DR CHRIS VAN TULLEKEN: How we learned to treat Covid-19 then beat it

How we learned to treat Covid-19, then beat it! DR CHRIS VAN TULLEKEN describes the front line of a battle that humanity can’t afford to lose

The next pandemic is already in the post. This month, the authorities in Guinea in West Africa declared a new Ebola outbreak; Saudi Arabia’s health ministry has reported four new cases of MERS, a coronavirus we catch from camels, writes Dr Chris van Tulleken

As an infectious diseases doctor at the Hospital for Tropical Diseases, which is part of University College London Hospital (UCLH), I see patients with infections — and I also study viruses in the lab at University College London next door.

Yet despite my clinical and research experience, over the past year I’ve been utterly wrong about so much of this pandemic — and especially about the infection it would cause.

When I first realised in early 2020 that we were facing a global pandemic of Covid-19, I imagined that this new foe would be a virus that largely affected the lungs — a more serious version of the four coronaviruses that already circulate and cause colds.

This was the received wisdom following a very similar but far more deadly coronavirus that emerged in 2003: SARS.

That belief changed entirely last March when my twin brother, Xand, caught Covid.

His symptoms were miserable but expected: cough, fever, exhaustion and loss of smell and taste. 

He seemed to manage them well in isolation, and within a fortnight appeared to be on the road to full recovery.

But then one morning, early in his recovery, while I was working a shift on a Covid ward at UCLH, Xand came into A&E as an urgent case. 

He’d developed a dangerous heart rhythm disorder, atrial fibrillation, likely as a result of the virus inflaming his heart.

Xand had a heart rate of 170 beats per minute (it should have been around 60) and his blood pressure was low. Colleagues from the A&E and anaesthetics teams sedated Xand and cardioverted him — giving him a large electric shock to temporarily stop his heart, allowing it to restart in a normal rhythm.

It was a terrifying and, for me, tearful moment. This is a fairly routine procedure but the worst consequences are severe.

Covid is starting to make many of us wonder if contracting a virus as an adult may explain the symptoms many previous patients have been struggling with. The latest science of long Covid is just one of the topics covered in a new BBC Horizon special, to be broadcast this Thursday, that marks nearly a year since Britain first entered lockdown

Nor was this to be the last time: Xand came into the emergency room twice more as the year went on. It was clear that Covid had damaged his heart.

As this was unfolding in my own family, it was becoming clear from patients and colleagues from other specialties that Covid affects every organ system — even in those who don’t have a serious infection.

We now know from hard-won experience that it can have widespread and devastating effects, causing strokes and brain inflammation, clots and heart attacks.

And contrary to media reports, we were seeing these problems in many young and previously healthy people. A few died, but many have been left devastated by an apparently mild illness.

Xand is still taking medication to keep his heart in rhythm.

Meanwhile, other effects on the heart are still unfolding. Only last week, a study by UCL found high levels of potentially chronic heart problems among people who have survived hospitalisation with Covid — revealed in blood tests for troponin, a protein released from injured heart muscle.

The lessons learned: Doctors Chris (left) and Xand van Tulleken in a Horizon report. We now know from hard-won experience that it can have widespread and devastating effects, causing strokes and brain inflammation, clots and heart attacks

Perhaps the most worrying side-effect for younger people is long Covid — a cluster of different symptoms along with severe ongoing fatigue.

For a long time, the medical profession has been unable (and, occasionally, unwilling) to help people with fatigue syndromes such as ME (myalgic encephalomyelitis) and fibromyalgia. They often have normal test results and they can get written off.

Covid is starting to make many of us wonder if contracting a virus as an adult may explain the symptoms many previous patients have been struggling with.

Covid-19 facts

  • 10-30% of people who get Covid are responsible for 90% of further infections
  • There are 200 new Covid vaccines currently in development — 60 are in clinical trials 

The latest science of long Covid is just one of the topics covered in a new BBC Horizon special, to be broadcast this Thursday, that marks nearly a year since Britain first entered lockdown.

Presented by me, Xand and Dr Guddi Singh, a paediatrician at Guy’s and St Thomas’ NHS Foundation Trust, it features interviews from scientists and clinicians at the forefront of the fight.

We have learned so much in the past year, and now have the knowledge to end the pandemic and stop the appalling sickness and death caused both by the coronavirus and by lockdowns.

And the data we have seen seem to make some choices increasingly clear if we want to relegate this virus from a lethal pandemic to an occasional pestilence.

Here are some of the lifesaving lessons that we’ve learned. 

Genetics are key to beating pandemic 

What we know about the new coronavirus, how it behaves and how to tackle it, is the culmination of the revolution in genetics that started with the project to sequence the human genome.

In the 20 years since that was completed, we haven’t quite seen the promised benefit to us all. Until now.

The story of this pandemic — past, present and future — can be written with an alphabet of just four letters: those of the genetic code that’s common to all life.

These letters — A, T, C and G — are the building blocks of the DNA blueprint in all our cells, including many viruses. The ways in which these letters are combined in long sequences determine what makes all living things unique.

It is thanks to the advances in genetics, unimaginable even a few years ago, that we now know enough about how this virus spreads and mutates so we can actively end this pandemic and return to normal life.

What we know about the new coronavirus, how it behaves and how to tackle it, is the culmination of the revolution in genetics that started with the project to sequence the human genome

The sequence of the Covid-19 genome was published in January 2020 — astoundingly fast. This meant that by early February, Professor Teresa Lambe and the team in Oxford (working with AstraZeneca), along with other scientists around the world, were already designing the vaccines many of us have now had.

As Teresa explained when we interviewed her, the vaccines licensed in the UK are gene-based, which means they don’t need a sample of the virus to start testing and manufacturing: they just need the genetic code, which can be sent in an email. (This massively speeds up the development process as there’s no need to culture live virus.)

Genetics have also allowed us to diagnose the virus. The gold standard PCR test is a genetic test that looks for parts of the virus genome. It is highly accurate and has allowed us to understand so much of the virus biology.

Genetic technology has also enabled the Covid-19 Genomics UK Consortium (COG-UK) to track the emergence of new variants by sequencing diagnostic samples from all over the UK.

As Professor Sharon Peacock, who heads up COG-UK, told me, it is thanks to this work that we are now increasingly sure that our homegrown ‘Kent’ variant, which swept across England last November, is not just more transmissible but may also be more deadly, hospitalising a greater proportion of the patients who get it.

For a while, it had seemed like this virus changed relatively slowly — a couple of mutations a month. But not now.

We know that allowing a surge to spread through the population once the vulnerable are vaccinated will give an advantage to those variants capable of spreading in vaccinated people. People are seen in Regents Park, London

I also spoke with an old friend and colleague, Ravi Gupta, a professor of clinical microbiology at the Cambridge Institute of Therapeutic Immunology and Infectious Disease and member of NERVTAG (the body that advises the Government on new respiratory viruses).

He described his shock when he first saw the gene sequence for the Kent variant: it had not one or two but 23 different DNA mutations. He’d seen this exact pattern in a patient with a perilously weak immune system (as a result of chemotherapy for cancer) with Covid at Addenbrooke’s Hospital in Cambridge who’d been suffering with the virus for 100 days.

The patient was given ‘convalescent plasma’ from those who had recovered from Covid. The plasma contained antibodies that should, theoretically, kill the infection. Instead, the virus evolved to get around this by accumulating mutations in its DNA. By the time the patient had died, the virus had evolved 37 separate mutations.

This may be where some of the new variants are coming from — chronic cases in patients with immune dysfunction where the virus has a unique opportunity to try out different evasion strategies.

The genetic sequences that we use to diagnose patients are now also being used to build the next round of vaccines. We are going to see variants emerge around the globe, but instead of starting from scratch, the sequence can be plugged in and an updated vaccine produced in months, not years. I can’t imagine where we would have been now with this pandemic had it not been for genetics — but without doubt, we would be desperately worse off.

Vaccines get us on road to freedom 

Eventually, once as many people as possible are vaccinated, herd immunity will reduce transmission of the virus. But this will take many months — and we are a very long way off having natural immunity from the massive waves of virus that have spread.

In the meantime, reducing transmission is vital for the success of our vaccine rollout. Allowing the virus to continue to spread before widespread vaccination will not only lead to deaths and long Covid but also risks the emergence of vaccine-resistant strains.

It is a law of biology as immutable as the law of gravity that viruses mutate when they spread. Every infected person and transmission gives a chance to the virus. We know that allowing a surge to spread through the population once the vulnerable are vaccinated will give an advantage to those variants capable of spreading in vaccinated people.

We are going to see variants emerge around the globe, but instead of starting from scratch, the sequence can be plugged in and an updated vaccine produced in months, not years

Currently, our vaccines work superbly well. Surrendering an advantage to the virus by allowing it to start spreading rapidly would be a terrible waste. It will also kill many young, fit people and leave many others devastated with the consequences of infection.

Dying of Covid-19 now is like being a soldier shot dead on Armistice Day when the ink is drying on the treaty but the ceasefire is yet to begin. This is now a vaccine-preventable disease. If everyone complies with lockdown right now, that vaccine potential won’t be wasted. 

Why more patients are now surviving 

The hospital death rate from Covid has dropped spectacularly. Partly this is due to the case mix of patients (tragically, many people most likely to die have already died), but in large part it’s also due to advances in clinical care.

The high-tech solutions, especially the drugs, make the headlines — but they’re not the only thing making the difference, as I saw when I went to interview Mark Vargas, a senior charge nurse on the intensive care unit (ICU) nursing team at University College London Hospital.

I watched his team perform an emergency ‘prone’ on one of the sickest patients. This is where the patient is flipped onto their front to allow improved blood and air flow in their lungs.

Done badly, it is extraordinarily dangerous, as the ventilator tube can be pulled out. As it is such a risky procedure, in the past it was done only a few times per year, but the patient I saw flipped over while filming Horizon was the third patient expertly and safely proned that day.

Proning is just one of a huge suite of changes made in ICU so that, despite the fact that they are now looking after five patients with just two nurses (the ratio would normally be 1:1), survival rates have still improved.

We need to spot the super-shedders 

To reduce transmission and the worst effects of long Covid, it’s vital we find the people who spread the most virus and isolate them.

Scientific studies have revealed that the vast majority of people who contract Covid-19 never pass it on — and that between 10 to 30 per cent of infected people are responsible for 90 per cent of all transmissions.

This may be partly down to some people’s biology. In the Horizon programme, Mark Woolhouse, a professor of infectious disease epidemiology at Edinburgh University, refers to these people as super-shedders, because they release unusually large numbers of virus particles. 

This was starkly demonstrated in the summer of 2020, when an airliner landed in Ireland from the Middle East carrying 49 passengers.

It was later discovered that 13 were infected with Covid-19. Most of them did not go on to infect anyone else; however, five of the passengers went on to infect 43 other people.

We also know that there are super-spreader events which are crucial. If a super-shedder patient is sitting quietly at home alone, then they won’t infect anyone. But if they go to a party, say, they could infect a huge number of others present.

Super-spreader events tend to be poorly ventilated, indoor environments with lots of crowding: weddings, churches, choirs, gyms, funerals, restaurants. Loud talking or singing massively increases the risk. Clubs and pubs are prime examples.

Any case of Covid is most likely to have been infected at a superspreader event or by a super-shedder. This means that simply isolating the contacts of an infected person, as we currently do, is important — but what we would ideally do is look backwards at all the people our case may have caught it from.

This will identify the superspreader event or person and allow tracing of their contacts — which will produce many more cases who need to be isolated. This is called backward tracing and it is not trivial. It takes resources and money and needs transmission rates to be low enough to do it.

As I write, there are more than 10,000 new cases each day. It is simply not possible to trace and isolate everyone linked to every one of them.

But what is clear is that if our vaccines and our current tracing methods are going to work, we must ensure that transmission rates in the community are at rock bottom before we start to open up the places where it spreads best.

Rapidly opening up venues where large numbers of people are indoors with poor ventilation for prolonged periods may lead to the emergence of vaccine-resistant strains and another cycle of deaths from Covid, followed by lockdown.

I would rather catch Covid-19 now than a year ago. But knowing about long Covid, I would much rather not get it at all. And that is the point of continuing to drive down the daily infection numbers whilst we roll out mass vaccination and effective tracking and tracing. 

Danger of trusting in herd immunity 

When we do the maths, it looks like we will need to vaccinate many more people against Covid-19 than was previously hoped to achieve herd immunity, which will prevent the virus from spreading.

Indeed, we might have to vaccinate as many as 97 per cent of the population. This is because the new variants we’ve seen so far are significantly more contagious than the strain from China.

Certainly, we can’t rely on natural herd immunity emerging by sufficient people getting infected and surviving to develop their own immune resistance, as some mooted early on. That idea was always extraordinarily naïve and dangerous.

When we do the maths, it looks like we will need to vaccinate many more people against Covid-19 than was previously hoped to achieve herd immunity, which will prevent the virus from spreading

This has been underlined by the fact that high levels of natural transmission have allowed new strains to emerge — and it looks like these can go through the population and re-infect people. 

Nor do I think that anyone with expert knowledge believes we can eradicate Covid-19 in the way that we wiped out smallpox — the only virus we have managed to eradicate. But we can reduce its impact with vaccines.

I’m a great fan of vaccination, but I’m not a fan of mandatory vaccination because it generates suspicion. We need to persuade people about how great and safe these vaccines are, not threaten them with ‘no jab, no job’.

Carrots and information work better than sticks. 

Covid-19 has now killed some 2.5 million people worldwide and infected 110 million, many of whom will suffer long-term consequences, and cost the world an estimated £16 trillion.

But compared to what might have happened, we’ve got off relatively lightly. It’s estimated there are more than a million viruses in animals able to infect us, and any one may become a pandemic far worse than this. Imagine a virus that kills 5 to 10 per cent of those it infects, and that this was the death rate in children.

The next pandemic is already in the post. This month, the authorities in Guinea in West Africa declared a new Ebola outbreak; Saudi Arabia’s health ministry has reported four new cases of MERS, a coronavirus we catch from camels.

We know that the more humans invade wild ecosystems, the more we expose ourselves to deadly viruses that can jump from animal species into us. And these jumps are happening more often, driven by global consumption, health inequalities, climate change, agricultural practices and environmental destruction.

We need to improve our global surveillance systems for spotting and stopping novel viral outbreaks. If we don’t, it is a racing certainty that we will see the next pandemic within our lifetimes.

Coronavirus — A Horizon special: What We Know Now, Thursday at 9pm on BBC2.

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Was it T-cells or prayer? 116-year-old nun survives COVID-19

covid

Whether it was the power of her prayers or her T-cells that did it, 116-year-old French nun Lucile Randon has survived COVID-19.

The nun, whose religious name is Sister André, is the second-oldest known living person in the world, according to the Gerontology Research Group, which validates details of people believed to be aged 110 or older.

French media report that the nun, whose religious name is Sister André, tested positive for the virus in mid-January in the southern French city of Toulon. But just three weeks later she is fit as a fiddle—albeit it in her regular wheelchair. She is even healthy enough to look forward to her 117th birthday on Thursday.

She told Var-Matin newspaper “I didn’t even realize I had it.”

Sister André, who is blind, did not even worry when she heard the news of diagnosis.

“She didn’t ask me about her health, but about her habits,” David Tavella, the communications manager for the care home where she lives, told the paper. “For example, she wanted to know if meal or bedtime schedules would change. She showed no fear of the disease. On the other hand, she was very concerned about the other residents.”

Not all shared Sister André’s luck: In January, 81 of the 88 residents of the facility tested positive and about 10 died, according to the newspaper.

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Huge Gaps in Vaccine Data Make It Next to Impossible to Know Who Got the Shots

As they rush to vaccinate millions of Americans, health officials are struggling to collect critically important information — such as race, ethnicity and occupation — of every person they jab.

The data being collected is so scattered that there’s little insight into which health care workers, or first responders, have been among the people getting the initial vaccines, as intended — or how many doses instead have gone to people who should be much further down the list.

The gaps — which experts say reflect decades of underfunding of public health programs — could mean that well-connected people and health personnel who have no contact with patients are getting vaccines before front-line workers, who are at much higher risk for illness. Federal and state officials prioritized health workers plus residents and staffs of nursing homes for the first wave of shots.

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Although officials leading President Joe Biden’s covid response have pledged to tackle racial inequities as they seek to control the pandemic, lapses in reporting race or ethnicity could hinder efforts to identify and track whether minorities hit especially hard by the pandemic are getting shots at a high-enough rate to achieve hoped-for levels of herd immunity. So far, limited data in multiple states shows Black residents are getting vaccinated at lower rates than whites.

“Every state knows where they’ve sent vaccine, and every provider has to report inventory. But as far as who is being vaccinated, that one is a little more tricky,” said Claire Hannan, executive director of the Association of Immunization Managers.

Data that eventually makes its way to the Centers for Disease Control and Prevention and other federal systems is “only going to be as good as whatever you can get out of the vaccine registries” that vary by state, said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials. “They’re all different and, going into this, they were all at different stages of how robust they were.”

There are 64 immunization registries in the United States that gather information for states, territories and a handful of large cities — and they aren’t connected. Meanwhile, real-time data in the U.S. public health system is virtually nonexistent, Plescia said.

Reporters at KHN examined the data being gathered versus what the CDC says is supposed to be collected for every person vaccinated, which includes: name, address, sex, date of birth, race and ethnicity, the date and location where they were vaccinated, and the shot they received (currently only two products are available, from Pfizer-BioNTech and Moderna). Not on its list: occupation, even though initial vaccine distribution largely hinges on place of work, prioritizing health care personnel, long-term care facilities and then other essential workers such as teachers, grocery store workers and firefighters.

Dr. Katherine Poehling, a pediatrician at the Wake Forest School of Medicine who’s on the CDC advisory committee that issued vaccine priority recommendations, declined to comment on whether occupation should have been a required element for reporting to the CDC.

“I think you can always wish for more data, but really what we’re going for is vaccinating everybody that wants to be vaccinated,” she said. “The fact that there was something available on day one was really remarkable,” she said, referring to a database that could track vaccine shipments and allocations by state.

Still, gaps are evident, including holes in CDC rules for reporting race and ethnicity. Race and ethnicity information are missing from at least hundreds of thousands of vaccine doses that have already been administered and reported to state public health authorities.

Texas’ vaccine data on Wednesday showed that race or ethnicity was unknown for more than 700,000 people. Virginia’s dashboard shows that data was missing for nearly 300,000 vaccinations, or 52% of vaccine doses, as of Tuesday. The same was true for tens of thousands of vaccinations in Colorado and Maryland.

In Minnesota, state law prohibits the sharing of data on race and ethnicity.

“It is important how many shots are administered, but it is critical that we get good race and ethnicity information about who is receiving it so we can identify disparities and other problems,” said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

The CDC declined to say how many of the vaccine records it had received were missing the information. In response to questions, CDC spokesperson Kristen Nordlund said the agency plans to publish race, ethnicity and other demographic data next week.

The Department of Health and Human Services did not respond to multiple requests for comment.

Dr. Marcella Nunez-Smith, chair of the Biden administration’s covid-19 health equity task force, on Wednesday conceded that the racial and ethnicity data is “incomplete” but said it wasn’t the only way to gauge progress of the vaccine rollout on the ground.

“We can think about things like neighborhoods and communities as metrics and ways to track as well,” she said. “We’re building our equity dashboard right now, and we’ll rely on government sources as well as sources of data external to government.”

The ongoing struggle for complete data shows how little has changed for the CDC since the virus appeared in the U.S. one year ago and its early efforts to collect data identifying covid-infected people were widely panned.

So far, the CDC has publicly stated how many vaccines have been distributed nationwide and how many doses administered. Its dashboard includes a breakdown of how many shots have been given by state and in long-term care facilities. Walgreens and CVS together have given more than 2.5 million doses in nursing homes and other long-term care facilities, though neither company has released data on race or whether the shots were given to patients or staffers.

State and federal health officials know where vaccines go as officials must track inventory by facility. Several states have released breakdowns of doses administered by the type of institution, providing a window into how many shots are being used in hospitals, nursing homes, pharmacies, primary care practices, public health departments and tribal health sites. And when signing up for an appointment, individuals may be asked to provide their occupation to attest they qualify for a shot under a state’s rules at a given time.

Maryland and Ohio require providers to submit data on the occupations of vaccine recipients, in a break with CDC practice. But several states contacted by KHN said they do not collect that information, such as Idaho, Michigan, Minnesota, Texas and Virginia.

Electronic health records manufacturers that provide software to hospitals and other facilities said they are scrambling to modify the software to accommodate data reporting requirements that vary by state.

Occupation is one example. Another: Texas law requires the state to collect information on all medications given “in response to a declared disaster or public health emergency,” said State Health Services spokesperson Chris Van Deusen.

Leigh Burchell, vice president of policy and government affairs at the EHR firm Allscripts, said these variations are “obstacles none of us has tackled before,” though she thinks that, overall, “successes outweigh failures” as companies have had to adjust quickly during the pandemic.

EHR systems can connect to state registries, which ultimately send vaccine tracking data to the CDC. A lack of “a coordinated, national public health infrastructure” continues to be a problem that “forces everyone to work less efficiently than would be optimal,” Burchell said.

Health IT consultant Reed Gelzer said the situation reflects the 30-year-plus failure of the public health system to modernize data collection. He said officials need look no further than chronic problems tracking childhood immunizations, handled in some states at the county level, and in others at the state level, often poorly. A national system to track immunizations has never existed, which he argues should have been discussed before the vaccine rollout.

“As far as I know, even in the earliest days of the pandemic, nobody did stress-testing of the information system,” Gelzer said.

Cerner, a major electronic health records company, says that some hospitals are using an existing workplace health system to track employees who have been vaccinated while others create a patient record for vaccinated employees as well as for patients. The systems can capture demographic details, but the data fields to do that have to be turned on and it’s unclear whether its client hospitals have done so.

The CDC and other federal agencies rely on a complicated web of systems to get data about who’s been vaccinated. State and local vaccine registries, known as immunization information systems, are the most comprehensive source of records and the “source of truth,” Hannan said.

Those registries have long-standing connections to providers’ electronic health records, said Rebecca Coyle, executive director of the American Immunization Registry Association. But they aren’t meant to capture certain information, such as a patient’s medical history and occupation.

Those state and local registries transmit data to an HHS-owned clearinghouse, where personal details are redacted.

The clearinghouse gets data from other sources, too. These include a new CDC vaccination clinic mobile app called VAMS, as well as pharmacies, prisons and federal agencies like the Department of Veterans Affairs and the Indian Health Service.

A limited slice of the data then moves to another CDC repository known as the “Data Lake,” where it can be analyzed and reported to the CDC and Tiberius, a separate software platform developed by federal contractor Palantir for former President Donald Trump’s Operation Warp Speed effort. The Data Lake also receives information on shipment and vaccine orders from the CDC’s VTrckS system.

On top of that dizzying array of tools, many states use another, third-party software system, PrepMod, to manage vaccine inventory, appointments and reporting.

When asked whether not having data on occupations could hinder tracking whether priority groups have received their shots, Nordlund of the CDC said it’s unnecessary to vaccinate all individuals in one phase before initiating the next.

“This means ideally hitting a sweet spot that maximizes getting vaccine into arms while also being mindful of the priority groups,” Nordlund said, “especially because these are people who are higher risk for complications from covid-19 or are more likely to be exposed to the virus because of their jobs.”

Lawmakers recently attempted to address the nation’s antiquated public health data infrastructure, partly by appropriating $500 million under the CARES Act to the CDC. In an August letter to Rep. Lucy McBath (D-Ga.), former CDC director Dr. Robert Redfield said the agency would use the funds to update how state and health departments report data to federal officials, improve the CDC’s own data infrastructure, and develop new standards for public health reporting.

Additionally, tucked into the massive year-end spending bill Congress passed in late December was a requirement that HHS expand and improve public health data systems used by the CDC and award grants to state and local health departments to upgrade their infrastructure.

The Biden administration has made promises to strengthen the federal government’s approach to data collection on vaccination efforts.

KHN data reporter Hannah Recht and KHN correspondent Lauren Weber contributed to this report.

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Borderline personality disorder: Don’t ignore it

adolescent

For many years, clinicians have been hesitant to diagnose adolescents with Borderline Personality Disorder (BPD), believing it was a mental health “death sentence” for a patient because there was no clear treatment. Carla Sharp, professor of psychology and director of the Developmental Psychopathology Lab at the University of Houston, begs to differ.

And her new research, published in Journal of Abnormal Child Psychology backs her up.

“Like adult BPD, adolescent BPD appears to be not as intractable and treatment resistant as previously thought,” reports Sharp. “That means we should not shy away from identifying BPD in adolescents and we shouldn’t shy away from treating it.”

Borderline Personality Disorder is marked by patterns of varying moods, self-image and behavior, and it results in impulsive actions, problems in relationships and a tendency to think in purely black and white. People with BPD may experience intense episodes of anger, depression and anxiety that can last from a few hours to days.

Sharp said Borderline Personality Disorder is treatable, therapy helps, and early intervention for adolescents is of critical importance.

“We ignore Borderline Personality Disorder at our peril, because compared with other mental disorders, BPD is among the leading causes of suicidal behaviors and self-harm in young people,” she said. Up to 10% of BPD patients will die by suicide.

Sharp’s research is the first study to show that adolescent borderline pathology follows a similar downward course after discharge from inpatient treatment previously demonstrated for adults. Her conclusions come after examining data collected from 500 adolescent inpatients and following them every six months over an 18-month follow-up period to measure their symptoms of BPD.

The results showed a significant downward trend of BPD features across all time points and across both parent-and adolescent self-reporting which mirrors the reduction in BPD symptomology reported for adults with BPD. Interestingly, the teens Sharp studied were not undergoing specialized treatment for BPD and yet they still improved.

“It sends a message to clinicians: ‘Don’t put your head in the sand!’ If the pathology is there, diagnose it and treat it with your best evidence-based treatment,” said Sharp emphatically. The standard therapies for BPD in adults and adolescents currently are dialectical behavior therapy and mentalization-based therapy. But even if clinicians are not trained in those specialized treatments, it would be ethically appropriate to make use of best available scientific evidence to inform practice, consistent with practice-based evidence recommendations from the American Psychological Association, she said.

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Coronavirus: why combining the Oxford vaccine with Russia’s Sputnik V vaccine could make it more effective

Coronavirus: why combining the Oxford vaccine with Russia's Sputnik V vaccine could make it more effective

When the efficacy of the Oxford/AstraZeneca vaccine was announced in late 2020, there was some confusion. The overall efficacy of the vaccine at stopping people developing symptomatic COVID-19, two weeks after the second dose, was 70%. But this wasn’t the whole picture.

This figure was based on averaging the results from two groups. In one group, which was given two full doses, the vaccine was 62% effective at stopping people developing symptoms. But in the second group, a dosing error meant that volunteers received a half dose followed by a full one. This ended up being 90% protective against developing COVID-19.

This was intriguing. Why would giving people less of the vaccine lead to a more effective immune response? The answer to this may lie in the design of the vaccine, and could mean that there are ways to make this vaccine—and others that use the same design—more effective.

How the Oxford vaccine works

Vaccines work by exposing the immune system to recognisable parts—or “antigens”—of pathogens that cause disease, such as bacteria or viruses. The immune system then mounts a response. Immune cells called B cells make antibodies to destroy the pathogen. Sometimes T cells can also be called into action, which eliminate our own cells that have been infected with the pathogen.

Some B and T cells then remember the antigens for the future. At some future point, if the person is exposed to the pathogen, these long-lasting memory cells can quickly order more antibodies to be made to destroy the pathogen and attack infected cells.

In effect, the principle of vaccination is to “mimic” an infection, but in a controlled way so that immunity is generated without causing illness. After a few weeks, once T cells and B cells have been generated, the person vaccinated will be protected. For certain vaccines, this requires two doses, as in some people the first dose alone won’t generate complete immunity. The booster dose ensures as many people as possible acquire protection.

In the case of the coronavirus vaccines, a number of methods are used to present the virus’s antigens to the immune system. Some, such as the Sinopharm and Sinovac vaccines in China, simply present the body with a whole, inactivated version of the coronavirus. But others instead instruct the vaccinated person’s own cells to produce a specific part of the coronavirus: the spike protein on its outer surface, which is a particularly recognisable antigen.

These vaccines do this by delivering the part of the coronavirus’s genetic code that encodes the spike protein into the cells of the body, which then read the code and start making the protein. Some, such as the Pfizer/BioNTech and Moderna vaccines, deliver the code in the form of messenger RNA (mRNA). Others use a harmless virus to get the genetic code inside cells; the Oxford vaccine uses chimpanzee adenovirus, genetically altered so that it’s unable to reproduce, called ChAdOx1. These are known as viral-vector vaccines.

How design could affect efficacy

It’s not yet known why the reduced-dose regimen of the Oxford vaccine showed better efficacy in trials, but it could be down to the viral vector.

When a person is given a viral-vector vaccine, as well as generating an immune response against the coronavirus’s spike protein, the immune system will also mount a response against the viral vector itself. This immune response may then destroy some of the booster dose when it is subsequently delivered, before it can have an effect. This has long been recognised as a problem.

However, a lower first dose might not allow for a strong anti-vector immune response to develop, which could leave the booster dose unscathed and lead to greater overall efficacy. If it turns out that this is the case, then future work will need to establish the optimum dosing regimen for generating the strongest immune response.

The Russian Sputnik V vaccine acknowledges that immunity to the viral vector could be a problem, but comes up with a different solution. It uses two different human adenoviruses—Ad26 and Ad5 (out of the 50 that affect humans) – for its two vaccine doses. This heterologous (or hybrid) vaccine, with different vectors for prime and booster vaccinations, is less likely to have one jab generate an immune response against the viral vector that then interferes with the other. The vaccine is therefore less likely to have a reduced efficacy.

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Now that psychiatric care has gone online, many patients want it to stay there

Now that psychiatric care has gone online, many patients want it to stay there

Only a year ago, Michigan Medicine psychiatrists were trying to recruit patients to give telepsychiatry a try, with very little success.

The psychiatrists worked with people by video only 26 times in six months, while 30,000 visits happened in person. But that changed quickly when the coronavirus pandemic forced closures in the area in late March.

Now, not only have patients seeking help with mental health issues been working through their emotions and experiences by video and phone for months—many would like to keep those options, a new study shows.

“Telepsychiatry is an interesting tool for various reasons in terms of providing early access to care, connecting patients in rural areas or who live far away from clinics to be able to get good evidence-based care,” said study author Dr. Jennifer Severe, a psychiatrist who helped launch a test of telehealth initiatives at the University of Michigan’s outpatient psychiatry clinic.

“Even patients who are closer, based on life burden and expectation, they might not be able to keep up with their appointments, so telehealth actually offers a way to remain connected with care, regardless of how busy people’s lives might be,” Severe said.

For the study, published recently in the journal JMIR Formative Research, researchers surveyed 244 patients or parents of minor patients in summer 2020. The patients had mental health appointments in the first weeks of the pandemic shutdown.

Most of the survey participants had their own or their child’s first pandemic-time appointment through a video call. A minority of patients, 13.5%, started telepsychiatry with phone visits. That group was more likely to be older than 45.

Nearly all of the study participants who had a telepsychiatry visit said it went as well as expected or better.

About half (46.7%) said they were likely to continue with telepsychiatry even after in-person visits were available again. Those who had appointments by phone instead of video were much less likely to want to continue remote mental health care in the future.

“The excitement is there, but we need to make sure that we have a way to keep up with the demand,” Severe said.

This data could help inform the decisions of health insurers and government agencies who will make decisions about whether and how to pay mental health care providers for future virtual care, Severe said.

To improve access, while the survey was ongoing, senior study author Dr. Mary Carol Blazek led development of a program called Geriatric Education for Telehealth Access, or GET Access, to help older patients.

The study didn’t cover the issue of no-shows and appointment cancelations, but those have been reduced substantially, according to Michigan Medicine.

Phone and video visits within established patient-mental health provider relationships are equally effective, Severe said.

However, for first visits, the therapists typically try to avoid using the phone because it can reduce communication cues and limits observing facial expressions, interaction and movement, which can help evaluate mental health status. Sometimes physical exams can be required to assess a patient’s balance and mobility, as well as check for medication side effects.

“Sometimes communication might be difficult. Sometimes you might need to do a physical exam. There might be a lack of important physical exam approaches and communication techniques that might be missing,” Severe said. “So, that’s one reason I will say telehealth might not be for everyone.”

Severe hopes to see more of a blended approach after the pandemic, where a patient may do a face-to-face visit, followed by a couple of telehealth visits, and then return for another face-to-face visit.

During the pandemic, telehealth has been responsible for saving small mental health practices while also continuing to help patients, said Vaile Wright, senior director of health care innovation for the American Psychological Association.

“The evidence is pretty strong. People are having mental health difficulties, much more so than in the past and, thankfully, they are seeking out treatment,” Wright added. “I think telehealth makes it possible for them to do so safely.”

For some people, it may be harder to connect in a virtual environment. For others, it may make it easier because they don’t have to get time off work, figure out child care or travel to the office.

Issues to consider are ensuring that patients understand the online platform, have adequate internet accessibility and have adequate privacy in their homes to have a mental health appointment. Backup safety plans also need to be considered, Wright said.

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People eventually adopt healthy behaviors – but it can take time we don’t have during a pandemic

Why do we do things that are bad for us—or not do things that are good for us—even in light of overwhelming evidence?

As someone with a long career in pharmacy, I have witnessed some pretty dramatic shifts in public health behavior. But I won’t sugarcoat it. It generally takes years—or even decades—of dragging people, kicking and screaming, to finally achieve new and improved societal norms.

This plodding time course seems to be an innate human defect that existed long before the current-day pandemic mask and social distancing conundrums. Historically, people aren’t fond of being told what to do.

Notable victories

Attitudes toward smoking have undergone dramatic changes over the past 50 years. Although there has been a gradual decline in smoking, from 42% of the American population in 1965 to the low teens today, there still are a lot of smokers in the U.S. – and premature deaths due to smoking. Even health care workers fall prey to this unhealthy and highly addictive habit.

There was a strongly held view that smoking was a personal decision that do-gooders and the government should keep their noses out of—until the issue was framed differently by studies showing harm caused by secondhand smoke. You are welcome to do what you want to yourself, but it becomes a horse of a different color when it affects others.

Today, public smoking restrictions have become commonplace. But this change in societal behavior didn’t happen overnight or without painful discourse. The journey from the initial 1964 surgeon general’s report on smoking and health to the 2006 surgeon general’s report on secondhand smoke to today was a fractious one.

Another about-face has been the adoption of seat belts. Seat belts save lives. And most people now use them as a result of the nagging warning alarm, the marketing of automobile safety, the law and the data.

This change in behavior, however, followed a rocky road over many years. In my earlier days, I can remember more than one occasion when I hopped into a friend’s car, put on my seat belt and was then chastised for having so little faith in my friend’s driving ability.

Seat belts were required to be installed in new cars starting in 1964 and New York enacted the first seat belt use law in 1984. In the U.S., seat belt use rose from 14% in 1983 to 90% in 2016.

Continuing challenges

In the medical arena, much effort has been expended in promoting healthy behaviors—diet, exercise, sleep hygiene, adherence to prescribed drugs and immunizations. Frankly, the success has been mixed.

Studies have suggested many possible variables associated with not following accepted medical advice: age, gender, race, education, literacy, income, insurance copays, level of physician and pharmacist care—and plain old stubbornness. But there is no single, easily addressable cause of nonadherence to healthy behaviors.

For example, properly prescribed cholesterol-lowering drugs called statins literally add years to patients’ lives by reducing heart attacks and strokes. Even in people with insurance coverage and minimal side effects, 50% of patients discontinue statin therapy within one year of receiving their first prescription.

Vaccines and immunization offer another window into the puzzle of human behavior. Life expectancy in the U.S. rose from 40 years in 1860 to 70 years in 1960. These gains resulted largely from decreased infant and child mortality due to infectious diseases. A better understanding of infectious diseases along with scientific advances, vaccines and antibacterial drugs were the primary factors for this profound increase in life expectancy.

Common sense alone makes the value of vaccines abundantly clear; how many people do you know who are suffering from polio or smallpox? Yet some intelligent, thoughtful friends, family and neighbors are convinced vaccines are not helpful and are even harmful. Some believe wearing a mask is nothing more than a “feel good” placebo. I believe these contrarian beliefs make better press and are therefore more frequently reported than mainstream ones, but clearly there is reason for concern.

The current crisis

Historically, changes in societal behavior that benefit public health occur in fits and starts—and never fast enough for the individuals who fall victim before society comes around.

The urgency imposed by the coronavirus has actually resulted in comparatively swift behavioral changes (masks, hand-washing, distancing) in the U.S. – as scientists learned how the coronavirus is spread, how dangerous it can be and which groups are more susceptible. But these behavioral changes were not as complete or as fast as they should—or could—have been when judged by far better outcomes in other countries.

I am discouraged by the battle between the scientific method and political ideology when it comes to public health. Ideology never seems to change and is therefore more comforting to some—while science evolves as new findings debunk old ideas or confirm new ones. It is clear to all who want to listen: controlling the virus and maintaining the economy is not an either/or choice—they are interdependent.

At the same time, I am buoyed that the tide seems to be turning. As a better understanding of treating COVID-19 has emerged and with more than one highly effective vaccine on the horizon, the “idiot scientists” are gaining ground, both in the lab and at the bedside. Even the most prominent ideologues run to the hospital to get the best treatments science can offer when the effect of their maskless behavior rears up to bite them.

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Why we need to get creative when it comes to talking about pain

What [do] I mean by sitting in a pit of fire? You’ve got every nerve ending that’s just going hellfire, and you just don’t know what to do with yourself.

Forty-two year old Emma has experienced chronic pain from a spinal cord injury for the last year. For Emma and many others, living with severe pain is now part and parcel of everyday life. It is estimated that 35-51% of people in the UK live with chronic pain. But communicating that experience can be a challenging endeavor.

We interviewed people with spinal cord injuries and women with endometriosis – a condition where tissue resembling the lining of the womb grows elsewhere in the body causing severe pain—in an effort to find out about their experiences and to learn more about how they talk about pain.

This research suggests that the inability to communicate pain effectively may partly account for delays in diagnosing some conditions. We also found that people with various types of chronic pain—such as that caused by endometriosis and spinal cord injury – often use metaphors to describe it.

Many speak of their pain in terms of being attacked. What might sound overly dramatic actually uses a variety of mechanisms, ranging from conveying high levels of pain severity and trying to make sense of the experience, to expressing the emotional consequences.

In using these expressions, sufferers may be trying to elicit support and empathy from others. At the moment though, widespread practice in pain consultation involves the use of numerical rating scales asking people to identify a number that best represents their pain.

The use of such potentially simplistic and reductionist tools means that a holistic assessment of the physical, psychological and social complexity of the pain experience is neglected.


https://youtube.com/watch?v=eakyDiXX6Uc%3Fcolor%3Dwhite

Using metaphors to talk about pain

In conducting our research, we found that the ways people spontaneously talk about their experience of pain go beyond the measuring capacities of the standard assessment tools. For example, the McGill pain questionnaire asks people to rank each of the descriptive words such as “searing,” “pinching” and “flashing” in terms of their pain intensity.

But many people describe their pain in ways that aren’t measured in this questionnaire. For example, one participant described their pain as feeling like “you’re dragging your organs.” Such creative and detailed descriptions often capture both the severity and the distress pain causes. However, not all expressions convey the intended message effectively.

Common pain descriptors such as “shooting” and “stabbing” pain may fail to articulate intended meaning as they have lost their metaphorical force due to overuse. These are known as dead metaphors. So more detailed creative descriptions, often involving similes, may be more effective in helping the listener to understand, assess and provide better support.

We found interesting examples of creative and extended metaphors such as: “It feels like somebody putting barbed wire through your belly button in a figure of eight … And then they set fire to the barbed wire and it starts getting hot and everything’s just being squished inside you.”

Using highly personal and creative metaphors like this provides a mechanism to communicate pain in one’s own terms rather than being restricted by standardised assessments. “It’s like some little devil in the corner. Yeah, you know like that little exorcist thing in the corner … torturing me.”

This language could help others understand more clearly how a sufferer is feeling and perhaps elicit some support. However, these benefits may come at a cost to the person in pain. We also found that some metaphorical expressions alluding to torture and attack could reflect individuals’ perceptions of pain as a physical threat, leading to higher levels of distress, fear and despair.

As a result, the use of such language could increase the attention that an individual pays to their pain. This has been shown to also lead to an increase in pain intensity, as people become more aware of, and sensitive to, the sensation.

Promoting effective pain talk

Pain is a private experience; encouraging people to find different and more appropriate ways to talk about it can help them make sense of their unique experience and describe it more effectively.

People with different conditions tend to use similar types of metaphorical expressions. For example, we found that words like “pins and needles” and “electricity” are often used to describe nerve pain associated with conditions like spinal cord injury. Similarly, expressions involving physical action such as “tearing” and “pulling” are more commonly found in descriptions of endometriosis pain.

This, in turn, can potentially guide doctors to identify potential causes of pain in certain conditions, like endometriosis. For example, a description such as “feeling like a balloon is about to explode” may point to inflammation, while “felt like I had tiny people with ropes tied tightly around my insides and pulling down” may be indicative of a deeper, more visceral pain.

Pain is also an all-round experience, and its impact goes beyond the physical. The way that someone talks about their experience can also highlight its effect on other parts of their lives, such as mental health and socialising. For example, pain described as “all-consuming” could reveal an emotional dimension while talking about how people in pain “hide from the world” could indicate a drive to conceal pain from others and avoid seeking help.

Encouraging people to talk about pain in their own terms is key to understanding and supporting their individual needs. In fact, this is what our participants ask for: “Listen closely” or “Be more open-minded about the difficulty of describing pain I can’t explain well.”

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India says it may approve vaccine in weeks, outlines plan

India’s health ministry announced Tuesday that some COVID-19 vaccines are likely to receive licenses in the next few weeks and outlined an initial plan to immunize 300 million people.

Health officials said three vaccine companies have applied for early approval for emergency use in India: Serum Institute of India, which has been licensed to manufacture the AstraZeneca vaccine, Pfizer Inc., and Indian manufacturer Bharat Biotech.

“Some of them may get licensed in the next few weeks,” federal health secretary Rajesh Bhushan said.

India says its initial immunization plan revolves around three priority groups: 10 million healthcare workers, 20 million front-line workers such as the police and military, and 270 million other people either above age 50 or who have diseases that make them more vulnerable to COVID-19’s effects.

The health ministry has previously set a target of August 2021 for immunizing these people.

India’s population is nearly 1.4 billion.

Bhushan said India would rely on its existing immunization programs, which are among the largest in the world. Every year, India immunizes 26 million infants and 30 million pregnant women with 300 million vaccine doses.

But there are challenges. Even before the pandemic, vaccine coverage for children in India was patchy. It is lowest among India’s indigenous communities, where only 56% of newborns are vaccinated.

Health officials also need to ensure that the emphasis on coronavirus vaccines doesn’t disrupt existing immunization programs. That means more people must be trained to administer vaccines. The immunization of adults will also require different medical personnel instead of pediatricians, and may face more resistance to the shots.

“My worry is that we’ve not seen adult immunization before,” said Dr. Gagandeep Kang, infectious diseases expert at Christian Medical College at Vellore in southern India.

Serum Institute of India, the world’s largest vaccine manufacturer, applied for an emergency use license for the Oxford University-AstraZeneca vaccine based on phase-three trials in India and other countries, health officials said at a news conference.

The Indian company Bharat Biotech applied for a license for its experimental inactivated virus vaccine without completing phase-three trials, they said. According to Indian rules for accelerated approval of vaccines, a company can be granted a license if regulators are “satisfied with the risk-benefit ratio,” said Balram Bharagava, head of the Indian Council of Medical Research.

Pfizer applied for permission to import its experimental mRNA vaccine for sale and distribution without clinical trials in India, the officials said. The company said in a statement that it would supply the vaccine “only through government contracts based on agreements with respective government authorities” after approval. Its vaccine needs to be stored at very cold temperatures, which India’s existing infrastructure is unlikely to be able to provide. ___

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Nailed It! Jennifer Lopez Goes Nude for New Single’s Steamy Cover

Surprise, surprise! Jennifer Lopez is baring it all as she gears up to release her next big hit.

Jennifer Lopez’s Ageless Moments Through the Years

The two-time Grammy nominee, 51, unveiled the cover art for her new single, “In the Morning,” on Wednesday, November 25. In the image, Lopez is completely naked and only wearing her massive engagement ring from Alex Rodriguez.

“Surprise! Here’s the official cover art for #InTheMorning ✨ ,” she captioned the post. “Single drops Friday ✨.”

https://www.instagram.com/p/CIBrHrYJ72B/

A post shared by Jennifer Lopez (@jlo)

The day before releasing the official cover, Lopez teased the upcoming single by sharing a snippet of the track along with a video clip that contained various shots of her bare body.

See Jennifer Lopez’s Fierce Bikini Body in Us Weekly’s ‘Best Bodies’ Issue

It is no secret that Lopez has put in the hard work to stay fit over the years. When she appeared in Us Weekly’s “Best Bodies” issue in 2015, the Hustlers actress opened up about her fitness routine.

“Very rarely will I skip my workout,” she told Us at the time. “Sometimes, I work too late the night before, and I’m like, ‘Ugh, I can’t do this.’ But I tell myself, ‘Just do it. It’s only an hour.’ It’s just talking yourself off the ledge of being a lazy bum.”

The Bronx native added that she will always “try to live a healthy lifestyle” and is “always looking for something that’s gonna help me embrace that lifestyle.” Lopez additionally said that she is motivated to stay in shape because of her 12-year-old twins, Max and Emme, whom she shares with ex-husband Marc Anthony.

“I try to teach them the right things to eat: a lot of greens, fruits, and grains,” she previously shared. “They’re starting to learn that’s a way of life.”

Fittest Celebs Over 50

Lopez is an ageless beauty. In a 2018 cover story for Harper’s Bazaar, she shared her secret for boosting her confidence in her fifth decade.

“Affirmations are so important. I am youthful and timeless. I tell myself that every day, a few times a day,” she told the magazine at the time. “It sounds like clichéd bullshit, but it’s not. Age is all in your mind. Look at Jane Fonda.”

The “Lonely” singer has been engaged to Rodriguez since March 2019. Throughout their relationship, the retired New York Yankees player has frequently gushed about what a powerhouse she is.

“Jennifer is an amazing person. She’s the hardest working. She’s got, like, 10 jobs,” Rodriguez, 45, said on ABC’s Nightline in 2017. “She loves sports, she’s an athlete herself, great mother, great daughter, great friend.”

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