around half of asymptomatic Covid-19 infections can also cause damage to the lungs.

In early November, a study published in The Lancet on 41 autopsies of Covid-19 patients offered a possible reason: It found that the virus caused major structural changes in the lungs, including extensive blood clotting, scarring of respiratory tissue, and the fusion of many smaller cells into larger cells. (Based on the fact that these were autopsies, these were all severe cases, limiting the implications that can be drawn.)

The authors suggest that, unlike other types of pneumonia, these structural changes may stem “from the persistence of infected and dysfunctional cells in the lungs” — which may help explain why some of these symptoms linger. Though we still don’t know the exact mechanics, continuing lung symptoms are perhaps the most common of them.

It’s still unclear how long these symptoms might last; some long-Covid patients have reported improvements in their breathing, although much slower than they would have liked. One study of mildly ill patients in China found that 70 percent had abnormal lung scans three months after their initial illness.

Blood clotting and other cardiovascular issues


Early in the pandemic, doctors noticed that many Covid-19 patients were having serious blood clotting problems, with reports of clogging dialysis machines and clots in the arms and legs called deep vein thromboses. But some patients, like Brown — who went back to the hospital with blood clots three months after her initial symptoms — are also experiencing clots weeks or months later.

Large blood clots can cause tissue damage, requiring amputations. Smaller clots can restrict blood flow in the lungs, impairing normal oxygen exchange. If clots travel to the brain or heart, they can also cause strokes or heart attacks, as 23-year-old Riley Behrens recently suffered after a coronavirus infection. “Before this, I was a healthy young athlete with no major medical conditions,” she tweeted after a Covid-related stroke. “Now, I’m being told I will likely never return to contact sports because of lasting lung and brain damage. The risk for a second stroke will always be there.”

It’s hard to know how common clotting problems are in Covid-19 patients, but reports of conditions linked to clotting have certainly increased: A study published in Annals of Vascular Surgery recently found a twofold increase during the pandemic in major amputations, which are sometimes required after a clot is found. And multiple researchers have reported a spike in the number of stroke patients, including young people like Behrens who would not normally be at high risk for strokes, as well as in patients who didn’t know they’d had the coronavirus but later tested positive for antibodies.

A study published in Science in mid-November may have identified one of the reasons for this abnormal clotting: In half of 172 hospitalized coronavirus patients, the scientists found autoantibodies — proteins that are supposed to defend against invaders that instead start to attack the body’s own cells. When these autoantibodies were injected into lab mice, the animals developed blood clots. The researchers suggest that these proteins could be sparking a dangerous loop between clotting and hyperinflammation. A December preprint also found a significant percentage of Covid-19 patients developed autoantibodies, and the more severe their symptoms, the more autoantibodies they had.

But Covid-19’s cardiovascular impacts don’t end with coagulation. Half of 1,216 Covid-19 patients in one study also had heart abnormalities, and one in seven had severe cardiac issues.

“People can present without any lung symptoms, and have just heart or brain involvement,” says Eric Topol, a professor of molecular medicine and director of the Scripps Research Translational Institute. These can include cardiomyopathy, a disease of the heart muscle that makes it harder for your heart to pump; myocarditis, or inflammation of the heart muscle; and pericarditis, inflammation of the pericardium, the two thin layers of tissue that surround the heart and help it function. One study on 54 college athletes who’d had mild Covid-19 cases found that a third had pericarditis, even though about the same number had been asymptomatic.

Many long-Covid patients are also experiencing persistent heart concerns months after their initial illness. Kate Meredith of Beverly, Massachusetts, for example, first got sick in March. Now, she has tachycardia, or an abnormally elevated heart rate. “If I get up to do the dishes, it jumps to 140 [beats per minute],” she says.

Leticia Soares and Israel Slick, of Ontario, both also got Covid-19 in April. They each independently reported heart palpitations and tachycardia to the same doctor, who speculated Slick’s condition might be related to his Covid-19 infection, while Soares, who is Latina, was told to seek counseling. (Many Black and brown long-Covid patients say they’ve experienced gaslighting and medical racism when they try to seek treatment.)

Cardiovascular symptoms may arise from the coronavirus directly impacting the endothelium. These cells control vascular functions, including enzymes that direct blood clotting. The endothelium is also important for proper immune function, and its imbalance could help explain the cytokine storms seen in many patients with severe Covid-19 cases. “There’s no shortage of ways by which this virus can hurt the heart,” Topol concludes.

Immune system

Damaged endothelial cells can also stimulate mast cells, a type of blood cell that’s part of the immune system. Their job is to defend against foreign bodies by releasing chemicals like histamines. Activated mast cells were recently found in autopsies of Covid-19 patients and are linked to clots and pulmonary edemas.

Some long-Covid patients are reporting symptoms and inflammation similar to mast cell activation syndrome (MCAS), a chronic, multisystem condition that causes allergic responses, GI problems, and neurological issues.

Frances Simpson, a psychology lecturer at Coventry University in the UK, says she and her 5- and 9-year old were infected with Covid-19 in March and have had long-Covid symptoms since, including new allergic reactions. “When you read about possible mast cell activation syndrome,” she says, “we can tick all of the symptoms off between us” — things like headaches, rashes, and extreme fatigue. Moreover, some of the drugs that have been shown to help with severe Covid-19 cases, like famotidine and aspirin, inhibit mast cell activation.

Immunology is very complicated, but it also appears that T cells, an important component of the immune system, may also play a role in long Covid, as they do in other inflammatory and autoimmune conditions.

The CDC is now calling a particular set of inflammatory symptoms in multiple organs after an initial infection multisystem inflammatory syndrome in adults, or MIS-A — after a similar post-viral condition that was first reported in children, called MIS-C. Both children’s and adults’ symptoms in these cases overlap with MCAS, with problems like chest tightness, abdominal pain, rash, and inflammation, strengthening the argument that mast cells may be involved.

Nervous system

New research is also homing in on the many, sometimes severe, neurological symptoms that long-Covid patients have reported. One peer-reviewed paper found that a surprising 40 percent of patients with Covid-19 showed some kind of neurologic manifestation, and more than 30 percent had impaired cognition. These symptoms — including brain fog, extreme fatigue, difficulty with short-term memory, intense headaches, and tingling or numbness — are common in long-Covid patients.

Some long-Covid patients develop dysautonomia, a disorder of the autonomic nervous system that can be triggered by viral infections. The autonomic nervous system controls involuntary functions in our bodies such as heart rate and digestion. When it is damaged by an infection, these functions can go out of whack.

Davis, for example, has been diagnosed with a form of dysautonomia called postural orthostatic tachycardia syndrome (POTS), where blood vessels don’t respond to chemical signals efficiently. When she stands, blood pools in her lower extremities, making her feel faint and exacerbating her brain fog. The nervous system continues to release hormones to tighten her non-responding blood vessels, increasing her heart rate and making her shake.

There’s also increasing evidence that SARS-CoV-2 can actually cross the blood-brain barrier, a layer of specialized cells that protect the brain, and harm the nervous system directly. In April, researchers found that a 40-year-old woman in Los Angeles with headaches, seizures, and hallucinations had RNA from the coronavirus in her cerebrospinal fluid.

One study recently found an explanation for how that may have occurred: The virus can directly enter and damage cells in the brain’s choroid plexus, which has cells with ACE2 receptors. “This can lead to leakage across this important barrier, that normally prevents entry of pathogens into the cerebrospinal fluid and the brain,” says study co-author Madeline Lancaster, a biologist and the group leader at the MRC Laboratory of Molecular Biology in Cambridge, UK.

The brain is normally protected from your blood, so it’s a big problem to have that barrier penetrated. During viral infections, many immune cells are activated and circulating through the body. Lancaster explains that even if the virus itself doesn’t get past the barrier, having “those inflammatory cytokines leak into the brain, where they really do not belong, can have serious repercussions.” One example is encephalitis, or inflammation of the brain itself, as found in this study of 12 Covid-19 patients in the UK.

Lancaster says viruses may penetrate the blood-brain barrier more often than previously thought. “The Covid crisis has shined a light on overlooked post-viral chronic fatigue syndrome (CFS),” she says. “There’s a lot of indication that inflammation of the brain can lead to those symptoms. There’s a huge overlap between those conditions and long Covid.”

But though post-viral symptoms may linger for months or even years, it can be hard for doctors to find clues in neurological tests. While encephalitis can be seen on MRIs, damage to the cerebrospinal fluid might not be visible. (Doctors can, however, look for elevated biomarkers like cytokines.) “Unfortunately, that’s one of the reasons a lot of patients with CFS have been told it’s all in their heads. We’ve let those patients down,” says Lancaster.

Neuro-inflammation can cause emotional and behavioral changes. Sammie, who asked that her last name not be used to protect her privacy, says she and her daughter were both infected in the UK with Covid-19 in March. Since then, her 15-year-old daughter has had headaches, dysautonomia, fatigue, and extreme anxiety and emotional outbursts. “She’s not a crier. She’s normally very stoic,” Sammie says, but over the last few months, “she’s had irrational outbursts, just sobbing her heart out.”

One study of 62,354 patients recently published in The Lancet Psychiatry journal found that one in five were diagnosed with a mental health disorder within three months of testing positive for the coronavirus. “But what’s the chicken and what’s the egg?” Lancaster asks. “It could be that there are people with leakier brains to start with, who when they get Covid-19 are more likely to have viral entry into their brain.”

Neuro-inflammation might also help explain some of the weirder long-Covid symptoms reported by parents of children who have had Covid-19, like something called Alice in Wonderland syndrome, an alteration of visual perception where objects or body part sizes are perceived incorrectly. Simpson says her son’s vision regularly goes blurry, and he describes people’s heads “going small.”

Gretchen Drown of Portland, Maine, also says that her 15-year old son, who got Covid-19 in March, describes “things looking weird,” and that during these episodes, his pupils get strangely dilated. Drown’s son also now has headaches and extreme fatigue, which worsen after he overexerts himself, making it hard to keep up with school.

Damaging the blood-brain barrier also hurts its ability to make cerebrospinal fluid, which is important for providing nutrients to the brain and removing its normal waste. Lancaster calls the cerebrospinal fluid the plumbing system of the brain. “Imagine your house with all your toilets clogged — a similar thing can happen in the brain,” she says.

Much of this fluid cycling normally occurs during sleep, so Lancaster suggests that Alice in Wonderland syndrome — and possibly other common neurological symptoms in long Covid, like extreme fatigue and insomnia — might be related to the virus compromising the body’s ability to generate and manage this fluid.

Children and long Covid

As the pandemic began, it appeared most children had mild cases of Covid-19. But while clinicians have not been tracking long Covid in children, it’s clear from the many parents Vox interviewed that children of any age can and do experience persistent symptoms that can completely alter their ability to function.

That no one seems to be paying attention to pediatric long-Covid cases is a source of extreme frustration. Multiple parents reported that during their efforts to get their children care, medical providers accused them of Munchausen syndrome, a psychological disorder where someone pretends to be ill.

Sammie says when a nurse suggested it to her, “I literally think if I hadn’t had a mask on, my jaw would have fallen off. I felt so broken — it makes me feel emotional talking about it now.” Since then, she’s complained to the clinic and actually gotten a letter of apology. But her experience demonstrates the hurdles parents face in getting their children the care they need. “I think there are a lot more children who are ill, and who no one is connecting the dots for,” Sammie says.

While it’s hard to quantify something no one is tracking, the American Academy of Pediatrics suggests about 11 percent of US Covid-19 cases are children, with over 1,460,905 children contracting the virus as of December 3. It’s easier to count more acute Covid-19 consequences, like MIS-C: In one study of kids under 18 with MIS-C, 14.8 percent exhibited new neurological symptoms like headaches, muscle weakness, and reduced reflexes. The youngest child with persistent symptoms Vox found was 18 months; the oldest was 15.

While some of the symptoms parents have reported in children are similar to adult long-Covid cases — headaches, extreme fatigue, difficulty concentrating or forming new memories, anxiety, depression, tachycardia, dysautonomia, lingering or recurrent fevers — others differ. Some parents in the long-Covid kids online group Sammie formed, for example, have been reporting frequent nosebleeds.

Some of the parents, like Simpson, are themselves suffering from long Covid. “In many families who have kids with long Covid, there’s a mother or father who has it as well. People should be tripping over themselves to research if this is genetic,” she says.

But in the meantime, for parents like Sammie, Simpson, Meredith, and Drown, there are few resources to help their children recover. Though it hasn’t been easy, Sammie hasn’t given up trying to get her daughter into more specialized care. “If I don’t advocate for my child, who the hell is going to do it?” she asks.

Parents worry about how their children’s lives might be impacted by the long-term effects of this disease. For adult patients, too, the repercussions are potentially huge.

One doctor, whose family asked that her name be withheld for privacy reasons, first got sick this spring. She eventually despaired of finding treatment for her long-Covid symptoms. She recently drove to New York — because she wanted to be near the best researchers she knew of — before ending her life. She donated her body to science.

For those who survive, like Brown, the questions are pervasive. “How will this affect me when I want to have a baby?” Brown asks. “What is next? We have no idea. No one can tell me anything specific.” She’s frustrated that friends her age still assume that if they get infected, they’ll recover.

“You might be okay, but you might not,” Brown says. She says she’s angry about how the pandemic has been measured in deaths rather than in lives disrupted. “The disparities are shocking. And more will be lost if we don’t make adjustments.”
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Re: Post-COVID Clinics / Long Haulers

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“I’ve lost who I am”: An Anchorage teacher’s coronavirus infection affected her brain. Now she’s having to relearn basic living.

12/27/20


https://www.adn.com/alaska-news/anchora ... ic-living/


Life wasn’t always like this for Libby Pederson.

She used to know how to dress herself in the morning without notes. Cooking dinner did not confound her.

That changed in November, when the 44-year-old got sick with the coronavirus and developed mysterious neurological symptoms that landed her in the hospital. Ever since, Pederson has been struggling to heal from what doctors say can be a little-known, little-understood consequence of the virus: persistent and debilitating brain and cognitive problems.

On the worst days, the days when she sits on her couch or stays in bed, Pederson wonders if she’ll return to being the busy and capable single mom and special education teacher at an Anchorage elementary school she was just two months ago.

“I feel like I’ve lost who I am,” she said.

Virus and the brain

The way coronavirus wreaks havoc on some patients’ respiratory systems has been well documented. But scientists are just beginning to understand how the coronavirus can affect the brain.

Researchers around the world have been compiling documentation of COVID-19 patients with neurological symptoms ranging from psychosis to memory loss, according to an article published in the journal Nature in September. The people experiencing neurological damage often aren’t otherwise very sick. And they aren’t always older, either.


“We’ve seen this group of younger people without conventional risk factors who are having strokes, and patients having acute changes in mental status that are not otherwise explained,” a UK neurologist said in the Nature article.

It isn’t clear whether coronavirus actually has the ability to enter the brain, or whether a haywire immune response to the virus causes inflammation, according to Nature. It’s also not known exactly how many people in Alaska have experienced neurological symptoms like Pederson.

“Complications of COVID-19 infection are not reportable to the Alaska Department of Health and Social Services, so we do not know how many neurological complications have occurred in Alaska,” said Joseph McLaughlin, chief of the Alaska Section of Epidemiology.


“I was just wanting to die”

Pederson’s coronavirus experience began unremarkably: On Nov. 13, her daughter held up a scented candle for her to sniff and she smelled nothing. The next day her ability to taste vanished. Pederson hurried to get a COVID-19 test.

By the time she got the positive results back, her head was throbbing with a level of pain she’d never experienced before, even as a longtime migraine sufferer. Headaches are among less common but still recognized symptoms of the coronavirus.

Pederson says she spent days “curled up in the fetal position” in her darkened bedroom. Her 20-year-old daughter took care of things around the house, she thinks.

“It was just wanting to die in my room,” she said. “I really honestly don’t know what happened that week in the house.”

On Nov. 18, the pain drove her to the emergency room. The acute pain dissipated with time, but her thinking and speech remained murky -- like driving in the dark without headlights.


By early December, “things just weren’t making sense,” she said. She would turn on gas burners and wander away. She began to stutter. Her children found her dressed in snow gear, standing in the pantry. She couldn’t explain what she was doing there.

When Pederson called her primary doctor for help on Dec. 2, her speech was so broken by stuttering she was told to hang up and head to the emergency room, she said.

That’s where she encountered Dr. Ben Westley, an Anchorage infectious disease specialist.

Westley said he was initially concerned that Pederson, because of her neurological symptoms, had viral encephalitis -- a very serious but straightforward diagnosis. Tests revealed she did not. A sensitive MRI of Pederson’s brain did find inflammation, said Westley, who was authorized by Pederson to discuss her medical treatment.

The symptoms she continues to experience -- persistent, debilitating trouble with concentration, memory, attention, speech and fatigue -- fall into a category of COVID-19 damage that’s poorly understood.

“It seems pretty clear to me now that she has some form of other lingering symptoms related to COVID-19 that we really don’t understand very well,” he said.


What Pederson is experiencing is distressing, but he’s confident that she will continue to recover, Westley said.

“The whole thing is scary,” he said. “When you get it and you feel terrible and you just don’t feel better -- that’s stressful, hard thing for anybody.”

Getting back to normal

Five weeks after her COVID-19 diagnosis, Pederson’s days are filled with therapy appointments: occupational, physical and speech.


At a recent physical therapy appointment, she practiced walking on a treadmill, working on her balance. At occupational therapy, she studied a sample electric bill, trying to answer questions like “What is the total amount of your bills?”

As an elementary school special education teacher, she finds herself applying techniques she uses with her young students, such as teaching them to break complex tasks down into smaller, more manageable chunks.

She leaves herself notes about the steps she needs to take to get dressed. Making dinner requires a detailed plan.

“I have to constantly think through the whole meal: Turn the burner off. Wash the dishes. Things that were common sense before,” she said.


There’s no real long-term prognosis because what happened to her is so rare. Working with young special education students and their families has helped her both to see the work ahead, but also to have hope.

Some people think she’s on vacation, or don’t believe she’s sick because she physically looks OK. COVID-19 affects every person differently, she said, and “it’s just luck of the draw, how it affected me so bad.”

“I’m not enjoying this. I’m not having fun,” she said. “I feel like I’ve gone to hell and I’m trying to dig my way out.”
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Re: Post-COVID Clinics / Long Haulers

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What Long Flu Sufferers of the 1918-1919 Pandemic Can Tell Us About Long COVID Today

12/31/20

https://time.com/5915616/long-flu-1918-pandemic/


“We were leaden-footed for weeks, to the point where each step meant a determined effort,” Miss Goring recalled. “It also was very difficult to remember any simple thing, even for five minutes.”

Miss Goring was describing the period of her convalescence after the 1918 flu pandemic, which she lived through in her native South Africa. Her memories form part of a collection published by South African historian Howard Phillips on the centenary of that disaster. It’s not the only one. Another collection published around the same time by New Zealand historian Geoffrey Rice is also littered with references to long-term symptoms of that flu—from “loss of muscular energy” to “nervous complications.” Some convalescents, recalled a Dr. Jamieson who worked at a hospital in Nelson, on New Zealand’s South Island, “passed through a period of apathy and depression,” or experienced tremor, restlessness, or sleeplessness.

What’s striking about reading these accounts ten months into a new pandemic, is the historical echo they provide of “Long Covid”—that mysterious affliction, or afflictions, that dogs some patients who were infected with the SARS-CoV-2 virus long after any initial symptoms have subsided, and apparently long after the virus has left their body. “Day 163 post Covid,” tweeted one Long Covid sufferer on Sept. 16. “I managed to walk for 20 mins without chest pain while keeping my heart rate below 120.”

One definition of Long Covid is “not recovering [for] several weeks or months following the start of symptoms that were suggestive of Covid, whether you were tested or not.” It’s an unavoidably woolly definition, until research elucidates the various post-COVID-19 syndromes that Long Covid almost certainly comprises. But in the meantime, it does the job of giving sufferers a label, so that they are more likely to be taken seriously and treated—to the extent that medicine has any treatment to offer them—and which recognises that the the virus can cause chronic symptoms that are distinct from the indirect impact on health of the pandemic’s social or economic fallout.

Research into Long Covid is getting underway—belatedly, because some sufferers were never hospitalized, not having experienced the severe respiratory symptoms that can characterise the acute disease—but for now there are more questions about it than answers. Nobody knows what proportion of those infected with the virus experience lingering symptoms, for example, and the bewildering diversity of those symptoms is only now becoming apparent. Profound fatigue is probably the most common, but others include breathlessness, aches, palpitations, rashes, and pins and needles. No tissue or organ seems to be spared—something that comes as no surprise to Debby van Riel.

A virologist at Erasmus University in Rotterdam, the Netherlands, van Riel has spent years studying how flu causes ravages beyond the respiratory tract. She has done so in human cells grown in a dish, in animal models and in patients—trying to capture, from the different angles these offer, the complex cascade of biochemical events that infection with various subtypes of the influenza A virus sets off in the body’s tissues.

Her subjects have included H5N1, the aggressive “bird” flu that—until last year—was considered a leading candidate for the cause of the next pandemic, the H1N1 “swine” flu that caused the most recent flu pandemic, in 2009, and the mother of them all, the virus that caused the so-called “Spanish” flu pandemic of 1918. Earlier this year, van Riel switched her attention to SARS-CoV-2, the virus that causes COVID-19, and saw that—though it behaves differently from flu—it too has effects far beyond the respiratory tract. “At least in its severe form, we should consider COVID-19 a systemic disease,” she says—something that is also true of flu.

Given these similarities, perhaps history can offer us some insights into what to expect from Long Covid. “The incapacity caused by the flu and its after-effects seriously affected the country’s economy for some time,” wrote Phillips in 1990, in Black October, his comprehensive study of the 1918 epidemic in South Africa. In what is now Tanzania, to the north, post-viral syndrome has been blamed for triggering the worst famine in a century—the so-called “famine of corms”—after debilitating lethargy prevented flu survivors from planting when the rains came at the end of 1918. “Agriculture suffered particular disruption because, not only did the epidemic coincide with the planting season in some parts of the country, but in others it came at the time for harvesting and sheep-shearing.” Kathleen Brant, who lived on a farm in Taranaki, New Zealand, told Rice, the historian, about the “legion” problems farmers in her district encountered following the pandemic, even though all patients survived: “The effects of loss of production were felt for a long time.”

A century ago, a greater proportion of the world’s economy was derived from agriculture, but it wasn’t only agriculture that was affected. Phillips recounts the case of a train driver who was involved in an accident in 1919 who later explained that he suffered a blackout while at the controls: “He claimed that this was the after-effect of an attack of Spanish flu the previous year, which had left him ‘never… quite the same since.’” Similar reports came from all over the world. British doctors noted that cases of nervous disorders including “melancholia”—what we would call depression—showed a marked increase in 1919 and 1920. Schoolteachers lamented that it would take their pupils months or years to recover lost ground.

The trouble with discussing the 1918 pandemic is that it overlapped with World War I, making it difficult if not impossible to determine the relative contributions of the two disasters to any subsequent wave of lethargy or mental illness (the pandemic – like today’s – might also have had indirect effects on health, due to the bereavement and social upheaval it brought in its wake). Studies from countries that were neutral in the war, such as Norway, are therefore invaluable, since they afford a glimpse of the impact of the pandemic that is uncomplicated by that of the war. Norwegian demographer Svenn-Erik Mamelund provided such evidence when he combed the records of psychiatric institutions in his country to show that the average number of admissions showed a seven-fold increase in each of the six years following the pandemic, compared to earlier, non-pandemic years.

As precious as such findings are, we need to be cautious in interpreting them. For one thing, there’s no way of demonstrating, retrospectively, a causal link between the flu and the psychiatric illnesses those patients were suffering from. For another, the taboos around mental illness, as strong if not stronger then than now, mean the numbers may not accurately reflect the extent of the phenomenon. Although it’s almost impossible to gauge how common “Long Flu” was in the years after 1918, the working assumption is that it affected only a small proportion of survivors—and this is also the working assumption regarding Long Covid, on the basis of still-sketchy data.

Nevertheless, given the tens of millions who have already been infected by SARS-CoV-2, even a small minority could amount to substantial misery, not to mention social and economic fallout—as it did 100 years ago. That’s reason enough, says psychiatrist Simon Wessely of King’s College London, “to investigate the Long Covid cases with the same rigour and vigour that studies like PHOSP-COVID are investigating the hospitalised cases.”
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Re: Post-COVID Clinics / Long Haulers

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Returning to physical activity after covid-19

1/8/21


https://www.bmj.com/content/372/bmj.m4721

(For informational purposes only - Follow your doctor's advice)

What you need to know

Risk stratify patients before recommending a return to physical activity in people who have had covid-19. Patients with ongoing symptoms or who had severe covid-19 or a history suggestive of cardiac involvement need further clinical assessment

Only return to exercise after at least seven days free of symptoms, and begin with at least two weeks of minimal exertion

Use daily self monitoring to track progress, including when to seek further help


Our professional experience suggests that, after mild suspected covid-19, a proportion of people experience a prolonged recovery, particularly when trying to return to exercise. Moreover, there is increasing recognition of potential long term complications of covid-19, including enduring illness (“post-acute” or “long” covid), cardiopulmonary disease, and psychological sequelae in some people.1234 This article offers a pragmatic approach to help patients safely return to physical activity after symptomatic SARS-CoV-2 infection, focusing on those who have lost fitness or had a prolonged period of inactivity but who do not have an enduring post-acute covid-19 illness. It is based on current evidence and consensus statements, and our own multidisciplinary experience in sports and exercise medicine, rehabilitation, and primary care.

The health benefits of being physically active, from cardiovascular to mental health, are well established.56 Conversely, the harms of physical inactivity mean it is a major risk factor for non-communicable disease worldwide, alongside others such as cigarette smoking or obesity.7 Before the covid-19 pandemic, over a third of people in the UK were not physically active enough for good health.8 There is evidence of a further decline in physical activity since the start of the pandemic for people with chronic conditions such as obesity and hypertension9; conditions associated with worse outcomes from covid-19.10 Brief advice in primary care can help people to take up physical activity, with the associated lifelong positive health impacts, and help those recovering from illness to return to previous levels of physical activity or beyond.11 People may feel unsure of how and when to return to physical activity after covid-19, and whether it is safe. Some may have tried to return to their baseline exercise, and found they were unable to do so, causing concern (“When will I get back to normal”?).

Consensus statements published to date have focused on athletes, discussing how and when to return to sporting activity after covid-19.1213 However, physical activity (any movement of the body where energy is expended) encompasses much more than sport, and is, or should be, part of everyday life. UK public health guidance is for 150 minutes of moderate intensity physical activity (where there is moderate effort, the rate of breathing increases but it is easy to talk) or 75 minutes of vigorous intensity physical activity (the rate of breathing increases and it is difficult to talk) per week, in addition to muscle strengthening activities on at least two days each week.6 Although this can include exercise (planned and structured physical activity done with the intention of improving physical fitness1114) and sport, it can include other activities not traditionally thought of as exercise, such as gardening, carrying heavy shopping bags, or walking. When discussing physical activity with patients, reflect together on their goals and how they might achieve them. Understanding that small modifications count (such as carrying shopping home rather than driving) can help reshape perceptions of what is realistic, practical, and achievable.
What are the risks of physical activity after covid-19?

Current understanding of recovery from covid-19 is limited, but preliminary research has highlighted several key concerns. The first is the potential for cardiac injury, including from viral myocarditis (see box 1). This is important, as taking exercise in the presence of myocarditis is associated with increased morbidity and mortality.15

Myocarditis, covid-19, and exercise

Most data on cardiac injury after covid-19 illness is from patients who were hospitalised and cannot be extrapolated to those with mild illness.15 Indeed, the incidence of myocarditis in those who were asymptomatic or had mild to moderate disease is unknown.13

One study of serum troponin measurements and cardiovascular magnetic resonance imaging in unselected patients after a diagnosis of covid-19 demonstrated ongoing myocardial inflammation in 60% at a median time of 71 days from diagnosis.4 Although 33% of participants were classified as severely unwell and required hospitalisation, and 67% were recovering at home, it is unclear how the mildness or severity of illness in the latter group was established, and how the recruitment procedure avoided the potential risks of selection bias. It is also unclear as to whether the findings indicate myocarditis or cardiac injury from other causes, and how clinically important the findings are for long term health or morbidity.

Indeed, in an autopsy study of 21 patients who died from covid-19, only three (14%) were found to have lymphocytic infiltrates suggestive of myocarditis.16 Moreover, viral myocarditis can be a feature of many circulating viruses, including influenza.17

Thromboembolic complications, such as pulmonary emboli, are also associated with covid-19.181920 Long term effects on pulmonary function are not currently known, but data from the 2003 severe acute respiratory syndrome coronavirus (SARS-CoV) epidemic suggest persistent impairments in pulmonary function and exercise capacity in survivors.21

Finally, primary psychiatric phenomena, such as psychosis, have been identified as a potential presenting feature of covid-19,22 and psychological sequelae after infection can include post-traumatic stress disorder, anxiety, and depression.23

Some of these potential risks, viral myocarditis in particular, understandably lead to caution when advising a return to physical activity or exercise after infection. Without evidence from robust studies to inform practice, all current guidance to date is based on consensus or expert opinion. A consensus statement from sports clinicians of the European Federation of Sports Medicine Associations from July 2020 recommends a review with a sports and exercise medicine physician after mild symptomatic infection, and investigations including echocardiography and lung function testing where cardiopulmonary symptoms were present.24 Guidance from the Netherlands Society of Cardiology states that, for those with systemic features including fever, electrocardiography testing should be considered before resumption of activity.25 However, the incidence of myocardial injury (box 1) or thromboembolic complications after mild or moderate covid-19 in the community is currently unknown but thought to be low. Therefore, a balance is needed between obstructing an already inactive population from undertaking physical activity at recommended levels beneficial for their health, and the potential risk of cardiac or other consequences for a small minority. There is no perfect solution given the current uncertainties and the varying availability of resources globally, such as cardiopulmonary investigations or dedicated sports and exercise medicine services. We advocate a pragmatic approach that enables a gradual return to physical activity while mitigating risks.

How do I know if my patient can safely return to physical activity?


A risk-stratification approach can help maximise safety and mitigate risks, and a number of factors need to be taken into account. First, is the person physically ready to return to activity? In the natural course of covid-19, deterioration signifying severe infection often occurs at around a week from symptom onset. Therefore, consensus agreement is that a return to exercise or sporting activity should only occur after an asymptomatic period of at least seven days,21242627 and it would be pragmatic to apply this to any strenuous physical activity (fig 1). English and Scottish Institute of Sport guidance suggests that, before re-initiation of sport for athletes, activities of daily living should be easily achievable and the person able to walk 500 m on the flat without feeling excessive fatigue or breathlessness.27 However, we recommend considering the person’s pre-illness baseline, and tailoring guidance accordingly. Some may not have been able to walk 500 m without breathlessness before their covid-19 illness, and they should not be precluded from starting physical activity at a level tolerable for them (see fig 1, phases 1 to 3).

The second factor is that ongoing symptoms, regardless of system, may be indicative of a post-acute covid-19 illness. This will require assessment in primary care initially, and potentially liaison with local post-covid-19 rehabilitation services.121 Assessment and management of post-acute covid-19 illness is covered elsewhere.1 Whether there is a role for graded physical activity as a treatment for this condition is currently unclear.

People who had more severe covid-19 illness, such as those who were hospitalised, are thought to be at higher risk of cardiac complications121321242527 and thromboembolic events.1520 We recommend that their graduated rehabilitation be managed in conjunction, or after discussion and liaison, with local post-covid-19 services. People who did not require hospital treatment but who had symptoms during their illness suggestive of myocardial injury, such as chest pain, severe breathlessness, palpitations, symptoms or signs of heart failure, or syncope and pre-syncope, should be assessed with a physical examination and considered for further investigations. Depending on the severity of the symptoms encountered, investigations may include 12-lead electrocardiography, with abnormal findings prompting referral to cardiology or post-covid-19 services.25 The cardio-respiratory examination may reveal signs suggestive of costochondritis or musculoskeletal pain, which can be safely managed in primary care. Discuss findings indicating pulmonary oedema, fibrosis, pleural effusion, added heart sounds, ongoing hypoxia, or new arrhythmias with local post-covid-19 rehabilitation or cardiology services. Investigations in secondary care may include serum troponin levels, electrocardiography, and echocardiography (fig 1).121325 Both European and US guidelines advocate restrictions on exercise for three to six months in cases of myocarditis confirmed by cardiac magnetic resonance imaging or endomyocardial biopsy.1317212529

Third, with regards respiratory symptoms, persistent cough and breathlessness are expected to resolve after several weeks,115 but progressive, non-resolving or worsening symptoms may indicate pulmonary-vascular complications such as pulmonary embolism, concomitant pneumonia or post-inflammatory bronchoconstriction,15 and these patients should be discussed with secondary care services accordingly.

Finally, is the person psychologically ready to embark on a physical activity programme? Physical activity has a positive impact on mood and mental wellbeing56 and has a role in the prevention and treatment of mental health conditions. The presence of such conditions should not preclude people from physical activity, but allows for additional support when needed. Psychological sequelae of covid-19 infection can be screened for in the consultation. Ask about mood, sleep, appetite, and motivation. Listen to, acknowledge, and validate the patient’s concerns. If further support is needed, people can be directed to self care resources, community services, and peer support. In some cases, coordination with local psychological support or post-covid-19 rehabilitation services may be needed (fig 1).121 Psychological screening tools for returning to physical activity and sport do exist, but they are likely to be outside the scope of the standard primary care consultation.2730

How do I guide a patient back to physical activity?

There is no clear, evidence based way to guide return to physical activity, but a prudent approach is that it should be gradual, individualised, and based on subjective tolerance of the activity. Once a patient has been risk stratified and symptom-free for at least seven days, a phased approach can be used to increase physical activity levels to either baseline or guideline levels or beyond.21 If the person was not physically active before covid-19, this can be an opportune moment to discuss becoming more active. Return, or new development, of symptoms—including cough, abnormal breathlessness, palpitations, fever, and anosmia—indicate the need to stop, seek medical advice if required, and restart the process when symptom-free.27 People might be expected to be more breathless for a given activity after a period of illness or inactivity. However, a degree of subjective assessment is needed to assess if this is consistent with the given activity and level of fitness, and if it is improving. A graduated progression includes increases in volume (time doing the activity) and load (intensity).

Brief discussions regarding physical activity in primary care can follow a modified “3As” approach: ask, assess, and advise/assist.11 Begin by asking for permission to discuss the topic, and gauging the person’s current levels of activity. Assess their current perspectives and goals regarding physical activity and if they would like to do more. Advise by providing information, such as that below, and signposting to resources (box 2). Suggest they set goals and consider monitoring their progress, such as by using a diary. Assist them by helping break down barriers (such as reinforcing that even brief periods of activity are effective for improving health,31 household and garden tasks all contribute, and that active travel is often a feasible way of incorporating physical activity into a day).

How to start

Phases 1-2


Begin with light intensity activity for at least two weeks.1321 The Borg Rating of Perceived Exertion (RPE) scale is a subjective assessment of how hard someone feels they are working and can be helpful to guide people in choosing what activities to do as they progress through the phases of increasing physical activity. They rate their complete subjective feeling of exertion, including shortness of breath and fatigue, on a scale from 6 (no exertion at all) to 20 (maximal exertion).28 Light intensity exercise is equivalent to an RPE of under 11 (fig 1), when a person feels minimal to light exertion. They should be able to hold a full conversation without difficulty at this level. Activities might include household and light garden tasks, gentle walking, and balance or yoga exercises.32 Breathing, stretching, and light strengthening activities can also be incorporated.21 Examples of these can be found on the NHS website https://www.nhs.uk/live-well/exercise/f ... exercises/ and in the resources in box 2. We recommend spending seven days (phase 1) on extremely light intensity activity (RPE 6-8), including flexibility and breathing exercises, for as long as the person feels able to do them, followed by a further seven days (phase 2) incorporating light intensity activity (RPE 6-11) such as walking and light yoga, with graduated increases at 10-15 minutes per day at the same RPE when tolerated.


Phases 3-4


Progress to more challenging movement activities depending on pre-illness capacity. These might include intervals of two 5-minute blocks of activity such as brisk walking, going up and down stairs, jogging, swimming, or cycling separated by a block of recovery. The person should not feel that the exercise is “hard,” and we would suggest working to an RPE of 12-14 (moderate intensity, not out of breath and could hold a conversation). Progress by adding an interval per day as tolerated.

Phase 4 would involve more complex movement that challenges coordination, strength, and balance, such as running but with changes in direction, side-steps, shuffles, and circuits of body weight exercises, but again without it feeling hard. After completing phase 4, people should then feel able to return to their baseline (pre-covid) level of activity or more.

We propose a minimum of seven days at each phase to prevent sudden increases in training load (see fig 1). However, people should stay at the phase they feel comfortable with for as long as necessary. They should monitor for any inability to feel recovered at 1 hour after exercise and on the day after, abnormal breathlessness, abnormal heart rate, excessive fatigue or lethargy, and markers of mental ill health. If these occur, or the person fails to progress as expected, they should step back to an earlier phase of activity and seek medical advice when unsure. Keeping a diary of exercise progression, along with RPE, any changes in mood, and, for those who are used to measuring it, objective fitness data such as heart rate, can be helpful for monitoring progress.

A patient’s perspective

I work as a healthcare assistant and had my first symptoms of covid-19 in April, including shortness of breath, cough, and high heart-rate. Once the fever had ended, I felt extremely fatigued when doing the smallest amount of exercise. I was used to being able to walk and swim for at least an hour and a half, so this was debilitating for me

Using techniques from physiotherapy and the NHS covid patient support website, I slowly started to be able to do more. The exercise I found most helpful was stretching. This helped to expand my chest and lungs, so the more intense exercises got easier. It helped to be able to do these stretches prior to a more intense exercise such as walking, as my lungs felt they could hold more air. The breathing techniques were particularly helpful and something I do regularly. I found walking to also be most beneficial as it was an exercise I could control. I could walk at a speed and for a distance that was manageable for me and gradually increase this while using a “fitbit” to check my heart rate and recovery time.

It has now been about 10 weeks since my first symptoms, and I would say I am at around 70% of my pre-covid fitness. I am aware of my own limitations and am still working to improve these every day.
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Re: Post-COVID Clinics / Long Haulers

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COVID-19 survivors can show persistent symptoms six months after recovery, study finds

1/13/21


https://www.news-medical.net/news/20210 ... finds.aspx


Viral infections are self-limiting. When the body’s immune system has won over the battle, the body is expected to shortly recover. However, many convalescents from the coronavirus disease 2019 (COVID-19) experience persistent symptoms that can last for months.

Called “long haulers” these individuals experience a variety of symptoms, such as the difficulty of breathing, a cough, and fatigue.

Now, researchers at the Wuhan Research Center for Communicable Disease Diagnosis and Treatment, the Chinese Academy of Medical Sciences in China revealed that some patients who had recovered from COVID-19 are experiencing symptoms that persisted for more than six months.

In the study, published in The Lancet, the team aimed to determine the long-term health consequences of COVID-19. Further, they wanted to describe the long-term health consequences of patients with COVID-19 who have been discharged from the hospital.

The study


The study involved more than 1,700 patients who were treated in Wuhan City, the initial epicenter of the coronavirus pandemic when it first emerged in late 2019. It revealed that 76 percent suffered at least one symptom months after they were discharged from the hospital.

Originally, there were 2,469 patients, but some were excluded from the study. About 33 patients died after discharge due to complications of pulmonary, heart, and kidney disease, while 25 patients were readmitted to the hospital because of underlying disease complications. One of these patients needed to be readmitted due to acute pulmonary embolism because of deep vein thrombosis (DVT). Meanwhile, three patients developed ischemic stroke.

The researchers conducted an ambidirectional cohort study of patients with confirmed COVID-19 who had been discharged from the Jin Yin-tan Hospital between Jan. 7, 2020, and May 29, 2020. They conducted interviews with patients using a series of questionnaires for symptom evaluation and health-related quality of life. The patients also underwent physical examinations, a 6-min walking test, and blood tests.

The follow-up was conducted between June 16, 2020, and September 3, 2020.

The study findings indicate that even those who recovered from COVID-19 could suffer long-lasting health effects. Approximately 73 percent of the patients reported at least one symptom at follow-up and a higher percentage was seen in women. About 63 percent of the respondents experienced fatigue or muscle weakness, 26 percent had sleep difficulties, and 23 percent had anxiety and depression.

Also, patients who had more severe disease tended to have continued lung damage as seen on X-rays. They had more severe impaired pulmonary diffusion capacities and abnormal chest imaging manifestations.

Notably, 13 percent of patients who did not appear to have acute kidney injury during hospitalization showed signs of kidney malfunction.

The study findings showed that many patients continue to live with some of the effects of the virus after recovering. These symptoms may hinder day-to-day activities and may negatively impact one’s quality of life.


" To our knowledge, this is the largest cohort study with the longest follow-up duration assessing the health consequences of adult patients discharged from the hospital recovering from COVID-19,” the researchers noted.

The researchers noted that it is crucial to conduct larger follow-up studies not only in China but in other countries that reported cases of COVID-19.

We found that fatigue or muscle weakness, sleep difficulties, and anxiety or depression were common, even at 6 months after symptom onset. This is consistent with data from previous SARS long term follow-up studies,” they concluded.

The researchers noted that the study results support that those with severe disease need post-discharge care since they experience more persistent symptoms.

Longer follow-up studies in a larger population are necessary to understand the full spectrum of health consequences from COVID-19,” the recommended.

COVID-19 global toll

The coronavirus disease has now reached 191 countries and regions across the globe. The global case toll has topped 91.77 million. The death toll has reached 1.96 million, while those who have recovered have reached 50.76 million.

The United States reports the highest number of COVID-19 cases, with more than 22.86 million cases and over 381,000 deaths. Other countries with a high number of cases include India, with more than 10.49 million cases, Brazil, with 8.19 million cases, Russia, with 3.43 million cases, and the United Kingdom, with 3.17 million cases, among others.

Source:

COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) - https://gisanddata.maps.arcgis.com/apps ... 7b48e9ecf6

Journal reference:

Huang, C., Huang, L., Wang, Y., et al. (2021). 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. The Lancet. https://doi.org/10.1016/S0140-6736(20)32656-8, https://www.thelancet.com/journals/lanc ... lltext#%20
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Re: Post-COVID Clinics / Long Haulers

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Evidence that Long COVID-19 impacts children

2/2/21


https://www.news-medical.net/news/20210 ... ldren.aspx


The ongoing coronavirus 2019 (COVID-19) pandemic has caused over one hundred million reported infections, with over 2.23 million deaths worldwide. While most cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are asymptomatic or mild, some patients report long-haul symptoms, often severely debilitating in nature. However, it is unclear how many children are affected similarly. A new preprint research paper posted to the medRxiv* server recently reports early findings in this area.

The persistence of COVID-19 symptoms beyond a few weeks was first described in Italy as 'Long COVID.' Since then many studies have reported on 'Long COVID' among adults. For instance, over three-fourths of 1,700 patients from Wuhan in one study still had symptoms six months after the initial diagnosis.

Long COVID's impact on children is also likely to be significant. The mental ill-health induced by the restrictions on social interactions and even on moving out of the house during some phases of the pandemic has been widely reported. Besides this, the educational losses allegedly suffered by children, particularly those from underprivileged or minority subgroups, have received attention.

Children with COVID-19 have also been reported, in rare cases, to develop a systemic illness, including the Multisystem Inflammatory Syndrome (MIS). Here, many parts of the body, including the heart, lungs, brain, kidneys, skin, eyes, and gut, become inflamed, typically following mild COVID-19. While death is uncommon, about 70% may require intensive care.

Study details


The research analyzed children aged 18 years or less who had received a microbiological diagnosis of COVID-19 at a single center. The study did not include those with severe disabling symptoms. The children's health data came from the caregivers and was captured on a questionnaire created by the Long COVID ISARIC study group.

The interviews all took place between September 1st and January 1st. They were classified into symptomatic and asymptomatic (based on the acute phase of infection), and further according to their requirement for hospitalization. A final categorization was made based on the time from the COVID-19 diagnosis to the time of the interview.

The children in the study numbered 129, all diagnosed between March and November 2020, with a mean age of 11 years. The number of males and females were roughly equivalent. Immediate complications included MIS in three of the children, while two had myocarditis.

Persistence of symptoms

The average period from diagnosis to evaluation was ~163 days. Of the group, ~42% had a complete recovery. Within the group, 53% of children were reported to have one or more symptom 120 or more days after diagnosis, fitting the diagnosis of Long COVID. Strikingly, 36% of them had one or two symptoms at the time of evaluation, and 23% three or more symptoms.

When assessed by severity, insomnia was reported in about a fifth of them, while 15% complained of respiratory symptoms. These included chest tightness and pain. About 12% complained of nasal congestion, while ~10% each had tiredness, difficulty concentrating, and muscle pain. About 7% were said to have joint pain. Headaches and palpitations were also frequent.

Such symptoms were more frequent in children who had symptomatic illness or were required to be hospitalized with COVID-19. Interestingly, however, they were also found in children who had had an asymptomatic illness.

What are the implications?


This pioneering study lays bare the existence of Long COVID in children as well as in adults. The caregivers for over half the children said their charges had persistent symptoms at 120 days or more from infection, and in the 68 children in this group, fully 43% had symptoms severe enough to distress them or impair their daily activities.

The study was carried out at a single center, with only a few pediatric cases. However, the investigators plan to continue their assessments until 24 months from the diagnosis. They also intend to include controls from the household of the participating children, both with and without a history of COVID-19.

The lesson to be taken away from this study is that though children have a mild or asymptomatic infection with SARS-CoV-2, the illness's impact may still be significant.

"The evidence that COVID-19 can have a long-term impact on children as well, including those with asymptomatic/paucisymptomatic COVID-19, highlight the need for pediatricians, mental health experts and policymakers to implement measures to reduce the impact of the pandemic on child's health."

*Important Notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Journal reference:

Buonsenso, D. et al. (2021). Preliminary Evidence on Long COVID in children. medRxiv preprint. doi: https://doi.org/10.1101/2021.01.23.21250375. https://www.medrxiv.org/content/10.1101 ... 21250375v1
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Re: Post-COVID Clinics / Long Haulers

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Long-Haul Covid Cases Cast New Light on Chronic Fatigue Sufferers

2/2/21


https://khn.org/news/article/long-haul- ... sufferers/


Four weeks after San Diego pediatric nurse Jennifer Minhas fell ill with covid-19 last March, her cough and fever had resolved, but new symptoms had emerged: chest pain, an elevated heart rate and crushing fatigue. Her primary care physician told her she was just anxious, and that none of her other covid patients had those issues. “That wasn’t what I needed to hear,” Minhas said.

At times, she’s been too exhausted to hold up her head. “I was kind of a zombie for months, shuffling around unable to do much of anything.”

The clinical term for the flattening fatigue Minhas describes is “post-exertional malaise.” It is a common symptom among patients who have not recovered from covid. It is also consistent with a standard feature of another chronic illness: myalgic encephalomyelitis, also known as chronic fatigue syndrome, or ME/CFS.

ME/CFS patients also report cognitive impairment — “brain fog” — and orthostatic intolerance, in which standing upright produces a racing heart rate and lightheadedness. Minhas has experienced these symptoms, as have many other “long haulers,” the tens of thousands of post-covid patients who haven’t recovered.

The percentage of covid patients who become long haulers is hard to pin down — in part because many early covid patients were not tested in time to detect the virus. But “long covid” is potentially an enormous problem. A recent study of 1,733 covid patients in Wuhan, China, found three-quarters of them still had symptoms six months after being released from the hospital.

As of January, doctors had documented more than 21 million cases of covid in the United States. “If just 5 percent develop lingering symptoms,’’ — about 1 million cases — “and if most of those with symptoms have ME/CFS, we would double the number of Americans suffering from ME/CFS in the next two years,” Harvard Medical School professor Dr. Anthony Komaroff wrote recently in the Harvard Health Letter.

The cause of ME/CFS is unknown, but multiple studies have found it follows acute infections with viruses — everything from the 1918 “Spanish” flu to Ebola. “A certain percentage of people don’t recover,” said Leonard Jason, a researcher at DePaul University.

Scientists are trying to figure out the mechanisms of the disease and why it develops in certain people and not others. According to the Centers for Disease Control and Prevention, ME/CFS shares certain characteristics with autoimmune diseases, in which the immune system attacks healthy tissue in the body. Multiple studies are underway to explore this and other potential causes.

Doctors who specialize in treating ME/CFS are beginning to pivot to long-covid patients. Dr. Peter Rowe, whose clinic at Johns Hopkins is one of the country’s leading centers for ME, has so far seen four long haulers at his practice. “All of them meet the criteria for ME/CFS,” he said.

Despite years of research, there is no biomarker for ME/CFS, so blood tests are ineffective as a diagnostic tool. Rowe’s approach is to tease apart which symptoms may have identifiable causes and treatments, and address those. One example: A 15-year-old boy Rowe was treating for ME/CFS was so sick that even sitting upright a few hours a day exhausted him and made schoolwork virtually impossible. The boy’s heart rate while lying down was 63; when he stood up it skyrocketed to 113. This effect is known as postural orthostatic tachycardia syndrome, or POTS.

Rowe knew from interviews with the boy’s mother that he had an extraordinary appetite for salt. So much so that he kept a shaker at his bedside and would regularly sprinkle salt on his hand and lick it off.

Rowe hypothesized that he was dealing with a sodium retention problem. To counter it, he prescribed the steroid fludrocortisone, which promotes sodium resorption in the kidneys. Three weeks later, the boy had recovered so dramatically he was helping a neighbor with a landscaping project, pushing rocks around in a wheelbarrow. “He was a different kid,” Rowe said.

Such a course of treatment would not be applicable in a typical case, Rowe said, “but it does emphasize the potential for patients to get a substantial improvement in their CFS symptoms if we address the orthostatic intolerance.”

Beginning in the 1980s, many doctors treating ME/CFS prescribed a combination of cognitive behavioral therapy and an exercise regimen based on a now discredited assertion that the illness had no biomedical origin. That approach proved ineffective — patients often got demonstrably worse after pushing beyond their physical limits. It also contributed to a belief within the medical establishment that ME/CFS was all in your head, a narrative that has largely been refuted.

“ME/CFS was never a mostly behavioral problem, although it has been cast as that,” Rowe said.

Answers have been slow to arrive, but attitudes about the illness are beginning to change. Advocates of patients point to a 2015 report by the Institute of Medicine that called ME/CFS “a serious, chronic, complex, systemic disease” and acknowledged that many doctors are poorly trained to identify and treat it. The CDC says as many as 90% of the estimated 1 million U.S. patients with ME/CFS may be undiagnosed or misdiagnosed.

The problem is exacerbated by a reluctance to provide health care coverage to patients whose illnesses aren’t easily diagnosed, said Joe Dumit, a medical anthropologist at the University of California-Davis. “Making patients prove they are not just suffering, but suffering from a documented illness, saves money. So, I worry about the way in which covid long haulers will be treated as the numbers rise.” The best treatment in many cases may be rest or reduced workload, “which translates into some form of disability coverage,” he said.

But since long haulers typically sicken immediately after having had a testable viral infection, perhaps they won’t be disbelieved, Rowe said — after all, their illness “starts as a ‘real’ illness.’’

Long haulers may also help researchers better understand the onset of the illness because they are being studied as their symptoms emerge, while ME/CFS patients often aren’t seen until they’ve been ill for two or more years, he said.

“There’s no question that this legitimizes in many ways the experience of people with ME/CFS who have felt they weren’t believed,” DePaul’s Jason said.

In July, the nonprofit Solve ME/CFS launched an initiative aimed at understanding similarities between long haulers and patients with ME/CFS. Dubbed You+ME and underwritten by the National Institutes of Health, it includes an app that enables registrants to record their symptoms and their effects over time.

Such efforts may further diminish the tendency of doctors to ignore patients’ complaints of symptoms that seem to have no evident cause, said Lauren Nichols, 32, a long hauler with a long list of miseries — everything from severe gastrointestinal problems to shingles in her left eye.

“I was one of those people who falsely believed that if you can’t see the illness it’s psychosomatic,” said Nichols, who helps administer Body Politic, a support group for long-covid patients that has found common cause with the ME/CFS community.

“Now I’m living it,” she said. “If I have one message for doctors, it’s ‘Believe your patients.’”
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