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How the Human Life Span Doubled in 100 Years

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Between 1920 and 2020, the average human life span doubled. How did we do it? Science mattered — but so did activism.
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The Covid-19 Vaccine and Children

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Abby Goodnough and
An advisory committee to the Centers for Disease Control endorsed the Pfizer-BioNTech vaccine on Wednesday for use in children ages 12 to 15.
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The Pfizer-BioNTech vaccine was tested in more than 2,000 children, and produced a stronger immune response in them than it had in adults.
None of the children who got the vaccine became infected with the coronavirus, while 18 children in the placebo group had symptoms of Covid-19, indicating that the vaccine was highly effective for the age group.
The vaccine also appeared to be safe in adolescents, with side effects comparable to those seen in 16- to 25-year-olds. Fevers were slightly more common in 12- to 15-year-olds, but the trend toward more fevers at younger ages was seen also in earlier trials.
Younger adolescents will be able to get the shot in a variety of places, including pediatricians’ offices, some pharmacies and school-based clinics.
Some sites may require appointments; others will offer the vaccine on a walk-in basis.
Many health departments are planning to use mobile vaccination units to reach children in their neighborhoods or at parks, camps and other places where they congregate.
Eligibility will likely expand within months to even younger children. Pfizer plans to seek emergency authorization in September to administer its vaccine to children between the ages of 2 and 11.
Moderna’s clinical trial results for its vaccine in 12- to 17-year-olds are expected within weeks. Its results for children ages 6 months to 12 years old are expected later this year.
Catch up on the latest coronavirus news.
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Experts Call for Sweeping Reforms to Prevent the Next Pandemic

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Swift mask mandates and travel restrictions, an international treaty and the creation of new bureaucracies are among the recommendations presented to the W.H.O.

The next time the world faces an outbreak of a fast-spreading and deadly new pathogen, governments must act swiftly and be ready to restrict travel or mandate masks even before anyone knows the extent of the threat, according to a pair of new reports delivered to the World Health Organization.
The studies are intended to address missteps over the past year that led to more than 3.25 million deaths, some $10 trillion in economic losses and more than 100 million people pushed into extreme poverty.
“Current institutions, public and private, failed to protect people from a devastating pandemic,” concluded one of the reports, released on Wednesday, which called the Covid-19 pandemic “the 21st century’s Chernobyl moment.”
“Without change,” it said, these institutions “will not prevent a future one.”
The reviews, released in advance of this month’s meeting of the W.H.O.’s governing assembly, were written by appointees who donated countless hours in the midst of their own countries’ pandemic fights to interview hundreds of experts, comb through thousands of documents, gather data and seek counsel from public and private institutions around the world.
Pandemics, the authors concluded, are an existential threat on the order of a chemical or nuclear weapon, and preparing for them must be the responsibility of the highest levels of political leadership rather than only health departments, often among the least powerful of government agencies.
The reviews, requested last year by the 194 country representatives governing the W.H.O., also called for nations to provide predictable and sustainable financing to the W.H.O. and to their national preparedness systems.
“W.H.O. is underpowered and underfunded by its member states,” Helen Clark, a former prime minister of New Zealand and an author of one of the reports, said at a media conference this week.
Whether the recommendations lead to lasting change is an open question. Ms. Clark’s group, the Independent Panel for Pandemic Preparedness and Response, pointedly noted that since the H1N1 pandemic in 2009, there have been 11 high-level commissions and panels that produced more than 16 reports, with the vast majority of recommendations never implemented.
These reports “sit closed gathering dust in U.N. basements and government shelves,” said Ellen Johnson Sirleaf, another author of that report, who served as president of Liberia during the Ebola outbreak there in 2014 and 2015.
Under the current international health regulations, “there’s no enforcement mechanism,” said Dr. Lothar H. Wieler, president of the Robert Koch Institute in Berlin, who led the second major review, in which scientists scrutinized how those regulations functioned in the pandemic.
Both reports supported the creation of an international pandemic treaty that would establish consequences if countries failed to live up to their commitments. Those might include quickly sharing samples and sequences of emerging pathogens, providing rapid access to teams deployed by the W.H.O. for early investigation and response, and ensuring equitable distribution of vaccines, medicine and tests around the world.
Both reviews also noted that early in the coronavirus pandemic, many countries all but ignored the formal warning issued by the W.H.O., known as a Public Health Emergency of International Concern. Its unfortunate acronym, Pheic, is often pronounced “fake,” one of the reports noted. (Whether the proposal to change this to “Phemic” will prove more stirring remains to be seen.)
The independent panel also concluded that the warning could have been declared at least a week earlier than it was — on Jan. 22, 2020, instead of Jan. 30.
Even then, “so many countries chose to wait and see,” only taking concerted action once intensive care beds were filled, Ms. Clark said.
Her group contends that if its recommendations on political leadership, financing and surveillance systems had been in place, the coronavirus outbreak would not have become a pandemic. It also said that digital tools, such as those that scrape social media for rumors of new outbreaks, should be better incorporated into official responses.
Notably, the panel did not delve into individual countries’ failures in its report, determining that blame would not be “a very useful approach,” said Dr. Anders Nordström, who helped lead the effort.
But the group did commission a study of 28 countries with high, medium and low Covid death rates. Some of the countries with the lowest tolls had previously invested in outbreak control systems after experiencing SARS, MERS and Ebola, the report said. Successful countries acted quickly, coordinated across multiple government agencies, meticulously isolated people with the virus and quarantined those exposed to it.
The worst performing countries had underfunded, fragmented health systems and “uncoordinated approaches that devalued science.” Those with the highest death tolls, including Brazil and the United States, denied the seriousness of the pandemic and discouraged action, the panel members said in interviews.
On some key points, the reports came to different conclusions. The Independent Panel for Pandemic Preparedness and Response argued that the international health regulations governing how countries are supposed to prepare for and report emerging outbreaks “serve to constrain rather than to facilitate rapid action.” It noted that some countries assessed as highly prepared under the framework also had high death rates early in the pandemic.
But the other group, which spent months reviewing those regulations, found that many could have helped but were “simply not implemented by various countries,” Dr. Wieler said.
Some countries were not even aware that the regulations existed, his group reported. Others lacked laws vital to responding to outbreaks, such as those authorizing quarantines.
Changing those regulations would require “negotiations for years,” Dr. Wieler said, noting that the latest set took a decade to finalize. Instead, one of his committee’s major recommendations was to increase countries’ accountability for their obligations, including though a pandemic treaty and a periodic review of their preparedness that would involve other countries.
The independent panel also proposed creating an international council led by heads of state to keep attention on health threats and to oversee a multibillion-dollar financing program that governments would contribute to based on their ability. It would promise quick payouts to countries contending with a new outbreak, giving them an incentive to report.
“There’s only going to be the political will to create those things when something catastrophic happens,” said Dr. Mark Dybul, one of the panel members. These recommendations stemmed in part from his experience leading the President’s Emergency Program for AIDS Relief, known as Pepfar, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, he said.
But Dr. Wieler, who led the other international review, said that in general, creating new institutions rather than focusing on improving existing ones could increase costs, complicate coordination and damage the W.H.O.
The recommendations of panels after global emergencies have sometimes been embraced. The Ebola outbreak of 2014 and 2015 led to the creation of the W.H.O.’s health emergencies program, aimed at boosting the agency’s role in managing health crises as well as providing technical guidance. A report released this month noted that the new program had received “increasingly positive feedback” from countries, donors and partner agencies as it managed dozens of health and humanitarian emergencies.
The W.H.O. before the Ebola outbreak and after it are “two different agencies basically,” said Dr. Joanne Liu, a former international president of Doctors Without Borders and a member of the independent panel. Dr. Liu was one of the W.H.O.’s most trenchant critics during the Ebola response, and she noted a “marked improvement” in how quickly the agency had declared an international emergency this time.
Dr. Liu said her biggest fear was that as wealthier countries gained an upper hand on the virus because of vaccines, they would leave low- and middle-income countries behind, with Covid-19 becoming “a neglected pandemic because they are going to be the only ones fighting it — a bit like H.I.V. and T.B.”
To avert that, the panel released a slew of urgent recommendations and called for the world’s entire population to be immunized within a year.
Wealthy countries with a good vaccine pipeline should commit to making at least a billion doses available to the poorest countries by September through programs like Covax, a global effort to provide vaccines equitably throughout the world, the group said.
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How U.S. Epidemiologists Are Returning (Carefully!) to Everyday Life

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Vaccinations mean the pandemic is moving to a phase when behavior will depend on people’s individual tolerance for risk.
Margot Sanger-KatzClaire Cain Miller and
Epidemiologists are starting to hug again.
They’re also running errands, gathering outdoors with friends and getting haircuts in far greater numbers than before.
Epidemiologists were asked to identify which of these activities they had done in the last 30 days, or would have done if necessary, assuming they would wear a mask or distance as needed.
In a new informal survey this month by The New York Times, 723 epidemiologists in the United States responded to questions about their life now and how they are navigating this in-between phase of the pandemic, when vaccines have become widespread and cases are declining nationally, but herd immunity is not assured and Covid-19 remains a threat.
We have surveyed these public health experts periodically throughout the pandemic. As a group, they remain conservative in their choices about how to behave safely, and are more cautious than many Americans. But their increasing willingness to return to more prepandemic activities shows that even people most aware of what could still go wrong are starting to become more optimistic.
“Vaccines have given me freedom,” said Dianne Neumark-Sztainer, who leads the epidemiology division at the University of Minnesota. “I was very strict all year but am now returning, slowly, to life.”
What was making them most comfortable, they said, was vaccines. “I am feeling very hopeful about the prospect of Covid-19 being controlled as a result of public uptake of vaccination,” said Lindsey Ferraro, an epidemiology graduate student at the University of Alabama at Birmingham.
When enough Americans become immunized and infections decrease, they said, the country could enter a new phase, when coronavirus precautions would become less about minimizing risk as much as possible, and more about making choices based on one’s individual risk tolerance and health profile.
“I balance risks very carefully with benefits,” said Luther-King Fasehun, a doctor and an epidemiology Ph.D. student at Temple University. “I have my master’s level health economics training to thank for this. Some benefits are almost always worth it.”
Over all, the epidemiologists’ advice was to hold on to most precautions just a little bit longer, particularly when it comes to indoor activities or those with large groups of strangers.
“There is a strong likelihood that we will experience unexpected problems due to moving about as if the Covid pandemic was no longer a threat,” said Jana Mossey, an epidemiologist who retired from Drexel University.
But for some activities, federal health officials have begun updating their advice to the public and allowing more freedoms. The guidance has been somewhat vague, so we asked epidemiologists to expand on it.
The Centers for Disease Control and Prevention said that fully vaccinated people could gather indoors with other vaccinated people without precautions, but it did not specify how many households could do so at once.
In the survey, a plurality of epidemiologists said they would recommend limiting such gatherings to two households at a time. But a sizable number said larger gatherings among vaccinated people were OK.
“There are no magic numbers here,” said Noelle Cocoros, an epidemiologist at Harvard. “Establishing some guidelines are important, but as soon as you put a number on something, it becomes gospel for many people and impacts their understanding of risk.”
Some said the issue wasn’t about vaccine effectiveness, but about how to know and trust that everyone at a large gathering was fully immunized.
“Vaccinated people are quite safe,” said Maria Glymour, an epidemiologist at the University of California, San Francisco. “If you know everyone’s vaccinated, it’s OK. I’d just worry that with a large group, you of course cannot know that.”
Those who said that vaccinated people should continue to limit the number of people they see indoors noted that vaccines aren’t 100 percent effective, and that the more people are in a space, the more chances the vaccine has to fail. Many said they would hesitate to gather indoors until children could also be vaccinated. (The F.D.A. approved use of the Pfizer vaccine for children 12 to 15 this week.)
“It is not ‘one size fits all,’” said Alicia Riley, a sociologist and epidemiologist at the University of California, San Francisco, expressing a version of the profession’s unofficial motto: It depends. “How safe it is depends on the local levels of community transmission.”
The C.D.C. has also said that people no longer need masks when they are outdoors and can maintain physical distance from others, like on a walk, regardless of whether they’re vaccinated. Most epidemiologists agreed.
“This policy was always idiotic,” said Joe Lewnard, an epidemiologist at the University of California, Berkeley, who supported maskless exercise.
Others disagreed: “Even with the vaccine, we still have to be concerned about some of the variants to which the vaccines are less effective,” said Lorraine Dean, an epidemiologist at Johns Hopkins. “I still plan to wear my mask for quite a while.”
More said masks were necessary in outdoor situations when distance couldn’t be maintained, like picnicking or hiking. A quarter said masks were always necessary then.
“Think of always ensuring two of three: masks, distancing, outdoors, particularly if among nonvaccinated individuals,” said Eyal Oren, an epidemiologist at San Diego State University.
When it comes to outdoor activities with large crowds where it is hard to maintain distance, like at a concert or protest, the epidemiologists were almost all in agreement that masks were still necessary, regardless of vaccination status. Some suggested continuing to avoid such events if possible. “There will almost certainly be vaccinated and unvaccinated people mixing in such an event,” said Steve Ostroff, an epidemiologist with a private consulting practice.
The endless decision-making about how to behave in the pandemic remains complicated. But risk calculations are beginning to change. Eventually, pandemic decision-making for vaccinated people could become less about protecting society at large, and more about one’s own willingness to take on risk.
“I think that when all the high-risk groups are vaccinated, it is time to shift attention to letting everyone decide for themselves what risks they are comfortable with for themselves,” said Anders Huitfeldt, an epidemiologist at the University of Southern Denmark.
Some epidemiologists say this shift can happen as soon as individuals are vaccinated: “Being vaccinated should throw open the floodgates to everything you could do before,” said Zachary Binney, an epidemiologist at Emory.
But many said coronavirus precautions remained important for protecting high-risk people and slowing the virus’s spread, even for vaccinated people: “While I am comfortable taking personal risks, I would not tolerate risks that could harm others,” said Kevin Andresen, who leads the Covid response team at the Colorado Department of Public Health. “Covid precautions protect everyone, not just me.”
Assessing and balancing risk trade-offs is a key part of epidemiologists’ training. But even among epidemiologists, comfort with risk varies by the individual. Over all, 71 percent of the epidemiologists who completed our survey said they were extremely or somewhat risk-averse — especially when it comes to Covid-19.
“I live in Hawaii and free-dive with sharks,” said F. DeWolfe Miller, an epidemiologist at the University of Hawaii. “Preventing Covid transmission is another matter.”
Respondents said their Covid-19 risk tolerance was informed by the particulars of their daily life, like their need to work outside the home or the health status of their family members.
“I would be more comfortable taking risks if I did not have young, unvaccinated children whom I want to keep healthy and who need to be in day care for me to keep working,” said Stephanie Leonard, an epidemiologist at Stanford.
For some questions, variations in individual risk tolerance drove a large difference in answers. Epidemiologists who described themselves as risk-averse were nine points more likely than those who were more comfortable with risk to say that vaccinated people should limit indoor social gatherings to just one other vaccinated household, for example.
But on other questions, the experts were more united: They are almost all staying away from indoor fitness studios and say masks are still necessary in large crowds, even outdoors.
Their day jobs also influenced the risk they were willing to take. We surveyed two different groups. Members of the Society for Epidemiologic Research work primarily in academic research. The Council of State and Territorial Epidemiologists mainly works for governments that are trying to make decisions about how to balance reopening businesses and schools while still protecting public health. Members of the latter group have had to become more comfortable with accepting some level of risk.
Among the differences, government epidemiologists were 19 percentage points more likely than academics to have worked in a shared office in the last month. And 8 percent of the academics said fully vaccinated people should still avoid socializing indoors, while just a single government epidemiologist said so.
The epidemiologists are highly aware that risk is inherent in many things people do. More than at any time in the last year, most are feeling hopeful that Covid-19 will eventually become just another risk in daily life, but not one that paralyzes us.
“We’ve all learned how very resilient we are,” said Jane Clougherty, who teaches public health at Drexel University. “This too shall pass, and we are finally seeing the evidence.”
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How Hospitals Can Help Patients and the Planet

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Health care systems are trying to answer the central question of how to care for patients when climate change threatens their ability to remain open.

This article is part of our new series on the Future of Health Care, which examines changes in the medical field.
As climate change moves from a model of the future to the reality of the present, health care systems across the country are facing a difficult set of questions. What are doctors supposed to do when wildfires, rising floodwater or other natural disasters threaten their ability to provide care for patients? How can these institutions be resilient in the face of these disasters?
To Ramé Hemstreet, these aren’t abstract questions. Mr. Hemstreet is the vice president for operations and chief sustainable resources officer for Kaiser Permanente, the California-based health care system. The state is already dealing with the effects of climate change: During the wildfires in Northern California in 2017 and 2019, Kaiser Permanente had to evacuate more than 100 patients from one facility in Santa Rosa and find a way to care for the surrounding communities.
“The climate crisis is a human health crisis, and we’re already living that in California,” Mr. Hemstreet said.
For the last decade or so, Mr. Hemstreet and his colleagues at the company have been trying to move it away from fossil fuels, largely to reduce the company’s contribution to climate change. But, it has also become clear that depending on fossil fuels is a hindrance to providing health care, as the effects of climate change are increasingly part of the lived experience of many Americans.
Around the country, hospitals and health care systems are trying to answer the central question of how to care for patients when climate change threatens their ability to keep hospitals open. Many of the changes to improve resilience are not sleek, tech-forward responses to crisis. Rather, they often represent common-sense solutions: moving technical equipment from basements where floodwater could damage it up to higher floors; organizing patient transfers in advance of catastrophes; improving energy efficiency; better air filters; and more backup systems and redundancies, just in case.
Since 2012, Boston Medical Center has lowered its energy use by nearly 40 percent and reduced its greenhouse gas emissions from all sources of energy by 90 percent while caring for more patients. Some of those reductions have come from a cogeneration plant for electricity and heat, which operates 35 percent more efficiently than separately relying on the electric utility for its energy needs. The hospital has also bought enough solar power from a solar farm in North Carolina to account for all of its electricity.
B.M.C., the largest safety-net hospital in New England, serving the uninsured and underinsured community in the Boston area, has also extended its sustainability efforts beyond renewable electricity and heating, including a rooftop garden at the hospital that grows about 6,000 pounds of food a year for its food pantry, inpatient meals and a hospital-based farmer’s market, and a biodigester that converts food waste into water.
Robert Biggio, an engineer who served in the merchant marine and now is the senior vice president of facilities and support services for the hospital, learned resilience on the high seas. “Being on a ship in the middle of the ocean, people can’t get to you,” he said. “You don’t have a choice about being resilient.”
While it is often argued that sustainability and climate-friendliness is too expensive, all of the system upgrades — including a cogeneration plant and a chilled-water loop cooling system, rather than a costly new tower — have saved B.M.C., a nonprofit, significant amounts of money.
“Reducing waste is more efficient and also improves resiliency,” Mr. Biggio said. “They do go hand-in-hand.”
Health care in the United States is responsible for a tremendous amount of waste and a significant amount of greenhouse gas emissions. For every hospital bed, the American health care system produces about 30 pounds of waste every day; over all, it accounts for about 10 percent of national greenhouse gas emissions.
Much of the waste comes from the shift toward single-use disposable items, apart from the personal protective equipment that is intended only for single use. Many hospitals are contracting outside companies to clean and reprocess many of these items; Kaiser Permanente made a commitment to recycle, reuse or compost 100 percent of its nonhazardous waste by 2025.
As for greenhouse gas emissions, hospitals have to have backup power, which is usually provided by diesel generators. These run on fossil fuels and produce fine particulate matter, known as PM 2.5, which contributes to asthma and other illnesses. Air quality around hospitals, which have to test their generators regularly, is often poor.
A recent study found that, compared with white people, people of color are more exposed to PM 2.5 from all sources, and Black Americans are the most affected. As a result, these communities, which often lack access to health care, are more likely to suffer from the health consequences of this exposure. PM 2.5 is also responsible for 85,000 to 200,000 excess deaths a year in the United States (according to the study), and long-term exposure to PM 2.5 is correlated with hospitalization for Covid-19.
During fire season and heat waves, power can go out or electric utilities may shut off power to avoid sparking fires or creating systemwide blackouts, both of which mean that hospitals have to run on their generators.
That hospitals are partly responsible for this pollution, Mr. Hemstreet said, is an unacceptable irony.
Kaiser Permanente has been buying utility-scale renewable energy since 2015, and in 2018 finalized a deal to buy 180 megawatts of wind and solar power, as well as 110 megawatts of battery storage, which is being built. Since 2010, it has put 50 megawatts of solar power on its facilities and is installing a nine megawatt-hour battery at the company’s Ontario, Calif., campus that would allow most of the facility to go off the grid entirely.
In New York City, space limitations and less abundant sunshine make ambitious installations more difficult, but heat waves present a similar challenge — the possibility of blackouts and rolling outages taking out air-conditioning, with higher temperatures endangering some older adults and those who are sick, especially.
Like B.M.C., NYU Langone Health has built a cogeneration plant for electricity, heat and steam turbine-power air-conditioning. According to Paul Schwabacher, senior vice president of facilities management at NYU Langone, it is 50 percent more efficient than utility power.
The cogeneration plant construction was in process before Hurricane Sandy in 2012, which was an eye-opening experience for the hospital system. During the storm, floodwater reached the lower floors of the hospital, leaving behind 15 million gallons of contaminated water. More than 300 patients had to be evacuated from the hospital, including newborns in intensive care, carried by doctors and nurses down many flights of stairs.
The hospital was closed for two months after the storm, during which time there were about 100 electricians working on repairs, Mr. Schwabacher said. “We made lemonade,” he said, adding that they undertook repairs that would have been much more difficult while the hospital was open, like cleaning out all of the air ducts. They also rebuilt and expanded the emergency department, which had been flooded during the storm.
Since then, the hospital has built a new building, as well as restored older ones.
NYU Langone’s greatest effort toward resilience, however, is new flood barriers around the perimeter of the campus, which are intended to protect against a storm surge seven feet above the level caused by Hurricane Sandy. The campus also has a 12-foot-high steel storm barrier at the loading dock that can be hydraulically or manually raised; valves on drains and sewage lines to prevent back flows from flooding outside streets; and steel gates and doors to hold back floodwater in critical locations throughout the facility.
But building walls won’t keep the effects of climate change away. That will come from reductions in greenhouse gas emissions from society as a whole, Mr. Schwabacher said.
“We feel very, very confident that we’ll be protected, but we know that the next disaster will be different than the last disaster.”
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His Legs Suddenly Felt Paralyzed. Could Intense Workouts Be the Cause?

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When he tried to get up, he realized he couldn’t move. His weakness had a surprising cause — and an even more surprising cause behind the cause.

“I can’t move my legs,” the 26-year-old man told his younger brother, who towered above him as he lay sprawled on the floor. He’d been on his computer for hours, he explained, and when he tried to stand up, he couldn’t. His legs looked normal, felt normal, yet they wouldn’t move.
At first, he figured his legs must have fallen asleep. He pulled himself up, leaning on his desk, and slowly straightened until he was standing. He could feel the weight on his feet and knees. He let go of the desk and commanded his legs to move. Instead, they buckled, and he landed on the floor with a thud.
His brother awkwardly pulled him onto the bed. Then they waited. Surely this weird paralysis would disappear just as suddenly as it came. An hour passed, then two. I’m calling an ambulance, the younger brother announced finally. Reluctantly, the elder agreed. He was embarrassed to be this helpless but worried enough to want help.
When the E.M.T.s arrived, they were as confused as the brothers. The medics asked what the young man had been up to. Nothing bad, he assured them. For the past few weeks he had been getting back into shape. He changed his diet, cut out the junk and was drinking a protein concoction that was supposed to help him build muscle. And he was working out hard every day. He’d lost more than 20 pounds, he added proudly.
Hearing about this extreme diet and exercise regimen, the E.M.T.s told the man he was probably dehydrated. He needed fluids and some electrolytes. A couple of bottles of Gatorade and he would very likely feel a lot better. And if he didn’t, he could call again.
With his brother’s help, the man moved himself to a sitting position. He drank some water and Gatorade and waited to start feeling better. He fell asleep, still waiting. By the following afternoon he was having trouble sitting upright. He was drinking yet another Gatorade when he noticed that the bottle felt heavy. He realized with a start that the weakness had moved into his arms. Call the ambulance, he told his brother. This can’t be dehydration.
A new set of E.M.T.s agreed. They hoisted the weakened man onto a stretcher, fastened the straps tightly and headed down the stairs. The man felt himself pitch forward as the stretcher tilted down. Was he going to fall? He imagined himself tumbling down the stairs like a sack of potatoes, completely unable to protect himself. The straps held him on the stretcher, but that feeling of helplessness terrified him.
Dr. Getaw Worku Hassen was the emergency-medicine doctor on duty that night at Metropolitan Hospital in Upper Manhattan. He asked the patient if anything like this had happened before. No, the patient replied, though recently his thighs had felt tired and weak at times. It never lasted long, and he figured it was from working out so hard. The man asked if he might have had a stroke. Would he ever be able to walk again? Hassen reassured him that his symptoms didn’t look like a stroke. But, the doctor acknowledged, he wasn’t sure what it did look like.
On exam, the man’s heart was racing at 110 beats a minute. And his blood pressure was high. He couldn’t lift either leg off the stretcher — not even an inch. His arms were weak as well. But his reflexes, sensation and the rest of his nervous system seemed otherwise normal.
Hassen told the man that they would need to wait for the results of his blood work and other tests. He would be back when he knew more. Moments later the doctor was called by the lab. One of the patient’s electrolytes was dangerously low — his potassium.
Potassium is probably the most important electrolyte we measure routinely. It is essential for every cell in the body, and its movement in and out of cells is key to many of the body’s functions. Hassen immediately ordered potassium to be given both by mouth and intravenously. He wasn’t sure why this young man had such a low level of potassium but knew that if he didn’t get more, he could die. Cells in the heart depend on the flow of potassium to work properly. Either too much or too little of it could cause the heart to develop a life-threatening arrhythmia.
The patient was admitted to the intensive-care unit so that his heart could be monitored as the deficit was reduced. The patient says he could feel strength flowing back into his muscles almost as soon as he started getting the replacement electrolyte. By morning he felt strong enough to stand. By midafternoon, he could walk. The doctors gave him potassium tablets to take every day for the next week and told him to stay hydrated if he was going to keep up this fitness regimen. And, of course, he should follow up with his regular doctor.
A few days later, when Hassen returned to the hospital for his next shift, he wondered what had happened to the man with the weakened legs. He saw that his potassium had come back to a normal level and that he had been discharged. These days, financial pressures push doctors caring for hospitalized patients to narrow their focus to identifying life-threatening conditions and addressing those enough to stabilize the patient. Patients are then sent back to their primary-care doctors to determine the hows and whys behind the conditions that sent them to the hospital in the first place. Hassen accepted this reality, and yet to him the real pleasure of medicine wasn’t just identifying and addressing the serious symptoms but figuring out the cause behind the cause of the symptom. This man’s weakness was caused by low potassium. But what made his potassium low?
Hassen reviewed the notes from the patient’s overnight stay. In the emergency department, he had been weak, his heart racing, his blood pressure high and his potassium low. When electrolytes were repleted, his strength returned and his blood pressure dropped. But his heart continued to race. Heart rates are often high in the E.R.: Patients are scared and sometimes sick, often in pain. But this man’s heart rate stayed high even as everything else got better. That struck Hassen as strange.
And so Hassen turned to the internet. He eventually found a case report that bore a striking resemblance to his patient: a young man with weak legs, low potassium and a high heart rate. That patient turned out to have something Hassen had never heard of: thyrotoxic periodic paralysis, muscle weakness where the low potassium was being caused by an excess of thyroid hormone.
The thyroid is a gland located in the neck that helps control the body’s metabolic rate. Too much thyroid hormone causes the body to race. Too little, and it slows to a crawl. Unchecked, either state can be fatal. Rarely, in some people — usually young, often male — too much thyroid hormone can make circulating potassium levels drop and cause weakness.
Hassen called the lab. He ordered tests to check the level of thyroid hormone in the sample. It was very high. He called the patient and got no answer, and he had no way to leave a message. He called the number a dozen times over the course of the next few weeks. Finally, maybe accidentally, the patient picked up.
Hassen explained what he’d discovered. He gave the patient the name of an endocrinologist in the area. It turned out the young man had what is known as Graves’s disease. This is an autoimmune disease in which the patient’s own antibodies induce the thyroid gland to produce too much hormone. It’s often treated with radioactive iodine, which kills off some or most of the hormone-producing cells in the gland. This man, instead, chose to take a medicine that interferes with the gland’s ability to make thyroid hormone.
This diagnosis was made almost four years ago. The patient gave up his intensive diet and exercise regimen and is now trying just to stay in shape and eat smarter — and to take his medicine every day. Sometimes when he feels his thighs are tired or weak, he eats a banana or avocado to get the potassium that he thinks his body is craving. He is determined to never relive that kind of helplessness again.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is ‘‘Diagnosis: Solving the Most Baffling Medical Mysteries.’’ If you have a solved case to share with Dr. Sanders, write her at Lisa.Sandersmd@gmail.com.

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How Exercise May Help Us Flourish

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Physical activity can promote a sense of purpose in life, creating a virtuous cycle that keeps you moving.

Our exercise habits may influence our sense of purpose in life and our sense of purpose may affect how much we exercise, according to an interesting new study of the reciprocal effects of feeling your life has meaning and being often in motion. The study, which involved more than 18,000 middle-aged and older men and women, found that those with the most stalwart sense of purpose at the start were the most likely to become active over time, and vice versa.
The findings underscore how braided the relationship between physical activity and psychological well-being can be, and how the effects often run both ways.
Science already offers plenty of evidence that being active bolsters our mental, as well as physical, health. Study after study shows that men and women who exercise are less likely than the sedentary to develop depression or anxiety. Additional research indicates that the reverse can be true, and people who feel depressed or anxious tend not to work out.
But most of these studies examined connections between exercise and negative moods. Fewer have delved into positive emotions and their links with physical activity, and fewer still have looked at the role of a strong sense of purpose and how it might influence whether we move, and the other way around.
This omission puzzled Ayse Yemiscigil, a postdoctoral research fellow with the Human Flourishing Program at Harvard University, who studies well-being. “A sense of purpose is the feeling that you get from having goals and plans that give direction and meaning to life,” she says. “It is about being engaged with life in productive ways.”
This definition of purpose struck her as overlapping in resonant ways with many people’s motivations for exercise, she says. “Active people often talk about how exercise gives structure and meaning to their lives,” she says. “It provides goals and achievements.”
In that case, she thought, physical activity plausibly could contribute to a sense of purpose and, likewise, a sense of purpose might influence how likely we are to exercise.
But there was scant evidence to support those ideas. So, for the new study, which was published in April in the Journal of Behavioral Medicine, she and her colleague Ivo Vlaev, a professor of behavioral science at the University of Warwick in England, set out to find links, if any, between moving and meaning.
They began by turning to the large and ongoing Health and Retirement Study, which gathers longitudinal data about the lives, attitudes and activities of thousands of American adults aged 50 or older. It asks them at the start about their physical health, background, daily activities and mental health, including if they agree with statements like, “I have a sense of direction and purpose in life,” or “My daily activities often seem trivial and unimportant.” The study’s researchers then checked back after a few years to repeat the queries.
Then, Dr. Yemiscigil and Dr. Vlaev drew records for 14,159 of the participants. To enlarge and enrich their sample, they also gathered comparable data for another 4,041 men and women enrolled in a different study that asked similar questions about people’s physical activities and sense of purpose.
Finally, they collated and compared the results, determining, first, how much and how vigorously people moved, and also how strong their sense of purpose seemed to be. The researchers then assessed how those disparate aspects of people’s lives seemed to be related to one another over the years, and they found clear intersections. People who started off with active lives generally showed an increasing sense of purpose over the years, and those whose sense of purpose was sturdier in the beginning were the most physically active years later.
The associations were hardly outsize. Having a firm sense of purpose at one point in people’s lives was linked, later, with the equivalent of taking an extra weekly walk or two. But the associations were consistent and remained statistically significant, even when the researchers controlled for people’s weight, income, education, overall mental health and other factors.
“It was especially interesting to see these effects in older people,” Dr. Yemiscigil says, “since many older people report a decreasing sense of purpose in their lives, and they also typically have low rates of engagement in physical activity.”
This study was based, though, on people’s subjective estimates of their exercise and purposefulness, which could be unreliable. The findings are also associational, meaning they show links between having a sense of purpose at one point in your life and being active later, or vice versa, so do not prove one causes the other.
But Dr. Yemiscigil believes the associations are sturdy and rational. “People often report more self-efficacy” after they take up exercise, she says, which might prompt them to feel capable of setting new goals and developing a new or augmented purpose in life. And from the other side, “when you have goals and a sense of purpose, you probably want to be healthy and live long enough to fulfill them.” So, cue exercise, she says.
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Why Haven’t You Scheduled Your Covid Vaccine?

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If you’re feeling hesitant about getting your shot, we want to hear your questions.
The rate at which people are making appointments for their Covid-19 shots is decreasing across the country. Are you among those people who have not received the vaccine?
The Well desk wants to hear from readers who are hesitant about getting the shot — or have questions on behalf of someone who has concerns. What would you like more information about? Do you have new questions about young people and vaccination? Are you fearful of side effects, or have you read conflicting information from different sources? Tell us what you want to know, and we’ll track down the answers.
How to submit a question: You can use the form below to send us your questions.
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CDC Chief Defends Coronavirus Pandemic Guidance as Impatience Mounts

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At a Senate hearing on the federal government’s pandemic response, Republicans criticized the government’s guidance for cruise ships, fishermen, summer camps and outdoor mask wearing.

WASHINGTON — The director of the Centers for Disease Control and Prevention on Tuesday defended the agency against accusations that federal scientists were being too slow to update their pandemic-control guidance and overly conservative with their recommendations, especially on outdoor mask wearing.
At a Senate hearing with other top federal health officials on the federal government’s pandemic response, Republicans accused the C.D.C.’s director, Dr. Rochelle P. Walensky, of accommodating special interests in the agency’s guidance for schools and of failing to recognize the low risk of outdoor transmission of the coronavirus.
They said that the agency had lost the trust of Americans looking to return to normal life.
Their complaints echoed mounting exasperation — even among some public health experts — with the federal government’s pace in relaxing its recommendations as states across the country move to reopen their economies.
Frustrations ranged from the practical — asking children to wear masks at camp — to the fantastic — suggestions that the National Institutes of Health had conspired with the Chinese to supercharge viruses, an accusation that Dr. Anthony S. Fauci called “entirely and completely incorrect.”
And they came as the White House moved to increase access to coronavirus vaccines with a new pledge from the ride-share giants Uber and Lyft, which President Biden said would begin offering free rides to and from tens of thousands of vaccination sites.
Senator Susan Collins, Republican of Maine, complained at the hearing that the C.D.C. had allowed the American Federation of Teachers to exert undue influence over its school reopening guidance, compromising its scientific integrity.
Dr. Walensky said that a change to the schools guidance was because of an “oversight” — its draft guidance had neglected to include materials on how to protect teachers with compromised immune systems. The back-and-forth was a normal part of the agency’s process for drafting guidance, she said, when agency scientists consider outside advice from industry experts. C.D.C. scientists wrote the recommendations themselves, Dr. Walensky said.
Ms. Collins also accused the C.D.C. of using faulty data in its recent mask guidance for the outdoors. The agency announced last month that “less than 10 percent” of transmission was occurring outdoors, a statistic infectious disease experts said was a misleading exaggeration. Dr. Walensky said that the C.D.C. had used a rigorous aggregation of studies in a renowned medical publication, The Journal of Infectious Diseases, to back that figure.
And Ms. Collins quoted pediatricians saying that the C.D.C.’s guidance for summer camps — in which federal officials said that children could be within three feet of peers in same-group settings but must wear masks at all times — was illogical. Dr. Walensky allowed that the guidance would change now that adolescents can receive the vaccine.
“We have unnecessary barriers to reopening schools, exaggerating the risks of outdoor transmission and unworkable restrictions on summer camps,” Ms. Collins said. “It matters because it undermines public confidence in your recommendations, in the recommendations that do make sense.”
Dr. Walensky said that the C.D.C. was working to update its guidance as more Americans get vaccinated and as scientists glean new insight. The agency’s drafting process — seeking internal and external expert input — was collaborative and responsive, she said.
Senator Bill Cassidy, Republican of Louisiana, told Dr. Walensky that the public was “beginning to disregard what you say that’s true,” warning of consequences if the C.D.C. did not update guidance on how Americans could return to the office. He also accused the agency of being slow to acknowledge the minimal risk of outdoor transmission.
“The American people have just lost patience with us,” he said.
As health officials defended the Biden administration’s work, the White House announced its latest moves to bolster the nation’s vaccinations. In a meeting with six governors from both parties, including Republicans from Ohio and Utah, Mr. Biden said that the ride-sharing initiative was part of an aggressive new phase of the administration’s efforts to address vaccine hesitancy and access.
The White House said that Uber and Lyft would promote the free rides until July 4, the target date of Mr. Biden’s goal of at least partly vaccinating 70 percent of adults.
Health officials have said that Americans remain eager to get inoculated — providers are administering about 2.19 million doses per day on average — but a lack of transportation has hindered access.
The Senate hearing on Tuesday was dominated by discussion of the C.D.C.’s guidance materials. Senator Richard M. Burr, Republican of North Carolina, linked the agency’s guidance-drafting process to the administration’s ability to get more Americans vaccinated.
“If we continue to fail at the trust that they have in us making the calls that are appropriate,” he said, then “we’re going to fail.”
Senator Lisa Murkowski, Republican of Alaska, said that her state was still waiting on the C.D.C. to update its cruise ship guidance, which was threatening to sap the state’s tourism industry.
She also said that federal mask requirements for transportation hubs were compromising the work of fishermen, who faced more danger in wearing a mask than not but who are fearful of failing to comply with the government’s orders.
“You’re out on a boat. The winds are howling. Your mask is soggy wet,” Ms. Murkowski said. “Tell me how anybody thinks that this is a sane and a sound policy.”
On the other side of the United States, fisherman were struggling with the same enforcement policies, said Senator Maggie Hassan, Democrat of New Hampshire. She said she had met with some in her state who had been fully vaccinated but nagged by members of the Coast Guard about keeping masks on.
Dr. Walensky said the agency was finalizing guidance to deal with the problem.
At one point on Tuesday, Senator Christopher S. Murphy, Democrat of Connecticut, stepped in to defend the officials testifying.
“We suffered through four years with a president who literally made things up about this virus, who simplified the story over and over and over again,” he said. “We still have a lot to learn. And so I, frankly, appreciate the fact that we have leaders today who recognize that we still have gaps in information who occasionally may err on the side of caution in order to save lives.”
The hearing took several heated detours to address accusations that the National Institutes of Health, where Dr. Fauci is a top official, had supported research in a laboratory in Wuhan, China, where some top Trump administration officials maintained the novel coronavirus might have leaked from. Most scientists agree that the coronavirus most likely emerged in the natural world and spread to humans from animals.
Senator Rand Paul, Republican of Kentucky, who is known for sparring with Dr. Fauci, accused the government’s top infectious disease expert of backing an American scientist’s collaboration with the Wuhan Institute of Virology. The institute houses a state-of-the-art laboratory known for its research on coronaviruses.
Dr. Fauci quickly shot down the suggestion about so-called gain of function research, saying the N.I.H. had never supported such work there.
Katie Rogers contributed reporting.
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Trump supporters aren't crying and looting. Yeah, we are angry, but we are level-minded and strong. We are resilient and we will fight on, not whine and complain. See you in court, Dems!

We love you, President Trump. Hope you and your family recover quickly. Take care and best wishes. https://twitter.com/realDonaldTrump/status/1312158400352972800

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