Long Covid webinar from HCA Healthcare UK

May 15, 2021

Source: Hannah Davis @ahandvanish (@itsbodypolitic, @patientled)

There are a lot of #LongCOVID gems in this webinar from HCA Healthcare UK. I’m going to try to tweet them succinctly:

1. Non-hospitalized COVID patients had a slower recovery than hospitalized patients.

2. At 12 months out, the majority of non-hospitalized #LongCOVID patients are still not back to work full time.


Next speaker is a cardiologist.

3. Cardiac MRIs are helpful. Even when they look normal from a functioning standpoint, supepicardial late gadolinium enhancement can be identified, showing post-viral myocarditis. (Screenshotted case was in a patient 200+ days out from onset).

4. The case above had normal X-ray and normal echo. Treatment here included colchicine (3 month course) and ivabradine. Some fatigue and brain fog improved!

#LongCOVID

5. A list of blood tests and cardiac imaging to do in #LongCOVID patients (though all of these can come back normal as well).

6. More treatment options for non-hospitalized patients with cardiovascular complications:

7. In summary, “cardiac MRIs are what I’ve found most helpful”. #LongCOVID

8. He has seen patients with these same cardiac symptoms after the vaccine. He expected that they’d had COVID and not known, but 5 of the patients had never had COVID.


Next up is a neurologist.

9. Endotheliitis of the brain vessels is possible, a likely cause of neurologic sequelae, though there may other be factors.

10. Here are a list of warning signs in headaches to look out for. I particularly find the pulsatile tinnitus symptom interesting since that’s a common symptom (he mentions it as a sign of intracranial pressure).

11. #LongCOVID migraine management (~46:30) – some of these are contraindicated with cardio symptoms:

12. He mentions there are 3 types of #LongCOVID dizziness which can be identified.

He also mentions that patients with brain fog need to do cognitive pacing!


Next up: hematological complications of #LongCOVID:

13. About 40% of non-hospitalized patients with mild symptoms have elevated D-Dimer:

14. There are obvious T-cell differences in patients with #LongCOVID (these are all mild, non-hospitalized patients), particularly having low CD4+ effector memory cells:


Next up is a talk on treatment strategies, though he starts by saying there are very few.

15. Four key barriers to recovery include 1) poor gut health, 2) overexertion, 3) overworking, and 4) sleep disruption.

From what he sees, patients with any of these don’t recover quickly.

16. Ear/Nose/Throat deserves a specific mention. Speech & language, vocal therapy are important. Autonomic function testing is important. Respiratory therapy for those with breathing issues. Some need GI imaging. Some do develop autoimmune issues, even a year later. #LongCOVID

17. Interestingly, he mentions that of patients who have PTSD, they have “health-related/long combat PTSD”, which does NOT get treated with CBT or other forms of psychotherapy. #LongCOVID

18. He recommends probiotics like Symprove (side note – I strongly agree with this provided it’s a good probiotic like Align or ABX Support). #LongCOVID

19. “The strategy of physical and psychological therapy does not work for these patients.” #LongCOVID

20. Addressing sleep is crucial (I also agree with this – take meds until you can sleep on your own again.) “If patients do not sleep, they do not recover. (side note – this might be related to the brain’s glymphatic drainage symptom, which happens most during sleep!)

#LongCovid

21. Specific suggestions for dysfunctional breathing and dysautonomia. “Dysautonomia (esp POTS) is a common component of #LongCOVID, and it’s particularly severe in younger patients.”

22. Treating patients with a combination of H1 and H2 antihistamines helps many symptoms!

23. Here’s a chart on Loratidine/Feofenadine plus Famotidine (Pepcid). (I’ve written about it elsewhere, but Pepcid has also been shown to alleviate even some breathing and neurological symptoms).

These are safe, well-tolerated treatments.

24: A chart showing a wide range of symptoms, including neurological and respiratory symptoms, responding to anti-histamine treatments:

(side note – some patients with SIBO, dysbiosis, or other GI issues should be careful/take good probiotics alongside this). #LongCOVID

25. He reports that patients see an improvement between 1-12 weeks after starting this regiment. This implies the pathophysiology is more complicated than just histamine, because histamine responses are over the course of hours, not weeks. #LongCOVID

26. About 70% of people who menstruate have worsening symptoms leading up to menstruation #LongCovid

Cycle regulation drugs or HRT can alleviate symptoms:

27. “Microvascular clotting is a feature of #LongCOVID.”

Patients have headaches, poor exercise tolerance, extreme lethargy. Elevated VWF in many of these patients.

28. He did a test which essentially subjected their blood to shear stress. 29% clotted within 5 minutes 🤯

Low dose aspirin significantly reduces this. #LongCOVID

29. Jury is out on ivermectin, but it might work, should be considered in a clinical trial. Main problem is that major regulators have stated ivermectin should not be used outside of clinical trials. #LongCOVID

30. On vaccines – “we’ve all heard anecdotes that #LongCOVID patients get better after vaccination – my experience is that those patients are few and far between. In fact, most patients seem to get worse after the vaccine – usually transiently so, but sometimes not.”

31.

3 anecdotal treatments that might help #LongCOVID in some cases:

1. Fluvoxamine
2. Statins
3. Anti-coagulants

Next up is a 20 min Q&A

32.
Q: When patients prevent with migraine headaches, what imaging is more helpful, CT or MRI?

A: MRI, if possible, though we don’t know mechanisms of the brain disease, but MRI may show more subtleties. #LongCOVID

33.
Q: Could there be a post-viral imbalance between the sympathetic and parasympthetic nervous system and perturbed hypothalamic pituitary axis?

A: Yes, we’re hearing about vagal nerve disturbance, esp tachycardias, the POTS

34.
A continued: Some autopsy studies have showed virus in the brainstem (cc @microbeminded2). So I think the answer is yes, there is some data supporting that.

Different doctor: this is akin to a vagal neuropathy with sympathetic hyperactivity

(https://twitter.com/ahandvanish/status/1391488899365670912)

35. continued: causing POTS, sleep dysfunction. Blocking sympathetic responses can help.

⭐️Important: the one symptom that was *not affected* by antihistamine treatment is dysautonomia.⭐️ #LongCOVID

“There was absolutely no effect in any patient on dysautonomia symptoms.”

36. Q: what doses of H1 and H2 antihistamines are used? #LongCOVID

A: “I start patients with over the counter loratadine, 10mg 2x daily, in combination with famotidine, 40mg, at night. I assess patients every 2 weeks – if they don’t respond, I change Loratidine to Fexofenadine +

37 cont’d: sometimes increase dose of famotidine for a period of time. In patients who respond and then stagnate, I consider the introduction of ketotifen at night, which is sedating (good for sleep dysfunction patients) and is also considered a mast cell stabilizer.” #LongCOVID

38: cont’d “In some patients with mild gut symptoms, can consider sodium cromoglicate; in patients with airway symptoms you can consider montelukast.” #LongCOVID

39. Q: Does oxygen desaturation on exercise help distinguish between cardiac & respiratory causes?

A: Yes, bc cardiac causes of breathlessness *do not* lead to oxygen desaturation, implies respiratory causes. He does recommend a physiological stress echo if no resp issues found.

40. The above answer got cut off so may want to listen, around 1:49:00.

41. Q: Cardiac MRIs are often not available; what other options?

A: Pericarditis can sometimes be diagnosed with ECG or echo, but these tests are often normal, it requires specialist review as well. Natriuretic peptide tests help, are usually but not always elevated. #LongCOVID

42.
Q: Have a patient with high D-Dimer, discharged from ER, LC clinic appnt is 6 months away. What to do?

A: Hard decision, some options include risk-assessed prophylaxis, referral to thrombosis specialist

43. One more answer: there’s no real risk to offer patients antihistamine regime.

44. Back to the oxygen desaturation: we see this often, patients with normal cardiac/respiratory tests but low oxygen saturation. It seems reasonable to assume microvascular disease is responsible, in which cases low dose aspirin or anticoagulation seems reasonable #LongCOVID

45. Q: What’s causing adverse vaccine reactions in #LongCOVID patients?

A: Probably abnormal immune reaction. Probably *not* the antibody response to spike protein, since we would’ve seen this happen when people make antibodies naturally.

46. That concludes the webinar! Hope this was helpful for the #LongCOVID community. ❤️

For #17, I meant to say “should not” get treated with CBT – it requires a different type of treatment.

Originally tweeted by Hannah Davis 🦈 (@ahandvanish) on 21/05/2021.

A cry for the invisible country

.

noche negra toqu de queda

“Enjoy your time in Nicaragua”.

“Honduras, but thanks anyway” I corrected him. My acquaintance couldn’t even recall what country I was talking about just a few minutes ago. At that time I wasn’t aware yet that this perhaps wasn’t an accidental slip of the tongue, but in fact characteristic for our unfamiliarity with Honduras. Back in 2011 I went there to investigate theater organizations and the cultural infrastructure of the country. Since I lived in Mexico City for more than 3 years, when organized crime proliferated after a governmental change, experiencing the tough side of society from nearby, for me that was still a very manageable situation. Thus, Latin American street-wise, I considered myself well prepared for this interesting assignment in Honduras.

Once there, first thing I did was trying to understand more of the context I was going to work in and get my network involved by writing a blog. This unexpectedly became my first personal experience with restricted freedom of speech. We, from countries that take democracy for granted and tend to confuse freedom of speech with being rude, are not used to think twice about what to publish. So I wrote about how the country still hadn’t overcome the devastation caused by Hurricane Mitch in 1998, how the 2009 coup d’etat worsened the situation, and how I admired the people who I was going to work with because of their limitless efforts to educate and cheer up the people with theater.

Not much later I was called by a high official ranting to me for about 40 minutes that a coup was never proved, that I was defaming the country with these lies, that it was dangerous to write something like that. “You know, I don’t want to see you leave the country in a coffin, and by the way, your visa is not valid long enough, I must warn you that Honduran prisons aren’t very comfortable either. Oh, by the way, that time I had to search for those Dutch journalists and that couple, the state I found them in… that was dirty, you don’t want to know, it was such a hassle to bring their bodies back to the Netherlands. So that blog of yours, you can choose, delete it, or leave the country between 6 planks. It’s up to you of course.”

Well ..

I deleted the blog because I couldn’t oversee how it would affect me and the people I worked with. During my stay I learned more about local politics and interviewed someone who researched the ties between the government and organized crime. The names he mentioned now show up in the articles of for example BBC Mundo, names of close relatives of the current and previous president. Organized crime is deeply infiltrated in the government and governmental bodies like the police. Honduras is a free zone for organized crime, facilitating the drug production chain of the region, involving the many local organized gangs as their operators.

I’m sorry to say that the country has by far the highest murder rate of the world, a disturbing femicide rate and impunity of 95%, and has the most inequality of Latin America. I can wander off and go in detail about these problems, but Honduras is much more than crime. People like you and me try to live there and move forward. I know brave and well educated people investing their lives in contributing to a healthier future for the country. They are my friends and deserve to be seen, like the majority of the people who just want to live a humble life in peace in a country with so much beauty.

noche negra Choloma

Why this article, why now? At this moment Honduras needs attention for the huge irregularities in the latest elections that lead the country more and more into a dictatorship. Now martial law is imposed. From a reliable source I receive messages like:

Latest: The constitutional guarantees are suspended from 10 o’clock on Friday night, due to the looting of shops and supermarkets and the demonstrations that are taking place all over the country … It is getting ugly, hopefully nothing bad happens. God take care of us all and Honduras.

I GOT THIS NOTICE. Regulation of the Ministry of the Interior. Starting tomorrow, there are new rules of communication. All calls are recorded. All records of telephone calls are recorded. WhatsApp is monitored. Twitter is monitored, Facebook is monitored. All social media and forums are monitored. Inform those who do not know. Your devices are connected to departmental systems. Be careful not to send unnecessary messages. Avoid saying anything with friends or family. Tell your children and be careful. It is important to convey the message because there is another form of surveillance in the country. Incredible but true. Please transmit as I did to your loved ones. IT IS SUGGESTED TO ERASE ALL PHOTOS AND VIDEO MESSAGES FROM YOUR CELL PHONES DAILY. DO NOT MENTION NAMES AND SURNAMES AND ADDRESSES OF YOUR CONTACTS AND FAMILIES THROUGH MESSAGES .

These messages go with tanks driving in the streets. The images of tanks are not unfamiliar to my Honduran friends. During the 2009 coup, when communication was shut off, street lighting switched off, helicopters in the air, they saw those tanks in their streets too.

To help you understand the news (if any) you’ll see, I’ll stick to an overview of some facts. Since 1982, after democracy just returned to the country, the constitution prohibits reelection of the president. The coup in 2009 was to prevent a referendum about a change in the constitution in favor of a 2nd term presidency. Coup organizers were using the argument that then president Manuel Zelaya of the liberal party was seeking dictatorship. The people involved in the coup, the National Party and the country’s elite, took power since then.

One of the key figures of the coup, Juan Orlando Hernández, is the current president. During his term he replaced 4 magistrates of the supreme court of justice who are against reelection of the president. Then the court decreed the constitution unconstitutional… uhm yes, paving the way to reelection. With these actions in mind of course one could question credibility of the president with regard to democracy. And against this background the elections of last week took place.

I cite from the declaration of Honduran intellectuals and artists(2):

From the very moment that a politicized Supreme Court of Justice authorized the unconstitutional re-election of the person who currently holds the Presidency of the Republic, we knew that we were facing a process marked by illegality. However, when the options were closed, the Honduran people decided to participate. The preliminary results show a marked decrease in the high degree of abstention that characterized the two previous electoral processes.

With the motivation to bring change to the country by the ballot the election attendance was much higher than previous times. From my friends I heard about irregularities at the ballot box. Now the opposition, directed by Salvador Nasralla of the Anti-Corruption Party, as well as the current president claim victory. Despite or probably due to the disputable decree of the supreme court, for the opposition reelection of Orlando Hernández is considered unconstitutional, which is understandable.

The riots of the last few days are not just protests about disagreement with the results of the elections. Given the context of power being in the hands of an undemocratic and organized crime related elite, Honduras is undergoing a next step towards dictatorship. And that fact deserves much more attention than it gets now.

Even when you don’t care about the Honduran people, people like you and me, living so far away from your own comfortable bed, be aware that a country so corrupt and heavily involved in organized crime destabilizes the region, which in turn affects global stability. So, please become aware and please share this message.

Thanks for reading.

Marie-Thérèse Woltering

Rotterdam, 2nd of December 2017

More info:

Latest footage on Youtube: Noche Negra Honduras

Sources (Spanish translates pretty well to English in Google Translate):

  1. BBC Mundo: http://www.bbc.com/mundo/noticias-america-latina-42079038, and more recent articles.
  2. Manifesto of Honduran intellectuals and artists http://79.170.44.136/elzanganotuerto.hn/manifiesto-de-los-intelectuales-y-artistas-de-honduras-sobre-la-situacion-politica-de-los-comicios-electorales-2017/
  3. https://www.hrw.org/world-report/2017/country-chapters/honduras
  4. http://abcnews.go.com/International/men-women-honduras-inside-dangerous-places-earth-woman/story?id=47135328