COVID news and More 6/24/23
Hospitalizations and emergency room visits for COVID remain low at this time. Sacramento’s wastewater spike from last week came back down this week and wastewater levels of SARS-CoV-2 are low in most places in the United States. XBB.1.5 is slowly being pushed out by several of its subvariants, but none appears to be strong enough to cause a new COVID wave.
Although SARS-CoV-2 virus levels are low at this time, it is important to remember that 10% of vaccinated people who get an Omicron infection or reinfection will get Long COVID which can be extremely disabling. Omicron subvariants have been found to cause more reinfections than prior variants and Omicron infections are associated with higher hospitalizations. Two new studies on air pollution showed that higher air pollution is associated with increased severity of COVID infections. Air pollution on its own triggers lung inflammation which is worsened with infection.
This week, there was a very comprehensive review of SARS-CoV-2 and the human host immune response. I included a figure from the review which is quite complex, but shows possible targets for therapies. A study from the UK shows that university students suffered from prolonged and high levels of psychological distress and anxiety from the pandemic. Traditional psychological support was inaccessible due to COVID-19 restrictions, and many mental health programs were overwhelmed by the number of students seeking help. Authors suggest “to counteract this, mental health services must be available online or accessible via social media platforms or mobile phone applications.”
Long COVID
Inflammation of the Vagus nerve was shown to contribute to autonomic dysfunction in a new study from Hamburg. The SARS-CoV-2 virus and inflammatory monocytes were found in the vagus nerve post-mortem. The SARS-CoV-2 induced vagus nerve inflammation was followed by autonomic dysfunction, authors noted.
In another study this week from Barcelona, researchers did a comprehensive structural and functional assessment of various organs innervated by the Vagus nerve, including the respiratory and digestive systems and the autonomous innervation of the heart. The authors concluded that their findings showed a central pathogenic role of Vagus nerve dysfunction in the pathophysiology of Long COVID.
I looked into Vagus nerve stimulation which is starting to be used to treat POTS associated with Long COVID, but I found the literature confusing, as no particular device appears to be standard. Also, treatment protocols varied in different studies. A review from 2021 on research regarding transcutaneous vagus nerve stimulation (tVNS) offered a consensus from an international group of experts recommending a set of minimal reporting items to guide future tVNS studies.
Endothelial cells make a layer that lines blood vessels which is called the endothelium. A preprint study from the journal Circulation shows that endothelial dysfunction and injury of cardiac microvasculature may underlie Long COVID associated POTS which they abbreviate as PACS+POTS. The authors looked at the Reactive Hyperemia Index measured with a device called the EndoPat and found endothelial dysfunction in the heart along with reduced cardiac stress reactivity that appeared to be specific to PACS+POTS.
A case report of a Long COVID patient with exertional dyspnea reported that Electrical Impedance Tomography (EIT) can be used to visualize disturbed ventilation of the lungs, both at rest and under stress. In Long COVID patients with chronic fatigue, SARS-CoV-2 was also found to trigger a reactivation of dormant adenovirus in the mouth. Adenovirus IgG antibody was elevated in the saliva of people with a ME/CFS and Long COVID, but was not increased in plasma however.
In non-COVID news this week, a national survey by KFF shows that 68% of OB/GYN physicians feel that the Dobbs ruling has worsened their ability to manage pregnancy-related emergencies. Obstetricians surveyed also believe that the new abortion restrictions worsened pregnancy-related mortality, worsened racial and ethnic inequities in maternal health, and have considerably hurt the ability to attract new doctors to the field of Obstetrics and Gynecology.
There are no safe levels of benzene, a carcinogen, which can increase the risk of leukemia, lymphoma, and asthma. A new study from Stanford shows that using a single gas stove burner or an oven set to 350° for 45 minutes raised benzene levels in the room significantly. In smaller homes such as apartments, the researchers found that gas stove pollutants including carbon monoxide, formaldehyde and methane, in addition to benzene, quickly traveled through the home where they lingered for hours. Gas stoves leak pollutants and methane gas even when they are turned off.
The USPSTF now recommends that asymptomatic adults age 19 through 64, including those who are pregnant and postpartum, should be screened for anxiety disorders using questionnaires and screening tools. The group had already recommended anxiety screening for children ages 8 to 18.
Other articles this week show that pumping out significant amounts of groundwater over the last 100 years has changed the tilt of the Earth’s axis. Colchicine was approved for treating cardiovascular disease because of its anti-inflammatory properties. An article shows that obesity increases the risk of clonal hematopoiesis of indeterminate potential (CHIP), a precursor to blood cancers, but that treatment with a calcium channel blocker or metformin reduced this risk. Metformin, a generic diabetes drug that has also been shown to reduce viral load from SARS-CoV-2 infection, certainly has many uses.
Have a good rest of your weekend,
Ruth Ann Crystal MD
COVID news:
WHO Weekly Epidemiological Updates: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports
US Variant tracker: https://covid.cdc.gov/covid-data-tracker/#variant-proportions
CDC COVID Hospitalizations (blue) and Emergency Room (orange) visits tracker: https://covid.cdc.gov/covid-data-tracker/index.html#trends_weeklyhospitaladmissions_7dayeddiagnosed_00
US Wastewater Monitoring:
CDC Wastewater Monitor https://covid.cdc.gov/covid-data-tracker/#wastewater-surveillance
Wastewater from NWSS and Biobot in a US map format:
https://iowacovid19tracker.org/
“Fantastic resource for WW (wastewater). Allows charting of individual states.” @JPWeiland
Sewer Coronavirus Alert Network (SCAN) project by Stanford University:
6/22/23 CDC MMWR: SARS-CoV-2 Reinfections and Associated Hospitalizations and Deaths Among Adults Aged ≥18 Years https://buff.ly/46iTUkE
COVID reinfections were rare (~1%) through the Delta wave variant.
COVID reinfections have significantly increased since Omicron BA.1 and continues to increase with newer subvariants.
Trial Mount Sinai, NY: Multisite Study Is Investigating Role of Pituitary Hormone Deficiency in Post-COVID Fatigue https://buff.ly/3JrFpB9
Regarding severe fatigue with Long COVID, "We hypothesize that pituitary hormone abnormality is underestimated, since these hormones are not routinely measured."
Two clinical sites each seek to enroll 150 participants who will receive blood tests assessing pituitary gland function, namely cortisol, growth hormone, thyroid hormone and sex hormone, and answer a short online survey.
6/21/23 Eur Resp J: Air pollution and COVID-19 severity https://buff.ly/43OCI4Q
Air pollution increases the risk of SARS-CoV-2 infections, and COVID hospitalization and deaths.
Pre-admission ambient air pollution and blood soot particles predict hospitalisation outcomes in COVID-19 patients https://buff.ly/3JozaOF
Long-term exposure to air pollution and risk of SARS-CoV-2 infection and COVID-19 hospitalization or death: Danish nationwide cohort study https://buff.ly/3Jr6CUu
CDC COCA Webinar Thursday, June 15, 2023 - Evaluating and Supporting Patients with Long COVID in Returning to Work for Healthcare Providers https://buff.ly/3MGgb2J
Slides here https://buff.ly/3qSyIlk
Long COVID workplace accommodations https://buff.ly/3JNIHz9
Medical Provider Support Letters for Long COVID workplace accommodations with template https://buff.ly/3phck4B
6/20/23 MedRxiV (Hamburg): Vagus nerve inflammation contributes to dysautonomia in COVID-19 https://buff.ly/3pm9Zpe
SARS-CoV-2 is detectable in postmortem vagus nerve specimens together with inflammatory cell infiltration derived primarily from monocytes.
SARS-CoV-2 induces vagus nerve inflammation appeared to be followed by autonomic dysfunction.
Maladaptive respiratory rate predicts lethal outcome in COVID-19
6/19/23 Lancet preprint (Barcelona): Vagus Nerve Dysfunction in the Post-COVID-19 Condition (PCC, Long COVID) https://buff.ly/3XvqnAt
Vagus nerve dysfunction was found in people with Long COVID as evaluated by a comprehensive structural and functional assessment of various organs innervated by the Vagus nerve, including the respiratory and digestive systems and in autonomous innervation of the heart.
The authors conclude that these findings point to a central pathogenic role of Vagus nerve dysfunction in the pathophysiology of the PCC (Long COVID).
3/23/21 Front. Hum. Neurosci: International Consensus Based Review and Recommendations for Minimum Reporting Standards in Research on Transcutaneous Vagus Nerve Stimulation (Version 2020) https://buff.ly/3JuTrC4
Transcutaneous vagus nerve stimulation (tVNS) by stimulating either the auricular branch or the cervical bundle of the vagus nerve.
Method details needed for comparison of studies, replication of studies, and study participant safety.
Based on this review, and consensus among participating authors, we propose a set of minimal reporting items to guide future tVNS studies.
6/19/23 Circulation: Arrhythmia and Electrophysiology (ahead of print): Microvascular Dysfunction and Reduced Cardiac Stress Reactivity in Postural Orthostatic Tachycardia Associated With Postacute COVID-19 (PACS+POTS) https://buff.ly/46db571
Microvascular endothelial dysfunction is common in patients with PACS-associated POTS (PASC+POTS) 1+ year after mild primary infection.
seen by low Reactive Hyperemia Index. (seen on ENDO-Pat)
Cardiac endothelial injury may underlie vascular impairment in PACS+POTS and appears specific to POTS from Long COVID (PASC).
In the Figure below:
Reactive hyperemia index was significantly lower in PACS+POTS compared with both healthy and PACS-POTS (Figure).
The dotted line represents the cutoff for endothelial dysfunction (1.67).
No significant differences were detected in myocardial perfusion reserve (Figure, left).
ΔT1 was lower in patients with PACS+POTS (Figure, right) compared with healthy individuals but not compared with PACS-POTS.
6/19/23 MedRxiV (Columbia Univ): Association of Long COVID with housing insecurity in the United States, 2022-2023 https://buff.ly/3NFcvQN
People with Long COVID were nearly twice as likely to experience significant difficulty with household expenses, be behind on housing payments, and face likely eviction or foreclosure compared to people who recovered from COVID infection without Long COVID.
Functional limitation and current symptoms which impact day-to-day life were associated with higher prevalence of housing insecurity.
6/19/23 Frontiers in Immunology: SARS-CoV-2 and the host-immune response https://buff.ly/3CV9Hc9
Comprehensive review on SARS-CoV-2 human responses including a detailed summary of the current understanding of the host immune response to SARS-CoV-2.
ICD-10 diagnosis code for POTS is G90.A
ME Action Pacing Guides: https://www.meaction.net/resource/pacing-and-management-guide/
6/18/23 British Journal of Education Studies: Long-term mental health impacts of the COVID-19 pandemic on university students in the UK, a longitudinal analysis over 12 months https://buff.ly/3qYtHaI
Data from May 2020 to May 2021.
"The COVID-19 pandemic has caused a significant, negative impact on the well-being of British university students. Students are suffering from prolonged and high levels of psychological distress and anxiety. Levels of flourishing in students are still very low."
6/15/23 Infection: Visualizing exertional dyspnea in a post-COVID patient using electrical impedance tomography (EIT) https://buff.ly/3PpLja2
Case report. Uncoordinated breathing and an uneven distribution of ventilation was noted in the Long COVID patient.
"EIT is suitable for visualizing disturbed ventilation of the lungs, both at rest and under stress."
6/15/23 Frontiers in Medicine: Post-COVID sequelae effect in chronic fatigue syndrome: SARS-CoV-2 triggers latent adenovirus in the oral mucosa https://buff.ly/3NGXOwB
Saliva samples for IgG against human adenovirus (HAdV): patients with ME/CFS (n=84) and healthy controls (n=94), with either mild/asymptomatic SARS-CoV-2 infection or no infection.
In plasma there was no HAdV IgG elevation.
COVID-19 triggered reactivation of dormant HAdV in the oral mucosa of ME/CFS patients indicating an exhausted dysfunctional antiviral immune response in ME/CFS that allows reactivation of adenovirus upon stress encounter such as COVID-19.
Other news:
For my AI friends:
https://twitter.com/sophiaamoruso/status/1671919315371843586
6/17/23 NY Times: Study Compares Gas Stove Pollution to Secondhand Cigarette Smoke https://buff.ly/43OigB2
A single gas burner on high or an oven set to 350 degrees for 45 minutes raised benzene levels above the upper range of indoor concentrations seen in secondhand tobacco smoke.
Benzene is a carcinogen which can increase the risk of leukemia and lymphoma and also asthma. No level of exposure is safe.
The Stanford team detected higher concentrations of some pollutants from gas stoves in tiny New York kitchens and found that those pollutants quickly traveled throughout the home and lingered, sometimes for hours.
Gas stoves emit other harmful pollutants like nitrogen dioxide, carbon monoxide and formaldehyde and can also leak methane, a potent greenhouse gas, even when they are turned off.
Original study: 6/15/23 Environmental Science and Technology: Gas and Propane Combustion from Stoves Emits Benzene and Increases Indoor Air Pollution https://buff.ly/3CzSFjh
6/17/23 CNN: HHS announces actions from Walgreens and CVS to ensure women’s access to medications https://buff.ly/43Q9aDR
Walgreens and CVS are voluntarily updating training and creating specialized teams to ensure that women have access to birth control, methotrexate and misoprostol.
6/19/23 CBS: OB-GYN shortage expected to get worse as medical students fear prosecution in states with abortion restrictions https://buff.ly/446YkJu
"It's very clear that Idaho is no longer a safe place to practice medicine," Dr. Huntsberger said.
"If I'm an OB-GYN resident coming out of residency and I'm looking around at different options, why would I look at Idaho and say, 'Oh, I really want to move there to the state where I could be charged with a felony for providing medical care?'" she said.
6/21/23 KFF: A National Survey of OBGYNs’ Experiences After Dobbs https://buff.ly/43SQqnv
Most OBGYNs (68%) say the Dobbs ruling has worsened their ability to manage pregnancy-related emergencies.
Large shares of OBGYNs also believe that the Dobbs decision has:
worsened pregnancy-related mortality (64%),
racial and ethnic inequities in maternal health (70%) and
the ability to attract new OBGYNs to the field (55%).
6/19/23 Nature: Rampant groundwater pumping has changed the tilt of Earth’s axis https://buff.ly/4678L1v
Gravitational surveys have measured the depletion of underground reservoirs, which is caused in large part by irrigation, especially in northwestern India and western North America.
6/20/23 These Are the Investors You Should Know if You’re Fundraising for Your Healthcare Startup — Halle Tecco https://buff.ly/434ZXqp
5/2023 Green Journal (Ob/Gyn): Diagnosis of Pregnancy Complications Using Blind Ultrasound Sweeps Performed by Individuals Without Prior Formal Ultrasound Training https://buff.ly/46exNvx
Blind ultrasound sweeps with low-cost, portable device by non-medical people can identify high-risk pregnancies when reviewed by MFM doctors.
6/20/23 CV Business: FDA approves colchicine, the first anti-inflammatory drug for treating cardiovascular disease https://buff.ly/3Naavyo
Colchicine can reduce the risk of myocardial infarction (MI), stroke, coronary revascularization and cardiovascular death in higher risk patients and “was shown to reduce the risk of cardiac events by 31% on top of statin medications.”
6/20/23 Healio: Obesity may increase risk for blood cancer https://buff.ly/44baS2B
6% of obese people in the study had clonal hematopoiesis of indeterminate potential (CHIP).
Treatment with a calcium channel blocker, either alone or in combination with metformin helped.
6/21/23 Washington Post: Primary care providers urged to ask about anxiety during checkups https://buff.ly/42T8v3e
New USPSTF guidelines state that asymptomatic adults ages 19 through 64, including those who are pregnant and postpartum, should be screened for anxiety disorders, using questionnaires and other screening tools.
In October, the group also recommended anxiety screening for children ages 8 to 18.
