Greetings all! I haven’t done an informative post for awhile and since I’m in a neuro/surgical ICU, I figured I discuss subarachnoid hemorrhage (SAH), particularly in a critical care context.
Millions of people continue to suffer from exhaustion, cognitive problems and other long-lasting symptoms after a coronavirus infection. The exact causes of the illness, known as long Covid, are not known. But new research offers clues, describing the toll the illness takes on the body and why it can be so debilitating.
Diagnosing Long Covid
Patients with severe Covid may wind up in hospitals or on ventilators until their symptoms resolve. Damage to the body from severe Covid — pneumonia, low oxygen, inflammation — typically shows up on traditional diagnostic tests.
Long Covid is different: A chronic illness with a wide variety of symptoms, many of which are not explainable using conventional lab tests. Difficulties in detecting the illness have led some doctors to dismiss patients, or to misdiagnose their symptoms as psychosomatic. But researchers looking more deeply at long Covid patients have found visible dysfunction throughout the body.
Studies estimate that perhaps 10 to 30 percent of people infected with the coronavirus may develop long-term symptoms. It’s unclear why some people develop long Covid and others don’t, but four factors appear to increase the risk: high levels of viral RNA early during an infection, the presence of certain autoantibodies, the reactivation of Epstein-Barr virus and having Type 2 diabetes.
The Immune System
“Dang, why am I always so sick?”— Messiah Rodriguez, 17
Long Covid patients appear to have disruptedimmune systems compared to post-Covid patients who fully recover. Many researchers believe chronic immune dysfunction after a coronavirus infection may set off a chain of symptoms throughout the body.
One possibility is that the body is still fighting remnants of the coronavirus. Researchers found that the virus spreads widely during an initial infection, and that viral genetic material can remain embedded in tissues — in the intestines, lymph nodes and elsewhere — for many months.
Figure: Coronavirus RNA is visible in different body tissues at 500x magnification. Daniel Chertow et al., preprint via Research Square
Ongoing studies are trying to determine if these viral reservoirs cause inflammation in surrounding tissues, which could lead to brain fog, gastrointestinal problems and other symptoms.
Figure: Coronavirus components persist in one patient’s small intestine, 92 days after the start of their Covid symptoms. Christian Gaebler et al., Nature
Researchers have also found evidence that Covid may trigger a lasting and damaging autoimmune response. Studies have found surprisingly high levels of autoantibodies, which mistakenly attack a patient’s own tissues, many months after an initial infection.
A third possibility is that the initial viral infection triggers chronic inflammation, possibly by reactivating other viruses in the patient’s body that are normally dormant. The reactivation of Epstein-Barr virus, which infects most people when they are young, might help predict whether a person will develop long Covid, one study found.
Inside the intricate world of the immune system, these explanations may coexist. And just as different long Covid patients may have different symptoms, they may also have different immune problems, too. Identifying the problems that are central to each patient’s illness will be critical for guiding treatment, said Dr. Akiko Iwasaki, an immunologist at Yale.
For instance, a patient with autoantibodies might benefit from immunosuppressive medication, while a patient with remnants of the Covid virus should receive antivirals, Dr. Iwasaki said. “Depending on what each person has, the treatment would be quite different.”
The Circulatory System
“Something as simple as climbing on a ladder all of a sudden became a mountain.”— Eddie Palacios, 50
Many long Covid patients struggle with physical activity long after their initial infection, and experience a relapse of symptoms if they exercise. Initial studies suggest that dysfunction in the circulatory system might impair the flow of oxygen to muscles and other tissues, limiting aerobic capacity and causing severe fatigue.
In one study, patients with long-lasting Covid symptoms had unexpected responses to riding a bike. Despite having apparently normal hearts and lungs, their muscles were only able to extract a portion of the normal amount of oxygen from small blood vessels as they pedaled, markedly reducing their exercise capacity.
One possible culprit: Chronic inflammation may damage nerve fibers that help control circulation, a condition called small fiber neuropathy. The damaged fibers, seen in skin biopsies, are associated with dysautonomia, a malfunction of automatic functions like heart rate, breathing and digestion that is very common in long Covid patients.
Figure: Chronic inflammation in long Covid patients may damage small nerve fibers. Peter Novak et al., Annals of Neurology
These findings demonstrate that people with long Covid are suffering systemic physical problems, rather than just being anxious or out of shape, said Dr. David M. Systrom, an exercise physiologist at Brigham and Women’s Hospital who helped conduct the bike study.
“You can’t make up small fiber neuropathy by skin biopsy. That isn’t in somebody’s head,” Dr. Systrom said. “You can’t make up poor oxygen extraction to this degree. All of these are objective measures of disease.”
South African researchers found another circulation problem: Microscopic blood clots. Tiny clots that form during an initial Covid infection will typically break down naturally, but might persist in long Covid patients. These clots could block the tiny capillaries that carry oxygen to tissues throughout the body.
Figure: Platelets in the blood can become hyperactivated in Covid and long Covid patients, contributing to microclots. Etheresia Pretorius et al., Cardiovascular Diabetology
Inflammatory substances called cytokines, which are often elevated in long Covid patients, may injure the mitochondria that power the body’s cells, making them less able to use oxygen. Walls of blood vessels may also become inflamed, limiting the uptake of oxygen.
Whatever the cause, low oxygen levels may contribute to long Covid’s most common symptom, severe fatigue. Some long Covid patients meet the criteria for ME/CFS (also known as chronic fatigue syndrome), which often starts after a viral infection. Researchers have found that ME/CFS patients also suffer from a lack of oxygen triggered by circulatory problems. That puts enormous strain on the body’s metabolism and makes simple activities feel like strenuous exercise.
The Brain
“I approach a red light, my brain knows that it’s red, but it’s not reacting to the rest of my body to put my foot on the brake. Do you understand how terrifying that is?”— Samantha Lewis, 34
Even people with mild cases of Covid can experience sustained cognitive impairments, including reduced attention, memory and word-finding. Possible long-term neurological problems from Covid constitute “a major public health crisis,” according to Dr. Avindra Nath, the clinical director of the National Institute of Neurological Disorders and Stroke.
Researchers found a wide range of dysfunction in the brains of long Covid patients. Although it is unclear how often the virus directly penetrates the brain, even mild infections appear to cause significant brain inflammation, according to the researchers, who included Dr. Nath, Dr. Iwasaki and Dr. Michelle Monje, a neurologist at Stanford.
Infections may trigger the over-activation of immune cells called microglia in a way that appears similar to the process that can contribute to cognitive problems in aging and some neurodegenerative diseases.
Figure: Microglia are activated in the brain of a Covid patient, contributing to brain inflammation. Anthony Fernández-Castañeda et al., preprint via bioRxiv. Photos: Myoung-Hwa Lee
Another research group found that long Covid may significantly reduce the amount of blood that reaches the brain, a finding that has was also seen in patients with a related chronic condition, ME/CFS, before the pandemic.
The Lungs
“I couldn’t breathe. It literally felt like someone was sitting on my chest.”— Angelica Baez, 23
Shortness of breath is a frequent symptom of long Covid. But common lung tests — including chest X-rays, CT scans and functional tests — often come back normal.
Using specialized M.R.I. scans, a team of British researchers found preliminary evidence of lung damage in a small group of long Covid patients who had never been hospitalized. Detailed scans of their lung function indicated that most of the patients took up oxygen less efficiently than healthy people did, even if the structure of their lungs appeared to be normal.
The researchers cautioned that a larger group of patients will be needed to confirm the findings. If the results hold up, possible explanations for the observed shortness of breath include microclots in lung tissues or a thickening of the blood-air barrier that regulates the uptake of oxygen in the lungs.
Living With Long Covid
“It’s really not something you can push through.”— Dr. Abigail Bosk
Many hospitals now offer post-Covid clinics or recovery programs, which bring together doctors with experience treating long Covid patients. Given the number of patients, some doctors and programs have long waits for appointments. It can help to plan ahead and try multiple options.
— Americans with long Covid may qualify for disability benefits, although without conclusive medical results, many people face roadblocks.
— Three leading researchers into long Covid often share information about the latest findings on Twitter: Dr. Amy Proal, a microbiologist at PolyBio Research Institute; Dr. David Putrino, the director of rehabilitation innovation for the Mount Sinai Health System; and Dr. Iwasaki, the Yale immunologist.
— Health Rising covers the latest research into long Covid, ME/CFS and other chronic illnesses in detail.
— Gez Medinger, a video producer, interviews some prominent researchers into long Covid on YouTube.
— A video interview with Dr. Svetlana Blitshteyn, a neurologist and the director of the Dysautonomia Clinic, offers advice for treatment and an overview of current research into autonomic disorders.
— A detailed guide to understanding, treating and living with orthostatic intolerance is available from the Johns Hopkins Children’s Center.
Source: by Josh Keller (The New York Times). Illustration by Violet Frances for Bryan Christie Design. Produced by Jonathan Corum. Additional reporting by Pam Belluck and Amanda Morris.
Leonardo da Vinci (1452-1519), known as one of the pivotal figures in the development of Western art, was also one of the most original and perceptive anatomists of his or any other era. Although he spent over 25 years investigating the workings of the human body, only a few friends and associates had any intimation of the extent of his medical research. He never taught the subject and never published any of his findings.
The problem with Sickle Cell is that it’s a bit too complicated and most people don’t understand how it works. So here are a few basic facts from you might want to know.
[We’re not doctors or medical professionals. We recommend you seek professional medical advice if you think you may be affected by Sickle Cell. If you have any more suggestions to add to this list please let us know]
1. You can’t “catch” Sickle Cell
Sickle Cell Disease (also known as Sickle Cell Disorder or Anaemia) is not contagious. Repeat, you can not catch it. It’s passed down to a child from its parents genetically.
2. Sickle Cell is NOT a terminal disease
Sickle Cell is very painful and serious disease which can cause a range of health issues and in some cases short life expectancy. In Nigeria 98% of children born with Sickle Cell Disease die before they’re 5 years old. However, when diagnosed early and with support, it’s also a manageable condition. There’s no practical cure yet, but people with the disorder can live into their 50s, 60s and beyond when they manage their condition carefully. The point is, people with Sickle Cell should be hopeful and their families and friends shouldn’t consign them to an early death.
3. People with Sickle Cell trait are usually perfectly healthy carriers
People who have the genetic trait also known as “AS”, “AC” or one of the Thalassemia variant statuses, do not normally suffer any symptoms. There are some exceptions to this but it’s generally not a health issue if you carry the trait. People who have “full” Sickle Cell Disease, also referred to as SS or SC, will likely have significant health difficulties however.
4. The Sickle Cell “trait” is extremely common in Ghana and other African countries.
Some statistics say that between 20-25% of all Ghanaians and Nigerians have either the Sickle Cell trait AS or AC. Most of us don’t know we have it because it’s normally harmless, so you’d never be able to guess without a proper test. Some of those tests don’t look for AC, so people should specifically ask for AS, AC and Thalassemia screening.
5. If two parents who have the Sickle Cell “Trait” have a baby, it might be born with full Sickle Cell Disease
If a mother and father have one of the Sickle Cell traits, the future child is at significant risk of being born with “full” Sickle Cell Disease. There’s a 1 in 4 chance this will happen. If you choose to take that risk, you should be prepared and speak to a doctor about treatment and testing of the child. Before having children, we recommend you ask a doctor or clinic to check your status and for them to provide genetic counselling if you carry the trait.
6. Getting tested for Sickle Cell trait will NOT ruin your life.
If you have it, the trait doesn’t normally cause any health problems. Then you and your future partner can make informed decisions when it comes to making babies. Remember that if both parents are carriers, there is a 1 in 4 chance the baby will have full Sickle Cell Disease. There are other situations like when one parent has full ‘SS’ sickle cell and the other has ‘AS’. In those cases it’s always wise to talk to an informed, up to date doctor before having children.
7. People with Sickle Cell are not sick all the time!
People with Sickle Cell Disease feel okay most of the time. When they have a ‘crisis’, that’s when the mis-shaped blood cells prevent enough oxygen getting around the body and the pain starts. At this stage, they often need to be admitted to hospital for treatment with pain killers, hydration and other treatments.
8. People with Sickle Cell can live full, productive lives.
Many successful Ghanaians in business, entertainment and government have Sickle Cell Disease. Yes, even though Sickle Cell Disease is a serious health problem, when it’s managed well, sufferers can live productive lives, have children and work. They deserve consideration from others when they’re sick, but they shouldn’t be discriminated against.
9. Don’t wait, don’t leave it too late, find out if you have the trait!
Relax, having the trait is NOT like finding out you have a disease because there are is no suffering and it’s not contagious. You will be simply be able to make informed decisions about having kids with your future or current partner. Go to your doctor, clinic or ask someone you trust to suggest a testing facility near to home.
10. Sickle Cell children can ONLY be born to parents who BOTH carry the trait
That’s right, if a kid has Sickle Cell Disease, the kid’s parents both have the trait, or have Sickle Cell. There are no known exceptions, despite what some men might like to believe.
11. There is no available cure for Sickle Cell Disease
There are medical treatments like Hydroxyurea but no practically available cure. Even though this is a such huge health, social and economic problem in Africa, the research and funding levels are astonishingly low. Maybe that’s because most of the people who have the condition can’t afford to pay for expensive treatments.
12. Sickle Cell Stigma is wrong.
People with Sickle Cell Disease have a tough time, they deserve admiration and support. They didn’t catch it, it happened to them before they were born. We all have friends and family with Sickle Cell Disease, let’s treat them with the respect they deserve.
13. Sickle Cell is not a “curse”
It’s a genetic disorder not a curse. It’s serious, but people who manage their Sickle Cell Disease can live long happy lives. If anyone tries to tell you something different, they don’t know what they’re talking about.
14. People with Sickle Cell are not immune to Malaria
People with the “AS” trait have more immunity than those without, but people with full Sickle Cell Disease have no immunity and are actually at greater risk.
15. Not only black people can have Sickle Cell
Sickle Cell is very common in Africa and amongst people of African descent. However, it’s also prevalent in the Middle East, Asia, North and Latin America.
I prep for sickle cell exchanges all the time in the Blood Bank. They often require specific antigen negative units (often Rh family antigens) or even washing of the unit on top of testing for Hgb S. Some exchanges even exceed 14 units for one transfusion sitting.
Splinting is an important part of the trauma resuscitation process. No patient should leave your trauma resuscitation room without splinting of all major fractures. It reduces pain, bleeding, and soft tissue injury, and can keep a closed fracture from becoming an open one.
But what about imaging? Can’t the splint degrade x-rays and hamper interpretation of the fracture images? Especially those pre-formed aluminum ones with the holes in them? It’s metal, after all.
Some of my orthopedic colleagues insist that the splint be removed in the x-ray department before obtaining images. And who ends up doing it? The poor radiographic tech, who has no training in fracture immobilization and can’t provide additional pain control on their own.
But does it really make a difference? Judge for yourself. Here are some knee images with one of these splints on:
Amazingly, this thin aluminum shows up only faintly. There is minimal impact on interpretation of the tibial plateau. And on the lateral view, the splint is well posterior to bones.
On the tib-fib above, the holes are a little distracting on the AP view, but still allow for good images to be obtained.
Bottom line: In general, splints should not be removed during the imaging process for acute trauma. For most fractures, the images obtained are more than adequate to define the injury and formulate a treatment plan. If the fracture pattern is complex, it may be helpful to temporarily remove it, but this should only be done by a physician who can ensure the fracture site is handled properly. In some cases, CT scan may be more helpful and does not require splint removal. And in all cases, the splint should also be replaced immediately at the end of the study.
In my next post, I’ll look at the use of CT scans when this type of splint is in use.
