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COVID-19: WHO's new coronavirus treatment guidelines - what's changed and why

New advice on how to treat coronavirus has been issued by the World Health Organisation (WHO) as it also begins a wide-reaching study into the effects of so-called "long COVID".

For COVID-19 patients at home, WHO is now suggesting the use of a pulse oximetry machine to measure oxygen levels in the blood - but warns that this should only be done after full patient education and with medical follow-up support if necessary.

For hospitalised patients, WHO is recommending the use of low-dose anticoagulants to prevent clots forming in blood vessels, known as thrombosis.

And for sufferers who are already using supplemental oxygen, the organisation is officially endorsing the positioning of patients on their stomachs to increase oxygen flow. This is known as "awake prone positioning".

The new guidelines also include a recommendation that healthcare professionals favour "clinical judgement over models" in making decisions for individual patients.

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Source: Sky News, 26 January 2021

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COVID-19: We can't bounce back with only physicians

For the last 10 months, everyone in healthcare has lived their lives as if they were trapped in a burning building without a fire escape. 

No matter how much water we throw on the fire or how many firefighters (healthcare providers in this instance) we send in, we cannot gain control of the flames. The catastrophic loss of life has been insurmountable, and we often haven’t had enough physicians to take care of everyone. 

This is not new for a healthcare system. For years prior to this pandemic, there has been a physician shortage in the United States that is expected to worsen over the coming years. The Association of Medical Colleges (AAMC) predicts that the US could see a shortage between 54,000 and 139,000 physicians in both primary and specialty care by 2033. Although the total physician supply is expected to grow, it won’t be at a fast enough rate to outpace demand. 

This is where physician assistants (PAs) and advanced practice nurses (APRNs) come in. Many people don’t realise that PAs and APRNs have been around for over 50 years. 

For 50 years, a plethora of research has shown that PAs and APRNs are safe, reliable, high quality healthcare providers and essential members of the healthcare team. But too often critics claim that because they have not gone through physician training, they cannot provide exceptional medical and surgical care. In fact, they already do. A recent comprehensive review of PA and APRN outcomes from 2008 to 2018 found that PAs and APRNs had similar outcomes compared to physicians including hospital length of stay, readmission rates, quality and safety and patient and staff satisfaction. 

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Source: The Hill, 16 January 2021

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COVID-19: Vaccines to be compulsory for frontline NHS staff in England

Frontline NHS staff in England will have to be fully vaccinated against Covid, the health secretary has announced.

A deadline is expected to be set for 1 April next year to give unvaccinated staff time to get both doses, Sajid Javid told the Commons.

Between 80,000 and 100,000 NHS workers in England were unvaccinated, said Chris Hopson, head of NHS Providers.

Thursday is the deadline for care home workers in England to get vaccinated.

The government's decision follows a consultation which began in September and considered whether both the Covid and flu jabs should be compulsory for frontline NHS and care workers. Mr Javid said the flu vaccine would not be made mandatory.

There will be exemptions for the Covid vaccine requirement for medical reasons, and for those who do not have face-to-face contact with patients in their work, he added.

In a statement to MPs, Mr Javid said: "Having considered the consultation responses, the advice of my officials and NHS leaders including the chief executive of the NHS, I have concluded that all those working in the NHS and social care will have to be vaccinated."

"We must avoid preventable harm and protect patients in the NHS, protect colleagues in the NHS and of course protect the NHS itself."

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Source: BBC News, 9 November 2021

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Covid-19: Vaccine effectiveness wanes more rapidly for cancer patients, study finds

Covid-19 vaccination is effective for cancer patients but protection wanes much more rapidly than in the general population, a large study has found.

Vaccine effectiveness is much lower in people with leukaemia or lymphoma, those with a recent cancer diagnosis, and those who have had radiotherapy or systemic anti-cancer treatments within the past year, according to the research published in Lancet Oncology.

The authors of the world’s largest real world health system evaluation of Covid-19 in cancer patients highlighted the importance of booster programmes, non-pharmacological strategies, and access to antiviral treatment programmes in order to reduce the risk that Covid-19 poses to cancer patients.

Peter Johnson, professor of medical oncology at the University of Southampton and joint author of the study, said, “This study shows that for some people with cancer, covid-19 vaccination may give less effective and shorter lasting protection. This highlights the importance of vaccination booster programmes and rapid access to covid-19 treatments for people undergoing cancer treatments.”

Study leader, Lennard Lee, department of oncology, University of Oxford, said, “Cancer patients should be aware that at 3-6months they are likely to have less protection from their coronavirus vaccine than people without cancer. It is important that people with a diagnosis of cancer are up to date with their coronavirus vaccination and have had their spring booster if they are eligible.”

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Source: BMJ, 24 May 2022

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Covid-19: US will end public health emergency on 11 May, says Biden

President Joe Biden has announced to the US Congress that he will end the country’s Covid-19 public health emergency on 11 May, although about 500 Americans are currently dying every day from Covid-19. He also plans to end the related national Covid-19 emergency.

In contrast, the World Health Organization said on 27 January that the Covid-19 pandemic was still a public health emergency.

The US administration’s statement said that extending the emergencies until May would provide time for an orderly transition. Ending the emergencies will mean that many Americans will lose the health insurance provided through the Medicaid programme, which helps people on low incomes and was extended during the pandemic. Many others will find that they no longer get free tests, treatments, or vaccines.

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Source: BMJ, 1 February 2023

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Covid-19: US sees increase in sexually transmitted diseases and teen drug overdose deaths

The prevalence of sexually transmitted diseases (STDs) and deaths from drug overdoses increased in the US over the past two years, showing the pandemic’s effect on public health.

“Even in the face of a pandemic, 2.4 million cases of chlamydia, gonorrhoea, and syphilis were reported,” the US Centers for Disease Control and Prevention (CDC) said.

STDs declined during the early months of the pandemic in 2020 but then increased rapidly. Cases of gonorrhoea increased by 10% during 2020 compared with 2019. Cases of primary and secondary syphilis increased by 7% and congenital syphilis in newborns increased by 13%.2 New data suggest that primary and secondary syphilis—the most infectious stages of the disease—continued to increase during 2021, the CDC said. 

Jonathan Mermin, director of CDC’s national centre for HIV, viral hepatitis, STD, and tuberculosis prevention, said, “The unrelenting momentum of the STD epidemic continued even as prevention services were disrupted.” His colleague, Leandro Mena, director of CDC’s division of STD prevention, said, “The pandemic increased awareness of a reality we’ve long known about STDs. Social and economic factors—such as poverty and health insurance status—create barriers, increase health risks, and often result in worse health outcomes for some people.”

Another disturbing trend during the pandemic has been the increase of deaths from drug overdoses, especially among teenagers. Just over 100 000 Americans died of drug overdoses during the year to April 2021, according to the CDC’s national centre for health statistics—an increase of 28.5% from the previous year.

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Source: BMJ, 19 August 2022

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Covid-19: US approves emergency use of convalescent plasma despite warnings over lack of evidence

The US Food and Drug Administration (FDA) has approved convalescent plasma for emergency use in hospital patients with COVID-19.

The announcement on 23 August said that the FDA had concluded that plasma from recovered patients “may be effective” in treating the virus and that the “potential benefits of the product outweigh the known and potential risks.” The move came despite the absence of results from randomised controlled trials, with only a preprint paper on the effects on hospitalised COVID-19 patients being published to date.

Experts have warned that although these early findings show promise there is not enough evidence to show that it works.

Plasma from recovered patients was approved on a case by case basis by the FDA for people critically ill with COVID-19 in March. Since then more than 70 000 patients have been treated with plasma. Emergency use approval allows clinicians to use unapproved medical products to diagnose, treat, or prevent serious or life threatening diseases or conditions when there are no adequate, approved, and available alternatives.

The FDA’s commissioner, Stephen Hahn, said, “I am committed to releasing safe and potentially helpful treatments for covid-19 as quickly as possible in order to save lives. We’re encouraged by the early promising data that we’ve seen about convalescent plasma. The data from studies conducted this year shows that plasma from patients who’ve recovered from covid-19 has the potential to help treat those who are suffering from the effects of getting this terrible virus.”

But Martin Landray, professor of medicine and epidemiology at the University of Oxford and lead researcher for the RECOVERY trial, which is comparing treatments for COVID-19, including convalescent plasma for hospital patients, urged caution. He said, “There is a huge gap between theory and proven benefit. That is why randomised clinical trials are so important. At present, we simply don’t know if it works."

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Source: BMJ, 25 August 2020

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COVID-19: UK surpasses 60,000 deaths

More than 60,000 people in the UK have now died within 28 days of a positive COVID-19 test, official figures show.

A further 414 were recorded on Thursday, taking the total to 60,113.

Two other ways of measuring deaths - where Covid is mentioned on the death certificate, and the number of "excess deaths" for this time of year - give higher total figures.

Only the US, Brazil, India and Mexico have recorded more deaths than the UK, according to Johns Hopkins University.

However, the UK has had more deaths per 100,000 people than any of those nations. In terms of deaths per 100,000 people, the UK is the seventh-highest country globally, behind Belgium, San Marino, Peru, Andorra, Spain and Italy.

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Source: BBC News, 

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COVID-19: Trump’s “distraction” by the 2020 election led to thousands of deaths, says pandemic response adviser

Deborah Birx, who was the White House coronavirus response coordinator under President Donald Trump, has told a congressional inquiry that at least 129 000 lives could have been saved if his administration had provided adequate testing and properly communicated the gravity of the situation to the public.

But the election year “just took people’s time away and distracted them from the pandemic,” she told the House Select Subcommittee on the Coronavirus Crisis. “I felt like the White House had gotten somewhat complacent through the campaign season.”

Asked if Trump did everything he should have to counter the pandemic, she said, “No. And I’ve said that to the White House. I believe I was very clear to the president in specifics of what I needed him to do.”

“If we had fully implemented the mask mandates, the reduction in indoor dining, the getting friends and family to understand the risk of gathering in private homes, and we had increased testing, then we probably could have decreased fatalities by 30-40%.” That would amount to at least 129 000 preventable covid deaths over the course of the Trump presidency, which saw roughly 429 000 reported deaths attributed to the coronavirus."

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Source: BMJ, 28 October 2021

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COVID-19: Shielding doctors express concerns about returning to work

Doctors who have been shielding during the covid-19 pandemic have said they are worried for their safety when they return to work.

From 1 August those who are at high risk of serious illness if they contract covid-19 will no longer be advised to shield in England, Scotland, and Northern Ireland.123 But doctors who have been shielding during the pandemic have expressed concerns about their safety when they return to work, and say they feel forgotten by their employers.

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Source: BMJ, 21 July 2020

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COVID-19: Safety of lateral flow tests questioned after they are found to miss half of cases

The lateral flow devices used in the community testing pilot in Liverpool only picked up half the COVID-19 cases detected by polymerase chain reaction (PCR) tests and missed 3 out of 10 cases with higher viral loads, according to the government’s own policy paper.

Given the low sensitivity of the Innova lateral flow devices when used in the field, experts are questioning how they can be used to allow care home residents to have contact with relatives over Christmas safely or for students to know for certain that they are not infected before returning home.

The information can only be found by looking in annex B of the document, Community testing: a guide for local delivery, which was published on 30 November. This is the first publicly available information about the field evaluation of the Innova tests in Liverpool which has been criticised for its lack of transparency, accuracy of the tests used, and costs and potential harms.

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Source: BMJ, 4 December 2020

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Covid-19: Public inquiry must include effects on children, say experts

The government’s upcoming Covid-19 public inquiry must include the effect of the pandemic on children and young people, a group of leading doctors and scientists have said.

The draft terms of reference for the inquiry were published on 15 March but made no specific mention of children or young people other than a single reference to “restrictions on attendance at places of education."

“There is no doubt that school closures and broader lockdowns harmed children,” said the letter to the Times signed by 50 people including Russell Viner, former president of the Royal College of Paediatrics and Child Health, and Andrew James, president of the Royal College of Psychiatrists. “Educational losses have been most marked in children from deprived families and in vulnerable children.”

They pointed out that mental health problems increased from being experienced by one in nine children and young people before the pandemic to one in six during 2020 and 2021. Childhood obesity rates last year were at least 20% above previous years.

One of the signatories to the letter, education committee chair Robert Halfon, has also written directly to the inquiry chair Heather Hallet.3 “The closure of schools and the restrictions placed on education settings has been nothing short of a national disaster for children and young people, not only in terms of their educational attainment but also with regards to their mental health and wellbeing, their life chances, and their safety,” he wrote.

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Source: BMJ, 24 March 2022

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COVID-19: Pfizer’s paxlovid is 89% effective in patients at risk of serious illness, company reports

Pfizer’s oral antiviral drug paxlovid significantly reduces hospital admissions and deaths among people with COVID-19 who are at high risk of severe illness, when compared with placebo, the company has reported.

The interim analysis of the phase II-III data, outlined in a press release, included 1219 adults who were enrolled by 29 September 2021. It found that, among participants who received treatments within three days of COVID-19 symptoms starting, the risk of covid related hospital admission or death from any cause was 89% lower in the paxlovid group than the placebo group.

Commenting on the announcement, England’s health and social care secretary, Sajid Javid, said, “If approved, this could be another significant weapon in our armoury to fight the virus alongside our vaccines and other treatments, including molnupiravir, which the UK was the first country in the world to approve this week.”

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Source: BMJ, 8 November 2021

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COVID-19: People are not being warned about pitfalls of mass testing

Only a third of local authorities that are rolling out lateral flow testing have made the test’s limitations clear to the public—including that it does not pick up all cases and that people testing negative could still be infected, an investigation by The BMJ has found.

A search of the websites of the 114 local authorities rolling out lateral flow testing found that 81 provided information for the public on rapid COVID-19 testing. Of these, nearly half (47%; 38) did not explain the limitations of the tests or make it clear that people needed to continue following the restrictions or safety measures even if they tested negative, as they could still be infected.

Although 53% (43) did advise people to continue to follow the current measures after a negative result, only 32% (26) were clear about the test’s limitations or its potential for false negatives. The advice the websites gave to the public about a negative test result ranged from “A single negative test is not a passport to carrying on your daily life ‘virus-free’... don’t let a negative COVID-19 test give you a false sense of security” to “It is good news that you don’t have the coronavirus.”

On 10 January England’s health secretary, Matt Hancock, launched the drive for local authorities to test asymptomatic people who cannot work from home, to try to halt the spread of the virus. But many public health experts are concerned about false reassurance from mass testing.

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Source: BMJ, 26 January 2021

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Covid-19: Patients without respiratory symptoms no longer have to wear a face mask in GP surgeries

Patients who enter general practices in England no longer have to wear a face mask unless they have respiratory symptoms, NHS England and NHS Improvement says. But the updated guidance also underlines the importance of local risk assessments and says that increased measures can be used when deemed necessary.

A letter sent to clinical commissioning groups and trusts set out the changes to infection prevention and control measures following updates from the UK Health Security Agency.1 It said that health and care staff should continue to wear face masks as part of personal protective equipment when working with patients with suspected or confirmed covid-19, including untriaged patients in primary care and emergency departments.

It said that universal masking should be applied when there is a known or suspected cluster of SARS-CoV-2, for example during an outbreak or if new variants of concern emerge. Health and care staff working in non-clinical areas such as offices and social settings do not need to wear masks unless it is their personal preference or if there are specific problems raised by a risk assessment.

Patients with respiratory symptoms who are required to attend for emergency treatment should wear a face mask, if tolerated, or be offered one on arrival. All other patients are “not required” to wear a face mask but can if they prefer. In settings where patients are at high risk of infection owing to immunosuppression, such as oncology or haematology, patients might be encouraged to wear a face mask after a local risk assessment.

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Source: BMJ, 13 June 2022

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COVID-19: patient dies after catching virus in Brighton ward where beds not distanced

A CORONER has slammed a hospital trust after a vulnerable patient caught Covid-19 on a ward where beds were not socially distanced.

Senior coroner for Brighton and Hove, Veronica Hamilton-Deeley, has sent a rare Regulation 28 report for the prevention of future deaths to the Royal Sussex County Hospital, following the death of 78-year-old Brian Button last October.

The grandfather-of-three from Pevensey was admitted to hospital after a fall, but contracted coronavirus on the Catherine James ward within the Acute Respiratory Unit.

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Covid-19: parents unable to see dying son

Parents to Ollie Bibby, 27, were unable to see their dying son in UCL Hospital and describe their experience as being treated 'like criminals'. 

Outrage has come after Matt Hancock, England's Health Secretary was caught having an affair with aide, breaking the social distancing rules. Mother, Penny Bibby, has said she is 'livid' that Mr Hancock broke the rules whilst she and her husband were unable to see their dying son. 

UCLH have responded that they are learning from the family's experience and are confident he received the appropriate care and treatment and offer their 'sincere condolences'. 

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Source: BBC News, 29 June 2021

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COVID-19: Packed hospitals raised death risk by 20%

COVID-19 patients in England's busiest intensive care units (ICUs) in 2020 were 20% more likely to die, University College London research has found.

The increased risk was equivalent to gaining a decade in age.

By the end of 2020, one in three hospital trusts in England was running at higher than 85% capacity. Eleven trusts were completely full on 30 December, and the total number of people in intensive care with Covid has continued to rise since then.

The link between full ICUs and higher death rates was already known, but this study is the first to measure its effect during the pandemic.

Tighter lockdown restrictions are needed to prevent hospitals from being overwhelmed, says study author Dr Bilal Mateen.

Researchers looked at more than 4,000 patients who were admitted to intensive care units in 114 hospital trusts in England between April and June last year. They found the risk of dying was almost a fifth higher in ICUs where more than 85% of beds were occupied, than in those running at between 45% and 85% capacity. That meant a 60-year-old being treated in one of these units had the same risk of dying as a 70-year-old on a quieter ward.

The Royal College of Emergency Medicine sets 85% as the maximum safe level of bed occupancy. However, the team found there was no tipping point after which deaths rose - instead, survival rates fell consistently as bed-occupancy increased.

This suggests "a lot of harm is occurring before you get to 85%".

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Source: BBC News, 14 January 2021

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COVID-19: Oxford-AstraZeneca coronavirus vaccine approved for use in UK

The Oxford-AstraZeneca vaccine has been approved for use in the UK, with the first doses due to be given on Monday amid rising coronavirus cases.

The UK has ordered 100 million doses - enough to vaccinate 50 million people.

This will cover the entire population, when combined with the full order of the Pfizer-BioNTech jab, Health Secretary Matt Hancock said.

It comes as millions more people in England are expected to be placed under the toughest tier four restrictions.

On Tuesday, 53,135 new Covid cases were recorded in the UK - the highest single day rise since mass testing began - as well as 414 more deaths within 28 days of a positive test.

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Source: BBC News, 30 December 2020

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COVID-19: Oxford University vaccine is highly effective

The coronavirus vaccine developed by the University of Oxford is highly effective at stopping people developing COVID-19 symptoms, a large trial shows.

Interim data suggests 70% protection, but the researchers say the figure may be as high as 90% by tweaking the dose.

The results will be seen as a triumph, but come after Pfizer and Moderna vaccines showed 95% protection.

However, the Oxford jab is far cheaper, and is easier to store and get to every corner of the world than the other two.

So the vaccine will play a significant role in tackling the pandemic, if it is approved for use by regulators.

"The announcement today takes us another step closer to the time when we can use vaccines to bring an end to the devastation caused by [the virus]," said the vaccine's architect, Prof Sarah Gilbert.

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Source: BBC News, 23 November 2020

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Covid-19: out-of-hours providers are drafted in to manage non-urgent patients in community

Regional NHS leaders in England have been ordered to immediately organise a primary care management service to care for covid-19 patients who “do not require immediate admission” to hospital.

In a letter sent on 8 March, seen by The BMJ, NHS England and NHS Improvement’s strategic incident director for coronavirus, Keith Willett, has ordered regional primary care and public health directors to set up a 24 hour, seven day a week service to manage patients in the community. This service should be delivered by an out-of-hours provider, and every part of England must be covered by Tuesday 10 March, the letter said.

The service will be used to manage patients who are deemed well enough to be isolated at home, with active monitoring for people who are at high risk of developing severe illness, and advice to those not deemed high risk on what to do if their illness deteriorates.

The letter advises that patients “remain in isolation until 5 days after resolution of symptoms, unless [they are a] healthcare worker or work with high risk groups, in which case require one negative sample 5 days after resolution of symptoms before return to work.”

People with mild illness and not in a high risk group will be told to isolate themselves at home and will be given health advice on how to identify deterioration. All patients managed at home will be given a phone number to call if they feel more unwell.

The letter said that the community service should be provided by a nurse and GP team and that all clinical information should be recorded and transferred to the patient’s general practice.

Providers must also provide regular situation reports, including confirmed numbers of patients cared for under the service, numbers of patients who deteriorate, and numbers of patients admitted to and discharged from the service.

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Source: BMJ, 9 March 2020

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Covid-19: One in eight adults develops long covid symptoms, study suggests

One in eight Covid-19 patients (12.7%) is likely to experience long term symptoms, a study from the Netherlands has reported.

Using digital questionnaires, researchers collected data on the frequency of 23 symptoms commonly associated with Covid in an uninfected population and in people who had had a Covid diagnosis.

The findings, published in the Lancet, found that 21.4% of adults who had had Covid experienced at least one new or severely increased symptom three to five months after infection when compared with before. This compared with only 8.7% of uninfected people followed over the same period.

The core Long Covid symptoms highlighted by the researchers include chest pain, difficulties breathing, pain when breathing, painful muscles, loss of taste and smell, tingling extremities, lump in throat, feeling hot and cold, heavy arms or legs, and general tiredness.

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Source: BMJ, 4 August 2022

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COVID-19: Nursing shortage warning as winter looms

Widespread nursing shortages across the NHS could lead to staff burnout and risk patient safety this winter, the Royal College of Nursing has warned.

The nursing union said a combination of staff absence due to the pandemic, and around 40,000 registered nursing vacancies in England was putting too much strain on the remaining workforce.

The government says more than 13,000 nurses have been recruited this year.

It has committed to 50,000 more nurses by 2025.

It also hopes England's four-week lockdown will ease pressure on the NHS.

The RCN has expressed concern that staff shortages are affecting every area of nursing, from critical care and cancer services to community nursing, which provides care to people in their own homes.

The union said it was worried the extra responsibility and pressure placed on senior nurses could lead to staff "burnout", as hospitals struggle to clear the backlog of cancelled operations from the first wave of coronavirus and cope with rising numbers of new Covid patients, as well as the annual pressures that winter typically brings.

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Source: BBC News, 7 November 2020

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COVID-19: NHS waits at record high as second wave hits care

The Covid surge in January hit key services including cancer and routine surgery, NHS England figures show.

Less than half the expected number of operations were done, pushing the waiting list to a record-high of 4.6m. More than 300,000 of those have been waiting more than a year for treatment - compared to 1,600 before the pandemic began.

Surgeons described it as a dire situation which would take a long time to turnaround.

Tim Mitchell, of the Royal College of Surgeons of England, said: "Behind today's statistics are people waiting in limbo. Many will be in considerable pain, others will have restricted mobility and be at risk of isolation and loneliness."

"Dealing with this daunting backlog will take time, and also sustained investment in the NHS," he said.

Similar problems are also being seen in Scotland where 39,000 people have been waiting over a year for treatment.

The NHS Confederation has warned the true picture could be much worse with nearly 6 million fewer referrals made by GPs in England for routine treatments, which includes operations such as knee and hip replacements, last year, suggested there was an additional hidden backlog. The organisation, which represents hospitals, said it was likely people have not sought help or found it difficult to access services during the pandemic.

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Source: BBC News, 11 March 2021

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COVID-19: NHS leaders braced for longer waiting times as service deals with fallout

Waiting times for tests and treatment not related to COVID-19 are likely to increase significantly in the second half of 2020 because of the fallout from the pandemic, the head of NHS England has acknowledged.

Giving evidence to the Commons health select committee on 30 June, NHS England’s chief executive Simon Stevens said that contrary to some commentary, the NHS’s overall waiting list actually dropped by over half a million people between February and April 2020 because fewer people were coming forward for treatment.

But, he added, “As referrals return we expect that will go up significantly over the second half of the year.”

Stevens said that there were 725 000 fewer elective admissions to NHS hospitals during March and April, but that number has begun to recover significantly. “As we speak, we think we’re now somewhere north of 55% of pre-covid-19 elective activity levels,” he said. He added that he hoped the NHS would return to around three quarters of normal activity levels by July or August.

Stevens told MPs that the NHS would pursue a range of measures to increase capacity over the coming months, including extending the deal with the private sector to use its facilities, and repurposing some of the Nightingale hospitals for diagnostic testing.

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Source: BMJ, 1 July 2020

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