For refrigerators across America, the passing of Thanksgiving promises a major purge. The good stuff is the first to go: the mashed potatoes, the buttery remains of stuffing, breakfast-worthy cold pie. But what’s that in the distance, huddled gloomily behind the leftovers? There lie the marginalized relics of pre-Thanksgiving grocery runs. Heavy cream, a few days past its sell-by date. A desolate bag of spinach whose label says it went bad on Sunday. Bread so hard you wonder if it’s from last Thanksgiving. The alimentarily unthinking, myself included, tend to move right past expiration dates. Last week, I considered the contents of a petite container in the bowels of my fridge that had transcended its best-by date by six weeks. Did I dare eat a peach yogurt? I sure did, and it was great. In most households, old items don’t stand a chance. It makes sense for people to be wary of expired food, which can occasionally be vile and incite a frenzied dash to the toilet, but food scientists have been telling us for years—if not decades—that expiration dates are mostly useless when it comes to food safety. Indeed, an enormous portion of what we deem trash is perfectly fine to eat: The food-waste nonprofit ReFED estimated that 305 million pounds of food would be needlessly discarded this Thanksgiving. Expiration dates, it seems, are hard to quit. But if there were ever a moment to wean ourselves off the habit of throwing out “expired” but perfectly fine items because of excessive caution, it is now. Food waste has long been a huge climate issue—rotting food’s annual emissions in the U.S. approximate that of 42 coal-fired power plants—and with inflation’s brutal toll on grocery bills, it’s also a problem for your wallet. People throw away roughly $1,300 a year in wasted food, Zach Conrad, an assistant professor of food systems at William and Mary, told me. In this economy? The only things we should be tossing are expiration dates themselves. Expiration dates, part of a sprawling family of labels that includes the easily confused siblings “best before,” “sell by,” and “best if used by,” have long muddled our conception of what is edible. They do so by insinuating that food has a definitive point of no return, past which it is dead, kaput, expired—and you might be, too, if you dare eat it. If only food were as simple as that. The problem is that most expiration dates convey only information about an item’s quality. With the exception of infant formula, where they really do refer to expiration, dates generally represent a manufacturer’s best estimate of how long food is optimally fresh and tasty, though what this actually means varies widely, not least because there is no federal oversight over labeling. Milk in Idaho, for example, can be “sold by” grocery stores more than 10 days later than in neighboring Montana, though the interim makes no difference in terms of quality. Some states, such as New York and Tennessee, don’t require labels at all. Date labels have been this haphazard since they arose in the 1970s. At the time, most Americans had begun to rely on grocery stores to get their food—and on manufacturers to know about its freshness. Now “the large majority of consumers think that these [labels] are related to safety,” Emily Broad Leib, a Harvard Law Professor and the founding director of its Food Law and Policy Clinic, told me. A study she co-authored in 2019 found that 84 percent of Americans at least occasionally throw out food close to the date listed on the package. But quality and safety are two very different things. Plenty of products can be edible, if not tasty, long past their expiration date. Safety, to food experts, refers to an item’s ability to cause the kind of food poisoning that sends people to the hospital. It’s “no joke,” Roni Neff, a food-waste expert at Johns Hopkins University, told me. Consider milk, which is among the most-wasted foods in the world. Milk that has already soured or curdled can—get this—still be perfectly safe to consume. (In fact, it makes for fluffy pancakes and biscuits and … skin-softening face masks.) “If you take a sip of that milk, you’re not going to end up with a foodborne illness,” Broad Leib said, adding that milk is one of the safest foods on the market because pasteurization kills all of the germs. Her rule of thumb for other refrigerated items is that anything destined for the stove or oven is safe past its expiration date, so long as it doesn’t smell or look odd. In industry speak, cooking is a “kill step”—one that destroys harmful interlopers--if done correctly. And then there is the pantry, an Eden of forever-stable food. Generally, dry goods never become unsafe, even if their flavor dulls. “You’re not taking your life into your hands if you’re eating a stale cracker or cereal,” said Broad Leib. Of course it would just be easier if labels were geared toward safety, but for the majority of food, the factors are too complex to sum up in a single date. Food is considered unsafe if it carries pathogens such as listeria, E. coli, or salmonella that can cause foodborne illness. These sneak into food through contamination, like when E. coli–tainted water is used to grow romaine lettuce. Proper storage, which means temperatures colder than 40 degrees Fahrenheit or hotter than 140 degrees Fahrenheit, inhibits their growth (except for listeria, which is particularly scary because it can thrive during refrigeration). It would be extremely difficult for a label to reflect all of this information, especially given that unsafe storage and contamination tend to occur after purchase, in hot car trunks and on unsanitized countertops. But as long as food doesn’t carry these germs to begin with, pathogens won’t suddenly appear the moment the clock strikes midnight on the expiration date. “They’re not spontaneous. Your crackers aren’t, like, contracting salmonella from the shelf,” said Broad Leib. There is, however, one category of food that should be labeled. Sometimes referred to as “foods pregnant women should avoid,” it includes certain ready-to-eat products such as deli meats, raw fish, sprouted vegetables, and unpasteurized milk and cheese, Brian Roe, a professor at Ohio State University’s Food Innovation Center, told me. These require extra caution because they can carry listeria, which is invisible to the senses, and are usually served cold—that is, they don’t go through a kill step before serving. Experts I spoke with agreed that high-risk foods should be identified as such, because there’s no way to tell if they’ve become unsafe. As things stand, the date label is the only information available, and it is “not helping people protect themselves from that handful of foods,” said Broad Leib. To overcome this setback, efforts are under way in the Senate and the House to replace all date labels with two phrases: best if used by to denote quality and use by for safety. But it’s one thing to know expiration dates are bogus and another to live accordingly. In America, dates have become a tradition we can’t escape, Neff said, adding that the stickler of each household usually gets to set the rules. And even for more adventurous eaters, date labels serve a purpose: They’re a tool for calibrating judgment, or merely for providing the comfort of a reference point. “There’s something about seeing a number there that we think tells us something that gives us a sense of security,” Neff said. Manufacturers, meanwhile, maintain date labels because they don’t want to risk consumers buying products past their prime, even if they are safe and still (mostly) tasty. Although there’s no perfect way to know whether food is safe or not, there are better ways than expiration dates to tell. The adage “When in doubt, throw it out” doesn’t cut it anymore, said Neff; if you’re not sure, just look it up. Good tools are available online: She recommends FoodKeeper, an app developed by the U.S. Department of Agriculture, which lets users look up roughly how long food lasts. The Waste-Free Kitchen Handbook, by the food-waste pioneer Dana Gunders, gives detailed practical advice, such as scraping a half-inch below blue-green mold on hard cheese to safely recover the rest. Leftovers require slightly more caution, noted Broad Leib, because reheating, transferring between containers, and frequent touching with utensils (which, admit it, have been in your mouth) introduces more risk for contamination; her recommendation is to eat them within three to five days, and reheat them well—to a pathogen-killing internal temperature of 165 degrees Fahrenheit. And if doing so proves tedious, consider Roe’s take on the old saying: “When in doubt, cover it with panko, fry it up, and give it to your kids.” Yet for most foods, one tactic reigns supreme: the smell test. Your senses can give you most of the information you need. “If something smells off, you know,” said Broad Leib. Humans evolved disgust because it taught us to avoid the stench of pathogen-tainted food. But because most people are out of practice, they struggle to tell good from bad or don’t trust their senses. To be fair, it can be hard to discern whether weird smells are coming from the milk or the carton. To restore the food knowledge that has been lost since Americans shifted away from agriculture, all of the experts I spoke with supported the revival of home-economics classes—albeit with different branding and less sexism. Teaching students how to handle perishable food means teaching them what perished looks and smells like. Adults can learn this at home, of course, by opening that milk carton and daring to sniff deeply. It may be the first sniff of the rest of your life. It’s unlikely that we’ll ever return en masse to the pre-1970s idyll of purchasing food directly from farmers or growing it ourselves. Americans are “several generations removed now from agriculture and food production, so we don’t know our food as well as they once did,” Jackie Suggitt, the director of capital, innovation, and engagement at ReFED, told me. A smell rebellion, if you will, can’t restore our severed relationship with food, but hey, it’s a start. The lonely items lingering in one’s post-Thanksgiving fridge may be one inhale away from renewed relevance. If I deigned to sniff that “expired” heavy cream, I might be delighted to encounter a future garnish for pumpkin pie. And what is wilted spinach anyway but a can of artichokes away from dip? from https://ift.tt/F6aUjEB Check out http://natthash.tumblr.com
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The World Health Organization has recommended a new name for monkeypox, asking countries to forget the original term in favor of a new one, “mpox,” that scientists hope will help destigmatize the disease. But in the United States, the request seems to be arriving late. The outbreak here has already been in slow retreat for months—and has already left many Americans’ minds. About 15 cases are now being recorded among Americans each day, less than 4 percent of the tally when the surge was at its worst. After a sluggish and bungled early rollout, tests and treatments for the virus are more available; more than a million doses of the two-shot Jynneos smallpox vaccine have found their way into arms. San Francisco and New York—two of the nation’s first cities to declare mpox a public-health emergency this past summer—have since allowed those orders to expire; so have the states of New York and Illinois. “I think this is the endgame,” says Caitlin Rivers, an infectious-disease epidemiologist at the Johns Hopkins Center for Health Security. But “endgame” doesn’t mean “over”—and mpox will be with us for the foreseeable future. The U.S. outbreak is only now showing us its long and ugly tail: 15 daily cases is not zero daily cases; even as the number of new infections declines, inequities are growing. Black and Latino people make up a majority of new mpox cases and are contracting the disease at three to five times the rate of white Americans, but they have received proportionately fewer vaccines. “Now it’s truly the folks who are the most marginalized that we’re seeing,” says Ofole Mgbako, a physician and population-health researcher at New York University. “Which is also why, of course, it’s fallen out of the news.” If the virus sticks around (as it very likely could), and if the disparities persist (as they almost certainly will), then mpox could end up saddling thousands of vulnerable Americans each year with yet another debilitating, stigmatized, and neglected disease. [Read: America should have been able to handle monkeypox] At this point, there’s not even any guarantee that this case downturn will persist. “I’m not convinced that we’re out of the woods,” says Sara Bares, an infectious-disease physician at the University of Nebraska Medical Center, in Omaha. Immunity, acquired through infection or vaccines, is now concentrated among those at highest risk, says Jay Varma, a physician and epidemiologist at Weill Cornell Medicine. But researchers still don’t know how well those defenses can stave off another infection, or how long they might last—gaps in knowledge that may be tough to fill, now that incidence is so low. And although months of advocacy and outreach from the LGBTQ community have cut down on risky sexual activities, many cautionary trends will eventually reset to their pre-outbreak norm. “We know extensively from other sexually transmissible infections that behavior change is not usually the most sustained response,” says Boghuma Kabisen Titanji, an infectious-disease physician at Emory University. At the same time, this year’s mpox outbreaks are stranger and more unwieldy than those that came before. A ballooning body of evidence suggests that people can become infectious before they develop symptoms, contrary to prior understanding; some physicians are concerned that patients, especially those who are immunocompromised, might remain infectious after the brunt of visible illness resolves, says Philip Ponce, an infectious-disease physician at the University of Texas Health Science Center at San Antonio and the medical director of San Antonio’s Kind Clinic. (Some 40 percent of Americans who have been diagnosed with mpox are living with HIV.) Researchers still don’t have a good grip on which bodily fluids and types of contact may be riskiest over the trajectory of a sickness. Cases are still being missed by primary-care providers who remain unfamiliar with the ins and outs of diagnosis and testing, especially in people with darker skin. And although this epidemic has, for the most part, continued to affect men who have sex with men, women and nonbinary people are getting sick as well, to an underappreciated degree. [Read: What should worry most Americans about our monkeypox response] Intel on the only mpox-fighting antiviral on the shelf, a smallpox drug called tecovirimat, also remains concerningly scant, even as experts worry that the virus could develop resistance. The treatment has been given a conditional greenlight for use in people who are currently, or at risk of becoming, severely sick. Anecdotally, it seems to work wonders, shaving days or weeks off the painful, debilitating course of symptoms that can send infected people into long-term isolation. But experts still lack rigorous data in humans to confirm just how well it works, Bares, who’s among the scientists involved in a nationwide study of the antiviral, told me. And although clinical trials for tecovirimat are under way, she added, in the U.S., they’re “struggling to enroll patients” now that infections have plummeted to such a sustained low. It’s a numerical problem as well as a sociocultural one. “The urgency with which people answer questions declines as case counts go down,” Varma told me. Recent CDC reports show that a growing proportion of new infections aren’t being reported with a known sexual-contact history, stymieing efforts at contact tracing. That might in part be a product of the outbreak’s gradual migration from liberal, well-off urban centers, hit early on in the epidemic, to more communities in the South and Southwest. “In small towns, the risk of disclosure is high,” Bares told me. In seeking care or vaccination, “you’re outing yourself.” When mpox cases in Nebraska took an unexpected nosedive earlier this fall, “a colleague and I asked one another, ‘Do you think patients are afraid to come in?’” Those concerns can be especially high in certain communities of color, Ponce told me. San Antonio’s Latino population, for instance, “tends to be much more conservative; there’s much more stigma associated with one being LGBT at all, let alone being LGBT and trying to access biomedical interventions.” Hidden infections can become fast-spreading ones. Monitoring an infectious disease is far easier when the people most at risk have insurance coverage and access to savvy clinicians, and when they are inclined to trust public-health institutions. “That’s predominantly white people,” says Ace Robinson, the CEO of the Pierce County AIDS Foundation, in Washington. Now that the mpox outbreak is moving out of that population into less privileged ones, Robinson fears “a massive undercount” of cases. Americans who are catching the virus during the outbreak’s denouement are paying a price. The means to fight mpox are likely to dwindle, even as the virus entrenches itself in the population most in need of those tools. One concern remains the country’s vaccination strategy, which underwent a mid-outbreak shift: To address limited shot supply, the FDA authorized a new dosing method with limited evidence behind it—a decision that primarily affected people near the back of the inoculation line. The method is safe but tricky to administer, and it can have tough side effects: Some of Titanji’s patients have experienced swelling near their injection site that lasted for weeks after their first dose, and now “they just don’t want to get another shot.” The continued shift of mpox into minority populations, Robinson told me, is also further sapping public attention: “As long as this is centered in BIPOC communities, there’s going to be less of a push.” Public interest in this crisis was modest even at its highest point, says Steven Klemow, an infectious-disease physician at Methodist Dallas Medical Center and the medical director of Dallas’s Kind Clinic. Now experts are watching that cycle of neglect reinforce itself as the outbreak continues to affect and compress into marginalized communities, including those that have for decades borne a disproportionate share of the burden of sexually associated infections such as syphilis, gonorrhea, and HIV. “These are not the groups that necessarily get people jumping on their feet,” Titanji told me. Some of the people most at risk are moving on as well, Robinson told me. In his community in Washington, he was disappointed to see high rates of vaccine refusal at two recent outreach events serving the region’s Black and American Indian populations. “They had no knowledge of the virus,” he told me. Titanji has seen similar trends in her community in Georgia. “There’s some sense of complacency, like, ‘It’s no longer an issue, so why do I need to get vaccinated?’” she said. [Read: America is zooming through the pandemic panic-neglect cycle] The tide seems unlikely to shift. Even tens of thousands of cases deep into the American outbreak, sexual-health clinics—which have been on the front lines of the mpox response—remain short on funds and staff. Although the influx of cases has slowed, Ponce and Klemow are still treating multiple mpox patients a week while trying to keep up the services they typically offer—at a time when STI rates are on a years-long rise. “We’re really assuming that this is going to become another sexually associated disease that is going to be a part of our wheelhouse that we’ll have to manage for the indefinite future,” Klemow told me. “We’ve had to pull resources away from our other services that we provide.” The problem could yet worsen if the national emergency declared in August is allowed to expire, which would likely curb the availability of antivirals and vaccines. Rivers still holds out hope for eliminating mpox in the U.S. But getting from low to zero isn’t as easy as it might seem. This current stretch of decline could unspool for years, even decades, especially if the virus finds a new animal host. “We’ve seen this story play out so many times before,” Varma told me. Efforts to eliminate syphilis from the U.S. in the late ’90s and early 2000s, for instance, gained traction for a while—then petered out during what could have been their final stretch. It’s the classic boom-bust cycle to which the country is so prone: As case rates fall, so does interest in pushing them further down. Our memories of public-health crises never seem to linger for long. At the start of this mpox outbreak, Titanji told me, there was an opportunity to shore up our systems and buffer ourselves against future epidemics, both imported and homegrown. The country squandered it and failed to send aid abroad. If another surge of mpox cases arrives, as it very likely could, she said, “we will again be going back to the drawing board.” from https://ift.tt/2lxgRd5 Check out http://natthash.tumblr.com A canker sore—a painful white ulcer inside the mouth—might be brought on by stress. Or the wrong toothpaste. Or certain foods: tomatoes, peanuts, cinnamon. Or an iron deficiency. Or an allergy. Or a new prescription. Or an underlying autoimmune disease. Even though millions of people suffer from them every year, researchers still don’t know much about what fundamentally causes these sores. This leaves doctors and dentists stuck playing detective with their patients—running down a checklist, trying to figure out which of more than a dozen potential triggers could’ve set off the gnarly little lesions. That list is long and spans different specialties in medicine. It includes trauma to the mouth, stress, diet, genetics, hormones, allergies, vitamin deficiencies, autoimmune diseases, and gastrointestinal diseases. Diana V. Messadi, a professor at the UCLA School of Dentistry, told me that canker sores are multifactorial, which makes them hard to study. Cold sores, by comparison, offer a much tidier story: They’re viral infections (herpes simplex) and thus are treatable with antivirals. (Cold sores are pimplelike blisters that usually form around the lips, whereas canker sores are white ulcers that occur inside the mouth.) [Read: The overblown stigma of genital herpes] Canker sores can be loosely sorted into two buckets. In Bucket A are the smaller, more common sores, the kind a person might get two or three times a year. These sores are bright, nagging, and painful, and they make eating and talking difficult. They usually aren’t life-threatening. In Bucket B are larger cankers, usually more than a centimeter wide. (Technically, a third bucket exists that includes herpetiform, or clustered, sores—but this type is rare.) Big or small, some sores are linked to an underlying disease, like Crohn’s, Behçet’s, HIV/AIDS, or celiac disease. In a way, these cases are better understood: The sores are a secondary effect of something else going on in the body—something a doctor can test for and identify. The human mouth is a weird place. Canker sores occur in what’s called the oral mucosa, which is doctor-speak for the skin (it’s not actually skin) inside your mouth. Even though the mucosa is tucked away inside your cheeks, it gets exposed to a lot. Salsa, notes Nasim Fazel, a former professor at UC Davis who started the college’s oral-mucosal clinic, “is a chemical irritant. You don’t rub salsa on your skin.” But people do eat salsa—and chips, nuts, and other foods that are spicy or acidic or sharp, and that can damage the lining of the mouth. Some of these wounds later develop into canker sores. Because the mouth is dirty, white blood cells like to hang out there; Andres Pinto, a professor at the Case Western Reserve University’s school of Dental Medicine, told me that this way, they can react quickly to a potential infection. But sometimes, this surveillance system fails, and the body can actually self-injure. This is thought to be part of what causes typical canker sores, Pinto explained: Immune dysregulation is the “common denominator” behind the ulcers. Inflammation can help the body heal, but too much inflation can cause the mucosa to break down, which is what we see when we look at the oval-shaped wounds. Beyond that, canker sores are still idiopathic, meaning doctors don’t really know why they happen. The body’s immune system is deeply complicated; as my colleague Ed Yong wrote in 2020, it’s where “intuition goes to die.” “The problem with all these immune-mediated conditions, oftentimes, is we still don’t know why they come,” Alessandro Villa, the chief of oral medicine at the Miami Cancer Institute, told me. “At the end of the day, it’s still a big mystery.” Another lingering mystery is why some people get canker sores while others live in ignorant bliss, free of their specific kind of torture. Genetics is starting to help solve that one. “Using sophisticated computers, we can actually detect which genes are associated with what we see in the mouth,” Pinto told me. “What I just said is a big step,” he added. “It took probably 30 years to develop that last sentence.” [Read: Paxlovid mouth is real—and gross] More research is needed to better treat patients, especially those with bad or chronic sores. Topical steroids can help, but they don’t address the underlying causes. A spokesperson for the FDA told me there are no available FDA-approved prescription options specifically for canker sores. Comparatively speaking, the United States does not have a lot of providers that specialize in this area. Fazel, formerly of UC Davis, is a rare combination of dentist and dermatologist who sometimes sees patients with debilitating cases. “I’m kind of using the same meds as I was using 10 years ago,” she told me. “It’s kind of sad.” Oral-medicine specialists are dentists with extra training in such ailments. But only about 400 practice in the United States, Pinto estimated. A representative for the American Academy of Oral Medicine told me the organization currently has 281 active members (although it noted that there may be additional nonmembers practicing). Fazel, for her part, thinks dermatologists are better equipped to treat canker sores, because dentists “can’t prescribe the big guns.” (The “big guns,” in this case, are medicines that modulate the immune system to calm inflammation.) Even if a patient does manage to see the right provider, that’s only the first step. They’ll still need to go through the checklist, trying to determine what their triggers are—while the bigger question of what actually causes the sores remains unknown. from https://ift.tt/IZEaSji Check out http://natthash.tumblr.com In the Northern Hemisphere, this year’s winter hasn’t yet begun. But Melissa J. Sacco, a pediatric-intensive-care specialist at UVA Health, is already dreading the arrival of the one that could follow. For months, the ICU where Sacco works has been overflowing with children amid an early-arriving surge of respiratory infections. Across the country, viruses such as RSV and flu, once brought to near-record lows by pandemic mitigations, have now returned in force, all while COVID-19 continues to churn and the health-care workforce remains threadbare. Most nights since September, Sacco told me, her ICU has been so packed that she’s had to turn kids away “or come up with creative ways to manage patients in emergency rooms or emergency departments,” where her colleagues are already overwhelmed and children more easily slip through the cracks. The team has no choice: There’s nowhere else for critically ill kids to go. Similar stories have been pouring in from around the nation for weeks. I recently spoke with a physician in Connecticut who called this “by far the worst spike in illness I’ve seen in 20 years”; another in Maryland told me, “There have been days when there is not an ICU bed to be found anywhere in the mid-Atlantic.” About three-quarters of the country’s pediatric hospital beds are full; to accommodate overflow, some hospitals have set up tents outside their emergency department or contemplated calling in the National Guard. Last week, the Children’s Hospital Association and the American Academy of Pediatrics asked the Biden administration to declare a national emergency. And experts say there’s no end to the crisis in sight. When Sacco imagines a similar wave slamming her team again next fall, “I get that burning tear feeling in the back of my eyes,” she told me. “This is not sustainable.” [Read: The worst pediatric-care crisis in decades] The experts I spoke with are mostly optimistic that these cataclysmic infection rates won’t become an autumn norm. But they also don’t yet fully understand the factors that have been driving this year’s surge, making it tough to know with certainty whether we’re due for an encore. One way or another, COVID has certainly thrown the typical end-of-year schedule out of whack. Respiratory viruses typically pick up speed in late fall, peak in mid-to-late winter, and then bow out by the spring; they often run in relay, with one microbe surging a bit before another. This year, though, nearly every pathogen arrived early, cresting in overlapping waves. “Everything is happening at once,” says Kathryn Edwards, a pediatrician and vaccinologist at Vanderbilt University. November isn’t yet through, and RSV has already sent infant hospitalizations soaring past pre-pandemic norms. Flu-hospitalization rates are also at their worst in more than a decade; about 30 states, plus D.C. and Puerto Rico, are reporting high or very high levels of the virus weeks before it usually begins its countrywide climb. And the country’s late-summer surge in rhinovirus and enterovirus has yet to fully abate. “We just haven’t had a break,” says Asuncion Mejias, a pediatrician at Nationwide Children’s Hospital. Previous pandemics have had similar knock-on effects. The H1N1-flu pandemic of 2009, for example, seems to have pushed back the start of the two RSV seasons that followed; seasonal flu also took a couple of years to settle back into its usual rhythms, Mejias told me. But that wonky timetable wasn’t permanent. If the viral calendar is even a little more regular next year, Mejias said, “that will make our lives easier.” This year, flu and RSV have also exploited Americans’ higher-than-average vulnerability. Initial encounters with RSV in particular can be rough, especially in infants, whose airways are still tiny; the sickness tempers with age as the body develops and immunity builds, leaving most children well protected by toddlerhood. But this fall, the pool of undefended kids is larger than usual. Children born just before the pandemic, or during the phases of the crisis when mitigations aplenty were still in place, may be meeting influenza or RSV for the first time. And many of them were born to mothers who had themselves experienced fewer infections and thus passed fewer antibodies to their baby while pregnant or breastfeeding. Some of the consequences may already have unfurled elsewhere in the world: Australia’s most recent flu season hit kids hard and early, and Nicaragua’s wave at the start of 2022 infected children at rates “higher than what we saw during the 2009 pandemic,” says Aubree Gordon, an epidemiologist at the University of Michigan. [Read: What a ‘tripledemic’ means for your body] In the U.S., many hospitals are now admitting far more toddlers and older children for respiratory illnesses than they normally do, says Mari Nakamura, a pediatric-infectious-disease specialist at Boston Children’s Hospital. The problem is worsened by the fact that many adults and school-age kids avoided their usual brushes with flu and RSV while those viruses were in exile, making it easier for the pathogens to spread once crowds flocked back together. “I wouldn’t be surprised,” Gordon told me, “if we see 50 to 60 percent of kids get infected with flu this year”—double the estimated typical rate of 20 to 30 percent. Caregivers too are falling sick; when I called Edwards, I could hear her husband and grandson coughing in the background. By next year, more people’s bodies should be clued back in to the season’s circulating strains, says Helen Chu, a physician and an epidemiologist at the University of Washington. Experts are also hopeful that the toolkit for fighting RSV will soon be much improved. Right now, there are no vaccines for the virus, and only one preventive drug is available in the U.S.: a tough-to-administer monoclonal antibody that’s available only to high-risk kids. But at least one RSV vaccine and another, less cumbersome antibody therapy (already being used in Europe) are expected to have the FDA’s green light by next fall. Even with the addition of better tech, though, falls and winters may be grueling for many years to come. SARS-CoV-2 is here to stay, and it will likely compound the respiratory burden by infecting people on its own or raising the risk of co-infections that can worsen and prolong disease. Even nonoverlapping illnesses might cause issues if they manifest in rapid sequence: Very serious bouts of COVID, for instance, can batter the respiratory tract, making it easier for other microbes to colonize. A few experts have begun to wonder if even milder tussles with SARS-CoV-2 might leave people more susceptible to other infections in the short or long term. Given the coronavirus’s widespread effects on the body, “we can’t be cavalier” about that possibility, says Flor Muñoz Rivas, a pediatrician at Baylor College of Medicine. Mejias and Octavio Ramilo, also at Nationwide, recently found that among a small group of infants, those with recent SARS-CoV-2 infections seemed to have a rougher go with a subsequent bout of RSV. The trend needs more study, though; it’s not clear which kids might be at higher risk, and Mejias doubts that the effect would last more than a few months. Gordon points out that some people may actually benefit from the opposite scenario: A recent brush with SARS-CoV-2 could bolster the body’s immune defenses against a second respiratory invader for a few days or weeks. This phenomenon, called viral interference, wouldn’t halt an outbreak by itself, but it’s thought to be part of the reason waves of respiratory disease don’t usually spike simultaneously: The presence of one microbe can sometimes crowd others out. Some experts think last year’s record-breaking Omicron spike helped punt a would-be winter flu epidemic to the spring. Even if all of these variables were better understood, the vagaries of viral evolution could introduce a plot twist. A new variant of SARS-CoV-2 may yet emerge; a novel strain of flu could cause a pandemic of its own. RSV, for its part, is not thought to be as quick to shape-shift, but the virus’s genetics are not well studied. Mejias and Ramilo’s data suggest that the arrival of a gnarly RSV strain in 2019 may have pushed local hospitalizations past their usual highs. [Read: Will we get Omicron’d again?] Behavioral and infrastructural factors could cloud the forecast as well. Health-care workers vacated their posts in droves during the pandemic, and many hospitals’ pediatric-bed capacity has shrunk, leaving supply grossly inadequate to address current demand. COVID-vaccination rates in little kids also remain abysmal, and many pediatricians are worried that anti-vaccine sentiment could stymie the delivery of other routine immunizations, including those against flu. Even temporary delays in vaccination can have an effect: Muñoz Rivas points out that the flu’s early arrival this year, ahead of when many people signed up for their shot, may now be aiding the virus’s spread. The new treatments and vaccines for RSV “could really, really help,” Nakamura told me, but “only if we use them.” Next fall comes with few guarantees: The seasonal schedule may not rectify itself; viruses may not give us an evolutionary pass. Our immune system will likely be better-prepared to fend off flu, RSV, rhinovirus, enterovirus, and more—but that may not be enough on its own. What we can control, though, is how we choose to arm ourselves. The past few years proved that the world does know how to drive down rates of respiratory disease. “We had so little contagion during the time we were trying to keep COVID at bay,” Edwards told me. “Is there something to be learned?” from https://ift.tt/V1XpEHi Check out http://natthash.tumblr.com Since the start of 2022, I’ve consumed more than my body weight in sweet potatoes. The average American eats closer to the equivalent of one (1) fry a day, but for the past decade, I’ve had at least half a pound of the roots at almost every dinner. I travel with sweet potatoes more reliably than I travel with my spouse. All I need in order to chow down is a microwave and something to cushion my hands against the heat. Tomorrow, Americans will finally put sweet potatoes in the spotlight—and still not appreciate all that they’re worth. Families across the country will smother the roots with sugar and butter beneath a crunchy marshmallow crust. This classic casserole may be the only serving of sweet potatoes some people have all year—which is a travesty in terms of both quantity and (sorry) preparation style. Sweet potatoes deserve so much more than what Thanksgiving serves them. And maybe they’d get it, if they weren’t so misunderstood. For starters, sweet potatoes are not potatoes or yams. Each belongs to a distinct family of plants. And although potatoes and yams are technically tubers, a riff on a plant stem, sweet potatoes are a modified root. The common name doesn’t exactly help, which is why many experts want to change it from sweet potato to … sweetpotato. Even in grocery stores, confusion abounds. A small part of Lauren Eserman-Campbell, a geneticist and sweet-potato expert at the Atlanta Botanical Garden, dies every time she spots a can of Bruce’s Yams. Mostly, the sweet potatoes in American markets resemble Bruce’s (Not) Yams: orange-fleshed, brown-skinned, sugary, moist. But the plant’s true range is much more diverse. The outside comes in earthy umbers, ruddy reds and purples, and sandy beiges; the interior can be cream, buttercup yellow, cantaloupe, lilac, even a shade of violet that verges on black. Some are rather watery; others are almost as dry and starchy as bread. Not all of them are even perceptibly sweet. And thanks to the plant’s zany genetics—six copies of each of 15 chromosomes—nearly every combo of color, texture, taste, shape, and sugar and water content can spring out of a cross between, say, a dryish, veiny purple and a moist, smooth-skinned orange. Craig Yencho, a sweet-potato breeder and geneticist at North Carolina State University, told me that, given enough time, “I could find a sweet potato that would be enjoyable to just about any consumer.” The common misconception that potatoes are fattening and devoid of nutrition (slander!) might make some people assume the same or worse of sweet potatoes. But that couldn’t be further from the truth. Pit their nutritional profile against other staple crops, such as rice, wheat, and corn—all of which command a larger share of the world market—and, in many respects, “sweet potato is on top,” says Samuel Acheampong, a geneticist at the University of Cape Coast, in Ghana. The orange-fleshed varieties, in particular, come chock-full of iron, zinc, and beta-carotene, a precursor to vitamin A; the purples are rich in cancer-fighting anthocyanins. Even sweet-potato leaves are a powerhouse, packed with folate and a surprising amount of protein. Also, they’re delicious stir-fried. [Read: America’s lost story of crops rewrites the history of farming] Sweet potatoes tend to get America’s attention only in November, but they’re hardy, flexible, and ubiquitous enough to be an anytime, anywhere kind of food. They’ve taken root on every continent, save for Antarctica; they’ve been rocketed into space. Acre for acre, sweet potatoes also yield edible crop far more efficiently than many other plants do, “and that is really important in families where they don’t have enough quality food,” says Robert Mwanga, a sweet-potato geneticist based in Uganda, where some locals eat the roots at nearly every meal. In Kenya, sweet potatoes have sustained communities when other crops have failed. Among some populations, the roots have earned an apt moniker: cilera abana, protector of the children. But even among scientists, sweet potatoes get, if not a bad rap, at least an underwhelming one. “It’s a tiny community, and there’s not a lot of funding,” Eserman-Campbell told me. “I went to a sweet-potato breeders’ meeting one time, and I just thought there would be more people there.” It doesn’t help that the plants can be a bit of a genetic pain, Mwanga told me. Their many copied chromosomes make breeding tricky, and new sweet-potato varieties can be propagated only by clonal cuttings. Among consumers, the sweet potato has also struggled to shed its reputation as a poor person’s food, turned to in times of famine or war and culturally linked to rural, low-income farmers. People in the Western world are catching on—especially now that nutritionists so often tout sweet potatoes as a superfood, says Ana Rita Simões, a taxonomist at Kew Gardens, in London. In the past decade, demand for Yencho’s sweet potatoes has tripled, maybe quintupled; “I have never seen a crop take off like that,” he said. [Read: The correct time to eat Thanksgiving dinner] Culinarily, though, Americans are still batting in the sweet potato’s minor leagues. The big hitter remains the Thanksgiving casserole—a dish Acheampong likes but remains a bit mystified by. “You guys add a lot of sugar,” he told me, which is amusing, considering that the orange-fleshed varieties are already plenty sweet. Plus, the casserole is (gasp) under the thumb of Big Confection: Its invention was commissioned as part of a ploy to sell more marshmallows. It’s sugar all the way down. I am not here to yuck anyone’s yam; I celebrate any dish that features sweet potatoes. More preferable, though, would be casting these wonderful roots in a starring role. In other parts of the world, sweet-potato recipes run the gamut from sugary to savory, from appetizer to main to dessert. They’re pureed, stir-fried, noodle-fied; they’re blended into soups, beverages, and pastries. They’ve even found their way into booze. Imagine how they could dress our Thanksgiving tables: sweet potatoes roasted; sweet potatoes grilled; sweet potatofurkey—I mean, why the heck not. [Read: How to engineer the optimally delicious Thanksgiving plate] Or perhaps there is a more modest proposal to be made: Enjoy the roots all on their own. Yencho, like me, is a purist; he likes his sweet potatoes plain, baked until soft, no condiments necessary. They just don’t need anything else. from https://ift.tt/2dG0SLD Check out http://natthash.tumblr.com Paxlovid is a paradoxlovid. The game-changing antiviral swooped in during the pandemic’s worst winter with the promise of slowing COVID deaths to a trickle. But since it became widely available this spring, death rates have hardly budged. According to the White House, the problem is not the drug but the fact that too few people are taking it. A recent CDC report found that from April to July, less than one-third of America’s 80-plus-year-olds with COVID ended up taking Paxlovid, even though they had the most to gain from doing so. What gives? Some Americans may be having trouble accessing Paxlovid, but clearly, a significant proportion of patients and doctors are just saying no to antiviral drugs. There are no national statistics on Paxlovid refusal, so I talked with physicians around the country to learn more about their motivations. Who are the anti-Paxxers, and how dangerous is their dogma? First things first: Paxlovid hesitancy does seem to be political, but that’s not the whole story. As a rule, fewer prescriptions of the drug are given out per capita in red states than in blue ones: Wyoming, for example, appears to be the nation’s leading anti-Paxxer state, with just one course of treatment given out for every 125 residents; in Rhode Island, the most Pax-enthusiastic state, it’s one in 28. (I’m using courses of treatment per capita rather than per COVID case because of the general unreliability of case data these days and differences in testing and reporting practices among states.) Still, clinicians working in deep-red parts of the country told me that, on this matter at least, their patients are not significantly divided by politics. “Republicans and Democrats both love Paxlovid,” says Jason Bronner, the medical director of primary care at St. Luke’s Medical System, in Idaho. Some 20 to 30 percent of his COVID patients decline to take the drug, he told me, but they don’t appear to be driven by the same polarized attitudes he sees around vaccines. Jessica Kalender-Rich, a geriatrician at the University of Kansas Health System, told me that she still gets occasional requests for ivermectin, and that some of her patients insist that COVID is a hoax. But the ones who outright refuse Paxlovid are not obsessing over microchips or government overreach. Instead, they mostly tell her that they’re worried about treatment side effects and rebound infections of the virus. Rebound COVID came up again and again when I asked doctors why their patients are hesitant to take Paxlovid. The link between the drug and a return of symptoms after an initial recovery has been the subject of much concern and debate since the spring; just last week, researchers reported in a study that has not yet been peer-reviewed that symptom rebound is more than twice as common among Paxlovid takers than among those who decline it. The fact that so many prominent figures in the federal government—including President Joe Biden, First Lady Jill Biden, CDC Director Rochelle Walensky, and White House Chief Medical Adviser Anthony Fauci—have now had rebound certainly doesn’t help inspire confidence. One of Kalender-Rich’s patients specifically cited Fauci’s experience when refusing the drug. (The next day, the patient felt worse and accepted a prescription.) [Read: Of course Biden has rebound COVID] Rebound may not be dangerous, but you have to admit that it doesn’t sound like a good time. “People will say, ‘I’d rather be really sick for four or five days than just kind of sick for two weeks,’” says Adam Fiterstein, the chief of urgent care at the New York medical network ProHealth. The threat of rebound might be especially scary for geriatric patients and their family, because it means spending more time alone. “For some of these older adults, that isolation time is actually way worse than the virus at this point in the pandemic,” Kalender-Rich said. Paxlovid mouth—a bitter, metallic taste that can last throughout the course of treatment—can also be a concern for the elderly, who may already suffer from lack of appetite or other issues that restrict their eating. Drug interactions are another source of worry for the anti-Paxxers. Official COVID-treatment guidelines warn that the antiviral may have ill effects when combined with any of more than 100 other medications. Geriatric patients in particular might need to tweak their daily regimens of pills while under treatment with Paxlovid, Kalender-Rich told me. That’s hardly ever a problem medically, she said, but some people are still reluctant to make the change, especially if a previous doctor told them to never, ever skip a dose. These potential downsides are extra salient for people who don’t fear COVID like they used to. The patients who refuse Paxlovid are the ones who are doing well, Bronner said: “They don’t feel totally sick and are not scared like they were in previous waves.” Hundreds of Americans are still dying daily from COVID, but any given community might have seen only a handful of severe cases and deaths since the spring. Many patients “don’t feel like they need to take a medicine, because their neighbor was fine,” Kalender-Rich said. [Read: Paxlovid mouth is real—and gross] Doctors too can be anti-Paxxers. Hans Duvefelt, a primary-care physician in rural Maine, won’t prescribe Paxlovid to his patients. He told me via email that he avoids it on account of rebound risk, side effects, kidney concerns, and drug interactions. “Paxlovid is an inferior choice,” he said, when compared with molnupiravir, another COVID antiviral. To be clear, the data hold that molnupiravir is less effective than Paxlovid at preventing hospitalization and death. Also, a June preprint found that patients treated with molnupiravir rebounded at least as often as those treated with Paxlovid. Duvefelt did not respond to follow-up questions, so I couldn’t ask him about these data. Other doctors believe in the good Paxlovid can do but still struggle with the decision to prescribe. “This is a much more nuanced risk-benefit discussion than giving somebody amoxicillin for strep throat,” Jeremy Cauwels, the chief physician at Sanford Health in South Dakota, told me. “If you’re looking at that as an ER doctor, who by definition has no follow-up with the patient, it’s very hard to say, ‘I’m going to give you a drug that interacts with lots of medications.’” Persistent uncertainty about exactly how much Paxlovid helps people who are up to date on their COVID shots doesn’t help. Regardless of what’s causing Paxlovid hesitancy, the exact stakes are difficult to define. Last month, Ashish Jha, the Biden administration’s COVID-19 response coordinator, told The New York Times that daily deaths from the pandemic could drop by almost 90 percent if every COVID patient over the age of 50 were treated with Paxlovid or monoclonal antibodies. The doctors I spoke with mostly didn’t dispute this; Kalender-Rich said she “would believe a number closer to 75 percent” but agreed with the general sentiment. That said, none of the doctors I spoke with could point me toward any specific cases where one of their patients refused Paxlovid only to end up severely ill or dead. And no one knows how many deaths could be reduced specifically by attacking anti-Paxxer beliefs as opposed to, say, removing barriers to access and encouraging more testing. Because anti-Paxxerism appears to be less organized and ideological than anti-vaxxerism, some favored strategies to combat the latter—targeting influencers on social media, for example—might not work. The doctors I spoke with said that the best venue for changing minds is the exam room. “It really comes down to a face-to-face conversation” about the risks and benefits of the drug, Cauwels said: “Our patients still trust us enough to have that conversation.” Pax-hesitant providers, on the other hand, may just need a bit more time to feel convinced that the drug is safe and effective when used correctly; some may be waiting on more data from large, randomized clinical trials. “Across different parts of the country, adoption of new things is always going to be slower,” Kalender-Rich said. That’s not exactly a comforting thought when hundreds of people are still dying every day, but it does suggest, at the very least, that we have something to look forward to. from https://ift.tt/U9VoXZx Check out http://natthash.tumblr.com After nearly three years of constantly thinking about COVID, it’s alarming how easily I can stop. The truth is, as a healthy, vaxxed-to-the-brim young person who has already had COVID, the pandemic now often feels more like an abstraction than a crisis. My perception of personal risk has dropped in recent months, as has my stamina for precautions. I still care about COVID, but I also eat in crowded cafés and go mask-free at parties. Heading into the third pandemic winter, things have changed. Most Americans seem to have tuned out COVID. Precautions have virtually disappeared; except for in the deepest-blue cities, wearing a mask is, well, weird. Reported cases are way down since the spring and summer, but perhaps the biggest reason for America’s behavioral let-up is that much of the country sees COVID as a minor nuisance, no more bothersome than a cold or the flu. And to a certain degree, they’re right: Most healthy, working-age adults who are up-to-date on their vaccinations won’t get severely ill—especially now that antivirals such as Paxlovid are available. Other treatments can help if a patient does get very sick. “People who are vaccinated and relatively healthy who are getting COVID are not getting that sick,” Lisa Lee, an epidemiologist at Virginia Tech, told me. “And so people are thinking, Wow, I’ve had COVID. It wasn’t that bad. I don’t really care anymore.” Still, there are many reasons to continue caring about COVID. About 300 people are still dying every day; COVID is on track to be the third-leading cause of death in the U.S. for the third year running. The prospect of developing long COVID is real and terrifying, as are mounting concerns about reinfections. But admittedly, these sometimes manifest in my mind as a dull, omnipresent horror, not an urgent affront. Continuing to care about COVID while also loosening up behaviors is an uncomfortable position to be in. Most of the time, I just try to ignore the guilt gnawing at my brain. At this point, when so few people feel that the potential benefit of dodging an infection is worth the inconvenience of precautions, what does it even mean to care about COVID? [Read: Hundreds of Americans will die from COVID today] In an ideal epidemiological scenario, everyone would willingly deploy the full arsenal of COVID precautions, such as masking and forgoing crowded indoor activities, especially during waves. But that kind of all-out response no longer makes sense. “It’s probably not realistic to expect people to take precautions every time, perpetually, or even every winter or fall, unless there is a particularly concerning reason to do that,” Jennifer Nuzzo, an epidemiologist at Brown University, told me. But, now more than ever, we must remember that COVID is not just a personal threat but a community one. For older and immunocompromised people, the risks are still significant. For example, people over 50 account for 93 percent of COVID-related deaths in the U.S., even though they represent just 35.7 percent of the population. As long as the death rate remains as high as it is, caring about COVID should mean orienting precautions to protect them. This idea has been around since the pandemic began, but its prominence faded as Americans put their personal health first. “If you’re otherwise healthy, it’s so easy just to think about yourself,” Lee said. “We have to think very carefully about that other part of infectious disease, which is the part where we can potentially hurt other people.” Orienting behavior in this way gives low-risk people a way to care about COVID that doesn’t entail constant masking or skipping all indoor activities: They can relax when they know they aren’t going to encounter vulnerable people. Like the productivity adage “work smarter, not harder,” this perspective allows people to take precautions strategically, not always. In practice, all it takes is some foresight. If you don’t live with vulnerable people, make it second nature to ask: Will I be seeing vulnerable people anytime soon? If the answer is no, do whatever you’re comfortable with given your own risk. If you are a healthy 30-something who lives alone, going to a Friendsgiving with other people your age is different from spending Thanksgiving dinner with parents and grandparents. If you will be seeing someone vulnerable, the most straightforward way to avoid giving them COVID is to avoid getting infected yourself, which means wearing a good mask in public settings and minimizing your interactions with others the week before, in what some experts have called a “mini-quarantine.” Not everyone has that luxury: Parents, for example, have to send their kids to school. Spontaneous interactions with vulnerable people are trickier to plan for, but they follow the same principle. On a crowded bus, for example, “there’s no question that if you’re close enough to someone who could be hurt by getting COVID and you could have it, then, yeah, a mask is the way to go,” Lee said. Of course, it isn’t always possible to know when someone is high-risk; young people, too, can be medically vulnerable. There’s no clear guidance for those situations, but remaining cautious doesn’t require much effort. “Carry a mask with you,” Lee said. “It’s not a big lift.” Get boosted—if not for yourself, then for them. Just 11.3 percent of eligible Americans have gotten the latest, bivalent shot, which potentially reduces your chances of getting COVID and passing it along. It also means getting tested, so you know when you’re infectious, and being aware of respiratory symptoms—of any kind. Alongside COVID, the flu and RSV are putting many people in the hospital, especially the very young and the very old. No matter how low your personal risk, if you have symptoms, avoiding transmission is crucial. “A reasonable thing to prioritize is: If you have symptoms, take care to prevent it from spreading,” Caitlin Rivers, an epidemiologist at Johns Hopkins University, told me. [Read: It’s a bad time to be a booster slacker] As we move away from a personal approach to COVID, we have an opportunity to expand the idea of what caring looks like. Low-risk people can, and should, take an active role in bolstering the protection of vulnerable people they know. In practical terms, this means ensuring that people in your life who are over 50—especially those over 65—are boosted and have a plan to get Paxlovid if they fall sick, Nuzzo said. “I think our biggest problem right now is that not everybody has enough access to the tools, and that’s a place where people can help.” She noted that she is particularly concerned about older people who struggle to book vaccine appointments online. Caring “doesn’t mean abstaining, per se. It means facilitating. It means enabling and helping people in your community.” This holiday season, caring could mean sitting down at a computer to make Grandma’s booster appointment, or driving her to the drugstore to get it. If you have lost your motivation to care about COVID, you might find it in the people you love. I didn’t feel a personal need to wear a mask at the concert I attended yesterday, but I did it because I don’t want to accidentally infect my partner’s 94-year-old grandfather when I see him next week. To have this experience of the pandemic is a privilege. Many don’t have the option to stop caring, even for a moment. Barring another Omicron-esque event, we thankfully won’t ever return to a moment where Americans obsess over COVID en masse. But this virus isn’t going away, so we can’t escape having a population that is split between the high-risk minority and the low-risk majority. Rethinking what it means to care allows for a more nuanced and liveable idea of what responsible behavior looks like. Right now, Nuzzo told me, the language we use to describe one’s position on COVID is “black-and-white, absolutist—you either care or you don’t.” There is space between those extremes. At least for now, it’s the only way to compromise between the world we have and the world we want. from https://ift.tt/6xKZ4m9 Check out http://natthash.tumblr.com You may not be aware of this, but you can read everything that your doctor writes about you. Go to your patient portal online, click around until you land on notes from your past visits, and read away. This is a recent development, and a big one. Previously, you always had the right to request your medical record from your care providers—an often expensive and sometimes fruitless process—but in April 2021, a new federal rule went into effect, mandating that patients have the legal right to freely and electronically access most kinds of notes written about them by their doctors. If you’ve never heard of “open notes,” as this new law is informally called, you’re not the only one. Doctors say that the majority of their patients have no clue. (This certainly has been the case for all of the friends and family I’ve asked.) If you do know about the law, you likely know a lot about it. That’s typically because you’re a doctor—one who now has to navigate a new era of transparency in medicine—or you’re someone who knows a doctor, or you’re a patient who has become intricately familiar with this country’s health system for one reason or another. When open notes went into effect, the change was lauded by advocates as part of a greater push toward patient autonomy and away from medical gatekeeping. Previously, hospitals could charge up to hundreds of dollars to release records, if they released them at all. Many doctors, meanwhile, have been far from thrilled about open notes. They’ve argued that this rule will introduce more challenges than benefits for both patients and themselves. At worst, some have fretted, the law will damage people’s trust of doctors and make everyone’s lives worse. A year and a half in, however, open notes don’t seem to have done too much of anything. So far, they have neither revolutionized patient care nor sunk America’s medical establishment. Instead, doctors say, open notes have barely shifted the clinical experience at all. Few individual practitioners have been advertising the change, and few patients are seeking it out on their own. We’ve been left with a partially implemented system and a big unresolved question: How much, really, should you want to read what your doctor is writing about you? The debate about open notes can be boiled down to a matter of practicality versus idealism. You’d be hard-pressed to find anyone, doctor or otherwise, who argues against transparency for patients in principle. At the same time, few people I spoke with for this article believe that the new rule has been put in place all that smoothly. For care providers, the primary concern has been the trouble that can come with writing notes for a new audience. Notes, generally scribbled in shorthand incomprehensible to the unknowing eye, have traditionally served doctors, and doctors alone. They allowed physicians to stay up to date on their patients and share information with colleagues for input on cases. Some doctors told me they worry that open notes could result in distress for patients who read something they don’t understand, and that highly technical language could make something sound worse than it is. Oncology, for instance, can involve an onslaught of potentially concerning terminology. (Psychotherapy notes are exempt from the new rule.) Other doctors fear that valuable information can be lost if they go too far in de-jargonizing notes to make them patient-friendly. Or that de-jargonizing notes is simply unfeasible. “Let’s say you came to me with pain and pointed to your mid-clavicular line. I’d just put ‘MCL,’” says Aldo Peixoto, a nephrologist at Yale. “But if I were writing for you to understand, I’d have to say ‘pain on the top-right portion of her abdomen in the line that runs from the middle of her clavicle,’ and so on. Rather than writing four lines of prose, I could’ve used literally three letters.” If that sounds quibbling, consider the trade-offs. Less time for doctors can translate into less time for patients. Many clinicians already write notes well into the evening. Certainly, the pandemic hasn’t helped. Some doctors told me that if they find themselves in a dilemma of either writing notes in less-efficient, plain language or fielding worried patient calls and messages, exhausted practitioners will face yet another burden. And then there’s the matter of trust. Jack Resneck, the president of the American Medical Association, the nation’s largest professional group of doctors and medical students, told me that doctors can need time and space with patients to get them to open up and be receptive to guidance through difficult situations. If these patients were to see notes too soon, Resneck said, they might “immediately flee and not come back to see you.” [Read: Why health-care workers are quitting in droves] As doctors have spent more time dealing with open notes, many have eased off their strongest objections. Some, including Resneck and the AMA, have warmed up to the new rule as certain exceptions have been granted, such as allowing doctors whose patients have parents or partners with access to their notes to omit certain details from their write-ups for privacy reasons. Other physicians seem to be coming to a somewhat awkward realization: On a practical level, many concerns about how this change affects patients are irrelevant, because most patients don’t yet know they have instant access to their notes in the first place. Every doctor I spoke with for this story told me that their patients were largely unaware. Many doctors and hospitals are not going out of their way to inform people about the new rule, so unless patients are particularly on top of shifting rules within our convoluted health-care system, they’re unlikely to encounter the notes on their own. Kerin Adelson, an oncologist at Yale, admitted she didn’t know how to find notes in her own patient portal. She spent several minutes with me on the phone fumbling through different tabs to locate them. Fans of open notes are frustrated that there is not a greater push for awareness. Even acknowledging that the new system has its shortcomings, many argue that the only way to make things better is to get people invested in the access they’ve recently been granted. Lydia Dugdale, a primary-care doctor at Columbia University, worries about ensuring equity. “Things like socioeconomic status, education, literacy: All of those issues affect the degree to which any given patient is going to want to read and correct and interrogate his or her health record,” she told me. Tom Delbanco, a Harvard doctor and one of the co-founders of OpenNotes, an initiative that spearheaded the push for access to doctors’ notes in the U.S., believes that the effort required to refrain from using “bad words” in notes is minor, and that it shouldn’t make any significant demands on clinicians’ schedules. Doctors who are now taking more time to write notes because of the change, he told me, “probably ought to because they’ve been writing lousy notes.” Open notes can be valuable for people with chronic conditions and their caregivers, who need to stay in the know. Liz Salmi, the communications and patient-initiatives director at OpenNotes, told me about pulling her full medical record eight years into dealing with brain cancer, before notes were easily and freely available. The document was 4,839 pages. To get a PDF, she said, she had to pay $15 for each DVD it was uploaded to, and her records spanned multiple discs. But the information was worth it: Having access to the record gave Salmi a way to remember all of the crucial bits of information she’d gotten piecemeal from various doctors. The fact that many people have no idea open notes exist doesn’t change the deeply personal questions at stake in the debate about whether the notes do more good or harm—questions that everyone must confront in one way or another in dealing with America’s medical system, whether or not they fully realize it. How much information do you truly want about your health, and how much do you trust your doctor to deliver it to you? What is a doctor’s role in informing people about their health? [Read: Following your gut isn’t the right way to go] Open notes are only part of this conversation. The new law also requires that test results be made immediately available to patients, meaning that patients might see their health information before their physician does. Although this is fine for the majority of tests, problems arise when results are harbingers of more complex, or just bad, news. Doctors I spoke with shared that some of their patients have suffered trauma from learning about their melanoma or pancreatic cancer or their child’s leukemia from an electronic message in the middle of the night, with no doctor to call and talk through the seriousness of that result with. This was the case for Tara Daniels, a digital-marketing consultant who lives near Boston. She’s had leukemia three times, and learned about the third via a late-night notification from her patient portal. Daniels appreciates the convenience of open notes, which help her keep track of her interactions with various doctors. But, she told me, when it comes to instant results, “I still hold a lot of resentment over the fact that I found out from test results, that I had to figure it out myself, before my doctor was able to tell me.” As Americans continue to age, get sick, and navigate the health-care system, many of us may become more invested in the idea of open notes. Until they play a more widespread role in people’s lives, however, the most pressing question about whether you truly want instant access to all your medical information might be how it affects your doctor’s life. Many physicians have come around to open notes, or at least have realized that allowing patients to see what has been written about them is not always a huge bother. But the bigger question of just how quickly patients should be able to access medical information, and how soon doctors should be available to help patients process it, continues to plague physicians. The advent of immediate data sharing “has been a major problem in terms of physician quality of life, and that’s eroded across the board,” Peixoto told me. “Doctors don’t want to be connected all the time. They actually have their lives.” Where we have landed, then, is an in-between. Patients can read their doctor’s notes and view test results at any hour of the day, but we can access our providers only at certain times. There is likely room for refinement. Allowing a patient to select whether they receive test results from their physician or their portal, or see notes only after their doctor has had the opportunity to walk them through the terminology used, for instance, could make all the difference, some doctors told me. For now, it’s worth asking yourself whether you want to access your patient portal alone, or want to wait until you can get your doctor on the line. from https://ift.tt/V3xCdM5 Check out http://natthash.tumblr.com This piece was originally published by Undark Magazine. Ben Salentine, the associate director of health-sciences managed care at the University of Illinois Hospital and Health Sciences System, hasn’t been weighed in more than a decade. His doctors “just kind of guess” his weight, he says, because they don’t have a wheelchair-accessible scale. He’s far from alone. Many people with disabilities describe challenges in finding physicians prepared to care for them. “You would assume that medical spaces would be the most accessible places there are, and they’re not,” says Angel Miles, a rehabilitation-program specialist at the Administration for Community Living, part of the Department of Health and Human Services. Not only do many clinics lack the necessary equipment—such as scales that can accommodate people who use wheelchairs—but at least some physicians actively avoid patients with disabilities, using excuses like “I’m not taking new patients” or “You need a specialist,” according to a paper in the October 2022 issue of Health Affairs. The work, which analyzed focus-group discussions with 22 physicians, adds context to a larger study published in February 2021 (also in Health Affairs) that showed that only 56 percent of doctors “strongly” welcome patients with disabilities into their practice. Less than half were “very confident” that they could provide the same quality of care to people with disabilities as they could to other patients. The studies add to a larger body of research suggesting that patients with conditions that doctors may deem difficult to treat often struggle to find quality care. The Americans With Disabilities Act of 1990 (ADA) theoretically protects the one in four adults in the U.S. with a disability from discrimination in public and private medical practices—but enforcing it is a challenge. Laura VanPuymbrouck, an assistant professor in the Department of Occupational Therapy at Rush University, calls the 2021 survey “groundbreaking—it was the crack that broke the dam a little bit.” Now researchers are hoping that medical schools, payers, and the Joint Commission (a group that accredits hospitals) will push health-care providers for more equitable care. Due in part to scant data, information about health care for people with disabilities is limited, according to Tara Lagu, a co-author of both the 2021 and 2022 papers and the director of the Institute for Public Health and Medicine’s Center for Health Services & Outcomes Research at Northwestern University Feinberg School of Medicine. The few studies that have been done suggest that people with disabilities get preventive care less frequently and have worse outcomes than their nondisabled counterparts. About a decade ago, Lagu was discharging a patient who was partially paralyzed and used a wheelchair. The patient’s discharge notes repeatedly recommended an appointment with a specialist, but it hadn’t happened. Lagu asked why. Eventually, the patient’s adult daughter told Lagu that she hadn’t been able to find a specialist who would see a patient in a wheelchair. Incredulous, Lagu started making calls. “I could not find that kind of doctor within 100 miles of her house who would see her,” she says, “unless she came in an ambulance and was transferred to an exam table by EMS—which would have cost her family more than $1,000 out of pocket.” In recent years, studies have shown that even when patients with disabilities can see physicians, their doctors’ biases toward conditions such as obesity, intellectual disabilities, and substance-use disorders can have profound impacts on the care they receive. Physicians may assume that an individual’s symptoms are caused by obesity and tell them to lose weight before considering tests. For one patient, this meant a seriously delayed diagnosis of lung cancer. Patients with mobility or intellectual challenges are often assumed to be celibate, so their providers skip any discussion of sexual health. Those in wheelchairs may not get weighed even if they’re pregnant—a time when tracking one’s weight is especially important, because gaining too little or too much is associated with the baby being at risk for developmental delays or the mother being at risk for complications during delivery. These issues are well known to Lisa Iezzoni, a health-policy researcher at Massachusetts General Hospital and a professor of medicine at Harvard Medical School. Over the past 25 years, Iezzoni has interviewed about 300 people with disabilities for her research into their health-care experiences and outcomes, and she realized that “every single person with a disability tells me their doctors don’t respect them, has erroneous assumptions about them, or is clueless about how to provide care.” In 2016, she decided it was time to talk to doctors. Once the National Institutes of Health funded the work, she and Lagu recruited the 714 physicians that took the survey for the study published in 2021 in Health Affairs. Not only did many doctors report feeling incapable of properly caring for people with disabilities, but a large majority held the false belief that those patients have a worse quality of life, which could prompt them to offer fewer treatment options. During the 2021 study, Iezzoni’s team recorded three focus-group discussions with 22 anonymous physicians. Although the open-ended discussions weren’t included in the initial publication, Lagu says she was “completely shocked” by some of the comments. Some doctors in the focus groups welcomed the idea of additional education to help them better care for patients with disabilities, but others said that they were overburdened and that the 15 minutes typically allotted for office visits aren’t enough to provide these patients with proper care. Still others “started to describe that they felt these patients were a burden and that they would discharge patients with disability from their practice,” Lagu says. “We had to write it up.” [Read: How wheelchair accessibility ramped up] The American Medical Association, the largest professional organization representing doctors, declined an interview request and would not comment on the most recent Health Affairs study. When asked about the organization’s policies on caring for patients with disabilities, a representative pointed to the AMA’s strategic plan, which includes a commitment to equity. Patients with disabilities are supposed to be protected by law. Nearly 50 years ago, Congress passed Section 504 of the Rehabilitation Act of 1973, which prohibited any programs that receive federal funding, such as Medicare and Medicaid, from excluding or discriminating against individuals with disabilities. In 1990, the ADA mandated that public and private institutions also provide these protections. The ADA offers some guidelines for accessible buildings, including requiring ramps, but it does not specify details about medical equipment, such as adjustable exam tables and wheelchair-accessible scales. Although these items are necessary to provide adequate care for many people with disabilities, many facilities lack them: In a recent California survey, for instance, only 19.1 percent of doctor’s offices had adjustable exam tables, and only 10.9 percent had wheelchair-accessible scales. Miles says she’s noticed an improvement in care since the ADA went into effect, but she still frequently experiences challenges in health care as a Black woman who uses a wheelchair. “We need to keep in mind the ADA is not a building code. It’s a civil-rights law,” says Heidi Johnson-Wright, an ADA coordinator for Miami-Dade County in Florida, who was not speaking on behalf of the county. “If I don’t have access to a wellness check at a doctor’s office or treatment at a hospital, then you’re basically denying me my civil rights.” The ADA isn’t easy to enforce. There are no “ADA police,” Johnson-Wright says, to check if doctor’s offices and hospitals are accessible. In many cases, a private citizen or the Department of Justice has to sue a business or an institution believed to be in violation of the ADA. Lawyers have filed more than 10,000 ADA Title III lawsuits each year since 2018. Some people, sympathizing with businesses and doctors, accuse the plaintiffs of profiteering. And it’s not just about accessible equipment. In 2018, the Justice Department sued a skilled nursing facility for violating the ADA, after the facility refused to treat a patient with a substance-use disorder who needed medication to help maintain sobriety. Since then, the department settled with eight other skilled nursing facilities for similar discrimination. “It is a violation of the ADA” to deny someone care based on the medications they need, Sarah Wakeman, an addiction-medicine specialist at Massachusetts General Hospital, wrote in an email, “and yet continues to happen.” Indeed, in the focus groups led by Lagu and Iezzoni, some of the doctors revealed that they view the ADA and the people it protects with contempt. One called people with disabilities “an entitled population.” Another said that the ADA works “against physicians.” The Department of Health and Human Services is aware of the issue. In a response to emailed questions, an HHS spokesperson wrote, “While we recognize the progress of the ADA, important work remains to uphold the rights of people with disabilities.” The Office of Civil Rights, the spokesperson continued, “has taken a number of important actions to ensure that health care providers do not deny health care to individuals on the basis of disability and to guarantee that people with disabilities have full access to reasonable accommodations when receiving health care and human services, free of discriminatory barriers and bias.” Researchers and advocates told me that the key to improving health care for those with disabilities is addressing it directly in medical education and training. “People with disabilities are probably one of the larger populations” that physicians serve, Salentine said. Ryan McGraw, a community organizer with Access Living, helps provide education about treating patients with disabilities to medical schools in the Chicago area. He regularly receives positive feedback from medical students but says the information needs to be embedded in the medical-school curriculum, so it’s not “one and done.” In one effort to address the issue, the Alliance for Disabilities in Health Care Education, a coalition of professionals and educators of which McGraw is a member, put together a list of 10 core competencies that should be included in a doctor’s education, including considerations for accessibility, effective communication, and patient-centered decision making. [Read: What police offers don’t know about the ADA] One of the simplest solutions might be hanging signs or providing accessible information in exam rooms on patients’ rights. “It’d be there for patients, but it’d be also there as a reminder to the providers. I think that’s a super easy thing to do,” Laura VanPuymbrouck says. Miles says this could be a good start, but “it’s not enough to just give people a little pamphlet that tells you about your rights as a patient.” Although all doctors should be willing and able to care for patients with disabilities, she thinks a registry that shows which providers take certain types of insurance, such as Medicaid, and also have disability accommodations, such as wheelchair-accessible equipment, would go a long way. Some advocates have called on the Joint Commission for more than 10 years to require disability accommodations for hospitals that want accreditation. The step could be effective, because accreditation “is extremely important” to hospitals, Lagu says. On January 1, 2023, new Joint Commission guidelines will require that hospitals create plans to identify and reduce at least one health-care disparity among their patients. Improving outcomes for people with disabilities could be one such goal. However, Maureen Lyons, a spokesperson for the Joint Commission, adds, “if individuals circumvent the law, standards won’t be any more effective.” Finally, Lagu says, “we have to pay more when you are providing accommodations that take time or cost money. There’s got to be some accounting for that in the way we pay physicians.” One of the most basic things people with disabilities are asking for is respect. The biggest finding of the 2021 survey, Iezzoni says, is that doctors don’t realize that the proper way to determine what accommodations a facility needs for patients with disabilities is to just ask the patients. “I can’t tell you how many times I go to a doctor’s office and I’m talking, but they’re not hearing anything,” Salentine says. “They’re ready to speak over me.” from https://ift.tt/GJjcgkS Check out http://natthash.tumblr.com In COVID terms, the middle of last autumn looked a lot like this one. After a rough summer, SARS-CoV-2 infections were down; hospitalizations and deaths were in a relative trough. Kids and workers were back in schools and offices, and another round of COVID shots was rolling out. Things weren’t great … but they weren’t the most terrible they’d ever been. There were vaccines; there were tests; there were drugs. The worst winter development the virus might produce, some experts thought, might involve the spawning of some nasty Delta offshoot. Then, one year ago this week, Omicron appeared. The first documented infection with the variant was identified from a specimen collected in South Africa on November 9, 2021; by December 1, public-health officials had detected cases in countries all around the globe, including the United States. Twenty days later, Omicron had unseated Delta as America’s dominant SARS-CoV-2 morph. The new, highly mutated variant could infect just about anyone it encountered—even if they’d already caught a previous version of the virus or gotten several shots of a vaccine. At the beginning of December, and nearly two years into the pandemic, researchers estimated that roughly one-third of Americans had contracted SARS-CoV-2. By the middle of February this year, that proportion had nearly doubled. Omicron’s arrival and rapid spread around the world was, and remains, this crisis’s largest inflection point to date. The variant upended scientists’ expectations about SARS-CoV-2’s evolution; it turned having COVID into a horrific norm. Now, as the U.S. approaches its Omicronniversary, conditions may seem ripe for an encore. Some experts worry that the emergence of another Greek-letter variant is overdue. “I’m at a loss as to why we haven’t seen Pi yet,” says Salim Abdool Karim, an epidemiologist at the Centre for the AIDS Programme of Research in South Africa. “I think there’s a chance we still will.” A repeat of last winter seems pretty unlikely, experts told me. But with a virus this unpredictable, there’s no guarantee that we won’t see disaster unspool again. [Read: The worst pediatric care crisis in decades] A lot has changed since last year. For one thing, population immunity to SARS-CoV-2 is higher. Far more people have received additional doses of vaccine, many of them quite recently, with an updated formula that’s better tailored to the variants du jour. Plus, at this point, nearly every American has been infected at least once—and most of them with at least some subvariant of Omicron, says Shaun Truelove, an epidemiologist and a modeler at Johns Hopkins University. These multiple layers of protection make it more challenging for the average SARS-CoV-2 spin-off to severely sicken people. They also raise transmission obstacles for the coronavirus in whatever form it takes. Omicron does seem to have ushered in “a different phase of the pandemic,” says Verity Hill, an evolutionary virologist at Yale. The variants that took over different parts of the world in 2021 rose in a rapid succession of monarchies: Alpha, Beta, Gamma, Delta. But in the U.S. and elsewhere, 2022 has so far been an oligarchy of Omicron offshoots. Perhaps the members of the Omicron lineage are already so good at moving among hosts that the virus hasn’t needed a major upgrade since. If that’s the case, SARS-CoV-2 may end up a victim of its own success. The Omicron subvariants BQ.1 and BQ1.1 appear capable of spreading up to twice as fast as BA.5, according to laboratory data. But their takeover in the U.S. has been slow and halting, perhaps because they’re slogging through a morass of immunity to the Omicron family. That alone makes it less likely that any single Omicron subvariant will re-create the sudden surge of late 2021 anytime soon. In South Africa and the United Kingdom, for instance, different iterations of Omicron seem to have triggered just modest bumps in sickness in recent months. (That said, those countries—with their distinct demographics and vaccination and infection histories--aren’t a perfect bellwether for the U.S.) For an Omicron 2021 redux to happen, SARS-CoV-2 might need to undergo a substantial genetic makeover—which Abdool Karim thinks would be very difficult for the virus to manage. In theory, there are only so many ways that SARS-CoV-2 can scramble its appearance while retaining its ability to latch onto our cells; by now, its options should be somewhat slimmed. And the longer the Omicron line of succession persists, the tougher it may be to upend. “It’s just getting harder to compete,” Hill told me. But the world has gotten overconfident before. Even if SARS-CoV-2 doesn’t produce a brand-new version of itself, low uptake of the bivalent vaccine could allow our defenses to wither, driving a surge all the same, Truelove told me. Our transmission-dampening behaviors too are slacker than they’ve been since the pandemic’s start. This time last year, 50 to 60 percent of Americans were regularly wearing masks. The latest figures, many of them several months old, are closer to 30 percent. “The more opportunities you give the virus to get into somebody,” Hill said, “the more chances you give it to get the group of mutations that could help it take off.” Immunocompromised people who remain chronically infected with older variants, such as Alpha or Delta, could also become the sites of new viral offshoots. (That may be how the world got Omicron to begin with.) Going on probability alone, “it seems more likely that we’ll keep going with these subvariants of Omicron rather than dealing with something wholly brand-new,” says Maia Majumder, an epidemiologist at Boston Children’s Hospital. But Lauren Ancel Meyers, an infectious-disease modeler at the University of Texas at Austin, warns that plenty of uncertainty remains. “What we don’t have is a really data-driven model right now that tells us if, when, where, and what kind of variants will be emerging in the coming months and years,” she told me. Our window into the future is only getting foggier too as fewer people submit their test results—or take any test at all—and surveillance systems continue to go offline. It wouldn’t take another Omicron-type event to hurl us into disarray. Maybe none of the Omicron subvariants currently jockeying for control will surge ahead of the pack. But several of them might yet drive regional epidemics, Majumder told me, depending on the local nitty-gritty of who’s susceptible to what. And as winter looms, some of the biggest holes in our COVID shield remain unpatched. People who are immunocompromised are losing their last monoclonal-antibody treatments, and although powerful drugs exist to slash the risk of severe disease and death, useful preventives and treatments for long COVID remain sparse. Our nation’s capacity to handle new COVID cases is also low, Majumder said. Already, hospitals around the country are being inundated with other respiratory viruses—RSV, flu, rhinovirus, enterovirus—all while COVID is still kicking in the background. “If flu has taken over hospital beds,” says Srini Venkatramanan, an infectious-disease modeler at the University of Virginia, even a low-key wave will “feel like it’s having a much bigger impact.” As the country approaches its second holiday season with Omicron on deck, this version of the virus may “feel familiar,” Majumder pointed out. “I think people perceive the current circumstances to be safer than they were last year,” she said—and certainly, some of them are. But the fact that Omicron has lingered is not entirely a comfort. It is also, in its way, a reminder of how bad things once were, and how bad they could still get. from https://ift.tt/b456eTm Check out http://natthash.tumblr.com |
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