Variants, inappropriate behaviour, Covid fatigue have led to a surge: Top doctors - The Daily Guardian
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Variants, inappropriate behaviour, Covid fatigue have led to a surge: Top doctors

The ongoing coronavirus surge is not really a sudden, one-off incident. About 100 years ago, there was a similar pandemic, healthcare experts tell The Sunday Guardian in an exclusive interview.

Shalini Bhardwaj

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Top doctors and healthcare experts Dr Rakesh Mishra, director of CSIR-CCMB, Dr Padma Srivastava, senior neurologist from All Indian Institute of Medical Sciences, and Dr S.K. Sarin, director of ILBS, told this paper why they think India is witnessing a massive surge in Covid-19 cases now and how this surge can be controlled. Excerpts:

Q. What explains the sudden surge in Covid-19?

Dr Rakesh Mishra: The most logical reason for the surge in Covid cases is that 2-3 months ago, things were in control, but gradually we started to become careless and common people thought that coronavirus is now gone and normal life can be resumed. We are seeing the consequence of that carelessness. When the number of cases rise, it picks up like a chain reaction. Political activities, farmers’ protests, marriage parties, local trains, schools reopening, restaurant opening, bars opening, malls opening and all such things mean lots of exposure to people in public and these things led to the sudden increase in cases. Also, over a period of time, more variants have emerged and this has affected a large number of people.

Q: In Punjab, we are seeing a lot of people been infected by the UK variant?

Dr Rakesh Mishra: You can actually link that very nicely if you see the data of the UK variant. It means that these are the travellers who initially came from the UK and then participated in some activity where a large number of people came together and then they went to smaller cities and villages and started to spread the virus. But the reason for spreading is only one which is when people are not careful. When people are in close proximity without protection to an infected person, who is also not protected, this is bound to happen. It doesn’t matter which variant it is.

Q. What would you like to say about the sudden surge?

Dr Padma Srivastava: Again, as Dr Mishra said, it is not really sudden. About 100 years ago, there was a very similar pandemic. There was also a second wave which was steeper and worse and then a third wave and then probably, it just vanished. So, what we are seeing today is not an unexpected development. What has happened now, as professor Mishra said, is the presence of variants. To add to it is Covid-inappropriate behavior, which may be due to Covid fatigue as well as overconfidence following the arrival of Covid vaccines. So, people threw caution to the wind at a time when mutants were present and active. Historically, we are going to hit waves and waves again. And for safety, vaccination and Covid-appropriate behaviour are the best bet.

Q: The situation in India is worsening, what are the steps we should all take now?

Dr S.K. Sarin: First, we have to accept that we have a difficult situation and we are actually having more infections now than we anticipated. This is likely to probably overshoot last year’s numbers; so first, we have to accept that we are down in the dumps, we are in trouble and, therefore, if we accept that, then certainly, we have to manage at least this wave of severe and rapidly spreading infection and then, the second step would be to think about how we can prevent a subsequent wave and not let these waves keep on coming and disturbing our economy and lives.

As Dr Mishra and Dr Padma have already said, in my opinion, this was anticipated even in January when things opened up very rapidly. We had the first mutant coming and the UK variant had come or at least was detected at that time and from then on, everyone knew that like in UK, in three months, it would lead to a major proportion of people getting infected. We are not doing as many sequencing as we should for the virus types, but it is anticipated that in a few weeks, this may become a major problem of viral variants infecting Indians. Of course, other variants are there; the virus has a life cycle of about 12-16 weeks until the time it has a major mutation.

So while they are occurring, we should be aware of mutants coming and infecting the population in different cities where it was not there. What is worrying is that we had opened up almost all our transport systems and our offices back in January thinking that the virus has gone away; also, we thought that now that the vaccine has arrived, all of us will be vaccinated soon. These two things have probably help the spread of the virus now. The worry now is the number of deaths piling up in the next 2 to 4 weeks’ time when the infection becomes deeper and more and more people get infected. I think the situation is difficult, but all of us have a collective responsibility.

Q: How can we check such waves?

Dr Rakesh Mishra: Genome sequencing let you explore the aspects of the virus–what kind of changes it is acquiring and if there is any particular area where a particular variant is increasing in number. We have to keep in mind that we are only generating the mutants by allowing the virus groups to spread across a large number of people and mutations are a natural process of any life form. Genome sequencing provides valuable information which gives us some hints about what might be happening, but to control the spread of the virus, we all have to be extremely careful and behave in a Covid-appropriate manner.

Q: Do you think lockdown is one of the useful options?

Dr S.K. Sarin: Once you finish two to four weeks of lockdown, people tend to think that the virus has gone and they start doing multiple times the level of activities they did earlier; so lockdown sometimes is not a very positive way of managing such things.

As Dr Padma said we have to get things like hospitals, ICU beds, drugs, protocols and healthcare workers in order; however, testing and tracing has to be as strict as possible. Lockdown has to be self imposed–you have to see that you actually lock yourself down compared to others to stop the transmission of the virus. The virus is like a villain, it will go away and then show up again and again.

We need to vaccinate our population faster; we have just done 7% vaccination of our population which is much less, especially with respect to areas where the virus is spreading fast like in Maharashtra or maybe Karnataka and Delhi. I think the age bar should be removed and mass vaccination is required as fast as possible. In the history of medicine, there has never been an occasion when the whole world has to be vaccinated and that too fast. So, there are challenges, challenges of making vaccines available, challenges of side effects, challenges of getting people to vaccinate and most importantly, getting people to accept a vaccine. Having said that, through the media, it is very important for us to communicate that there are two types of vaccines available: one is your mask and the second is the available vaccine and we have to employ both of them. Get your shot, do not be hesitant because there are advantages of getting a vaccine. Some people say he got two shots of vaccines, still he got infection, so what is the use of getting vaccination? But it is important to understand that if someone got vaccine shots and even then that person got infected, the infection will be milder. The severity of the disease is reduced as also the severity or possibility of transmitting the virus to others.

The other advantage of vaccines is that you will have antibodies which will at least last for six months to a year; but that should not make you abandon all the Covid-appropriate behavior. Also, once you have a vaccine, you can become and work like a frontline worker. No doctor, nurse, or healthcare worker should work if they have not received both doses of the vaccine. In fact, if there is a possibility, there is a support, we should test the immunization because vaccination is not equal to immunization; immunization means we have a high level of protective antibodies; we have not come to that stage yet. If you are over cautious that a certain vaccine may have side effects, we will lose more lives. Take whichever vaccine is available; they’re safe as millions have taken them.

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‘DRIVERS WITH SHIFT WORK SLEEP DISORDER 3 TIMES MORE LIKELY TO BE IN CRASH’

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As people working late-night may face a couple of health issues due to the disturbance in body clock, they may suffer from shift work sleep disorder. According to researchers, people who develop this condition are also three times more likely to be involved in an accident.

Individuals working in late shifts such as 11 pm -7 am, or the ‘graveyard’ shift, are more likely than people with traditional daytime work schedules to develop a chronic medical condition — shift work sleep disorder — that disrupts their sleep. According to researchers at the University of Missouri, people who develop this condition are also three times more likely to be involved in a vehicle accident. “This discovery has many major implications, including the need to identify engineering countermeasures to help prevent these crashes from happening,” said Praveen Edara, department chair and professor of civil and environmental engineering.

Edara added, “Such measures can include the availability of highway rest areas, roadside and in-vehicle messaging to improve a driver’s attention, and how to encourage drivers who may have a late-night work shift to take other modes of transportation, including public transit or ride-share services.”

Edara, one of the authors of the study, said the analysis was based on data collected from a real-world driving study for the second Strategic Highway Research Program established by the U.S. Congress.

As the demand for 24/7 business operations has increased in recent years to meet customer needs during all hours of the day and across multiple time zones, the traditional workday — once defined as 9 am -5 pm — has shifted for many people to include evening and night shifts, causing sleeping difficulties and leading to shifting work sleep disorder.

Edara said he was surprised to see shift work sleep disorder increase the risk of a traffic crash by nearly 300 per cent, as compared to both sleep apnea and insomnia, which both increased the risk of a crash by approximately 30 per cent.

Edara said previous studies have shown sleep disorders increase the risk for a traffic crash, but the majority of these studies were conducted in a controlled environment, such as a laboratory driving simulator. He believes this real-world data now validates those efforts.

“In the past, researchers have studied sleep disorders primarily in a controlled environment, using test-tracks and driving simulators,” Edara said.

Edara added, “Our study goes a step further by using actually observed crash and near-crash data from approximately 2,000 events occurring in six U.S. states. We’ve known for a while now that sleep disorders increase crash risk, but here we are able to quantify that risk using real-world crash data while accounting for confounding variables such as roadway and traffic characteristics.”

Edara said some of the limitations of their study include not having data for fatal crashes, and no formal measurement to define drowsiness.

PUTTING A SPOTLIGHT ON A NATIONAL PROBLEM

In the United States, the National Transportation Safety Board, or NTSB, is the federal agency that investigates major traffic accidents. Each year, they issue an annual “most wanted list” of safety improvements, and their 2019-2020 list includes “screening and treating obstructive sleep apnea” among the top 10 topic areas.

Edara said he hopes that by showing how big of a risk there is for traffic crashes caused by excessive daytime sleepiness, the researchers can help draw additional attention toward finding ways to keep people safe behind the wheel, including taking the driver out of the equation with ride-sharing options and automated vehicles. He said the ideal next step in this research would be to partner with medical professionals who have expertise in this area to better understand why this is happening.

“We want to partner with public health and medical professionals whose expertise is in sleep-related research to better understand why this is happening,” Edara said.

“That will also allow us to explore what kind of countermeasures we can develop and test to improve the overall safety of these drivers and the other motorists around them,” Edara concluded.

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SCREENING FOR OVARIAN CANCER DID NOT REDUCE DEATHS DURING STUDY

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A large-scale randomised trial of annual screening for ovarian cancer, led by UCL researchers, did not succeed in reducing deaths from the disease, despite one of the screening methods tested detecting cancers earlier.

Results from the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) have been published in a report in the medical journal The Lancet. In the UK, 4,000 women die from ovarian cancer each year. It is not usually diagnosed until it is at a late stage and hard to treat. UKCTOCS was designed to test the hypothesis that a reliable screening method that picks up ovarian cancer earlier can save lives when treatments are more likely to be effective.

The latest analysis looked at data from more than 200,000 women aged 50-74 at recruitment who were followed up for an average of 16 years. The women were randomly allocated to one of three groups: no screening, annual screening using an ultrasound scan, and annual multimodal screening involving a blood test followed by an ultrasound scan as a second-line test.

The researchers found that, while the approach using multimodal testing succeeded in picking up cancers at an early stage, neither screening method led to a reduction in deaths.

Earlier detection in UKCTOCS did not translate into saving lives. Researchers said this highlighted the importance of requiring evidence that any potential screening test for ovarian cancer actually reduced deaths and detected cancers earlier.

Professor Usha Menon (MRC Clinical Trials Unit at UCL), the lead investigator of UKTOCS, said: “UKCTOCS is the first trial to show that screening can definitely detect ovarian cancer earlier. However, this very large, rigorous trial shows clearly that screening using either of the approaches we tested did not save lives. We therefore cannot recommend ovarian cancer screening for the general population using these methods.

“We are disappointed as this is not the outcome we and everyone involved in the trial had hoped and worked for over so many years. To save lives, we will require a better screening test that detects ovarian cancer earlier and in more women than the multimodal screening strategy we used.”

Women aged between 50 and 74 were enrolled in the trial between 2001 and 2005. Screening lasted until 2011 and was either an annual blood test, monitoring changes in the level of the protein CA125, or a yearly vaginal ultrasound scan. About 100,000 women were assigned to the no screening group, and more than 50,000 women to each of the screening groups.

Blood test screening picked up 39 per cent more cancers at an early stage (Stage I/II) while detecting 10 per cent fewer late-stage cancers (Stage III/IV) compared to the no screening group. There was no difference in the stage of cancers detected in the ultrasound group compared to the no screening group.

The initial analysis of deaths in the trial occurred in 2015, but there was not enough data at that time to conclude whether or not screening reduced deaths. By looking at five more years of follow-up data from the women involved, researchers are now able to conclude that the screening did not save lives.

Professor Mahesh Parmar, Director of the MRC Clinical Trials Unit at UCL and a senior author on the paper, said: “There have been significant improvements in the treatment of advanced disease in the last 10 years since screening in our trial ended. Our trial showed that screening was not effective in women who do not have any symptoms of ovarian cancer; in women who do have symptoms early diagnosis, combined with this better treatment, can still make a difference to the quality of life and, potentially, improve outcomes. On top of this, getting a diagnosis quickly, whatever the stage of cancer, is profoundly important to women and their families.”

Professor Ian Jacobs, from the University of New South Wales (UNSW Sydney), a co-investigator who has led the ovarian cancer screening research programme since 1985 and who was the lead investigator of UKCTOCS from 2001-2014, said: “My thanks to the thousands of women, healthcare professionals and researchers who made this trial possible. The multimodal screening strategy did succeed in the detection of ovarian cancer at an earlier stage, but sadly that did not save lives. This is deeply disappointing and frustrating given the hope of all involved that we would save the lives of thousands of women who are affected by ovarian cancer each year.”

Professor Jacobs noted: “Population screening for ovarian cancer can only be supported if a test is shown to reduce deaths in a future randomised controlled trial. I remain hopeful that a new effective screening test will be found eventually, but it will take many years to conduct a large trial of the test. Realistically, this means we have to reluctantly accept that population screening for ovarian cancer is more than a decade away.”

A huge wealth of samples and data from the trial has been donated by the participants for future research. This resource referred to as the UKCTOCS Longitudinal Women’s Cohort (UKLWC), is now being used by researchers worldwide, helping to improve understanding of ovarian cancer as well as other cancers and other diseases such as cardiovascular disease.

Researchers say that the study has also generated insights into how best to design, conduct and analyse a large-scale randomised clinical trial particularly in individuals who have no signs of disease. These insights will be helpful to future trials in all areas of health. It has also contributed to advances in risk assessment, prevention and diagnosis of ovarian cancer.

The UKCTOCS trial was funded by the NIHR Health Technology Assessment (HTA) Programme and the charities Cancer Research UK and The Eve Appeal.

Michelle Mitchell, Cancer Research UK’s Chief Executive, said: “Trials don’t always find the result we had hoped for, but we need long-term studies like this to know whether new tests save lives. Cancer Research UK will continue to fund vital research into aggressive forms of ovarian cancer so we can reduce the impact of this disease.

“Screening is for people without symptoms, so it’s still important that if you notice unusual or persistent changes to talk to your doctor. Symptoms of ovarian cancer can be quite vague and similar to symptoms caused by less serious conditions, which can make spotting the disease tricky. Whether it’s needing to go to the toilet more often, pain, bloating, or something else, raise it with your GP – in most cases, it won’t be cancer but it’s best to get it checked out.”

Professor Nick Lemoine, Medical Director, NIHR Clinical Research Network, said: “These important findings from a large-scale trial, involving 200,000 participants, show that annual screening did not succeed in reducing deaths from ovarian cancer.

“However, it’s important to note that negative results can be as important as positive. The study has provided important new evidence and insights into how to conduct and analyse future large-scale randomised clinical trials into ovarian cancer, in the hope that this will prevent and diagnose this disease more effectively in the future.

“We thank every single person who took part.”

Athena Lamnisos, CEO, The Eve Appeal, said: “The threshold for introducing a national cancer screening programme is a mortality benefit. Of course, this is key – saving lives. It’s disappointing that this research programme did not show a reduction in mortality from ovarian cancer and so can’t be recommended as a national screening programme. However, the impact it had on earlier diagnosis is impressive and important.

“Ovarian cancer is so often diagnosed at stage 3 or 4 and shifting diagnosis one stage earlier makes a huge difference to both treatment options and quality of life. Earlier diagnosis will often reduce the amount and intensity of treatment, which makes all the difference to women and their families living with cancer. It may have also given them more precious time with their loved ones.”

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Battling Covid-19? Preparedness at home is crucial and critical

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As the second wave of Covid-19 continues to rage on, it is of paramount importance for everyone to remain alert and vigilant. Its indeed our responsibility toward ourselves and to our fellow citizens. Covid has affected each and every family in our neighborhood and so, being well prepared at home is crucial.

THINGS TO DO AT HOME:

Step 1: The first step of preparedness for every household is having adequate quantity of masks available at home. These can be cloth masks or surgical masks. While venturing out, wear a double cloth mask or one cloth and one surgical mask to ensure maximum protection at public places

Step 2: Another important device that every household should have is a digital thermometer. One should check the temperature of all individuals at home daily or check the temperature of the ones who experience some malaise, bodyache, fever or fatigue. Any axillary temperature more than 99.3 is considered as fever. So, this patient needs immediate attention and further evaluation. In this pandemic, every fever is Covid unless proven otherwise. Hence all fever patients should be tested for Covid.

Step 3: The third important device is a Pulse Oxymeter. It is essentially needed in patients who are home quarantined or taking treatment at home. If Pulse Oxymeter reading goes below 93% then one must visit a Covid care center or a hospital. Those patients who are availing Covid treatment at home should meticulously monitor body temperature and oxygen saturation using a Pulse Oxymeter and inform their care giving physician at intervals of 6hours

Step 4: We recommend a six-minute walk test for patients who are getting treated at home and whose oxygen levels are normal at room air and during resting. We recommend the patient walk in room for 6 minutes at a normal pace and recheck the oxygen levels. If oxygen levels drop after the walk, then it’s a sign of Early Hypoxia and this patient should look for beds in the hospital, or get an oxygen concentrator at home with the advice of their doctor. This test diagnoses Early Hypoxia as well as gives the patient some time to look for more medical aid.

PREPAREDNESS FOR HOUSING SOCIETIES:

I recommend all the housing societies that they should procure Oxygen Concentrators and some beds in their clubhouses. This will help them provide oxygen to Hypoxic (oxygen level less than 94%) patients till they get a hospital bed; this is a lifesaving measure. Here are some preparedness measures for housing societies:

• An emergency holding medical area should be created at the society’s clubhouse/ office/ Gymnasium; this designated area must have an attached bathroom and must function as an isolation area

• Have a simple mattress and pillow placed where the person could lie down

• Arrange for a Pulse Oximeter to measure blood oxygen saturation of the patient

• Arrange for an Oxygen Concentrator machine (which can be rented) to give up to 5liters per minute of Oxygen to a patient. Don’t get Oxygen Cylinders, they should be strictly reserved for hospitals

• Arrange for Hand Sanitizer, a box of gloves, N95 masks, normal masks and an Infrared Thermometer

• Follow local municipal COVID norms

• Following the guidelines of the BMC is a must. If there are more than 5 cases in a society then all members must restrict from venturing out. Society must follow the sanitization norms from time to time. Screen all visitors, house help, cooks, and caretakers of the elderly, coming into the society. Groceries for members can be ordered from one particular vendor to avoid too many people coming to the society

• Moreover, if you are 18 and above, get yourself registered for vaccination. This will give you immense immunity to fight the virus if you get infected

The author is Director, Emergency Medicine, Fortis Hospital, Mulund.

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AI TOOL USES CHEST X-RAY TO DIFFERENTIATE WORST COVID CASES

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According to a new study, a computer program that has been trained to see patterns by analysing thousands of chest X-rays — predicted with up to 80 per cent accuracy which Covid-19 patients would develop life-threatening complications within four days.

Developed by researchers at NYU Grossman School of Medicine, the program used several hundred gigabytes of data gleaned from 5,224 chest X-rays taken from 2,943 seriously ill patients infected with SARS-CoV-2, the virus behind the infections. The authors of the study, publishing in the journal NPJ Digital Medicine online, cited the “pressing need” for the ability to quickly predict which Covid-19 patients are likely to have lethal complications so that treatment resources can best be matched to those at increased risk. For reasons not yet fully understood, the health of some Covid-19 patients suddenly worsens, requiring intensive care, and increasing their chances of dying. In a bid to address this need, the NYU Langone team fed X-ray information into their computer analysis, also patients’ age, race, and gender, along with several vital signs and laboratory test results, including weight, body temperature, and blood immune cell levels. Also factored into their mathematical models, which can learn from examples, where the need for a mechanical ventilator and whether each patient went on to survive (2,405) or die (538) from their infections.

Researchers then tested the predictive value of the software tool on 770 chest X-rays from 718 other patients admitted for Covid-19 through the emergency room at NYU Langone hospitals from March 3 to June 28, 2020. The computer program accurately predicted four out of five infected patients who required intensive care and mechanical ventilation and/or died within four days of admission. “Emergency room physicians and radiologists need effective tools like our program to quickly identify those Covid-19 patients whose condition is most likely to deteriorate quickly so that health care providers can monitor them more closely and intervene earlier,” says study co-lead investigator Farah Shamout, PhD, an assistant professor in computer engineering at New York University’s campus in Abu Dhabi.

“We believe that our Covid-19 classification test represents the largest application of AI in radiology to address some of the most urgent needs of patients and caregivers during the pandemic,” says Yiqiu “Artie” Shen, MS, a doctoral student at the NYU Data Science Center. Study senior investigator Krzysztof Geras, PhD, an assistant professor in the Department of Radiology at NYU Langone, says a major advantage to machine-intelligence programs such as theirs is that its accuracy can be tracked, updated and improved with more data. He says the team plans to add more patient information as it becomes available. He also says the team is evaluating what additional clinical test results could be used to improve their test model.

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Pharmaceutical market reports strong growth in April, says Ind-Ra

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The 51.5% year-on-year growth in India’s pharmaceutical market during April was led by a low base effect as the market declined by 10.2% in April 2020 due to Covid-19 lockdown, as per India Ratings and Research (Ind-Ra).

The growth would have been stronger on an adjusted basis, it said. Acute therapies like anti-infective and vitamins benefitted significantly due to the second Covid wave as these therapies have a direct and indirect role in the treatment of patients. The acute therapy growth was also aided by a low base in April last year, said Ind-Ra.

During April 2021, volumes grew 34.5% YoY, price growth was 7% and product launches were at 10% attributed to acute therapy products. Ind-Ra estimated the market growth of 8% to 10% YoY during FY22.

ANI

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FATIGUE, MOOD DISORDERS ASSOCIATED WITH POST-COVID SYNDROME, CONFIRMS STUDY

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Patients diagnosed with the post-Covid-19 syndrome, also known as ‘PCS’, ‘Covid-19 long-haul syndrome’ and ‘Post-Acute Sequelae of SARS COV-2’, experience symptoms such as mood disorders, fatigue, and perceived cognitive impairment that can negatively affect returning to work and resuming normal activities.

The findings of the study were published in the journal Mayo Clinic Proceedings. The study reported on the first 100 patients to participate in Mayo Clinic’s Covid-19 Activity Rehabilitation program (CARP), one of the first multidisciplinary programs established to evaluate and treat patients with post-Covid-19 syndrome. The patients were evaluated and treated between June 1 and Dec. 31, 2020. They had a mean age of 45, and 68 per cent were female. They were evaluated a mean of 93 days after infection.

The most common symptom of patients seeking evaluation for the post-Covid-19 syndrome was fatigue. Of the patients in the study, 80 per cent reported unusual fatigue, while 59 per cent had respiratory complaints and a similar percentage had neurologic complaints. More than one-third of patients reported difficulties performing basic activities of daily living, and only 1 in 3 patients had returned to unrestricted work activity.

“Most patients in the study had no preexisting comorbidities prior to Covid-19 infection, and many did not experience symptoms related to Covid-19 that were severe enough to require hospitalization,” said Greg Vanichkachorn, M.D., medical director of Mayo Clinic’s Covid-19 Activity Rehabilitation program and first author of the study.

Dr Vanichkachorn added, “Most of the patients had normal or nondiagnostic lab and imaging results, despite having debilitating symptoms. That’s among the challenges of diagnosing PCS in a timely way and then responding effectively.”

Nonetheless, the symptoms often resulted in significant negative effects as patients tried to return to normal daily activities, including work.“Most patients with whom we worked required physical therapy, occupational therapy or brain rehabilitation to address the perceived cognitive impairment,” said Dr Vanichkachorn.

“While many patients had fatigue, more than half also reported troubles with thinking, commonly known as ‘brain fog.’ And more than one-third of patients had trouble with basic activities of life. Many could not resume their normal work life for at least several months,” added Dr Vanichkachorn.

Mayo Clinic developed the Covid-19 Activity Rehabilitation program at Mayo Clinic in Rochester in June 2020 to care for patients experiencing persistent symptoms after Covid-19 infection. In addition to Dr Vanichkachorn, Mayo Clinic staff from many speciality fields are involved in diagnostics and treatment. Among services provided is psychosocial support for patients who frequently report feelings of abandonment, guilt and frustration during the initial evaluation.

Mayo Clinic is conducting intensive research on post-Covid-19 syndrome, in part to better define how the condition presents across different socioeconomic groups and ethnicities.

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