Trisha Greenhalgh Profile picture
Aug 1, 2024 21 tweets 8 min read Read on X
Thread on our new state of the science review on #LongCovid. Commissioned by @TheLancet, peer-reviewed, coauthored with @sivanmanoj, @calirunnerdoc and Janko Nikolich. Link for free access is here (after 50 days that won’t work, then you’ll have to register and use this one:
1/kwnsfk27.r.eu-west-1.awstrack.me/L0/https:%2F%2…
thelancet.com/journals/lance…
In writing this article, we wanted to get the basic science of Long COVID into dialogue with the clinical management of this condition and the patient lived experience. @calirunnerdoc brought lived experience to our author team. 2/ Image
@calirunnerdoc Most but not all definitions of Long COVID put the cut-off at around 12 weeks (that is, if you’re still symptomatic 12 weeks after your initial COVID-19 infection, you’ve got Long COVID). 3/ Image
A LOT of people meet this definition. In the UK, for example, almost 2% of the entire population do (grey bar to the left on this histogram). Now look at the GREEN bars. The most socio-economically deprived fifth of the population has TWICE the prevalence as the most affluent fifth. Thanks to @chrischirp for drawing this chart from @ONS data. 4/Image
So who’s at risk? Well, all of us. But this graphic summarises the things that make you *more likely* to get Long COVID. In sum: don’t catch COVID-19. Top up your vaccines. If you do catch COVID-19, get it mildly. During acute COVID-19, rest up and if possible, take antivirals. And make sure you don’t catch it *again* since many cases of Long COVID arise from REinfections. (And also, make sure you’re male, previously healthy, and affluent). 5/Image
Long COVID is a multi-system disease and it sometimes seems like it causes every symptom in the book. But (and I learnt this from sitting in on Long COVID clinic heading hundreds of patient stories) there is often a *distinctive narrative* of how these symptoms fit together and fluctuate/persist/progress/resolve over time. 6/Image
The fatigue of Long COVID, for example, is a particular *kind* of fatigue. It’s persistent, draining, sometimes linked to triggers, and associated with sleep problems and cognitive blunting. 7/ Image
Long COVID can make you unable to do your job. Go back to the histogram in tweet 4 of this thread and look at the purple bars. Six percent of people who are “inactive, not looking for work” have Long COVID. This *inability to work* represents a huge human and economic/societal burden. We need to prevent it affecting more people (and help the people already suffering). 8/Image
The longer you’ve had Long COVID, the lower your chances of full recovery. This is why everyone with significant symptoms of this disease should be seen *promptly* for assessment and treatment. 9/ Image
The risk of organ damage is real, and while many people do recover, serious complications can occur even months after the acute infection. (Personally, I think many heart attacks and strokes occurring in people who had COVID-19 are misclassified as ‘unrelated’ to that infection because the doctors treating them aren’t making the connection). 10/Image
Long COVID results from bad stuff occurring at the micro level. The literature on this is vast and confusing. Coauthor Janko Nikolitch cut through it nicely in this panel. Three PRIMARY pathological mechanisms (viral persistence, immune dysregulation, endothelial inflammation/thrombosis). 11/Image
These primary mechanisms then lead to all sorts of *supplementary* mechanisms including (to quote from my forthcoming Substack): release of the neurotransmitter serotonin in the brain, neurones sending signals when they shouldn’t, antibodies attacking one’s own cells, mitochondria (the energy powerhouses of cells) losing their oomph, proteins that come out wonky because they’re not folded right, deposition of some of those proteins in the muscles and other tissues, and awakening of other dormant viruses (notably Epstein-Barr, which causes glandular fever). In addition, the balance between ‘friendly’ and ‘unfriendly’ bacteria in the gut can change, with the latter getting the upper hand. 12/
Unpacking what the *primary mechanisms* are in Long COVID is crucially important for developing *mechanism-focused therapies*. We talk a lot about these in the paper. We’re not there yet with a proven therapeutic intervention but loads of ongoing studies suggest we may be on the cusp of more effective therapies. 13/Image
Generalist primary care clinicians (e.g. GPs) have a vital role to play in the management of this miserable condition. The opposite of gaslighting is engagement, active listening, acknowledging the story, witnessing suffering and getting your head round what’s at stake for the patient. 14/Image
In the paper, we have a huge table listing various symptoms along with current recommended management. Here’s the first two rows of that table. 15/ Image
I had a go at summarising the whole paper in a single graphic. I’m not the world’s best artist so if someone wants to play with this and improve it, feel free! 16/ Image
Do vaccines cause Long COVID? Tweeps, the overwhelmingly most important cause of Long COVID is *catching COVID-19*. Vaccines protect you against this! But to tell it like it is, in VERY RARE instances there appears to be some link between vaccination and the development of Long COVID (we’re talking *many orders of magnitude* less common than after COVID-19 infection). The HOPE is that protein-based vaccines will be less likely to produce these rare complications. 17/Image
Meanwhile, the mainstay of treatment is rehabilitation therapy, particularly PACING. We don’t need any more trials comparing ‘graded exercise therapy’ (GET) to symptom-guided pacing, but we DO need more research on how to optimise the latter. 18/ Image
Thanks for following this thread. Loads more in the paper. The pdf should be up on @TheLancet website soon and I’ll post a link to my lay summary on Substack shortly. 19/
@TheLancet And here’s the lay summary of our #LongCovid paper on @IndependentSage Substack! open.substack.com/pub/independen…
People are asking for a link to the pdf of our Lancet paper on #LongCovid. Here it is
pdf.sciencedirectassets.com/271074/AIP/1-s…

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More from @trishgreenhalgh

May 22, 2024
It’s out! Our new state-of-the-science review of MASKS/RESPIRATORS in reducing transmission of respiratory infections. 13 authors (for our disciplines, see posts 3-4). 38000 words. 413 references. One conclusion: these devices work. For detail, read on. 1/
journals.asm.org/doi/10.1128/cm…
The commissioned review, which was independently peer-reviewed, had 3 objectives: 1. Summarize the evidence on masks/masking. 2. Examine why this evidence is so widely misunderstood, misinterpreted, or dismissed. 3. Outline an agenda for future research. 2/
Author team was chosen for breadth of expertise, including: public health, epidemiology, infectious diseases, biosecurity, fluid dynamics, materials science, mathematical modeling, data science, clinical trials, sociology, anthropology, psychology, and occupational hygiene. 3/
Read 48 tweets
Mar 18, 2024
BREAKING
The senior officers of the Royal College of Physicians commissioned a survey of MRCPs’ views on physician associates (PAs). They have today released the actual findings, but the back story is shocking. I’ll link to the raw data at the end of this 🧵.
1/
We now know that senior officers presented a flawed and distorted version of the findings at the Extraordinary General Meeting on 13th March 2024. Here’s my thread on that presentation (from before I’d seen the actual results).
2/
Of note is that after an outcry, the senior officer who presented the slides at the EGM resigned. He can tell his own story there. I am hearing he did not make the slides but was told he had to present them.
3/
Read 25 tweets
Mar 14, 2024
At yesterday’s #RCPEGM, a senior officer presented the results of a survey of MRCPs on their views about Physician Associates (PAs). They unwittingly supplied some good teaching material about how NOT to go about doing a questionnaire survey and how NOT to report the results. title slide 'RCP membership survey'
Here’s the first slide after the title slide. What do you notice? They jump straight into “methodology”. Students, don’t do this! Start with a RESEARCH QUESTION!! You must be clear what EXACTLY you want to find out, and from whom. Ideally, state some HYPOTHESES. "methodology" slide lacking research q
Here's the six questions that were sent out to MRCPs. Notice how the choice of words narrows the issue being explored. No Qs are asked about primary care (where PAs are seeing undifferentiated patients), yet RCP seeks to certify PAs for working in primary care. Six questions 1. How do you feel about physician associates being part of the MDT? 2. In secondary care, do you feel that you, or doctors you work with, are appropriately supervised and supported? 3. In secondary care, in your opinion, do you think physician associates are appropriately supervised and supported? 4. Does having a physician associate on your team impact on training opportunities for you? 5. Does working with a physician associate impact on training opportunities for doctor colleagues in your team? 6. Within your MDT, how well understood is the term ‘physician associate’?
Read 11 tweets
Dec 29, 2023
Our new paper:
‘Training needs for staff providing remote services in general practice: a mixed-methods study’, out today in @BJGPjournal
🧵 1/

bjgp.org/content/74/738…
Around one in 4 consultations in general practice occurs remotely (usually by telephone but sometimes as video or asynchronous e-consultation). Appointment booking and triage usually occur remotely too.
2/
Since the pandemic began, UK policy (especially English policy) has swung from ‘remote by default’ to ‘everyone has a right to a face to face consultation’. GP land is busy, has major workforce issues (esp not enough doctors) and is creaking under the strain of task-shifting.
3/
Read 23 tweets
Nov 29, 2023
Our paper on safety in remote GP consultations is getting a lot of coverage. Shout out to @oohGPwales who was lead author and analysed the 95 tragic safety incidents.
1/ 🧵
But NOTE: this paper is MAINLY about how remote care in GP land is remarkably SAFE. We followed 12 GP practices for 2y, looking for (among other things) evidence of patient harm from remote consultations. We found NONE.
2/
Staff in these 12 GP practices took a lot of measures to make sure that safety incidents didn’t happen. They often told patients “sorry you can’t have a phone consultation for that problem, you need to come and be examined”.
3/
Read 12 tweets
Aug 6, 2023
At @IndependentSage we've made a series of short MYTHBUSTER videos to address misconceptions about covid-19.

I'll thread them here. Some are still to come - will add as they come out.

Please disseminate, especially to people who might be confused about these issues.

0/
Myth-buster 1: Is there a point to vaccines if we can still get infected?


1/
Myth-buster 2: Is "natural" immunity better than vaccine immunity?


2/
Read 9 tweets

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