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Monkeypox virus found in asymptomatic people
The findings, published in Annals of Internal Medicine, follow a similar, non–peer-reviewed report from Belgium. Researchers in both studies tested swabs for monkeypox in men who have sex with men. These swabs had been collected for routine STI screening.
It’s unclear whether asymptomatic individuals who test positive for monkeypox can spread the virus, the French team wrote. But if so, public health strategies to vaccinate those with known exposure “may not be sufficient to contain spread.”
In an editorial accompanying their paper, Stuart Isaacs, MD, associate professor at the University of Pennsylvania, Philadelphia, said it “raises the question of whether asymptomatic or subclinical infections are contributing to the current worldwide outbreak.”
Historically, transmission of monkeypox and its close relative, smallpox, was thought to be greatest when a rash was present, Dr. Isaacs wrote. “Long chains of human-to-human transmission were rare” with monkeypox.
That’s changed with the current outbreak, which was first detected in May. On Aug. 17, the World Health Organization reported more than 35,000 cases in 92 countries, with 12 deaths.
Research methods
For the French study, researchers conducted polymerase chain reaction tests on 200 anorectal swabs from asymptomatic individuals that had been collected from June 5 to July 11 in order to screen for gonorrhea and chlamydia. Of those, 13 (6.5%) were positive for monkeypox.
During the study period, STI testing had been suspended in individuals with monkeypox symptoms because of safety concerns, the researchers reported.
The research team contacted the 13 monkeypox-positive patients and advised them to limit sexual activity for 21 days following their test and notify recent sexual partners. None reported having developed symptoms, but two subsequently returned to the clinic with symptoms – one had an anal rash and the other a sore throat.
In the Belgian report, posted publicly on June 21 as a preprint, 3 of 224 anal samples collected for STI screening in May tested positive for monkeypox. All three of the men who tested positive said they did not have any symptoms in the weeks before and after the sample was taken.
At follow-up testing, 21-37 days after the initial samples were taken, all patients who had previously tested positive were negative. This was “likely as a consequence of spontaneous clearance of the infection,” the authors of that paper wrote.
Clinical implications of findings are uncertain
Monica Gandhi, MD, MPH, a professor of medicine at the University of California, San Francisco, said in an interview that the clinical implications of the findings are uncertain because it’s not known how much viral transmission results from asymptomatic individuals.
Nevertheless, Dr. Gandhi said that “vaccinating all gay men for monkeypox who will accept the vaccine is prudent,” compared with a less aggressive strategy of only vaccinating those with known exposure, which is called ring vaccination. That way, “we can be assured to provide immunity to large swaths of the at-risk population.”
Dr. Gandhi said that movement toward mass vaccination of gay men is occurring in the United States, Canada, Europe, and Australia, despite limited vaccine supply.
She added that, although monkeypox has been concentrated in communities of men who have sex with men, “anyone with multiple sexual partners should be vaccinated given the data.”
However, a WHO official recently cautioned that reports of breakthrough infections in individuals who were vaccinated against monkeypox constitute a reminder that “vaccine is not a silver bullet.”
Non-vaccine interventions are also needed
Other experts stressed the need for nonvaccine interventions.
In his editorial, Dr. Isaacs said an “expanded” ring vaccination strategy in communities of high risk is likely needed, but ultimately the outbreak will only be controlled if vaccination is accompanied by other measures such as identifying and isolating cases, making treatment available, and educating individuals about how to reduce their risk.
Aileen Marty, MD, a professor of infectious diseases at Florida International University, Miami, said in an interview that the new evidence makes it “incredibly important” to inform people that they might be infected by a sex partner even if that person does not have telltale lesions.
Dr. Marty said she has been advising men who have sex with men to “reduce or eliminate situations in which they find themselves with multiple anonymous individuals.”
Although most individuals recover from monkeypox, the disease can lead to hospitalization, disfigurement, blindness, and even death, Dr. Marty noted, adding that monkeypox is “absolutely a disease to avoid.”
Authors of the French study reported financial relationships with Gilead Sciences, Viiv Healthcare, MSD, AstraZeneca, Theratechnologies, Janssen Pharmaceuticals, Pfizer, GlaxoSmithKline, and bioMérieux. Dr. Isaacs reported grants from the Department of Veterans Affairs and the National Institutes of Health and royalties from UpToDate. Dr. Gandhi and Dr. Marty reported no relevant financial interests.
The findings, published in Annals of Internal Medicine, follow a similar, non–peer-reviewed report from Belgium. Researchers in both studies tested swabs for monkeypox in men who have sex with men. These swabs had been collected for routine STI screening.
It’s unclear whether asymptomatic individuals who test positive for monkeypox can spread the virus, the French team wrote. But if so, public health strategies to vaccinate those with known exposure “may not be sufficient to contain spread.”
In an editorial accompanying their paper, Stuart Isaacs, MD, associate professor at the University of Pennsylvania, Philadelphia, said it “raises the question of whether asymptomatic or subclinical infections are contributing to the current worldwide outbreak.”
Historically, transmission of monkeypox and its close relative, smallpox, was thought to be greatest when a rash was present, Dr. Isaacs wrote. “Long chains of human-to-human transmission were rare” with monkeypox.
That’s changed with the current outbreak, which was first detected in May. On Aug. 17, the World Health Organization reported more than 35,000 cases in 92 countries, with 12 deaths.
Research methods
For the French study, researchers conducted polymerase chain reaction tests on 200 anorectal swabs from asymptomatic individuals that had been collected from June 5 to July 11 in order to screen for gonorrhea and chlamydia. Of those, 13 (6.5%) were positive for monkeypox.
During the study period, STI testing had been suspended in individuals with monkeypox symptoms because of safety concerns, the researchers reported.
The research team contacted the 13 monkeypox-positive patients and advised them to limit sexual activity for 21 days following their test and notify recent sexual partners. None reported having developed symptoms, but two subsequently returned to the clinic with symptoms – one had an anal rash and the other a sore throat.
In the Belgian report, posted publicly on June 21 as a preprint, 3 of 224 anal samples collected for STI screening in May tested positive for monkeypox. All three of the men who tested positive said they did not have any symptoms in the weeks before and after the sample was taken.
At follow-up testing, 21-37 days after the initial samples were taken, all patients who had previously tested positive were negative. This was “likely as a consequence of spontaneous clearance of the infection,” the authors of that paper wrote.
Clinical implications of findings are uncertain
Monica Gandhi, MD, MPH, a professor of medicine at the University of California, San Francisco, said in an interview that the clinical implications of the findings are uncertain because it’s not known how much viral transmission results from asymptomatic individuals.
Nevertheless, Dr. Gandhi said that “vaccinating all gay men for monkeypox who will accept the vaccine is prudent,” compared with a less aggressive strategy of only vaccinating those with known exposure, which is called ring vaccination. That way, “we can be assured to provide immunity to large swaths of the at-risk population.”
Dr. Gandhi said that movement toward mass vaccination of gay men is occurring in the United States, Canada, Europe, and Australia, despite limited vaccine supply.
She added that, although monkeypox has been concentrated in communities of men who have sex with men, “anyone with multiple sexual partners should be vaccinated given the data.”
However, a WHO official recently cautioned that reports of breakthrough infections in individuals who were vaccinated against monkeypox constitute a reminder that “vaccine is not a silver bullet.”
Non-vaccine interventions are also needed
Other experts stressed the need for nonvaccine interventions.
In his editorial, Dr. Isaacs said an “expanded” ring vaccination strategy in communities of high risk is likely needed, but ultimately the outbreak will only be controlled if vaccination is accompanied by other measures such as identifying and isolating cases, making treatment available, and educating individuals about how to reduce their risk.
Aileen Marty, MD, a professor of infectious diseases at Florida International University, Miami, said in an interview that the new evidence makes it “incredibly important” to inform people that they might be infected by a sex partner even if that person does not have telltale lesions.
Dr. Marty said she has been advising men who have sex with men to “reduce or eliminate situations in which they find themselves with multiple anonymous individuals.”
Although most individuals recover from monkeypox, the disease can lead to hospitalization, disfigurement, blindness, and even death, Dr. Marty noted, adding that monkeypox is “absolutely a disease to avoid.”
Authors of the French study reported financial relationships with Gilead Sciences, Viiv Healthcare, MSD, AstraZeneca, Theratechnologies, Janssen Pharmaceuticals, Pfizer, GlaxoSmithKline, and bioMérieux. Dr. Isaacs reported grants from the Department of Veterans Affairs and the National Institutes of Health and royalties from UpToDate. Dr. Gandhi and Dr. Marty reported no relevant financial interests.
The findings, published in Annals of Internal Medicine, follow a similar, non–peer-reviewed report from Belgium. Researchers in both studies tested swabs for monkeypox in men who have sex with men. These swabs had been collected for routine STI screening.
It’s unclear whether asymptomatic individuals who test positive for monkeypox can spread the virus, the French team wrote. But if so, public health strategies to vaccinate those with known exposure “may not be sufficient to contain spread.”
In an editorial accompanying their paper, Stuart Isaacs, MD, associate professor at the University of Pennsylvania, Philadelphia, said it “raises the question of whether asymptomatic or subclinical infections are contributing to the current worldwide outbreak.”
Historically, transmission of monkeypox and its close relative, smallpox, was thought to be greatest when a rash was present, Dr. Isaacs wrote. “Long chains of human-to-human transmission were rare” with monkeypox.
That’s changed with the current outbreak, which was first detected in May. On Aug. 17, the World Health Organization reported more than 35,000 cases in 92 countries, with 12 deaths.
Research methods
For the French study, researchers conducted polymerase chain reaction tests on 200 anorectal swabs from asymptomatic individuals that had been collected from June 5 to July 11 in order to screen for gonorrhea and chlamydia. Of those, 13 (6.5%) were positive for monkeypox.
During the study period, STI testing had been suspended in individuals with monkeypox symptoms because of safety concerns, the researchers reported.
The research team contacted the 13 monkeypox-positive patients and advised them to limit sexual activity for 21 days following their test and notify recent sexual partners. None reported having developed symptoms, but two subsequently returned to the clinic with symptoms – one had an anal rash and the other a sore throat.
In the Belgian report, posted publicly on June 21 as a preprint, 3 of 224 anal samples collected for STI screening in May tested positive for monkeypox. All three of the men who tested positive said they did not have any symptoms in the weeks before and after the sample was taken.
At follow-up testing, 21-37 days after the initial samples were taken, all patients who had previously tested positive were negative. This was “likely as a consequence of spontaneous clearance of the infection,” the authors of that paper wrote.
Clinical implications of findings are uncertain
Monica Gandhi, MD, MPH, a professor of medicine at the University of California, San Francisco, said in an interview that the clinical implications of the findings are uncertain because it’s not known how much viral transmission results from asymptomatic individuals.
Nevertheless, Dr. Gandhi said that “vaccinating all gay men for monkeypox who will accept the vaccine is prudent,” compared with a less aggressive strategy of only vaccinating those with known exposure, which is called ring vaccination. That way, “we can be assured to provide immunity to large swaths of the at-risk population.”
Dr. Gandhi said that movement toward mass vaccination of gay men is occurring in the United States, Canada, Europe, and Australia, despite limited vaccine supply.
She added that, although monkeypox has been concentrated in communities of men who have sex with men, “anyone with multiple sexual partners should be vaccinated given the data.”
However, a WHO official recently cautioned that reports of breakthrough infections in individuals who were vaccinated against monkeypox constitute a reminder that “vaccine is not a silver bullet.”
Non-vaccine interventions are also needed
Other experts stressed the need for nonvaccine interventions.
In his editorial, Dr. Isaacs said an “expanded” ring vaccination strategy in communities of high risk is likely needed, but ultimately the outbreak will only be controlled if vaccination is accompanied by other measures such as identifying and isolating cases, making treatment available, and educating individuals about how to reduce their risk.
Aileen Marty, MD, a professor of infectious diseases at Florida International University, Miami, said in an interview that the new evidence makes it “incredibly important” to inform people that they might be infected by a sex partner even if that person does not have telltale lesions.
Dr. Marty said she has been advising men who have sex with men to “reduce or eliminate situations in which they find themselves with multiple anonymous individuals.”
Although most individuals recover from monkeypox, the disease can lead to hospitalization, disfigurement, blindness, and even death, Dr. Marty noted, adding that monkeypox is “absolutely a disease to avoid.”
Authors of the French study reported financial relationships with Gilead Sciences, Viiv Healthcare, MSD, AstraZeneca, Theratechnologies, Janssen Pharmaceuticals, Pfizer, GlaxoSmithKline, and bioMérieux. Dr. Isaacs reported grants from the Department of Veterans Affairs and the National Institutes of Health and royalties from UpToDate. Dr. Gandhi and Dr. Marty reported no relevant financial interests.
FROM ANNALS OF INTERNAL MEDICINE
Antibiotic before oral surgery spares endocarditis; study validates guidelines
The strongest evidence yet to support clinical guidelines that recommend that people at high risk of endocarditis, such as those who’ve had previous episode the disease or who have a prosthetic cardiac valve, should take antibiotics before they have a tooth pulled or other types of oral surgery, comes from a new study that used two methodologies.
But it also pointed out that two-thirds of the time they aren’t getting that type of antibiotic coverage.
The researchers conducted a cohort study of almost 8 million retirees with employer-paid Medicare supplemental prescription benefits and dental benefits, then conducted a case-crossover study of 3,774 people from the cohort who’d been hospitalized with infectious endocarditis (IE) and who had invasive dental procedures. The bottom line is that the study supports the clinical guidelines from the American Heart Association and the European Society of Cardiology that recommend antibiotic prophylaxis (AP) before dental procedures for patients at high-risk of IE.
Likewise, lead author Martin Thornhill, MBBS, BDS, PhD, said in an interview, the findings also suggest that existing guidelines in the United Kingdom, which recommend against AP in these patients, “should be reconsidered.”
Those AHA and ESC guidelines, however, are “based on no good quality evidence,” said Dr. Thornhill, professor of translational research in dentistry at the University of Sheffield (England) School of Clinical Dentistry. “Other studies have looked at this, but we’ve done the largest study that has shown the clear association between invasive dental procedures and subsequent development of infective endocarditis.”
In the entire cohort of 7.95 million patients, 3,774 had cases of IE that required hospitalization. The study defined highest risk of IE as meeting one of these six criteria: a previous case of IE; a prosthetic cardiac valve or a valve repair that used prosthetic material; cyanotic congenital heart disease; palliative shunts or conduits to treat CHD; or a congenital heart defect that had been fully repaired, either by surgery or a transcatheter procedure, with prosthetic material or device – the latter within 6 months of the procedure.
Moderate IE risk included patients who had rheumatic heart disease, nonrheumatic valve disease or congenital valve anomalies—including mitral valve prolapse or aortic stenosis—or hypertrophic cardiomyopathy.
Risk classification and poor compliance
Highest-risk patients had significantly higher rates of IE a month after a dental procedure than lower-risk groups: 467.6 cases per 1 million procedures vs. 24.2 for moderate risk and 3.8 for low or unknown risk. A subanalysis found that the odds of IE were significantly increased for two specific dental procedures: extractions, with an odds ratio of 9.22 (95% confidence interval [CI], 5.54-15.88; P < .0001); and other oral surgical procedures, with an OR of 20.18 (95% CI, 11.22-37.74; P < .0001).
The study also found that 32.6% of the high-risk patients undergoing dental procedures got AP. “Clearly that shows a low level of compliance with the guidelines in the U.S.,” Dr. Thornhill said. “That’s something that needs to be addressed.”
The study was unique in that it used both a population cohort study and the case-crossover study. “It didn’t matter which of the two methods we used; we essentially came to the same result, which I think adds further weight to the findings,” Dr. Thornhill said.
This may be the best evidence to support the guidelines that clinicians may get. While the observational nature of this study has its limitations, conducting a randomized clinical trial to further validate the findings would be “logistically impossible,” he said, in that it would require an “absolutely enormous” cohort and coordination between medical and dental databases covering thousands of lives. An RCT would also require not using AP for some patients. “It’s not ethical to keep somebody off of antibiotic prophylaxis when there’s such a high risk of death and severe outcomes,” Dr. Thornhill said.
Ann Bolger, MD, emeritus professor of medicine at the University of California, San Francisco, and coauthor of an editorial comment on the study, said in an interview that this study is noteworthy not only for its dual methodology, but for the quality of the data that matched patients at high risk for IE with prescription and dental records. “The fact that they were able to have those details in enough granularity that they knew whether a dental procedure was likely to meet the criteria for these more invasive exposures really broke it open from my perspective,” she said.
She called the low compliance rate with AHA guidelines “one of the most sobering points of this,” and said it should put clinicians on notice that they must do more to educate and engage with high-risk patients. “The lines of communication here are somewhat fraught; it’s a little bit of a hot potato,” she said. “It’s a really great communications opportunity to get the provider’s attention back on this. You’re a cardiologist; you have to have this conversation when you see your patient with a prosthetic valve or who’s had endocarditis every time they come in. There’s a whole litany, and it takes 3 minutes, but you have to do it.”
The study received funding from Delta Dental of Michigan Research Committee and Renaissance Health Service Corp., and Dr. Thornhill received support from Delta Dental Research and Data Institute for the study. Dr. Bolger participated in the 2007 and 2021 AHA statements on AP to prevent IE.
The strongest evidence yet to support clinical guidelines that recommend that people at high risk of endocarditis, such as those who’ve had previous episode the disease or who have a prosthetic cardiac valve, should take antibiotics before they have a tooth pulled or other types of oral surgery, comes from a new study that used two methodologies.
But it also pointed out that two-thirds of the time they aren’t getting that type of antibiotic coverage.
The researchers conducted a cohort study of almost 8 million retirees with employer-paid Medicare supplemental prescription benefits and dental benefits, then conducted a case-crossover study of 3,774 people from the cohort who’d been hospitalized with infectious endocarditis (IE) and who had invasive dental procedures. The bottom line is that the study supports the clinical guidelines from the American Heart Association and the European Society of Cardiology that recommend antibiotic prophylaxis (AP) before dental procedures for patients at high-risk of IE.
Likewise, lead author Martin Thornhill, MBBS, BDS, PhD, said in an interview, the findings also suggest that existing guidelines in the United Kingdom, which recommend against AP in these patients, “should be reconsidered.”
Those AHA and ESC guidelines, however, are “based on no good quality evidence,” said Dr. Thornhill, professor of translational research in dentistry at the University of Sheffield (England) School of Clinical Dentistry. “Other studies have looked at this, but we’ve done the largest study that has shown the clear association between invasive dental procedures and subsequent development of infective endocarditis.”
In the entire cohort of 7.95 million patients, 3,774 had cases of IE that required hospitalization. The study defined highest risk of IE as meeting one of these six criteria: a previous case of IE; a prosthetic cardiac valve or a valve repair that used prosthetic material; cyanotic congenital heart disease; palliative shunts or conduits to treat CHD; or a congenital heart defect that had been fully repaired, either by surgery or a transcatheter procedure, with prosthetic material or device – the latter within 6 months of the procedure.
Moderate IE risk included patients who had rheumatic heart disease, nonrheumatic valve disease or congenital valve anomalies—including mitral valve prolapse or aortic stenosis—or hypertrophic cardiomyopathy.
Risk classification and poor compliance
Highest-risk patients had significantly higher rates of IE a month after a dental procedure than lower-risk groups: 467.6 cases per 1 million procedures vs. 24.2 for moderate risk and 3.8 for low or unknown risk. A subanalysis found that the odds of IE were significantly increased for two specific dental procedures: extractions, with an odds ratio of 9.22 (95% confidence interval [CI], 5.54-15.88; P < .0001); and other oral surgical procedures, with an OR of 20.18 (95% CI, 11.22-37.74; P < .0001).
The study also found that 32.6% of the high-risk patients undergoing dental procedures got AP. “Clearly that shows a low level of compliance with the guidelines in the U.S.,” Dr. Thornhill said. “That’s something that needs to be addressed.”
The study was unique in that it used both a population cohort study and the case-crossover study. “It didn’t matter which of the two methods we used; we essentially came to the same result, which I think adds further weight to the findings,” Dr. Thornhill said.
This may be the best evidence to support the guidelines that clinicians may get. While the observational nature of this study has its limitations, conducting a randomized clinical trial to further validate the findings would be “logistically impossible,” he said, in that it would require an “absolutely enormous” cohort and coordination between medical and dental databases covering thousands of lives. An RCT would also require not using AP for some patients. “It’s not ethical to keep somebody off of antibiotic prophylaxis when there’s such a high risk of death and severe outcomes,” Dr. Thornhill said.
Ann Bolger, MD, emeritus professor of medicine at the University of California, San Francisco, and coauthor of an editorial comment on the study, said in an interview that this study is noteworthy not only for its dual methodology, but for the quality of the data that matched patients at high risk for IE with prescription and dental records. “The fact that they were able to have those details in enough granularity that they knew whether a dental procedure was likely to meet the criteria for these more invasive exposures really broke it open from my perspective,” she said.
She called the low compliance rate with AHA guidelines “one of the most sobering points of this,” and said it should put clinicians on notice that they must do more to educate and engage with high-risk patients. “The lines of communication here are somewhat fraught; it’s a little bit of a hot potato,” she said. “It’s a really great communications opportunity to get the provider’s attention back on this. You’re a cardiologist; you have to have this conversation when you see your patient with a prosthetic valve or who’s had endocarditis every time they come in. There’s a whole litany, and it takes 3 minutes, but you have to do it.”
The study received funding from Delta Dental of Michigan Research Committee and Renaissance Health Service Corp., and Dr. Thornhill received support from Delta Dental Research and Data Institute for the study. Dr. Bolger participated in the 2007 and 2021 AHA statements on AP to prevent IE.
The strongest evidence yet to support clinical guidelines that recommend that people at high risk of endocarditis, such as those who’ve had previous episode the disease or who have a prosthetic cardiac valve, should take antibiotics before they have a tooth pulled or other types of oral surgery, comes from a new study that used two methodologies.
But it also pointed out that two-thirds of the time they aren’t getting that type of antibiotic coverage.
The researchers conducted a cohort study of almost 8 million retirees with employer-paid Medicare supplemental prescription benefits and dental benefits, then conducted a case-crossover study of 3,774 people from the cohort who’d been hospitalized with infectious endocarditis (IE) and who had invasive dental procedures. The bottom line is that the study supports the clinical guidelines from the American Heart Association and the European Society of Cardiology that recommend antibiotic prophylaxis (AP) before dental procedures for patients at high-risk of IE.
Likewise, lead author Martin Thornhill, MBBS, BDS, PhD, said in an interview, the findings also suggest that existing guidelines in the United Kingdom, which recommend against AP in these patients, “should be reconsidered.”
Those AHA and ESC guidelines, however, are “based on no good quality evidence,” said Dr. Thornhill, professor of translational research in dentistry at the University of Sheffield (England) School of Clinical Dentistry. “Other studies have looked at this, but we’ve done the largest study that has shown the clear association between invasive dental procedures and subsequent development of infective endocarditis.”
In the entire cohort of 7.95 million patients, 3,774 had cases of IE that required hospitalization. The study defined highest risk of IE as meeting one of these six criteria: a previous case of IE; a prosthetic cardiac valve or a valve repair that used prosthetic material; cyanotic congenital heart disease; palliative shunts or conduits to treat CHD; or a congenital heart defect that had been fully repaired, either by surgery or a transcatheter procedure, with prosthetic material or device – the latter within 6 months of the procedure.
Moderate IE risk included patients who had rheumatic heart disease, nonrheumatic valve disease or congenital valve anomalies—including mitral valve prolapse or aortic stenosis—or hypertrophic cardiomyopathy.
Risk classification and poor compliance
Highest-risk patients had significantly higher rates of IE a month after a dental procedure than lower-risk groups: 467.6 cases per 1 million procedures vs. 24.2 for moderate risk and 3.8 for low or unknown risk. A subanalysis found that the odds of IE were significantly increased for two specific dental procedures: extractions, with an odds ratio of 9.22 (95% confidence interval [CI], 5.54-15.88; P < .0001); and other oral surgical procedures, with an OR of 20.18 (95% CI, 11.22-37.74; P < .0001).
The study also found that 32.6% of the high-risk patients undergoing dental procedures got AP. “Clearly that shows a low level of compliance with the guidelines in the U.S.,” Dr. Thornhill said. “That’s something that needs to be addressed.”
The study was unique in that it used both a population cohort study and the case-crossover study. “It didn’t matter which of the two methods we used; we essentially came to the same result, which I think adds further weight to the findings,” Dr. Thornhill said.
This may be the best evidence to support the guidelines that clinicians may get. While the observational nature of this study has its limitations, conducting a randomized clinical trial to further validate the findings would be “logistically impossible,” he said, in that it would require an “absolutely enormous” cohort and coordination between medical and dental databases covering thousands of lives. An RCT would also require not using AP for some patients. “It’s not ethical to keep somebody off of antibiotic prophylaxis when there’s such a high risk of death and severe outcomes,” Dr. Thornhill said.
Ann Bolger, MD, emeritus professor of medicine at the University of California, San Francisco, and coauthor of an editorial comment on the study, said in an interview that this study is noteworthy not only for its dual methodology, but for the quality of the data that matched patients at high risk for IE with prescription and dental records. “The fact that they were able to have those details in enough granularity that they knew whether a dental procedure was likely to meet the criteria for these more invasive exposures really broke it open from my perspective,” she said.
She called the low compliance rate with AHA guidelines “one of the most sobering points of this,” and said it should put clinicians on notice that they must do more to educate and engage with high-risk patients. “The lines of communication here are somewhat fraught; it’s a little bit of a hot potato,” she said. “It’s a really great communications opportunity to get the provider’s attention back on this. You’re a cardiologist; you have to have this conversation when you see your patient with a prosthetic valve or who’s had endocarditis every time they come in. There’s a whole litany, and it takes 3 minutes, but you have to do it.”
The study received funding from Delta Dental of Michigan Research Committee and Renaissance Health Service Corp., and Dr. Thornhill received support from Delta Dental Research and Data Institute for the study. Dr. Bolger participated in the 2007 and 2021 AHA statements on AP to prevent IE.
FROM JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Higher rates of group B strep disease found in Black and Asian newborns
Health charities called for action to address racial health disparities after population-wide analysis by the UK Health Security Agency found that Black and Asian neonates had a significantly higher risk of early-onset group B streptococcal disease (GBS), compared with White infants.
One support group said more research was now needed to identify the cause of the disparity, and called for pregnant women to be better informed about the disease and what it could mean for them and their baby.
The study, published in Pediatrics, used UKHSA data on laboratory-confirmed infant group B streptococcal (iGBS) disease cases between Jan. 1, 2016, and Dec. 31, 2020, and were linked to hospital ethnicity records.
Cases of iGBS were defined as isolation of Streptococcus agalactiae from a normally sterile site at 0-6 days of life for early-onset iGBS and 7-90 days for late-onset disease.
Hospital data and parent-reported ethnicity
Researchers found 2,512 iGBS cases in England during the study period, 65.3% were early onset and 34.8% late onset, equivalent to 0.52 and 0.28 cases per 1000 live births respectively.
Researchers were able to link 85.6% of those to ethnicity. Among those 2,149 cases, Black infants had a 48% higher risk, and Asian infants a 40% higher risk of early onset iGBS, compared with White infants. Among those from an Asian background, the risk was 87% higher for Bangladeshi and 38% higher for Pakistani neonates.
Rates of early onset iGBS per 1,000 live births were 0.43 for White infants, 0.63 for Black infants, and 0.60 for those of Asian ethnicity.
In contrast, Indian infants had an early-onset rate of 0.47 per 1,000 live births, which was similar to White infants.
Black infants had 57% higher rates of late-onset iGBS (0.37) than White infants (0.24), the researchers reported.
The study authors highlighted previous research which found higher prevalence of group B streptococcal colonization in mothers from Black and some Asian ethnic groups, but lower prevalence in mothers from the Indian subcontinent. More research was needed to establish causes, the researchers said, including whether higher preterm birth rates in minority ethnic groups led to increased iGBS risk in neonates, or whether maternal group B streptococcal disease led to higher preterm birth rates and subsequent neonatal iGBS.
The researchers concluded: “Understanding the factors underpinning differences in rates of early-onset iGBS within south Asian groups in England may lead to new opportunities for prevention such as prioritized antenatal screening. Strategies to prevent neonatal iGBS must be tailored from high-quality quantitative and qualitative data to reach all women and protect all infants, irrespective of racial or ethnic background.”
‘Shocking but not surprising’
Commenting on the study, Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, said: “This research is striking reading, and is yet another example of how far we have to go to tackle health inequalities within women’s health care.”
Philip Steer, professor emeritus at Imperial College London, said that the results were “consistent with previous reports of higher GBS carriage and higher maternal and neonatal mortality rates in minority groups” and “emphasize the importance of studying not just whether, but why, these differences exist.” He added: “We need to understand the reasons for the differences before we can design much-needed intervention to eliminate them.”
Jane Plumb, chief executive of Group B Strep Support, called the findings “shocking, but unfortunately not surprising” and said that they offered “another example of racial disparities in maternal and neonatal health.” She said: “We’re calling for all pregnant women and birthing people to be informed about GBS and its risks, so they can make empowered choices for themselves and their baby. It is also critical that trusts sign up to take part in the internationally significant [National Institute for Health and Care Research]–funded GBS3 clinical trial, designed to improve the prevention of GBS infection.”
Baroness Shaista Gohir, chief executive of the Muslim Women’s Network, said: “With significantly higher rates of group B Strep infection in Black and Asian babies, greater efforts must be made to improve awareness among pregnant women within these communities.”
A version of this article first appeared on Medscape UK.
Health charities called for action to address racial health disparities after population-wide analysis by the UK Health Security Agency found that Black and Asian neonates had a significantly higher risk of early-onset group B streptococcal disease (GBS), compared with White infants.
One support group said more research was now needed to identify the cause of the disparity, and called for pregnant women to be better informed about the disease and what it could mean for them and their baby.
The study, published in Pediatrics, used UKHSA data on laboratory-confirmed infant group B streptococcal (iGBS) disease cases between Jan. 1, 2016, and Dec. 31, 2020, and were linked to hospital ethnicity records.
Cases of iGBS were defined as isolation of Streptococcus agalactiae from a normally sterile site at 0-6 days of life for early-onset iGBS and 7-90 days for late-onset disease.
Hospital data and parent-reported ethnicity
Researchers found 2,512 iGBS cases in England during the study period, 65.3% were early onset and 34.8% late onset, equivalent to 0.52 and 0.28 cases per 1000 live births respectively.
Researchers were able to link 85.6% of those to ethnicity. Among those 2,149 cases, Black infants had a 48% higher risk, and Asian infants a 40% higher risk of early onset iGBS, compared with White infants. Among those from an Asian background, the risk was 87% higher for Bangladeshi and 38% higher for Pakistani neonates.
Rates of early onset iGBS per 1,000 live births were 0.43 for White infants, 0.63 for Black infants, and 0.60 for those of Asian ethnicity.
In contrast, Indian infants had an early-onset rate of 0.47 per 1,000 live births, which was similar to White infants.
Black infants had 57% higher rates of late-onset iGBS (0.37) than White infants (0.24), the researchers reported.
The study authors highlighted previous research which found higher prevalence of group B streptococcal colonization in mothers from Black and some Asian ethnic groups, but lower prevalence in mothers from the Indian subcontinent. More research was needed to establish causes, the researchers said, including whether higher preterm birth rates in minority ethnic groups led to increased iGBS risk in neonates, or whether maternal group B streptococcal disease led to higher preterm birth rates and subsequent neonatal iGBS.
The researchers concluded: “Understanding the factors underpinning differences in rates of early-onset iGBS within south Asian groups in England may lead to new opportunities for prevention such as prioritized antenatal screening. Strategies to prevent neonatal iGBS must be tailored from high-quality quantitative and qualitative data to reach all women and protect all infants, irrespective of racial or ethnic background.”
‘Shocking but not surprising’
Commenting on the study, Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, said: “This research is striking reading, and is yet another example of how far we have to go to tackle health inequalities within women’s health care.”
Philip Steer, professor emeritus at Imperial College London, said that the results were “consistent with previous reports of higher GBS carriage and higher maternal and neonatal mortality rates in minority groups” and “emphasize the importance of studying not just whether, but why, these differences exist.” He added: “We need to understand the reasons for the differences before we can design much-needed intervention to eliminate them.”
Jane Plumb, chief executive of Group B Strep Support, called the findings “shocking, but unfortunately not surprising” and said that they offered “another example of racial disparities in maternal and neonatal health.” She said: “We’re calling for all pregnant women and birthing people to be informed about GBS and its risks, so they can make empowered choices for themselves and their baby. It is also critical that trusts sign up to take part in the internationally significant [National Institute for Health and Care Research]–funded GBS3 clinical trial, designed to improve the prevention of GBS infection.”
Baroness Shaista Gohir, chief executive of the Muslim Women’s Network, said: “With significantly higher rates of group B Strep infection in Black and Asian babies, greater efforts must be made to improve awareness among pregnant women within these communities.”
A version of this article first appeared on Medscape UK.
Health charities called for action to address racial health disparities after population-wide analysis by the UK Health Security Agency found that Black and Asian neonates had a significantly higher risk of early-onset group B streptococcal disease (GBS), compared with White infants.
One support group said more research was now needed to identify the cause of the disparity, and called for pregnant women to be better informed about the disease and what it could mean for them and their baby.
The study, published in Pediatrics, used UKHSA data on laboratory-confirmed infant group B streptococcal (iGBS) disease cases between Jan. 1, 2016, and Dec. 31, 2020, and were linked to hospital ethnicity records.
Cases of iGBS were defined as isolation of Streptococcus agalactiae from a normally sterile site at 0-6 days of life for early-onset iGBS and 7-90 days for late-onset disease.
Hospital data and parent-reported ethnicity
Researchers found 2,512 iGBS cases in England during the study period, 65.3% were early onset and 34.8% late onset, equivalent to 0.52 and 0.28 cases per 1000 live births respectively.
Researchers were able to link 85.6% of those to ethnicity. Among those 2,149 cases, Black infants had a 48% higher risk, and Asian infants a 40% higher risk of early onset iGBS, compared with White infants. Among those from an Asian background, the risk was 87% higher for Bangladeshi and 38% higher for Pakistani neonates.
Rates of early onset iGBS per 1,000 live births were 0.43 for White infants, 0.63 for Black infants, and 0.60 for those of Asian ethnicity.
In contrast, Indian infants had an early-onset rate of 0.47 per 1,000 live births, which was similar to White infants.
Black infants had 57% higher rates of late-onset iGBS (0.37) than White infants (0.24), the researchers reported.
The study authors highlighted previous research which found higher prevalence of group B streptococcal colonization in mothers from Black and some Asian ethnic groups, but lower prevalence in mothers from the Indian subcontinent. More research was needed to establish causes, the researchers said, including whether higher preterm birth rates in minority ethnic groups led to increased iGBS risk in neonates, or whether maternal group B streptococcal disease led to higher preterm birth rates and subsequent neonatal iGBS.
The researchers concluded: “Understanding the factors underpinning differences in rates of early-onset iGBS within south Asian groups in England may lead to new opportunities for prevention such as prioritized antenatal screening. Strategies to prevent neonatal iGBS must be tailored from high-quality quantitative and qualitative data to reach all women and protect all infants, irrespective of racial or ethnic background.”
‘Shocking but not surprising’
Commenting on the study, Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, said: “This research is striking reading, and is yet another example of how far we have to go to tackle health inequalities within women’s health care.”
Philip Steer, professor emeritus at Imperial College London, said that the results were “consistent with previous reports of higher GBS carriage and higher maternal and neonatal mortality rates in minority groups” and “emphasize the importance of studying not just whether, but why, these differences exist.” He added: “We need to understand the reasons for the differences before we can design much-needed intervention to eliminate them.”
Jane Plumb, chief executive of Group B Strep Support, called the findings “shocking, but unfortunately not surprising” and said that they offered “another example of racial disparities in maternal and neonatal health.” She said: “We’re calling for all pregnant women and birthing people to be informed about GBS and its risks, so they can make empowered choices for themselves and their baby. It is also critical that trusts sign up to take part in the internationally significant [National Institute for Health and Care Research]–funded GBS3 clinical trial, designed to improve the prevention of GBS infection.”
Baroness Shaista Gohir, chief executive of the Muslim Women’s Network, said: “With significantly higher rates of group B Strep infection in Black and Asian babies, greater efforts must be made to improve awareness among pregnant women within these communities.”
A version of this article first appeared on Medscape UK.
FROM PEDIATRICS
Is it COVID or long COVID? Your organs may know
There’s little doubt long COVID is real. The federal government recognizes long COVID as a condition and said in two reports issued in August that one in five adult COVID-19 survivors have a health condition related to their illness.
COVID-19 can damage multiple organs in the body. Sometimes this damage leads to long COVID; sometimes other reasons are at play. Doctors are beginning to sort it out.
“COVID itself can actually cause prolonged illness, and we don’t really call that long COVID,” said Nisha Viswanathan, MD, a doctor at UCLA Health in Los Angeles. But if symptoms extend beyond 12 weeks, that puts patients in the realm of long COVID.
Symptoms can range from mild to severe and can keep people from resuming their normal lives and jobs. Sometimes they last for months, according to the U.S. Department of Health & Human Services.
Multiorgan damage
Lung scarring and other lung problems are common after COVID, said Leora Horwitz, MD, an internal medicine specialist at New York University. Even after a mild case, people can have breathing issues for months, a team at Johns Hopkins Medicine, Baltimore, said in an online briefing. One study published in the journal Radiology found damage in people a full year after a COVID-19 diagnosis.
Some people have persistent heart, kidney, liver, and nervous system problems after COVID-19. A study published in 2020 in JAMA Cardiology found 60% of people who had COVID-19 had ongoing signs of heart inflammation. Nearly a third of people hospitalized for COVID-19 get kidney damage that can become chronic, and some end up needing dialysis or a transplant, said C. John Sperati, MD, a kidney specialist at Johns Hopkins Medicine.
This might be, in part, because SARS-CoV-2, the virus that causes COVID-19, directly infects the cells in many organs.
Nicole Bhave, MD, a cardiologist at University of Michigan Health, Ann Arbor is concerned that COVID-19 appears to increase the risk of heart problems in some people.
“Some of the uptick may just be recognition bias, in that people with symptoms are seeking care,” she said. “But there’s definitely a biological basis by which COVID could tip people over into a new diagnosis of heart failure.”
Inflammation
Inflammation is probably a key part of the long-term effects of COVID-19.
Some people have a serious immune reaction to COVID-19 called a cytokine storm, said Nitra Aggarwal Gilotra, MD, a cardiologist at Johns Hopkins Medicine. This release of inflammation-causing molecules called cytokines is meant to attack the invading virus. But it can be so severe that it wreaks havoc on healthy tissues and organs and causes lasting damage – if patients even survive it.
In some people, inflammation can affect the heart, causing myocarditis. Myocarditis symptoms include chest pain, breathlessness, and heart palpitations. Though rare, it can be serious and can raise the risk of other heart problems, including heart failure, down the line.
Long COVID may also trigger an autoimmune condition, said Eline Luning Prak, MD, PhD, a pathologist at the Hospital of the University of Pennsylvania, Philadelphia. Long COVID can share many hallmark symptoms with autoimmune diseases, including fatigue, widespread pain, memory problems, and mood disorders.
Blood clots
Studies have shown the overcharged inflammatory response to COVID-19 can cause blood clots. This sometimes overwhelming clotting was an early hallmark of COVID-19 infection, and when clots restrict blood flow in the brain, lungs, kidneys, or limbs, they can cause long-term damage. Some can be deadly. Researchers in Sweden found patients were at risk of deep vein thrombosis – a blood clot usually in the leg – up to 3 months after infection and at higher risk of a blood clot in the lung, called pulmonary embolism, for as long as 3 months.
Viral reservoirs
The virus itself may also linger in a patient’s body, causing continued symptoms and, potentially, new flare-ups. Zoe Swank, PhD, of Harvard Medical School, Boston, and colleagues reported in a preprint study that they found pieces of the SARS-CoV-2 virus in the blood of most patients with long COVID symptoms they tested – some as long as a year after infection. The study has not yet been peer reviewed.
Another team found evidence of the virus in stool up to 7 months later, which suggests the virus hides out in the gut. Other early studies have found bits of viral RNA in the appendix, breast tissue, heart, eyes, and brain.
Diabetes
Diabetes is a risk factor for getting severe COVID-19, and multiple studies have shown people can get diabetes both while battling infection and afterward. One study of veterans, published in The Lancet Diabetes and Endocrinology, found COVID-19 survivors were about 40% more likely to get diabetes over the next year.
There are a few ways this might happen. Insulin-producing cells in the pancreas have SARS-CoV-2 receptors – a type of molecular doorway the coronavirus can attach to. Damage to these cells could make the body less able to produce insulin, which in turn can lead to diabetes. The virus could also disrupt the balance in the body or cause inflammation that leads to insulin resistance, which can develop into diabetes, Ziad Al-Aly, MD, of the Veterans Affairs St. Louis Health Care System, and colleagues wrote.
Nervous system issues
People who get COVID-19 are also more vulnerable to postural orthostatic tachycardia syndrome (POTS). This affects what’s known as the autonomic nervous system, which regulates blood circulation, and includes those things that happen in your body without your having to think about them, like breathing, heartbeat, and digestion. POTS can cause common long COVID neurologic symptoms, including headaches, fatigue, brain fog, insomnia, and problems thinking and concentrating. “This was a known condition prior to COVID, but it was incredibly rare,” said Dr. Viswanathan. “After COVID, I’ve seen it with increasing frequency.”
Long-term outlook
Lasting issues after COVID-19 are much more likely after a moderate or severe infection. Still, plenty of people are battling them even after a mild illness. “As for why, that’s the billion-dollar question,” said Dr. Horwitz. “It’s well known that viral infections can cause long-term dysregulation. Why that is, we really just don’t know.”
Whether it’s virus hiding out in the body, long-term organ damage, or an autoimmune reaction likely differs from person to person. “I’m believing, increasingly, that it’s a combination of all of these, just based on how different patients are responding to different medications,” said Dr. Viswanathan. “One patient will respond to something beautifully, and another patient won’t at all.”
But it’s clear a significant number of people are facing long-term health struggles because of COVID-19, which has infected at least 580 million people globally and 92 million – likely many more – in the United States, according to Johns Hopkins University.
Even a small increased risk of conditions like heart disease or diabetes translates to a huge number of people, Dr. Horwitz said. “If even 1% of people getting COVID have long-term symptoms, that’s a major public health crisis, because that’s 1% of pretty much everybody in the country.”
A version of this article first appeared on WebMD.com.
There’s little doubt long COVID is real. The federal government recognizes long COVID as a condition and said in two reports issued in August that one in five adult COVID-19 survivors have a health condition related to their illness.
COVID-19 can damage multiple organs in the body. Sometimes this damage leads to long COVID; sometimes other reasons are at play. Doctors are beginning to sort it out.
“COVID itself can actually cause prolonged illness, and we don’t really call that long COVID,” said Nisha Viswanathan, MD, a doctor at UCLA Health in Los Angeles. But if symptoms extend beyond 12 weeks, that puts patients in the realm of long COVID.
Symptoms can range from mild to severe and can keep people from resuming their normal lives and jobs. Sometimes they last for months, according to the U.S. Department of Health & Human Services.
Multiorgan damage
Lung scarring and other lung problems are common after COVID, said Leora Horwitz, MD, an internal medicine specialist at New York University. Even after a mild case, people can have breathing issues for months, a team at Johns Hopkins Medicine, Baltimore, said in an online briefing. One study published in the journal Radiology found damage in people a full year after a COVID-19 diagnosis.
Some people have persistent heart, kidney, liver, and nervous system problems after COVID-19. A study published in 2020 in JAMA Cardiology found 60% of people who had COVID-19 had ongoing signs of heart inflammation. Nearly a third of people hospitalized for COVID-19 get kidney damage that can become chronic, and some end up needing dialysis or a transplant, said C. John Sperati, MD, a kidney specialist at Johns Hopkins Medicine.
This might be, in part, because SARS-CoV-2, the virus that causes COVID-19, directly infects the cells in many organs.
Nicole Bhave, MD, a cardiologist at University of Michigan Health, Ann Arbor is concerned that COVID-19 appears to increase the risk of heart problems in some people.
“Some of the uptick may just be recognition bias, in that people with symptoms are seeking care,” she said. “But there’s definitely a biological basis by which COVID could tip people over into a new diagnosis of heart failure.”
Inflammation
Inflammation is probably a key part of the long-term effects of COVID-19.
Some people have a serious immune reaction to COVID-19 called a cytokine storm, said Nitra Aggarwal Gilotra, MD, a cardiologist at Johns Hopkins Medicine. This release of inflammation-causing molecules called cytokines is meant to attack the invading virus. But it can be so severe that it wreaks havoc on healthy tissues and organs and causes lasting damage – if patients even survive it.
In some people, inflammation can affect the heart, causing myocarditis. Myocarditis symptoms include chest pain, breathlessness, and heart palpitations. Though rare, it can be serious and can raise the risk of other heart problems, including heart failure, down the line.
Long COVID may also trigger an autoimmune condition, said Eline Luning Prak, MD, PhD, a pathologist at the Hospital of the University of Pennsylvania, Philadelphia. Long COVID can share many hallmark symptoms with autoimmune diseases, including fatigue, widespread pain, memory problems, and mood disorders.
Blood clots
Studies have shown the overcharged inflammatory response to COVID-19 can cause blood clots. This sometimes overwhelming clotting was an early hallmark of COVID-19 infection, and when clots restrict blood flow in the brain, lungs, kidneys, or limbs, they can cause long-term damage. Some can be deadly. Researchers in Sweden found patients were at risk of deep vein thrombosis – a blood clot usually in the leg – up to 3 months after infection and at higher risk of a blood clot in the lung, called pulmonary embolism, for as long as 3 months.
Viral reservoirs
The virus itself may also linger in a patient’s body, causing continued symptoms and, potentially, new flare-ups. Zoe Swank, PhD, of Harvard Medical School, Boston, and colleagues reported in a preprint study that they found pieces of the SARS-CoV-2 virus in the blood of most patients with long COVID symptoms they tested – some as long as a year after infection. The study has not yet been peer reviewed.
Another team found evidence of the virus in stool up to 7 months later, which suggests the virus hides out in the gut. Other early studies have found bits of viral RNA in the appendix, breast tissue, heart, eyes, and brain.
Diabetes
Diabetes is a risk factor for getting severe COVID-19, and multiple studies have shown people can get diabetes both while battling infection and afterward. One study of veterans, published in The Lancet Diabetes and Endocrinology, found COVID-19 survivors were about 40% more likely to get diabetes over the next year.
There are a few ways this might happen. Insulin-producing cells in the pancreas have SARS-CoV-2 receptors – a type of molecular doorway the coronavirus can attach to. Damage to these cells could make the body less able to produce insulin, which in turn can lead to diabetes. The virus could also disrupt the balance in the body or cause inflammation that leads to insulin resistance, which can develop into diabetes, Ziad Al-Aly, MD, of the Veterans Affairs St. Louis Health Care System, and colleagues wrote.
Nervous system issues
People who get COVID-19 are also more vulnerable to postural orthostatic tachycardia syndrome (POTS). This affects what’s known as the autonomic nervous system, which regulates blood circulation, and includes those things that happen in your body without your having to think about them, like breathing, heartbeat, and digestion. POTS can cause common long COVID neurologic symptoms, including headaches, fatigue, brain fog, insomnia, and problems thinking and concentrating. “This was a known condition prior to COVID, but it was incredibly rare,” said Dr. Viswanathan. “After COVID, I’ve seen it with increasing frequency.”
Long-term outlook
Lasting issues after COVID-19 are much more likely after a moderate or severe infection. Still, plenty of people are battling them even after a mild illness. “As for why, that’s the billion-dollar question,” said Dr. Horwitz. “It’s well known that viral infections can cause long-term dysregulation. Why that is, we really just don’t know.”
Whether it’s virus hiding out in the body, long-term organ damage, or an autoimmune reaction likely differs from person to person. “I’m believing, increasingly, that it’s a combination of all of these, just based on how different patients are responding to different medications,” said Dr. Viswanathan. “One patient will respond to something beautifully, and another patient won’t at all.”
But it’s clear a significant number of people are facing long-term health struggles because of COVID-19, which has infected at least 580 million people globally and 92 million – likely many more – in the United States, according to Johns Hopkins University.
Even a small increased risk of conditions like heart disease or diabetes translates to a huge number of people, Dr. Horwitz said. “If even 1% of people getting COVID have long-term symptoms, that’s a major public health crisis, because that’s 1% of pretty much everybody in the country.”
A version of this article first appeared on WebMD.com.
There’s little doubt long COVID is real. The federal government recognizes long COVID as a condition and said in two reports issued in August that one in five adult COVID-19 survivors have a health condition related to their illness.
COVID-19 can damage multiple organs in the body. Sometimes this damage leads to long COVID; sometimes other reasons are at play. Doctors are beginning to sort it out.
“COVID itself can actually cause prolonged illness, and we don’t really call that long COVID,” said Nisha Viswanathan, MD, a doctor at UCLA Health in Los Angeles. But if symptoms extend beyond 12 weeks, that puts patients in the realm of long COVID.
Symptoms can range from mild to severe and can keep people from resuming their normal lives and jobs. Sometimes they last for months, according to the U.S. Department of Health & Human Services.
Multiorgan damage
Lung scarring and other lung problems are common after COVID, said Leora Horwitz, MD, an internal medicine specialist at New York University. Even after a mild case, people can have breathing issues for months, a team at Johns Hopkins Medicine, Baltimore, said in an online briefing. One study published in the journal Radiology found damage in people a full year after a COVID-19 diagnosis.
Some people have persistent heart, kidney, liver, and nervous system problems after COVID-19. A study published in 2020 in JAMA Cardiology found 60% of people who had COVID-19 had ongoing signs of heart inflammation. Nearly a third of people hospitalized for COVID-19 get kidney damage that can become chronic, and some end up needing dialysis or a transplant, said C. John Sperati, MD, a kidney specialist at Johns Hopkins Medicine.
This might be, in part, because SARS-CoV-2, the virus that causes COVID-19, directly infects the cells in many organs.
Nicole Bhave, MD, a cardiologist at University of Michigan Health, Ann Arbor is concerned that COVID-19 appears to increase the risk of heart problems in some people.
“Some of the uptick may just be recognition bias, in that people with symptoms are seeking care,” she said. “But there’s definitely a biological basis by which COVID could tip people over into a new diagnosis of heart failure.”
Inflammation
Inflammation is probably a key part of the long-term effects of COVID-19.
Some people have a serious immune reaction to COVID-19 called a cytokine storm, said Nitra Aggarwal Gilotra, MD, a cardiologist at Johns Hopkins Medicine. This release of inflammation-causing molecules called cytokines is meant to attack the invading virus. But it can be so severe that it wreaks havoc on healthy tissues and organs and causes lasting damage – if patients even survive it.
In some people, inflammation can affect the heart, causing myocarditis. Myocarditis symptoms include chest pain, breathlessness, and heart palpitations. Though rare, it can be serious and can raise the risk of other heart problems, including heart failure, down the line.
Long COVID may also trigger an autoimmune condition, said Eline Luning Prak, MD, PhD, a pathologist at the Hospital of the University of Pennsylvania, Philadelphia. Long COVID can share many hallmark symptoms with autoimmune diseases, including fatigue, widespread pain, memory problems, and mood disorders.
Blood clots
Studies have shown the overcharged inflammatory response to COVID-19 can cause blood clots. This sometimes overwhelming clotting was an early hallmark of COVID-19 infection, and when clots restrict blood flow in the brain, lungs, kidneys, or limbs, they can cause long-term damage. Some can be deadly. Researchers in Sweden found patients were at risk of deep vein thrombosis – a blood clot usually in the leg – up to 3 months after infection and at higher risk of a blood clot in the lung, called pulmonary embolism, for as long as 3 months.
Viral reservoirs
The virus itself may also linger in a patient’s body, causing continued symptoms and, potentially, new flare-ups. Zoe Swank, PhD, of Harvard Medical School, Boston, and colleagues reported in a preprint study that they found pieces of the SARS-CoV-2 virus in the blood of most patients with long COVID symptoms they tested – some as long as a year after infection. The study has not yet been peer reviewed.
Another team found evidence of the virus in stool up to 7 months later, which suggests the virus hides out in the gut. Other early studies have found bits of viral RNA in the appendix, breast tissue, heart, eyes, and brain.
Diabetes
Diabetes is a risk factor for getting severe COVID-19, and multiple studies have shown people can get diabetes both while battling infection and afterward. One study of veterans, published in The Lancet Diabetes and Endocrinology, found COVID-19 survivors were about 40% more likely to get diabetes over the next year.
There are a few ways this might happen. Insulin-producing cells in the pancreas have SARS-CoV-2 receptors – a type of molecular doorway the coronavirus can attach to. Damage to these cells could make the body less able to produce insulin, which in turn can lead to diabetes. The virus could also disrupt the balance in the body or cause inflammation that leads to insulin resistance, which can develop into diabetes, Ziad Al-Aly, MD, of the Veterans Affairs St. Louis Health Care System, and colleagues wrote.
Nervous system issues
People who get COVID-19 are also more vulnerable to postural orthostatic tachycardia syndrome (POTS). This affects what’s known as the autonomic nervous system, which regulates blood circulation, and includes those things that happen in your body without your having to think about them, like breathing, heartbeat, and digestion. POTS can cause common long COVID neurologic symptoms, including headaches, fatigue, brain fog, insomnia, and problems thinking and concentrating. “This was a known condition prior to COVID, but it was incredibly rare,” said Dr. Viswanathan. “After COVID, I’ve seen it with increasing frequency.”
Long-term outlook
Lasting issues after COVID-19 are much more likely after a moderate or severe infection. Still, plenty of people are battling them even after a mild illness. “As for why, that’s the billion-dollar question,” said Dr. Horwitz. “It’s well known that viral infections can cause long-term dysregulation. Why that is, we really just don’t know.”
Whether it’s virus hiding out in the body, long-term organ damage, or an autoimmune reaction likely differs from person to person. “I’m believing, increasingly, that it’s a combination of all of these, just based on how different patients are responding to different medications,” said Dr. Viswanathan. “One patient will respond to something beautifully, and another patient won’t at all.”
But it’s clear a significant number of people are facing long-term health struggles because of COVID-19, which has infected at least 580 million people globally and 92 million – likely many more – in the United States, according to Johns Hopkins University.
Even a small increased risk of conditions like heart disease or diabetes translates to a huge number of people, Dr. Horwitz said. “If even 1% of people getting COVID have long-term symptoms, that’s a major public health crisis, because that’s 1% of pretty much everybody in the country.”
A version of this article first appeared on WebMD.com.
Most people with Omicron don’t know they’re infected
Most people with Omicron likely don’t know it.
That’s according to a study in JAMA Network Open, which says 56% of people who have the Omicron variant of the coronavirus are unaware of their infection.
And it has an upside and a downside, depending on how you look at it, according to Time magazine.
“It’s good news, in some ways, since ) in vaccinated people,” Time says. “The downside is that many people are likely spreading the virus unintentionally.”
The study looked at 210 hospital patients and employees in the Los Angeles area. More than half who tested positive didn’t know it – because they had no symptoms, or they assumed they merely had a cold or allergies.
“The findings support early data from around the world suggesting that throughout the pandemic, anywhere from 25% to 40% of SARS-CoV-2 infections have been asymptomatic, which presents challenges for public health officials trying to control the spread of the virus,” Time reports.
The study found that awareness of infection rose after at-home tests became available this year. About three-quarters of people in January and February didn’t know their status, for example.
“Findings of this study suggest that low rates of Omicron variant infection awareness may be a key contributor to rapid transmission of the virus within communities,” the authors wrote. “Given that unawareness of active infection precludes self-initiated interventions, such as testing and self-isolation, even modest levels of undiagnosed infection can contribute to substantial population-level transmission.”
A version of this article first appeared on WebMD.com.
Most people with Omicron likely don’t know it.
That’s according to a study in JAMA Network Open, which says 56% of people who have the Omicron variant of the coronavirus are unaware of their infection.
And it has an upside and a downside, depending on how you look at it, according to Time magazine.
“It’s good news, in some ways, since ) in vaccinated people,” Time says. “The downside is that many people are likely spreading the virus unintentionally.”
The study looked at 210 hospital patients and employees in the Los Angeles area. More than half who tested positive didn’t know it – because they had no symptoms, or they assumed they merely had a cold or allergies.
“The findings support early data from around the world suggesting that throughout the pandemic, anywhere from 25% to 40% of SARS-CoV-2 infections have been asymptomatic, which presents challenges for public health officials trying to control the spread of the virus,” Time reports.
The study found that awareness of infection rose after at-home tests became available this year. About three-quarters of people in January and February didn’t know their status, for example.
“Findings of this study suggest that low rates of Omicron variant infection awareness may be a key contributor to rapid transmission of the virus within communities,” the authors wrote. “Given that unawareness of active infection precludes self-initiated interventions, such as testing and self-isolation, even modest levels of undiagnosed infection can contribute to substantial population-level transmission.”
A version of this article first appeared on WebMD.com.
Most people with Omicron likely don’t know it.
That’s according to a study in JAMA Network Open, which says 56% of people who have the Omicron variant of the coronavirus are unaware of their infection.
And it has an upside and a downside, depending on how you look at it, according to Time magazine.
“It’s good news, in some ways, since ) in vaccinated people,” Time says. “The downside is that many people are likely spreading the virus unintentionally.”
The study looked at 210 hospital patients and employees in the Los Angeles area. More than half who tested positive didn’t know it – because they had no symptoms, or they assumed they merely had a cold or allergies.
“The findings support early data from around the world suggesting that throughout the pandemic, anywhere from 25% to 40% of SARS-CoV-2 infections have been asymptomatic, which presents challenges for public health officials trying to control the spread of the virus,” Time reports.
The study found that awareness of infection rose after at-home tests became available this year. About three-quarters of people in January and February didn’t know their status, for example.
“Findings of this study suggest that low rates of Omicron variant infection awareness may be a key contributor to rapid transmission of the virus within communities,” the authors wrote. “Given that unawareness of active infection precludes self-initiated interventions, such as testing and self-isolation, even modest levels of undiagnosed infection can contribute to substantial population-level transmission.”
A version of this article first appeared on WebMD.com.
FROM JAMA NETWORK OPEN
How physicians and their organizations react to online hate
“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.
“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.
The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil.
Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”
At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.
A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.
Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
Police recommend supervision
Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.
Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.
According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.
Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
Leaving Twitter
A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.
At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.
In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.
“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.
“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.
“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.
“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.
Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.
General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
Harassment continues
The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”
“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.
The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”
Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”
For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
Increasing aggression
At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.
The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.
Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.
The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.
Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.
To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.
Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
Staying on Twitter
Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.
As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”
“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.
Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”
Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”
He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”
The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
Right-wing extremism
What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.
In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.
The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”
A version of this article first appeared on Medscape.com.
This article was translated from the Medscape German edition.
“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.
“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.
The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil.
Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”
At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.
A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.
Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
Police recommend supervision
Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.
Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.
According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.
Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
Leaving Twitter
A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.
At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.
In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.
“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.
“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.
“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.
“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.
Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.
General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
Harassment continues
The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”
“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.
The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”
Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”
For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
Increasing aggression
At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.
The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.
Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.
The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.
Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.
To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.
Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
Staying on Twitter
Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.
As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”
“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.
Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”
Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”
He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”
The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
Right-wing extremism
What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.
In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.
The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”
A version of this article first appeared on Medscape.com.
This article was translated from the Medscape German edition.
“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.
“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.
The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil.
Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”
At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.
A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.
Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
Police recommend supervision
Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.
Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.
According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.
Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
Leaving Twitter
A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.
At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.
In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.
“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.
“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.
“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.
“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.
Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.
General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
Harassment continues
The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”
“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.
The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”
Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”
For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
Increasing aggression
At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.
The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.
Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.
The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.
Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.
To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.
Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
Staying on Twitter
Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.
As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”
“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.
Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”
Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”
He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”
The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
Right-wing extremism
What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.
In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.
The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”
A version of this article first appeared on Medscape.com.
This article was translated from the Medscape German edition.
Stop smoking and reduce death risk from pneumonia?
; the risk decreased even more with added years of not smoking, according to data from nearly 95,000 individuals.
Smoking is associated with an increased risk for pneumonia, but the extent to which smoking cessation reduces this risk long-term has not been explored, wrote Tomomi Kihara, MD, PhD, of the University of Tsukuba, Japan, and colleagues on behalf of the Japan Collaborative Cohort.
In the Japan Collaborative Cohort Study for Evaluation of Cancer Risk, known as the JACC Study, a community-based cohort of 110,585 individuals aged 40-79 years participated in health screening exams and self-administered questionnaires that included information about smoking. Other findings from the study have been previously published.
In the current study published in Preventive Medicine, the researchers reviewed data from 94,972 JACC participants who provided data about smoking status, including 59,514 never-smokers, 10,554 former smokers, and 24,904 current smokers. The mean age of the participants was 57 years; 57% were women.
The respondents were divided into groups based on years of smoking cessation: 0-1 year, 2-4 years, 5-9 years, 10-14 years, and 15 or more years. The primary endpoint was an underlying cause of death from pneumonia.
Over a median follow-up period of 19 years, 1,806 participants (1,115 men and 691 women) died of pneumonia.
In a multivariate analysis, the hazard ratio for those who quit smoking, compared with current smokers, was 1.02 for 0-1 year of smoking cessation, 0.92 for 2-4 years, 0.95 for 5-9 years, 0.71 for 10-14 years, and 0.63 (0.48-0.83) for 15 or more years. The HR for never smokers was 0.50. The analysis adjusted for competing risk for death without pneumonia in the study population.
Most of the benefits of smoking cessation occurred after 10-14 years, the researchers wrote in their discussion of the findings, and smoking cessation of 10 years or more resulted in risk for death from pneumonia similar to that of never-smokers.
“To our knowledge, no previous studies have examined the association between years of smoking cessation and pneumonia in a general population,” they added.
The study findings were limited by several factors, including the use of data on smoking and smoking cessation at baseline as well as a lack of data on the use of tobacco products other than cigarettes, although alternative tobacco products are rarely used in Japan, the researchers noted. Other limitations include the use of pneumonia mortality as an endpoint, which could have ignored the impact of smoking cessation on less severe pneumonia, and the inability to clarify the association between smoking cessation and pneumonia mortality by sex because of the small number of female former smokers. However, the results were strengthened by the large sample size and long observation period, they said.
“The present study provides empirical evidence that smoking cessation may lead to a decline in the risk of mortality from pneumonia,” and supports smoking cessation as a preventive measure, the researchers concluded.
The study was supported by the Japanese Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare, Health and Labor Sciences; and an Intramural Research Fund for Cardiovascular Diseases of National Cerebral and Cardiovascular Center. The researchers had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
; the risk decreased even more with added years of not smoking, according to data from nearly 95,000 individuals.
Smoking is associated with an increased risk for pneumonia, but the extent to which smoking cessation reduces this risk long-term has not been explored, wrote Tomomi Kihara, MD, PhD, of the University of Tsukuba, Japan, and colleagues on behalf of the Japan Collaborative Cohort.
In the Japan Collaborative Cohort Study for Evaluation of Cancer Risk, known as the JACC Study, a community-based cohort of 110,585 individuals aged 40-79 years participated in health screening exams and self-administered questionnaires that included information about smoking. Other findings from the study have been previously published.
In the current study published in Preventive Medicine, the researchers reviewed data from 94,972 JACC participants who provided data about smoking status, including 59,514 never-smokers, 10,554 former smokers, and 24,904 current smokers. The mean age of the participants was 57 years; 57% were women.
The respondents were divided into groups based on years of smoking cessation: 0-1 year, 2-4 years, 5-9 years, 10-14 years, and 15 or more years. The primary endpoint was an underlying cause of death from pneumonia.
Over a median follow-up period of 19 years, 1,806 participants (1,115 men and 691 women) died of pneumonia.
In a multivariate analysis, the hazard ratio for those who quit smoking, compared with current smokers, was 1.02 for 0-1 year of smoking cessation, 0.92 for 2-4 years, 0.95 for 5-9 years, 0.71 for 10-14 years, and 0.63 (0.48-0.83) for 15 or more years. The HR for never smokers was 0.50. The analysis adjusted for competing risk for death without pneumonia in the study population.
Most of the benefits of smoking cessation occurred after 10-14 years, the researchers wrote in their discussion of the findings, and smoking cessation of 10 years or more resulted in risk for death from pneumonia similar to that of never-smokers.
“To our knowledge, no previous studies have examined the association between years of smoking cessation and pneumonia in a general population,” they added.
The study findings were limited by several factors, including the use of data on smoking and smoking cessation at baseline as well as a lack of data on the use of tobacco products other than cigarettes, although alternative tobacco products are rarely used in Japan, the researchers noted. Other limitations include the use of pneumonia mortality as an endpoint, which could have ignored the impact of smoking cessation on less severe pneumonia, and the inability to clarify the association between smoking cessation and pneumonia mortality by sex because of the small number of female former smokers. However, the results were strengthened by the large sample size and long observation period, they said.
“The present study provides empirical evidence that smoking cessation may lead to a decline in the risk of mortality from pneumonia,” and supports smoking cessation as a preventive measure, the researchers concluded.
The study was supported by the Japanese Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare, Health and Labor Sciences; and an Intramural Research Fund for Cardiovascular Diseases of National Cerebral and Cardiovascular Center. The researchers had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
; the risk decreased even more with added years of not smoking, according to data from nearly 95,000 individuals.
Smoking is associated with an increased risk for pneumonia, but the extent to which smoking cessation reduces this risk long-term has not been explored, wrote Tomomi Kihara, MD, PhD, of the University of Tsukuba, Japan, and colleagues on behalf of the Japan Collaborative Cohort.
In the Japan Collaborative Cohort Study for Evaluation of Cancer Risk, known as the JACC Study, a community-based cohort of 110,585 individuals aged 40-79 years participated in health screening exams and self-administered questionnaires that included information about smoking. Other findings from the study have been previously published.
In the current study published in Preventive Medicine, the researchers reviewed data from 94,972 JACC participants who provided data about smoking status, including 59,514 never-smokers, 10,554 former smokers, and 24,904 current smokers. The mean age of the participants was 57 years; 57% were women.
The respondents were divided into groups based on years of smoking cessation: 0-1 year, 2-4 years, 5-9 years, 10-14 years, and 15 or more years. The primary endpoint was an underlying cause of death from pneumonia.
Over a median follow-up period of 19 years, 1,806 participants (1,115 men and 691 women) died of pneumonia.
In a multivariate analysis, the hazard ratio for those who quit smoking, compared with current smokers, was 1.02 for 0-1 year of smoking cessation, 0.92 for 2-4 years, 0.95 for 5-9 years, 0.71 for 10-14 years, and 0.63 (0.48-0.83) for 15 or more years. The HR for never smokers was 0.50. The analysis adjusted for competing risk for death without pneumonia in the study population.
Most of the benefits of smoking cessation occurred after 10-14 years, the researchers wrote in their discussion of the findings, and smoking cessation of 10 years or more resulted in risk for death from pneumonia similar to that of never-smokers.
“To our knowledge, no previous studies have examined the association between years of smoking cessation and pneumonia in a general population,” they added.
The study findings were limited by several factors, including the use of data on smoking and smoking cessation at baseline as well as a lack of data on the use of tobacco products other than cigarettes, although alternative tobacco products are rarely used in Japan, the researchers noted. Other limitations include the use of pneumonia mortality as an endpoint, which could have ignored the impact of smoking cessation on less severe pneumonia, and the inability to clarify the association between smoking cessation and pneumonia mortality by sex because of the small number of female former smokers. However, the results were strengthened by the large sample size and long observation period, they said.
“The present study provides empirical evidence that smoking cessation may lead to a decline in the risk of mortality from pneumonia,” and supports smoking cessation as a preventive measure, the researchers concluded.
The study was supported by the Japanese Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare, Health and Labor Sciences; and an Intramural Research Fund for Cardiovascular Diseases of National Cerebral and Cardiovascular Center. The researchers had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
Physicians’ bad behavior seen at work, online by colleagues: Survey
“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”
But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.
For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.
Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.
“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
Bullying and harassment top bad behavior
When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.
Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.
Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).
Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
Speaking up
Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.
Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.
Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.
“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
Off the job
Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.
Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.
The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.
When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”
Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”
Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”
As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”
A version of this article first appeared on Medscape.com.
“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”
But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.
For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.
Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.
“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
Bullying and harassment top bad behavior
When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.
Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.
Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).
Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
Speaking up
Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.
Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.
Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.
“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
Off the job
Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.
Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.
The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.
When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”
Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”
Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”
As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”
A version of this article first appeared on Medscape.com.
“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”
But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.
For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.
Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.
“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
Bullying and harassment top bad behavior
When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.
Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.
Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).
Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
Speaking up
Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.
Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.
Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.
“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
Off the job
Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.
Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.
The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.
When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”
Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”
Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”
As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”
A version of this article first appeared on Medscape.com.
COVID-19 may trigger irritable bowel syndrome
Gastrointestinal symptoms are common with long COVID, also known as post-acute COVID-19 syndrome, according to Walter Chan, MD, MPH, and Madhusudan Grover, MBBS.
Dr. Chan, an assistant professor at Harvard Medical School, Boston, and Dr. Grover, an associate professor of medicine and physiology at Mayo Clinic, Rochester, Minn., conducted a review of the literature on COVID-19’s long-term gastrointestinal effects. Their review was published in Clinical Gastroenterology and Hepatology.
Estimates of the prevalence of gastrointestinal symptoms with COVID-19 have ranged as high as 60%, Dr. Chan and Dr. Grover report, and the symptoms may be present in patients with long COVID, a syndrome that continues 4 weeks or longer.
In one survey of 749 COVID-19 survivors, 29% reported at least one new chronic gastrointestinal symptom. The most common were heartburn, constipation, diarrhea, and abdominal pain. Of those with abdominal pain, 39% had symptoms that met Rome IV criteria for irritable bowel syndrome.
People who have gastrointestinal symptoms after their initial SARS-CoV-2 infection are more likely to have them with long COVID. Psychiatric diagnoses, hospitalization, and the loss of smell and taste are predictors of gastrointestinal symptoms.
Infectious gastroenteritis can increase the risk for disorders of gut-brain interaction, especially postinfection IBS, Dr. Chan and Dr. Grover write.
COVID-19 likely causes gastrointestinal symptoms through multiple mechanisms. It may suppress angiotensin-converting enzyme 2, which protects intestinal cells. It can alter the microbiome. It can cause or worsen weight gain and diabetes. It may disrupt the immune system and trigger an autoimmune reaction. It can cause depression and anxiety, and it can alter dietary habits.
No specific treatments for gastrointestinal symptoms associated with long COVID have emerged, so clinicians should make use of established therapies for disorders of gut-brain interaction, Dr. Chan and Dr. Grover recommend.
Beyond adequate sleep and exercise, these may include high-fiber, low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), gluten-free, low-carbohydrate, or elimination diets.
For diarrhea, they list loperamide, ondansetron, alosetron, eluxadoline, antispasmodics, rifaximin, and bile acid sequestrants.
For constipation, they mention fiber supplements, polyethylene glycol, linaclotide, plecanatide, lubiprostone, tenapanor, tegaserod, and prucalopride.
For modulating intestinal permeability, they recommend glutamine.
Neuromodulation may be achieved with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, azaperones, and delta ligands, they write.
For psychological therapy, they recommend cognitive-behavioral therapy and gut-directed hypnotherapy.
A handful of studies have suggested benefits from Lactiplantibacillus plantarum and Pediococcus acidilactici as probiotic therapies. Additionally, one study showed positive results with a high-fiber formula, perhaps by nourishing short-chain fatty acid-producing bacteria, Dr. Chan and Dr. Grover write.
Dr. Chan reported financial relationships with Ironwood, Takeda, and Phathom Pharmaceuticals. Dr. Grover reported financial relationships with Takeda, Donga, Alexza Pharmaceuticals, and Alfasigma.
A version of this article first appeared on Medscape.com.
Gastrointestinal symptoms are common with long COVID, also known as post-acute COVID-19 syndrome, according to Walter Chan, MD, MPH, and Madhusudan Grover, MBBS.
Dr. Chan, an assistant professor at Harvard Medical School, Boston, and Dr. Grover, an associate professor of medicine and physiology at Mayo Clinic, Rochester, Minn., conducted a review of the literature on COVID-19’s long-term gastrointestinal effects. Their review was published in Clinical Gastroenterology and Hepatology.
Estimates of the prevalence of gastrointestinal symptoms with COVID-19 have ranged as high as 60%, Dr. Chan and Dr. Grover report, and the symptoms may be present in patients with long COVID, a syndrome that continues 4 weeks or longer.
In one survey of 749 COVID-19 survivors, 29% reported at least one new chronic gastrointestinal symptom. The most common were heartburn, constipation, diarrhea, and abdominal pain. Of those with abdominal pain, 39% had symptoms that met Rome IV criteria for irritable bowel syndrome.
People who have gastrointestinal symptoms after their initial SARS-CoV-2 infection are more likely to have them with long COVID. Psychiatric diagnoses, hospitalization, and the loss of smell and taste are predictors of gastrointestinal symptoms.
Infectious gastroenteritis can increase the risk for disorders of gut-brain interaction, especially postinfection IBS, Dr. Chan and Dr. Grover write.
COVID-19 likely causes gastrointestinal symptoms through multiple mechanisms. It may suppress angiotensin-converting enzyme 2, which protects intestinal cells. It can alter the microbiome. It can cause or worsen weight gain and diabetes. It may disrupt the immune system and trigger an autoimmune reaction. It can cause depression and anxiety, and it can alter dietary habits.
No specific treatments for gastrointestinal symptoms associated with long COVID have emerged, so clinicians should make use of established therapies for disorders of gut-brain interaction, Dr. Chan and Dr. Grover recommend.
Beyond adequate sleep and exercise, these may include high-fiber, low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), gluten-free, low-carbohydrate, or elimination diets.
For diarrhea, they list loperamide, ondansetron, alosetron, eluxadoline, antispasmodics, rifaximin, and bile acid sequestrants.
For constipation, they mention fiber supplements, polyethylene glycol, linaclotide, plecanatide, lubiprostone, tenapanor, tegaserod, and prucalopride.
For modulating intestinal permeability, they recommend glutamine.
Neuromodulation may be achieved with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, azaperones, and delta ligands, they write.
For psychological therapy, they recommend cognitive-behavioral therapy and gut-directed hypnotherapy.
A handful of studies have suggested benefits from Lactiplantibacillus plantarum and Pediococcus acidilactici as probiotic therapies. Additionally, one study showed positive results with a high-fiber formula, perhaps by nourishing short-chain fatty acid-producing bacteria, Dr. Chan and Dr. Grover write.
Dr. Chan reported financial relationships with Ironwood, Takeda, and Phathom Pharmaceuticals. Dr. Grover reported financial relationships with Takeda, Donga, Alexza Pharmaceuticals, and Alfasigma.
A version of this article first appeared on Medscape.com.
Gastrointestinal symptoms are common with long COVID, also known as post-acute COVID-19 syndrome, according to Walter Chan, MD, MPH, and Madhusudan Grover, MBBS.
Dr. Chan, an assistant professor at Harvard Medical School, Boston, and Dr. Grover, an associate professor of medicine and physiology at Mayo Clinic, Rochester, Minn., conducted a review of the literature on COVID-19’s long-term gastrointestinal effects. Their review was published in Clinical Gastroenterology and Hepatology.
Estimates of the prevalence of gastrointestinal symptoms with COVID-19 have ranged as high as 60%, Dr. Chan and Dr. Grover report, and the symptoms may be present in patients with long COVID, a syndrome that continues 4 weeks or longer.
In one survey of 749 COVID-19 survivors, 29% reported at least one new chronic gastrointestinal symptom. The most common were heartburn, constipation, diarrhea, and abdominal pain. Of those with abdominal pain, 39% had symptoms that met Rome IV criteria for irritable bowel syndrome.
People who have gastrointestinal symptoms after their initial SARS-CoV-2 infection are more likely to have them with long COVID. Psychiatric diagnoses, hospitalization, and the loss of smell and taste are predictors of gastrointestinal symptoms.
Infectious gastroenteritis can increase the risk for disorders of gut-brain interaction, especially postinfection IBS, Dr. Chan and Dr. Grover write.
COVID-19 likely causes gastrointestinal symptoms through multiple mechanisms. It may suppress angiotensin-converting enzyme 2, which protects intestinal cells. It can alter the microbiome. It can cause or worsen weight gain and diabetes. It may disrupt the immune system and trigger an autoimmune reaction. It can cause depression and anxiety, and it can alter dietary habits.
No specific treatments for gastrointestinal symptoms associated with long COVID have emerged, so clinicians should make use of established therapies for disorders of gut-brain interaction, Dr. Chan and Dr. Grover recommend.
Beyond adequate sleep and exercise, these may include high-fiber, low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), gluten-free, low-carbohydrate, or elimination diets.
For diarrhea, they list loperamide, ondansetron, alosetron, eluxadoline, antispasmodics, rifaximin, and bile acid sequestrants.
For constipation, they mention fiber supplements, polyethylene glycol, linaclotide, plecanatide, lubiprostone, tenapanor, tegaserod, and prucalopride.
For modulating intestinal permeability, they recommend glutamine.
Neuromodulation may be achieved with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, azaperones, and delta ligands, they write.
For psychological therapy, they recommend cognitive-behavioral therapy and gut-directed hypnotherapy.
A handful of studies have suggested benefits from Lactiplantibacillus plantarum and Pediococcus acidilactici as probiotic therapies. Additionally, one study showed positive results with a high-fiber formula, perhaps by nourishing short-chain fatty acid-producing bacteria, Dr. Chan and Dr. Grover write.
Dr. Chan reported financial relationships with Ironwood, Takeda, and Phathom Pharmaceuticals. Dr. Grover reported financial relationships with Takeda, Donga, Alexza Pharmaceuticals, and Alfasigma.
A version of this article first appeared on Medscape.com.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Long COVID case study: persistent hormone deficiencies
A case study of a 65-year-old man in Japan with long COVID describes how he recovered from certain impaired hormone deficiencies that persisted for more than a year.
Days after the patient recovered from respiratory failure and came off a ventilator, he had a sudden drop in blood pressure, which responded to hydrocortisone.
The patient was found to have low levels of growth hormone and adrenocorticotropic hormone (ACTH), hypopituitarism, that persisted for more than a year. He also had low levels of testosterone that remained low at 15 months (the study end).
“An important finding in the present case is the eventual recovery from hypopituitarism over time but not from hypogonadism,” the researchers write in their study published in Endocrine Journal.
, which was confirmed using an insulin tolerance test, Kai Yoshimura, Kakogawa Medical Center, Japan, and colleagues report.
The findings show that “pituitary insufficiency should be considered in patients with prolonged symptoms of COVID-19,” they report, since it can be treated with hormone supplements that markedly improve symptoms and quality of life.
“It might be worthwhile to screen for endocrine dysfunction in patients with such persistent symptoms after their recovery from the acute disease,” the researchers conclude.
Case study timeline
The patient in this study was healthy without obesity, previous endocrine disease, or steroid use. He was admitted to hospital because he had dyspnea and fever for 8 days and a reverse transcription-polymerase chain reaction (RT-PCR) test that was positive for COVID-19.
He received ciclesonide 200 mcg/day for 2 days. Then he was put on a ventilator and the drug was discontinued and “favipiravir, ritonavir, and lopinavir, a standard regimen during the early phase of the COVID-19 pandemic, were initiated;” the researchers explain.
On day 25 of his hospital stay the patient had recovered from respiratory failure and was extubated.
On day 31, he had a negative PCR test for COVID-19.
On day 36, the patient’s blood pressure suddenly dropped from 120/80 mmHg to 80/50 mmHg. His plasma ACTH and serum cortisol levels were low, suggesting secondary adrenal insufficiency. The low blood pressure responded to hydrocortisone 100 mg, which was gradually tapered.
At day 96, the patient was discharged from hospital with a dose of 15 mg/day hydrocortisone.
At 3 months after discharge, an insulin tolerance test revealed that the patient’s ACTH and cortisol responses were blunted, suggestive of adrenal insufficiency. The patient also had moderate growth hormone deficiency and symptoms of hypogonadism.
At 6 months after discharge, the patient started testosterone therapy because his dysspermatism had worsened.
At 12 months after discharge, a repeat insulin tolerance test showed that both ACTH and cortisol responses were low but improved. The patient was no longer deficient in growth hormone.
At 15 months after discharge, early morning levels of ACTH and cortisol were now in the normal range. The patient discontinued testosterone treatment, but the symptoms returned, so he resumed it.
Long COVID symptoms, possible biological mechanism
The present case shows how certain COVID-19–associated conditions develop after the onset of, or the recovery from, respiratory disorders, the authors note.
Symptoms of long COVID-19 include fatigue, weakness, hair loss, diarrhea, arthralgia, and depression, and these symptoms are associated with pituitary insufficiency, especially secondary adrenocortical insufficiency.
In addition, an estimated 25% of sexually active men who recover from COVID have semen disorders such as azoospermia and oligospermia.
The underlying mechanism by which COVID-19 might trigger pituitary insufficiency is unknown, but other viral infections such as influenza-A and herpes simplex are also associated with transient hypopituitarism. An exaggerated immune response triggered by SARS-CoV-2 may explain the dysfunction of multiple endocrine organs, the researchers write.
The researchers have declared no conflicts of interest.
A version of this article first appeared on Medscape.com.
A case study of a 65-year-old man in Japan with long COVID describes how he recovered from certain impaired hormone deficiencies that persisted for more than a year.
Days after the patient recovered from respiratory failure and came off a ventilator, he had a sudden drop in blood pressure, which responded to hydrocortisone.
The patient was found to have low levels of growth hormone and adrenocorticotropic hormone (ACTH), hypopituitarism, that persisted for more than a year. He also had low levels of testosterone that remained low at 15 months (the study end).
“An important finding in the present case is the eventual recovery from hypopituitarism over time but not from hypogonadism,” the researchers write in their study published in Endocrine Journal.
, which was confirmed using an insulin tolerance test, Kai Yoshimura, Kakogawa Medical Center, Japan, and colleagues report.
The findings show that “pituitary insufficiency should be considered in patients with prolonged symptoms of COVID-19,” they report, since it can be treated with hormone supplements that markedly improve symptoms and quality of life.
“It might be worthwhile to screen for endocrine dysfunction in patients with such persistent symptoms after their recovery from the acute disease,” the researchers conclude.
Case study timeline
The patient in this study was healthy without obesity, previous endocrine disease, or steroid use. He was admitted to hospital because he had dyspnea and fever for 8 days and a reverse transcription-polymerase chain reaction (RT-PCR) test that was positive for COVID-19.
He received ciclesonide 200 mcg/day for 2 days. Then he was put on a ventilator and the drug was discontinued and “favipiravir, ritonavir, and lopinavir, a standard regimen during the early phase of the COVID-19 pandemic, were initiated;” the researchers explain.
On day 25 of his hospital stay the patient had recovered from respiratory failure and was extubated.
On day 31, he had a negative PCR test for COVID-19.
On day 36, the patient’s blood pressure suddenly dropped from 120/80 mmHg to 80/50 mmHg. His plasma ACTH and serum cortisol levels were low, suggesting secondary adrenal insufficiency. The low blood pressure responded to hydrocortisone 100 mg, which was gradually tapered.
At day 96, the patient was discharged from hospital with a dose of 15 mg/day hydrocortisone.
At 3 months after discharge, an insulin tolerance test revealed that the patient’s ACTH and cortisol responses were blunted, suggestive of adrenal insufficiency. The patient also had moderate growth hormone deficiency and symptoms of hypogonadism.
At 6 months after discharge, the patient started testosterone therapy because his dysspermatism had worsened.
At 12 months after discharge, a repeat insulin tolerance test showed that both ACTH and cortisol responses were low but improved. The patient was no longer deficient in growth hormone.
At 15 months after discharge, early morning levels of ACTH and cortisol were now in the normal range. The patient discontinued testosterone treatment, but the symptoms returned, so he resumed it.
Long COVID symptoms, possible biological mechanism
The present case shows how certain COVID-19–associated conditions develop after the onset of, or the recovery from, respiratory disorders, the authors note.
Symptoms of long COVID-19 include fatigue, weakness, hair loss, diarrhea, arthralgia, and depression, and these symptoms are associated with pituitary insufficiency, especially secondary adrenocortical insufficiency.
In addition, an estimated 25% of sexually active men who recover from COVID have semen disorders such as azoospermia and oligospermia.
The underlying mechanism by which COVID-19 might trigger pituitary insufficiency is unknown, but other viral infections such as influenza-A and herpes simplex are also associated with transient hypopituitarism. An exaggerated immune response triggered by SARS-CoV-2 may explain the dysfunction of multiple endocrine organs, the researchers write.
The researchers have declared no conflicts of interest.
A version of this article first appeared on Medscape.com.
A case study of a 65-year-old man in Japan with long COVID describes how he recovered from certain impaired hormone deficiencies that persisted for more than a year.
Days after the patient recovered from respiratory failure and came off a ventilator, he had a sudden drop in blood pressure, which responded to hydrocortisone.
The patient was found to have low levels of growth hormone and adrenocorticotropic hormone (ACTH), hypopituitarism, that persisted for more than a year. He also had low levels of testosterone that remained low at 15 months (the study end).
“An important finding in the present case is the eventual recovery from hypopituitarism over time but not from hypogonadism,” the researchers write in their study published in Endocrine Journal.
, which was confirmed using an insulin tolerance test, Kai Yoshimura, Kakogawa Medical Center, Japan, and colleagues report.
The findings show that “pituitary insufficiency should be considered in patients with prolonged symptoms of COVID-19,” they report, since it can be treated with hormone supplements that markedly improve symptoms and quality of life.
“It might be worthwhile to screen for endocrine dysfunction in patients with such persistent symptoms after their recovery from the acute disease,” the researchers conclude.
Case study timeline
The patient in this study was healthy without obesity, previous endocrine disease, or steroid use. He was admitted to hospital because he had dyspnea and fever for 8 days and a reverse transcription-polymerase chain reaction (RT-PCR) test that was positive for COVID-19.
He received ciclesonide 200 mcg/day for 2 days. Then he was put on a ventilator and the drug was discontinued and “favipiravir, ritonavir, and lopinavir, a standard regimen during the early phase of the COVID-19 pandemic, were initiated;” the researchers explain.
On day 25 of his hospital stay the patient had recovered from respiratory failure and was extubated.
On day 31, he had a negative PCR test for COVID-19.
On day 36, the patient’s blood pressure suddenly dropped from 120/80 mmHg to 80/50 mmHg. His plasma ACTH and serum cortisol levels were low, suggesting secondary adrenal insufficiency. The low blood pressure responded to hydrocortisone 100 mg, which was gradually tapered.
At day 96, the patient was discharged from hospital with a dose of 15 mg/day hydrocortisone.
At 3 months after discharge, an insulin tolerance test revealed that the patient’s ACTH and cortisol responses were blunted, suggestive of adrenal insufficiency. The patient also had moderate growth hormone deficiency and symptoms of hypogonadism.
At 6 months after discharge, the patient started testosterone therapy because his dysspermatism had worsened.
At 12 months after discharge, a repeat insulin tolerance test showed that both ACTH and cortisol responses were low but improved. The patient was no longer deficient in growth hormone.
At 15 months after discharge, early morning levels of ACTH and cortisol were now in the normal range. The patient discontinued testosterone treatment, but the symptoms returned, so he resumed it.
Long COVID symptoms, possible biological mechanism
The present case shows how certain COVID-19–associated conditions develop after the onset of, or the recovery from, respiratory disorders, the authors note.
Symptoms of long COVID-19 include fatigue, weakness, hair loss, diarrhea, arthralgia, and depression, and these symptoms are associated with pituitary insufficiency, especially secondary adrenocortical insufficiency.
In addition, an estimated 25% of sexually active men who recover from COVID have semen disorders such as azoospermia and oligospermia.
The underlying mechanism by which COVID-19 might trigger pituitary insufficiency is unknown, but other viral infections such as influenza-A and herpes simplex are also associated with transient hypopituitarism. An exaggerated immune response triggered by SARS-CoV-2 may explain the dysfunction of multiple endocrine organs, the researchers write.
The researchers have declared no conflicts of interest.
A version of this article first appeared on Medscape.com.