Tagged Tests (Medical)

Could a Smell Test Screen People for Covid?

Could a Smell Test Screen People for Covid?

A new modeling study hints that odor-based screens could quash outbreaks. But some experts are skeptical it would work in the real world.

A health worker in Altos de San Lorenzo, a neighborhood outside Buenos Aires, Argentina, administered a smell test last year.
A health worker in Altos de San Lorenzo, a neighborhood outside Buenos Aires, Argentina, administered a smell test last year.Credit…Alejandro Pagni/Agence France-Presse — Getty Images
Katherine J. Wu

  • Jan. 19, 2021, 5:49 p.m. ET

In a perfect world, the entrance to every office, restaurant and school would offer a coronavirus test — one with absolute accuracy, and able to instantly determine who was virus-free and safe to admit and who, positively infected, should be turned away.

That reality does not exist. But as the nation struggles to regain a semblance of normal life amid the uncontrolled spread of the virus, some scientists think that a quick test consisting of little more than a stinky strip of paper might at least get us close.

The test does not look for the virus itself, nor can it diagnose disease. Rather, it screens for one of Covid-19’s trademark signs: the loss of the sense of smell. Since last spring, many researchers have come to recognize the symptom, which is also known as anosmia, as one of the best indicators of an ongoing coronavirus infection, capable of identifying even people who don’t otherwise feel sick.

A smell test cannot flag people who contract the coronavirus and never develop any symptoms at all. But in a study that has not yet been published in a scientific journal, a mathematical model showed that sniff-based tests, if administered sufficiently widely and frequently, might detect enough cases to substantially drive transmission down.

Daniel Larremore, an epidemiologist at the University of Colorado, Boulder, and the study’s lead author, stressed that his team’s work was still purely theoretical. Although some smell tests are already in use in clinical and research settings, the products tend to be expensive and laborious to use and are not widely available. And in the context of the pandemic, there is not yet real-world data to support the effectiveness of smell tests as a frequent screen for the coronavirus. Given the many testing woes that have stymied pandemic control efforts so far, some experts have been doubtful that smell tests could be distributed widely enough, or made sufficiently cheat-proof, to reduce the spread of infection.

“I have been intimately involved in pushing to get loss of smell recognized as a symptom of Covid from the beginning,” said Dr. Claire Hopkins, an ear, nose and throat surgeon at Guy’s and St. Thomas’ Hospitals in the United Kingdom and an author of a recent commentary on the subject in The Lancet. “But I just don’t see any value as a screening test.”

A reliable smell test offers many potential benefits. It could catch far more cases than fever checks, which have largely flopped as screening tools for Covid-19. Studies have found that about 50 to 90 percent of people who test positive for the coronavirus experience some degree of measurable smell loss, a result of the virus wreaking havoc when it invades cells in the airway.

“It’s really like a function of the virus being in the nose at this exact moment,” said Danielle Reed, the associate director of the Monell Chemical Senses Center in Philadelphia. “It complements so much of the information you get from other tests.” Last month, Dr. Reed and her colleagues at Monell posted a study, which has not yet been published in a scientific journal, describing a rapid smell test that might be able to screen for Covid-19.

In contrast, only a minority of people with Covid-19 end up spiking a temperature. Fevers also tend to be fleeting, while anosmia can linger for many days.

A coronavirus testing site in Los Angeles. Smell tests, unlike P.C.R. and antigen tests, would not diagnose the disease nor look for the virus directly.
A coronavirus testing site in Los Angeles. Smell tests, unlike P.C.R. and antigen tests, would not diagnose the disease nor look for the virus directly.Credit…Kendrick Brinson for The New York Times

A smell test could also come with an appealingly low price tag, perhaps as low as 50 cents per card, said Derek Toomre, a cell biologist at Yale University and an author on Dr. Larremore’s paper. Dr. Toomre hopes that his version will fit the bill. The test, the U-Smell-It test, is a small smorgasbord of scratch-and-sniff scents arrayed on paper cards. People taking the test pick away at wells of smells, inhale and punch their guess into a smartphone app, shooting to correctly guess at least three of the five odors. Different cards contain different combinations of scents, so there is no answer key to memorize.

He estimated that the test could be taken in less than a minute. It is also a manufacturer’s dream, he said: A single printer “could produce 50 million of these tests per day.” Numbers like that, he argued, could make an enormous dent in a country hampered by widespread lack of access to tests that look directly for pieces of the coronavirus.

In their study, Dr. Larremore, Dr. Toomre and their collaborator Roy Parker, a biochemist at the University of Colorado, Boulder, modeled such a scenario using computational tools. Administered daily or almost daily, a smell screen that caught at least 50 percent of new infections was able to quash outbreaks nearly as well as a more accurate, slower laboratory test given just once a week.

Such tests, Dr. Larremore said, could work as a point-of-entry screen on college campuses or in offices, perhaps in combination with a rapid virus test. There might even be a place for them in the home, if researchers can find a way to minimize misuse.

“I think this is spot on,” said Dr. Carol Yan, an ear, nose and throat specialist at the University of California, San Diego. “Testing people repeatedly is going to be a valuable portion of this.”

Dr. Toomre is now seeking an emergency use authorization for the U-Smell-It from the Food and Drug Administration, and has partnered with a number of groups in Europe and elsewhere to trial the test under real-world conditions.

Translating theory into practice, however, will come with many challenges. Smell tests that can reliably identify people who have the coronavirus, while excluding people who are sick with something else, are not yet widely available. (Dr. Hopkins pointed to a couple of smell tests, developed before the pandemic, that cost about $30 each and remain in limited supply.) Should they ever be rolled out in bulk, they would inevitably miss some infected people and, unlike tests that look for the actual virus, could never diagnose disease on their own.

And smell loss, like fever, is not exclusive to Covid-19. Other infections can blunt a person’s sense of smell. So can allergies, nasal congestion from the common cold, or simply the process of aging. About 80 percent of people over the age of 75 have some degree of smell loss. Some people are born anosmic.

Moreover, in many cases of Covid-19, smell loss can linger long after the virus is gone and people are no longer contagious — a complication that could land some people in a post-Covid purgatory if they are forced to rely on smell screens to resume activity, Dr. Yan said.

There are also many ways to design a smell-based screen. Odors linked to foods that are popular in some countries but not others, such as bubble gum or licorice, might skew test results for some individuals. People who have grown up in highly urban areas might not readily recognize scents from nature, like pine or fresh-cut grass.

Smell also is not a binary sense, strictly on or off. Dr. Reed advocated a step in which test takers rate the intensity of a test’s odors — an acknowledgment that the coronavirus can drastically reduce the sense of smell but not eliminate it.

But the more complicated the test, the more difficult it would be to manufacture and deploy speedily. And no test, even a perfectly designed one, would function with 100 percent accuracy.

Dr. Ameet Kini, a pathologist at Loyola University Medical Center, pointed out that smell tests would also not be free of the problems associated with other types of tests, such as poor compliance or a refusal to isolate.

Smell screens are “probably better than nothing,” Dr. Kini said. “But no test is going to stop the pandemic in its tracks unless it’s combined with other measures.”

Could a Small Test Screen People for Covid-19?

Could a Smell Test Screen People for Covid?

A new modeling study hints that odor-based screens could quash outbreaks. But some experts are skeptical it would work in the real world.

A health worker in Altos de San Lorenzo, a neighborhood outside Buenos Aires, Argentina, administered a smell test last year.
A health worker in Altos de San Lorenzo, a neighborhood outside Buenos Aires, Argentina, administered a smell test last year.Credit…Alejandro Pagni/Agence France-Presse — Getty Images
Katherine J. Wu

  • Jan. 19, 2021, 5:49 p.m. ET

In a perfect world, the entrance to every office, restaurant and school would offer a coronavirus test — one with absolute accuracy, and able to instantly determine who was virus-free and safe to admit and who, positively infected, should be turned away.

That reality does not exist. But as the nation struggles to regain a semblance of normal life amid the uncontrolled spread of the virus, some scientists think that a quick test consisting of little more than a stinky strip of paper might at least get us close.

The test does not look for the virus itself, nor can it diagnose disease. Rather, it screens for one of Covid-19’s trademark signs: the loss of the sense of smell. Since last spring, many researchers have come to recognize the symptom, which is also known as anosmia, as one of the best indicators of an ongoing coronavirus infection, capable of identifying even people who don’t otherwise feel sick.

A smell test cannot flag people who contract the coronavirus and never develop any symptoms at all. But in a study that has not yet been published in a scientific journal, a mathematical model showed that sniff-based tests, if administered sufficiently widely and frequently, might detect enough cases to substantially drive transmission down.

Daniel Larremore, an epidemiologist at the University of Colorado, Boulder, and the study’s lead author, stressed that his team’s work was still purely theoretical. Although some smell tests are already in use in clinical and research settings, the products tend to be expensive and laborious to use and are not widely available. And in the context of the pandemic, there is not yet real-world data to support the effectiveness of smell tests as a frequent screen for the coronavirus. Given the many testing woes that have stymied pandemic control efforts so far, some experts have been doubtful that smell tests could be distributed widely enough, or made sufficiently cheat-proof, to reduce the spread of infection.

“I have been intimately involved in pushing to get loss of smell recognized as a symptom of Covid from the beginning,” said Dr. Claire Hopkins, an ear, nose and throat surgeon at Guy’s and St. Thomas’ Hospitals in the United Kingdom and an author of a recent commentary on the subject in The Lancet. “But I just don’t see any value as a screening test.”

A reliable smell test offers many potential benefits. It could catch far more cases than fever checks, which have largely flopped as screening tools for Covid-19. Studies have found that about 50 to 90 percent of people who test positive for the coronavirus experience some degree of measurable smell loss, a result of the virus wreaking havoc when it invades cells in the airway.

“It’s really like a function of the virus being in the nose at this exact moment,” said Danielle Reed, the associate director of the Monell Chemical Senses Center in Philadelphia. “It complements so much of the information you get from other tests.” Last month, Dr. Reed and her colleagues at Monell posted a study, which has not yet been published in a scientific journal, describing a rapid smell test that might be able to screen for Covid-19.

In contrast, only a minority of people with Covid-19 end up spiking a temperature. Fevers also tend to be fleeting, while anosmia can linger for many days.

A coronavirus testing site in Los Angeles. Smell tests, unlike P.C.R. and antigen tests, would not diagnose the disease nor look for the virus directly.
A coronavirus testing site in Los Angeles. Smell tests, unlike P.C.R. and antigen tests, would not diagnose the disease nor look for the virus directly.Credit…Kendrick Brinson for The New York Times

A smell test could also come with an appealingly low price tag, perhaps as low as 50 cents per card, said Derek Toomre, a cell biologist at Yale University and an author on Dr. Larremore’s paper. Dr. Toomre hopes that his version will fit the bill. The test, the U-Smell-It test, is a small smorgasbord of scratch-and-sniff scents arrayed on paper cards. People taking the test pick away at wells of smells, inhale and punch their guess into a smartphone app, shooting to correctly guess at least three of the five odors. Different cards contain different combinations of scents, so there is no answer key to memorize.

He estimated that the test could be taken in less than a minute. It is also a manufacturer’s dream, he said: A single printer “could produce 50 million of these tests per day.” Numbers like that, he argued, could make an enormous dent in a country hampered by widespread lack of access to tests that look directly for pieces of the coronavirus.

In their study, Dr. Larremore, Dr. Toomre and their collaborator Roy Parker, a biochemist at the University of Colorado, Boulder, modeled such a scenario using computational tools. Administered daily or almost daily, a smell screen that caught at least 50 percent of new infections was able to quash outbreaks nearly as well as a more accurate, slower laboratory test given just once a week.

Such tests, Dr. Larremore said, could work as a point-of-entry screen on college campuses or in offices, perhaps in combination with a rapid virus test. There might even be a place for them in the home, if researchers can find a way to minimize misuse.

“I think this is spot on,” said Dr. Carol Yan, an ear, nose and throat specialist at the University of California, San Diego. “Testing people repeatedly is going to be a valuable portion of this.”

Dr. Toomre is now seeking an emergency use authorization for the U-Smell-It from the Food and Drug Administration, and has partnered with a number of groups in Europe and elsewhere to trial the test under real-world conditions.

Translating theory into practice, however, will come with many challenges. Smell tests that can reliably identify people who have the coronavirus, while excluding people who are sick with something else, are not yet widely available. (Dr. Hopkins pointed to a couple of smell tests, developed before the pandemic, that cost about $30 each and remain in limited supply.) Should they ever be rolled out in bulk, they would inevitably miss some infected people and, unlike tests that look for the actual virus, could never diagnose disease on their own.

And smell loss, like fever, is not exclusive to Covid-19. Other infections can blunt a person’s sense of smell. So can allergies, nasal congestion from the common cold, or simply the process of aging. About 80 percent of people over the age of 75 have some degree of smell loss. Some people are born anosmic.

Moreover, in many cases of Covid-19, smell loss can linger long after the virus is gone and people are no longer contagious — a complication that could land some people in a post-Covid purgatory if they are forced to rely on smell screens to resume activity, Dr. Yan said.

There are also many ways to design a smell-based screen. Odors linked to foods that are popular in some countries but not others, such as bubble gum or licorice, might skew test results for some individuals. People who have grown up in highly urban areas might not readily recognize scents from nature, like pine or fresh-cut grass.

Smell also is not a binary sense, strictly on or off. Dr. Reed advocated a step in which test takers rate the intensity of a test’s odors — an acknowledgment that the coronavirus can drastically reduce the sense of smell but not eliminate it.

But the more complicated the test, the more difficult it would be to manufacture and deploy speedily. And no test, even a perfectly designed one, would function with 100 percent accuracy.

Dr. Ameet Kini, a pathologist at Loyola University Medical Center, pointed out that smell tests would also not be free of the problems associated with other types of tests, such as poor compliance or a refusal to isolate.

Smell screens are “probably better than nothing,” Dr. Kini said. “But no test is going to stop the pandemic in its tracks unless it’s combined with other measures.”

Kids and Covid Tests: What You Need to Know

So You Think Your Kid Needs a Covid Test

Here’s everything you need to know about when to get it and what to expect.

Credit…Sonia Pulido
Christina Caron

  • Jan. 13, 2021, 6:00 a.m. ET

My 4-year-old daughter is pretty tough when it comes to medical procedures. The flu shot? Not even a flinch. Stitches in her forehead? No big deal. Years earlier, she calmly watched as a nurse pricked her finger and squeezed the blood, drop by drop, into a tiny vial to test it for lead.

But the Covid test was different.

In early September, just before her preschool reopened, she began sneezing and had a sore throat. When her congestion worsened, we knew that she needed to get a coronavirus test. But as the nurse approached her, holding a long stick with a brush on the end resembling a pipe cleaner, she covered her face and backed away. In the end, two people had to hold her down. She screamed as the swab activated her lacrimal reflex, bringing tears to her eyes. It was over quickly, but she cried for half an hour afterward and insisted that she would never visit another doctor again. She now refers to that probe as “the needle.”

In late December she needed another test for her preschool, but this time she wasn’t sick. With the memory of her last experience still fresh in my mind, I immediately started researching. Were there less invasive tests to consider? If so, how would we find one? Would it be accurate enough? And was there an ideal way to prepare a squeamish young child who was averse to getting tested?

As it turned out, none of these questions had simple answers. So I consulted with five doctors and two of the largest urgent care providers in the United States to learn more.

How do I know if my child needs a test?

There are four main reasons a child might need to be tested:

  • They have symptoms

  • They have been exposed to someone infected with the virus

  • Their school, day care or a hospital requires it

  • They need it as a precaution before and after traveling

If your child has any symptoms of Covid — even mild ones like a runny nose or a sore throat — it’s a good idea for them to get tested and stay home, said Dr. Stanley Spinner, chief medical officer and vice president of Texas Children’s Pediatrics, the largest pediatric primary care group in the country, and Texas Children’s Urgent Care.

“We have seen, time and time again, kids with very mild symptoms with no known exposures who get tested with our very accurate PCR and sure enough, they come back positive,” Dr. Spinner said.

If your child has been in close contact with someone who tested positive for Covid-19 — even if your child does not have any symptoms — they should get tested, the experts said. The Centers for Disease Control and Prevention define close contact as spending at least 15 minutes within six feet of someone who has the coronavirus, or having any type of direct physical contact with an infected person, including kissing or hugging.

If your child is in school or day care, those institutions may have rules on when they must be tested, and how.

It’s safest to stay home, but if you and your children must travel, the C.D.C. recommends getting tested one to three days before your trip and then again three to five days after your trip.

If you’re still unsure if your child needs a test, call their pediatrician, said Dr. Kristin Moffitt, an infectious disease specialist at Boston Children’s Hospital. You can also take the C.D.C.’s clinical assessment tool, which can be used for any family member, including children.

Which types of tests are available for kids?

Virus testing for children is, for the most part, the same as it is for adults. The Food and Drug Administration has authorized the emergency use of two basic categories of diagnostic test. The most sensitive ones are the molecular PCR tests, which detect the genetic material of the virus and can take days to deliver results (some locations offer results in as little as a day). The second type of test, the antigen test, hunts for fragments of proteins that are found on or within the coronavirus. Antigen tests typically yield results quickly, within 15 minutes, but can be less sensitive than the molecular tests.

The way your provider collects your sample can vary. For instance, regardless of whether you get a PCR test or an antigen test, the collection method could be any of the following: nasopharyngeal swab (the long swab with a brush at the end that reaches all the way up the nose toward the throat); a shorter swab that is inserted about an inch into the nostrils; a long swab of the tonsils at the back of the throat; or a short swab swizzled on the gums and cheeks. The new saliva tests, which are still being vetted, require you to drool into a sterilized container, which could be difficult for young children.

FastMed Urgent Care, which has a network of more than 100 clinics in Arizona, North Carolina and Texas, currently uses a long swab to perform the rapid antigen test and a short swab for the PCR test, said Dr. Lane Tassin, one of the company’s chief medical officers. But MedExpress, a different urgent care group with clinics in 16 states, tests all patients with the shorter nasal swab when doing either PCR or antigen tests at its nearly 200 urgent care centers, said Jane Trombetta, the company’s chief clinical officer.

Which diagnostic test should my child get?

The type of test that your child gets will largely depend on what is available in your area, how long it takes to get the results back and why the child needs it, the experts said.

Some day care centers and schools will only accept PCR results for clearance to return to school, so it is best to double check their rules beforehand.

The long-swab molecular test is considered the “gold standard,” but other less-invasive testing methods are also reliable. For routine testing, Dr. Jay K. Varma, senior advisor for public health at the Office of the Mayor of New York City, said the shorter swab “performs basically as well as the longer, deeper swab does. That’s true in both adults and children.” In fact, he added, New York City’s public hospital testing sites began switching from the long swab to the short swab during the summer.

Dr. Jennifer Lighter, a pediatric infectious disease specialist at NYU Langone Health, said she likes the antigen tests because they can quickly identify Covid-positive kids when they are contagious. Antigen tests are most accurate when the amount of virus in the sample is highest — typically around the day that symptoms start.

If you have a preference on which test you’d like your child to get, call your pediatrician’s office first and ask what kinds of tests they perform and how they collect the samples. Clarify whether they use the shallow (anterior) swab or the long (nasopharyngeal) swab. If you want the more comfortable, shallow PCR test but your pediatrician’s office does not offer it, try other testing centers in your area, including pediatric urgent care centers.

Some tests are now available for home use. But if you’re using a home test, check the label. Some aren’t indicated for children.

Are there any downsides to getting my kid tested? Is it safe?

Many testing sites offer drive-through services where you don’t need to leave your car. But if you must walk into a clinic, the experts I spoke with said that the risk of getting Covid while you’re there is low.

“In my experience, everyone that is delivering health care now is being incredibly careful with infection control,” said Dr. Sean O’Leary, the vice chairman of the American Academy of Pediatrics’ committee on infectious diseases. “The risk of going into a health care facility is probably pretty low relative to a lot of the other things people are currently engaging in in the U.S.”

Testing facilities require people to wear masks and to maintain physical distancing, he added.

The experts also said that the tests themselves are not harmful for young children, including infants, even if done repeatedly. The long swab may produce discomfort for a brief period — Dr. O’Leary jokingly calls it the “brain biopsy” — but he is not aware of any long-term risk to the nose or throat.

How can I prepare my child for the test?

To avoid any surprises, ask your provider about which types of tests they offer and how they collect the samples ahead of time.

It’s usually best to be straightforward with your kid about what to expect. For short nasal swabs, explain that a doctor will tickle the inside of their nose with a cotton swab to collect their boogers, and that it won’t hurt.

For the long swab, you may want to prepare your child by explaining that the swab might feel a little uncomfortable, but that it will be over quickly. You can also share that kids of all ages are getting the test, even babies.

Over all, convey that it’s no big deal and it’s something that simply needs to get done, Dr. Lighter said.

“Kids are only as anxious as the information that’s coming to them,” she added.

If your child might be intimidated by the protective gowns, masks and face shields that health providers wear, explain that they wear that clothing to stay safe — kind of like how people wear cloth masks when they go outside.

Some hospitals have created videos like this one from the Children’s Hospital Colorado that show how the Covid test works and what families can expect. If your child is old enough to understand, it might be helpful to watch a video like this together and then talk about it afterward.

Try to find out how long you might need to wait. Many areas have long lines at testing sites, so consider bringing water, snacks and entertainment (crayons, storybooks) for your kids.

If your child’s pediatrician is administering Covid tests, it might be reassuring for your child to have the test performed by someone they are already familiar with. But if not, “try and go somewhere that has experience working with children,” Dr. O’Leary said. Doctors and nurses who test children regularly will most likely know what to do if your child is nervous or scared.

A Colonoscopy Alternative Comes Home

A Colonoscopy Alternative Comes Home

An at-home test for colon cancer is as reliable as the traditional screening, health experts say, and more agreeable.

Credit…Karlotta Freier

  • Jan. 11, 2021, 1:40 p.m. ET

Most Americans who are due for a colon cancer screening will receive a postcard or a call — or prompting during a doctor’s visit — to remind them that it’s time to schedule a colonoscopy.

But at big health care systems like Kaiser Permanente or the federal Veterans Health Administration, the process has changed. Patients who should be screened regularly (age 50 to 75) and who are of average risk, get a letter telling them about a home test kit arriving by mail.

It’s a FIT, which stands for fecal immunochemical test. The small cardboard mailer contains equipment and instructions for taking a stool sample and returning the test to a lab, to detect microscopic amounts of blood. A week or so later, the results show up on an online patient portal.

Five to 6 percent of patients will have a positive test and need to schedule a follow-up colonoscopy. But the great majority are finished with colon cancer screening for the year — no uncomfortable prep, no need to skip work or find someone to drive them home after anesthesia, no colonoscopy.

Last spring, when the coronavirus pandemic closed many medical facilities and postponed nonemergency procedures, this approach suddenly looked even more desirable.

“We know that from March to May, colon cancer screenings fell by about 90 percent,” said Dr. Rachel Issaka, a gastroenterologist at the University of Washington and the Fred Hutchinson Cancer Research Center. Although testing has resumed, she said, “we’re still not back to where we were.”

Yet colon cancer represents the third-highest cause of cancer deaths, after lung cancer and, tied for second place, breast and prostate cancer. Unlike those, colon cancer can be prevented with early detection.

With many older adults trying to avoid hospitals and surgical centers, even as their risk of colon cancer rises with age, an at-home test provides an alternative to colonoscopy — one that is both safer, with a lower risk of complications and Covid-19 exposure, and does as good a job.

“If your doctor tells you a colonoscopy is better, that’s not accurate,” said Dr. Alex Krist, chairman of the U.S. Preventive Services Task Force, an independent expert panel that reviews evidence and issues recommendations. “The data show the tests are equally effective at saving lives.”

The Task Force is updating its guidelines for colon cancer screening and this year will likely recommend lowering the age at which it should begin, to 45. But the recommendations on the upper end will remain unchanged: Based on strong evidence, adults up to age 75 should be screened regularly.

Beyond that age, the disadvantages begin to mount. The Task Force says the benefit of screening 76- to 85-year-olds is small, and that the decision should be an individual one, reached in consultation with a doctor.

Colon cancer develops slowly, explained Dr. James Goodwin, a geriatrician and researcher at the University of Texas Medical Branch in Galveston. Patients at older ages, who typically contend with several other diseases, may not live long enough to benefit. “You cause more harm than good,” Dr. Goodwin said.

The advice to stop screening isn’t always popular with patients. “People don’t like to hear about not living very long,” he said. But with colonoscopy, he noted, “you go through an unpleasant experience — or an unpleasant experience followed by an unpleasant diagnosis and unpleasant treatment — for something that, if you’d never known about it, wouldn’t cause you harm.”

Even if a test eventually finds colon cancer, surgery plus chemotherapy, the standard treatment, could itself endanger a frail older person. “I would be heavily biased against anyone getting a screening, of any sort, over age 80,” Dr. Goodwin said.

Although Americans still rely mostly on colonoscopy, his research has shown that for many older people, that test is overused, either because of the patients’ ages or because they are tested too frequently.

Yet screening is simultaneously underused. In 2018, according to the Centers for Disease Control and Prevention, only about 70 percent of adults were up-to-date on colorectal cancer testing. About one-fifth of those 65 to 75 had not been screened as recommended. Among those 50 to 65, where lack of Medicare or other insurance probably contributed, only about 63 percent were appropriately screened.

The Task Force has found several kinds of screening tests effective, but the ones used most for people at average risk are colonoscopy, at a recommended 10-year interval, or FIT annually.

A newer entry, an at-home test sold under the brand name Cologuard that detects blood and cancer biomarkers in stool, may be used every three years, but a study found it to be less effective than most other methods and far more expensive than FIT.

When screening is recommended, how does FIT stack up against colonoscopy?

Higher-risk patients — including those who have had colon cancer or parents or siblings with colon cancer, those with inflammatory bowel disorders like Crohn’s disease, and those who have had abnormal previous tests, including multiple or large polyps — should seek out a colonoscopy, often on an accelerated schedule. The procedure involves inserting a viewing instrument through the anus to directly visualize an anesthetized patient’s colon.

A colonoscopy offers one distinct advantage: if the gastroenterologist spots polyps, growths that over time could become cancerous (although most don’t), these can be removed immediately. “You’re preventing cancer, snipping out the things that could lead to cancer,” Dr. Goodwin said. After a negative colonoscopy, patients don’t need another for a decade.

But the procedure’s complications increase with age, although they remain low; the most serious, a perforated colon, requires hospitalization. Cleaning out the bowel on the day before the procedure, in preparation, is disruptive and disagreeable, and Dr. Goodwin notes that older patients sometimes experience cycles of diarrhea and constipation for weeks afterward.

Rural residents may find traveling to a facility difficult. The use of anesthesia means that every patient needs someone to drive or escort them home afterward. The prospect of spending two to four hours in a facility, even one using rigorous safety measures, will cause some older adults to postpone testing because of Covid-19 fears.

The FIT, which is far more widely used in other countries, avoids many of those difficulties. A marked improvement over earlier at-home stool tests, it requires a sample from one day instead of samples from three, and imposes no food or drug restrictions. A positive result still calls for a colonoscopy, but the great majority of patients avoid that outcome.

Why do so many Americans still undergo colonoscopies, then? “There’s a large financial incentive for people who do colonoscopies to do colonoscopies,” Dr. Goodwin said, so patients may not hear much about the alternatives.

“Many of my own patients are surprised to learn that there’s another way,” said Dr. Krist, also a family physician at Virginia Commonwealth University. “As they age, they want less invasive methods” and may be happy to switch.

Wider adoption of FIT could also save patients and insurers, notably Medicare, a boatload. The home test, which is available through several manufacturers, generally costs less than $20; a colonoscopy can easily exceed $1,000.

Moreover, with personalized messages to patients and follow-up reminders to return the kit, FIT use can result in more people being screened. That could prove important when the Preventive Services Task Force lowers the recommended age to 45, which would add 22 million Americans to the list of people advised to undergo colon cancer screening. Their needs, plus a backlog of patients who postponed tests during the pandemic, could swamp gastroenterology practices.

“If a provider doesn’t bring up” the possibility of an at-home test, Dr. Issaka said, “patients should feel empowered to ask about it.” Colon cancer screenings, of any type, “are considered non-urgent,” she said. “But they’re not optional.”

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Covid Guide: How to Get Through the Pandemic

Dec. 18, 2020

Hang in there, help is on the way

Times are tough now, but the end is in sight. If we hunker down, keep our families safe during the holidays and monitor our health at home, life will get better in the spring. Here’s how to get through it.

Tara Parker-Pope

Illustrations by Vinnie Neuberg

Everyone is tired of living like this. We miss our families and our friends. We miss having fun. We miss kissing our partners goodbye in the morning and packing school lunches. We miss travel and bars and office gossip and movie theaters and sporting events.

We miss normal life.

It has been a long, difficult year, and there are many tough weeks still ahead. The coronavirus is raging, and the United States is facing a grim winter, on track for 450,000 deaths from Covid-19 by February, maybe more.

But if we can safely soldier through these next few months, then normal life — or at least a new version of normal — will be within reach. New vaccines that are highly protective against coronavirus are being rolled out right now, first to health care workers and the most vulnerable groups, and then to the general population this spring.

“Help is on the way,” says Dr. Anthony S. Fauci, the nation’s top infectious disease expert. “A vaccine is literally on the threshold of being implemented. To me that is more of an incentive to not give up, but to double down and say, ‘We’re going to get through this.’”

The vaccine won’t change life overnight. It will take months to get enough people vaccinated so that the virus has nowhere to go. But the more everyone does their part to slow down the virus now — by wearing a mask and restricting social contacts — the better and faster the vaccine will work to slow the pandemic once we can all start getting vaccinated this spring.

“Why would you want to be one of the people who is the last person to get infected?” says Dr. Fauci. “It’s almost like being the last person to get killed in a war. You want to hang in there and protect yourself, because the end is in sight.”

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Hunker Down for a Little Bit Longer

The pandemic is surging, but as bad as things are, the end is in sight. By doubling down on precautions, we can slow the virus and save lives.

A crucial number to watch this winter is the test positivity rate for your state and community. The number represents the percentage of coronavirus tests that are positive compared to the overall number of tests being given, and it’s an important indicator of your risk of coming down with Covid-19. When positive test rates in a community stay at 5 percent or lower for two weeks, you’re less likely to cross paths with an infected person. Since the fall, the national test positivity rate has crept above 10 percent, and it’s been 30 percent or higher in several states.

Rising case counts and rising test positivity rates mean there is more virus out there — and you need to double down on precautions, especially if you have a high-risk person in your orbit. Cut back on trips to the store or start having groceries delivered. Scale back your holiday plans. Don’t invite friends indoors, even for a few minutes. Always keep six feet of distance from people who don’t live in your home. Skip haircuts and manicures until the numbers come down again. Wear a mask.

Close your leaky bubble.

Here’s the harsh reality of virus transmission: If someone in your family gets sick, the infection probably came from you, another family member or someone you know. The main way coronavirus is transmitted is through close contact with an infected person in an enclosed space.

“One of the challenges we have is that familiarity is seen as being a virus protector,” said Michael Osterholm, a member of President-elect Joseph R. Biden Jr.’s coronavirus advisory group and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “More likely than not, knowing someone is the risk factor for getting infected.”

This summer, 47 percent of Americans said they had formed a “pod” or social “bubble” that includes two or more households committed to strict precautions so the group can safely socialize indoors.But sometimes your bubble is leakier than you realize. Farhad Manjoo, an opinion columnist for The Times, had initially assumed his bubble was pretty small, but it turned out that he was having direct or indirect contact with more than 100 people.

Whether your bubble is just your immediate household — or you’ve formed a bubble with others — take some time to check in with everyone and seal the leaks. This requires everyone to be honest about the precautions they’re taking (or not taking). Dr. Osterholm said that convincing people that their friends might infect them has been one of the biggest challenges of the pandemic. He told the story of a man and a woman who both contracted Covid-19 after attending a wedding.

“He told me, ‘We didn’t fly. I knew everybody there,’” said Dr. Osterholm. “He somehow had the mistaken belief that by knowing the person, you won’t get infected from them. We’ve got to break through that concept.”

Mask up. You’re going to need it for a while.

A study by the Institute for Health Metrics and Evaluation at the University of Washington estimated that 130,000 lives could be saved by February if mask use became universal in the United States immediately.

Various studies have used machines puffing fine mists to show that high-quality masks can significantly reduce the spread of pathogens between people in conversation. And the common-sense evidence that masks work has become overwhelming. One well-known C.D.C. study showed that, even in a Springfield, Mo., hair salon where two stylists were infected, not one of the 139 customers whose hair they cut over the course of 10 days caught the disease. A city health order had required that both the stylists and the customers be masked.

Choose a mask with two or three layers that fits well and covers your face from the bridge of your nose to under your chin. “Something is better than nothing,” said Linsey Marr, professor of civil and environmental engineering at Virginia Tech and one of the world’s leading aerosol scientists. “Even the simplest cloth mask of one layer of material blocks half or more of aerosols we think are important to transmission.”

Watch the clock, and take the fun outside.

When making decisions about how you’re spending your time this winter, watch the clock. If you’re spending time indoors with people who don’t live with you, wear a mask and keep the visit as short as possible. (Better yet, don’t do it at all.) Layer up, get hand warmers, some blankets, an outdoor heater — and move social events outdoors.

In an enclosed space, like an office, at a birthday party, in a restaurant or in a church, you can still become infected from a person across the room if you share the same air for an extended period of time. There’s no proven time limit that is safest, but based on contact tracing guidelines and the average rate at which we expel viral particles — through breathing, speaking, singing and coughing — it’s best to wear a mask and keep indoor activities, like shopping or haircuts, to about 30 minutes.

Take care of yourself, save a medical worker.

The country’s doctors, nurses and other health care workers are at a breaking point. Long gone are the raucous nightly cheers, loud applause and clanging that bounced off buildings and hospital windows in the United States and abroad — the sounds of public appreciation each night at 7 for those on the pandemic’s front line.

“Nobody’s clapping anymore,” said Dr. Jessica Gold, a psychiatrist at Washington University in St. Louis. “They’re over it.”

In interviews, more than two dozen frontline medical workers described the unrelenting stress that has become an endemic part of the health care crisis nationwide. Jina Saltzman, a physician assistant in Chicago, said she was growing increasingly disillusioned with the nation’s lax approach to penning in the virus. In mid-November, she was astounded to see crowds of unmasked people in a restaurant as she picked up a pizza. “It’s so disheartening. We’re coming here to work every day to keep the public safe,” she said. “But the public isn’t trying to keep the public safe.”

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Scale Back Your Holiday Plans

How and when the pandemic ends will depend on the choices we make this winter, particularly around Christmas and New Year’s Eve.

Nobody wants to open presents by Zoom, light holiday candles at home alone or clink virtual champagne glasses to ring in the New Year.

But here we are, in the midst of a surging pandemic, on course to losing nearly a half million souls in less than a year. Despite the promise of a vaccine on the horizon, only a tiny fraction of Americans will be vaccinated by the end of December. Vaccines won’t enter large-scale distribution until spring 2021.

The only way to drive down infection rates for now will be to avoid large indoor gatherings, wear masks, cancel travel and limit your holiday celebrations to just those who live in your home.

Dr. Fauci said he, his wife and three daughters, who live in different parts of the country, all made a family decision not to travel for the holidays. It will be the first Christmas in 30 years that the entire family won’t be together.

“I’m a person in an age group that’s at high risk of serious consequences,” said Dr. Fauci. “That’s the first Thanksgiving since any of my three daughters were born that we have not spent it as a family. That was painful, but it was something that needed to be done. We are going to do the same thing over Christmas for the simple reason that I don’t see anything changing between Thanksgiving and Christmas and Hanukkah. In fact, I see it getting worse.”

If you do travel, get tested.

People who choose to travel over the holiday season despite the warnings should consider taking precautions. First, try to quarantine for at least a week (two weeks if possible) before your trip or visit with another household. The C.D.C. now recommends that domestic air travelers get tested before and after their trip.

Remember, a lot can go wrong between the time you take a test and the moment you hug Grandma. Not only are false negatives possible, you need to consider the risk of catching the virus after taking the test — in an airport, in a plane or from a taxi driver or rental car agent.

For a laboratory test, check the turnaround time in your area and try to schedule it as close as possible to your visit. If you’re using rapid testing, try to take more than one test over the days leading up to your visit, and if possible, get a rapid test on the same day you plan to visit family, friends or a vulnerable person. Test again after you arrive if you can.

Plan a safer holiday gathering.

If you’re determined to have people to your home for the holidays, keep the guest list small and consider these precautions.

Get tested: If testing is available in your area, consider asking all guests to be tested a few days before the holiday, timing it so they get the results before coming to your home. If rapid testing is available, get tested a few times during the week and on the day of the social event.

Move the event outside: Even if it’s cold outside, try hosting all or part of your holiday celebration outdoors. Look into space heaters and fire pits to warm a porch or patio. Even a partially open space, like a screened-in porch or a garage with the door open, is better than socializing indoors. If you decide to stay indoors, open the windows and turn on exhaust fans to help ventilate your home.

Wear masks: All guests should wear a mask when not eating. If you’re the host, set the example and put your mask on after the meal is over and everyone is enjoying the conversation. Limit the amount of time you spend together indoors.

Socialize outdoors the Scandinavian way.

In the pandemic, rather than feeling depressed that the arrival of cold weather will mean that you’ll be isolated indoors, apart from friends and family, we can take lessons from Scandinavians about how to continue getting together outdoors.

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Take Care of Yourself at Home

Covid-19 can be scary, but we’ve learned a lot about how to monitor the illness and home — and when to seek hospital care.

Since the start of the pandemic, we’ve learned a lot about how to care for people infected with Covid-19. Death rates from the disease are dropping as doctors have gotten better at treating it and advising patients when to seek medical care.

Steroids like dexamethasone have lowered the number of deaths among hospitalized patients by about one-third. And although limited in supply, monoclonal antibodies, a treatment given to President Trump when he was ill with coronavirus, can possibly shorten hospital stays when given early in the course of infection.

But the vast majority of patients with Covid-19 will manage the illness at home. Check in with your doctor early in the course of your illness, and make a plan for monitoring your health and checking in again if you start to feel worse.

Get tested if you have symptoms.

Ideally, you should be able to get a coronavirus test whenever you want it. But in the United States, test availability varies around the country, depending on whether supplies are low or labs are overwhelmed. Check with your doctor, an urgent care clinic or your local health department about where to get tested in your area.

If you feel sick, you should be tested for Covid-19. A dry cough, fatigue, headache, fever or loss of sense of smell are some of the common symptoms of Covid-19. After you take your test, stay isolated from others and alert the people you’ve spent time with over the last few days, so they can take precautions while you’re waiting for your result. Many tests will work best if you are in the first week of your symptoms.

Track your symptoms.

Marking your calendar at the first sign of illness, and tracking your symptoms and oxygen levels, are important steps in monitoring a coronavirus infection. Covid-19 has been unpredictable in the range of symptoms it can cause. But when it turns serious, it often follows a consistent pattern.

While every patient is different, doctors say that days five through 10 of the illness are often the most worrisome time for respiratory complications of Covid-19. Covid-19 is a miserable illness, and it’s not always easy to know when to go to the emergency room. It’s important during this time to stay in touch with your doctor. Telemedicine makes it possible to consult with your doctor without exposing others to your illness.

Get a fingertip pulse oximeter.

The best way to monitor your health during Covid-19 is to use a pulse oximeter, a small device that clips onto your finger and measures your blood oxygen levels. If it drops to 93 or lower, it could be a sign that your oxygen levels are dropping. Call your doctor or go to the emergency room.

Pro tip: One of the things to remember about reading a pulse oximeter is that many of them are designed to be read by someone facing you, not the person wearing it. If you’re looking at it upside down, a healthy reading of 98 could look like an alarming 86.

Caring for someone with Covid-19

Caring for someone with mild to moderate symptoms of the coronavirus is similar to caring for someone with the flu. Give them supportive care, fluids, soups and Tylenol, and have them take their temperature and monitor oxygen levels with a pulse oximeter regularly. Always wear a mask in the sick person’s room even if they are not there or have recovered. Coronavirus particles can last as long as three days on various surfaces, and can be shaken loose when you pick up clothes, change bedding or pick up soiled tissues.

The plight of “Covid long-haulers”

It’s unclear how many people develop lingering and sometimes debilitating symptoms after a bout of Covid-19. Such symptoms — ranging from breathing trouble to heart issues to cognitive and psychological problems — are already plaguing an untold number of people worldwide. Even for people who were never sick enough to be hospitalized, the aftermath can be long and grueling, with a complex and lasting mix of symptoms.

There is an urgent need to address long-term symptoms of the coronavirus, leading public health officials say, warning that hundreds of thousands of Americans and millions of people worldwide might experience lingering problems that could impede their ability to work and function normally.

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Look for Better Days This Spring

With the rollout of the vaccine, an end to the pandemic is in sight. Life will start to feel more normal in mid- to late 2021, depending on how many people get vaccinated.

Earlier this month, The Times spoke with Dr. Fauci about his predictions for the spring. Here’s what he had to say.

The end game for viral disease outbreaks, particularly respiratory diseases, is a vaccine. We can do public health measures that are tempering things, waiting for the ultimate showstopper, which is a vaccine. That’s why I’m saying we need to double down even more on public health measures to get us through to the period when enough people in this country will be vaccinated that the virus will have no place to go. It will be a blanket or an umbrella of herd immunity.

We have crushed similar outbreaks historically. We did it with smallpox. We did it with polio. We did it with measles. We can do it with this coronavirus. It requires a highly efficacious vaccine. Thank goodness we have that. We have multiple vaccines, two of which clearly are very efficacious, and I feel confident that the others that are coming along will be comparably efficacious.

Then the second part of that is getting the overwhelming majority of the population vaccinated. I think that likely will have to be about 70 to 75 percent of people in this country. If we do that, that will be the indicator of when things will get back to normal, when you won’t have to worry about going in a restaurant, when you won’t have to worry about having a dinner party, when the children won’t have to worry about going to school, when factories can open and not worry about their employees getting sick and going to the hospital. That will happen, I guarantee you. If people appreciate the importance of getting vaccinated, and we have a high uptake of vaccines, that will happen. That’s what the future will look like.

The future doesn’t need to be bleak. It’s within our hands to really shape the future, both by public health measures and by taking up the vaccine. — Dr. Fauci

What you need to know about the new vaccines

There aren’t enough doses right now for everyone, so initially the vaccine will be rationed for those who need it most. It will take time to produce and distribute the vaccine, and then schedule two vaccinations per person, three to four weeks apart. As more vaccines get approved, things will speed up. At least 40 million doses (enough for 20 million people) should be available from Pfizer and Moderna by the end of the year, and much more will come in 2021.

The challenges ahead for widespread vaccination

The success of the new vaccines will depend on more than how well they performed in a clinical trial. While there’s much reason for optimism, a lot can still go wrong.

First there’s the challenge of manufacturing and distributing the doses. Pharmaceutical manufacturers have struggled to ramp up vaccine production. They have run short on materials like the bags that line the containers in which the vaccines are made. Both of the leading vaccines must be stored in freezing conditions. And state and local governments have to figure out how to get the vaccines from production facilities into people’s arms.

The dark cloud hanging over vaccine distribution

The vaccines will be much less effective at preventing death and illness in 2021 if they are introduced into a population where the coronavirus is raging — as is now the case in the United States.

An analogy may be helpful here, says David Leonhardt, who writes The Morning newsletter for The Times. He explains that a vaccine that’s 95 percent effective, as Moderna’s and Pfizer’s versions appear to be, is a powerful fire hose. But the size of a fire is still a bigger determinant of how much destruction occurs.

Even if the vaccine is distributed at the expected pace, at the current infection level, experts predict that the country would still face a terrible toll during the six months after the vaccine was introduced. Almost 10 million or so Americans would contract the virus, and more than 160,000 would die.

There is one positive way to look at this: Measures that reduce the virus’s spread — like mask-wearing, social distancing and rapid-result testing — can still have profound consequences. They can save more than 100,000 lives in coming months.

Hoping vaccine skepticism will fade

Despite images of relieved health care workers getting a shot in the arm flashing across TV screens and news sites, a new survey finds that more than one-quarter of Americans say they probably or definitely will not get a coronavirus vaccination. The survey, by the Kaiser Family Foundation, found that Republican, rural and Black Americans were among the most hesitant to be vaccinated.

Nevertheless, confidence in the vaccine appears to be rising. Over all, 71 percent of respondents said they definitely would get a vaccination, an 8 percent increase from what Kaiser found in a September survey. Roughly a third (34 percent) now want the vaccine as soon as possible. A recent study from Pew Research showed that about 60 percent of Americans would definitely or probably get a vaccine, up from 51 percent of people asked in September.

Looking ahead to spring

While the majority of Americans won’t get their shots until spring, the vaccine rollout is a hopeful sign of better days ahead. We asked Dr. Anthony S. Fauci, as well as several epidemiologists and health and science writers for The Times, for their predictions about the months ahead. Here’s some of what they had to say.

When can we go to the movies or the theater?

“It depends on the uptake of the vaccine and the level of infection in the community. If you go to April, May, June and you really put on a full-court press and try to vaccinate everybody within a period of a few months, as you go from second to third quarter of the year, then you could likely go to movies, go to theaters, do what you want. However, it’s unlikely, given what we’re hearing about people’s desire to get vaccinated, that we’re going to have that degree of uptake. If it turns out that only 50 percent get vaccinated, then it’s going to take much, much longer to get back to the kind of normality that we’d like to see.” — Dr. Fauci

What did you learn from pandemic life?

“Staying home with my children has taught me that life with fewer errands to run and activities to partake in is kind of nice. I think in the future we will cut down on our family obligations.” — Jennifer Nuzzo, associate professor, Johns Hopkins

What’s one thing you’ll never take for granted again?

“I won’t take traveling to my extended family for granted.” — Alicia Allen, assistant professor, University of Arizona

Will we ever go to a big, crowded, indoor party without a mask again?

“If the level of infection in the community seems substantial, you’re not going to have the parties with friends in congregant settings. If the level of infection is so low that risk is minuscule, you’re going to see back to the normal congregating together, having parties, doing that. If we want to get back to normal it gets back to my message: When the vaccine becomes available, get vaccinated.” — Dr. Fauci


Contributors: Sara Aridi, Quoctrung Bui, Abby Goodnough, David Leonhardt, Apoorva Mandavilli, Donald G. McNeil Jr., Claire Cain Miller, Yuliya Parshina-KottasRoni Caryn Rabin, Margot Sanger-Katz, Amy Schoenfeld Walker, Noah Weiland, Jeremy White Katherine J. Wu and Carl Zimmer

New Scan Finds Prostate Cancer Cells Hiding in the Body

New Scan Finds Prostate Cancer Cells Hiding in the Body

The test seems likely to improve the diagnosis and treatment of a disease that kills 33,000 American men each year.

Dr. Mark Samberg, a retired urologist in Sacramento, learned his cancer had spread beyond his prostate with a new scan that finds radioactively tagged cancer cells in the body. 
Dr. Mark Samberg, a retired urologist in Sacramento, learned his cancer had spread beyond his prostate with a new scan that finds radioactively tagged cancer cells in the body. Credit…Max Whittaker for The New York Times
Gina Kolata

  • Dec. 16, 2020, 2:08 p.m. ET

After doctors found cancer in Dr. Mark Samberg’s prostate last spring, the 70-year-old retired urologist prepared to have his prostate removed. He knew that the surgery would cure him, assuming the cancer was confined to the organ.

But his doctors had a nagging concern — the cancer cells seen on the biopsy were aggressive and may already have escaped from his prostate. If so, the operation would not cure him. The problem for Dr. Samberg, and for many men with aggressive prostate cancer, was this: If there are cancer cells outside the prostate, how can they be found?

Now the Food and Drug Administration has approved a test that can locate prostate cancer cells wherever they are. Exuberant cancer specialists said the test would alter treatment for patients nationwide.

“It’s the most exciting thing in prostate cancer in my lifetime,” said Dr. Kirsten Greene, chair of the urology department at the University of Virginia School of Medicine.

The test relies on a radioactive tag attached to a molecule that homes in on prostate cancer cells that have spread to other locations in the body and may seed new tumors. Once tagged, the clusters of cells appear as bright spots on PET scans.

At the moment, the F.D.A.’s approval applies only to testing at the University of California, San Francisco, and the University of California, Los Angeles, which conducted clinical trials. But several companies hope to market similar tests soon.

“It’s absolutely fabulous,” said Dr. Oliver Sartor, professor of medicine at Tulane University School of Medicine. When he learned that the test had been approved, he said, he danced in his office “and had a toast of imaginary champagne.”

Now specialists are hoping to use the technique to kill cancer cells, not just find them. The idea is to attach a radioactive drug to the molecule that seeks out prostate cancer cells. The molecule will deliver the drug directly to those cells and, it is hoped, the radiation will destroy the cancer. Experiments already have begun at U.C.S.F. and U.C.L.A.

The road to the new test has been long. Nearly 30 years ago, researchers discovered that prostate cancer cells carry a unique protein on their surfaces called prostate specific membrane antigen, or P.S.M.A. More recently, researchers found small molecules that could home in on P.S.M.A.

Scientists theorized that radioactive tracers attached to those molecules could make prostate cancer cells visible on PET scans. In 2010, researchers at the University of Heidelberg in Germany published the first images of prostate cancer cells located in this way.

Over the past four years, studies involving about 1,000 patients by Dr. Jeremie Calais, a nuclear medicine physician at U.C.L.A., and Dr. Thomas Hope, a nuclear medicine physician at U.C.S.F., showed that the scan accurately detected prostate cancer cells anywhere in the body before treatment and even after treatment, when cancer may recur.

The research led to changes in treatment for most patients, including decisions to recommend targeted radiation, guided by the scans, rather than chemotherapy or androgen-blocking therapy, treatments that impact the entire body.

Dr. Hope described two situations in which the PET scans can transform treatment decisions.

Most men learn they have prostate cancer when a simple blood test finds high levels of prostate specific antigen, or P.S.A. The next step is a biopsy of the prostate and removal of cancer cells for examination to see how aggressive they appear.

Men often have MRI scans to see if the capsule surrounding the prostate has been breached — a sign the cancer has gotten out. And doctors consider how high P.S.A. levels are. The higher they are, the more cancer in the body and the more likely it has spread.

The second scenario occurs after a man has had his prostate removed or destroyed by radiation. If the patient’s P.S.A. levels start to rise months or years later, the cancer that doctors thought they had cured had already seeded itself elsewhere in the man’s body.

In both situations, “we know they have disease, but we don’t know where it is,” Dr. Hope said. The new scan seems able to show doctors where to look. The researchers are now conducting studies to see if these treatment revisions ultimately prolong patients’ lives.

Dr. Samberg, who lives in Sacramento, was one of the participants in the U.C.S.F. trial. Before his scheduled prostatectomy, the scan turned up cancerous cells in his bones and lymph nodes. “That was shocking,” he said.

Without the new test, the doctors would have removed Dr. Samberg’s prostate, and they would have realized he still had cancer when his P.S.A. levels began to rise. In such a case, doctors usually irradiate the area where the prostate used to be — the prostate bed, which is the site of remaining cancers a bit more than half the time.

For Dr. Samberg, that procedure, like the prostatectomy, would not have helped. “Standard therapy for me would fail,” he said. Instead, the discovery that his cancer was in his bones and lymph nodes pointed to targeted radiation therapy, hormonal therapy and, most recently, immunotherapy.

“I am in complete remission,” Dr. Samberg said. “I hope it makes a difference long term.”

Covid Testing: What You Need to Know

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What You Need to Know About Getting Tested for Coronavirus

Long lines, slow results and inconsistent advice have left many of us confused about when and how to get tested. We talked to the experts to answer your questions.

Dec. 9, 2020

Testing is essential to controlling the coronavirus. Once people know they are infected, they can isolate, alert others of the risk and stop the spread.

But months into the pandemic, many people still are frustrated and confused about virus testing. Long lines at testing sites, delays in getting results and even surprise testing bills have discouraged some people from getting tested. Many people don’t understand what a test can and can’t tell you about your risk — and wrongly think a test result that comes back negative guarantees they can’t spread the virus to others.

We asked some of the nation’s leading experts on testing to help answer common questions about how to get tested, what to expect and what the different tests and results really mean. Here’s their advice.

When should I be tested for coronavirus?

Ideally, you should be able to get a coronavirus test whenever you want it. But in the United States, test availability varies around the country. In some places, you still need a doctor’s prescription to get tested. In other communities, you can get tested easily by walking in to a clinic or even using a home test kit. There are four main reasons to get a test.

Symptoms: Feeling sick is the most urgent reason to get tested. A dry cough, fatigue, headache, fever or loss of sense of smell are some of the common symptoms of Covid-19. (Use this symptom guide to learn more.) While you’re waiting for your results, stay isolated from others and alert the people you’ve spent time with over the last few days, so they can take precautions. Many tests are most reliable during the first week you have symptoms.

Exposure: Did you find out that you recently spent time with an infected person? Were you in a risky situation, like an indoor gathering, or a large event or in an airport and airplane? You should quarantine and get tested. If testing isn’t widely available and you have only one chance to take a test, it’s best to get tested five to six days after a potential exposure to give the virus the opportunity to build up to detectable levels in the body. Test too early, and you might get a false negative result. If you’re in a city where it’s easy to get a test, get tested a few days after the exposure and, if it’s negative, get tested again in three or four days. If you think you’ve been exposed to the virus, the Centers for Disease Control and Prevention advises you quarantine for at least seven days and receive a negative test result before returning to normal activity.

Precautions: Some people get tested as a safeguard. Hospitals may require you to be tested before certain invasive medical procedures or surgery. Visitors to nursing homes may be given a rapid test before they are allowed to enter. Many colleges and boarding schools test students frequently and suggest they be tested before leaving campus and when they return. If you must travel, it’s a good idea to be tested before you leave, and a few days after you arrive. A negative test result is never a free pass to mingle with others, but knowing your infection status will lower the chance that you are unknowingly spreading the virus. Check on the turnaround time at the testing site in your area, and try to time it so you get a result as close as possible to the event or visit. Even if your test result is negative, you still need to wear a mask, maintain distance from others and take other precautions.

Community testing: In some cases, local health officials will encourage widespread testing for everyone, offering tests at health clinics, pharmacies and drive-through testing sites. Testing lots of people helps measure the level of spread in an area and can help slow or stop the spread in areas where known infections have occurred. In New York City, for instance, a health department advertising campaign is encouraging people to be tested often, even if they feel fine. “We learned that one of the ways we can control this virus effectively is by making sure as many people as possible are tested at a given time, so we can pick up people who are infected but don’t yet know they have the infection,” said Dr. Jay K. Varma, deputy commissioner for disease control at the New York City Health Department.

What type of test should I get?

Virus tests are categorized based on what they look for: molecular tests, which look for the virus’s genetic material, and antigen tests that look for viral proteins. The various tests all use a sample collected from the nose, throat or mouth that may be sent away to a lab or processed within minutes. Testing should be free or paid for by your insurance, although some testing centers are adding extra charges. Here are the common tests and some of the pros and cons of each.

Laboratory molecular test: The most widely available test, and the one most people get, is the P.C.R., or polymerase chain reaction, test, a technique that looks for bits of the virus’s genetic material — similar to a detective looking for DNA at a crime scene.

Pros: This test is considered the gold standard of coronavirus testing because of its ability to detect even very small amounts of viral material. A positive result from a P.C.R. test almost certainly means you’re infected with the virus.

Cons: Because these tests have to go through a laboratory, the typical turnaround time is one to three days, though it can take 10 days or longer to get results, which can limit this test’s usefulness, since you may be spreading virus during the waiting period. Like all coronavirus tests, a P.C.R. test can return a false negative result during the first few days of infection because the virus hasn’t reached detectable levels. (One study showed that among people who underwent P.C.R. testing three days after symptoms began, 20 percent still showed a false negative.) Another frustration of P.C.R. testing is that it sometimes detects the virus’s leftover genetic material weeks after a person has recovered and is no longer contagious. The tests are also expensive, costing hospitals and insurers $50 to $150 per test.

Rapid antigen test: An antigen test hunts for pieces of coronavirus proteins. Some antigen tests work sort of like a pregnancy test — if virus antigens are detected in the sample, a line on a paper test strip turns dark.

Pros: Antigen tests are among the cheapest (as little as $5) and speediest tests out there, and can deliver results in about 15 to 30 minutes. Some college campuses and nursing homes are using rapid tests to check people almost daily, catching many infectious people before they spread the virus. Antigen tests work best when given a few times over a week rather than just once. “It tells you, am I a risk to my family right now? Am I spreading the virus right now?” said Dr. Michael Mina, an epidemiologist at Harvard University’s School of Public Health and a proponent of widespread rapid testing. Though, he cautioned, “if the test is negative, it doesn’t tell you if you’re infectious tomorrow or if you were infectious last week.”

Cons: An antigen test is less likely than P.C.R. to find the virus early in the course of the infection. One worry is that a negative rapid test result will be seen as a free pass for reckless behavior — like not wearing a mask or attending an indoor gathering. (The White House Rose Garden event is a good example of how rapid testing can create a false sense of security.) A negative antigen test won’t tell you for sure that you don’t have the coronavirus — it only tells you that no antigens were detected, so you’re probably not highly infectious today. (In one study, a rapid antigen test missed 20 percent of coronavirus infections found by a slower, lab-based P.C.R. test.) Antigen tests also have a higher rate of false positive results, so a positive rapid test should be confirmed.

Rapid molecular test. Some tests combine the reliability of molecular testing with the speedy results of a rapid test. Abbott’s ID Now and the Cepheid Xpert Xpress rely on a portable device that can process a molecular test right in front of you in a matter of minutes.

Pros: These tests are speedy and highly sensitive, and they can identify those exposed to coronavirus about a day sooner in the course of an infection than a rapid antigen test. A rapid molecular test isn’t quite as accurate as the laboratory version, but you’ll get the result much fast

Cons: Depending on where you live, rapid molecular tests might not be widely available. They are also less convenient and often slower than many antigen tests. And like all coronavirus tests, a negative result isn’t a guarantee you don’t have the virus, so you’ll still need to take precautions. Like its laboratory cousin, a rapid molecular test can detect leftover genetic material from the virus even after you’ve recovered.

What happens during a coronavirus test?

Some tests require a health care worker to collect a sample through the patient’s nose or mouth. Other tests allow patients to use a swab or spit to collect their own samples.

  • Nose swab: Many tests collect a sample via the nose. The most reliable sampling method uses a nasopharyngeal swab — a long, flexible stick with absorbent material on the end — that is inserted deep into your nasal cavity until it reaches the upper part of your throat. A trained health worker must perform nasopharyngeal swab tests. A more comfortable method inserts a swab about a half-inch into one nostril and twists and rubs the swab on the inside of your nose for about 15 seconds. Less invasive nose swabs like these can often be self-administered.

  • Mouth swab: In some cases, you may be asked to say “ahh” as the swab is used to collect a sample from the back of your throat, similar to a common test for strep throat. Another method gathers fluids from your mouth by swabbing the cheeks, gums or tongue.

  • Saliva sample: One collection method requires the patient to drool into a test tube. There are no swabs involved, and people taking the test can collect their own saliva, making the procedure safer for health workers who don’t have to get near someone who might be infected.

What happens next? For laboratory tests, the sample is packaged, usually in a chemical soup that keeps it from degrading, and shipped to a facility that can process it. For a rapid test, the sample can be processed immediately, and the results given in a matter of minutes.

How do I get a test? How long will it take?

Roughly 2 million coronavirus tests are run in the United States every day. But testing availability varies considerably from state to state, even city to city. Tests are generally less available in rural areas or in communities where cases have surged and medical and laboratory resources are stretched.

The best way to find out about testing in your community is to check your local public health department website or call your doctor or a local urgent care clinic. Some cities and towns have also set up drive-in community testing sites. If your doctor or local public health clinic offers rapid testing, you usually can get the result in 15 to 30 minutes. But a positive rapid result might need to be confirmed by an additional test, especially if you don’t have symptoms.

In some communities, it can still be difficult to get the results of a laboratory P.C.R. test quickly. A survey from Northeastern University and Harvard Medical School found that this fall, patients had to wait days just to schedule a test and even more time to get results. On average it’s been taking six or seven days after symptoms start to find out if you have the virus, and by then most people are on their way to recovery, making the test pretty useless. (In some parts of the country, people have had to wait as long as two weeks to get test results.) The research also found that Black patients, on average, had to wait almost two days longer to get results than white patients.

Testing turnaround times are improving in some cities. In New York City, for instance, you can get a P.C.R. laboratory test result in about a day. If rapid testing is available in your area, you can get the result in minutes, but rapid tests work best when taken a few times over the course of a week.

What do the results mean for me?

A virus test can produce one of three results: positive (or virus detected), negative (or virus not detected) or inconclusive. Here’s what the results really mean.

Positive: A positive test result means you should continue to stay home and isolate, and alert people you spent time with over the past few days. If you feel sick, contact your primary care doctor for guidance, and monitor your symptoms at home, seeking medical attention when needed. The Centers for Disease Control and Prevention says that you still should wait at least 10 days after symptoms started, and go 24 hours without a fever, before ending isolation. For some people who are severely ill, this timeline might be longer.

Negative: If your test result is negative, it’s reassuring, but it’s not a free pass. You still need to wear a mask and restrict social contacts. False negatives happen and could mean that the virus just hasn’t reached detectable levels. (It’s similar to taking a pregnancy test too early: You’re still pregnant, but your body hasn’t created enough pregnancy hormones to be detected by the test.)

“A negative result is a snapshot in time,” said Paige Larkin, a clinical microbiologist at NorthShore University HealthSystem in Chicago, where she specializes in infectious disease diagnostics. “It’s telling you that, at that exact second you are tested, the virus was not detected. It does not mean you’re not infected.”

Inconclusive: Sometimes a test comes back inconclusive because the sample was inadequate or damaged, or a sample can get lost. You can get retested but, depending on how much time has passed, it might be easier to just finish 10 days of quarantine. If you are sick but receive a negative or inconclusive test, you should consult your health care provider.

If I get tested, can I see my family for the holidays?

Sorry, but a negative test does not mean you can safely visit another household or travel for the holiday to see friends and family. A lot can go wrong between the time you took the test and the moment you hug a family member. False negatives are common with coronavirus testing — whether it’s a laboratory P.C.R. test or a rapid antigen test — because it takes time for the virus to build up to detectable levels in your body. It’s also possible that you weren’t infected with the virus when you took the test, but you got infected while you were waiting for the results. And then consider the risk of catching the virus in an airport, on a plane or from a taxi driver or rental car agent — and you may end up bringing the virus home with you for the holidays.

“I don’t want somebody to have a negative test and think they can go visit grandma,” said Dr. Ashish Jha, dean of Brown University’s School of Public Health.

Despite these limits, if you feel you must travel, it’s a good idea to get tested. If you’re using rapid testing, try to take more than one test over the days leading up to your visit, including a test on the day you plan to see a vulnerable person. If you’re getting a laboratory test, check the turnaround time and try to schedule it as close as possible to your visit. While the test doesn’t guarantee you’re not infected, a negative result will lower the odds that you’ll be spreading the virus. And, of course, a positive test tells you that you should cancel your plans. A test “filters out those who are positive and definitely shouldn’t be there,” said Dr. Esther Choo, an emergency medicine physician and a professor at Oregon Health and Science University. “Testing negative basically changes nothing about behavior. It still means wear a mask, distance, avoid indoors if you can.”

Is home testing an option? Is it reliable?

Communities around the country, including in California, Minnesota and New Jersey, are starting to roll out home testing kits. The cost typically is covered by the government if it’s not covered by your personal insurance. To find out if home testing is available in your area, check your state or local health department website or ask your doctor.

Two types of home tests are currently available. Several companies offer customers the option of spitting in a test tube at home, and then shipping the sample to a laboratory for processing. Results are delivered electronically in a day or two.

In November, the Food and Drug Administration issued an emergency green light for the first completely at-home coronavirus test, made by Lucira. The Lucira test kit allows a person to swirl a swab in both nostrils, stir it into a vial, and use a battery-powered device to process the test and get a result in 30 minutes. The test kit requires a prescription and is not yet widely available. Several companies have rapid home tests in development but still need F.D.A. approval.

Some experts are concerned that widespread home testing is impractical. Even if a new generation of home tests is approved, they question whether people would use the tests correctly or as frequently as recommended, and whether they would isolate if they test positive. But home testing also has several prominent supporters, among them Dr. Anthony S. Fauci, the country’s top infectious disease expert. Dr. Fauci notes that home tests — from home pregnancy tests to home H.I.V. tests — have long prompted skepticism, and that when home H.I.V. test kits were first developed, many experts worried that people would become despondent if they got a positive result while home alone and act brashly. “That’s a standard pushback against home tests,” he said.

But Dr. Fauci and other proponents of home testing say that simple, cheap home kits could allow people to take daily tests before going to work in an office, grocery store or restaurant or before going to school (although it’s still not clear how well the tests work in children). Rapid testing at home a few days a week could potentially identify an infection even before a person develops symptoms.

“I have been pushing for that,” Dr. Fauci said. “I think home testing is the same as a pregnancy test and should be available to people. As long as there is some Covid around, then I think a home test would be useful.”

Should I get an antibody test?

This blood test is designed to detect antibodies that signal you were infected with coronavirus in the past, but shouldn’t be used to diagnose a current infection. It can take one to three weeks after infection for your body to begin producing antibodies. Blood is taken by pricking the finger or drawing blood from your arm through a needle. You can get the test through a doctor’s office, many urgent care clinics or a local public health clinic. You may be offered a free antibody test when you donate blood as well. The waiting time for results varies from a few days to two weeks.

Pros: An antibody test can tell you if you were infected with coronavirus in the past. But experts warn against assuming too much about what a positive result says about immunity to the virus. Scientists generally agree that the presence of antibodies most likely indicates some level of protection, but they don’t know to what extent or for how long. Although reinfections are thought to be rare, they have occurred, and experts stress that a positive result on an antibody test should not give someone a free pass to shirk masks or mingle with others.

Cons: Many antibody tests are inaccurate, some look for the wrong antibodies, and even the right antibodies can fade over time. Some tests are notorious for delivering false positives — indicating that people have antibodies when they do not. These tests may also produce false negative results, missing antibodies that are present at low levels. An antibody test should not be used by itself to determine whether a person is currently infected.

If you do decide to get an antibody test, the result should not change your behavior. You still need to take all public health precautions and assume that you can still contract or spread the virus. If you know you had the coronavirus, and it was confirmed by a diagnostic test at the time you were ill, you may be eligible to donate convalescent plasma, which can potentially help patients still suffering from Covid-19, who can get an infusion of your antibodies to accelerate their recovery time.

How much will virus testing cost me?

In most cases, your test for coronavirus should not cost you a dime. Congress passed laws requiring insurers to pay for tests, and the Trump administration created a program to cover the bills of the uninsured. Cities and states have set up no-cost testing sites.

However, some medical offices and private testing sites are adding extra charges or facility fees, so check in advance about the bill. A New York Times investigation by our colleague Sarah Kliff found that many people have been billed large, unexpected fees or denied insurance claims related to coronavirus tests, and they’ve faced bills ranging from a few dollars to more than $1,000.

To lower your chance of getting a surprise bill, she recommends the following precautions:

  • Get tested at a public testing site set up by your city, county or state health department. If a public test site isn’t an option where you live, you might consider your primary care doctor or a federally qualified health clinic.

  • Avoid getting tested at a hospital or free-standing emergency rooms. Those places often bill patients for something called a facility fee, which is the charge for stepping into the room and seeking service.

  • Ask ahead of time how you will be billed and what fees will be included. It can be as simple as saying: “I understand I’m having a coronavirus test. Are there any other services you’ll bill me for?”

  • If you don’t have insurance, ask ahead of time how providers handle uninsured patients. Ask if they are seeking reimbursement from the federal government’s provider relief fund or if they plan to bill you directly.

You can find more guidance in How to Avoid a Surprise Bill for Your Coronavirus Test. And if you have a coronavirus bill you want to share, submit it here.

What’s next for testing?

More than 200 tests for the coronavirus have been given emergency green lights by the F.D.A., with many more likely to come. Experts think some of the next wave of tests will include more products that can be self-administered from start to finish at home.

As the nation speeds toward the winter months, combination flu/coronavirus tests, which can search for both types of viruses at the same time, are likely to become increasingly common. Many of these tests are already available in doctors’ offices and clinics.

Researchers are also exploring other types of tests that might be able to measure other aspects of the immune response to the virus.

So what’s the bottom line?

More testing is needed to stop the spread of the coronavirus. The more testing we do and the faster we get the results back — whether it’s a P.C.R. test or a rapid test — the more information we have to make good choices and keep those around us safe. Tests are useful when used correctly, and when you know the limits of the information they give you. A positive test of any kind should keep you home and isolating. (If you have good reason to doubt the result, get tested again.)

A negative test is not a free pass to drop your mask and socialize in groups. It’s a snapshot in time. A negative P.C.R. test tells you that you were negative a few days ago when you took the test. A negative rapid antigen test tells you that you’re probably not infectious right now, but it’s better to take a few more tests over the next few days to be sure. In both cases it’s possible you still have the virus (just as it’s possible to get a negative pregnancy test and still be pregnant).

In general, if you have symptoms, your doctor will order a P.C.R. test to confirm if you have Covid-19. If you’re living on a college campus, or going to work in a factory or grocery store every day, frequent rapid testing can be a useful way to monitor your health regularly. Because testing has not been consistently available around the country, you may not have the option for getting either type of test quickly. Wearing a mask, maintaining your distance and restricting contact with people outside your household remain essential to stopping the spread of the coronavirus.

Produced by Jaspal Riyait

What You Need to Know About Getting Tested for Coronavirus

‘Nobody Sees Us’: Testing-Lab Workers Strain Under Demand

April Abbott, director of microbiology at Deaconess Hospital in Evansville, Ind., a mother of three who keeps a bed in her office for when her duties keep her overnight. “There is always more work to be done than the hours to do it in,” she said.
April Abbott, director of microbiology at Deaconess Hospital in Evansville, Ind., a mother of three who keeps a bed in her office for when her duties keep her overnight. “There is always more work to be done than the hours to do it in,” she said.Credit…Kaiti Sullivan for The New York Times

‘Nobody Sees Us’: Testing-Lab Workers Strain Under Demand

Laboratory technologists have been working nonstop to help the nation diagnose an ever-growing number of coronavirus cases.

April Abbott, director of microbiology at Deaconess Hospital in Evansville, Ind., a mother of three who keeps a bed in her office for when her duties keep her overnight. “There is always more work to be done than the hours to do it in,” she said.Credit…Kaiti Sullivan for The New York Times

Katherine J. Wu

By

  • Dec. 3, 2020, 5:00 a.m. ET

In March, April Abbott dragged a hospital bed into her office at Deaconess Hospital in Evansville, Ind. In the nine months since, she has slept in it a half-dozen times while working overnight in her clinical microbiology laboratory, where a team of some 40 scientists toils around the clock running coronavirus tests.

These all-night stints in the lab pull Dr. Abbott, the director of microbiology at Deaconess, away from her husband and three children, the oldest of whom is 8. A couple of times a week, she heads home for dinner, then drives back to work after the kids have gone to bed. She is at the lab when machines break. She is there to vet testing protocols for the lab. She is there when new testing sites open, flooding the lab with more samples to process.

“I do it because there is always more work to be done than the hours to do it in,” she said.

Nearly a year into a pandemic that has claimed more than 272,000 American lives, some 192 million tests for the coronavirus have been processed nationwide. Millions more will be needed to detect and contain the virus in the months ahead. Behind these staggering figures are thousands of scientists who have been working nonstop to identify the coronavirus in the people it infects.

Across the nation, testing teams are grappling with burnout, repetitive-stress injuries and an overwhelming sense of doom. As supply chains sputter and laboratories rush to keep pace with diagnostic demand, experts warn that the most severe shortage stymieing America’s capacity to test is not one that can be solved by a wider production line or a more efficient machine. It is a dearth of human power: the dwindling ranks in a field that much of the public does not know even exists.

When shortages arise, “there’s workarounds for almost everything else,” said Karissa Culbreath, the medical director and infectious disease division chief at TriCore Reference Laboratories in New Mexico. “But people are irreplaceable.”

In the absence of trained workers to process and analyze the nation’s tests, America’s diagnostic infrastructure will not merely wrinkle and slow, experts said. It will collapse.

“Doctors and nurses are very visible, but we work behind the scenes,” said Marissa Larson, a medical laboratory scientist supervisor at the University of Kansas Health System. “And we are underwater.”

‘I don’t even know where to start’

Darcy Velasquez, a medical technologist at Children’s Hospital Colorado in Aurora, begins her shifts at 5:30 a.m. with a refrigerator of up to 500 tubes, trying to clear a backlog before another shipment arrives at 8 a.m.
Darcy Velasquez, a medical technologist at Children’s Hospital Colorado in Aurora, begins her shifts at 5:30 a.m. with a refrigerator of up to 500 tubes, trying to clear a backlog before another shipment arrives at 8 a.m.Credit…Matthew Staver for The New York Times

The gold standard in coronavirus diagnostics hinges on a decades-old laboratory method called polymerase chain reaction, or P.C.R. The method is a signal amplifier: It can copy genetic material, including fragments of the genome of the coronavirus, over and over until it reaches detectable levels, making the virus discoverable even when it is extremely scarce in the body. P.C.R. is the metric against which all new testing techniques are compared; in the diagnostic landscape, few can match its ability to root out infection.

But such accuracy comes at a cost. Even highly automated forms of P.C.R. require people to handle tubes, babysit machines and scrutinize ambiguous results.

P.C.R.-based coronavirus tests also deal in DNA, the molecular language in which the human genome is written. The coronavirus, however, stores its genetic information in a close cousin called RNA, which must first be carefully extracted from virus particles, then converted to its more testable counterpart before diagnostics can proceed.

When laboratories are well stocked, P.C.R. diagnostics can run from start to finish in just a few hours. But since the spring, laboratories around the country have been hamstrung by severe, often unpredictable shortages of chemicals and plasticware needed for these protocols.

And caseloads have skyrocketed; America’s testing capacity has increased since March, but it has been vastly overtaken by the demand for tests.

“The spring pales in comparison to what we are experiencing now,” said Dr. Culbreath, of TriCore, which has run more than 600,000 coronavirus tests.

Amid the pandemonium, labs must still work through their queues for other infectious disease tests, including for sexually transmitted infections. “Labs are trying to maintain our standard of operation with everything else, with a pandemic on top of it,” Dr. Culbreath said.

Darcy Velasquez, a medical technologist at Children’s Hospital Colorado in Aurora, where cases continue to surge, is fighting to keep pace with some of her institution’s highest sample volumes yet. Her shifts in the lab begin at 5:30 a.m., sometimes to a double-door refrigerator already brimming with 500 tubes, each containing a fresh patient swab and a small volume of liquid — more than a full day’s work for one person.

Ms. Velasquez typically spends the first couple hours of her day frantically trying to clear as much of the backlog as she can before another batch arrives around 8 a.m., when the local clinic opens.

As much as an hour of that time might be spent simply de-swabbing samples: manually unscrewing and rescrewing caps and plucking out swabs, all without contaminating one sample with the contents of another.

“Sometimes you walk into these refrigerators full of specimens and you think, ‘I don’t even know where to start,’” Ms. Velasquez said.

Taylor Smith, a virologist and technologist for the Georgia Department of Public Health, with her dog, Spunk.Credit…Johnathon Kelso for The New York Times

At Georgia’s state public health laboratory, direct handling of patient samples must be done with extra safeguards to minimize the chances of exposing personnel to infectious virus. Taylor Smith, a virologist and technologist at the lab, spends a large fraction of her workday in a full-body gown, sleeve covers, two pairs of gloves, an N95 respirator and goggles.

Simply donning it all is exhausting. And although Ms. Smith has long been deft with lab instruments, the work always feels high-stakes, she said: “You’re constantly thinking about how to not contaminate yourself.”

To keep their experiments running, lab workers must be proficient mechanics. The instruments needed for diagnostic tests were not built to run continuously for months on end. But as more facilities transition to 24/7 testing, malfunctions and breakdowns have become more common, requiring people to fix them.

Tyler Murray, a clinical laboratory scientist at the University of Texas Medical Branch in Galveston, spends his days listening for telltale alarms — a sign that one of his instruments has failed or is low on chemical ingredients.

“I make sure I talk nicely to them,” Mr. Murray said of the lab’s machines, which he decorates with gleaming gold stars when they perform at their best. “I say, ‘Hey bud, you worked hard this week, I’m proud of you.’”

But morale is low among the humans. After 10-hour shifts at U.T.M.B., Mr. Murray heads home and lies on the floor beside his two cats, Arya and Cleo. “The fatigue builds,” he said. “You can’t help but feel it.”

Tyler Murray, a clinical laboratory scientist at the University of Texas Medical Branch in Galveston, with Cleo, one of his two cats.Credit…Go Nakamura for The New York Times

The invisible work force

The monotonous motions that lab workers engage in daily take a physical and mental toll. Technologists are nursing repetitive-use injuries, a result of hours of maneuvering tubes and pipettes, which take up and dispense liquids with the press of a plunger. Workers must also be vigilant sanitizers, pausing regularly to swap out soiled gloves, clear their workspaces of plastic debris and scour surfaces with harsh chemicals that leave their clothes freckled with stains.

“We’re accustomed to holding things up in the background,” said Natalie Williams-Bouyer, the director of the division of clinical microbiology at the University of Texas Medical Branch in Galveston. “We enjoy doing it because we know we’re helping people.”

But the enduring anonymity of testing labs has begun to splinter some spirits. Elizabeth Stoeppler, a senior medical technologist in the molecular microbiology lab at the University of North Carolina’s School of Medicine, said that an old volleyball injury, which inflamed a tendon in her elbow years ago, had flared up after months of long stints in the lab. A few of her co-workers are wrestling with carpal tunnel syndrome.

The strain has begun to affect Ms. Stoeppler outside of the lab. She bolts awake at 3 a.m., panicked about the previous day’s work. She recently started a prescription medication to improve her chances of getting a full night’s sleep.

“There’s signs everywhere that say, ‘Heroes work here,’” she said of her hospital. She loves her job, she added. “But nobody sees us. We’re just in the basement, or in the back.”

On a good day in a diagnostics lab, the phone might ring only a few times, with messages from clinicians inquiring about samples. But when “things are going poorly, it just rings off the hook,” said Rachael Liesman, the director of clinical microbiology at the University of Kansas Health System, where she frequently clocks 15-hour shifts.

To keep the lab on track, Dr. Liesman has put in some hours running tests herself — a task that is not a part of her normal job description. “It’s very strange to have your director on the bench,” said Ms. Larson, a supervisor in the lab. “When you see that, some flare guns should be going up.”

Marissa Larson, left, a medical laboratory scientist supervisor at the University of Kansas Health System, and Rachael Liesman, its director of clinical microbiology.Credit…Barrett Emke for The New York Times

In mid-November, Dr. Liesman’s lab suffered a three-day stretch during which a supply of chemicals nearly ran dry on a Friday, then a pair of machines failed on Saturday and Sunday.

“We were basically drowning in specimens” by Monday, she said. “I was paged by three different providers while brushing my teeth.”

Morale in the labs has flagged as the country continues to shatter records for caseloads, hospitalizations and deaths. The nation’s testing experts know these statistics better than anyone: They count the numbers themselves, sample by sample. But they are also easy targets of criticism and complaint.

“There is always this undercurrent of, it’s never good enough,” said Dr. Abbott, of Deaconess Hospital in Indiana. “It’s devastating. We’re working as hard as we can.”

Chelsa Ashley, a medical laboratory scientist at Deaconess, aches to be home with her three children, to whom she is a single mother, after 13-hour shifts in the lab. Once there, she struggles to leave her work behind.

“There’s that panicked feeling that I should have stayed to take care of our community samples,” she said. “There’s guilt, when you walk away.”

In the past few months, Ms. Ashley’s children, who are 18, 13 and 10, have had to become substantially more self-sufficient. Shaylan, her youngest, rouses herself from bed at 5:50 a.m. every day to spend a few moments with her mother before she heads off to work.

“Even if it’s only 10 minutes, it’s 10 minutes that we talk,” Ms. Ashley said. “That is one thing that has not changed.”

‘A dying breed’

For some, the tidal wave of stress brought on by the pandemic has proved untenable. Since March, scientists have trickled out of laboratories, leaving chasms of expertise in a field that for years has struggled to recruit fresh talent.

Joanne Bartkus, the former director of the Minnesota Department of Public Health Laboratory, retired from her position in May after a dozen years on the job. She pinned one of the pandemic’s crucial inflection points to March 6, the day President Trump publicly remarked that “anybody that wants a test can get a test.”

“That was when the poop hit the fan,” Dr. Bartkus said. Within about a week, her team went from receiving fewer than a dozen coronavirus testing samples each day to being inundated with roughly 1,000 daily specimens.

It was unlike anything Dr. Bartkus had seen in her years at the institution. In 2009, the year of the H1N1 flu pandemic, Minnesota’s public health laboratory tested about 6,000 patient samples. This spring, it broke that record in a couple of weeks.

Dr. Bartkus, who is 65, had already planned to retire before the year was up. By the time April came, she had hastened her timeline to May: “It didn’t take me long before I said, ‘OK, I’m done with this.’”

In interviews, several scientists noted that they were struggling to fill vacancies in their labs, some that were left open by overwhelmed technologists who had recently quit their jobs. While the need for such workers has grown in recent years, the number of training programs that build these skill sets has dropped.

“Medical technologists are a dying breed,” Ms. Stoeppler, of the University of North Carolina, said.

Natalie Williams-Bouyer, the director of the division of clinical microbiology at the University of Texas Medical Branch in Galveston. “I hope people can see us now,” she said.Credit…Go Nakamura for The New York Times

In Indiana, Dr. Abbott, of Deaconess Hospital, said her team had already performed more than 100,000 tests for the coronavirus. But the most chaotic months are most likely still ahead.

For the first time in nine years, Dr. Abbott is doing hands-on work in the lab to help her staff cope with rising demand. She has yet to take more than a day off at a time since the pandemic’s start, but insists that she can soldier on: “This is out of the sheer will of not wanting to be beaten by this pandemic.”

In the mini-refrigerator in her office, next to rotating bags of salad greens and a small cavalry of Diet Cokes, sits an unopened bottle of champagne that she purchased in March, intending to uncork it upon reaching a worthy testing milestone. Nothing has yet felt like enough.

“I can’t tell you what will feel like a reason to celebrate at this point,” Dr. Abbott said. “Ask me after the next 100,000 tests.”

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Despite Pandemic Shutdowns, Cancer Doesn’t Take a Break

While a raging pandemic continues to force shutdowns and slowdowns throughout the country, another major risk to human health is not taking a sabbatical: cancer.

In the early months of the pandemic, millions of people heeded warnings and fears about contracting the coronavirus and avoided, or couldn’t even get, in-person medical visits and cancer screenings, allowing newly developed cancers to escape detection and perhaps progress unimpeded.

During this time, there was a steep decline in screenings for cancer, as well as a reluctance of patients with cancer to participate in clinical trials for cancer treatments. Many mammography centers, dermatology offices and other venues for cancer screenings remained closed for months, and routine colonoscopies, which should be done in hospitals or surgical centers, were actively discouraged to minimize strain on medical personnel and equipment and reduce the risk of contagion.

Still, Dr. Norman E. Sharpless, director of the National Cancer Institute, warned in June that missed routine screenings could lead to 10,000 or more excess deaths from breast and colorectal cancers within the next decade.

Cancers cannot be treated unless they’re detected, and a review of 34 studies published in October in the BMJ reported that for every four-week delay in cancer detection and treatment, the risk of death from cancer rises nearly 10 percent, on average. The study found increased mortality following delays in treatment for 13 of 17 cancer types. Following a four-week delay in surgery for breast cancer, the death rate increased by 8 percent; for colorectal cancer, it rose 6 percent.

The hazard of delayed screenings is greatest for people with known risk factors for cancer: a family or personal history of the disease, a previous abnormal Pap smear, prior findings of polyps in the colon or rectum, or, in the case of breast and certain other cancers, having genetic mutations that seriously increase cancer risk.

Most screening facilities have since put safety procedures in place that greatly reduce the chance of contracting the coronavirus, both for staff and patients. Although I had postponed my annual mammogram for four months, when I did go in September I was impressed with how well the facility was run — no one else in the waiting room, everyone masked and hand sanitizer everywhere.

Dr. Barry P. Sleckman, director of the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham, said in an interview, “When it comes to screening for cancer, people should balance the possibility of contracting the virus with their potential cancer risk. People should do everything possible to keep up with cancer screenings.”

However, Dr. Sleckman added, “If a woman is young and has no family history of breast cancer, she can probably wait six months for her next screening mammogram.” He also suggested discussing the matter with one’s personal physician, who probably also knows the safest facilities for screening.

If someone is found to have cancer, he emphasized, “There’s no reason to delay treatment. If a woman has cancer in a breast, it needs to be removed, and she should go to a hospital where she can be treated safely.”

Dr. David E. Cohn, chief medical officer at The Ohio State University Comprehensive Cancer Center, said that in the early months of the pandemic “we experienced a significant decline in new patients. Even some patients with symptoms were afraid to come in or couldn’t even see their doctors because the offices were closed. This could result in a delayed diagnosis, more complex care and potentially a worse outcome.”

But he said his center has since returned to baseline, suggesting that, despite the fall’s surge in Covid-19 cases, few cancer patients now remain undiagnosed and untreated.

“We made creative adaptations to Covid” to maximize patient safety, Dr. Cohn said in an interview. “For certain cancers, instead of doing surgery upfront, we treated patients with radiation and chemotherapy first, then did surgery later” when there was less stress on hospital facilities and personnel and patients could be better protected against the virus.

Dr. Cohn said that certain kinds of supportive care can be delivered remotely to cancer patients and their families — even genetic counseling, if a DNA sample is sent in. However, he added, “the majority of cancer treatment has to be administered in person, and surveillance of cancer patients is best done in face-to-face visits.”

Now with the virus surging around the country, many medical centers may be forced to again limit elective procedures, those not deemed urgent. But, Dr. Sleckman said, “Cancer treatment is not elective — it’s urgent and should not be delayed.”

Learning that one has cancer, even when it is early and potentially highly curable, is likely to strain a person’s ability to cope with adversity, all the more so when the diagnosis occurs in the midst of an already highly stressful and frightening pandemic.

Kristen Carpenter, a psychologist at the Ohio cancer center, said the constraints of the pandemic are “using up a lot of people’s reserve for dealing with adversity.” Adding a cancer diagnosis on top of that may initially cause people to fear they can’t deal with it, she said in an interview.

But it is nearly always possible to make more room in a person’s “bucket of reserve,” she said, for example, by identifying things that bring joy or a sense of accomplishment. Even though the pandemic may preclude great joys, Dr. Carpenter said, “people can create a constellation of smaller joys, for example, by reading a book, taking a walk or even a long shower. A little goes a long way to relieve the stresses of the day and build up the reserve needed to help you deal with the cancer.”

Noting that many people have found new ways to interact with others during the pandemic, “this is all the more important to do in the face of cancer,” Dr. Carpenter said. “Remember, you’re not just your cancer. You’re a whole person experiencing something. Take time to identify your needs and tell people what they are — don’t wait for them to ask.”

This advice is especially critical to cancer patients whose disease or treatment has compromised their immunity, leaving them especially vulnerable to infection by the coronavirus. A friend with chronic lymphoma who must avoid in-person contact with her five young grandchildren visits them through a glass door and observes their delight in retrieving the little treats she leaves for them on her porch.

Think, too, of how you’ve faced difficulties in the past, “how you’ve adapted to things you previously believed to be unimaginably difficult,” Dr. Carpenter suggested. Resiliency in the face of cancer during Covid need not have a limit, she said.

Should Isolation Periods Be Shorter for People With Covid-19?

People with Covid-19, the illness caused by the coronavirus, are most infectious about two days before symptoms begin and for five days afterward, according to a new analysis of previous research.

A few patients who are extremely ill or have impaired immune systems may expel — or “shed” — the virus for as long as 20 days, other studies have suggested. Even in mild cases, some patients may shed live virus for about a week, the new analysis found.

The accumulating data presents a quandary: Should public health officials shorten the recommended isolation time if it means more infected people will cooperate? Or should officials opt for longer periods in order to prevent transmission in virtually all cases, even if doing so takes a harsher toll on the economy?

The Centers for Disease Control and Prevention recommends that infected people isolate for a minimum of 10 days from the beginning of their illness. The agency is considering shortening the recommended isolation period and may issue new guidelines as early as next week, according to two federal officials with knowledge of the discussions.

In September, France dropped its required period of isolation to seven days from 14 days, and Germany is considering shortening it to five days. (Isolation refers to people who are ill; quarantine refers to people who have been exposed to the virus and may become ill.)

Setting the isolation period at five days is likely to be much more palatable and may encourage more infected people to comply, said Dr. Muge Cevik, an infectious disease expert at the University of St Andrews in Scotland who led the new analysis, published in the journal The Lancet Microbe.

A recent survey in the United Kingdom showed that only one in five people were able to isolate for 10 days after developing symptoms. “Even if we do more testing, if we can’t ensure people self-isolate, I don’t think we’ll be able to control the spread,” Dr. Cevik said.

In the United States, many people don’t get tested for the infection until a day or two after they begin to feel ill. With the current delays, many receive results two or three days later, toward the end of the period during which they are infectious.

“Even if you were to get the P.C.R. test right on the very first day that you could, by the time you get the results back, 90 percent of your shedding has been completed,” said Dr. Michael Mina, a virologist at the Harvard T.H. Chan School of Public Health. “This meta-analysis shows just how short your transmission window is.”

Dr. Cevik and her colleagues set out to analyze the so-called kinetics of the coronavirus over the course of an infection, and to compare the pathogen to the closely related SARS and MERS viruses.

The researchers considered nearly 1,500 studies published from 2003 to June 2020 on the timing of infection in thousands of people, most of whom were sick enough to be hospitalized. The team drew data from 79 studies of the new coronavirus, 11 studies of MERS and eight studies of SARS.

People who never develop symptoms seem to carry about the same amount of the new coronavirus as symptomatic patients, Dr. Cevik and her colleagues found. But asymptomatic people seem to clear the virus more quickly from their bodies.

People with Covid-19 usually are most infectious a day or two before the onset of symptoms until about five days after, the analysis concluded. Yet patients may carry genetic fragments from the virus in their noses and throats for an average of 17 days, and, in some cases, for up to three months.

A few patients may carry infectious virus in their lungs — as opposed to the nose and throat — for as long as eight days after symptoms begin, noted Dr. Megan Ranney, an emergency physician at Brown University. For these patients, at least, isolation periods should probably be longer than five days, if only they could be identified.

“The trouble is, who has Covid pneumonia versus who doesn’t is not always fully apparent just based on physical exam,” she said. “They wouldn’t know it on their own.”

Older people tend to be infectious for longer than younger people, but no study in the analysis detected live virus beyond nine days of symptom onset. The results suggest that positive tests after that point find only genetic fragments, rather than whole live virus, Dr. Cevik said.

Because the infectious period seems to peak relatively quickly in the course of the illness, health care workers at community clinics may be at higher risk of becoming infected than those working in I.C.U. units, where patients tend to be in the later stages, Dr. Cevik added.

The analysis underscores data that have accumulated since March. In July, based on similar evidence, the C.D.C. truncated its recommendation for isolation to 10 days from 14 days.

But even at 10 days, the isolation period may be too long for many people, experts said. Patients may be financially unable to isolate for so long, or they may not feel sick enough to want to do so.

“If you could make that shorter for people, I think that would really help people comply with the public health guidelines,” said Angela Rasmussen, a virologist affiliated with the Center for Global Health Science and Security at Georgetown University, referring to the recommended isolation period.

But the new analysis is limited by the fact that only a few of the included studies looked at live virus, she added.

Some people who are older or very sick may be infectious for longer than a week. But if a shorter recommended period encourages more people to isolate, the benefit will more than offset any risk to the community from the small amount of virus that a few patients may still carry after five days, said Dr. Stefan Baral, an epidemiologist at Johns Hopkins University.

But some doctors said that they were not convinced by the analysis that five days of isolation would prevent transmission from a majority of people.

“There’s a sweet spot there, I would imagine, but I haven’t figured out where that is,” said Dr. Taison Bell, a critical care and infectious disease physician at the University of Virginia.

Dr. Cevik and other experts suggest that people can isolate as soon as they experience even mild symptoms, such as a sore throat or head and body aches — without venturing out for a P.C.R. test right when they are most infectious.

But Dr. Bell said he was unsure how this would work in practice, because these early symptoms were similar to those from other viral infections, including the common cold.

Dr. Cevik said a P.C.R. test should be performed after isolation ended, to confirm the diagnosis. Alternately, it may make sense to take a rapid antigen test — which can detect high amounts of virus — while isolating, to confirm an active coronavirus infection.

Other experts also endorsed the use of at-home rapid tests. “I think that’s a lovely solution,” Dr. Ranney said. “If you have symptoms, and you have a reliable test that you can do at home, stay home, test at home and isolate for five days.”

Over all, the new analysis underscores how quickly the coronavirus blooms in the body and the speed with which both patients and doctors must respond to keep it contained, Dr. Baral said. Levels of the MERS virus peak at seven to 10 days from symptom onset, and those of the SARS virus peak at Days 10 to 14.

By contrast, the new coronavirus “moves quick,” Dr. Baral said. “It’s a very difficult virus to control, as compared to SARS.”

Home isolation is safe for most of those newly infected with the coronavirus, he added — essentially the model of care that doctors use for patients suspected of having influenza.

Some countries already have adopted policies to make it easier for people to isolate. Vietnam provides income support to people who need to take time off work. Until May, the Japanese government asked patients who were young and had mild symptoms to stay home for four days before seeking testing.

Japan’s guidelines now ask patients to consult by phone with their doctors and to seek testing only if they seem likely to be infected. Anyone who tests positive is admitted to a hospital or a hotel to isolate. In the United States, New York City and Vermont have made similar accommodations available to infected patients.

Even if the rest of the country doesn’t implement such policies, having patients isolate at home — while wearing a mask, keeping windows open, cleaning high-touch surfaces and staying far from other household members — is more feasible for five days than for 10, Dr. Baral said.

“I do think there’s an element of diminishing returns with those last four or five days,” he said. “An intense amount of isolation during that first five to seven days would avert a ton of infections — a ton.”

Makiko Inoue contributed reporting from Tokyo.

Think Like a Doctor: The Boy With Nighttime Fevers Solved!

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Credit Andreas Samuelsson

On Thursday we asked Well readers to take on the case of a 7-year-old boy who’d been having fevers and drenching sweats nightly for over a month. More than 300 of you wrote in, and although 20 of you came up with the right diagnosis, only three of you figured out both the diagnosis and the test needed to confirm it.

The correct diagnosis is…

Coccidioidomycosis, or valley fever.

The diagnosis was made based on a lymph node biopsy.

The first reader to suggest this diagnosis and the test was Dr. Malkhaz Jalagonia, an internist from Zugdidi, in the Republic of Georgia. He says he’s never seen a case like this, but he’s fascinated by zebras and so recognized the disease immediately. Well done, Dr. Jalagonia!

One of the reasons I chose this case was that, although this diagnosis is rare in life, it was the most frequently suggested diagnosis in my last column – the one about the middle-aged man with a cough for over a year. I thought it would be fun to show what valley fever really looks like. Hope you did too.

The Diagnosis

Coccidioidomycosis is a lung infection usually caused by inhaling the spores of a tiny fungus called coccidioides. This organism grows as a mold, a few inches below the surface of the soil in deserts in parts of the southwestern United States, Mexico and other countries of Central America.

In dry conditions, the fungus becomes fragile and is easily broken up into tiny single-celled spores that can be sent airborne with even the slightest disturbance. And once these single cells are aloft they can remain suspended there for prolonged periods of time.

Infection is usually acquired by inhaling the spores. Once lodged in the lung, the organism begins to reproduce almost immediately. The time course between exposure and disease depends on the inhaled dose and the patient’s immune system.

Symptoms, or No Symptoms

Disease severity varies considerably. Nearly half of those who breathe in these spores have no symptoms, or symptoms are so mild they never visit the doctor’s office.

More severe infection usually takes the form of a slowly progressive pneumonia known as coccidioidomycosis, or valley fever. This illness is characterized by a cough, fevers, chest pain, fatigue and sometimes joint pain. Indeed, because of the prominent joint pain, in some cases — though not this one — the disease is also known as desert rheumatism.

Rashes are also seen in many patients. Those who get a rash seem to have a more benign course of illness. The thinking is that the skin symptoms are the result of an aggressive immune response in the host to the pathogen.

Symptoms can last for months, and in many cases they resolve without treatment. But in some cases they get worse.

Hard to Diagnose

Those who seek medical attention are often not diagnosed — or not diagnosed quickly — because the symptoms of valley fever are not very specific, and few of the tests that doctors usually order have features that are unusual enough to suggest the diagnosis.

Chest X-rays are often normal. Blood tests may be normal as well, though some patients, like this child, have an unusually high number of a type of white blood cell known as eosinophils. These cells are usually seen in allergic responses or with infections due to parasites.

The most important clue to the possibility of this infection is travel to one of the areas where the fungus lives. In the United States, valley fever is endemic primarily in Arizona and southern California, as well as parts of southern New Mexico and West Texas. Indeed, the name valley fever is a shorter and more general term for an earlier name, San Joaquin Valley fever, because it was so common in that part of California.

A Dramatic Rise

There has been a significant increase in the number of cases of coccidioidomycosis in the past 15 years, with nearly 10 times as many in areas where the fungus is found. Development in areas where the fungus is endemic is thought to be the primary cause. Better diagnostic testing may also play a role.

While this infection may cause only a minor illness in many, there are some – like this child – for whom the disease can spread beyond the lungs into the rest of the body. Disseminated coccidioidomycosis is usually seen in those with some problem with the immune system – an underlying disorder such as H.I.V., for example, or because someone is taking immune suppressing medications such as prednisone.

Once out of the lungs, the bugs can go anywhere in the body, though they seem to prefer joints, skin or bones. Those with disseminated disease have to be treated for a long time – often up to a year, or occasionally for life.

How the Diagnosis Was Made

The little boy had been sick for nearly a month, and his parents were getting quite worried. He was pale, thin and really, really tired.

With their pediatrician’s encouragement, they had gone on a long planned, much anticipated vacation to the mountains of Colorado. But the child wasn’t getting better, and so his mother took him to yet another doctor – this one in a walk-in clinic.

The results of some simple blood tests done at that visit worried the doctor, who suggested that the boy be taken to a hematologist, a specialist in diseases and cancers of the blood.

Now the parents were terrified. The mother faxed copies of the lab results to her brother, a researcher in immunology. He wasn’t a physician but showed the results to friends who were. They agreed with the doctor at the walk-in clinic: The boy needed to be seen by a hematologist.

A Series of Specialists

The next morning the family headed home to Minneapolis. They took the boy to his regular pediatrician, who sent them to a hematologist. It wasn’t cancer, that specialist told them. Maybe some kind of severe food allergy, he suggested, and referred them to a gastroenterologist.

Not a GI thing, that specialist told them, and he referred the now nearly frantic family to an infectious disease specialist and a rheumatologist.

Nearly 10 days after getting the alarming blood test results, the couple and their child found themselves in the office of Dr. Bazak Sharon, a specialist in infectious diseases in adults and children at the University of Minnesota Masonic Children’s Hospital. After introducing himself, Dr. Sharon settled down to get a detailed history of the boy and the family.

A Desert Visit, but Other Possibilities

When Dr. Sharon heard that the family had spent a week at a ranch in the desert of Arizona, he immediately thought of coccidioidomycosis. The fungus isn’t found in Minnesota or Colorado – which is probably why other doctors hadn’t considered it. But it is all over the part of Arizona where they’d visited.

Still, there were other possibilities that had to be ruled out, including some types of cancer. After Dr. Sharon examined the boy, he sent the family to the lab for a chest X-ray and some blood tests.

The results of those tests were concerning. The child was getting worse. Dr. Sharon wasn’t going to be back in clinic for a week, and he was certain the child needed to be seen and diagnosed well before then. He called a friend and colleague who was taking care of patients in the hospital, Dr. Abraham Jacob, and asked if he would admit the child and coordinate the needed diagnostic workup for the boy.

First Some Answers, Then More Questions

Once in the hospital, the child had a chest CT scan. The results were frightening. The lymph nodes that surround the trachea, the tube that carries inspired air to the lungs, were hugely enlarged. They were so big that the trachea was almost completely blocked. The opening at one point was just two millimeters wide – basically the dimensions of a cocktail straw. Any worsening of his disease might cause the tube to close completely, making breathing impossible.

A pediatric surgeon was brought in immediately. The enlarged lymph nodes had to be removed. First in order to protect the child’s airways. And second because those nodes would reveal what the little boy had.

But trying to do surgery on a 7-year-old boy’s neck was complicated. Although the surgeon could easily feel the enlarged gland in his neck, it was close to many vital blood vessels, nerves and organs. The child had to lie perfectly still, and with most children that could only be guaranteed if they were under anesthesia.

Risky Surgery

When the anesthesiologist saw the CT scan, the doctors’ concern grew. They could put the child to sleep, but if anything went wrong during surgery and they had to put a tube down his throat into his lungs, they weren’t sure it would be able to fit.

The trachea was so small, there was no guarantee they could get the tube into place. In order to do this safely, they said they needed to use a technique known as ECMO, or extracorporeal membrane oxygenation – basically a machine that allows them to oxygenate blood without sending it to the lungs.

Rather than subject the child to this risky procedure, Dr. Jacob and the surgeon decided to just take a piece of the lymph node out in order to make the diagnosis. Treatment of whatever the boy had would bring the size of the lymph node down.

Don’t Make a Move

When the boy was brought to the procedure room, the surgeon explained that he was going to put numbing medicine all around the bump in the boy’s neck and take out a piece of it. The child listened calmly and agreed.

He wasn’t to move at all, the surgeon explained. The child nodded solemnly. He understood. The boy was remarkably mature and so brave throughout the entire process of anesthetizing the region that the surgeon thought he might be able to continue and get the entire node out.

He paused in his surgery and consulted the parents. Would they allow him to try this? Their son was doing so well he was sure he could get it. They agreed, and the surgeon returned to his task. The lymph node came out without difficulty.

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Credit

It was sent to the lab and the answer came back almost immediately. The swollen tissue was filled with the tiny coccidioides. You can see a picture of these little critters here.

A Year of Medicine

The boy was started on an intravenous medicine for fungal infections. Then after a week it was changed to one he could take by mouth.

Because the infection had spread beyond the lungs, the child will have to take this medication for a year. After starting the medication, the child began to look a little better. Slowly he was less tired. Slowly he started to eat the way he used to.

It was a long road to the diagnosis, and an even longer road to cure, but at least they were on the right one.

A Perfect Storm?

The mother called the ranch in Arizona where they stayed to let them know what had happened.
The owner told them that their son was not the only person visiting then who got sick. At least one other guest, there at the same time, had come down with the disease.

Apparently the conditions for spread were perfect. Their stay had started off with some rain, followed by heat and some brisk wind. The moisture helped the fungus grow; the heat dried it out so that it could become easily airborne and inhaled when lifted by the wind.

Although the family has loved their visits to this ranch – this was their second year – the child’s mother tells me that she’s not sure she’ll be going back, at least for a couple of years. Most people exposed to valley fever become immune forever, but because her little boy was so very sick, she’s planning to wait a while before they return.

Doctors Should Listen to Patient Instincts

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When a patient complains that he or she doesn’t feel well, doctors should pay attention.

That’s the finding of a new study that suggests that how patients say they feel may be a better predictor of health than objective measures like a blood test. The study, published in Psychoneuroendocrinology, used data from 1,500 people who took part in the Texas City Stress and Health Study, which tracked the stress and health levels of people living near Houston.

The survey included self-assessments from a 36-item questionnaire as well as blood samples, which were analyzed for markers of inflammation and the activity of latent herpes viruses. (The viruses were benign and not the type associated with sexually transmitted disease or cold sores.) Inflammation and viral activity are general markers of immune system health, but they don’t typically cause any obvious symptoms or show up in traditional blood tests.

The study found that when people said they felt poorly, they had high virus and inflammation levels. People who reported feeling well had low virus and inflammation levels.

“I think the take-home message is that self-reported health matters,” said Christopher P. Fagundes, an assistant psychology professor at Rice University and a co-author of the study. “Physicians should pay close to attention to their patients. There are likely biological mechanisms underlying why they feel their health is poor.”

Think Like a Doctor: A Cough That Won’t Stop

Photo

Credit Andreas Samuelsson

The Challenge: A 43-year-old man starts to cough every time he takes a deep breath. Can you help him figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a healthy middle-aged man who starts coughing and just can’t stop. He can’t exercise. He can’t laugh. Sometimes he can’t even talk without interrupting himself with deep, awful-sounding hacks.

Below I provide much of the information available to the doctors who examined him. It took 18 months before a doctor figured out what was wrong. Can you do it any faster? The first reader to offer the correct diagnosis will receive a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a real-life case.

An Emergency 18 Months in the Making

“You should probably have that checked out in the E.R.,” the nurse suggested to the middle-aged man on the other end of the phone. “And sooner rather than later.” In the next few days? he asked. In the next few hours, the nurse replied.

The 43-year-old man hung up the phone more surprised than worried. He had been dealing with an annoying and persistent cough for a year and a half and none of the doctors or nurses he’d seen in that time seemed to think it was a big deal. Until now – since he started coughing up blood.

He called his wife to tell her what the nurse suggested. After work he was going to drive himself to the emergency room at the veterans’ hospital in downtown Denver. He could hear the relief in her voice when she asked if he wanted her to come with him. No, she had enough on her hands looking after their four children. He’d let her know what they said.

An Abnormal X-ray

In the E.R., the man’s complaint got him seen right away. His chest X-ray was normal, they told him. (The X-ray is shown here)

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Credit

But when they came back into his cubby wearing masks over their noses and mouths he suspected that the CT scan was not. The scan had shown some kind of hole in his lungs, the E.R. doctor told him. That’s why he was coughing up blood. One of the diseases that can cause those kinds of cavities was tuberculosis. Had he ever been exposed to TB? Not that he knew of. (The CT scan images are shown here.)

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Because TB was such a dangerous disease – and extremely contagious — they would have to find out if he had it. If he did, he would certainly need to be treated. And to make sure he didn’t infect anyone while he was being tested, he needed to be in a specialized room – a room where the air he breathed wouldn’t be breathed by anyone else. None of the hospital’s negative pressure rooms were available so they were going to transfer him to Presbyterian/St. Luke’s Medical Center, the big regional hospital just a couple of miles away. They had an available room and would be able to care for him.

You can read the patient’s history and physical from the E.R. here:

Admission Notes

The patient’s notes from the hospital.

The Patient’s Long Story

Dr. Karen Schmitz was the second-year resident assigned to care for the new guy sent over to be tested for TB. She could see the patient sitting up in bed talking on the phone as she secured the mask over her nose and mouth and entered the double-door room that would prevent any air-borne infectives from spreading. As she entered, the patient looked at her, smiled a warm smile, and held up a finger as if to say, “I’ll be with you in a minute.” As he finished up his phone call, the doctor looked at him carefully. He was a robust guy – youthful and healthy looking. He certainly didn’t look like any of the people she’d cared for with active TB. When he hung up, he apologized and the doctor introduced herself. She pulled up a chair and settled in. She knew from what she’d read in the chart that it was going to be a long story.

The bloody cough was pretty new, he told her. It started two weeks earlier. But the cough itself had been around for 18 months. He’d caught it a couple of summers ago, and it just never went away. At first he thought it was bronchitis – he’d had that a lot when he was a kid — but when it lasted for more than a couple of weeks, he went to see his primary care doctor. He’d never had a fever or any other sign of being sick. He had some runny nose and itchy eye symptoms that started weeks before the cough and so he and his doctors thought it was allergies. Or asthma. His doctor prescribed an antihistamine and later an inhaler. They fixed his runny nose, and eased up the chest tightness, but the hacking never slowed down.

He went to an ear, nose and throat specialist who scoped his nose and throat. Completely normal. He had a chest X-ray – also normal.

He saw a pulmonologist who, hearing that he had a little heartburn, started him on a powerful antacid medication. That pill completely fixed the heartburn but didn’t touch the cough.

That first year he’d seen three doctors in a half-dozen appointments, and had a scope, a chest X-ray and a slew of blood tests and still no one could tell him why he was coughing or how to make it stop. So he figured he’d just have to learn to live with it.

Not that he wanted that. Every time he took a deep breath he would cough. In the middle of telling a good story he’d have to stop to cough. Whenever he laughed, he coughed. Dozens of times a day, he coughed. He even had to give up exercising. Any time he exerted himself, even just a little, the cough would kick in with a shocking fierceness. Recently he’d tried riding his bike and just 15 minutes in he had to stop. Even though he was taking it easy, as soon as he started to breathe just a little harder than usual, he nearly keeled over. He had to get off his bike. He was doubled over with the ferocious hacking. Sweat and tears poured down his cheeks. He could hear the rasping sound of his breath between the deep jagged coughs. He wondered if he could even make it home. That was the last time he tried to exert himself. And that had been weeks earlier.

You can see the pulmonologist’s notes here:

Pulmonary Consult Note

The notes from the lung specialist.

The Doctor’s Visit

But eventually, he started to cough up blood. That happened the morning after he’d had another terrible blast of coughing. He’d gone with his wife and four children to Vail for Thanksgiving. As he was packing the car to come home he started coughing and felt as if it would never stop, as if he’d never be able to breathe again. But he recovered, until the next morning when he started to cough up blood. It scared him. And terrified his wife. When it didn’t get better after a couple of weeks, he’d decided to call the hospital, and the nurse on the phone sent him to the E.R.

Now, talking to Dr. Schmitz, he told her he never smoked and rarely drank. And even though it was legal, he never smoked pot either. He had been an officer in the Air Force and now was a real estate agent. He had spent a few months in Kuwait and another few in Saudi Arabia, but that was in the 1990s. He’d traveled a bit – mostly out west, but nothing recent. He took medicine for high cholesterol, the antihistamine and the antacid medicine, but that was it. His exam was unremarkable. Dr. Schmitz listened hard through her stethoscope as she placed it on his chest where she knew the hole in his lung was, but heard nothing abnormal.

She didn’t start him on antibiotics, because she didn’t yet know what she was treating, she told him. Tuberculosis seemed unlikely so she was going to test him for other infections as well. To make sure the team didn’t miss anything, they consulted an infectious diseases specialist and a pulmonologist.

You can see their notes here.

Infectious Disease Consult

Notes from the infectious disease specialist.

Dr. Schmitz checked on her patient throughout the day. He was always on the phone, his computer open, hard at work. So far they were doing nothing for the guy – just watching and waiting for answers. When the TB test came back negative, Dr. Schmitz thought he might very well be the healthiest patient in the entire hospital. Was she right? The patient got his diagnosis the very next day.

Solve the Mystery

What do you think is making this patient cough?

Post your answers in the comment section. I’ll tell you the answer tomorrow.

Pelvic Exams May Not Prolong Life, a Task Force Says

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Credit Stuart Bradford

Many women dread the indignity of the annual pelvic exam, in which they are poked and prodded with their feet in stirrups.

Now an influential government task force says there isn’t evidence that routine pelvic exams are necessary or prolong a woman’s life. Some experts think they may even do more harm than good.

And although some 60 million pelvic exams are done each year, the practice hasn’t been studied much. The United States Preventive Services Task Force, a panel of experts in preventative and primary care, declared today that the current evidence is “insufficient” to assess the balance of benefits and harms of the pelvic exam. The task force performed an exhaustive search of the medical literature published over the past 60 years and located only eight studies looking at the diagnostic accuracy of pelvic exams for just four medical conditions.

“We can’t make a recommendation one way or the other at this time,” said Dr. Maureen Phipps, the chairwoman of obstetrics and gynecology at Brown University’s Warren Alpert Medical School and a member of the task force. “We need more evidence.”

The finding refers only to the practice of routine pelvic exams for healthy women, and does not apply to women who are pregnant or those with existing conditions or symptoms that need to be evaluated.

“This is not a recommendation against doing the exam,” Dr. Phipps emphasized. “This is a recommendation to call for more research to figure out the benefits and harms associated with screening pelvic exams. That’s the big message here.”

This is the first time the Preventive Services Task Force has turned its attention to pelvic examinations, which can include a visual exam of external genitalia, an internal exam using a speculum, manual palpation to check the shape and size of the uterus, ovaries and fallopian tubes, and the simultaneous palpation of the rectum and vagina using lubricated gloves.

The recommendations about pelvic exams do not change current guidelines for cervical cancer screening, in which cells are collected from the surface of the cervix and vagina. The screening test is recommended every three years for women ages 21 to 29 and every five years for ages 30 to 65.

Pelvic exams have been subjected to quite a bit of scrutiny in recent years, possibly because of turf battles between physicians and reimbursement battles with insurers. The exams can be both time-consuming and expensive, in part because doctors are advised to have a chaperone present during the exam.

In 2014, the American College of Physicians told doctors to stop performing routine pelvic exams as part of a physical, saying there is no evidence they are useful and much evidence to suggest they can provoke fear, anxiety and pain in women, especially those who have suffered sexual abuse or other trauma.

The American Academy of Family Physicians endorsed that recommendation. But the American College of Obstetricians and Gynecologists (ACOG) continues to recommend an annual pelvic examination for women 21 and older, while acknowledging a dearth of data. Its Well-Woman Task Force, which was convened in 2015, recommended annual external exams but said internal speculum and bimanual exams for women without specific complaints or symptoms should be “a shared, informed decision between the patient and provider.”

“No woman should ever be coerced into having an exam, and that discussion should take place in a nonexam room environment, while the woman is fully dressed and sitting at equal level with the provider at a round table, without a desk between them,” said Dr. Barbara S. Levy, vice president for health policy at ACOG.

But Dr. Levy says that the exams should not be scrapped because trials – which would be difficult to design and fund — have not been carried out.

“I think there’s tremendous value in the laying on of hands,” Dr. Levy said. “Touch has a lot to do with establishing trust, and there are many things I can pick up on during a pelvic exam because I’m skilled and trained.”

She may pick up on the fact that a woman is experiencing abuse or domestic violence, or discover that a woman may benefit from interventions to strengthen muscles to prevent urinary incontinence down the line, she said, adding, “This is the art of medicine.”

Most obstetrician-gynecologists do routine pelvic exams, as do many other physicians, and the majority of preventive care visits between 2008 and 2010 included one, according to the task force’s report.

Health care providers say they can pick up on myriad gynecologic conditions during a pelvic exam, including cancers of the cervix, vagina, vulva, ovaries and endometrium, sexually transmitted diseases, genital warts and genital herpes, uterine fibroids, ovarian cysts and more.

But the task force found no studies that assessed how effective the exams are for reducing death and disease. So for example, although a pelvic exam might be useful in detecting ovarian cancer, the disease is relatively rare, so exams often result in false-positives that can lead to unnecessary surgery, the report said.

In four ovarian cancer screening studies with over 26,000 screened patients, more than 96 percent of the positive test results were false positives, meaning there was no real disease and many patients had unnecessary follow-up procedures.

But Dr. Levy said the call for more research is impractical. Exams are part of preventive care that is tricky to evaluate or assess, she said, and such studies are unlikely to get funded. “Looking for evidence-based answers to centuries-old processes and procedures doesn’t always make sense,” she said.

Direct-to-Consumer Lab Tests, No Doctor Visit Required

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Credit Jon Krause

Two years ago, Kristi Wood was tired and achy and could not think clearly, and she had no idea why.

“I was in a fog and feeling awful,” said Ms. Wood, 49, who lives in Seattle and is an owner of a hiking supply company.

Ms. Wood had her blood tested by a consumer service called InsideTracker, which analyzes 30 hormones and biomarkers, such as vitamin levels, cholesterol and inflammation. After the service told Ms. Wood she had excessive levels of vitamin D, she cut back on a supplement she had been using and said she almost immediately felt better.

Now she has her blood drawn and tested by InsideTracker every four months to check everything from her blood sugar to her B12 levels which, she said, “allows me to be proactive” about her health. The services typically send their customers to a nearby clinic where they can have a vial of their blood drawn and sent for analyses. But InsideTracker also offers customers the option to have nurses show up at their home and draw blood. (Such services are different from another blood testing company that has been much in the news, Theranos, which aims to provide laboratory test results from a single finger prick.)

Home testing services like InsideTracker say they are empowering consumers, allowing them to spot metabolic red flags before they progress to disease. But critics say the services often lack proper medical oversight and convince healthy people that they’re sick, leading to unnecessary testing and treatment.

Those concerns have not stopped people from seeking home testing. The market for direct-to-consumer laboratory tests was valued at $131 million last year, up from $15 million in 2010,according to Kalorama Information, a pharmaceutical-industry research firm.

In December, New York Attorney General Eric T. Schneiderman accused two companies, DirectLabs and LabCorp, of violating a state law that requires laboratory tests to be carried out at the request of licensed medical practitioners.

DirectLabs had sold hundreds of health tests to consumers, ranging from checks for heavy metals and vitamins to screening for parasites and disease. But Mr. Schneiderman said the person fulfilling the medical practitioner role was actually a chiropractor who had never met, spoken to or followed up with any patients.

DirectLabs did not respond to a request for comment. DirectLabs and LabCorp agreed to pay fines, and DirectLabs ceased operating in New York. In a statement, Mr. Schneiderman said that allowing consumers to be tested for serious medical conditions without consulting a physician put “their health in jeopardy.”

Advocates of home testing, however, say such cases do not reflect industry practices. InsideTracker and another leading company, WellnessFX, said they worked with doctors who reviewed all test results.

Paul Jacobson, the chief executive of WellnessFX, based in San Francisco, said the company complied with all regulations and offered customers the option of consulting with a doctor, nutritionist or registered dietitian to discuss their results.

WellnessFX sells packages ranging from $78 to $988, offering analyses of 25 to 88 blood biomarkers, including vitamins, lipids, cardiovascular markers and thyroid and reproductive hormones. Depending on the results, the company also suggests supplements, foods and exercise.

“You need to offer solutions to people; otherwise, you’re just giving them meaningless information,” Mr. Jacobson said.

Tara Boening, the dietitian for the Houston Rockets of the National Basketball Association, said the team started using InsideTracker this season. The players look at their reports (deficiencies are highlighted in red), which include suggested corrective actions such as eating more red meat and leafy greens if they are low in iron. The players “have been really receptive” to the information, Ms. Boening said.

But some doctors say that there is no evidence that such monitoring makes a meaningful improvement in health. Dr. Pieter Cohen, an assistant professor at Harvard Medical School and an internist at Cambridge Health Alliance, cautioned that the levels of vitamin D and other biomarkers that were optimal for one person might be very different from what is optimal for another person. He said InsideTracker’s lab reports, for example, classified vitamin D levels below 30 ng/mL as “low” — even though a level above 20 is perfectly normal and adequate for most people.

Dr. Cohen said his major concern with direct-to-consumer blood tests was that they screened for so many biomarkers and created seemingly arbitrary ranges for what is considered normal. Then they give people advice that they already know they should be following.

“The best-case scenario here is you lose your money and then you’re reminded to get more sleep and to eat more fruits, vegetables and fish,” he said. “The worst-case scenario is that you end up getting alarmed by supposedly abnormal results that are actually completely normal for you.”

InsideTracker was founded by Gil Blander, a biochemist who did postgraduate research on aging at M.I.T. He said the idea behind InsideTracker was analogous to routine maintenance for cars.

“We decided, let’s try to do that for humans,” Dr. Blander said. “We can help you find a small issue today that might be a big problem in the future.”

Some, like Joseph Roberts, say the services are life-changing. Four years ago, Mr. Roberts a former Army Ranger and a retired master sergeant, was plagued by fatigue, depression and weight gain despite frequent exercise. Mr. Roberts, then 39, said doctors told him his symptoms were a normal part of aging.

Eventually, he decided to have his blood tested with InsideTracker, and the results surprised him, he said. He was told he had low testosterone and vitamin D, as well as excessive levels of vitamin B12.

Mr. Roberts cut back on daily energy drinks, which are loaded with B12. He also saw a doctor to discuss his testosterone levels. He learned his low levels were linked to a brain injury he had sustained as a result of a roadside bomb explosion in Iraq in 2003. He began testosterone-replacement therapy and now regularly checks in with a doctor. He also has his blood tested with InsideTracker every four months.

“I’ve had a huge improvement in my quality of life,” he said. “It’s money well spent.”

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Medical Errors May Cause Over 250,000 Deaths a Year

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If medical error were considered a disease, a new study has found, it would be the third leading cause of death in the United States, behind only heart disease and cancer.

Medical error is not reported as a cause of death on death certificates, and the Centers for Disease Control and Prevention has no “medical error” category in its annual report on deaths and mortality. But in this study, researchers defined medical error as any health care intervention that causes a preventable death.

For example, in one case a poorly performed diagnostic test caused a liver injury that led to cardiac arrest, but the cause of death was listed as cardiovascular. In fact, the cause was a medical error. Diagnostic errors, communication breakdowns, the failure to do necessary tests, medication dosage errors and other improper procedures were all considered medical errors in the study.

Using studies published since 1999, the researchers calculated a mean rate of death from medical error. Then they applied this rate to the yearly number of hospital admissions. In this way, they estimated that an average of 251,454 deaths per year in the United States are caused by medical error. The study is in BMJ.

“Humans will always make mistakes, and we shouldn’t expect them not to,” said the lead author, Dr. Martin A. Makary, a surgeon at Johns Hopkins. “But we can engineer safe medical care to create the safety nets and protocols to address the human factor. Measuring the magnitude of the problem is the first step.”

Swipe Right to Connect Young People to H.I.V. Testing

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A screenshot of the Healthvana app.

A screenshot of the Healthvana app.Credit

Midway through her sophomore year of high school, my patient told her parents that she had missed two periods and was worried she might be pregnant.

Stunned to learn that she was sexually active, her parents took her to the pediatrician, who had another surprise: She wasn’t pregnant but she did have H.I.V.

I met her a few days later in my H.I.V. clinic, and watched her start crying as I told her that her H.I.V. was advanced and that she needed antiviral treatments really soon.

Sadly, her story of late diagnosis is far from uncommon. Ten thousand people ages 13 to 24 are given H.I.V. diagnoses every year in the United States, and epidemiologists estimate fully half of young people with H.I.V. do not know it. While the virus is no longer considered the death sentence it was decades ago, late diagnoses like my patient’s can undermine the life-saving benefits of antiviral medications, leading to greater risk of AIDS and death.

Part of the problem is the low rate of H.I.V. testing in young people, despite the recommendation by the Centers for Disease Control and Prevention that every sexually active person over the age of 13 get tested. Earlier this year, C.D.C. researchers reported in Pediatrics that pediatricians and parents are testing five times fewer young people for H.I.V. than recommended by national guidelines. Only 22 percent of sexually active high school students were ever tested for H.I.V., and, even worse, the likelihood that young women like my patient were tested for H.I.V. actually fell from 2011 to 2013.

Tio Pier, a Stanford University student who advocates for testing and sexual health education, says his high school teachers provided basic education about H.I.V. in a health class but, “they don’t follow up and say, ‘and if you feel like you need a testing resource you could go here…’ There was none of that.” Indeed, a 2015 survey showed that less than half of sexually active gay and bisexual adolescents even knew where they could get an H.I.V. test.

A number of groups are working on ways to improve access to H.I.V. testing for young people. Tim Kordic, a health educator with the Los Angeles Unified School District, is partnering with a company called Healthvana to place educational posters about H.I.V. in classrooms and provide students with a free iPhone app that harnesses GPS technology to locate nearby H.I.V. testing facilities.

Most public health departments and community health clinics offer free H.I.V. testing to people of all ages, and in New York and 30 other states, children under 18 have legal access to H.I.V. testing without parental notification. Kids who test positive can access life-saving H.I.V. therapy early, with drug costs often covered by the federally funded Ryan White HIV/AIDS Program. Kids who test negative leave the clinic better educated and probably with a pocketful of free condoms.

Ramin Bastani, the chief executive of Healthvana, says their app has delivered the results of over 200,000 H.I.V. and sexually transmitted infection tests to patients at participating health care providers across the country. The confidential service also gives users information on how to access treatment if a result is positive. Some young people post negative H.I.V. testing results on social media as a way of encouraging others to get tested, Mr. Bastani said.

Healthvana isn’t the only app seeking to connect youth to H.I.V. testing. The United States Department of Health and Human Services has its own locator app pointing out nearby testing services and a panoply of other resources like H.I.V. care, substance abuse services and housing assistance. Yet another app connects users to free condoms, and there is even a mobile game designed to sensitize youth to the risks of teenage pregnancy.

“It’s hard for teenagers to physically go places, and to know that they will be welcomed,” says Karen Rayne, a sexuality educator and author of the book “Breaking the Hush Factor: Ten Rules for Talking With Teenagers about Sex.” To Dr. Rayne, the privacy of a mobile app – including the ability to delete the app after use – is a great way to “draw teens out” and “give them the confidence to access a public physical space” like an H.I.V. testing clinic.

Mobile phone apps that connect youth to H.I.V. testing cannot supplant other proven H.I.V. prevention methods. Kids still need quality health education in school and optional school-based H.I.V. testing. Most important, kids need caring parents who support access to high-quality care.

My patient didn’t have access to any of these resources. Fearing fellow churchgoers would judge them for her diagnosis, her parents kicked her out of the house. She fought to finish high school while sleeping on a neighbor’s couch and struggled to take medications and keep her medical appointments. At 18 she moved to a new state, hoping to start a new life.

She and the 10,000 other young people in the United States given H.I.V. diagnoses every year deserve more. They need evidence-based sex education, supportive parenting and better access to the H.I.V. testing information that could save their lives.

Tim Lahey, M.D., M.M.Sc., is an H.I.V. physician, ethicist and director of education at the Dartmouth Institute for Health Policy & Clinical Practice in Dartmouth’s Geisel School of Medicine. He is a member of the Dartmouth Public Voices Fellowship.

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Think Like a Doctor: Packing on the Pounds Solved!

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Credit

On Thursday we challenged Well readers to take on the case of a 59-year-old woman who had not been able to stop gaining weight. I presented the case as it was presented to the doctor who made the diagnosis and asked for the final piece of data provided by the patient as well as the correct cause of her symptoms.

I thought the tough part of this case was something that few of my readers would have to contend with – that her complaints and past medical history were quite ordinary. Like many of us, she was overweight and she came to the doctor because she had difficulty losing weight. In the background she also had high blood pressure, obstructive sleep apnea and low back pain, knee pain and leg swelling. These are some of the most common reasons patients seek medical attention. Although her problems were run of the mill, the cause was not. And many of you had no difficulty spotting this zebra.

The correct diagnosis was…

Acromegaly

The last piece of data, provided by the patient, was a photograph taken several years before. It was only by seeing the changes in the patient’s face that had occurred over the past few years that the doctor recognized that this patient’s problem was unusual.

The first person to make this diagnosis was Dr. Clare O’Connor, a physician in the second year of her training in internal medicine. She plans to subspecialize in endocrinology. She says it was the swollen legs that didn’t compress that gave her the first clue. Well done.

The Diagnosis

Acromegaly is a rare disease caused by an excess of growth hormone, usually due to a tumor in the pituitary gland of the brain. The disease’s name, from the Greek, serves as a fitting description of the most obvious symptoms: great (mega) extremity (akron). The tumor secretes a protein called growth hormone that signals the liver to produce a substance called insulin-like growth factor 1, or IGF 1, which in turn tells cells throughout the body to start proliferating.

With the flood of IGF 1, soft tissues throughout the body begin to grow. This becomes visible as hands, feet, cheeks, lips and tongue enlarge. Although these are the changes that can be observed, other structures are similarly affected, causing cardiac problems (usually enlargement of the heart muscle or valves), respiratory problems (usually obstructive sleep apnea), metabolic problems such as diabetes, and excessive sweating and musculoskeletal problems such as carpal tunnel syndrome. The patient had all of these problems except diabetes.

Eventually, usually after years of untreated disease, bone will start to expand as well. This patient’s feet weren’t just swollen, the bones themselves were larger. The difference between the patient’s face in the doctor’s office and that in the picture wasn’t due to the years that had passed but to changes in their very structure. The lips, tongue and nose were broader. The bone of the chin was thicker, the cheeks wider.

Worth a Thousand Words

Once Dr. Donald Smith, the doctor who saw the patient at Mount Sinai Hospital, heard the summary of the case from the doctor in training who saw her first, he turned to the patient. Did she have anything to add?

She thought for a moment and then said, “Let me show you a picture.” She reached over to her purse and pulled out her driver’s license. That’s me just a few years ago, she told him. The picture showed an attractive middle-aged woman who bore little resemblance to the one before him. That’s when Dr. Smith knew that there was something more than simple weight gain at work.

It wasn’t low thyroid hormone causing this, he decided. A patient gaining this much weight due to thyroid disease should have other symptoms typical of thyroid disease as well.

Two other possibilities came to mind. Both were diseases of hormonal excess; both were characterized by rapid weight gain. First was Cushing’s disease, which is caused by an overproduction of one of the fight-or-flight hormones called cortisol; the second was acromegaly, which is caused by too much growth hormone.

How the Diagnosis Was Made

Dr. Smith looked at the patient, seeking clues that suggested either condition. He saw that just below her neck on her upper back was a subtle area of enlargement. This discrete accumulation of fat, known as a buffalo hump, can occur with normal weight gain, but it is also frequently seen in patients with Cushing’s disease.

Do you bruise more easily these days, he asked? Cushing’s makes the skin fragile, and it bruises more easily. No, she hadn’t seen that. Did she have dark purple stretch marks on her stomach from the weight gain? The rapid expansion of the abdomen can cause the fragile skin of these patients to develop stretch lines. No, again. So maybe not Cushing’s.

Have you changed shoe sizes in the past couple of years? the doctor asked. Enlargement of the hands and feet is rare but is the hallmark of acromegaly. Yes, she exclaimed. Just a few years ago she wore a size 8. Now she can barely squeeze into a size 13.

Can I look at your teeth, the doctor asked. He saw that there were gaps between most of her teeth. Was that new? Yes. She had been told that was from gum disease. “You don’t have gum disease. You have acromegaly,” the doctor declared confidently. The new spaces were evidence that her jaw had, like her feet, simply grown larger.

Dr. Smith referred the patient to Dr. Eliza B. Geer, an endocrinologist who specialized in diseases of the pituitary at Mount Sinai Hospital. She measured the level of growth hormone and IGF 1. Both were dramatically elevated. The final test was a glucose tolerance test. A sugary drink would normally suppress IGF 1. The patient’s level was unaffected. That confirmed the diagnosis; she had acromegaly. An M.R.I. scan revealed a tiny tumor on the pituitary, and a few weeks later the patient had surgery to remove the growth.

The Real Mystery

From the first moment I heard of this case I wondered, how could this have been missed? How could a woman go through such dramatic changes and not have her doctor think: acromegaly.

And yet this is a diagnosis that is frequently missed. The average time to diagnosis is five years. And, like this patient, most people with acromegaly are seen by many doctors before the correct diagnosis is made. Indeed, it is said that patients are more likely to be diagnosed by a doctor who has never seen them before than by their longstanding regular doctor – because these changes take place slowly, over years.

But in wondering about this missed diagnosis, I suddenly recalled a missed case of my own just over a decade ago. I was a few years into my practice and had a patient who had the same string of common problems: She was overweight, and she had high blood pressure, obstructive sleep apnea, spinal stenosis and carpal tunnel syndrome. She worked hard to keep all of her medical problems well controlled. She was really a model patient. One week she was seen by one of the trainees in my practice. That doctor took one look at her and saw what I had not. She ordered the test for acromegaly. Like this patient, my hardworking patient had clearly had acromegaly for years.

Missing the Diagnosis

How do we miss this disease? Acromegaly manifests itself in two ways. First, by causing a series of ordinary diseases that are among the most common problems that bring patients to the doctor. Most patients with these medical problems don’t have acromegaly.

It’s the second manifestation that may be the real issue for me and other doctors. The disease clearly causes changes in the face. The picture in my head of what acromegaly looks like is based on two actors affected with the disease: Richard Kiel, who played the murderous character Jaws in the James Bond movies, and Ted Cassidy, who played Lurch in the television series “The Addams Family.”

But those images are misleading. These actors had acromegaly during childhood, before their bones had stopped growing, and so the effect of the disease was profound and permanent. Their bodies were literally shaped by the disease. Mr. Kiel was 7-foot-2. Mr. Cassidy was 6-foot-9. Both had an exaggerated version of the facial changes of bony overgrowth, with prominent brows and massive jaws. Because of these dramatic changes, those who get the excess growth hormone before puberty are said to have gigantism, rather than acromegaly.

In contrast, when the disease strikes during adulthood, the bones have very limited ability to grow. The changes are thus more subtle and so, often enough, the diagnosis is missed.

This patient decided to show her doctor the photograph after a remark made by her sister. What’s happened to your face? she asked. That’s when the patient began to believe that the distressing changes she saw in the mirror weren’t just from getting older.

How the Patient Fared

The patient had surgery to remove the tumor nine months ago and now feels great. She had attributed so many of her symptoms – the fatigue, the sweatiness, the pain in virtually every joint — to getting older and heavier. But it’s clear now that they were caused by the hormonal excess.

The bony changes will be with her forever (goodbye, size 8 feet). But she’s happy that she can see her ankles once more and will finally be able to lose some weight.