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Trained to see patterns by analyzing thousands of chest X-rays, a computer program predicted with up to 80 percent accuracy which COVID-19 patients would develop life-threatening complications within four days, a new study finds.
Developed by researchers at NYU Grossman School of Medicine, the program used several hundred gigabytes of data gleaned from 5,224 chest X-rays taken from 2,943 seriously ill patients infected with SARS-CoV-2, the virus behind the infections.
The authors of the study, publishing in the journal npj Digital Medicine online May 12, cited the “pressing need” for the ability to quickly predict which COVID-19 patients are likely to have lethal complications so that treatment resources can best be matched to those at increased risk. For reasons not yet fully understood, the health of some COVID-19 patients suddenly worsens, requiring intensive care, and increasing their chances of dying.
In a bid to address this need, the NYU Langone team fed not only X-ray information into their computer analysis, but also patients’ age, race, and gender, along with several vital signs and laboratory test results, including weight, body temperature, and blood immune cell levels. Also factored into their mathematical models, which can learn from examples, were the need for a mechanical ventilator and whether each patient went on to survive (2,405) or die (538) from their infections.
Researchers then tested the predictive value of the software tool on 770 chest X-rays from 718 other patients admitted for COVID-19 through the emergency room at NYU Langone hospitals from March 3 to June 28, 2020. The computer program accurately predicted four out of five infected patients who required intensive care and mechanical ventilation and/or died within four days of admission.
“Emergency room physicians and radiologists need effective tools like our program to quickly identify those COVID-19 patients whose condition is most likely to deteriorate quickly so that health care providers can monitor them more closely and intervene earlier,” says study co-lead investigator Farah Shamout, PhD, an assistant professor in computer engineering at New York University’s campus in Abu Dhabi.
“We believe that our COVID-19 classification test represents the largest application of artificial intelligence in radiology to address some of the most urgent needs of patients and caregivers during the pandemic,” says Yiqiu “Artie” Shen, MS, a doctoral student at the NYU Data Science Center.
Study senior investigator Krzysztof Geras, PhD, an assistant professor in the Department of Radiology at NYU Langone, says a major advantage to machine-intelligence programs such as theirs is that its accuracy can be tracked, updated and improved with more data. He says the team plans to add more patient information as it becomes available. He also says the team is evaluating what additional clinical test results could be used to improve their test model.
Geras says he hopes, as part of further research, to soon deploy the NYU COVID-19 classification test to emergency physicians and radiologists. In the interim, he is working with physicians to draft clinical guidelines for its use.
Funding support for the study was provided by National Institutes of Health grants P41 EB017183 and R01 LM013316; and National Science Foundation grants HDR-1922658 and HDR-1940097.
Besides Geras, Shamout, and Shen, other NYU Langone researchers involved in this study are co-lead investigators Nan Wu; Aakash Kaku; Jungkyu Park; and Taro Makino; and co-investigators Stanislaw Jastrzebski; Duo Wong; Ben Zhang; Siddhant Dogra; Men Cao; Narges Razavian; David Kudlowitz; Lea Azour; William Moore; Yvonne Lui; Yindalon Aphinyanaphongs; and Carlos Fernandez-Granda.

SharecloseShare pageCopy linkAbout sharingimage copyrightGetty ImagesThere were serious failures by both the World Health Organization (WHO) and individual governments in the world’s response to the coronavirus pandemic, an independent review has found.The panel established by the WHO called the response a “toxic cocktail”.Without urgent change the world will be at the mercy of another disease outbreak, it said. The WHO should have declared the outbreak in China an international emergency earlier, the report said.The Independent Panel for Pandemic Preparedness and Response argued that the WHO’s Emergency Committee should have acted to do so at its first meeting on 22 January last year instead of waiting until 30 January.Coronavirus cases, deaths, vaccinations by countryWHO says India Covid variant of ‘global concern’The month following the WHO’s declaration was “lost” as countries failed to take appropriate measures to halt the spread of the virus, the Covid-19: Make it the Last Pandemic report said. The report was compiled in an effort to find answers as to how the coronavirus has killed more than 3.4 million people.The report says the WHO was hindered by its own regulations that travel restrictions should be a last resort, with Europe and America wasting the entire month of February, acting only when their hospitals began to fill up. When countries should have been preparing their healthcare systems for an influx of Covid patients, much of the world descended into a “winner takes all” scramble for protective equipment and medicines, the report said.To prevent another catastrophic pandemic, the report suggests key reforms: The WHO should have a global health threats council with the power to hold member states accountableThere should be a disease surveillance system to publish information without the approval of countries concernedVaccines must be classed as public goods and there should be a pandemic financing facility”The situation we find ourselves in today could have been prevented,” co-chair Ellen Johnson Sirleaf, a former president of Liberia, told reporters. “It is due to a myriad of failures, gaps and delays in preparedness and response.”Panel co-chair and former New Zealand Prime Minister Helen Clark said it was “critical to have an empowered WHO”.”If travel restrictions had been imposed more quickly, more widely, again that would have been a serious inhibition on the rapid transmission of the disease and that remains the same today,” she added.The 21st Century’s ‘Chernobyl moment’The most eye-catching line of this report is that the pandemic was the 21st Century’s “Chernobyl moment” and its assertion that the world wasted time in February 2020 while the virus took hold. The panel calls for better processes and structures to spot the next highly infectious pathogen. As well as better funding for the World Health Organization to make it stronger and give it more teeth. After the worst shock to the global economy since World War Two, all countries will agree that it’s a case of “never again”. But will meaningful reform be possible when so much of the current response is still about putting national interests first? The panel has called for rich countries to share one billion doses of vaccine by September, for example. Yet still many nations with large stockpiles remain reluctant to declare their hand.There are some issues the panel didn’t have time to consider in depth. The most fundamental one remains our relationship with the animal world to stop viruses jumping to humans in the first place.

Vaccinations mean the pandemic is moving to a phase when behavior will depend on people’s individual tolerance for risk.Picnicking in a park in Philadelphia last month. Even epidemiologists, the most aware of all that can go wrong, are starting to do ordinary things again like gather with friends.Hannah Beier for The New York TimesEpidemiologists are starting to hug again.They’re also running errands, gathering outdoors with friends and getting haircuts in far greater numbers than before.What Epidemiologists Are Doing Now

Swift mask mandates and travel restrictions, an international treaty and the creation of new bureaucracies are among the recommendations presented to the W.H.O.The next time the world faces an outbreak of a fast-spreading and deadly new pathogen, governments must act swiftly and be ready to restrict travel or mandate masks even before anyone knows the extent of the threat, according to a pair of new reports delivered to the World Health Organization.The studies are intended to address missteps over the past year that led to more than 3.25 million deaths, some $10 trillion in economic losses and more than 100 million people pushed into extreme poverty.“Current institutions, public and private, failed to protect people from a devastating pandemic,” concluded one of the reports, released on Wednesday, which called the Covid-19 pandemic “the 21st century’s Chernobyl moment.”“Without change,” it said, these institutions “will not prevent a future one.”The reviews, released in advance of this month’s meeting of the W.H.O.’s governing assembly, were written by appointees who donated countless hours in the midst of their own countries’ pandemic fights to interview hundreds of experts, comb through thousands of documents, gather data and seek counsel from public and private institutions around the world.Pandemics, the authors concluded, are an existential threat on the order of a chemical or nuclear weapon, and preparing for them must be the responsibility of the highest levels of political leadership rather than only health departments, often among the least powerful of government agencies.N95 masks being decontaminated last spring, when protective equipment was in short supply in the United States.Brian Kaiser for The New York TimesThe reviews also called for nations to provide predictable and sustainable financing to the W.H.O. and to their national preparedness systems.“W.H.O. is underpowered and underfunded by its member states,” Helen Clark, a former prime minister of New Zealand and an author of one of the reports, said at a media conference this week.Whether the recommendations lead to lasting change is an open question. Ms. Clark’s group, the Independent Panel for Pandemic Preparedness and Response, pointedly noted that since the H1N1 pandemic in 2009, there have been 11 high-level commissions and panels that produced more than 16 reports, with the vast majority of recommendations never implemented.These reports “sit closed gathering dust in U.N. basements and government shelves,” said Ellen Johnson Sirleaf, another author of that report, who served as president of Liberia during the Ebola outbreak there in 2014 and 2015.Under the current international health regulations, “there’s no enforcement mechanism,” said Dr. Lothar H. Wieler, president of the Robert Koch Institute in Berlin, who led the second major review, in which scientists scrutinized how those regulations functioned in the pandemic.Both reports supported the creation of an international pandemic treaty that would establish consequences if countries failed to live up to their commitments. Those might include quickly sharing samples and sequences of emerging pathogens, providing rapid access to teams deployed by the W.H.O. for early investigation and response, and ensuring equitable distribution of vaccines, medicine and tests around the world.Both reviews also noted that early in the coronavirus pandemic, many countries all but ignored the formal warning issued by the W.H.O., known as a Public Health Emergency of International Concern. Its unfortunate acronym, Pheic, is often pronounced “fake,” one of the reports noted. (Whether the proposal to change this to “Phemic” will prove more stirring remains to be seen.)The independent panel also concluded that the warning could have been declared at least a week earlier than it was — on Jan. 22, 2020, instead of Jan. 30.Even then, “so many countries chose to wait and see,” only taking concerted action once intensive care beds were filled, Ms. Clark said.Family members said goodbye to a grandmother dying from Covid-19 last year at North Shore University Hospital in New York.Victor J. Blue for The New York TimesHer group contends that if its recommendations on political leadership, financing and surveillance systems had been in place, the coronavirus outbreak would not have become a pandemic. It also said that digital tools, such as those that scrape social media for rumors of new outbreaks, should be better incorporated into official responses.Notably, the panel did not delve into individual countries’ failures in its report, determining that blame would not be “a very useful approach,” said Dr. Anders Nordström, who helped lead the effort.But the group did commission a study of 28 countries with high, medium and low Covid death rates. Some of the countries with the lowest tolls had previously invested in outbreak control systems after experiencing SARS, MERS and Ebola, the report said. Successful countries acted quickly, coordinated across multiple government agencies, meticulously isolated people with the virus and quarantined those exposed to it.The worst performing countries had underfunded, fragmented health systems and “uncoordinated approaches that devalued science.” Those with the highest death tolls, including Brazil and the United States, denied the seriousness of the pandemic and discouraged action, the panel members said in interviews.On some key points, the reports came to different conclusions. The Independent Panel for Pandemic Preparedness and Response argued that the international health regulations governing how countries are supposed to prepare for and report emerging outbreaks “serve to constrain rather than to facilitate rapid action.”A grave prepared in New Delhi last month for a man who died from Covid-19.Atul Loke for The New York TimesBut the other group, which spent months reviewing those regulations, found that many could have helped but were “simply not implemented by various countries,” Dr. Wieler said.Some countries were not even aware that the regulations existed, his group reported. Others lacked laws vital to responding to outbreaks, such as those authorizing quarantines.Changing those regulations would require “negotiations for years,” Dr. Wieler said, noting that the latest set took a decade to finalize. Instead, one of his committee’s major recommendations was to increase countries’ accountability for their obligations, including though a pandemic treaty and a periodic review of their preparedness that would involve other countries.The independent panel also proposed creating an international council led by heads of state to keep attention on health threats and to oversee a multibillion-dollar financing program that governments would contribute to based on their ability. It would promise quick payouts to countries contending with a new outbreak, giving them an incentive to report.“There’s only going to be the political will to create those things when something catastrophic happens,” said Dr. Mark Dybul, one of the panel members. These recommendations stemmed in part from his experience leading the President’s Emergency Program for AIDS Relief, known as Pepfar, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, he said.But Dr. Wieler, who led the other international review, said that in general, creating new institutions rather than focusing on improving existing ones could increase costs, complicate coordination and damage the W.H.O.The recommendations of panels after global emergencies have sometimes been embraced. The Ebola outbreak of 2014 and 2015 led to the creation of the W.H.O.’s health emergencies program, aimed at boosting the agency’s role in managing health crises as well as providing technical guidance. A report released this month noted that the new program had received “increasingly positive feedback” from countries, donors and partner agencies as it managed dozens of health and humanitarian emergencies.The W.H.O. before the Ebola outbreak and after it are “two different agencies basically,” said Dr. Joanne Liu, a former international president of Doctors Without Borders and a member of the independent panel. Dr. Liu was one of the W.H.O.’s most trenchant critics during the Ebola response, and she noted a “marked improvement” in how quickly the agency had declared an international emergency this time.A health worker with a dose of China’s Sinopharm vaccine last week in Colombo, Sri Lanka.Dinuka Liyanawatte/ReutersDr. Liu said her biggest fear was that as wealthier countries gained an upper hand on the virus because of vaccines, they would leave low- and middle-income countries behind, with Covid-19 becoming “a neglected pandemic because they are going to be the only ones fighting it — a bit like H.I.V. and T.B.”To avert that, the panel released a slew of urgent recommendations and called for the world’s entire population to be immunized within a year.Wealthy countries with a good vaccine pipeline should commit to making at least a billion doses available to the poorest countries by September through programs like Covax, a global effort to provide vaccines equitably throughout the world, the group said.

Vaccinations mean the pandemic is moving to a phase when behavior will depend on people’s individual tolerance for risk.Picnicking in a park in Philadelphia last month. Even epidemiologists, the most aware of all that can go wrong, are starting to do ordinary things again like gather with friends.Hannah Beier for The New York TimesEpidemiologists are starting to hug again.They’re also running errands, gathering outdoors with friends and getting haircuts in far greater numbers than before.What Epidemiologists Are Doing Now

Health care systems are trying to answer the central question of how to care for patients when climate change threatens their ability to remain open.This article is part of our new series on the Future of Health Care, which examines changes in the medical field.As climate change moves from a model of the future to the reality of the present, health care systems across the country are facing a difficult set of questions. What are doctors supposed to do when wildfires, rising floodwater or other natural disasters threaten their ability to provide care for patients? How can these institutions be resilient in the face of these disasters?To Ramé Hemstreet, these aren’t abstract questions. Mr. Hemstreet is the vice president for operations and chief sustainable resources officer for Kaiser Permanente, the California-based health care system. The state is already dealing with the effects of climate change: During the wildfires in Northern California in 2017 and 2019, Kaiser Permanente had to evacuate more than 100 patients from one facility in Santa Rosa and find a way to care for the surrounding communities.“The climate crisis is a human health crisis, and we’re already living that in California,” Mr. Hemstreet said.For the last decade or so, Mr. Hemstreet and his colleagues at the company have been trying to move it away from fossil fuels, largely to reduce the company’s contribution to climate change. But, it has also become clear that depending on fossil fuels is a hindrance to providing health care, as the effects of climate change are increasingly part of the lived experience of many Americans.Around the country, hospitals and health care systems are trying to answer the central question of how to care for patients when climate change threatens their ability to keep hospitals open. Many of the changes to improve resilience are not sleek, tech-forward responses to crisis. Rather, they often represent common-sense solutions: moving technical equipment from basements where floodwater could damage it up to higher floors; organizing patient transfers in advance of catastrophes; improving energy efficiency; better air filters; and more backup systems and redundancies, just in case.Since 2012, Boston Medical Center has lowered its energy use by nearly 40 percent and reduced its greenhouse gas emissions from all sources of energy by 90 percent while caring for more patients. Some of those reductions have come from a cogeneration plant for electricity and heat, which operates 35 percent more efficiently than separately relying on the electric utility for its energy needs. The hospital has also bought enough solar power from a solar farm in North Carolina to account for all of its electricity.B.M.C., the largest safety-net hospital in New England, serving the uninsured and underinsured community in the Boston area, has also extended its sustainability efforts beyond renewable electricity and heating, including a rooftop garden at the hospital that grows about 6,000 pounds of food a year for its food pantry, inpatient meals and a hospital-based farmer’s market, and a biodigester that converts food waste into water.Dr. Joshua Barocas, an infectious-diseases physician at Boston Medical Center, getting the Covid-19 vaccine. The hospital has been making sustainability efforts, including a rooftop garden that grows about 6,000 pounds of food a year.Pool photo by Erin ClarkRobert Biggio, an engineer who served in the merchant marine and now is the senior vice president of facilities and support services for the hospital, learned resilience on the high seas. “Being on a ship in the middle of the ocean, people can’t get to you,” he said. “You don’t have a choice about being resilient.”While it is often argued that sustainability and climate-friendliness is too expensive, all of the system upgrades — including a cogeneration plant and a chilled-water loop cooling system, rather than a costly new tower — have saved B.M.C., a nonprofit, significant amounts of money.“Reducing waste is more efficient and also improves resiliency,” Mr. Biggio said. “They do go hand-in-hand.”Health care in the United States is responsible for a tremendous amount of waste and a significant amount of greenhouse gas emissions. For every hospital bed, the American health care system produces about 30 pounds of waste every day; over all, it accounts for about 10 percent of national greenhouse gas emissions.Much of the waste comes from the shift toward single-use disposable items, apart from the personal protective equipment that is intended only for single use. Many hospitals are contracting outside companies to clean and reprocess many of these items; Kaiser Permanente made a commitment to recycle, reuse or compost 100 percent of its nonhazardous waste by 2025.As for greenhouse gas emissions, hospitals have to have backup power, which is usually provided by diesel generators. These run on fossil fuels and produce fine particulate matter, known as PM 2.5, which contributes to asthma and other illnesses. Air quality around hospitals, which have to test their generators regularly, is often poor.A recent study found that, compared with white people, people of color are more exposed to PM 2.5 from all sources, and Black Americans are the most affected. As a result, these communities, which often lack access to health care, are more likely to suffer from the health consequences of this exposure. PM 2.5 is also responsible for 85,000 to 200,000 excess deaths a year in the United States (according to the study), and long-term exposure to PM 2.5 is correlated with hospitalization for Covid-19.During fire season and heat waves, power can go out or electric utilities may shut off power to avoid sparking fires or creating systemwide blackouts, both of which mean that hospitals have to run on their generators.A patient is evacuated from the Feather River Hospital during a wildfire in Paradise, Calif. in 2018. Hospitals in Northern California have been hit hard by the fires and the shutoff of power by utilities, forcing hospitals to run on generators. Kaiser Permanente has been moving toward more renewable energy.Josh Edelson/Agence France-Presse — Getty ImagesThat hospitals are partly responsible for this pollution, Mr. Hemstreet said, is an unacceptable irony.Kaiser Permanente has been buying utility-scale renewable energy since 2015, and in 2018 finalized a deal to buy 180 megawatts of wind and solar power, as well as 110 megawatts of battery storage, which is being built. Since 2010, it has put 50 megawatts of solar power on its facilities and is installing a nine megawatt-hour battery at the company’s Ontario, Calif., campus that would allow most of the facility to go off the grid entirely.In New York City, space limitations and less abundant sunshine make ambitious installations more difficult, but heat waves present a similar challenge — the possibility of blackouts and rolling outages taking out air-conditioning, with higher temperatures endangering some older adults and those who are sick, especially.Like B.M.C., NYU Langone Health has built a cogeneration plant for electricity, heat and steam turbine-power air-conditioning. According to Paul Schwabacher, senior vice president of facilities management at NYU Langone, it is 50 percent more efficient than utility power.The cogeneration plant construction was in process before Hurricane Sandy in 2012, which was an eye-opening experience for the hospital system. During the storm, floodwater reached the lower floors of the hospital, leaving behind 15 million gallons of contaminated water. More than 300 patients had to be evacuated from the hospital, including newborns in intensive care, carried by doctors and nurses down many flights of stairs.The hospital was closed for two months after the storm, during which time there were about 100 electricians working on repairs, Mr. Schwabacher said. “We made lemonade,” he said, adding that they undertook repairs that would have been much more difficult while the hospital was open, like cleaning out all of the air ducts. They also rebuilt and expanded the emergency department, which had been flooded during the storm.Since then, the hospital has built a new building, as well as restored older ones.NYU Langone’s greatest effort toward resilience, however, is new flood barriers around the perimeter of the campus, which are intended to protect against a storm surge seven feet above the level caused by Hurricane Sandy. The campus also has a 12-foot-high steel storm barrier at the loading dock that can be hydraulically or manually raised; valves on drains and sewage lines to prevent back flows from flooding outside streets; and steel gates and doors to hold back floodwater in critical locations throughout the facility.But building walls won’t keep the effects of climate change away. That will come from reductions in greenhouse gas emissions from society as a whole, Mr. Schwabacher said.“We feel very, very confident that we’ll be protected, but we know that the next disaster will be different than the last disaster.”

When he tried to get up, he realized he couldn’t move. His weakness had a surprising cause — and an even more surprising cause behind the cause. “I can’t move my legs,” the 26-year-old man told his younger brother, who towered above him as he lay sprawled on the floor. He’d been on his computer for hours, he explained, and when he tried to stand up, he couldn’t. His legs looked normal, felt normal, yet they wouldn’t move.At first, he figured his legs must have fallen asleep. He pulled himself up, leaning on his desk, and slowly straightened until he was standing. He could feel the weight on his feet and knees. He let go of the desk and commanded his legs to move. Instead, they buckled, and he landed on the floor with a thud.His brother awkwardly pulled him onto the bed. Then they waited. Surely this weird paralysis would disappear just as suddenly as it came. An hour passed, then two. I’m calling an ambulance, the younger brother announced finally. Reluctantly, the elder agreed. He was embarrassed to be this helpless but worried enough to want help. When the E.M.T.s arrived, they were as confused as the brothers. The medics asked what the young man had been up to. Nothing bad, he assured them. For the past few weeks he had been getting back into shape. He changed his diet, cut out the junk and was drinking a protein concoction that was supposed to help him build muscle. And he was working out hard every day. He’d lost more than 20 pounds, he added proudly. Hearing about this extreme diet and exercise regimen, the E.M.T.s told the man he was probably dehydrated. He needed fluids and some electrolytes. A couple of bottles of Gatorade and he would very likely feel a lot better. And if he didn’t, he could call again.With his brother’s help, the man moved himself to a sitting position. He drank some water and Gatorade and waited to start feeling better. He fell asleep, still waiting. By the following afternoon he was having trouble sitting upright. He was drinking yet another Gatorade when he noticed that the bottle felt heavy. He realized with a start that the weakness had moved into his arms. Call the ambulance, he told his brother. This can’t be dehydration. A new set of E.M.T.s agreed. They hoisted the weakened man onto a stretcher, fastened the straps tightly and headed down the stairs. The man felt himself pitch forward as the stretcher tilted down. Was he going to fall? He imagined himself tumbling down the stairs like a sack of potatoes, completely unable to protect himself. The straps held him on the stretcher, but that feeling of helplessness terrified him. A Quick Test ResultDr. Getaw Worku Hassen was the emergency-medicine doctor on duty that night at Metropolitan Hospital in Upper Manhattan. He asked the patient if anything like this had happened before. No, the patient replied, though recently his thighs had felt tired and weak at times. It never lasted long, and he figured it was from working out so hard. The man asked if he might have had a stroke. Would he ever be able to walk again? Hassen reassured him that his symptoms didn’t look like a stroke. But, the doctor acknowledged, he wasn’t sure what it did look like.On exam, the man’s heart was racing at 110 beats a minute. And his blood pressure was high. He couldn’t lift either leg off the stretcher — not even an inch. His arms were weak as well. But his reflexes, sensation and the rest of his nervous system seemed otherwise normal. Hassen told the man that they would need to wait for the results of his blood work and other tests. He would be back when he knew more. Moments later the doctor was called by the lab. One of the patient’s electrolytes was dangerously low — his potassium. Photo illustration by Ina JangThe Cause Behind the CausePotassium is probably the most important electrolyte we measure routinely. It is essential for every cell in the body, and its movement in and out of cells is key to many of the body’s functions. Hassen immediately ordered potassium to be given both by mouth and intravenously. He wasn’t sure why this young man had such a low level of potassium but knew that if he didn’t get more, he could die. Cells in the heart depend on the flow of potassium to work properly. Either too much or too little of it could cause the heart to develop a life-threatening arrhythmia. The patient was admitted to the intensive-care unit so that his heart could be monitored as the deficit was reduced. The patient says he could feel strength flowing back into his muscles almost as soon as he started getting the replacement electrolyte. By morning he felt strong enough to stand. By midafternoon, he could walk. The doctors gave him potassium tablets to take every day for the next week and told him to stay hydrated if he was going to keep up this fitness regimen. And, of course, he should follow up with his regular doctor. A few days later, when Hassen returned to the hospital for his next shift, he wondered what had happened to the man with the weakened legs. He saw that his potassium had come back to a normal level and that he had been discharged. These days, financial pressures push doctors caring for hospitalized patients to narrow their focus to identifying life-threatening conditions and addressing those enough to stabilize the patient. Patients are then sent back to their primary-care doctors to determine the hows and whys behind the conditions that sent them to the hospital in the first place. Hassen accepted this reality, and yet to him the real pleasure of medicine wasn’t just identifying and addressing the serious symptoms but figuring out the cause behind the cause of the symptom. This man’s weakness was caused by low potassium. But what made his potassium low? A Striking ResemblanceHassen reviewed the notes from the patient’s overnight stay. In the emergency department, he had been weak, his heart racing, his blood pressure high and his potassium low. When electrolytes were repleted, his strength returned and his blood pressure dropped. But his heart continued to race. Heart rates are often high in the E.R.: Patients are scared and sometimes sick, often in pain. But this man’s heart rate stayed high even as everything else got better. That struck Hassen as strange. And so Hassen turned to the internet. He eventually found a case report that bore a striking resemblance to his patient: a young man with weak legs, low potassium and a high heart rate. That patient turned out to have something Hassen had never heard of: thyrotoxic periodic paralysis, muscle weakness where the low potassium was being caused by an excess of thyroid hormone.The thyroid is a gland located in the neck that helps control the body’s metabolic rate. Too much thyroid hormone causes the body to race. Too little, and it slows to a crawl. Unchecked, either state can be fatal. Rarely, in some people — usually young, often male — too much thyroid hormone can make circulating potassium levels drop and cause weakness. Hassen called the lab. He ordered tests to check the level of thyroid hormone in the sample. It was very high. He called the patient and got no answer, and he had no way to leave a message. He called the number a dozen times over the course of the next few weeks. Finally, maybe accidentally, the patient picked up. Hassen explained what he’d discovered. He gave the patient the name of an endocrinologist in the area. It turned out the young man had what is known as Graves’s disease. This is an autoimmune disease in which the patient’s own antibodies induce the thyroid gland to produce too much hormone. It’s often treated with radioactive iodine, which kills off some or most of the hormone-producing cells in the gland. This man, instead, chose to take a medicine that interferes with the gland’s ability to make thyroid hormone.This diagnosis was made almost four years ago. The patient gave up his intensive diet and exercise regimen and is now trying just to stay in shape and eat smarter — and to take his medicine every day. Sometimes when he feels his thighs are tired or weak, he eats a banana or avocado to get the potassium that he thinks his body is craving. He is determined to never relive that kind of helplessness again.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.

Physical activity can promote a sense of purpose in life, creating a virtuous cycle that keeps you moving.Our exercise habits may influence our sense of purpose in life and our sense of purpose may affect how much we exercise, according to an interesting new study of the reciprocal effects of feeling your life has meaning and being often in motion. The study, which involved more than 18,000 middle-aged and older men and women, found that those with the most stalwart sense of purpose at the start were the most likely to become active over time, and vice versa.The findings underscore how braided the relationship between physical activity and psychological well-being can be, and how the effects often run both ways.Science already offers plenty of evidence that being active bolsters our mental, as well as physical, health. Study after study shows that men and women who exercise are less likely than the sedentary to develop depression or anxiety. Additional research indicates that the reverse can be true, and people who feel depressed or anxious tend not to work out.But most of these studies examined connections between exercise and negative moods. Fewer have delved into positive emotions and their links with physical activity, and fewer still have looked at the role of a strong sense of purpose and how it might influence whether we move, and the other way around.This omission puzzled Ayse Yemiscigil, a postdoctoral research fellow with the Human Flourishing Program at Harvard University, who studies well-being. “A sense of purpose is the feeling that you get from having goals and plans that give direction and meaning to life,” she says. “It is about being engaged with life in productive ways.”This definition of purpose struck her as overlapping in resonant ways with many people’s motivations for exercise, she says. “Active people often talk about how exercise gives structure and meaning to their lives,” she says. “It provides goals and achievements.”In that case, she thought, physical activity plausibly could contribute to a sense of purpose and, likewise, a sense of purpose might influence how likely we are to exercise.But there was scant evidence to support those ideas. So, for the new study, which was published in April in the Journal of Behavioral Medicine, she and her colleague Ivo Vlaev, a professor of behavioral science at the University of Warwick in England, set out to find links, if any, between moving and meaning.They began by turning to the large and ongoing Health and Retirement Study, which gathers longitudinal data about the lives, attitudes and activities of thousands of American adults aged 50 or older. It asks them at the start about their physical health, background, daily activities and mental health, including if they agree with statements like, “I have a sense of direction and purpose in life,” or “My daily activities often seem trivial and unimportant.” The study’s researchers then checked back after a few years to repeat the queries.Then, Dr. Yemiscigil and Dr. Vlaev drew records for 14,159 of the participants. To enlarge and enrich their sample, they also gathered comparable data for another 4,041 men and women enrolled in a different study that asked similar questions about people’s physical activities and sense of purpose.Finally, they collated and compared the results, determining, first, how much and how vigorously people moved, and also how strong their sense of purpose seemed to be. The researchers then assessed how those disparate aspects of people’s lives seemed to be related to one another over the years, and they found clear intersections. People who started off with active lives generally showed an increasing sense of purpose over the years, and those whose sense of purpose was sturdier in the beginning were the most physically active years later.The associations were hardly outsize. Having a firm sense of purpose at one point in people’s lives was linked, later, with the equivalent of taking an extra weekly walk or two. But the associations were consistent and remained statistically significant, even when the researchers controlled for people’s weight, income, education, overall mental health and other factors.“It was especially interesting to see these effects in older people,” Dr. Yemiscigil says, “since many older people report a decreasing sense of purpose in their lives, and they also typically have low rates of engagement in physical activity.”This study was based, though, on people’s subjective estimates of their exercise and purposefulness, which could be unreliable. The findings are also associational, meaning they show links between having a sense of purpose at one point in your life and being active later, or vice versa, so do not prove one causes the other.But Dr. Yemiscigil believes the associations are sturdy and rational. “People often report more self-efficacy” after they take up exercise, she says, which might prompt them to feel capable of setting new goals and developing a new or augmented purpose in life. And from the other side, “when you have goals and a sense of purpose, you probably want to be healthy and live long enough to fulfill them.” So, cue exercise, she says.

If you’re feeling hesitant about getting your shot, we want to hear your questions.The rate at which people are making appointments for their Covid-19 shots is decreasing across the country. Are you among those people who have not received the vaccine?The Well desk wants to hear from readers who are hesitant about getting the shot — or have questions on behalf of someone who has concerns. What would you like more information about? Do you have new questions about young people and vaccination? Are you fearful of side effects, or have you read conflicting information from different sources? Tell us what you want to know, and we’ll track down the answers.How to submit a question: You can use the form below to send us your questions.Tell us what you want to know.

Long term use of prescription meds for insomnia doesn’t seem to improve disturbed sleep in middle-aged women, suggests research published in the online journal BMJ Open.
There was no difference in sleep quality or duration between those who did and didn’t take these meds for 1 to 2 years, the findings show.
Disturbed sleep — difficulty falling and/or staying asleep and waking early — is common. An estimated 9 million adults in the US alone say they take prescription meds to try and get a good night’s sleep.
Poor quality sleep is associated with ill health, including diabetes, high blood pressure, pain and depression, and various drugs are prescribed to induce shut-eye.
These include benzodiazepines, Z-drugs which include zolpidem, zaleplon and eszopiclone, as well as other agents mostly intended for other conditions (off label use), such as quelling anxiety and depression.
The clinical trial data indicate that many of these drugs work in the short term (up to 6 months), but insomnia can be chronic, and many people take these drugs for longer, say the researchers.