should do one of those airplane announcements, you know, where our destination is COVID-19, and if you're going somewhere else, you should leave now. I am Les Kertay. I am a psychologist by training. I'm an industry consultant. I remain as senior VP of behavioral health for Axiom Medical. I don't have any conflicts that are relevant to this particular presentation. I always tell people that means I have lots of opinions, but people don't pay me for them. My colleague, Dr. Caruso, is an occupational medicine physician who's a consultant. No known conflicts of interest. I just discovered that we're going to be uploading the slides. I apologize that they didn't get done, but the last edition of the slides got uploaded at 1225 today. It's not my record. My record is finishing the last slide as I'm walking onto stage. But part of that is that this literature is so extensive, and it's constantly changing and constantly growing that it's been really difficult to keep up. By the way, I'm incapable. We got lavalier mics because I'm incapable of standing still when I'm presenting, and if this were my class at the university, I'd be walking to the back to make sure that all of you are awake back there. Dr. Caruso and I worked on this together. We have two presentations at this conference. We worked on both of them together, but we decided that it was most efficient if one of us was the primary presenter for each presentation, the other is the discussant. It's a little ironic that he's the presenter for mind, body, and the psychologist is the discussant, but there you go. This is what we did in 2022. Last year, we reviewed the literature. We went through definitions, prevalence. We're going to go through much of the same material. We're in a very different place in 2023 in some ways, and in other ways, we are exactly where we were, meaning that a great deal, a great number of the answers that we have about COVID and particularly post-COVID syndromes is, I don't know, that remains the case. I'm going to try to tell you what I think we do know, and I'm going to focus on the themes in that information, which will give us some sense of where are we and where do we think that we ought to be going. Just to put this in perspective, it's like we're all acting as if COVID is over. 7.3 million people have died worldwide since the beginning. 1.1 million U.S. deaths since the beginning. Notice the weekly numbers. Up through March of 2022, we still have 1,500 to 2,000 deaths a week in the U.S. I looked it up this morning. The average plane flight in the United States has 100 people on it. That's the equivalent of 15 to 20 planes falling out of the sky and killing everyone on board per week. We're not done, and I think that's really, really important to bear in mind. That's one of the things that I think really gets my attention. So let's talk a little bit about what's changed, and that's really the question of this presentation. Where are we now? We're going to look at terminology, incidence and prevalence, causation, pathology. What do we know about evolution? There's a lot of I don't knows in this. The information that we have on vaccination and reinfection is limited, but there's a little bit. We'll talk about diagnosis and management and what we've learned. These are the themes in what we found, and I've tried to organize all of this. Part of what happened as we were preparing this presentation is that if you're a person who keeps up with the COVID literature and the long COVID literature, it's changing constantly, and things are being published constantly. We're now at the point where we're getting systematic reviews of systematic reviews, and we still have a lot of the same problems. So what I've tried to do is organize the presentation around some of these themes, and these are the five big ones. Right? We still have a lot of trouble with definition and the design of studies, which is one of the reasons that the answer to a lot of questions is I don't know. The U.S. is an outlier, interestingly enough, in both self-reported incidents. The U.S. has much higher incidence of self-reported post-COVID syndromes than the rest of the world, but we are also an outlier in all-cause mortality, which suggests that there's more to it than just more people are reporting. There are multiple things that are going on here. I'm going to make the case that the ROI on NIH's $1.5 billion investment in long COVID to this point is exactly zero, and I'll make that point a little more pointedly later. The best practice management is still to focus on function. That's the good news for this group, because if there's anything we know, it's we know about focusing on function. Right? That's the really good news here, and again, a lot of the answers are I don't know. We'll start with terminology. I got this slide actually from a presentation that Dr. Marcos Iglesias, a friend and colleague, he did a presentation recently at Eastern Claims Conference, and I thought this was really interesting. I've always been enamored of the fact I read someplace that as far as we know, the brain is the only organ that's ever named itself. Interestingly enough, as far as we can tell, long COVID is the only illness that's ever been named by the patients. Right? This is not a term that came out of medicine. You know, hashtag long COVID was first used in May of 2020. It's pretty early on, if you'll recall. In June of 2020, we had a small paper describing nine patients saying that COVID-19 can last for several months, and then long haul COVID around that same time was coined by Amy Watson in a Facebook group, the long haul COVID fighters, and I have to say there's a fair amount of, I think, problematic information that gets promulgated there, but there's also really good information, so it's worth looking at. You know, patients do know something about what's going on with them, but this is really fascinating, right? We have, and we've now invested, again, NIH has invested $1.5 billion investigating a disease that was named by the patients. I think that's kind of an intriguing thing. The terminology remains all over the place, long COVID, long term COVID, long haul COVID, post-acute sequelae or PASC. Our preferred term is just post-COVID conditions, and you'll see some reasons behind why we like that. Pick one. Part of the problem in the literature is that people use different definitions and different language to describe these things, and some papers that I've read actually use these same terms as if they're referencing different things. I don't think there's a basis for that in the science. This is the Department of Health and Human Services working definition, which I will confess makes me a little bit crazy, as you can tell from all the color in this. It used to have more color. I took some out today, but this highlights a couple of issues that you're going to see. One is that the Department of Health and Human Services says these signs, symptoms, and conditions are present for four weeks or more. So that's one definition is duration. They describe it as relapsing and remitting or progressing or worsening over time. That's an interesting thought that it's worsening over time. Addresses the possibility of severe and life-threatening events, even months or years after infection. Notice that this was published in 2022. So how did we know that it can last for months or years? How did we know that it had life-threatening complications at that point? I mean, we were too early in this. And assumes biological causes with different sets of risk factors and outcomes. I would suggest that that definition is a little bit out over its skis in terms of there being biological causes that we can identify or in different sets of risk factors. The WHO definition continues continuation of development or new symptoms three months after the initial. So we had one that says four weeks. We have one that says three months or more after. And then lasting two months or more with no other explanation. That's an important caveat in that that gets ignored a lot. But this highlights one of the, and we do now have an ICD-9 code or ICD-10 code, you can tell my age. In the articles that we read in preparing for this talk, we saw ranges of duration anywhere from four weeks to six months in the definition of long COVID or post-COVID conditions that was being described. Well, you can imagine, I mean, how does that impact prevalence, incidence, duration? What's the bias in that? Why did somebody pick four weeks and somebody else picked three months and somebody else picked six months? I mean, obviously because we see declining, and you'll see this in a minute, because we see declining report of symptoms over time, if you pick six months, you're going to come up with one set of numbers. If you pick four weeks, you're going to come up with a different set of numbers. That's a huge problem. That's just in the ones that we read. These are papers since the 2022 presentation that we did last year. Here's my bottom line in this question of incidence and prevalence. We still can't agree on what we're measuring, when to measure it, or how best to measure it. We do not have consensus on this. That doesn't mean that we aren't learning something, but it does mean that when we read the literature, we really have to like dig into the articles to understand what they're talking about. Also, this is usually mentioned in the systematic reviews and the meta-analyses. It's really important to go beyond the systematic reviews and actually look at the original papers, because chances are they didn't use the same definitions in the underlying studies, and that's a big deal. A little bit more about incidence and prevalence. I use this slide because one of my favorite sayings is, if you hear hoofbeats, don't think zebra. We'll get to that in a minute. This is a repeat from our presentation last year that I just want to point out, because I got really, really, initially, I got really interested being a psychologist in these studies that we were seeing where we had this huge spike of anxiety and depression associated with COVID. I started to ask myself, well, how are we assessing that? We have huge numbers in some of these studies. We had a VA study that had 7 million people in the study. How did we measure that? I decided that I would take a look at the question of sensitivity and specificity, and in terms of what we know about base rate in depressive disorders. These are the assumptions of this particular square. Point prevalence of about 8% for a depressive disorder. In any two-week period, that's the population. The sensitivity of the PHQ-9 is about 0.88, and the specificity is also about 0.88. That's unusual. Makes the PHQ-9 an unusual instrument in this. Note, by the way, that I couldn't really get reliable information for the PHQ-2, which is actually what's mostly used in these studies. Let's just say it's equivalent to the PHQ-9, 0.88. Those are pretty good numbers. What that means is that with a point prevalence of 8% and sensitivity and specificity of 0.88, you get 110 population negatives out of 1,000 points, which means 61% of the positives on the PHQ-9 are false positives. I have since repeated this with screening measures for anxiety, PTSD, a number of other things, and they all come out about the same. Now, does that mean that we shouldn't screen for mental health conditions? Well, no, but it does mean that we absolutely have to stop using screening measures as a diagnostic, and it means that if we're looking at epidemiology of mental health conditions, we have to really be aware that we're not talking about the gold standards. We're not talking about diagnosable conditions. We're talking about positive screens, and those are two very different things. I think that's worth keeping in mind. The other thing to keep in mind is baselines. Many of the studies, this is one thing that has improved in the last 12 months. One of the things that's improved is that we're starting to see more studies that look at comparing baseline symptom and condition to post-COVID, which makes some sense, but we're going to see that if you don't take into account baselines, we get very weird numbers. This is not an eye test. You're going to have the slides. This actually comes from a series of studies that are now somewhat old, 1993 to 2003. These were from TBI studies. These are the incidences of common symptoms in the healthy population, the people who did not report a TBI. I'm going to use this as an example later for something to point something out, but what you'll see is that headache, forgetfulness, dizziness, ear ringing, all of these things have pretty high incidences in the healthy population. Well, okay, so if those are the symptoms that are being reported post, in this case, TBI or post-COVID, well, have we factored in how that compares to the baseline and does it make a difference? The answer is that in many, many studies, we have not done that work. We do know that there are risk factors. Severity is a decent predictor of post-COVID symptoms. That actually makes sense medically. We would expect that. Underlying health conditions makes a difference. Vaccination turns out to make quite a difference in terms of COVID severity and also post-COVID. And we know that pre-COVID, some of these risk factors had an impact on severity, diabetes, Epstein-Barr, viremia, hypertension, obesity, and a psychiatric diagnosis pre-morbid was a good predictor. And then demographic factors. These should be relatively familiar if you've been following along with the literature. And I assume that you have at least a passing interest in this or you wouldn't have wandered in. This is a global study looking at symptom duration. This is a good study across a number of different countries. I got interested in it because it sorted out these three symptom clusters. And we're starting to see that there are different clusters that happen. And these are showing up more and more in the literature. Persistent fatigue with pain or mood swings. Cognitive problems is in a cluster kind of all by itself. I'm going to say a little bit about that specifically as we get to it. And then ongoing respiratory problems is actually the single largest group. That's the biggest one. Overall, after adjusting for pre-COVID health status, the incidence of post-COVID conditions, they used a three-month definition was about 6.2%. So that gave me sort of a baseline. What's it look like across the world? Compare that to some of the other things that we've seen. This is work comp data. New York State New York State Insurance Fund found an incidence of 31% of people continuing treatment post-COVID. In their sample, NCCI found 24%, 47% of hospitalized patients. This morning, I attended an excellent presentation on COVID and workers' compensation, citing the WCRI data particularly. They found 7% report of symptoms, which is a lot closer to the rest of the world. But those data were from six months post-COVID. So again, if it's declining post-initial condition, we'd expect that that number would be smaller. But that got a lot closer. How's that translate into the workforce? This is from the Household Pulse Survey. So this is all self-report. These are people reporting their own symptoms. And from their data, which started in June 2022, about 16 million working-age Americans have long COVID. That's 7.7% of the working-age population. That's a lot. Of those, about 2 to 4 million, which is 1% to 2%, were out of work. It's a significant amount of money. Again, compare that to the Federal Reserve Bank of Minneapolis, finding 24.1% of people who contracted COVID experienced symptoms for three months or more. Guess what they didn't control for? They didn't require as much as they didn't require an actual positive test or diagnosis. They didn't even require a presumptive diagnosis. We'll get to that again in just a minute. In trying to correct for this, this was a study. Ballering 2022 is a good study. They looked at pre and post. And they specifically tried to control for premorbid conditions. This is out of the Netherlands, so it's not quite the same. We have to acknowledge that. But 21.7% of COVID patients had at least one symptom, at least moderately increased 90 to 150 days after COVID. However, when they corrected for premorbid condition, that dropped to about 12.7%. So that's considerably lower than what we got when we simply looked at it without measuring baselines. That begins to correct some of the numbers. I won't spend a lot of time here, but the important here in Belinsky's paper, and by the way, we'll upload the whole reference list for these articles as well. So you'll have all of this. If you want to dig into it. And if you're obsessive compulsive, I highly encourage it. Or if you need help getting to sleep at night. This was really interesting because the US had substantially higher all-cause mortality than any of the other comparator countries, almost double the next highest, which was Finland. And this is across both Omicron and Delta. It varied a little bit based on the, not too surprisingly, based on the strain. But this is a lot higher. And this is kind of my favorite way of looking at what impacted COVID and the pandemic together, because I think those are two separate things. What impact did it have? Because it gets away from all of that question of, well, did people die of COVID or did they die with COVID? It just looks at, well, how many more people are dying during this period of time? And it's quite significant. So we're an outlier. They did look a little bit more closely at vaccination rates. And so what they did was they looked at the US data by county. And what they found is that the all-cause mortality rates in counties with the lowest vaccination rates were substantially higher than those with the highest vaccination rates. And then when they went back and looked at the countries, they found the same thing. So clearly, and this is a part of an accumulating body of information, that whatever you think about the vaccinations, how vaccinations got politicized is a whole other conversation. Probably appropriate for a psychologist, but I won't go there. But it's clear that vaccination status reduces severity of the disease. It reduces the number of deaths. It just does. At this point, I think the evidence is pretty overwhelming. Yes, there are some studies that shed some question on it. But I think, in general, that it's fairly uncontroversial. This was an interesting study. Ahmad, late 2022 publication, just looked at deaths with the COVID ICD-10 code and text that referenced past or long COVID or any of those labels. And it's a fairly small number. Not sure what that means, but it's at least an interesting insight into a different methodology to look at, well, OK, what's all-cause mortality? What's specific to COVID? But it has all the problems of, well, how good a job did we do at recording cause of death? And so it's problematic, but it's interesting. In general, what we're finding, this is kind of a summary of the data that are accumulating. Somewhere in the neighborhood of about 6% of people who have COVID, who have diagnosed COVID, continue to have symptoms subsequently. So this is when it's controlled for. You actually have to have had a diagnosed condition. It's one month or more after. We're starting to zero in on that 6% to 7% range. Remember what we were seeing a year ago? I mean, we were seeing reports of 20%, 40%, 50% of people who had long COVID. And everybody was terrified. Now, not only did we have a novel disease that might kill us, we had a novel disease that might make us chronically ill forever. It's starting to look considerably smaller than that. We are actually, these are data from the PULSE study. So even in self-reported data, we're seeing a gradual decline in the number of people that are reporting post-COVID, either currently or ever had it, post-COVID conditions. And it's starting to go down. But note the difference between this slide, roughly 6-ish percent, and self-report. Those numbers are very different. Again, it makes a difference what the methodology is. And then finally, looking at mental health symptoms before or after. This is a really well-done study published just this year, looking at studies that accounted for incidents of symptoms of general mental health distress, anxiety, or depression. Those were the three things that they looked at in periods of time before COVID, and then since COVID. And when they corrected for that, what they found were statistically significant, but very small, decrease in general mental health, depression, and anxiety for women. There was some indication that it was somewhat worse for parents. And it was somewhat worse for students. Now, if you think about that, that makes perfect sense. Who was more impacted by job layoffs? Women. Who were more likely to be home taking care of their kids? Women. Makes perfect sense when you think about it. The important thing here is that when we corrected for baseline, the differences are extremely small. And in the general population, none of those three, general mental health, depression, or anxiety, none of them were worse from before to after. That's really important, because that's a totally different picture than the data that we were presenting a year ago. So now we're starting to see something that begins to make a little bit more sense. So long COVID appears to be less common than earlier in the pandemic. It's not really clear whether it's lower severity of the variants or other factors, but that certainly is happening. The incidence of post-COVID impacting work, the percentage of people that reported impacting work, is roughly the same in the US and the UK. We often use the US and UK as comparators. It's roughly the same. But the incidence of post-COVID conditions itself is substantially smaller in the UK. So I will tell you, I don't know exactly what to make of that. But there remain these kind of differences in self-report and in terms of how it impacts work. I'm going to say more about that in just a little bit. And finally, vaccination makes a difference. I hope that that's not terribly controversial. Here's the bottom line. We're zeroing in on what the incidence is. It's lower than we thought it was. It's lower than uncontrolled self-report. And it seems to be decreasing over time. So I guess I'll take a minute just to say something. I've mentioned it before. I think we have to really think about COVID as one thing, as the diagnosed COVID. And we have to think about the pandemic as something else. Most of us, when COVID first happened, we stayed home a lot. We lost a lot of our typical coping mechanisms. We weren't going out and hanging out with friends. We were dealing with a novel condition that we didn't know what was going to help. Were masks going to help? Was cleaning surfaces going to help? Remember spraying your grocery bags down with bleach? I mean, we didn't know. And so we were scared. I mean, is it any wonder that we had a high incidence of reported symptoms of anxiety? I mean, we were sitting around waiting to die. But partly, the way that we reacted to that in the US was to really constrain our activity in ways that some other places didn't, and some places within the US didn't. Then it became all politicized, and we lost all control over anything. My point here is that the pandemic has won us over. I can't tell you what they are, but I think that it just makes sense to begin to look at both. The great unknown is like the operative word in that particular title. The Department of Health and Human Services is a great example of that. It's a great example of what we're trying to do, and it's a great example of what we're doing. And I think that we're going to continue to do that. I think that we're going to continue to do that, and we're going to continue to do that, and we're going to continue to do that. 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Then we have all of these. These are all the things that are being reported. And by the way, almost all of these come from a listing on the CDC website for symptoms of post COVID conditions. Fatigue, post exertional malaise, fever, dyspnea, etc, etc, etc. I won't read the whole thing. They do not mention dysautonomia and POTS, but we're hearing a lot about that. You know, now I'm going to go back to that. In just a second, I'm going to go back to that baseline slide. Because here's the symptom frequency as it's being as it's being reported. I'm going to draw your attention to that box. These are the most common things that are reported post COVID, which is ongoing respiratory problems. Again, makes a certain amount of sense, particularly in the earlier variants and the variants that have had primarily respiratory impact. It just makes sense, right? We have ongoing things. Good news is we should be able to assess for this and offer at least supportive treatments for it. Right. Now let's look at fatigue. 13 to 87%. It's pretty wide. Right. But that's the symptom frequency across studies of post COVID conditions is Mickelson's summary article. This is fatigue in this old set of data about baseline fatigue in studies of the healthy cohorts associated with studies of TBI. And what you'll notice is that it ranges from a low of 46% to a high of 46. Yeah, 46 point or 76.9%. There's the number. There's that set of numbers. You know, fatigue is incredibly my point is fatigue is incredibly common. So what do we do with post COVID reported fatigue? Is it baseline fatigue? Is it something new? Is it, you know, and, of course, we have the problem. I'll come back to this, but we have the problem of people misremembering their histories naturally, which is substantially problematic. You know, one of the things that's also getting getting reported very, very frequently is brain fog. And, of course, there's the question of, what is it? And when people have studied it in association with post COVID conditions or any other condition, what we find is that it's relatively common as a baseline, and it does not show up in cognitive testing. Has anybody ever gotten up after not enough sleep and felt a little foggy? Right, raise your hand if you have not. I mean, fatigue, brain fog. You know, this is a very common condition that is not measurable. And yes, it's a very real subjective experience. When I am brain fog, I am brain fog, and I should not be entrusted with, you know, high powered construction equipment, nor should I probably be driving long distances. That being said, I do not blame it on, you know, the fact that I whacked my head a few weeks ago or on respiratory conditions. By the way, I've met for some bizarre reason, I have to find wood. This is not wood. I have to find wood to knock on. I've never I haven't yet gotten COVID, which is very interesting given that my wife has had it twice. I've stayed in the same room with her. She had a very severe case and then a much milder case later. I've never gotten it. Right? We really need to study that. Right? Why do some of us get it multiple times, others of us don't get it despite clear exposure? You know, I think that's just an interesting question. When we look at memory deficits, they also are all over the map. Essentially, every time that we've looked at this, any summary articles about neuropsychological testing of people, post COVID, we are not finding evidence to document those cognitive complaints. Again, bear in mind and those of you who have heard me speak before who know me and know us know that our kind of mantra consistently now is rigor with compassion. Right? It's one thing to look at epidemiology and causation. It's another thing to have a patient in front of you that you need to take care of. So I'm not saying that people don't have symptoms that we shouldn't care about them. What I am saying is that we probably need a different approach than saying, Oh my gosh, that's because you had COVID. Because chances are it's probably not. Psychological changes. This one is another one where we looked at pre and post, we looked at people who had COVID for short periods of time, they tended to get have more depressive and anxious symptoms. The depression stayed, the anxiety didn't, did not control unfortunately, for pre morbid condition. Anxiety got better in the short COVID group didn't get better in the long COVID group. None of this is should be surprising to us. This is a fascinating study out of France. I really it's a well controlled study I give I give Dr. Caruso credit for finding this. It's a really well done study out of France that demonstrated basically that the belief in having had COVID correlated more highly with post COVID conditions than actually having had the condition. That's it. That's a really important study in two ways. One is it could give us pause to say, people who are reporting post COVID aren't having a problem. That's one thing to do. That's the rigor part. You know, the compassion part of me says, our beliefs have a lot to do with the way that we process information, and how we respond to people who present with symptoms. And it's really important to pay attention to those things. And I'll get I'll say more about that in in a minute, right? You know, many of the predictable, the good news is that many of the predictable sequelae of severe infection have testing available with known treatments, we should, we should assess for those things. And we should provide supportive treatment, respiratory distress, cardiac problems. Some of the medically explained conditions have some testing available. tilt test table for pots, for example, I cannot tell you the number of cases that I have seen of pots that were diagnosed without bothering to do tilt test table, or even doing the simple exam of sit in the chair, let me see what your pulse is, stand up, take your pulse. I mean, it's a really simple exam to do. I can't tell you how many cases of pots I've seen where that no one's ever done it. Well, what differences make? Well, for one thing, you want to you want to differentiate between pots and postural orthostatic hypotension, right? Like, what is it dehydration? I mean, these are things that really need to get done. We could do them. But But unfortunately, too often, we don't and you all probably know better. So we can diagnose expected sequelae, but we really have no diagnostic measures for long for long COVID. So let's stop pretending, right? Maybe we'll find one eventually. We don't have it at this point. All right, last thing. We are learning something some authors have suggested that we focus on myalgic encephalopathy, chronic fatigue syndrome literature for suggestions for treatment. I personally don't recommend that because I don't think that most of that literature is very helpful for people with chronic fatigue syndrome, my, you know, myalgic encephalopathy, call it what you what you'd like. It does point out something useful, which is that post viral conditions have been known for a long period of time. This is not something that's brand new to COVID. So I think that's an important finding. paxlovid seems to have some pretty good outcomes at this point that's still being tested. Some of these treatments are, are, are helpful, you know, dozens of rapport, dozens of clinical trials nationwide, are already underway or starting soon, many of which are aided by 1.5 billion, I want to emphasize again, $1.5 billion investment from the National Institutes of Health. I have to do this other brief aside, you know, the difference between a million and a billion. Right? A million seconds is 11 days, a billion seconds is 23 years. Right? When you're talking about $1.5 billion, you're talking about a lot of money. And we've gotten, we don't have diagnostic measures, we don't really have anything. There, there is, there are arguments for multidisciplinary treatment. This is an example of paper by Lane lays out the reasoning for all of this. Unfortunately, although this is a very well written and well articulated article, there are no outcomes reported. You know, which didn't help me evaluate whether it's helpful or not. Right? More is not necessarily better. You know, what did we find after we looked like really, really hard at what works, pay attention to function. That's the good news. We're, we're in a room full of occupational medicine professionals. You know, the only programs that we have seen that consistently report good results are those that focus on, you know, doing the initial testing for things that are testable and treatable, and then providing reassurance in a meaningful way, and helping people get back to function. It's the only thing we've found that works. By the way, it's pretty much the only thing that works in disability in general, but long COVID can be an ADA condition. I will point out that Department of Health and Human Services, you know, got pretty waxed pretty eloquently about lung damage, heart damage, kidney damage, neurological damage, for, you know, long term damage, none of which we have good evidence for. But nevertheless, you know, there it is. And there's the justification. This is also data from the National Pulse Survey. People, there are quite a large number of people back to self report, the numbers are bigger. Quite a number of people report symptoms of long COVID and report some functional impairment. But many fewer of those people report that those functional limitations are significant. That might explain why there are so many fewer people out of work than report long COVID in general. Okay, this is Les Cortes potshot recommendation for treatment protocol. It starts with unsurprisingly, listen to your patient, have them tell you what it is that's going on. Secondly, take a careful history including risk factors, look for risk factors, understand prior treatments, verify infection, if you can, how severe was it? What's their vaccination status, all the things that we could do. Take a careful review of systems. Trust but verify. I'll say more about that in just a minute. But it's really important to listen to your patient, but that doesn't. So I always listen to my patients. I don't necessarily take their word for everything they tell me. Because a, they're psychotherapy patients, and by definition, they may distort things. That's part of why they're there. But that's also true in medicine. I'll say just a little bit more about that in just a second, where we'll wrap up. Test for known sequelae where you can, and then listen some more. Do a reasonable amount of testing for things that are testable. Keep listening, keep talking to that person. Once you get to that point, and you haven't found anything you can treat, reassurance and support is the most important thing. And notice reassurance has to have meaning to the person. It's going to be fine. How many of you have been told when you have a complaint, it's going to be fine? How many times does your spouse say to you, don't worry, honey, it'll be fine? How's that work for you? How's that work, more importantly, how's that work for your spouse? Probably not that well. Simply reassuring is not enough. You have to be able to say to someone, listen, I've taken the history, I've looked at where you are, we've done the testing that we can for things that we can offer treatment for. What's left is really about helping you get back to your life. And that's what I'm going to help you do. That's reassurance that most people can relate to. Notice, I said, I'm going to help you get back to your life, not back to work. Because that takes that complication out of the question. So that's a whole other topic. I'm happy to talk about it sometime. Educate on the value of function, including work. We all know the negative health outcomes of being out of work are awful. And you know, involve employers when you can for accommodations. That's the one thing that we found that actually works. And then listen some more to what they say and keep talking to them. So that's my treatment recommendation. There you have it. That is, in a nutshell, is what the programs that seem to be working seem to have gone for them. You know, bottom line is, I've said it a couple of times, we have no ROI. But the good news is we know what to do, because we've always known what to do. A very quick return to the fact that, you know, we have a lot of these difficulties in the literature, I've been mentioning them as I go along. If you're not aware of it, there's a very interesting cautionary tale from Dr. Paul Garner, who was an infectious disease doc, who always was, you know, kind of skeptical about chronic fatigue syndrome. He had post COVID syndrome, he was became the darling of the CFS ME crowd, because he was admitting that he had these terrible symptoms. And then he had the audacity to encounter someone who helped basically helped him, reassured him, helped him with something he could understand, he got better, and said, and published that and said, Listen, this worked for me, you should try this. And he has since been in widely vilified by those support groups, which I think is telling right people who with long COVID people with with chronic fatigue syndrome, are really vilifying him. I thought it was interesting one month of time 2022. They found in Australia 1.6 tweets looking for deep state hoax bioweapon and COVID 1.6 million likes and 580,000 retweets in one month at the end of 2022, when supposedly disinformation is better. My personal favorite was a response on a blog post of a friend of mine who was writing about ivermectin and worker comp, and saying, you know, yay, we finally got rid of it. And one of the comments was about how important it was for her post COVID patients. And my personal favorite, some people benefit from serotonin focus medications to minimize the depression and anxiety caused by the neural inflammation that disrupts the serotonin absorption in the brain. There are like eight things in that one phrase for which there is absolutely no scientific basis whatsoever. This is what's passed, but it sounds smart, right? And this is what happens. Okay. I guess I, unfortunately, somehow the slide got got dropped out, I did forget to there, it's in your deck, but I probably hit it inadvertently. Look at the literature about how, how much people distort their previous histories, right? We always remember that our past as being better. Oh, no, doc, I never had back pain. It's important to read records. Let me, let me just put it, let me just leave it at that. You know, here's what we know, we can't agree on what we're measuring studies remain plagued by bias and poor design. I think we're getting there in terms of incidents, and it's lower than we thought. And certainly lower than self report, we can't rely on that. There's still no diagnostic measures or known treatments, and misinformation and disinformation refuses to die. But focusing on function is the one thing that we know that works. And I'll, I'll leave you with that, right? This is, this is our kind of mantra. So, all right. And I didn't leave time for questions, but I'm going to hang out. So I apologize. Thank you very much. How'd I do it, chief?

long COVID

post-COVID conditions

terminology

diagnose

patient symptoms

respiratory problems

fatigue

brain fog

reassurance

vaccination