AdvertisementContinue reading the main storySupported byContinue reading the main storyDiagnosisHer Eyelid Drooped and She Kept Getting Weaker. What Was Going On?Dozens of tests turned up nothing. Then a specialist had a theory.Credit…Photo illustration by Ina JangMarch 4, 2021, 5:00 a.m. ETThe voice on the phone was kind but firm: “You need to go to the emergency room. Now.” Her morning was going to be busy, replied the 68-year-old woman, and she didn’t feel well. Could she go later today or maybe tomorrow? No, said Dr. Benison Keung, her neurologist. She needed to go now; it was important. As she hung up the phone, tears blurred the woman’s already bad vision. She’d been worried for a while; now she was terrified. She was always healthy, until about four months earlier. It was a Saturday morning when she noticed that something seemed wrong with her right eye. She hurried to the bathroom mirror, where she saw that her right eyelid was drooping, covering the top half of the brown of her iris. On Monday morning, when she met her eye doctor, she was seeing double. Since then she’d had tests — so many tests — but received no answers. The woman walked to the bedroom where her 17-year-old granddaughter was still asleep. She woke her and asked for help getting dressed. Her hands were too weak for her to button her own clothes or tie her shoes. When she was completely dressed, she sent the girl to get her mother. She would need a ride to the hospital. She hadn’t been able to drive since she started seeing double. Dozens of TestsThe events of the past few months had left the woman exhausted. First, she had seen her eye doctor. He took one look at her and told her that she had what’s called a third-nerve palsy. The muscles of the face and neck, he explained, are controlled by nerves that line up at the top of the spine. The nerve that controlled the eyelid, called the oculomotor nerve, was the third in this column. But he didn’t know what was affecting it or how to fix the problem. She needed to see a neuro-ophthalmologist, a doctor who specialized in the nerves that control the eyes. That specialist saw her right away, but he couldn’t tell her what had caused her double vision either. And since then, she had seen many specialists and had dozens of tests: blood tests, CT scans, M.R.I.s, biopsies. No one could tell her what she had, but she now knew a long list of terrible diseases that she didn’t have. It wasn’t a brain tumor or an aneurysm. She hadn’t had a stroke. There was no sign of a vasculitis. All that testing was draining. She felt so weak, so tired. She was a salesperson in a department store and often had to move items on the floor. It wasn’t a strenuous job, but lately it was a lot harder. Her hands seemed to lack strength; she bought a brace for her wrist, but it didn’t help much. It got so bad that it was hard to even open a door. When she told Dr. Alissa Chen, her primary-care doctor, about it, Chen got worried. She was still in training, but the patient trusted her. Chen examined her hands and arms closely. Her muscles were very weak. That’s when she ended up in the hospital the first time. Chen sent her straight from her office to the emergency room. She spent three days in the hospital. There she met Keung, a specialist in diseases of the nerves and muscles. He ordered more blood tests, another M.R.I. and a spinal tap. By the time she went home, he had only added to the list of diseases that had been ruled out. It wasn’t multiple sclerosis or Guillain-Barré syndrome. It probably wasn’t sarcoidosis. It probably wasn’t cancer, though she was supposed to go see an oncologist to make sure. Credit…Photo illustration by Ina Jang400 in a MillionWhen she got home from the hospital, Chen called her. She had a theory about what the patient might have. Had she ever heard of a disease called myasthenia gravis (M.G.)? In this rare disorder, the body’s immune system attacks what’s called the neuromuscular junction, the point where the nerves connect to the muscles to tell them what to do. It often starts in the eyes — with a droopy eyelid and double vision. But then it usually spreads to other parts of the body. Patients with myasthenia have muscles that tire out much more quickly than normal. There are fewer than 400 cases per million people, and Chen had never seen a case; still, she thought there was a strong chance the patient had it. A simple blood test could give them an answer. She had ordered it already, and she urged the patient to go to the lab and get it. Three weeks later when she went back to see her doctor, the patient still hadn’t gotten the test. And now she had a new problem: Her mouth felt weak. Talking was hard; her voice was different. By the end of even a short conversation, her words were reduced to whispers. She couldn’t smile, and she couldn’t swallow. Sometimes when she was drinking water, it would come out of her nose rather than go down her throat. It was strange. And scary. Chen wasn’t there, so she saw a colleague, Dr. Abhirami Janani Raveendran, who was also a trainee. Raveendran had never seen M.G. either but knew that it could affect the muscles of the mouth and throat. She urged the patient to get the blood test, and she sent Keung a note updating him about the patient’s disturbing new symptoms and the possible diagnosis. When Keung saw the message, he was alarmed. He agreed that these symptoms made myasthenia gravis a likely diagnosis. And a dangerous one: Patients with M.G. can lose strength in the muscles of the throat and the diaphragm and become too fatigued to take a breath. He called the patient. Her voice, he noticed, was nasal and thin — signs of muscle weakness. She said she wasn’t having any trouble breathing, but Keung knew that could change. That’s why he told her to go to the hospital right away. He scared her. He meant to.A Series of Small ShocksAfter the patient got Keung’s urgent call, her daughter drove her to the emergency department at Yale New Haven Hospital, and she was admitted to the step-down unit. This is the section for patients who are not quite sick enough to need the I.C.U. but might get to that point before long. Every few hours a technician came in to measure the strength of her breathing. If it got too low, she would have to go to the I.C.U. and maybe end up on a breathing machine.Keung wasn’t certain that the patient had myasthenia. Her eyelid was always droopy, her vision always double. With M.G., he would expect those symptoms to worsen after using the muscle and improve after resting. And M.G. usually affected the muscles closest to the body. He would expect her shoulders to be weak, not her hands. Despite his uncertainty, he decided to start the treatment for M.G. He didn’t want to risk having her become even weaker. She was given high-dose steroids and intravenous immunoglobulins to suppress the parts of the immune system attacking the connection between her nerves and her muscles. The next day Keung performed a test that would show whether the patient had M.G. In the repetitive-nerve-stimulation test, a tiny electrode is placed over the muscle, in this case the abductor digiti minimi, the muscle that moves the pinkie finger. A series of small (and uncomfortable) shocks is delivered in rapid sequence, each causing the muscle to contract. In someone with normal nerves and muscles, each identical shock will produce an identical muscle contraction. In this patient, though, the first shocks produced weak contractions and then they became even weaker. That drop-off is characteristic of M.G. The blood test that Chen had been urging her to get was done in the hospital. It was positive. She had myasthenia gravis.The patient stayed in the hospital for nearly two weeks. That first night her breathing was so bad she almost ended up in the I.C.U. And there were days when her arms were so weak she couldn’t even feed herself. Her daughters and granddaughters took turns coming to see her in the hospital to help her eat and care for herself. But slowly her strength began to return. Her voice came back, and she was able to swallow. She graduated from puréed foods to chopped and ultimately back to a normal diet. And finally she went home. That was four months ago. She will probably need to take immune-suppressing medications for the rest of her life. And she still has double vision in bright light. But, she told me when I saw her recently, she can smile again. That’s important, too.Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is ‘‘Diagnosis: Solving the Most Baffling Medical Mysteries.’’ If you have a solved case to share with Dr. Sanders, write her at Lisa .Sandersmd@gmail.com.AdvertisementContinue reading the main story

#masthead-section-label, #masthead-bar-one { display: none }At HomeFall in Love: With TenorsConsider: Miniature GroceriesSpend 24 Hours: With Andra DayGet: A Wildlife CameraAdvertisementContinue reading the main storySupported byContinue reading the main storyTimes InsiderHow Our At Home Writer Is Coping at HomeWe asked Melissa Kirsch to talk about ways she keeps her spirits up and her day meaningful. For her, it starts with a movie night.Keeping a log book of some of the small details of a day can serve as a record of this time.Credit…Getty ImagesMarch 4, 2021, 3:44 a.m. ETTimes Insider explains who we are and what we do, and delivers behind-the-scenes insights into how our journalism comes together.As we remain in quarantine, unsure if the slow jog to normalcy is a few more miles or a million, Melissa Kirsch, a culture and lifestyle editor, is part of a team at The New York Times that spends a lot of time thinking about how to embrace a full and fulfilling life in isolation. We asked Ms. Kirsch, who writes the At Home newsletter, to share what she has learned in the last year and talk about some of her own strategies for living well during an uncertain time. The following are her edited comments.Give myself something to look forward to. On Monday nights, I meet up with two friends on FaceTime to watch a crime documentary. We don’t talk during the movie, but having them in the room, even on a screen, makes the experience more exciting. If my energy starts to flag in the middle of a Monday afternoon, I’ll remember it’s movie night and feel both relief and anticipation. It’s not an actual movie in a theater, but it still feels special.Think about how I want to look back on this time. I find myself consciously trying to do things that will make me feel better about this experience in the future. That may mean reading more or cooking more or trying to be creative about the ways that I connect with other people — like writing letters or meeting people for walks in the cold. I don’t want this year to turn into a blur of Zoom chats and Netflix.Write down tiny details. I keep a log book, which is an idea that I got from the artist Austin Kleon. Every day, or as often as I can, I try to write down the most mundane details of the day. Today, I might write something about the fact that I reheated farro for lunch or that I spoke to somebody at The Times about a computer problem. Those tiny details that make up a day are the things we’ll forget when we look back on this time. I hope that when I read them over a decade from now, the complexion of the days will come to life: what it was really like, separate from the larger narrative of “a year in quarantine.”Act like I’m a person with a purpose. I try to give some structure to the day, even if it’s just by making my bed and taking a shower and leaving the house first thing in the morning for even a short walk before work. Doing those things really helps me feel normal. Another thing is bedtime. Going to bed at a reasonable time has helped keep some kind of armature to the days.Differentiate my days. I really want to get better at clearly demarcating the weekend from the week. We normally think of the weekend as a time to slow down. Each day is so similar to the one before, so I’m trying to see the weekend as a time to kind of speed up. So I might have a socially distanced outdoor hang with one friend in the middle of the day and meet up with another friend in the evening, and squeeze in cooking and cleaning and errands. I don’t have a commute or a social schedule, so I tend not to need more down time to recover from the week; I need up time.Make exercise part of my “social” life. When my daily life is busy and chaotic, I often treat exercise as a solo activity, a short period of time for contemplation before re-engaging with the world. Since so much of my time is already spent disengaged from the world these days, I’ve started jogging without headphones, purposely trying to take advantage of the moments when I’m outside the house and around other people, even if I’m not deliberately interacting with them. I purposely jog down the street that has outdoor restaurant seating or a playground, routes I would have avoided before. This way, I’m not just exercising to keep my mind and body in shape, but also to inhabit my neighborhood, to feel how we’re all connected, living our lives in parallel.Seek out information. Whether it’s jogging somewhere more populated or intentionally taking a walk someplace with more shops and more things to look at, I try to make each outing an exercise in replenishing my experience of the world. Our thoughts and actions and creativity are inspired by the people and things around us. And when we have limited people and things around us, it makes life smaller. Even though we’re social distancing, we still need social interactions, information input that keeps our minds sharp and our personalities interesting.Create a tiny routine. These can be small pleasurable things. A routine doesn’t have to be an elaborate, punishing system that you impose on your day. Rather, you can take the tiny things that you do every day and just sort of keep doing them. It can be deciding that you’re going to just have coffee on your stoop every morning or to walk your dog at 1 p.m. I make my bed each morning and do the crossword puzzle during lunch. These are pretty rudimentary elements of a day, but they’re two poles between which to hang the hours of the morning. Anything you do regularly and with intention can give the day some shape and some meaning.AdvertisementContinue reading the main story

SharecloseShare pageCopy linkAbout sharingimage copyrightReutersGermany is changing its stance on the Oxford-AstraZeneca vaccine, allowing over-65s to receive the jab, Chancellor Angela Merkel says.The country previously approved it for under-65s only, citing insufficient data on its effects on older people.That led to public scepticism about its effectiveness, with some Germans spurning it, leaving many doses unused.But on Wednesday Mrs Merkel said recent studies had now provided enough data to approve it for all ages.Various studies have shown the AstraZeneca vaccine is highly effective among the elderly.Belgium says it will also approve the vaccine for older people, following France earlier this week.France approves AstraZeneca vaccine for over-65sWhat’s behind France’s AstraZeneca turnaround?Oxford vaccine does protect older people, Europe toldAbout 5% of Germans have so far received a first vaccine shot.Mrs Merkel said Germany would also follow the UK example of stretching the interval between vaccine doses, to offer as many people as possible an initial shot.What led to scepticism about the AstraZeneca jab?The EU’s medical regulator approved the use of the Oxford-AstraZeneca vaccine for all age groups in January.But the rollout was met by some public scepticism after regulators in countries including France, Belgium and Italy recommended that it should not be used for people over 65. Like Germany, they citied insufficient data on its efficacy for older people.In January French President Emmanuel Macron said the jab was “quasi-ineffective” for older age groups – a suggestion strongly refuted by the UK government and British medical regulators.The debate came amid an acrimonious dispute between AstraZeneca and the EU over vaccine supplies to member states.Since then, stocks of the Oxford-AstraZeneca jab have gone unused in several European countries, slowing vaccination efforts.Meanwhile the UK – which approved the Oxford-AstraZeneca jab for all age groups – has offered a first does of a vaccine to 20.7 million people, almost a third of its population.Last week Carsten Watzl, head of the German Society for Immunology, urged his country to change its mind on the Oxford-AstraZeneca vaccine.In an interview with the BBC, he predicted regulators would have to reverse their decision to not recommend the jab for older people and suggested Mrs Merkel should take the vaccine live on TV to prove it is safe.How is Germany planning to ease restrictions?Mrs Merkel said she had agreed to a phased easing of restrictions with leaders of Germany’s federal states but added that there was the option of an “emergency brake” if case numbers got out of control.”We are at the threshold of a new phase of the pandemic that we can go into not carelessly but still with justified hope,” Mrs Merkel said.From Monday up to five people from two households will be allowed to meet, with children under 14 exempt. Some shops will reopen provided that regional case numbers are below 50 per 100,00 people. If cases rise over 50 per 100,000 then customers will have to book slots to visit shops. If cases rise to over 100 per 100,000 over three days in a row then restrictions will be reimposed.What do we know about the AstraZeneca vaccine?The UK has been using the vaccine made by AstraZeneca, a UK-Swedish pharmaceutical firm, in its mass immunisation programme since December.UK health officials say it provides “high levels of protection” for all ages. Covid vaccines cut risk of serious illness by 80%No one who received the vaccine in trials was admitted to hospital or became seriously ill with Covid-19.The vaccine is given via two injections to the arm, the second between four and 12 weeks after the first.

SharecloseShare pageCopy linkAbout sharingimage copyrightEPAWhen Argentina’s Congress voted to legalise abortion up to the 14th week of pregnancy, Renata (not her real name) felt excited.”How cool,” the 20-year-old from northern Brazil remembers thinking in late December. A student and supermarket worker, Renata saw it as the start of something new in a region where abortion is mostly illegal.But she thought little more of it until a week later, when she found out she was pregnant herself. Then, she says, her world collapsed. “Under no circumstances could I be pregnant,” she told me, explaining that in the city where she lives, jobs are impossible to come by – all the more so because of the pandemic. And she knew she would have been furloughed on lower pay if she told her employer. “Everything has to be right to bring a child into this world,” she explains, adding that after having seen her mother bring up two children alone she never wanted to have to go through that herself. But few options were open to her.Abortion is banned in Brazil unless the pregnancy is a result of rape, woman’s life is in danger or if the fetus is anencephalic, a rare condition that prevents part of the brain and skull from developing.So Renata decided she would travel to Colombia where – although restrictions are similar to those in Brazil – interpretation of the law is broader and so it is easier to access legal abortions. She had even borrowed money to pay for the flight, which was going to be her first trip abroad ever. But then, Colombia banned incoming flights from Brazil because of a new Covid-19 variant detected in the Amazon. “I started to cry,” Renata recalls. “It was my last hope, I was inconsolable.”Now, through the help of a charity called Miles for the Lives of Women (Milhas pela vida das mulheres), whereby people donate airmiles to help women access safe abortions abroad, Renata is travelling to Mexico City, where abortions during the first 12 weeks of pregnancy are legal.”It’s the best decision for me,” she says, unwavering.Powerful women’s rights movementIn Brazil alone, an estimated one million women access clandestine abortions every year. The only places where abortions are currently legal in Latin America are Uruguay, Cuba, Guyana and parts of Mexico. And now, of course, Argentina. Many pro-choice activists hope that the change in law in Argentina will put pressure on other countries to follow suit.image copyrightReutersIn Argentina, those who supported the National Campaign for the Right to Legal, Safe and Free Abortion wore a green bandana. It is a symbol that has since been taken up by many other activists in the region and which has come to represent the peaceful resistance by a growing women’s rights movement which argues that society needs to change. More about abortion in Latin AmericaArgentines on abortion vote: ‘I felt relieved’The rape survivors facing an ‘impossible choice’ in BrazilChile abortion bill: ‘My pregnancy was torture’Debora Diniz, a professor of anthropology at the University of Brasília, says that it is unusual for a symbol to spread to other countries in this way. “Traditionally, Latin America doesn’t operate in this way,” the prominent feminist activist says.”It was a colonised region, looking much more to the global north. And now we’re looking to each other. Even a country that understands itself as a continent, like Brazil, is using the green scarf to represent women’s causes.”Conservatism and the churchBut Latin America is deeply divided. It is a region where religion and conservatism reign. While Argentina moved in one direction in December, a month later, Honduras’ Congress added an outright abortion ban to its constitution, making it harder than ever to legalise the procedure in the future..So it is not a straightforward path.”When the law passed in Argentina, people in Honduras started talking about whether it [the pressure to legalise abortion] would spread in the region, and that probably in Honduras, it [legalisation of abortion] could happen too,” says Álvaro Hernández of Ola Celeste (Blue Wave), an anti-abortion group that backed the change to the constitution. “Here in Honduras, there are a lot of cultural issues. Honduras is a Christian country and abortion hasn’t been a topic of debate here,” he says. And while the church may be very influential in Honduras, groups of women still took to the streets to protest against the abortion ban. image copyrightReutersIn Argentina, many credited centre-left President Alberto Fernández for helping to push through the legalisation of abortion. But in neighbouring Brazil, far-right President Jair Bolsonaro condemned the move and conservative groups remain strong. “I don’t think it’s going to be that easy to legalise [abortion in Brazil],” says Celene Salomão, who has campaigned vociferously for the São Paulo chapter of 40 Days for Life, an international religious anti-abortion campaign. Ms Salomão says that senators in Argentina came under a lot of pressure from left-wing groups to legalise abortion. But she thinks that President Bolsonaro will stand firm in the knowledge that he has the backing of religious groups.”A lot of Brazilians are Christians, not only Catholics but other denominations too – and we are all against.”Chile pushing for changeIn Chile, right-wing President Sebastian Piñera has also made it clear that he opposes a change in the law, even though in January – in the wake of Argentina’s decision – Chile’s Congress started debating decriminalising abortion in the first 14 weeks of pregnancy. image copyrightReutersOne of the issues that unites pro-choice activists is the argument for safe access to abortions. They say the discussion should not be about support for, or opposition to, abortion but instead focus on women’s health. They argue that women will have abortions whether they are legal or not, so allowing them legal access to terminations will be safer and cut down then number of women who die as a result of clandestine abortions. Dr Karla Figueroa says that since abortion was decriminalised in Mexico City, no woman has died from having a termination. “That’s the most important thing in terms of public health,” the doctor at GineClinic says.And it is a message spreading across the region. “The life and health of women angle is very much present in the discussion in Colombia,” says Mariana Ardila, managing attorney at Women’s Link Worldwide.She is campaigning to remove the criminal element to abortion, to ensure that the women who have abortions and the medical teams carrying them out, are not prosecuted.”Criminal law is actually the worst instrument, and it has a lot of consequences on imposing stigma and creating fear among healthcare personnel,” she says.Pro-choice activists in the region say the legalisation of abortion in Argentina has galvanised their fight. “I hope it serves as a watershed moment,” says Dr Karla Figueroa in Mexico City. For Debora Diniz, too, it provides further motivation. “In Brazil, we have some of the most active and vibrant black feminists in the region,” she says. “It’s a diverse feminism, and maybe something will come from it.”

#masthead-section-label, #masthead-bar-one { display: none }The Coronavirus OutbreakliveLatest UpdatesMaps and CasesRisk Near YouVaccine RolloutNew Variants TrackerAdvertisementContinue reading the main storySupported byContinue reading the main storyA Few People Report Delayed Skin Reactions to the Covid VaccineDoctors are reporting additional, minor symptoms that appear several days after people have received their shots.By sharing the information about reactions, doctors said they wanted to help prevent the needless use of antibiotics and to ease patients’ worries about getting their second vaccine shot.Credit…Mike Kai Chen for The New York TimesMarch 3, 2021, 6:27 p.m. ETSome people are having delayed reactions to their first dose of a Covid vaccine, with their arms turning red, sore, itchy and swollen a week or so after the shot.The reactions, though unpleasant, appear to be harmless. But the angry-looking skin condition can be mistaken for an infection, according to a letter published on Wednesday in The New England Journal of Medicine. The doctors said they wanted to share information about the cases to help prevent the needless use of antibiotics and to ease patients’ worries and reassure them that they can safely get their second vaccine shot.“We modified our patient handout once we started seeing this,” Dr. Kimberly G. Blumenthal, an author of the letter and an allergist at Massachusetts General Hospital, said in an interview. “We had said it was normal to get redness, itching and swelling when you get the vaccine. We changed the wording to say it can also start seven to 10 days after you get the vaccine.”The letter describes the experiences of 12 people who had “delayed large local reactions” that began four to 11 days after the first shot of the Moderna vaccine, within a median of eight days. The report is not a controlled study, but rather a series of cases that came to the doctors’ attention because the vaccine recipients were concerned and wanted to know whether they should get the second shot.Most were vaccinated at Massachusetts General Hospital, where both the Moderna and Pfizer-BioNTech vaccines were administered. But the delayed reactions occurred only in people who had received the Moderna shot, Dr. Blumenthal said, adding, “I don’t understand why.”Delayed skin reactions in various patients after receiving the mRNA Covid vaccines.Credit…New England Journal of MedicineModerna reported delayed skin reactions in its large clinical trial in 0.8 percent of recipients after the first dose, and 0.2 percent after the second dose.The Coronavirus Outbreak

#masthead-section-label, #masthead-bar-one { display: none }The Coronavirus OutbreakliveLatest UpdatesMaps and CasesRisk Near YouVaccine RolloutNew Variants TrackerAdvertisementContinue reading the main storySupported byContinue reading the main storyFauci Is Giving His Coronavirus Model to the SmithsonianDr. Anthony S. Fauci’s donation of his 3-D virus model to the Smithsonian’s National Museum of American History comes as museums are working to document the Covid-19 era.“I wanted to pick something that was really meaningful to me and important because I used it so often,” Dr. Anthony S. Fauci said of his decision to give the model to the Smithsonian.Credit…Smithsonian’s National Museum of American HistoryMarch 3, 2021, 5:13 p.m. ETA piece of personal pandemic history belonging to the nation’s top infectious disease expert has found a new home at the Smithsonian’s National Museum of American History.Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases, presented his three-dimensional model of the coronavirus to the museum’s national medicine and science collections on Tuesday at a ceremony that was conducted by videoconference.“I wanted to pick something that was really meaningful to me and important because I used it so often,” Dr. Fauci said in an interview on Wednesday about his decision to give the model to the museum.The model, which he said was made with a 3-D printer at the National Institutes of Health, is a blue sphere studded with spikes replicating the spiked proteins that can latch onto cells in our airways, allowing the virus to slip inside. Dr. Fauci said he had often used it as a visual aid when briefing members of Congress and former President Donald J. Trump about the virus.“It’s a really phenomenally graphic way to get people to understand,” he said.Dr. Fauci announced the donation and showed off the model as he was being awarded the museum’s Great Americans medal on Tuesday for his leadership of the nation’s Covid-19 response and his contributions to the fights against other infectious diseases, such as AIDS.The National Museum of American History said its curators had been collecting items from the pandemic for a future exhibition, called “In Sickness and in Health,” that will examine “more than 200 years of medicine in the U.S. including Covid-19.” The museum has also been accepting digital submissions from the public through the platform “Stories of 2020.”The spread of the coronavirus has presented an opportunity for museums and institutions across the country to document a pandemic as it is happening. Many have done the same with the protests against racial injustice that played out across much of the country last year.The Coronavirus Outbreak