Thoughts on new study indicating the vaccination only reduces long COVID chances by 15%?

[futureapppsy2]

Long COVID after breakthrough SARS-CoV-2 infection - Nature Medicine

A new analysis using the US Department of Veterans Affairs national healthcare databases demonstrates that Long COVID can occur after breakthrough SARS-CoV-2 infection; however, the risk of death attributable to COVID and incidence of post-acute sequelae were substantially reduced (but not fully...

www.nature.com

This is getting a lot of press, but I have some doubts about the generalizability given that the sample is mostly old and sick Veterans (VA data), pre-booster, and pre-Omicron, and other studies generally show a much more significant long COVID risk reduction with vaccination.

Thoughts?

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[chessknt]

Seems like a waste of time to research it to be honest. It isn't going to convince the unvaccinated (because nothing will) and the vaccinated are already going to get the benefit, whatever it may be. Much higher yield areas to focus on for PASC.

 

[wholeheartedly]

It’s also complicated because there are too many definitions of “long covid” floating around so it makes comparing studies really challenging/futile.

 

[Kaustikos]

It’s also complicated because there are too many definitions of “long covid” floating around so it makes comparing studies really challenging/futile.

THIS. It's a major, painful factor about trying to do long covid studies when we don't even have a consensus agreement about HOW to diagnose it.
Nor a scoring measure about severity
Nor about whether or not their symptoms are actually from long covid or just fatigue or what not from the pandemic
The only useful studies I've found are studies showing elevated inflammatory markers.

 

[wholeheartedly]

THIS. It's a major, painful factor about trying to do long covid studies when we don't even have a consensus agreement about HOW to diagnose it.
Nor a scoring measure about severity
Nor about whether or not their symptoms are actually from long covid or just fatigue or what not from the pandemic
The only useful studies I've found are studies showing elevated inflammatory markers.

Probably still too early to know how to diagnose it, but consistency across surveillance/study definitions of what we’re even going to look at to figure those things out and try to characterize this would definitely be helpful. Could have levels to like probable and confirmed.

This early, probably ok to be a bit broad as there’s a historical tendency in medicine to dismiss what we can’t readily find biomarkers etc for, only to realize much later that there was something legit there.

Covid, and the subsequent inflammatory response hits so many different body systems and differently in different people, this is going to be one very messy system to sort out.

 

[Kaustikos]

Probably still too early to know how to diagnose it, but consistency across surveillance/study definitions of what we’re even going to look at to figure those things out and try to characterize this would definitely be helpful. Could have levels to like probable and confirmed.

This early, probably ok to be a bit broad as there’s a historical tendency in medicine to dismiss what we can’t readily find biomarkers etc for, only to realize much later that there was something legit there.

Covid, and the subsequent inflammatory response hits so many different body systems and differently in different people, this is going to be one very messy system to sort out.

I'm okay with broad definitions at the moment. But I think it'd be important for ID/IDSA to get together and make guidelines for diagnosing and severity. I know that there are certain programs that are collecting data and meeting to publish recs but I don't know when this will be available.

 

[chessknt]

I'm okay with broad definitions at the moment. But I think it'd be important for ID/IDSA to get together and make guidelines for diagnosing and severity. I know that there are certain programs that are collecting data and meeting to publish recs but I don't know when this will be available.

Well the just launched a national registry to build a database last month so... A long time

 

[DrMetal]

It’s also complicated because there are too many definitions of “long covid” floating around so it makes comparing studies really challenging/futile.

There's no such thing as "long covid" or covid "long haul".

It's BS, it's quickly becoming the fibromyalgia of the 2020s.

There is such a thing as hospital/ICU exhaustion (if hospitalized for a long time, maybe even PTSD), and there is such a thing as comorbidities that were exacerbated by COVID. But if you get the proper mental health help and/or manage the HTN/DM/COPD etc, then the patient should do well. (assuming of course that the patient complies, which is a big assumption).

I don't know what's worse: the patient who refuses to take their inhalers, their insulin and BP meds, and then blames their demise on Covid "long haul"? Or the physician who's too scared to tell it to them like it is?

 

[wholeheartedly]

There's no such thing as "long covid" or covid "long haul".

It's BS, it's quickly becoming the fibromyalgia of the 2020s.

There is such a thing as hospital/ICU exhaustion (if hospitalized for a long time, maybe even PTSD), and there is such a thing as comorbidities that were exacerbated by COVID. But if you get the proper mental health help and/or manage the HTN/DM/COPD etc, then the patient should do well. (assuming of course that the patient complies, which is a big assumption).

I don't know what's worse: the patient who refuses to take their inhalers, their insulin and BP meds, and then blames their demise on Covid "long haul"? Or the physician who's too scared to tell it to them like it is?

Throughout the history of medicine there have been a lot of conditions that were thought to be made up that turned out not to be. We know covid impacts a large number of body systems and that actual damage and physiologic changes can be detected months later. This is all pretty new. I don’t think some humility and further investigation is unwarranted here.

 

[DrMetal]

Throughout the history of medicine there have been a lot of conditions that were thought to be made up that turned out not to be. We know covid impacts a large number of body systems and that actual damage and physiologic changes can be detected months later. This is all pretty new. I don’t think some humility and further investigation is unwarranted here.

Fine. Show me the basic science to prove it.

Look, no doubt, COVID (and the severe immunological response that ensues) can damage organs, but this usually only occurs in those with underlying conditions (you had CHF, with an EF of 50%, now after a long COVID hospitalization your EF is 25%). Ok. But treat the condition, the CHF, and you should respond.

Now in the case of the elderly and comorbid, I'll make concessions that there may be a 'long haul' phenomena.

What's really irking me is the <50 yo crowd, who never spent a day in the hospital, now blaming every somatic pain on their COVID infection from 12 months ago. (and the medical providers who support this).

 

[wholeheartedly]

Fine. Show me the basic science to prove it.

Look, no doubt, COVID (and the severe immunological response that ensues) can damage organs, but this usually only occurs in those with underlying conditions (you had CHF, with an EF of 50%, now after a long COVID hospitalization your EF is 25%). Ok. But treat the condition, the CHF, and you should respond.

Now in the case of the elderly and comorbid, I'll make concessions that there may be a 'long haul' phenomena.

What's really irking me is the <50 yo crowd, who never spent a day in the hospital, now blaming every somatic pain on their COVID infection from 12 months ago. (and the medical providers who support this).

That’s what the scientist are working on and given the number of systems impacted and the fact that covid hits people differently, it’s probably going to take quite a bit of time to sort through. There’s likely not just one thing going on.


People could still get pretty sick without going to the hospital. In one early Chinese study they did lung imaging of a group of patients quarantined to the hospital and even the folks who were asymptomatic showed notable lung changes from baseline. I haven’t been keeping a list of studies but there are other studies out there showing people didn’t have to be really sick to show signif changes and damage.

Why is it so bad to reserve judgement until more thorough and robust studies are in?

 

[hotsaws]

Fine. Show me the basic science to prove it.

Look, no doubt, COVID (and the severe immunological response that ensues) can damage organs, but this usually only occurs in those with underlying conditions (you had CHF, with an EF of 50%, now after a long COVID hospitalization your EF is 25%). Ok. But treat the condition, the CHF, and you should respond.

Now in the case of the elderly and comorbid, I'll make concessions that there may be a 'long haul' phenomena.

What's really irking me is the <50 yo crowd, who never spent a day in the hospital, now blaming every somatic pain on their COVID infection from 12 months ago. (and the medical providers who support this).

Totally agree. It's not like we can prove "long covid" isn't a thing but I think it's been widely over called and, worse off, perpetuated by medical providers. The whole covid thing became so politicized that it seems to have clouded judgement. There was no politics surrounding Lyme disease and pretty sure the vast majority of ID and non-ID docs agree that "chronic lyme" is not a thing. We all see these functional/somatic patients in our various fields and you can pretty much spot the phenotype immediately. It might be a nocebo effect on large scale, perpetuated by various forms of media and poor medical messaging. We might also just be validating, spending money on, and potentially doing harm to countless people who are just looking for another label to add to their cluster of nondiagnoses. This is excluding people who had prolonged admissions or suffered end organ damage.

Reserving judgment is fine. I personally am skeptical but I'm not saying its impossible or that they are all faking it. I do think it's reckless to do extensive workups on patients without good cause. If you order enough studies, you will find something. If "the science" on this is approached with bias, you can select cohorts and outcomes that can be combined with creative statistical analysis and give you ...something.

 

[DrMetal]

That’s what the scientist are working on and given the number of systems impacted and the fact that covid hits people differently,

Scientists (at least the good ones) aren't working on this problem, they know better. The problem is, that the problem is not well defined.

Scientists like to work on well defined problems (and that's hard enough), like solving the crystal structure of the next spike protein variant and designing small molecules to target it.

What doctors like to do (sometimes) is chase figments of their imagination. We'll come up with a 'syndrome' to ascribe a diagnosis to our patients, to alleviate their anxiety (to alleviate our own anxiety). Then the next 10 years of our outpatient practice will be flooded with BS chronic complaints, FMLA paperwork, etc etc. Look no further than chronic fatigue syndrome, fibromyalgia, chronic lyme.

Again, evidence of end organ damage, which can be demonstrated by an objective study? reduced EF in an echo, reduced FEV1 in a PFT, rising serum creatinine), MDD from prolonged hospitalization? Then Game on. Let's treat those conditions.

 

[futureapppsy2]

Fine. Show me the basic science to prove it.

Look, no doubt, COVID (and the severe immunological response that ensues) can damage organs, but this usually only occurs in those with underlying conditions (you had CHF, with an EF of 50%, now after a long COVID hospitalization your EF is 25%). Ok. But treat the condition, the CHF, and you should respond.

Now in the case of the elderly and comorbid, I'll make concessions that there may be a 'long haul' phenomena.

What's really irking me is the <50 yo crowd, who never spent a day in the hospital, now blaming every somatic pain on their COVID infection from 12 months ago. (and the medical providers who support this).

Does the literature actually support the idea that COVID post-viral effects are generally only limited to those with severe COVID and/or pre-existing conditions? Iirc, one prominent concern in the literature is people getting mild or asymptomatic COVID infections but then having significant post-viral effects.

 

[wholeheartedly]

You always seem so angry about this stuff. Patients are frustrating sure, but the patient is the one with the disease here, whatever it is.

You don’t seem to realize, this is definitely being studied. Boatloads of money have been allocated to scientists and state health departments to study it. It seems like you made your mind up and aren’t even bothering to follow the literature or what’s going on for updates anymore.

Lupus, MS, endometriosis and many others were all blown off as not real or psychosomatic with the same attitude for a long time before the science advanced enough to show they were legit. A lot of needless suffering from that, a lot of harm. Medicine does not have a good track record with complex, hard to pin down conditions like that.

Poorly defined, overcalled, bunch of different things hodge-podged together, sure that’s the point of doing the research.

How likely that this many people previously normally functioning, sometimes high functioning, people did a complete 180 and are just imagining, faking, psychologically overwhelmed that this is all just really nothing?

How likely that you, who don‘t seem to be actually following this issue closely now, know better than the physicians and scientists who are keeping up to date with the science? They’re all just suckers or not good scientists? Really?

There’s certainly not enough evidence to have your mind made up yet.


There’s a quote I really like:

”In medicine you’re either humble, or you’re about to be.”

 

[DrMetal]

one prominent concern in the literature is people getting mild or asymptomatic COVID infections but then having significant post-viral effects.

I would contend that there's something else going on there . . . perhaps mental health related, perhaps some other pathophysiology.

When have we ever known a mild URI to cause such post-viral effects, 12 months downstream, in otherwise perfectly healthy (or near healthy) people? Is Sars COV2 some new magic virus that exacerbates a 32-yo F chronic fatigue, or fibromyalgia, some 2 years after her initial infection?

Look, maybe. But medicine is a game of statistics.

If you were in a Vegas Casino betting $10,000 on Red (Red = validity of actual covid "long haul") or Black (it's something else, mental health most likely), what would you bet on???

Wesley Snipes knows . . .

 

[DrMetal]

There’s a quote I really like:

”In medicine you’re either humble, or you’re about to be.”

I'm all for humility, but I'm also all for some arrogance and good old fashioned staunchness when we know we're right about something, our advocacy for vaccination, our admonishment of pseudotreatments (HCQ, Ivermectin, etc). Take a frickin stand. [mind you, I don't think this is going to happen, most physicians are too cowardice].

You always seem so angry about this stuff.

SDN is for angry physicians.

 

[Trousseau]

I am skeptical. If this is a real, biological thing, we should see it prevalent in other countries where CoVid spread like wildfire, eg India, Mexico, Brazil, etc. Do we have that?

There are a lot of resources and a lot of people looking into this. As we all know, motivated and well-resourced scientists usually find the results they're looking for, by hook or by crook.

Until I see hard evidence: pathognomonic findings on Brain MRIs, Ejection Fraction drops, independent Creatinine rises...something, anything...I will remain skeptical. This is the new Chronic Lyme sham.

 

[wholeheartedly]

I would contend that there's something else going on there . . . perhaps mental health related, perhaps some other pathophysiology.

When have we ever known a mild URI to cause such post-viral effects, 12 months downstream, in otherwise perfectly healthy (or near healthy) people? Is Sars COV2 some new magic virus that exacerbates a 32-yo F chronic fatigue, or fibromyalgia, some 2 years after her initial infection?

Look, maybe. But medicine is a game of statistics.

If you were in a Vegas Casino betting $10,000 on Red (Red = validity of actual covid "long haul") or Black (it's something else, mental health most likely), what would you bet on???

Wesley Snipes knows . . .

How would we have known if other viral URIs or other infections did do this? If patients in bery small numbers scattered across a region come in complaining about things like to their primary doc, they get a basic workup, nothing is found or no cause ID’d and that’s probably the end of the workup.

With covid you have such a huge number of people infected at once and such wide communication about what physicians are seeing in their patients, that you can pick out a pattern now.

 

[wholeheartedly]

It’s worth noting we still have vast gaps in our knowledge of virology and the the full impacts of viral infections on hosts.

things like chronic hepatitis from hep b can lead to liver failure years later.

we know certain viral infections that seemed to have cleared up quickly are associated with cancer decades later with no abnormalities noted in the interim.

we have varicella that can reactivate causing shingles later in life with no abnormalities detected in the interim

kids can rwcover from measles and then decades later get PSSE when it reactivates but seem perfectly normal in the meantime

it surprised the hell out of everyone when they found ebola still living and viable in the semen over a yaer later and atill capable of causing infection. in some cases it reactivated to cause another in the original host.


these viruses aren’t doing nothing in the body that whole time, our immune systems likely aren’t either. to think that weird stuff isn’t going on with other viruses and we just don’t know about it yet, seems shortsighted. we have a whole helluva lot left to learn about infections and our bodies responses to them, normal and abnormal.

 

[DrMetal]

region come in complaining about things like to their primary doc, they get a basic workup, nothing is found or no cause ID’d and that’s probably the end of the workup.

And it should be the end of the work up. You look your patient in the face, and sternly but politely tell him there's nothing wrong (usually after an extensive workup), and to go about the business of his/her life. That's it, we're done. Of course, we've lost this ability in Western medicine.

 

[wholeheartedly]

And it should be the end of the work up. You look your patient in the face, and sternly but politely tell him there's nothing wrong (usually after an extensive workup), and to go about the business of his/her life. That's it, we're done. Of course, we've lost this ability in Western medicine.

You completely missed the point there.

That was in response to if it was real and happening with other URIs, why we haven’t seen it. it’s because epidemiologically there wouldn’t have enough cases in proximity to pickup on the pattern, ie signal to small to detect, and those symptoms likely would be shrugged off after a basic workup doesn’t find anything unusual. so even if real we wouldn’t have known.

So you can’t use the appearance of an absence of this occurring with other URIs or vial infections, when we haven’t really looked for it, as proof that it can’t be happening with covid.

 

[wholeheartedly]

Anyway, there’s a cost to overworking up stuff but please don’t forget the cost of dismissing something that might be real. that’s much harder to undo. It’s a very fine line and nobody should be blowing it off as easy or being quick to judge.

 

[chessknt]

And it should be the end of the work up. You look your patient in the face, and sternly but politely tell him there's nothing wrong (usually after an extensive workup), and to go about the business of his/her life. That's it, we're done. Of course, we've lost this ability in Western medicine.

That is bad medicine and you are talking out your ass. This is an evolving disease and while some of it captures people in the fibromyalgia flavor there are plenty who aren't. There will be more data eventually but just blowing people off who have a difficult to treat disease process is burnout terrible medical care you should be ashamed of delivering. The autonomic dysfunction and fatigue syndrome is absolutely real and very difficult to treat.

Here is longitudinal data from SARS survivors:

Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up - PubMed

Psychiatric morbidities and chronic fatigue persisted and continued to be clinically significant among the survivors at the 4-year follow-up. Optimization of the treatment of mental health morbidities by a multidisciplinary approach with a view for long-term rehabilitation, especially targeting...

pubmed.ncbi.nlm.nih.gov

Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study - PubMed

The clinical and sleep features of chronic post-SARS form a syndrome of chronic fatigue, pain, weakness, depression and sleep disturbance, which overlaps with the clinical and sleep features of FMS and chronic fatigue syndrome.

pubmed.ncbi.nlm.nih.gov

Impact of severe acute respiratory syndrome (SARS) on pulmonary function, functional capacity and quality of life in a cohort of survivors - PubMed

The exercise capacity and health status of SARS survivors was considerably lower than that of a normal population at 6 months. Significant impairment in surface area for gas exchange was noted in 15.5% of survivors. The functional disability appears out of proportion to the degree of lung...

pubmed.ncbi.nlm.nih.gov

Data for PASC is shorter but some good data is already showing longer effects:

One-Year Trajectory of Cognition in Older COVID-19 Survivors

This cohort study evaluates cognitive functioning and decline in elderly COVID-19 survivors in China over a period of 12 months postinfection.

jamanetwork.com

Long-term cardiovascular outcomes of COVID-19 - Nature Medicine

Individuals with COVID-19 are at increased long-term risk for a wide range of cardiovascular disorders, even for individuals who were not hospitalized during the acute phase of the infection.

www.nature.com

Publications – Patient Led Research Collaborative

patientresearchcovid19.com

 

[DrMetal]

That is bad medicine and you are talking out your ass. This is an evolving disease and while some of it captures people in the fibromyalgia flavor there are plenty who aren't. There will be more data eventually but just blowing people off who have a difficult to treat disease process is burnout terrible medical care you should be ashamed of delivering. The autonomic dysfunction and fatigue syndrome is absolutely real and very difficult to treat.

These studies are looking at mostly severe infections, those hospitalized. I'll give credence to their being some signal there in the prolonged hospitalized cases, but I'd also contend there are a lot of confounding factors. Also, most of this data was collected over telemedicine, and most were subjective reports by patients ("I dont feel right, sure my cognitions is down"), as opposed to actual objective evidence (neuropsych testing, etc, which was impossible during the pandemic, still is).

The young and not severe (never hospitalized), no way I buy that.

You know how you can tell that a diagnosis or 'syndrome' is BS? When everyone couples it with something else, to make it more believable. It's not just fatigue syndrome, it's "autonomic dysfunction and chronic fatigue syndrome". It's not just fibromyalgia, its "major depression and fibromyalgia". Nobody wants to realize the former is very real and likely the cause of the latter (that the latter doesn't really exist as a disease entity itself).

 

[Trousseau]

Right, this is odd. It's one thing if the guy who came in with Sepsis and ATN and was on Nonrebreather for a week got "Long Covid."

But most of the people who claim to have it appear to have been relatively unaffected by the virus.

What kind of virus mainly gives indolent long-term sequelae to the otherwise unaffected?

 

[futureapppsy2]

Right, this is odd. It's one thing if the guy who came in with Sepsis and ATN and was on Nonrebreather for a week got "Long Covid."

But most of the people who claim to have it appear to have been relatively unaffected by the virus.

What kind of virus mainly gives indolent long-term sequelae to the otherwise unaffected?

Not quite the same thing but HPV is generally asymptomatic immediately after infection but has been linked to a lot of cancers down the line.

 

[Kaustikos]

These studies are looking at mostly severe infections, those hospitalized. I'll give credence to their being some signal there in the prolonged hospitalized cases, but I'd also contend there are a lot of confounding factors. Also, most of this data was collected over telemedicine, and most were subjective reports by patients ("I dont feel right, sure my cognitions is down"), as opposed to actual objective evidence (neuropsych testing, etc, which was impossible during the pandemic, still is).

The young and not severe (never hospitalized), no way I buy that.

You know how you can tell that a diagnosis or 'syndrome' is BS? When everyone couples it with something else, to make it more believable. It's not just fatigue syndrome, it's "autonomic dysfunction and chronic fatigue syndrome". It's not just fibromyalgia, its "major depression and fibromyalgia". Nobody wants to realize the former is very real and likely the cause of the latter (that the latter doesn't really exist as a disease entity itself).

Woah, buddy! Get with the times! It's called "Systemic Exercise Intolerance Disease, not fibromyalgia. You old fart

/s

 

[chessknt]

These studies are looking at mostly severe infections, those hospitalized. I'll give credence to their being some signal there in the prolonged hospitalized cases, but I'd also contend there are a lot of confounding factors. Also, most of this data was collected over telemedicine, and most were subjective reports by patients ("I dont feel right, sure my cognitions is down"), as opposed to actual objective evidence (neuropsych testing, etc, which was impossible during the pandemic, still is).

The young and not severe (never hospitalized), no way I buy that.

You know how you can tell that a diagnosis or 'syndrome' is BS? When everyone couples it with something else, to make it more believable. It's not just fatigue syndrome, it's "autonomic dysfunction and chronic fatigue syndrome". It's not just fibromyalgia, its "major depression and fibromyalgia". Nobody wants to realize the former is very real and likely the cause of the latter (that the latter doesn't really exist as a disease entity itself).

Of course the data isn't perfect but there is definitely a signal. SARS infected a small fraction of the people COVId did and there are still examples of permanently disabled people from it a decade later. Did all those people have fibromyalgia too?

I have several outpatients who are completely debilitated by pasc who didn't have severe infections. They have lost their jobs, their kids are scared of their illness, they don't travel anymore... Telling them it is all in their head when prior to the infection they were functional employed well adjusted people is wrong. I think it is complely premature to think that there is suddenly an epidemic of fibromyalgia in previously completely normal functional people after a poorly understood viral infection. It is a comfortable belief to have because it makes you feel good about being unable to help them but it ignores their reality and the growing body of evidence.

 

[chessknt]

Right, this is odd. It's one thing if the guy who came in with Sepsis and ATN and was on Nonrebreather for a week got "Long Covid."

But most of the people who claim to have it appear to have been relatively unaffected by the virus.

What kind of virus mainly gives indolent long-term sequelae to the otherwise unaffected?

Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS)

Find out about myalgic encephalomyelitis, also known as chronic fatigue syndrome or ME/CFS. It’s a long-term condition with a wide range of symptoms. Extreme tiredness is the main symptom.

www.nhs.uk

There are some people who develop chronic probably immune driven problems in response to infections. Is it really such a stretch to believe that a virus nobody in the world had any exposure to is trigging bizarre auto immune like symptoms?

 

[Trousseau]

Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS)

Find out about myalgic encephalomyelitis, also known as chronic fatigue syndrome or ME/CFS. It’s a long-term condition with a wide range of symptoms. Extreme tiredness is the main symptom.

www.nhs.uk

There are some people who develop chronic probably immune driven problems in response to infections. Is it really such a stretch to believe that a virus nobody in the world had any exposure to is trigging bizarre auto immune like symptoms?

I don’t put much stock in chronic fatigue syndrome, it’s another wastebasket diagnosis (often I see it in patients who don’t want to admit to themselves that overeating and Norco for Osteoarthritis are the cause of their chronic fatigue).

—-

As I have indicated, my priors are against “Long Covid” being a thing (except in cases of severe infections and protracted clinical courses). I have stated the evidence that would change my mind.

 

[chessknt]

I don’t put much stock in chronic fatigue syndrome, it’s another wastebasket diagnosis (often I see it in patients who don’t want to admit to themselves that overeating and Norco for Osteoarthritis are the cause of their chronic fatigue).

—-

As I have indicated, my priors are against “Long Covid” being a thing (except in cases of severe infections and protracted clinical courses). I have stated the evidence that would change my mind.

It must be intellectually and clinically convenient to unilaterally declare difficult to understand, treat, and diagnose illnesses as fake/psychological. Do you also not believe in severe asthma in the obese because their pft don't fit in rigidly defined criteria despite having symptoms? Or how about chronic pain syndromes, they are all just opiate addicts right since they don't have evidence or reduced ejection fractions?

Have you even practiced medicine? People rarely meet rigidly defined diagnostic criteria and there are huge variations in presentations. Not every person you meet is a disability scam artist trying to con their way out of working again...

 

[DoctwoB]

While all the concerns regarding long-covid remain true (poorly defined, often subjective, unclear incidence, likely a degree of nocebo effect) are valid, there is abundant evidence that there are demonstrable physiologic changes that can occur after a COVID infection

NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals

NEJM Journal Watch reviews over 250 scientific and medical journals to present important clinical research findings and insightful commentary

www.jwatch.org

Respiratory function in patients post-infection by COVID-19: a systematic review and meta-analysis

Evidence suggests lungs as the organ most affected by coronavirus disease 2019 (COVID-19). The literature on previous coronavirus infections reports that patients may experience persistent impairment in respiratory function after being discharged. Our ...

www.ncbi.nlm.nih.gov

are jut a few with 5 seconds of googling

Who the hell are you to say that those structural CNS changes may not be impacting your patient's post-covid fatigue or feeling of cognitive decline? We may not be able to prove something in medicine, hell we may not be able to help it at all, but the least we can do is validate and work with our patients.

 

[hotsaws]

I'm not so sure these are high functioning people that suddenly did a 180. That's often how you'll see cases of chronic fatigue or some other functional illness presented on social media. That sort of bias and cognitive dissonance is necessary because to admit otherwise would suggest a more insidious cause and essentially exclude some disease-related trigger (and imply underlying mental/spiritual/social health problem) like covid/EBV/lyme...whatever. This kind of recall bias is seen in patients and their families all the time. Often when we evaluate these patients for some similar disorder, we see that its far more complex. In pediatrics, I see family dynamics and pressures of aging. In adults, I see life events, divorce, breakups, etc. or other red flags for mental health etiology. We often also see that the "sickness" in the patient has been chronic and insidious.

If endemic respiratory viruses caused post-viral syndromes then that would essentially just be the norm in the population. On sniff test alone, it would be very unusual for a new coronavirus variant to suddenly have a marked post-viral syndrome that didn't result from the countless other coronaviruses and other respiratory viruses that circled the globe multiple times per year for our entire life.

There is an ENORMOUS confounding variable with all the publicity and panic for two years. There's also an inherent bias here from healthcare providers who supported that. There's also a much more likely explanation and that's that the people suffered emotional trauma, social isolation, elevated levels of fear/anixety, missed life events, wearing masks (whether they wanted to or not), etc. This can result in a litany of subjective complaints and legitimate suffering that is being mismanaged if all the attention is going toward trying to identify and treat some organic post-viral syndrome. Now physicians deciding the legitimacy of the fallout from covid have an inherent bias because many of us were proponents of aggressive interventions.

Conditions like hep c and MS had clear objective findings, just no diagnosis for a while. That's a big difference from a condition that's pretty much entirely subjective. If you're suggesting that varicella has some post viral effect, then that's pretty much most of society because of it's ubiquity prior to vaccination. That kind of runs the same logic as anti-vaxers who suggest that we have some kind of ongoing chronic inflammation from vaccines. I don't believe ME is a neurological disease, really, but I'm no neurologist. I think its a fancy name created in an attempt to legitimize the syndrome.

 

[chessknt]

I'm not so sure these are high functioning people that suddenly did a 180. That's often how you'll see cases of chronic fatigue or some other functional illness presented on social media. That sort of bias and cognitive dissonance is necessary because to admit otherwise would suggest a more insidious cause and essentially exclude some disease-related trigger (and imply underlying mental/spiritual/social health problem) like covid/EBV/lyme...whatever. This kind of recall bias is seen in patients and their families all the time. Often when we evaluate these patients for some similar disorder, we see that its far more complex. In pediatrics, I see family dynamics and pressures of aging. In adults, I see life events, divorce, breakups, etc. or other red flags for mental health etiology. We often also see that the "sickness" in the patient has been chronic and insidious.

If endemic respiratory viruses caused post-viral syndromes then that would essentially just be the norm in the population. On sniff test alone, it would be very unusual for a new coronavirus variant to suddenly have a marked post-viral syndrome that didn't result from the countless other coronaviruses and other respiratory viruses that circled the globe multiple times per year for our entire life.

There is an ENORMOUS confounding variable with all the publicity and panic for two years. There's also an inherent bias here from healthcare providers who supported that. There's also a much more likely explanation and that's that the people suffered emotional trauma, social isolation, elevated levels of fear/anixety, missed life events, wearing masks (whether they wanted to or not), etc. This can result in a litany of subjective complaints and legitimate suffering that is being mismanaged if all the attention is going toward trying to identify and treat some organic post-viral syndrome. Now physicians deciding the legitimacy of the fallout from covid have an inherent bias because many of us were proponents of aggressive interventions.

Conditions like hep c and MS had clear objective findings, just no diagnosis for a while. That's a big difference from a condition that's pretty much entirely subjective. If you're suggesting that varicella has some post viral effect, then that's pretty much most of society because of it's ubiquity prior to vaccination. That kind of runs the same logic as anti-vaxers who suggest that we have some kind of ongoing chronic inflammation from vaccines. I don't believe ME is a neurological disease, really, but I'm no neurologist. I think its a fancy name created in an attempt to legitimize the syndrome.

Your premise is flawed because humanity had not evolved with this virus. Its effects are completely unprecedented so to assume that all other viruses MUST behave the same is wrong.

 

[DrMetal]

We may not be able to prove something in medicine

I do have this personality flaw where I demand evidence of something---long haul COVID, chronic fatigue syndrome, fibromyalgia, God---before I believe that it exists. It's the scientist in me. It's a bad habit, I know, I gotta shake it, I'm working on it.

 

[VA Hopeful Dr]

I'm not so sure these are high functioning people that suddenly did a 180. That's often how you'll see cases of chronic fatigue or some other functional illness presented on social media. That sort of bias and cognitive dissonance is necessary because to admit otherwise would suggest a more insidious cause and essentially exclude some disease-related trigger (and imply underlying mental/spiritual/social health problem) like covid/EBV/lyme...whatever. This kind of recall bias is seen in patients and their families all the time. Often when we evaluate these patients for some similar disorder, we see that its far more complex. In pediatrics, I see family dynamics and pressures of aging. In adults, I see life events, divorce, breakups, etc. or other red flags for mental health etiology. We often also see that the "sickness" in the patient has been chronic and insidious.

If endemic respiratory viruses caused post-viral syndromes then that would essentially just be the norm in the population. On sniff test alone, it would be very unusual for a new coronavirus variant to suddenly have a marked post-viral syndrome that didn't result from the countless other coronaviruses and other respiratory viruses that circled the globe multiple times per year for our entire life.

There is an ENORMOUS confounding variable with all the publicity and panic for two years. There's also an inherent bias here from healthcare providers who supported that. There's also a much more likely explanation and that's that the people suffered emotional trauma, social isolation, elevated levels of fear/anixety, missed life events, wearing masks (whether they wanted to or not), etc. This can result in a litany of subjective complaints and legitimate suffering that is being mismanaged if all the attention is going toward trying to identify and treat some organic post-viral syndrome. Now physicians deciding the legitimacy of the fallout from covid have an inherent bias because many of us were proponents of aggressive interventions.

Conditions like hep c and MS had clear objective findings, just no diagnosis for a while. That's a big difference from a condition that's pretty much entirely subjective. If you're suggesting that varicella has some post viral effect, then that's pretty much most of society because of it's ubiquity prior to vaccination. That kind of runs the same logic as anti-vaxers who suggest that we have some kind of ongoing chronic inflammation from vaccines. I don't believe ME is a neurological disease, really, but I'm no neurologist. I think its a fancy name created in an attempt to legitimize the syndrome.

If we had a time machine I bet we'd see exactly this kind of thing whenever one of our now ubiquitous respiratory pathogens first appeared. But if a virus has been around for literally generations (if not centuries) its not new anymore.

I mean, someone earlier posted exactly this kind of thing happening with SARS... you know, the most recent novel coronavirus pre-COVID.

 

[chessknt]

If we had a time machine I bet we'd see exactly this kind of thing whenever one of our now ubiquitous respiratory pathogens first appeared. But if a virus has been around for literally generations (if not centuries) its not new anymore.

I mean, someone earlier posted exactly this kind of thing happening with SARS... you know, the most recent novel coronavirus pre-COVID.

And Sars only infected about 8000 people compared to 550 million+++ covid cases. We are going to see weird stuff with those numbers.

 

[Trousseau]

Have you even practiced medicine?

Yes, I do.

I am not sure your examples are valid. Bronchospastic diseases have demonstrable symptoms and history even if the PFTs are not what they should be. Chronic Pain is more up in the air, but as I understand it, it has modeled pathogenesis (a gradually developing dysfunctional neurological response to protracted painful stimuli), and there are medications (eg Cymbalta, Elavil) that do help (albeit evidence for Elavil isn’t great) without directly blunting the pain itself. The point is that there is *something* there.

I am more skeptical about Chronic Fatigue because the symptoms are much more vague and nonspecific than even that of chronic pain, that there is not a specific pathogenesis of it, and that in my clinical experience it shows up in patients with much more obvious causes of fatigue. You know what we say about hoofbeats and zebras…but in this case I don’t even think they’re hoofbeats.

As I said, I’m willing to entertain the possibility of Long CoVid for now, though I’m skeptical. I would prefer to wait until much of the worry and politicizing has faded, cooler heads prevail, and more time has passed to observe long-term sequelae.

 

[chessknt]

Yes, I do.

I am not sure your examples are valid. Bronchospastic diseases have demonstrable symptoms and history even if the PFTs are not what they should be. Chronic Pain is more up in the air, but as I understand it, it has modeled pathogenesis (a gradually developing dysfunctional neurological response to protracted painful stimuli), and there are medications (eg Cymbalta, Elavil) that do help (albeit evidence for Elavil isn’t great) without directly blunting the pain itself. The point is that there is *something* there.

I am more skeptical about Chronic Fatigue because the symptoms are much more vague and nonspecific than even that of chronic pain, that there is not a specific pathogenesis of it, and that in my clinical experience it shows up in patients with much more obvious causes of fatigue. You know what we say about hoofbeats and zebras…but in this case I don’t even think they’re hoofbeats.

As I said, I’m willing to entertain the possibility of Long CoVid for now, though I’m skeptical. I would prefer to wait until much of the worry and politicizing has faded, cooler heads prevail, and more time has passed to observe long-term sequelae.

So what do you tell patients who show up to your clinic who have lost their jobs, in their 30s-40s, feel like they can barely function, are having trouble at home because the working spouse is now having to do everything, and asks for help? DO you tell them that after a thorough workup you have concluded they need psychiatric evaluation because they are crazy? What happens if they are undergoing psychiatric care and still have these symptoms? I have a patient who has demonstrated profound exertional tachycardia to the 180s with minimal exertion (like 200 feet on a 6mwt) that was previously a mountain climber 6 months ago. She can't even walk from the parking lot to my office now. Her mother moved in with her to help with her kids because she can't keep up with them while her husband works. She has complied with every recommendation her physicians have made with essentially no improvement. Am I to believe there is no underlying non-psych etiology for her sudden development of dysautonomia?

I get that you want more data--I do too. But I have to take care of people with this now, just like I had to take care of the dying COVID people in the ICU when we didnt know what to do with that either. As a clinician you don't have the luxury of waiting for all of the data to be produced and processed and turned in to guidelines unless you abdicate your responsibility to care for people with this.

 

[DoctwoB]

I do have this personality flaw where I demand evidence of something---long haul COVID, chronic fatigue syndrome, fibromyalgia, God---before I believe that it exists. It's the scientist in me. It's a bad habit, I know, I gotta shake it, I'm working on it.

You may be being facetious, but you're not wrong.

Most (a majority) of medicine exists in the gray areas. Even something as seemingly simple as diagnosing a UTI often isn't. Positive culture is meaningless without symptoms. Negative or contaminated culture in presence of symptoms doesn't completely rule it out. Often patients with recurrent UTI symptoms don't truly have recurrent UTIs, but their episodic pelvic symptoms may have been triggered by a true infection. Now we have newer molecular diagnostic tests showing urine is never actually sterile and uropathogens are usually present at baseline. Most of what we think we know is wrong or a rough approximation of the truth. In practicing medicine, try to be humble and patient-centric in your approach, because we don't know much.

 

[VA Hopeful Dr]

Yes, I do.

I am not sure your examples are valid. Bronchospastic diseases have demonstrable symptoms and history even if the PFTs are not what they should be. Chronic Pain is more up in the air, but as I understand it, it has modeled pathogenesis (a gradually developing dysfunctional neurological response to protracted painful stimuli), and there are medications (eg Cymbalta, Elavil) that do help (albeit evidence for Elavil isn’t great) without directly blunting the pain itself. The point is that there is *something* there.

I am more skeptical about Chronic Fatigue because the symptoms are much more vague and nonspecific than even that of chronic pain, that there is not a specific pathogenesis of it, and that in my clinical experience it shows up in patients with much more obvious causes of fatigue. You know what we say about hoofbeats and zebras…but in this case I don’t even think they’re hoofbeats.

As I said, I’m willing to entertain the possibility of Long CoVid for now, though I’m skeptical. I would prefer to wait until much of the worry and politicizing has faded, cooler heads prevail, and more time has passed to observe long-term sequelae.

Ah, well there's the issue. You're only a year out of residency.

I don't mean this as a slight, when I first got out I followed the evidence to a T and if something didn't fit I immediately disregarded it. Its pretty common in brand new attendings.

 

[Gastrapathy]

@DoctwoB While that is all true, overdiagnosis and overtesting are also harmful and the industries that spring up around it can do great harm to patients. We should be skeptical at baseline about everything. Do as much of nothing as possible is still good advice.

I will say that this study actually might support the existence of long covid if the vaccine can impact it at all.

 

[DrMetal]

So what do you tell patients who show up to your clinic who have lost their jobs, in their 30s-40s, feel like they can barely function, are having trouble at home because the working spouse is now having to do everything, and asks for help? DO you tell them that after a thorough workup you have concluded they need psychiatric evaluation because they are crazy?

Yes! That's exactly what you should do (maybe not call them 'crazy'). You'll be a better doctor to them if you treat (or refer them to someone who can) their underlying mental health issues.

@DoctwoB While that is all true, overdiagnosis and overtesting are also harmful and the industries that spring up around it can do great harm to patients. We should be skeptical at baseline about everything. Do as much of nothing as possible is still good advice.

This, +1000%, well said.

 

[DrMetal]

Yes, I do.

Shred that piece of Sh#$. Means nothing, only that you were able to take and pass someone's 300-Q multiple guess test. Meanwhile, none of us can think freely and objectively, and stand up to BS.

Ah, well there's the issue. You're only a year out of residency.

Ah, there it is! (surprised it took this long). The quintessential SDN "you don't know what you're talking about because you're a M1/R1/F1 or first year attending".

 

[VA Hopeful Dr]

Ah, there it is! (surprised it took this long). The quintessential SDN "you don't know what you're talking about because you're a M1/R1/F1 or first year attending".

Doesn't make it less true

 

[DoctwoB]

@DoctwoB While that is all true, overdiagnosis and overtesting are also harmful and the industries that spring up around it can do great harm to patients. We should be skeptical at baseline about everything. Do as much of nothing as possible is still good advice.

I will say that this study actually might support the existence of long covid if the vaccine can impact it at all.

Obviously everything needs to be taken in the context of risk vs. benefit.

One of our bugaboo's in urology is chronic pelvic pain/interstitial cystitis, chronic prostatitis, etc. A lot of people with a lot of symptoms of what is likely a bunch of different pathophysiologies with definitely psychiatric and chronic pain physiology mixed in. The fact that they don't have a demonstrable pathologic diagnosis (or a worthless one, as prostatic inflammation on pathology correlates incredibly poorly with symptoms) doesn't make their symptoms or suffering less real. So we look at potential things that could help them and risks/benefits of each. Personally my patients end up with some lifestyle modification, pelvic floor physical therapy, NSAIDS for flares, sometimes TCAs (with psych involved) and the vast majority do well. Would they have done well with placebos? Some of them certainly, which is why we start with low/no risk interventions.

 

[hotsaws]

Right, well, all those ubiquitous respiratory viruses are new the first time you see them. All those RNA respiratory viruses are mutating from year to year anyway. By the time you're an adult, you would have lived through countless individual post-viral states. If respiratory post-viral syndromes are a thing, then that's just part of being human. Again, I'm not saying there's not a legit post-covid that we may discover as a unique disease entity, I'm just saying I am highly skeptical and doubtful. I like the way DrMetal put it above with a betting analogy.

It's terrible that there's a taboo on mental health problems in our society. I think that's a major problem here. We don't have the infrastructure to address it and many of us are too busy or conflict avoidant to do it ourselves. Can pretty much guarantee that we will allocate billions for tests and pharmaceuticals ...with only pennies for mental health. I think it's fine to "do no harm" and admit that you have no idea if long covid is a thing but you know you don't know enough to diagnose or treat it. Validating and acknowledging someone's suffering can be helpful and is also just a decent thing to do. Validating or perpetuating false beliefs can be harmful because it distracts from potentially addressing the real underlying pathology and often results in excess testing and a ton of unneeded medications. Honestly, we've all seen it, right? Some patient with a functional illness that's like 30yo and shows up on a bunch of medications/interventions that are not benign (beta blockers, fludricortisone, Synthroid, SSRIs, TCAs, opiates, vitamins (the kind you pay cash for), ports, feeding tubes, weird diet restrictions....). Sometimes all of these in the same patient...medications that literally contradict one another. And, yet, here they are seeing another specialist with essentially the same complaints as when they first started. I think this is often a result of a bunch of well meaning providers who try and contribute their little part. These patients have had a battery of tests and often repeated them. Useless tests can lead to more useless tests. Moreover, ordering tests and trialing therapies can perpetuate anxiety and further solidify false beliefs. This is a more extreme example but not all that uncommon. With the large scale of the covid pandemic, if "long covid" goes this route, our profession will have potential to do great harm.

Anyways, I certainly fit into the category of newer residency/fellowship grads. So perhaps I will eat my words after a few decades of practice. I clearly have a bias and probably very jaded from burnout. These are just my limited observations and opinions.

 

[chessknt]

Right, well, all those ubiquitous respiratory viruses are new the first time you see them. All those RNA respiratory viruses are mutating from year to year anyway. By the time you're an adult, you would have lived through countless individual post-viral states. If respiratory post-viral syndromes are a thing, then that's just part of being human. Again, I'm not saying there's not a legit post-covid that we may discover as a unique disease entity, I'm just saying I am highly skeptical and doubtful. I like the way DrMetal put it above with a betting analogy.

It's terrible that there's a taboo on mental health problems in our society. I think that's a major problem here. We don't have the infrastructure to address it and many of us are too busy or conflict avoidant to do it ourselves. Can pretty much guarantee that we will allocate billions for tests and pharmaceuticals ...with only pennies for mental health. I think it's fine to "do no harm" and admit that you have no idea if long covid is a thing but you know you don't know enough to diagnose or treat it. Validating and acknowledging someone's suffering can be helpful and is also just a decent thing to do. Validating or perpetuating false beliefs can be harmful because it distracts from potentially addressing the real underlying pathology and often results in excess testing and a ton of unneeded medications. Honestly, we've all seen it, right? Some patient with a functional illness that's like 30yo and shows up on a bunch of medications/interventions that are not benign (beta blockers, fludricortisone, Synthroid, SSRIs, TCAs, opiates, vitamins (the kind you pay cash for), ports, feeding tubes, weird diet restrictions....). Sometimes all of these in the same patient...medications that literally contradict one another. And, yet, here they are seeing another specialist with essentially the same complaints as when they first started. I think this is often a result of a bunch of well meaning providers who try and contribute their little part. These patients have had a battery of tests and often repeated them. Useless tests can lead to more useless tests. Moreover, ordering tests and trialing therapies can perpetuate anxiety and further solidify false beliefs. This is a more extreme example but not all that uncommon. With the large scale of the covid pandemic, if "long covid" goes this route, our profession will have potential to do great harm.

Anyways, I certainly fit into the category of newer residency/fellowship grads. So perhaps I will eat my words after a few decades of practice. I clearly have a bias and probably very jaded from burnout. These are just my limited observations and opinions.

Again humanity itself had never seen a coronavirus like this. While everyone has a first exposure effect to the common respiratory viruses there are two things that make them different--they occur in childhood when the immune response is different and there has been a bi-directional evolutionary pressure from previous viruses co-evolving with humanity that resulted in the highest chance for a benevolent effect. For all we know there were a subset of people who were debilitated but not killed after the flu and they all died because they got left behind by their hunter gatherer communities until there genes were gone.

 

[hotsaws]

We don't know that we've never seen a coronavirus or other respiratory virus like this. Assuming you mean one with a similar virulence, transmissibility, and bad outcomes. We just happen to live in a time with readily available global transportation, a much older average age, the ability to support ones physiology to a much greater degree in a hospital setting, and higher prevalence of comornidities such as obesity and diabetes. We've certainly seen pandemics caused by respiratory viruses and likely endured countless mutations of the more common ones. Long covid is being pitched as affecting all ages at this point. Certainly the immune response varies in the very young vs the very old but mostly quite similar in between. Are you suggesting that age-dependent immune response predisposes to autoantibody formation or specific sensitized T cells? If long covid were immune-mediated, it shouldn't be very good at hiding from screening tests that readily pick up on the kind of damage that results from that (ie inflammatory markers, end organ damage, etc.). When looking to immune-mediated pathology, it's usually apparent if there is an auto-immune, auto-inflammatory, or immuno deficiency at play. It's not always easy to diagnose exactly what it is but it's usually apparent that something objective is going on.

For the purposes of this discussion, I am under the impression that we are not limiting long covid to those who were severely ill and admitted to the hospital or suffered end organ damage. I completely agree that these folks are likely to have a prolonged recovery and possible chronic sequelae. Not sure if its long covid or post-hospital deconditioning/myopathy/neuropathy or just end organ damage or whatever. Either way, that cohort fully deserves a more extensive workup. No argument from me there. I thought we were talking about long covid as some sort of post viral syndrome that affects a wide age range and those that even had mild illnesses -- that's where I have strong doubts that anything significant exists that is not essentially supratentorial.