Opinion piece: Long covid: new wine in need of new bottles, 2021, Bannerjee

Finding solutions to long covid will require new ways of thinking across clinical services and research, says Amitava Banerjee

William Osler famously said, “Listen to the patient, he is telling you the diagnosis.” For long covid, patients have not only told us the diagnosis since April 2020, but also gave a clear steer as to how we should proceed with this new disease: “recognition, research, and rehabilitation.”1 We have made mixed progress across these areas.

It is not hard to see why we have not always been successful in responding to long covid. From HIV/AIDS to Ebola, emerging disease threats with coordinated international responses are usually acute and infectious. A new chronic condition, albeit as a post-acute complication of SARS-CoV-2 infection, requires new ways of thinking across clinical, public health, policy, and academic disciplines. Whether it be the World Health Organisation (WHO), governments, or research funders, emergency preparedness has tended to exclude chronic and post-infectious disease management, but long covid must change that.

Recognition of a new disease requires it to be classifiable and recordable, facilitating monitoring, research, and treatment. SNOMED CT codes for long covid were developed and released in the UK in November 2020,2 followed by ICD-10 codes and a WHO case definition in June and October of 2021.34 However, the uptake of these codes is still low in the UK2 and worldwide, leading to a systematic underestimation of the disease burden of long covid in routine care, despite high estimated prevalence from self-reported surveys (e.g. 1.7% of the UK population as of 5 September 2021).5

https://www.bmj.com/content/375/bmj.n2736

 

Due to the large numbers and (newly perceived) urgent need caused by the pandemic, much of this knowledge dissemination is outpacing the traditional path of peer-reviewed publication. This developing knowledge seems to be on something of an exponential viral rate of transmission. I'm personally observing this happening at "internet speed".

I know I'm an optimist but I see the timeline of ME understanding forming a hockeystick graph, courtesy of COVID. (Flat for decades courtesy of BPS).

 

I don't know if we were mentioned in this essay, but the first I heard of Wessely was an article in the ME Association magazine in the 80s called "New Wine in Old Bottles" where he said that ME was just the modern name for neurasthenia with the implication it was not a viral infection but a psychological consequence of the modern world.

 

"When it comes to long covid, traditional models of care and research need to move pragmatically, adaptively, iteratively, and rapidly, considering dissemination and implementation in parallel"

I am sceptical that this says anything useful
I am also worried by the last bit. You get things right before you disseminate care.
Pragmatic has been an unhelpful term for this sort of problem.

I'm interested in seeing some new knowledge rather than mission statements.

 

Listen to the patient they are telling you the diagnosis. Sounds good but it takes time to diagnose some things, it is a process, a rather imperfect one for both clinicians and patients. As for care, validation and support is a good start and being clear on evidence base and harms.

 

Yes, I'm much more keen on getting the new information rapidly to people working in different domains, so the knowledge can build - possibly from unexpected quarters. Less so on rolling out treatments before they've been validated.

I wonder if the German apheresis clinic (through the best of intentions) have painted themselves into a corner. One good thing though is the machines are a rate limiting step. They can't possibly scale to global need - it would be a big ask even if the manufacturing, distribution and healthcare workforces hadn't been severely depleted. Suspect attention will be turned to the anti-coagulant therapies, which can be evaluated in the appropriate manner.

 

Gosh that's interesting. My great-grandfather was diagnosed with neurasthenia in the mid 1930s, and from 85 years distance, I would 'diagnose' him with ME.

Wow. I have seen it referenced as "I will argue that ME is simply a belief, the belief that one has an illness called ME". From a presentation on "Microbes, Mental Illness, The Media and ME - The Construction of Disease" given at the 9th Eliot Slater Memorial Lecture, Institute of Psychiatry, 12th May 1994.

If my severe case of the optimisms comes to pass, certain people are going to have a lot of "egg" on their faces pretty soon.

 

The article refers to Long covid as a "new disease" or "new chronic condition" four times. If long covid turns out to be the result of the same biological dysfunction as ME/CFS, it's hardly going to be a "new disease."

 

Wessely is quiet these days. Could it have something to do with a pandemic causing a ME-like illness en masse?

 

It was the other way around: Old wine in new bottles

 

From the use of this title one is left wondering whether the author is aware of the apparent allusion to Wessely, and, if not whether he should be.

It is rather telling, if Bannerjee thinks that this is an entirely new wine. What is his level of understanding of the chronic illness or disease following infection.

As a footnote, it seems to have been Shorter who killed off the neurasthenia association, by pointing out that, over the years , the term seemed to have been applied in four different sets of circumstances.

 

I did wonder about that when posting this, but as Bannerjee is corresponding author on this new paper, Preprint: Post-COVID assessment in a specialist clinical service: a 12-month, single-centre analysis of [....] 1325 individuals, 2021, Heightman et al which has no discussion of Covid infection leading to ME my guess is either he has no awareness of the possible connection, or he has and wants to disassociate all of Long Covid and ME without actually saying so.

 

It is interesting to see that he is at UCL, where Tim Kendall just happens to be the visiting Professor for Mental Health.NHS England » Professor Tim Kendall

 

Much of the contained history was interesting to read. Some of the early physicians seemed on point.

Perhaps replace 'concept' with 'pseudorandom day-to-day experiences'.

Fast-forward 30 years and in this very forum are a number of your colleagues that would have appreciated some help — some dating back to the time you were writing this. And then perhaps they and others might have been able to help all the other, non-doctory patients escape this disease. Cheers mate, thanks a lot.

Aged like corked wine in cracked bottles.

 

Don't you all like that "spurious" with its clear allusion to Eisenberg?

It is just illness behaviour, not disease. Nothing to worry about here.

 

When my kids were small, when it went quiet was the time to start worrying what they were up to.

 

I used to have a good memory but it has got much worse. I will have to remember to check these things Glad there is always someone here who gets it right, I wish my family would stop relying on me!

In the ME days, it was felt that medical staff and teachers were at particular risk of ME because they were constantly exposed to microbes. Something similar has happened with longcovid.

 

I feel as though, just as people were busy trying to meddle with the evidence base for the new guideline, they're probably busy influencing the key information disseminated about it, which follows.