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We Need to Know How Menopause Changes Women’s Brains

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This might turn out to be a crucial window to try to prevent Alzheimer’s and other chronic diseases that often accompany older age.

During menopause, which marks the end of a woman’s menstrual cycles, her ovaries stop producing the hormones estrogen and progesterone, bringing an end to her natural childbearing years. But those hormones also regulate how the brain functions, and the brain governs their release — meaning that menopause is a neurological process as well. “Many of the symptoms of menopause cannot possibly be directly produced by the ovaries, if you think about the hot flashes, the night sweats, the anxiety, the depression, the insomnia, the brain fog,” says Lisa Mosconi, an associate professor of neurology at Weill Cornell Medicine and director of its Women’s Brain Initiative. “Those are brain symptoms, and we should look at the brain as something that is impacted by menopause at least as much as your ovaries are.”
In June, Mosconi and her colleagues published in the journal Scientific Reports one of the few studies to observe in detail what happens to the brain throughout the menopause transition, not just before and after. Using various neuroimaging techniques, they scanned the brains of more than 160 women between the ages of 40 and 65 who were in different stages of the transition to examine the organ’s structure, blood flow, metabolism and function; they did many of the same scans two years later. They also imaged the brains of men in the same age range. “What we found in women and not in men is that the brain changes quite a lot,” Mosconi says. “The transition of menopause really leads to a whole remodeling.”
On average, women in the United States enter the menopause transition — defined as the first 12 consecutive months without a period — at around 50; once diagnosed, they are in postmenopause. But they may begin to have hormonal fluctuations in their 40s. (For some women, this happens in their 30s, and surgical removal of the ovaries causes immediate menopause, as do some cancer treatments.) Those fluctuations cause irregular periods and potentially a wide variety of symptoms, including hot flashes, insomnia, mood swings, trouble concentrating and changes in sexual arousal. During this phase, known as perimenopause, which averages four years in length (but can last from several months to a decade), Mosconi and colleagues observed that their female subjects experienced a loss of both gray matter (the brain cells that process information) and white matter (the fibers that connect those cells). Postmenopause, however, that loss stopped, and in some cases brain volume increased, though not to its premenopausal size. The researchers also detected corresponding shifts in how the brain metabolized energy, but these did not affect performance on tests of memory, higher-order processing and language. This suggests that the female brain “goes through this process, and it recoups,” says Jill M. Goldstein, a professor of psychiatry and medicine at Harvard Medical School and founder and executive director of the Innovation Center on Sex Differences in Medicine at Massachusetts General Hospital. “It adapts to a new normal.”
Understanding what happens in the brain around the time of the menopause transition could inform when and how doctors treat a given woman’s symptoms. Hormone therapy — whether estrogen alone or in combination with a progestogen — is not ordinarily prescribed until postmenopause, and carries risks; on the other hand, it can help treat hot flashes, bone loss or undesirable urinary or vaginal changes for women under 60 (or who have begun menopause within the past 10 years), according to the North American Menopause Society. Some women who receive hormone therapy might also gain cognitive benefits, but more evidence is needed to identify who should be treated. Randomized control trials of postmenopausal women have tried to assess whether hormone therapy decreased the risk of Alzheimer’s disease or other cognitive declines, but these have returned mixed results so far.
Yet Mosconi and colleagues found that women in their study who had a particular genetic risk factor for Alzheimer’s disease began to develop amyloid plaques, which are linked to the disease, during perimenopause in their late 40s and early 50s — earlier than previously thought. If the brain changes significantly during perimenopause, that might turn out to be a crucial window during which to try to prevent Alzheimer’s and other chronic diseases that often accompany older age. (Because hormone therapy is not generally prescribed for perimenopausal women, clinical trials on its potential cognitive benefits have not been done for them.)
Several major chronic diseases, including Alzheimer’s, appear to afflict women disproportionately. As Goldstein and her colleagues noted in a January opinion column in JAMA Psychiatry, more than two-thirds of those diagnosed with Alzheimer’s are women (only in part because they live longer, and older people are at greater risk). Women, too, are at twice the risk of developing a major depressive disorder, and they do so in tandem with cardiovascular disease at twice the rate men do — a combination, the authors point out, that increases their risk of death from cardiovascular causes as much as fivefold. Heart disease is also a risk factor for Alzheimer’s.
Figuring out why those health disparities exist and what to do about them will require researchers to consider sex and gender specifically as variables, which science has been slow to do. Over the past 30 years, for example, researchers hoping to understand age-related cognitive decline have generally analyzed data from men and women collectively, obscuring differences between the sexes as far as when deficits tend to appear and how to diagnose them. “We need to think about designing studies from the outset in a way that’s relevant for women and men,” says Janine Austin Clayton, director of the Office of Research on Women’s Health at the National Institutes of Health. “Men and women both undergo chronological aging and reproductive aging, but in distinct ways,” she says. “Not looking at those separately masks findings and is a missed opportunity.”
Another challenge is separating the impacts on health caused by aging versus those caused by the hormonal changes that accompany menopause. Ideally, you would compare a large number of women who are experiencing them to women of the same age who are not. But by their 50s, most women have reached perimenopause; by their 60s, almost all are postmenopausal. Mosconi and her colleagues accounted for this by comparing women with age-matched men. But, as Stephanie Faubion, director of the Mayo Clinic Center for Women’s Health and medical director of the NAMS, points out, “Men’s brains are going to be different than women’s.”
The fact that women can experience significant brain changes around menopause also raises questions about how commonly this happens and the extent to which it affects women’s daily lives, says Pauline Maki, a professor of psychiatry, psychology and obstetrics & gynecology at the University of Illinois at Chicago College of Medicine. It’s crucial to note, she says, that women frequently report cognitive deficits around menopause, and that such symptoms are usually temporary. But her work has shown that they are more likely to have a lasting impact on low-income women of color — probably, she says, because those women have higher rates of stress, disrupted sleep and other mental-health burdens that “make the brain more vulnerable.”
Conversely, there are a number of possible preventive measures to protect cognitive health before and after the menopause transition. Abstaining from tobacco, being physically active, eating a plant-rich diet, reducing stress and getting enough sleep — these are all ways to support brain function. “Menopause is a critical window, when a woman might begin to develop the first signs of chronic disease,” Clayton says. As such, it’s an important time for her to check in with her health care provider and discuss her reproductive history and menopause status, each of which can influence her disease risk and treatment options. In turn, providers of all kinds need to be prepared to care for women throughout their transition: “It’s not just in the realm of gynecology,” Faubion says, “and we have to stop thinking of it that way.”
Kim Tingley is a contributing writer for the magazine.

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Cats Are So Not Appreciated. Think Again.

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Researchers who work on the genomes of domestic and wild cats say their DNA holds clues to human as well as feline health.

Leslie Lyons is a veterinarian and specialist in cat genetics. She is also a cat owner and general cat partisan who has been known to tease her colleagues who study dog genetics with the well-worn adage that “Cats rule. Dogs drool.”
That has not been the case with research money and attention to the genetics of disease in cats and dogs, partly because the number of dog breeds offers variety in terms of genetic ailments and perhaps because of a general bias in favor of dogs. But Dr. Lyons, a professor at the University of Missouri, says there are many reasons cats and their diseases are invaluable models for human diseases. She took up the cause of cat science this week in an article in Trends in Genetics.
“People tend to either love them or hate them, and cats are often underappreciated by the scientific community,” she writes. But, she says, in some ways the organization of the cat genome is much like the human genome, and cat genomics could help in the understanding of the vast amount of mammalian DNA that does not constitute genes, and is poorly understood.
Among the advances in veterinary medicine that have benefited humans, she pointed out that remdesivir, an important drug in combating Covid, was first successfully used against a cat disease caused by another coronavirus.
She is the director of the 99 Lives Cat Genome Sequencing Initiative and as part of that project, she and a group of colleagues, including Wes Warren at the University of Missouri and William Murphy at Texas A&M University, recently produced the most detailed genome of the cat to date, which surpasses the dog genome.
“For the moment,” Dr. Lyons said.
I spoke last week with Dr. Lyons, Dr. Warren and Dr. Murphy, who refer to themselves as Team Feline. Dr. Lyons was visiting Texas, and with two of her colleagues she talked about why the genomes of cats are important to medical knowledge.
I report on animal science, and over the years, I admitted to the members of Team Feline, I seem to have written more about dogs than cats. The dog-cat rivalry in genomic science is mostly a good-natured rivalry, but just to assess what I was getting myself into I first asked about the scientists’ nonscientific approach to cats and dogs.
The conversation has been edited for length and clarity.
First, their personal preferences:
Dr. William Murphy: I do have cats and dogs as pets, but I prefer cats.
Dr. Wes Warren: I’m a dog owner. Unfortunately I’m allergic to cats.
Dr. Leslie Lyons: He has a very expensive dog that keeps having problems.
Why were you moved to write the article promoting the cause of cat science?
Dr. Lyons: Throughout my career, I’ve been trying to get people to recognize that our everyday pets have the same diseases as us and can really provide important information if we can understand what makes them tick a little bit better, how their genomes are constructed.
You have high quality genomes of several species of cats beyond the domestic cat?
Dr. Lyons: We already have the lions and tigers, the Asian leopard cat, Geoffroy’s cat, a half-dozen species with really, really good genomes that are even better than the dog genomes at this point in time.
Dr. Murphy: By far. It was actually better quality than the human reference genome until very recently. The goal is to have the complete encyclopedia of the cat’s DNA, so we can actually fully understand the genetic basis for all traits in the cat.
Dr. Lyons: For example the allergy gene that Wes is allergic to. We completely understand that gene now. We can maybe even knock it out of the cat to produce cats that are more hypoallergenic or at least understand what elicits the immune response better.
How are cat diseases a good model for human diseases?
Dr. Lyons: What we’re discovering is different species have different health problems. We should really be picking the right species.
Dr. Warren: We know that dogs get cancer more frequently, similar to ourselves. Cats don’t get cancer very often. And that’s a fascinating story of evolution. So are there signals or clues in the genome of the cat that allows us to zero in better on why cats get certain types of cancers and understand the differences among dogs, cats and humans.
How about the cats that are subjects of the research?
Dr. Lyons: Genomic research is fantastic because all we need is maybe a blood sample. And so once we have the blood sample, we don’t have to do experimentation on an animal. We’re actually observing what animals already have. We’re working with the diseases that are already there.
What about wild species?
Dr. Murphy: High quality genomes for wild cats can aid in their species survival plans and their recovery in the wild.
Dr. Lyons: We see half a dozen health problems in wild felids. We have a study of transitional cell carcinoma in fishing cats, inherited blindness in black-footed cats, polycystic kidney disease in Pallas’s cats. Snow leopards have terrible eye problems, probably because of inbreeding in zoos. So understanding their genomes can help us to stop those problems in the zoo populations, and that will help humans with the same conditions as well.
How about ancient DNA and cats? There’s been a lot of work on that in dogs. How is that progressing in cats?
Dr. Lyons: A couple of groups are moving forward with ancient DNA. I worked on some mummy cats and we showed that the mitochondrial DNA types that we found in the mummified cats are present more commonly in Egyptian cats today than they are anywhere else. So the cats of the pharaohs are the cats of present day Egyptians.
To switch gears: I’ve always been a dog person but I’ve been thinking about getting a cat. Any tips?
Dr. Lyons: Get two. They’ll be buddies. And give them something to scratch. Otherwise it is going to be your couch.
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Vaccinated People Should Be Tested After Exposure Even Without Symptoms, C.D.C. Says

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In addition to revising its mask guidance on Tuesday, the Centers for Disease Control and Prevention also quietly updated its testing recommendations for people who are fully vaccinated against the coronavirus.
The agency now advises that vaccinated people be tested for the virus if they come into contact with someone with Covid-19, even if they have no symptoms. Previously, the health agency had said that fully vaccinated people did not need to be tested after exposure to the virus unless they were experiencing symptoms.
“Our updated guidance recommends vaccinated people get tested upon exposure regardless of symptoms,” Dr. Rochelle P. Walensky, the agency’s director, said in an email to The New York Times. “Testing is widely available.”
Fully vaccinated people should wear a mask in public indoor spaces after exposure, the agency said. Three to five days later, they should be tested for the virus.
If the results come back negative, they can stop wearing masks indoors. If results are positive, the infected should isolate at home for 10 days.
Although people who are fully vaccinated may still get infected with the virus, these breakthrough infections tend to be mild or asymptomatic. The vaccines authorized in the United States provide strong protection against the worst outcomes, including severe disease, hospitalization and death, including from the Delta variant.
The new testing recommendation came on the same day that the agency recommended that fully vaccinated people return to wearing masks indoors under some circumstances. When levels of community transmission are high, everyone, regardless of vaccination status, should wear masks indoors when they are in public, the agency now says.
The agency also recommended that vaccinated people in close contact with unvaccinated people, including children under age 12, consider wearing masks in public indoor spaces whatever the transmission rates in the local community. In a shift, the agency also recommended universal masking in schools.
For months, the C.D.C. had resisted recommending masks for vaccinated people, even as the highly contagious Delta variant spread and the World Health Organization recommended continued mask wearing.
The change was prompted by new data suggesting that even vaccinated people who are infected by Delta may carry large amounts of the virus and transmit it to others, Dr. Walensky said at a news briefing on Tuesday.
Apoorva Mandavilli contributed reporting.
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Weekly Health Quiz: Masks, Heart Health and Olympic Sports

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If you're interested in trying this sport, added to the Olympics for the first time this year, it would be a good idea to first learn how to fall without getting seriously injured:
Pole vault
Cheerleading
Skateboarding
Cycling
Some three million Americans have this common heart condition, which may cause the heart to race or flutter, but many people do not know they even have it:
Endocarditis
Atrial fibrillation
Myocarditis
Heart failure
The Centers for Disease Control and Prevention is now recommending that people wear masks indoors in areas where:
You cannot maintain social distancing
Ventilation is poor
Coronavirus transmission rates are high
You are uncertain of the vaccination status of others
About what percentage of Americans aged 65 and older are fully vaccinated against Covid-19:
50 percent
60 percent
70 percent
80 percent
People fully vaccinated against coronavirus account for about what percentage of Covid-19 hospitalizations?
3 percent
10 percent
22 percent
40 percent
This disease causes zigzag shaped fibers to accumulate in the lungs, heart or other parts of the body:
Amyloidosis
Berylliosis
Chondrocalcinosis
Dactylitis
Women doctors in this field of medicine were at increased risk of pregnancy loss:
Pediatrics
Surgery
Gynecology
Psychiatry
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Dr. J. Allan Hobson, Who Studied the Dreaming Brain, Dies at 88

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He disputed the Freudian view that dreams held encrypted codes of meaning, believing instead that they resulted from random firings of neurons in the brain.

Dr. J. Allan Hobson, a psychiatrist and pioneering sleep researcher who disputed Freud’s view that dreams held hidden psychological meaning, died on July 7 at his home in East Burke, Vt. He was 88.
The cause was kidney failure resulting from diabetes, said his daughter, Julia Hobson Haggerty.
For some time, sleep was not taken seriously as an academic pursuit. Even Dr. Hobson, who was a professor of psychiatry at Harvard Medical School and director of the Laboratory of Neurophysiology at the Massachusetts Mental Health Center, joked that the only known function of sleep was to cure sleepiness.
But over a career that spanned more than four decades, his own research and that of others showed that sleep is crucial to normal cognitive and emotional function, including learning and memory.
In more than 20 books — among them “The Dreaming Brain” (1988); “Dreaming as Delirium: How the Brain Goes Out of its Mind” (1999), and “Dream Self” (2021), a memoir — he popularized his research and that of others, including the findings that sleep begins in utero and is essential for tissue growth and repair throughout life.
“He showed that sleep isn’t a nothing state,” Ralph Lydic, who conducted research with Dr. Hobson in the 1980s and is a professor of neuroscience at the University of Tennessee, said in a phone interview.
“He demonstrated that the brain is as active during R.E.M. sleep as it is during wakefulness,” he added, referring to sleep characterized by rapid eye movement. “We know as much about sleep as we do in part because of him.”
One of his most influential contributions to dream research came in 1977, when Dr. Hobson and a colleague, Robert McCarley, produced a cellular and mathematical model that they believed showed how dreams occur. Dreams, they said, are not mysterious codes sent by the subconscious but rather the brain’s attempt to attribute meaning to random firings of neurons in the brain.
This view, that dreams are the byproduct of chemical reactions, was a departure from psychological orthodoxy and heresy to Freudians, and it remains in dispute.
But to Dr. Hobson, the content of dreams was not as important as the electrical activity of the brain during the dream state.
His work became foundational for many other sleep researchers, including Carlos H. Schenck, whose team in Minnesota found a link between behavioral disorders during R.E.M. sleep — punching one’s bed partner, for example, or even jumping out of a window — and the likelihood in some of those people of developing Parkinson’s disease.
“Allan Hobson helped us understand the dream abnormalities of R.B.D. right from the beginning in 1986,” Dr. Schenck said in an email, referring to R.E.M. sleep behavioral disorders.
Dr. Hobson thrived on controversy, and it was no surprise to many that he challenged his own profession of psychoanalysis and its founding father. Even as a child, he constantly questioned the status quo. At 4, he took measurements and concluded that Santa Claus could not fit down the chimney.
“I’m skeptical about any absolute set of rules, scientific rules, moral rules, behavioral rules,” he said in a 2011 interview with The Boston Globe. “That’s one reason why I don’t feel bad taking on Sigmund Freud. I think Sigmund Freud has become politically correct. Psychoanalysis has become the bible, and I think that’s crazy.”
Tired of tossing and turning? There are some strategies you could try to improve your hours in bed.
In one of his books, “Out of Its Mind: Psychiatry in Crisis — A Call for Reform” (2002, with Jonathan A. Leonard), he called for an overhaul of the profession.
“I think people became disillusioned with psychoanalysis because it was, ultimately, a strange way of caring for people,” he told The New York Times in 2002.
“There was this tendency in the psychoanalytic world to imply that everything was psychodynamic,” he added, noting that some doctors reflexively blamed mothers for their children’s behavior.
But Dr. Hobson softened his views in his later years.
“He came to believe that psychoanalysis could be useful for treating mental disorders,” Dr. Lydic said, “but he did not believe in a rigid symbolism in the interpretation of dreams.”
For the most part, Dr. Hobson still believed, as the saying goes, that a cigar was just a cigar.
John Allan Hobson was born on June 3, 1933, in Hartford, Conn. His mother, Ann (Cotter) Hobson, was a homemaker. His father, John Robert Hobson, was a lawyer.
John attended the Loomis School, now the Loomis Chaffee School, in Windsor, Conn., graduating in 1951. He spent a year abroad, then returned to study at Wesleyan University in Connecticut, where he majored in English, graduating in 1955. He received his medical degree from Harvard Medical School in 1959.
He married Joan Harlowe in 1956; they divorced in 1992. He married Dr. Rosalia Silvestri in the mid-1990s, and she survives him.
In addition to his wife and daughter, Dr. Hobson is survived by four sons, Ian, Christopher, Andrew and Matthew; his brother, Bruce; and four grandchildren.
After medical school, Dr. Hobson interned for two years at Bellevue Hospital in Manhattan. In lieu of military service, he served in the Public Health Service of the National Institutes of Health.
He was influenced by Michel Jouvet, a neurophysiologist who discovered the region of the brain that controls rapid eye movement and who helped steer Dr. Hobson to study sleep and dreams.
Apart from his research, Dr. Hobson was most passionate about his farm in Vermont, which he acquired in 1965 and had since been its steward.
He converted part of one barn on the property into a small, interactive sleep museum and classroom for local students, basing it on his multimedia exhibit “Dreamstage,” which celebrated the art and science of sleep and toured science museums across the United States in the late 1970s. His museum featured, among other things, a preserved brain as well as artwork of brains.
The farm was a gathering place for family and friends. Dr. Hobson’s children said that the dining room table was often the scene of celebratory recitations of poetry and song. Afterward, the kitchen would fill with the sound of Big Band favorites and become a dance floor.
Dr. Hobson wrote in his memoir that he spent 10 years reading all of Marcel Proust — twice. He read 10 pages a day.
“I simply admire his persistent and revealing self-analysis and his description of mental life in and at the edges of sleep,” Dr. Hobson told The Globe. “His self-observation is much more careful than that of Freud.”
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He Was Coughing Up Blood. But His Lungs Looked O.K.

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The obvious place to look isn’t always the right place.

“I’ve been coughing up blood,” the 59-year-old man confessed to his wife as they drove toward New York City from their home in Connecticut. It started the night before, he admitted when she asked. After 40 years of marriage, his wife, a nurse, was used to this kind of nonchalance from her husband, though it always carried a kind of punch. Take this exit, she instructed. They were near an urgent-care center in Brewster, N.Y. He needed to get this checked out.
It was quiet when the couple walked in to urgent care, so her husband was seen right away. He had a runny nose and a cough for the past couple of days, and a few times he’d seen streaks of blood in what he coughed up, he told the nurse. His chest hurt a little when he took a deep breath, but otherwise he felt just fine. His vital signs, however, told a different story. He didn’t have a fever, but his oxygen level was at 91 percent. Even with the worst cold, his oxygen should have been 98 to 100 percent. Did he feel short of breath? Not particularly, he said. Maybe when he was walking from the car, but sitting here now? Not at all. He needed a CT scan of his chest, the couple was told, and so he was transferred to the emergency department at Northern Westchester Hospital in Mount Kisco, N.Y.
The CT didn’t reveal any clots in the arteries of the lungs, so he didn’t have the feared pulmonary embolus, which could have caused his low oxygen and hemoptysis (coughing up blood) without other symptoms. Even so, the images were far from normal. There were patches of a light haze in areas that should be dark in both lungs. Maybe pneumonia? People usually feel sicker than this man when they have pneumonia, but how else could they explain the low oxygen level? He was started on antibiotics and admitted for observation.
Dr. Tara Shapiro was the doctor assigned to his care that night. She was not at all sure the problem was in the man’s lungs. The CT scan also revealed a heart that was thicker and more muscular-looking than it should be. This kind of hypertrophy, as it’s called, is frequently seen in patients who have high blood pressure, when the heart has to work hard to squeeze its payload into the bloodstream. But this man didn’t have high blood pressure.
The patient had a full cardiac work-up a few months earlier that he said was normal. But Shapiro was still worried that it was his heart and not his lungs that was failing him. His oxygen level improved greatly in just the few hours he’d been in the hospital. It was far too early for the antibiotics to have done this. More likely it was from the powerful diuretic he’d already been given in case the haziness in his lungs was fluid rather than an infection. A muscular heart doesn’t pump as well as a normal heart and sometimes can’t keep up. When that happens, fluid can get backed up — right into the lungs.
Shapiro reached out to a cardiologist colleague, Dr. Ronald Wallach. He was one of the most knowledgeable doctors she knew. Wallach saw the patient the following day, just before he was discharged. The patient’s wife was reassured by the doctor’s white hair and air of quiet authority. Her husband, something of a hardhead, would certainly listen to this guy.
After hearing the man’s story, Wallach asked if he had been short of breath before. Well, maybe it had been going on for a while, the man acknowledged. How long? The man’s wife gave him a sharp look. Certainly for the past several months, at least since the summer, he said. That’s when he’d had some serious trouble breathing.
He was out one weekend on his motorboat with his wife and adult daughter. The women were on inner tubes in the cove just behind New Rochelle Harbor, enjoying the sun and calm waters. Then suddenly: “Throw me the rope,” he heard his wife shout. He looked up to see the two women moving rapidly away from his boat, caught in the oceanbound tide. He wrapped one end of a rope around his body and threw the other end out to his wife. It took a couple of tries, but she got it. He struggled to pull wife and daughter back to the side of the boat. As they clambered over the side, it was his wife who noticed his breathing. His face was red and shiny with sweat, and he was panting for breath. Are you OK? she asked. He nodded his head and held up a finger as if to say give me a minute. It took more than a minute — a lot more. It scared her. He was a tough guy, but it might have scared him too, because, though he refused to go to the emergency room then, he did see his primary-care doctor later that week.
That doctor immediately sent him to a pulmonologist and then a cardiologist. The lung doctor gave him a diagnosis of asthma. It’s unusual at this age, the doctor said, but it happens. He gave the patient an inhaler to use when he felt short of breath. It didn’t help. The cardiologist ordered a stress test. The patient lasted only a few minutes before he was too out of breath to continue. His EKG was normal throughout the test, so his cardiologist chalked it up to his asthma. He was an elevator mechanic and that meant that most days he had to climb stairs — sometimes lots of stairs — to fix broken machinery. The man noticed the stairs had become a little harder on him over the past year or so, but, he asked Wallach with shrug and a smile, what can you do?
It was the EKG done in the emergency department that provided Wallach with the last clue he needed to make his diagnosis. An EKG measures the electricity generated by the heart in order to make the muscles contract effectively. A thick, muscular heart will make an EKG tracing that is bigger, more exaggerated than normal. The more muscle present, the bigger the signal. But this man’s heart generated a signal that was smaller than normal. Less electricity could suggest less muscle. Was this man’s heart enlarged by something other than muscle?
There are diseases that can invade cardiac muscles to make them look bigger but be weaker. A disease like that could account for all the man’s symptoms — the thick-looking walls, the overflow into the lungs, the strange EKG, the shortness of breath, even the hemoptysis. “I think you might have something serious,” Wallach told the patient. A cardiac M.R.I. could give them the answer. The patient got that test a few days later. He wasn’t out of the scanner for more than 20 minutes when his phone rang. It was Wallach. The images told the story: The man had a disease known as amyloidosis.
Amyloidosis is the final result of many disease processes that ultimately cause zigzag-shaped fibers to accumulate in different parts of the body. Cardiac amyloidosis can be a result of a cancer known as multiple myeloma. In this cancer, a type of white cell called a plasma cell creates abnormal fibers that can break down and form the characteristic saw-toothed fibers of amyloidosis. These jagged fibers can also be a result of aging. In this version of the disease, carrier proteins known as transthyretins break down and take on the abnormal but characteristic irregular folds of amyloidosis. In both diseases, these serrated fibers travel through the body, invading and accumulating in muscle — often the heart muscle.
Tests on blood and urine quickly showed that his disease wasn’t due to myeloma. That was a relief; the prognosis for patients with cardiac amyloidosis from multiple myeloma is poor. They often die within a year of getting the diagnosis. A biopsy of the heart muscle proved that it was the form of amyloidosis associated with aging. This type of amyloidosis is also progressive but much more slowly. The patient was referred to a cardiothoracic surgeon at Columbia University. Sooner or later, he was going to need a heart transplant.
Three years passed before Wallach heard again from the patient. He wrote to let Wallach know he’d received his heart transplant and was doing well. He was writing to say thank you: “You saved my life.”
I asked Wallach how he could make this diagnosis when other doctors had not. He called it the Aunt Tilly Sign. “If I described Aunt Tilly to you and sent you out into a crowd to find her, you’d probably fail. But if you’d ever seen Aunt Tilly” — he snapped his fingers — “no problem. You’d find her in a second. It’s all about recognition.”
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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What to Know About New C.D.C. Mask Guidelines for the Vaccinated

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Daniel E. SlotnikApoorva Mandavilli and
The Centers for Disease Control and Prevention recommended on Tuesday that people vaccinated against the coronavirus resume wearing masks in schools and in public indoor spaces in parts of the country where the virus is surging, marking a sharp turnabout from their advice just two months ago.
The pandemic in the United States is very different than it was in May, when it seemed as if the worst was in the past. Confirmed cases are surging in parts of the country with low vaccination rates, and there are more reports of breakthrough infections with the highly contagious Delta variant in fully immunized people.
Vaccines are effective against the worst outcomes of infection, even with the variant, and conditions are nowhere near as bad as they were last winter. But the new guidance amounts to a weary acknowledgment that the lagging vaccination effort has fallen behind the ever-evolving virus. Fewer than 50 percent of the country is fully vaccinated, according to federal data.
“This is not a decision we at C.D.C. have made lightly. This weighs heavily on me,” Dr. Rochelle P. Walensky, the agency’s director, said at a news briefing on Tuesday.
transcript
We acted with the data that we had at the time, the data that we had at the time, the country mostly had alpha — alpha among breakthrough vaccinated infections was not being transmitted to other people. The data that we have right now is different. We have a country that is full of Delta. Delta is a more transmissible virus. And the new data that we have is that Delta is able, in those rare breakthrough infections, to be transmitted to others. The most important thing that we need to say right now is we have — a lot of this country that has a lot of viral burden. That’s driven a lot by people who — mostly by people who are unvaccinated. Those are the people that are driving the new infections. But at an individual level, we believe everybody should be wearing a mask in those areas with substantial and high transmission. We are now a country that is the majority of Delta. We know that our young children, 11 and younger, cannot be vaccinated. We know that our vaccinated individuals, in the rare case that there are a breakthrough, have the potential to pass the virus on to unvaccinated individuals. We know that our 12 to 17-year-olds, right now, have only about 30 percent coverage in fully, in being fully vaccinated. And so taking all of that information together, we believe that the C.D.C. — the C.D.C. recommends that K through 12 schools should be opened for full-time in-person learning. But in those indoor settings, everyone should be masked. And I think the most important thing to recognize is most of the transmission across this country is related to people who are unvaccinated. That is where the majority of transmissions are occurring.
Here’s what we know:
The C.D.C. has long recommended that unvaccinated people wear masks indoors. But Tuesday’s regulations mean that even people who have been completely inoculated will once again need to mask up in public indoor spaces in parts of the country where the virus is ascendant.
In schools, health officials now recommended universal masking, regardless of vaccination status and community transmission of the virus, and additional precautions for staff, students and visitors. But they should still plan on returning to in-person learning in the fall.
How this will play out in states that have prohibited mask mandates in schools remains to be seen as well as communities where people may be weary of wearing masks.
Some states immediately adopted the new guidelines, including Illinois. The state’s public health director, Dr. Ngozi Ezike, said that despite the effectiveness of current vaccines, “we are still seeing the virus rapidly spread among the unvaccinated.”
“The risk is greater for everyone if we do not stop the ongoing spread of the virus and the Delta variant,” she said.
Gov. Steve Sisolak of Nevada followed suit on Tuesday. Starting Friday, Nevada residents in counties with high rates of transmission will be required to wear masks in public indoor spaces, regardless of vaccination status. The mandate includes Clark County, home to Las Vegas.
The C.D.C. said Americans should resume wearing masks in areas where there are more than 50 new infections per 100,000 residents over the previous seven days, or more than 8 percent of tests are positive for infection over that period.
Health officials should reassess these figures weekly and change local restrictions accordingly, the agency said. By those criteria, all residents of Florida, Arkansas and Louisiana, for example, should wear masks indoors. Nearly two-thirds of U.S. counties qualify, many concentrated in the South.
“The Delta variant is showing every day its willingness to outsmart us,” Dr. Walensky said at the news briefing. “In rare occasions, some vaccinated people infected with a Delta variant after vaccination may be contagious and spread the virus to others.”
Data from several states and other countries show that the variant behaves differently from previous versions of the coronavirus, she added: “This new science is worrisome and unfortunately warrants an update to our recommendation.”
In the past, Dr. Walensky has said the nation is in a “pandemic of the unvaccinated” — a point she reiterated on Tuesday. But she also said that she is concerned that vaccinated people with breakthrough infections might pass the virus on to unvaccinated family members or people with weakened immune systems.
With the earlier Alpha variant officials did not believe a vaccinated person could transmit the virus, she said.
Dr. Anthony S. Fauci, the Biden administration’s top pandemic adviser, said the C.D.C. is correct to revisit its recommendations as the virus evolves, he said.
“I don’t think you can say that this is just flip-flopping back and forth,” he said. “They’re dealing with new information that the science is providing.”
But that was before the arrival of the Delta variant, which now accounts for the bulk of infections in the United States. C.D.C. officials were persuaded by new scientific evidence showing that even vaccinated people may become infected and may carry the virus in great amounts, Dr. Walensky acknowledged at the news briefing.
But she said masking is only a “temporary measure,” and, adding, “What we really need to do to drive down these transmissions in the areas of high transmission is to get more and more people vaccinated and in the meantime, to use masks.”
When asked whether he thought the C.D.C.’s new mask guideline could lead to some confusion, President Biden said on Tuesday afternoon that the pandemic was continuing “because of the unvaccinated, and they’re sowing enormous confusion.”
“The more we learn, the more we learn about this virus and the Delta variant the more we have to be worried and concerned,” he said. “There’s only one thing we know for sure, if those other hundred million people got vaccinated we’d be in a very different world. So get vaccinated, if you haven’t you’re not nearly as smart as I said you were.”
The C.D.C. should have simply made a universal recommendation and told all Americans to wear masks indoors, said Ali Mokdad, an epidemiologist at University of Washington and former C.D.C. scientist. “The director said the guidance is for people in areas of high transmission, but if you look at the country, every state is seeing a rise in transmission,” Dr. Mokdad said. “So why not say, ‘Everybody in the U.S. should be wearing a mask indoors?’ The whole country is on fire.”
Jesus Jiménez contributed reporting.
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Covid Variant Adds to Worker Anxieties

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Some see an undue rush by employers to get workplaces back to normal, whether by dropping precautions or imposing new rules.

When Kelly Harris, a personal grocery shopper in Steubenville, Ohio, was vaccinated in March against Covid-19, it was a huge relief. “I felt the weight of the world off my shoulders,” she said.
Her sense of relief has turned to dread. After most supermarkets eased masking requirements in May, mask wearing plummeted in her area. She worried about bringing the virus home to her school-age children.
Then, as the Delta variant proliferated in recent weeks, her anxiety levels spiked again. “I try to stay away from everybody and use self-checkout,” she said. “It has me pretty stressed out.”
Judging from the policies of the stores Ms. Harris frequents, many employers appear to regard the recent increase in Covid infections as a mere blip on the long-awaited road to normal.
Some companies have intensified their efforts to return to a pandemic before-times, easing safety protocols while expecting employees to return to previous routines.
But for many workers, the perception is quite different: a sense of rising vulnerability and frustration even for the vaccinated, who find themselves inundated with stories of breakthrough infections and long Covid.
The gulf between employers’ actions and workers’ concerns appears to foreshadow a period of rising tensions between the two, and unions appear to be positioning themselves for it. Some unions are calling on companies to do more to keep members safe, while others are questioning new vaccination requirements. The two positions may seem at odds, but they send a common message: Not so fast.
“I think we’re rushing to return to normal,” said Marc Perrone, the president of the United Food and Commercial Workers, which has over one million members in industries like groceries and meatpacking.
Many workers complain about a mismatch between plans their employers appear to have made before the rise of the variant and the reality of the past few weeks.
For much of the pandemic, Amazon has offered free on-site Covid testing for employees. It incorporated a variety of design features into warehouses to promote social distancing. But a worker at an Amazon warehouse in Oregon, who did not want to be named for fear of retribution, said there had been a gradual reduction in safety features, like the removal of physical barriers to enforce social distancing.
Kelly Nantel, an Amazon spokeswoman, said that the company had removed barriers in some parts of warehouses where workers don’t spend much time in proximity, but that it had kept up distancing measures in other areas, like break rooms.
“We’re continuously evaluating the temporary measures we implemented in response to Covid-19 and making adjustments in alignment with public health authority guidance,” Ms. Nantel said. She added that the company would “begin ramping down our U.S. testing operations by July 30, 2021.”
At REI, the outdoor equipment and apparel retailer, four workers in different parts of the country, who asked not to be named for fear of workplace repercussions, complained that the company had recently enacted a potentially more punitive attendance policy it had planned to put in place just before the pandemic. Under the policy, part-time workers who use more than their allotted sick days are subject to discipline up to termination if the absences are unexcused. The workers also said they were concerned that many stores — after restricting capacity until this spring — had become more and more crowded.
Halley Knigge, a spokeswoman for REI, said that under its new policies the company allowed part-time workers to accrue sick leave for the first time and that the disciplinary policy was not substantively new but merely reworded. The stores, she added, continue to restrict occupancy to no more than 50 percent capacity, as they have since June 2020.
Workers elsewhere in the retail industry also complained about the growing crowds and difficulty of distancing inside stores like supermarkets. Karyn Johnson-Dorsey, a personal shopper from Riverside, Calif., who finds work on Instacart but also has her own roster of clients, said it had been increasingly difficult to maintain a safe distance from unmasked customers since the state eased masking and capacity restrictions in mid-June.
“You have whole families who are picking out a pound of ground beef,” she said. “Children who are not vaccinated because of age are touching everything, not masked, either.”
Ms. Johnson-Dorsey, who had Covid last year and was vaccinated in March, said that what she was encountering in stores had become a major source of worry as the Delta variant spread. “I think it’s just showing that maybe we jumped too quickly to try and beat this imaginary deadline,” she said.
On Tuesday, after the Centers for Disease Control and Prevention provided new guidance on masking, some employers said they would adjust their policies as warranted.
“We’d always defer to state and local ordinances on capacity and masking mandates,” said a spokeswoman for Albertsons, which also owns Safeway and Jewel-Osco. “We don’t have a national mandate on capacity at this time.”
Ms. Harris and Ms. Johnson-Dorsey, the personal shoppers, do not belong to a union, but Bob O’Toole, the president of the food workers local in Chicago, which represents more than 15,000 workers in the grocery, meatpacking and food-processing industries, said many of his members shared their sentiments.
“The employees don’t feel as though the employers are doing anything to enhance safety after so many precautions were relaxed,” he wrote in a text message.
Mr. Perrone, the international president for the food workers union, said in a statement on Tuesday that the new C.D.C. guidance wasn’t sufficient and urged a national mask mandate.
Public-sector workers, too, have expressed safety concerns as officials move to get government services back to prepandemic norms. In Chicago, Mayor Lori Lightfoot recently brought back office-based city employees who had been working remotely during the pandemic.
But one of the unions representing them, the Illinois council of the American Federation of State, County and Municipal Employees, has argued that more needs to be done to space workers apart and improve ventilation.
“The workplaces where those people work could be sources of transmission because we live in a cubicle world where people are often very close together,” said Roberta Lynch, the union’s executive director in the state. “We want to ensure that people who have high-risk work locations are able to work safely.”
A spokeswoman for the mayor did not respond to a request for comment.
The Office and Professional Employees International Union, which represents nurses who are increasingly subject to vaccine requirements around the country, is unlikely to take a position on the mandates per se but will seek to have a voice in setting policy to guarantee that employees are treated fairly, said Sandy Pope, its bargaining director. For example, the union wants to ensure that no workers are disciplined or fired for refusing the vaccine if they have legitimate reasons for doing so.
“We will demand to be consulted on these things,” Ms. Pope said. “I know a couple of members who have legitimate health issues that have prevented them from being vaccinated.”
The union, which also represents clerical workers at insurance companies, credit unions and universities, has employee-management committees pushing to arrange adequate ventilation systems for workers, with mixed results, she said. She added that the union was preparing for a potential standoff in September, when many employers have said they will end hybrid work arrangements and require full-time attendance.
“I think that’s going to be the big fight,” Ms. Pope said. “A number of employers had September as the target date.”
By contrast, the United Automobile Workers union said it was working with major automakers through a Covid task force to help make safety decisions. General Motors and Ford Motor both recently reinstituted masking for all employees at separate sites in Missouri, and Ford reinstituted masking at offices in Florida, after the companies assessed virus-related data in those regions. And a number of employers, including Amazon and the meat processor JBS, have had vaccination facilities for workers on site.
Some unions may have been spared a fight by the C.D.C.’s move on Tuesday. In Las Vegas, the Culinary Workers Union, which represents casino workers, has been calling for the return of a mask requirement for all customers indoors since Nevada relaxed the requirement in May. The casinos had not heeded the call, but after the C.D.C. announcement, the state said it would reimpose an indoor mask mandate.
In other cases, a reckoning still looms. The federal government’s mask mandate on airplanes is set to expire after Sept. 13, and unions representing airplane personnel are uneasy about the possibility that it will lapse, though Tuesday’s C.D.C. announcement suggests it may be more likely to be extended. The unions have applauded the airlines for moving to stop the spread of the coronavirus on airplanes by installing more sophisticated air filtration systems, but maintain that they are not sufficient.
“Filtration is helpful for circulated air in the cabin,” said Sara Nelson, president of the Association of Flight Attendants. “But it doesn’t stop the general spread from one person to another sitting six inches apart.”
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C.D.C. to Recommend Some Vaccinated People Wear Masks Indoors Again

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Daniel E. SlotnikApoorva Mandavilli and
The Centers for Disease Control and Prevention recommended on Tuesday that people vaccinated against the coronavirus resume wearing masks in schools and in public indoor spaces in parts of the country where the virus is surging, marking a sharp turnabout from their advice just two months ago.
The pandemic in the United States is very different than it was in May, when it seemed as if the worst was in the past. Confirmed cases are surging in parts of the country with low vaccination rates, and there are more reports of breakthrough infections with the highly contagious Delta variant in fully immunized people.
Vaccines are effective against the worst outcomes of infection, even with the variant, and conditions are nowhere near as bad as they were last winter. But the new guidance amounts to a weary acknowledgment that the lagging vaccination effort has fallen behind the ever-evolving virus. Fewer than 50 percent of the country is fully vaccinated, according to federal data.
“This is not a decision we at C.D.C. have made lightly. This weighs heavily on me,” Dr. Rochelle P. Walensky, the agency’s director, said at a news briefing on Tuesday.
transcript
We acted with the data that we had at the time, the data that we had at the time, the country mostly had alpha — alpha among breakthrough vaccinated infections was not being transmitted to other people. The data that we have right now is different. We have a country that is full of Delta. Delta is a more transmissible virus. And the new data that we have is that Delta is able, in those rare breakthrough infections, to be transmitted to others. The most important thing that we need to say right now is we have — a lot of this country that has a lot of viral burden. That’s driven a lot by people who — mostly by people who are unvaccinated. Those are the people that are driving the new infections. But at an individual level, we believe everybody should be wearing a mask in those areas with substantial and high transmission. We are now a country that is the majority of Delta. We know that our young children, 11 and younger, cannot be vaccinated. We know that our vaccinated individuals, in the rare case that there are a breakthrough, have the potential to pass the virus on to unvaccinated individuals. We know that our 12 to 17-year-olds, right now, have only about 30 percent coverage in fully, in being fully vaccinated. And so taking all of that information together, we believe that the C.D.C. — the C.D.C. recommends that K through 12 schools should be opened for full-time in-person learning. But in those indoor settings, everyone should be masked. And I think the most important thing to recognize is most of the transmission across this country is related to people who are unvaccinated. That is where the majority of transmissions are occurring.
Here’s what we know:
The C.D.C. has long recommended that unvaccinated people wear masks indoors. But Tuesday’s regulations mean that even people who have been completely inoculated will once again need to mask up in public indoor spaces in parts of the country where the virus is ascendant.
In schools, health officials now recommended universal masking, regardless of vaccination status and community transmission of the virus, and additional precautions for staff, students and visitors. But they should still plan on returning to in-person learning in the fall.
How this will play out in states that have prohibited mask mandates in schools remains to be seen as well as communities where people may be weary of wearing masks.
The C.D.C. said Americans should resume wearing masks in areas where there are more than 50 new infections per 100,000 residents over the previous seven days, or more than 8 percent of tests are positive for infection over that period. Health officials should reassess these figures weekly and change local restrictions accordingly, the agency said.By those criteria, all residents of Florida, Arkansas and Louisiana, for example, should wear masks indoors. Nearly two-thirds of U.S. counties qualify, many concentrated in the South.
“The Delta variant is showing every day its willingness to outsmart us,” Dr. Walensky said at the news briefing.
Data from several states and other countries show that the variant behaves differently from previous versions of the coronavirus, she added: “This new science is worrisome and unfortunately warrants an update to our recommendation.”
In the past, Dr. Walensky has said the nation is in a “pandemic of the unvaccinated” — a point she reiterated on Tuesday. But she also said that she is concerned that vaccinated people who are in a place with substantial or high transmission could contract a breakthrough infection, and could pass the virus onto unvaccinated family members or those with weakened immune systems and others most at risk.
The C.D.C. is now conducting outbreak investigations in clusters, Dr. Walensky said. Officials are examining the amount of virus in breakthrough infections, which she said is “pretty similar” to the amount of virus in unvaccinated people. With the earlier Alpha variant officials did not believe a vaccinated person could transmit the virus, she said.
“The virus is changing, we are dealing with a dynamic situation,” said Dr. Anthony S. Fauci, the Biden administration’s top pandemic adviser. The C.D.C. is correct to revisit its recommendations as the virus evolves, he said.
“I don’t think you can say that this is just flip-flopping back and forth,” he added. “They’re dealing with new information that the science is providing.”
But that was before the arrival of the Delta variant, which now accounts for the bulk of infections in the United States. C.D.C. officials were persuaded by new scientific evidence showing that even vaccinated people may become infected and may carry the virus in great amounts, Dr. Walensky acknowledged at the news briefing.
But she said masking is only a “temporary measure,” and, adding, “What we really need to do to drive down these transmissions in the areas of high transmission is to get more and more people vaccinated and in the meantime, to use masks.”
When asked whether he thought the C.D.C.’s new mask guideline could lead to some confusion, President Biden said on Tuesday afternoon that the pandemic was continuing “because of the unvaccinated, and they’re sowing enormous confusion.”
“The more we learn, the more we learn about this virus and the Delta variant the more we have to be worried and concerned,” he said. “There’s only one thing we know for sure, if those other hundred million people got vaccinated we’d be in a very different world. So get vaccinated, if you haven’t you’re not nearly as smart as I said you were.”
The C.D.C. should have simply made a universal recommendation and told all Americans to wear masks indoors, said Ali Mokdad, an epidemiologist at University of Washington and former C.D.C. scientist. “The director said the guidance is for people in areas of high transmission, but if you look at the country, every state is seeing a rise in transmission,” Dr. Mokdad said. “So why not say, ‘Everybody in the U.S. should be wearing a mask indoors?’ The whole country is on fire.”
Jesus Jiménez 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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