Internal Medicine Faces a New Challenge as SARS-CoV-2 Infection Becomes Chronic

Limited research has been done on the follow-up and long-term effects of SARS-CoV-2 infection, despite the fact that there is growing evidence to support the idea that many SARS-CoV-2 patients, even those with mild symptoms or those who are asymptomatic, develop either long-term symptoms that negatively impact their quality of life or sequelae that may be fatal or crucial to their survival [1]. According to the guidelines, the acute phase of an infection lasts from the time it first manifests itself until four weeks have passed. In a similar vein, the Spanish Society for General Medicine (SEMG, to give it the Spanish acronym) published data from its survey of individuals with "long COVID," a term the society uses to refer to the collection of symptoms affecting multiple organs in individuals with COVID-19 (with or without a confirmed diagnosis) who continue to experience symptoms after what is thought to be the acute phase of the disease has ended4. 1,834 of the 2,120 patients who took part in the survey had symptoms consistent with long COVID.

The Impact of COVID-19 on Lung Cancer Incidence in England: Analysis of the National Lung Cancer Audit 2019 and 2020 Rapid Cancer Registration Datasets.

BACKGROUND: The COVID-19 pandemic has caused significant disruption to health-care services and delivery worldwide. The impact of the pandemic and associated national lockdowns on lung cancer incidence in England have yet to be assessed. RESEARCH QUESTION: What was the impact of the first year of the COVID-19 pandemic on the incidence and presentation of lung cancer in England? STUDY DESIGN AND METHODS: In this retrospective observational study, incidence rates for lung cancer were calculated from The National Lung Cancer Audit Rapid Cancer Registration Datasets for 2019 and 2020, using midyear population estimates from the Office of National Statistics as the denominators. Rates were compared using Poisson regression according to time points related to national lockdowns in 2020. RESULTS: Sixty-four thousand four hundred fifty-seven patients received a diagnosis of lung cancer across 2019 (n = 33,088) and 2020 (n = 31,369). During the first national lockdown, a 26% reduction in lung cancer incidence was observed compared with the equivalent calendar period of 2019 (adjusted incidence rate ratio [IRR], 0.74; 95% CI, 0.71-0.78). This included a 23% reduction in non-small cell lung cancer (adjusted IRR, 0.77; 95% CI, 0.74-0.81) and a 45% reduction in small cell lung cancer (adjusted IRR, 0.55; 95% CI, 0.46-0.65) incidence. Thereafter, incidence rates almost recovered to baseline, without overcompensation (adjusted IRR, 0.96; 95% CI, 0.94-0.98). INTERPRETATION: The incidence rates of lung cancer in England fell significantly by 26% during the first national lockdown in 2020 and did not compensate later in the year.

Ninety-day mortality following lung cancer surgery: outcomes from the English national clinical outcomes audit.

Accurately explaining perioperative mortality and risk to patients is an essential part of shared decision making. In the case of lung cancer surgery, the currently available multivariable mortality prediction tools perform poorly, and could mislead patients. Using data from 2004 to 2012, this group has previously produced data tables for 90-day postoperative mortality, to be used as a communication aid in the consenting process. Using National Lung Cancer Clinical Outcomes audit data from 2017 to 2018, we have produced updated early mortality tables, to reflect current thoracic surgery practice.

Delivery of liver services within primary care can improve treatment outcomes in persons experiencing homelessness

BackgroundPersons experiencing homelessness (PEH) often have complex health needs compounded by difficulty accessing healthcare. Liver disease is the third commonest cause for death in PEH after accidents and suicides. Some studies have identified chronic hepatitis C (CHC) in up to 50% of this population. Alcohol disorders are also extremely common.MethodsFrom June 2018, a weekly Hepatology clinic was co-located with a primary care clinic serving a population of 2,500 PEH. Blood borne virus testing, near patient HCV RNA testing, transient elastography and anti-viral drug dispensing for Hepatitis B and C was introduced. All patients with HCV were treated in line with national guidelines.ResultsBetween the period of June 2018 and November 2020, 326 patients were reviewed within the Hepatology clinic. A total of 1,236 appointments were offered with 632 attendances (51.1%).241 patients were referred due to a positive HCV Ab test. 193 were RNA positive (80%), 30 RNA negative (12.4%) and 19 had unknown HCV RNA status. Transient elastography was performed on 138 with 31 having advanced fibrosis.Treatment was initiated on 101/193 HCV RNA positive patients. 93 patients were receiving opiate substitution therapy. 65% had a co-existing mental health diagnosis whilst 24% had a significant alcohol intake, 2% were co-infected with Hepatitis B and C and 3% were co-infected with both Hepatitis C and HIV. The genotypes were 44 G1a;3 G1b;6 G2;34 G3;1 G4 and 13 unknown.There is a high rate of sustained virological response (SVR) being achieved with 61 patients having achieved SVR (82%). 13 patients needed to re-start treatment. 37 have SVR 12 pending. 3 patients have relapsed.Of the remaining 92 known RNA positive patients within the clinic, 40 identified within our service have been treated elsewhere during the peak of the Covid-19 pandemic. 24 SVR blood tests were performed for the patients treated in other locations. 21 patients are approved to start treatment. 9 are awaiting genotyping and transient elastography. 5 are no longer patients of the primary care clinic and attempts have been made to arrange onward referrals to Hepatology services in their new locations and 5 patients have died.ConclusionPersons experiencing homelessness often have difficulty accessing healthcare. By facilitating access to Hepatology services tailored to their needs at a site where they access primary care and receive opiate substitution therapy, favourable SVR rates can be achieved with significant risk reduction.

Things fall apart. The cultural complex in contemporary times1.

These extraordinary months due to COVID-19 and the Black Lives Matter protests, set as they are against a backdrop of the increasingly worrying climate emergency, have brought fear, anxiety and discord across the globe. But we have also experienced a deepening of our understanding of our connectedness, protests against injustice, expressions of social concern and a demand for change. The concept of the cultural complex as developed by Singer & Kimbles (2004) offers a helpful means of connecting the psychology of the individual psyche and the political phenomena of power relations. Using a small example to illustrate how it might operate at a local level, I suggest that a fundamental shift is taking place raising profound levels of anxiety as we move from the known to the unknown. The bipolar nature of these complexes means the extremes are surfacing bringing fears of the very real possibility of more entrenched attacks on democracy from the far right and the hunkering down behind armed borders. But there is also hope that different ways of living together may be developing from the ground up, ways that are rooted in our sense of interdependence - with each other and our planetary home.

Ces mois extraordinaires du fait de la COVID-19 et des manifestations du mouvement Black Lives Matter - sur un fond d'urgence de plus en plus inquiétante concernant le climat - ont généré de la peur, de l'angoisse et de la discorde dans le monde entier. Mais nous avons également fait l'expérience de l'approfondissement de notre compréhension de notre interdépendance, de manifestations contre l'injustice, d'expressions de sollicitude sociétale et de requête pour du changement. Le concept de complexe culturel tel qu'il apparait chez Kimbles et Singer (2004) offre un moyen utile de relier la psychologie de l'individu et le phénomène politique des relations de pouvoir. Utilisant un petit exemple pour illustrer comment cela fonctionnerait au niveau local, je suggère qu'un glissement fondamental se produit, qui fait venir à la surface des niveaux profonds d'angoisse tandis que nous passons du connu à l'inconnu. La nature bipolaire de ces complexes implique que les extrêmes font surface amenant des peurs liées à la possibilité tout à fait réelle d'attaques plus tenaces de la démocratie de la part de l'extrême droite et d'un retranchement derrière des frontières armées. Mais il existe aussi l'espoir que des manières différentes de vivre ensemble se développent à partir de la base, des manières enracinées dans un sentiment d'interdépendance - les uns envers les autres et envers notre maison planétaire.

Estos meses extraordinarios debido al COVID-19 y a las protestas del movimiento Black Lives Matter, sobre un fondo de preocupación creciente a raíz de la emergencia climática, ha traído miedo, ansiedad y desacuerdos a través del planeta. Pero también hemos experimentado una profundización en nuestra comprensión de nuestra conectividad, protestas contra la injusticia, expresiones de preocupación social y una demanda de cambio. El concepto de complejo cultural desarrollado por Kimbles y Singer (2004) ofrece una vía posible para conectar la psicología de la psique individual y el fenómeno político de las relaciones de poder. Utilizando un pequeño ejemplo para ilustrar como esto podría operar a nivel local, sugiero que está teniendo lugar un cambio fundamental, elevando profundos niveles de ansiedad a medida que nos movemos desde lo conocido a lo desconocido. La naturaleza bipolar de estos complejos significa que los extremos están emergiendo a la superficie, trayendo miedos a la posibilidad real de ataques más consolidados a la democracia desde la extrema derecha, y el acto de refugiarse detrás de fronteras armadas. Pero también hay esperanza de que puedan estar desarrollándose modos diferentes de convivencia desde la base, modos enraizados en nuestro sentido de interdependencia - con cada otro/a y con nuestro hogar planetario.

To the Point: advising students applying to Obstetrics and Gynecology residency in 2020 and beyond.

This article, from the "To the Point" series by the Undergraduate Medical Education Committee of the Association of Professors of Gynecology and Obstetrics, is a guide for advising medical students applying to Obstetrics and Gynecology residency programs. The residency application process is changing rapidly in response to an increasingly complex and competitive atmosphere, with a wider recognition of the stress, expense, and difficulty of matching into graduate training programs. The coronavirus disease 2019 pandemic and societal upheaval make this application cycle more challenging than ever before. Medical students need reliable, accurate, and honest advising from the faculty in their field of choice to apply successfully to residency. The authors outline a model for faculty career advisors, distinct from mentors or general academic advisors. The faculty career advisor has detailed knowledge about the field, an in-depth understanding of the application process, and what constitutes a strong application. The faculty career advisor provides accurate information regarding residency programs within the specialty, helping students to strategically apply to programs where the student is likely to match, decreasing anxiety, expense, and overapplication. Faculty career advisor teams advise students throughout the application process with periodic review of student portfolios and are available for support and advice throughout the process. The authors provide a guide for the faculty career advisor in Obstetrics and Gynecology, including faculty development and quality improvement.

Medical Education and Safety as Co-priorities in the Coronavirus Disease 2019 (COVID-19) Era: We Can Do Both.

As hospitals and medical schools confronted coronavirus disease 2019 (COVID-19), medical students were essentially restricted from all clinical work in an effort to prioritize their safety and the safety of others. One downstream effect of this decision was that students were designated as nonessential, in contrast to other members of health care teams. As we acclimate to our new clinical environment and medical students return to the frontlines of health care, we advocate for medical students to be reconsidered as physicians-in-training who bring valuable skills to patient care and to maintain their status as valued team members despite surges in COVID-19 or future pandemics. In addition to the contributions students provide to medical teams, they also serve to benefit from the formative experiences of caring for patients during a pandemic rather than being relegated to the sidelines. In this commentary, we discuss factors that led to students' being excluded from this pandemic despite being required at the bedside during prior U.S. public health crises this past century, and we review educational principles that support maintaining students in clinical environments during this and future pandemics.