A neurologist’s quest to solve Covid-related neurological disorders | Hacker News Reader

A neurologist’s quest to solve Covid-related neurological disorders

chicagomag.com

169 pointspama178 comments

There are already some comments here making implicit or explicit comparisons between "long covid" and "anxiety", "stress", or "depression". There's a better article about the pathology of covid-related "brain fog" here: https://www.theatlantic.com/health/archive/2022/09/long-covi...

> Of long COVID’s many possible symptoms, brain fog “is by far one of the most disabling and destructive,” Emma Ladds, a primary-care specialist from the University of Oxford, told me. It’s also among the most misunderstood.

> Long-haulers with brain fog say that it’s like none of the things that people—including many medical professionals—jeeringly compare it to. It is more profound than the clouded thinking that accompanies hangovers, stress, or fatigue. ... It is not psychosomatic, and involves real changes to the structure and chemistry of the brain. It is not a mood disorder: “If anyone is saying that this is due to depression and anxiety, they have no basis for that, and data suggest it might be the other direction,” Joanna Hellmuth, a neurologist at UC San Francisco, told me.

> And despite its nebulous name, brain fog is not an umbrella term for every possible mental problem. At its core, Hellmuth said, it is almost always a disorder of “executive function”—the set of mental abilities that includes focusing attention, holding information in mind, and blocking out distractions. These skills are so foundational that when they crumble, much of a person’s cognitive edifice collapses. Anything involving concentration, multitasking, and planning—that is, almost everything important—becomes absurdly arduous.

Like, say, autism, covid-related "brain fog" will probably have a lot of people dubiously diagnosing themselves, but it is still a real disorder with an observable set of symptoms that are being taken quite seriously by medical researchers.

I'd also remind people that it took several years of significant research resources around the world before HIV/AIDS became well understood once it spread into the western nations. Setting aside the obvious differences in severity, we've still got a brand new virus exhibiting many different behaviors in many people, and it's likely that we still have a lot to discover about its mechanisms and long-term effects.

Interesting counterpoint to consider is that there was a study that showed that 50% of people who said they had covid never actually had covid. Can’t find the specific reference but it was a study around covid symptoms.

I think ultimately what’s annoying is that even though there may be some real post-viral complications there’s probably a lot of people who are saying they have long covid that don’t. Long covid also doesn’t mean anything, could mean lung damage or it could mean brain fog.

Cancer doesn't mean anything... It could be liver cancer or it could be brain cancer.

Correct, different types of cancer have varying levels of seriousness and probability of survival. I’d rather have skin cancer than brain cancer.

With all due respect: If you claim something as outlandish as "50% of people who claim they had covid never had covid" with the words "can't find the study", it really isn't a counterpoint to consider.

I believe this is the study being referenced. https://jamanetwork.com/journals/jama/fullarticle/2787741

Yep that’s the one, google search was pretty much useless for finding this.

Thank you for sharing - and note that this is not the full study.

If you follow the ling for the full study, you end up at https://jamanetwork.com/journals/jamainternalmedicine/fullar....

I recommend reading the comments, there are serious concerns about the validity of the study.

There are also fundamental math errors - which the authors acknowledge, search for "we acknowledge" in the comments. Funny part - even while acknowledging it, they still fail to do the math correctly - PPV is 39.7% not 59%.

Still not enough, read Esther Rodriguez' comment on the paper.

Still not enough, read this post on numerical inconsistencies: https://pubpeer.com/publications/0a3dd058f6fb53312c5ddd858ad... (Although I think this is possibly addressed by https://jamanetwork.com/journals/jamainternalmedicine/fullar... - but I currently don't have the time to follow up in detail)

The paper is, as the kids say, "somewhat sus".

Might be innocent mistakes. Might even still be a correct conclusion - but this paper alone can't stand by itself, and there's nothing else backing it up (as far as I can tell with a quick search)

Brain fog is a common term in autoimmune and other communities. People get dismissed constantly because they look fine. If you try learn, and or do something about it, you get a hypochondriac / lazy label.

Like having severe flu. But no outwards symptoms. No one believes you. You can sort of function in short bursts. But gotta rest constantly. Trying to think is very hard.

Autoimmune diseases could be more prevalent than we last thought. They remain statistically under-diagnosed and frequently people don't go deep enough into finding their root illness (most people don't have the tools) and get caught in broad categories like ADHD.

It's strange we live in a world of hyper-connected, hyper-monitored data collection but autoimmune diseases still have decades-long delays on getting a correct diagnosis. There's some real world changing stuff to be made in new tech connecting people to their root illness and allowing the voluntary option to visit a doctor to get it solved.

hEDS is possibly the most under diagnosed condition yet is so easy to test and has been known about since Hippocrates. 90%+ of people with it will never be diagnosed, those that are take decades of gaslighting first. Many people with it will go on to develop Me/CFS/LongCovid, and many LongCovid studies are finding that they have 30% of their cohort with it.

Tech could probably start narrowing down health solutions for people. I wonder. Theorycrafting for a moment.

Someone who owns facial recognition cameras, could also analyze a swarm of other features, by the means of big tech style research and development. Gait analysis, body temperature with millimeter wave scanners, pose and skeletal estimation, arm->body ratio, skin pallor, hair length, face mood and health markers, maybe analyse mouth or teeth images with enough resolution and correct camera angle.

With pose estimation and kinematic animation you could start harvesting body language and mannerisms. Common ticks, impulsive behaviour can be grouped together.

If you also record and analyze speech, across phones and mall microphones, one could isolate out tourettes (and some speech pathologies?).

An awful lot of vaguery could be made clear...

I wonder if treating these diagnostic conditions like a programming language and organising the diagnostic routes properly, we could allow for a technique for the user in combination with a properly designed website, to individually narrow down their own experience into a doctors apppointment, and waste less resources on 'wild goose chase' doctor appointments, intiated by clueless patients.

What ever happened to Watson's autodiagnosing abilities?

I used to work in behavioral analytics for a big internet company. It was pretty obvious that behaviors are largely genetic and you can pin things down to particular conditions. Eventually we’ll find out which genes do what so you’ll just need to do DNA sequencing for most physical/psychological conditions.

IBM happened to Watson. They’re still around but I don’t think their approach is very good.

I think it's systemic, there's other diseases like stomach ulcer disease that took a long time to pin down the exact cause.

https://en.m.wikipedia.org/wiki/Timeline_of_peptic_ulcer_dis...

I do not deny that this exists and is a real symptom. The issue is when you classify regular anxiety and stress as long COVID in addition to actual neurological issues caused by COVID (which multiple studies have done), it inflates the overall numbers and dilutes the seriousness of the brain fog issues. That is also how you end up with long COVID as the “third leading neurological disorder” in the U.S.

Entirely agreed.

There isn’t a single person here that wouldn’t have said they think anxiety depression and stress are major issues in 2019. I’ll be waiting for someone to prove long covid anxiety vs just regular pre-covid anxiety. At the same time, are we ignoring a majorly damaged economy, recession, raising prices, etc?

I’d ask if that is long covid too, but the answer is yes, the debate is just differences in reasoning.

Is it the third-leading neurological disorder in the US? That is what the article is about.

It’ll likely impact around 5 to 10% of the population. Roughly 10% are susceptible but half of those will recover in their own. Basically ME/CFS but way more people impacted.

What are you basing this estimate on? From the article, it sounds like funding is scant:

> Koralnik complains that no government money has been earmarked specifically for research into long COVID’s significant neurological manifestations, and that the NIH hasn’t assigned a neurologist to review such grant applications. “Therefore, it’s been very difficult, if not impossible, to get funded for the research for neuro-COVID,” he says.

Would difficulty getting funding bias early prevalence estimates?

I think the numbers in this article are overstated but are within the ballpark.

Covid isn’t the only virus to cause ME/CFS and it isn’t even the worst. MERS is worse and was studied extensively. It requires a genetic predisposition that appears to only exist in 10% of people. Within that 10% there is a spectrum of severity with half recovering. Unfortunately as someone with the gene mutation for hEDS I’m extremely susceptible to it and do indeed have ME/CFS (predating covid) which to me is largely indistinguishable from LongCovid. I have a strong personal stake and have extensively researched it.

Well, Long Covid is prpbably a worse version of it as it apparently can for reservoirs in susceptible people. So not only are they immune dysregulated, but also sick repeatedly...

Many viruses hide in reservoirs. EBV is famous for reactivating. ME/CFS appears to be a threshold condition where once you pass a threshold you enter a diseased state and it’s a crapshoot to how bad it gets. From what I’ve seen LongCovid is not worse than ordinary ME/CFS, it appears to be exactly the same.

That is highly speculative. Severely immunocompromised patients can experience persistent SARS-CoV-2 infections lasting months, but otherwise there is no reliable evidence of such reservoirs. Coronaviruses don't stick around like, for example, herpesviruses.

In the last pandemic, referring to Spanish Flu, there was a parallel and subsequent pandemic of encephalitis lethargica, found to be caused by an opportunistic virus amongst a population with a prior exposure to the flu and war. that also involved a distortion of cognitive function, and encephalitis in general is brain swelling.

Both severe and death of or in addition to COVID relies on opportunistic infections, as multiple of your bodies' defenses are down.

I've always wondered if there was a parallel viral infection going around, that was discredited solely because somebody qualified never looked.

Given the overlapping similarities, might be worth a closer look, if it can't easily be attributed directly to the Sars-Cov-2 virus, just the experiencing of having COVID.

I'm leaning towards an interaction from a yet-to-be-discovered genetic trait that's causing an autoimmune disorder, but your hypothesis is interesting and there are certainly a lot of possible sources for secondary infection.

A few studies found that 30% of LongCovid cohorts have hEDS and 40%+ are hypermobile. Both are autosomal dominant hereditary conditions.

> “If anyone is saying that this is due to depression and anxiety, they have no basis for that, and data suggest it might be the other direction,” Joanna Hellmuth, a neurologist at UC San Francisco, told me.

Paywalled on the article you link, so maybe it's explained more in detail there, but what does "the other direction" mean? Is this doctor claiming that depression/anxiety would protect against it? Or that it causes "the other direction" of symptoms e.g. happiness, relaxation? Neither of those seem to track with other reporting I've seen.

Sorry, try this link: https://archive.ph/0HYix

I understood that line to mean that covid-related brain fog may be causing anxiety, depression, etc., but I paused on that line of the article too.

>It is not psychosomatic, and involves real changes to the structure and chemistry of the brain.

I'm not one of the people that completely denies long COVID is a thing, but this statement seems strange. It at least reads as "it's not psychosomatic because it causes real changes" but a psychosomatic illness causes real changes without a clear cause.

They could be two unconnected statements poorly quoted, but "it caused physical changes" is too often used to dismiss a psychosomatic cause.

What makes this all so complicated is that there could very well be both many people whose problems are primarily biological, and others who are experiencing some kind of psychosomatic issue. There’s a ton of variation in people. COVID effects different people in such different ways, there is no simple definitive answer to this that we will be able to apply to every individual.

I agree, which is why I find a neurologist stating in certain terms "it's not psychosomatic" strange.

Psychosomatic means "real symptoms caused or made worse (noticeable) by state of mind". They're saying there's actual damage involved, that it's not just psychological.

Don't real symptoms cause actual damage?

The difference is the cause, not the effect.

If both long COVID and a psychosomatic illness could have caused the effect, how are they determining the cause?

Long COVID is defined by its symptoms - it's the effect, not a cause. Damage from COVID (the acute phase) and mental state are two possible causes. They're claiming that COVID is directly causing damage that then leads to Long COVID, and that mental state doesn't play a role.

I would believe something very much in the opposite direction:

Many people with anxiety/depression/miscelaneous psychological diagnoses have conditions triggered by long acting neurological effects triggered by diseases such as viruses.

This is just the neurological side of COVID damage. There's also the cardiac side.[1] "78% of patients who previously had the virus showed structural changes or damage to their hearts, including inflammation and scarring."[1] This can be seen in MRI scans. It's not subjective. "What we found is that even in people who did not have any heart problems start with, were athletic, did not have a high BMI, were not obese, did not smoke, did not have kidney disease or diabetes—even in people who were previously healthy and had no risk factors or problems with the heart—COVID-19 affected them in such a way that manifested the higher risk of heart problems than people who did not get COVID-19."[2]

It's an inflammation-causing disease, and it doesn't seem to stop at the respiratory system.

Heart damage may not be permanent. Too early to tell.

[1] https://health.clevelandclinic.org/covid-19-can-also-damage-...

[2] https://publichealth.jhu.edu/2022/covid-and-the-heart-it-spa...

I had a stroke just shy of a month ago. 38yo male, no risk factors, healthy BMI, 12+ hours of intense exercise per week. In the neurology ward of the hospital I was told they'd seen a massive uptick in otherwise-healthy adults experiencing strokes over the past few years.

My last COVID infection was about 11 months ago, that I know of.

All this is to say that I'm not surprised by your comment at all. We'll never really know if my stroke specifically was caused by COVID, but I think it's becoming more and more that there are a whole host of ongoing health concerns directly related to it.

Are you vaccinated?

That is the essential question. A more recent Covid vaccination is more likely to be the culprit than from Covid 11 months ago.

It is. But covid is still there to be precise. Just not so much (still too much for my taste) in media any more.

Unfortunately for your hypothesis, my most recent vaccination was nine months prior. The risks identified with vaccines right now appear to be in the period immediately following vaccination whereas COVID tends to create elevated risks for a significantly longer period of time.

It will be hard to tell for all of these problems whether they stem from COVID or the vax, as most people have had both.

I have friends who have long COVID (brain fog) since they got the disease ... yes it's probably overhyped and there might be a lot of misdiagnosis out there, but it is a real sickness.

it makes me sad to read on hackernews how it's probably just depression, anxiety and we should not believe what "the media is telling us."

It is certainly highly correlated with pre-existing psychological distress. That doesn't mean people aren't suffering, but the 'HN response' isn't coming from nowhere either.

https://www.medscape.com/viewarticle/980527

“ In an analysis of almost 55,000 adult participants in three ongoing studies, having depression, anxiety, worry, perceived stress, or loneliness early in the pandemic, before SARS-CoV-2 infection, was associated with a 50% increased risk for developing long COVID”

People with a cortisol hypersensitivity are more likely to develop dysautonomia which is one of the underpinnings of LongCovid. So people with existing psychological conditions being ‘over represented’ in getting LongCovid is of absolutely no surprise.

> People with a cortisol hypersensitivity are more likely to develop dysautonomia

So are people with HIV, Parkinson’s etc… I’m not sure how that is at all relevant here

Your statement confuses me. The relevance is stated in my second sentence. In case it’s not obvious, cortisol hypersensitivity will present as psychological problems.

Cortisol hypersensitivity is not a medical term or diagnosis - I assumed you meant hypercortisolism? That has nothing to do with psychological problems.

https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=gluc...

You literally linked to glucocorticoid hypersensitivity (not Cortisol hypersensitivity) which is an underpinning of Cushing syndrome (hypercortisolism) - again nothing to do with psychological problems

“Cortisol is a glucocorticoid hormone that your adrenal glands produce and release.”

It’s the underpinnings of many different problems. And think about it for a sec, if you found yourself hypersensitive to cortisol how do you think your brain would react?

> And think about it for a sec, if you found yourself hypersensitive to cortisol

Medicine isn't 'think about it for a sec' - you made direct claims using unscientific terms - Cushings is a very specific and relatively rare disease that has no realm of relevance here. Not sure where you are trying to go with this but it is obvious you have no medical background or standing.

You know there is a difference between producing too much cortisol and being hypersensitive to it? They are logically two different things.

And please enlighten me on your medical background / standing. I used to teach stats to doctors to help them understand medical tooling.

Our knowledge of the brain and mental illness is shaky. Our health professionals consistently prescribed antidepressants which did more bad than good to people.

People with chronic fatigue syndrome have problem getting a diagnosis.

There is not enough meat to trust the experts, but you do you.

Data point of 1: Try quitting caffeine. Worked wonders for my brain fog and anxiety. Again, data point of 1

data point of 1: one of the friends who has brain fog now does not drink caffeine, alcohol, is a health nut (eats healht, cares about sleeping enough and does regular e exercise... more than me). again data point of 1.

thanks for the "very helpful" suggestion.

You're very welcome! Hopefully it helps!

Anyone with brain fog and other mental symptoms should seriously consider questioning their diet, and whether it has changed in the past 3 years or so.

I have a long history of psychiatric troubles such as C-PTSD, anxiety, etc. I have steadfastly resisted medication for it, but when I did accept medication I was afflicted with brain fog and other terrible side-effects. However, I recently committed to an organic diet of fresh fruits, vegetables and meals prepared from scratch. Contrast this with my previous diet of fast food, casual restaurants and plenty of delivery, and it was like night and day.

One of the chief benefits of switching to a healthy diet was the end of brain fog and an absolute renaissance of good sleep hygiene. I woke up with the dawn and I had plenty of energy throughout the day. I ate several small meals on a regular basis and I slept soundly and restfully. My blood pressure dropped to normal levels and I experienced much less stress, and I benefited from increased exercise through housework and meal prep.

As soon as I "fall off the wagon" and begin to eat restaurant food again, I return to horrible insomnia, brain fog, and reduced executive function. I have trouble working through the day.

So I can't blame the psychoparmaceuticals for this stuff anymore, it was 95% my diet. I'm super glad that I found a way out, and I'm grateful for the clarity and health promised by better lifestyle choices.

There is serious lake of food research ,i bet most of fast food we eat can't be considered human food ,also i have conspiracy ,big food companies try to impede these research

I'm glad that you're figuring something out, but alas the prescription may not be so easy for many.

So, can you come over and cook for me? Because reduced executive function sure makes it hard to cook! Or even meal plan!

Also you'll have to figure something out for my incredibly picky 4 year old... good luck!

I want to add (without proof) that stopping caffeine consumption, frequent orgasms (once a day every day = frequent) and information consumption (video streaming, social media, gaming, Reddit, hacker news, forums, news sites & comments) will have similar effects on mental clarity after about 3 or 4 days of being "sober". Give it a shot.

Another thing that makes a difference is self care: clean your place, throw stuff away, take a warm bath for relaxation (not to get clean), moisturize your body and be thankful toward it. Do some stretches for 15 minutes. Buy new towels & bedding. Buy something that makes your place smell nice. Wash all your clothes, bedding, towels frequently. If you have crappy old furniture, get rid of it, esp if it makes you feel icky. If you have permanent carpets, get rid of them and get wood floors or decent tiles. Try to get rid of all plastics and replace it with glass (kitchen) or cotton (clothing & fabrics).

If you are used to always having music playing, experiment with music deprivation for a few days, or at least, music without lyrics.

Not going to get into alcohol consumption, nicotine and cannabis - they all have effects on your mental state and modulating how often you use them makes a massive difference.

Lastly, do get therapy (and medication) if you need to or a good friend you can talk to, it makes a difference. Walks in nature while talking about life can help.

If you are forced to use the internet to earn money, minimize the noise: get Firefox + ublock origin for starters. After that, get a raspberry pi and install pihole on it, and search for different lists for it to block various aspects of the internet on your network: on top of ads/trackers, you can block porn, social media, gambling sites. You can also view semi real time which domains are loading on your network and which device is using it, and blocking it right there and then. Using pihole will greatly improve your relationship with the internet and information in general. You can also set your router to disable wifi between say 23:00 and 05:00, if you have trouble disconnecting. Even better if you can trim it to 21:00 and 07:00, but make sure your family knows.

Try to prefer long form content over short ones, especially comments. Reading hundreds of comments a day is like having hundreds of conversations a day - it will exhaust you. By extension, do not do it before bed. Leave your phone in another room to charge. The bedroom's purpose should be rest and relaxation (sleep & sex & self care) only. Try to remove every other thing from it that gives it more functions (tv/desk/excercise equipment). Do not eat in bed.

Also try to disconnect from work when your work hours end. Set boundaries with your teammates and clients, that also mean blocking time on your calendar so they cannot book meetings with you. Make other people use the calendars and make sure you keep it up to date and encourage them to also use theirs and to disconnect from work when possible.

Remove work email/chat programs from your phone if possible. Switch off notifications for all apps except a handful of apps. Mute all group chats if you are on WhatsApp/similar. If you use slack, you can set you active hours so it won't send notifications.

Remember to schedule leave, try to take at least one day off a month to do nothing (I recommend spending time in nature if possible). Travel to a different part of your city/province if you can, a change in scenery is good.

Basically, you need to curate exactly what your time and attention span gets spent on every day. You only have so many "attention points" to spend, so make sure you spend them on stuff that matters to you. Automate the things that you cannot escape (getting a dishwasher is worth it washing dishes agitates you or you spend 2+ hours a week on it). Calculate how much you are worth per hour in money terms, when deciding to buy something or paying for some service (like getting a cleaning crew to clean your place instead of doing it yourself).

Sounds like you're very sensitive to salt. Restaurant food has a ton of salt, because that's what makes it taste good.

I had a very mild case of Covid. 101 fever for < 24 hours. No coughing or congestion. However, I've been without my sense of smell for weeks now. It's so weird to literally smell nothing. I can't smell freshly ground coffee. I can't smell the food I eat. I can't tell if milk is spoiled. I can't even tell if I need to apply deodorant or not. To those claiming "long covid" is really just anxiety, can you explain this manifestation?

That’s not long covid, that’s post-acute sequelae SARS-CoV-2 infection (PASC) which is a different category. If you also have crushing fatigue you might also have long covid. The basic test for this is the test for PEM, exercise as hard as you can and repeat in two days. If you too fatigued to do anywhere close to the same workout then you likely have PEM and LongCovid/ME/CFS.

PASC is considered long covid. Literally the name "post-acute sequelae" means a condition after the acute phase.

I’m aware of what PASC means, it’s a superset of LongCovid that includes other organ damage that is unique to covid. It’s possible to have PASC without having LongCovid but impossible to have LongCovid without PASC.

Again, I think you just have your own definition for long Covid. The CDC does not share your definition: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/...

Long covid is a patient community driven term relating to the ME/CFS class of symptoms. The CDC is using it incorrectly.

Mayo clinic also conflates "long covid" and PASC: https://www.mayoclinic.org/diseases-conditions/coronavirus/i...

As does Johns Hopkins: https://www.hopkinsmedicine.org/coronavirus/pact/index.html

Something to consider: maybe it's your usage of long covid that's incorrect?

See https://youtu.be/tFQBcu5qlmE?t=485 for a breakdown of terminology. This is how it started and where it is going back to. This is a bit of history that I've personally lived.

If you investigate you'd probably be surprised just how behind the 8-ball these institutions are. Their inability to predict the bleedingly obvious as corona viruses have a history of triggering ME/CFS. Their many decades of gaslighting patients and recommending harmful treatments such as exercise and cognitive behavioural therapy.

Those of us from the ME/CFS space knew this was coming and knew people with Long Covid were going to be gaslit so we've been educating them on what to expect and how best to treat it. Plus we don't mind that they're rebranding ME/CFS as Long Covid as we'd like these institutions to actually do their job and do some research. We're not expecting an apology for the decades of gaslighting. The main thing we want is for people to not waste time rediscovering what we already know. Conflating the Long Covid (ME/CFS) part of PASC with the organ damage part muddies the water and diminishes focus.

People aren't trying to say loss of smell is just anxiety. They are try to say that anxiety can just be anxiety (The thought of covid itself can cause anxiety), so some of the reported symptoms are dubious. The one that can be tested more objectively have much less room for dispute (processing speed, attention, executive function, and memory).

Hope your smell returns sooner rather than later. My mom has been without hers for 9 months now, which seems to be in the rather unlucky category.

I had pretty bad case of Delta, all symptoms were gone in 2 weeks, smell returned after 3 weeks (one week later after other symptoms). I'm grateful to my immune system without any COVID "vaccine".

I don't see anyone claiming loss of smell is long COVID, it's two entirely different things, loss of smell is symptom of COVID and you can have it longer or shorter. "Long COVID" is now catchphrase to cover pretty much anything for hypochondriacs. Sure minority of people claiming they have long term issues after COVID can have something which we could call "long COVID", but most of people claiming they have long COVID are hypochondriacs. Ocassional headache? Long COVID. Tiredness? Long COVID. Etc. I've had "long COVID" years ago before COVID.

Honestly I'm not surprised US nation addicted to drugs especially antidepressants is major nation experiecing long COVID, while this long COVID pretty much doesn't exist poorer the country you go and it's exclusive to few western countries.

My brother hasn’t been able to smell since (first?) getting Covid. That was nearly 2 years ago. He hasn’t smelled anything in nearly 2 years!

I lost taste and smell, and a regular taking of the following supplements helped me get it back: a) EGCg (from green tea, so take in morning) b) Magnesium Threonate (helps w/ neural repair) c) Agmatine and PQQ (I took both, and I mix up their purposes) d) NAC (this might have been just for immune boost)

If you had to just try 2 of them, I'd try EGCg and Magnesium Threonate -- but it might help you recover your senses. The only thing off for me now is eggs, I'm super sensitive to the sulfur in them.

I read some of the “Long COVID” studies a while back, and they all included things like anxiety, depression, and mental state weeks or months after testing positive for COVID. Linking this to COVID is an example of bad science. Correlation does not equal causation. People could be experiencing these symptoms for a multitude of reasons including, but not limited to, government mandates, rules, policies, inflation, economic difficulties, isolation, remote work, etc.

Even their comment about the impact of vaccines can be explained in this context:

> The vaccines are certainly helping. Before they became available, about one-third of everyone infected with the virus came down with long COVID, Koralnik says. “There is brand-new data showing that if you’ve been double vaccinated and boosted, then the risk of developing long COVID, if you get COVID, is probably more like 16, 17 percent

If your state of mind and anxiety about things are included as “long COVID” symptoms, it makes sense that the peace of mind offered to people who get vaccinated would put them in a better head space to not experience these symptoms regardless of how effective the vaccines are.

None of this means that it is impossible to have lingering COVID symptoms. Of course that can happen, but that can happen with any disease.

>If your state of mind and anxiety about things are included as “long COVID” symptoms, it makes sense that the peace of mind offered to people who get vaccinated would put them in a better head space to not experience these symptoms regardless of how effective the vaccines are.

Correlation does not equal causation.

No, but when a certain set of symptoms are expected in a certain situation, it does not make sense to invent a new hypothetical disease without having any proof of it except for those very symptoms.

Long COVID is not a "new hypothetical disease" but a collection of various post COVID symptoms that have strong correlations (hi!) with pre-existing non-psychological conditions. The fact that these disparate health issues are grouped into this neat-sounding category is unfortunate I agree, but also is a consequence of you know, millions and millions of people with issues all at once.

> People could be experiencing these symptoms for a multitude of reasons including, but not limited to, government mandates, rules, policies, inflation, economic difficulties, isolation, remote work, etc.

But if people who have tested positive experience these symptoms at a higher rate than people who haven’t, while both populations are exposed to mandates, inflation, etc., then it is reasonable to question whether mandates, inflation, etc. are the cause or the long-term effects of COVID.

I agree, but that is not what the study in the linked article shows. It looks like they only looked at people who had previously tested positive for COVID:

> They ran an analysis of the first 509 COVID patients treated at Northwestern Memorial Hospital and, in a paper published later that year, reported that 42 percent of them experienced neurological symptoms upon contracting COVID, 63 percent upon being hospitalized, and 82 percent over the entire course of the disease.

From what I have seen, this is the same with the other long COVID studies I have seen as well as the other references in this article. Do you have an example of a study that compares long COVID symptoms of people who tested positive compared to people who never had COVID? I would be very interested in reading that.

People who tested positive have definitely had more psychological stress, simply due to knowing they tested positive, which added up to the before mentioned stress factors.

Also, people who took tests in the first place are people who were more likely to feel stressed due to the existence of this disease than people who never did any test at all.

It is possible that people who got covid have increased anxiety about long covid which leads to additional issues.

This post completely blows off & tells people who keep feeling something that they are wrong & unjustified, that since we're not fully sure we can believe them & it's not worth regarding their cases as real.

I not humbly disagree. I dont see how we could ever even begin to be a society if we allow mistrust & rejection of possibilities to be the primary shaper of our opinions & positions. The refusal to regard here is actively harmful.

> I read some of the “Long COVID” studies a while back, and they all included things like anxiety, depression, and mental state weeks or months after testing positive for COVID. Linking this to COVID is an example of bad science.

Yo, what? Excuse you? You're going to disregard people's reports & assessments, call it bad science, just throw up correlation does not equal causation qed & pretend like the job is done? People feel like shit, have incredibly fuzzy brain states for a while after covid. Even those who physically (aerobically) recover still doubt how healed their are, are anxious because the brain still feels behind. Maybe some of this anxiety you disregard is because they are never sure if they ever will really truly ever recover; this has felt like shit to me and Im never sure Im back to who I was before this ordeal. That seems widely reported, real to me & I'd expect some familiarity with thay from others. That feeling of brain fog is real, that worrying & anxiety is real although perhaps not directly entirely attributable, but a serious & clear & inarguable & concerning secondary effect that we frankly dont have a ton of good data to help people fully through. Even if we did have the data, people are still allowed to be afraid. Afraid of flying, afraid of escallators, afraid their bloody mind is scrambled & not really recovering like it should be.

Sorry comrade but science aint always so simple & clear & direct. Finding out can be hard. Just because the facts dont conveniently line up to make sometbing clear right away doesnt give you license to disresged, to ignore possibly real information. There's a word for argumentation that tries to make information in general less believed, less real: disinformation. Please dont border so close to being actively denialist of possoble validity.

Look, it might be annoying, but if it weren't for that kind of attitude they'd have already discovered all the science and written all of the software a few thousand years ago in Babylon and we'd be out of work.

> This post completely blows off & tells people who keep feeling something that they are wrong & unjustified, that since we're not fully sure we can believe them & it's not worth regarding their cases as real.

No, it does not. It's just saying that anxiety and depression are completely normal reactions to the global pandemic crisis. If someone is claiming that "long" COVID is a thing, they need to have better evidence than "people are depressed and anxious".

The rest of your post is written in a confrontational attitude that I don't even want to read.

> The rest of your post is written in a confrontational attitude that I don't even want to read.

That's a shame. I felt the same way when I started reading your post, but I did finish it. That's how I know you'd benefit from reading a little further - they go on to explain what you're missing.

> It's just saying that anxiety and depression are completely normal reactions to the global pandemic crisis.

You forgot "mental state" in that list of things the person said were almost certainly not covid & shouldnt be believed or trusted as being a part of long covid.

> The rest of your post is written in a confrontational attitude that I don't even want to read.

The original @fsociety999 parent was "confrontational" against reports & beliefs that are widely reported & I dont want to read that disinformation & cruel hot take skepticism either. But I did & I responded, because it matters & even the bad, especially the bad, needs addressing. My post is far from perfect & saintly & I absolutely could do better, but this was actively disdainful posting making up preffered causes & excuses to disregard what seems like quite possibly real & evident meaning.

I came here to read and basically make this comment.

The GP was very dismissive - or at least cast FUD on the whole notion.

We are in this place where we are the best experts about our own body, yet at the same time that experience and knowledge is being cast doubt on because ... why exactly? Why is it so hard to take people seriously?

Other comments in here seem to be basically like "well you were fragile/brain weird before so whatever I guess".

Just remember, every person who is struggling after a bout of COVID and not feeling right... that is a person, that could be your friend, parent, sibling, loved one...

Ultimately the proper response imo is "that is really concerning and we should do more research" rather than "well this happens after every illness". Which is "true" but also not really true, simply because long covid is way more prevalent than lingering symptoms after EB, the flu, colds, etc.

That was already happening before COVID.

I'm not surprised that people are more depressed and anxious after 2 years of no fun, no social interaction and being locked up in their homes.

Calling it "long COVID" is just another piece of disinformation trying to make COVID look bigger than what it is.

Also covering narrative of "great" and "safe" experimental vaccines.

Couldn't we just prove this by brain-scanning long covid people and brain-scanning people who don't have long covid but lived through the pandemic anyways? My understanding is that long covid actually has measurable brain scan abnormalities that anxiety, depression, or whatever can't explain...

Alas, no. Research is starting to find biomarkers for long Covid. (IIRC, it's mostly antigen presence right now).

That's part of the problem. We don't have clear biomarkers, we don't have a clear definition what it is, we don't have agreement what symptoms exactly are included, and we aren't even fully aligned on what "long" means. (>4 weeks? >6 weeks? >3 months?)

Post-exertional malaise (PEM) is probably the most agreed upon core symptom of LongCovid and is easy to test. Do a max exertion exercise two days apart, if the second one is nowhere near the first one then it’s likely you have PEM and LongCovid.

A two-day cardiopulmonary exercise test can be useful to diagnose ME/CFS regardless of whether it was caused by a SARS-CoV-2 infection or something else. But it's not definitive by itself. Maximum exercise capacity varies significantly day-to-day for the same individual based on nutrition, sleep, alcohol consumption, menstrual cycle, mental state, and other factors. In most test protocols they stop when the patient gives up, but some days people are just more willing to suffer and push through the pain to get a little farther. We can get some additional clues by looking at certain objective measures like HRV but even that isn't definitive.

Long COVID is really more of a syndrome, a rough grouping of symptoms rather that a specific condition. It's so vague and covers such a wide range of different symptoms as to be clinically useless.

People with PEM won't get anywhere close to their original score. Those who have it bad won't even be able to get out of bed.

Long Covid is ME/CFS re-branded. Some people / institutions muddy the water with other PASC organ damage but a real effort is being made to disambiguate it.

That's correct, we know that COVID can and does have an effect on the brain but we don't know the extent of what it does or how it relates to what people colloquially call Long COVID.

That said, it's always disappointing to see people push quackery like dietary fixes or claiming it's just a sociological thing. Especially the sociological angle because it isn't just limited to places like the US (where I presume people are pushing the theory for political reasons). It appears in places regardless if they did full on lockdowns or did a more light touch like in Sweden. It makes me think that nowadays people would claim Shingles is fake and made up and unrelated to Chicken Pox.

Unsurprisingly the sociological origins for long covid are being pushed very hard in Sweden. Due to the nature of public health care and very narrow opinion corridor, this also means no care at all for LC for those affected.

Virtually every qualified professional (by their opinion or their qualifications) jumped into the fight against COVID (and in some cases the fight against the fight against COVID). Long COVID is receiving a minute fraction of the attention because the risks are so much lower. Almost everyone’s gone back to their day jobs while governments, non profits, and corporations allocate resources by consensus as is done in peaceful times.

High quality disease research takes place over years and decades through hundreds to thousands of studies. We’re still looking for a cure for HIV, long COVID could be harder to treat. We have no idea.

There are two pieces here which need to be picked apart:

1) Does Long Covid exist differentially relative to others who went through the pandemic?

2) Has the medical establishment been sweeping aside a whole host of genuine complaints of unspecified origin that are now landing under "Long Covid"?

What is becoming increasingly clear is that viruses suck worse than anybody thought, and we need to start paying attention to that.

Ha listen to you denying something tens of millions of people are suffering with is even real.

It's taking out athletes, professional athletes, left and right.

There are multiple studies showing severe mitochondria dysfunction for months, years afterwards.

It's even identical to the years after the original SARS in 2003.

But yeah, must not be real because you read some papers.

I guess one person at a time has to experience it for themselves but then it's too late because there's no actual cure like ME-CFS, your life quality just sucks for whatever time you have left.

They didn’t deny long covid is real. They explained that this particular study is shit science because it didn’t control for these very basic confounding factors.

Correlation may not equal causation, but correlation does define syndromes. In medicine, a "syndrome" is any collection of findings that tend to occur together. A syndromic label says nothing about how or why the findings occur together, only that they do.

As syndromes become better understood, they can morph into a disease. For example, swollen lymph nodes in gay men was a syndrome in 1981, but as knowledge evolved, we came to know it as AIDS and then HIV.

So "long covid" is definitely a syndrome. Hopefully medical science will someday learn enough to know whether it is a disease or not.

It's also quite possible that the covid infection itself didn't cause those symptoms, but the experience of getting sick, having to quarantine, telling people you have a disease everyone is afraid of, etc. causes mental stress that leads to persistent depression and anxiety.

Some of this could be related to the corticosteroids (glucocorticoids) sometimes given to treat long COVID:

https://edition.cnn.com/2022/08/30/health/oral-inhaled-stero...

https://bmjopen.bmj.com/content/12/8/e062446

This is also given to sufferers of asthma and hayfever.

Very anecdotal but the people I know who got long COVID were all doing perfectly fine until after they got COVID. So, at least the 2+ years before they got omicron didn't cause them to be depressed. They also are not affected by the economic situation and have stable jobs. None of them have any material differences in circumstances compared to before they had COVID and all of them had COVID late in the omicron wave after being fully vaccinated.

Of course, that's purely anecdotal but it does hint that there must be something else happening.

Elephant in room.

Long Covid is what scares me when my employer keeps pressuring us to get back into the office.

It scares your employer too because they don't want employees using their disability policies and so they'll claim it doesn't exist and you're making it up and fight you over it.

Most Americans have been infected already, and the virus will never go away. All of us will be exposed, so it hardly matters whether that exposure happens in an office or somewhere else.

https://www.medpagetoday.com/opinion/vinay-prasad/94646

Then it's fair to reduce the total risk by needless return-to-office policies.

With every new infection, more damage accumulates. Huge increases in heart disease, strokes, and risk of Long Covid. The answer is not to give up and just catch every variant, but to delay it as long as possible with reasonable measures like never eating indoor at a restaurant and wearing a NIOSH approved mask when you go out.

It's sad to see people consumed by irrational germophobia to the point that they won't even eat in restaurants. Meanwhile the rest of us are enjoying ourselves, living normal lives.

It's not irrational. I was already infected by SARS-2 and it has already disabled me. I've been experiencing chest pain, heart palpitations, and chronic fatigue for months. I just got back from a doctor's visit where it was discovered that one of my organs has scarring.

But do go on about "irrational fears."

Given how common this appears. I’d really like to see a breakdown by

- age, gender, weight, race

- country, state, city

- medical interventions attempted, vaccine status, etc

- prior medical history

- drugs taken on a daily basis

I have a sneaking suspicion there’s some key factors here. This isn’t unheard of for viruses, even the flu can cause “brain fog”.

There’s also a chance the spike protein can cause this. There’s a few discussions on it, but it’s one of the reasons people were concerned about potential side effects from the vaccines (which utilize the spike protein).

Funny enough, the later point was mentioned in the global planning scenario of a coronavirus outbreak in oct 2019. Page 59 discusses vaccine side effects causing neurological issues

https://jhsphcenterforhealthsecurity.s3.amazonaws.com/spars-...

> While the federal government appeared to have appropriately addressed concerns around the acute side effects of Corovax, the long-term, chronic effects of the vaccine were still largely unknown. Nearing the end of 2027, reports of new neurological symptoms began to emerge. After showing no adverse side effects for nearly a year, several vaccine recipients slowly began to experience symptoms such as blurry vision, headaches, and numbness in their extremities. Due to the small number of these cases, the significance of their association with Corovax was never determined.

I’m sure it’s unrelated, but interesting none-the-less.

I dunno man, to take your comment at face value requires me to presuppose that medical researchers are just really bad at their job. I have a sneaking feeling that if it was as easy as you say it may be, it would have been discovered already. That's the basic kind of regression analysis that if it showed something significant, someone would have a slam dunk paper, and probably even a nobel prize or whatever lined up...

Causation is very hard to “prove” and requires a massive dataset. Particularly at all the skews I mentioned. Each skew requires a multiple more data. I’m not saying they’re bad at their job, might just not be organized properly to gather said data.

> I'm sure it's unrelated

Because it's not 2027 yet and people aren't newly discovering this and it's almost never from the vaccine but rather from the virus itself? In what way do you think it could be "related", like that they planned out the pandemic and published it? I'm assuming I've misunderstood this part of your comment.

It’s in their theoretical scenario because it’s a common / obvious enough issue to appear there. Viruses often cause neurological symptoms, vaccines and medicines can do the same thing. Combine the two and it confounds the potential issues and ease of identification. That’s all I’m saying, to identify causes you need a lot of data. Much of which isn’t / wasn’t being collected and needs to start being collected

> Given how common this appears.

It seems to be pretty uncommon in Europe and poorer the countries you go, it's almost as if there was causation between people taking antidepressants and visiting shrink and long COVID, especially combined with how much talked the "long COVID" is in MSM.

Lower availability of psychologists, drugs and long COVID coverage in MSM usally results in almost none long COVID cases.

It's common enough, we just have way fewer COVID cases, so total numbers are lower. The susceptibility to a variety of autoimmune diseases and dysregulation also varies based on HLA group (as in is correlated pretty decently), making it another explanation for different rates of it.

For anyone with Long Covid, there is an online support group with a lot of resources available (it does use Slack). The group can be found at: https://www.wearebodypolitic.com/covid-19

> The upshot: There may be no correlation between the severity of your COVID case and the lasting effect on your brain.

The simplest explanation here is that there’s also no correlation between COVID and “Long Covid”

I have a strong feeling a large amount of “long covid” may be the collective anxiety and stress combined with a reduction in social interaction

There's also a strong correlation between the demographics of those who tend to have higher rates of mental illness and those who tend to suffer more from long covid.

Can you point out where I can this data point in the article? I must have missed it.

https://www.medscape.com/viewarticle/980527

According to this article, rates of depression during COVID outbreak, were 27.5%. So, at least a decent chance this happens by chance? Also they mention worry, perceived stress and loneliness. Did anyone not perceive stress during the pandemic? 50% seems like a pretty low correlation. I can’t read your article because it’s login walled.

https://www.bu.edu/articles/2021/depression-rates-tripled-wh...

No, it was 50% off those that experienced that BEFORE covid - so it was controlled

Right but 50% of people who had long COVID had experienced “worry, perceived stress, or loneliness” in the past ( not ti mention depression/anxiety) I’d expect that number to be much higher.

> Right but 50% of people who had long COVID had experienced

Read more carefully that isn't what the paper showed - it showed that those with previous psychological problems were 50% more likely to have long covid COMPARED to those that didn't have previous problems

I feel that my skepticism of much of the COVID hysteria, whether actually well-founded or not, helped me avoid a lot of this anxiety and stress over the past couple of years.

I took advantage of a nearly 2-year paid "work from home" vacation, and did a lot of other things I probably would not have done otherwise, including joining a gym and getting myself in shape for the first time in my life, and making some new friends.

It can’t have been good for people who are already anxiety-prone or otherwise have mental health issues to be subjected to two years of “going outside will kill everyone you love”.

It's not. The most common mix of symptoms track closely timing wise post covid onset and do not overlap in general with anxiety and stress symptoms. For example chills, exercise intolerance, difficulty breathing after eating, visual snow, tinnitus.

Im not saying long covid doesn’t exist. Only that it is going to be really fun to figure out what it is when a lot of people think they have it.

All of those symptoms seem like they could be stress induced to me at any rate. If you find any reviewed studies let me know.

Personally I find it odd how confidently you are in your assumptions in an area you state you are uninformed about. It's harmful to perpetuate the perception that long covid sufferers are simply stressed out.

Also exercise intolerance is definitely not a stress symptom, exercise is often recommended as remedy for stress. Yet this is one of the most common long covid symptoms.

Anytime there is a new disorder it is completely neglected in science as long as possible despite real suffers being denied real treatment and acknowledgement for a very long time.

Thing is, there are lots of things that are completely neglected by science and only some of them are new disorders.

But there is a correlation, that's the point of the article, isn't it? :-)

The article presents zero real evidence to show that Long Covid is more than what would be expected from all the confounding factors as a result of the pandemic more broadly (anxiety, lack of social contact, losing a job, being stuck inside and not exercising for an entire year, constant FUD, psychosomatic symptoms from reading about Long Covid being a big thing, etc.).

I and many others don't doubt that Long Covid is real for some people, but the degree to which it's supposedly presenting (30% of infections claimed in this article) seems really odd without some kind of controlled study. I'd like to see something comparing Long Covid rates in people whose lives were minimally impacted by the pandemic (if such people exist - maybe in countries that didn't lock down?) to those whose lives were significantly impacted.

Long Covid is basically the same as ME/CFS which is also real and existed prior to the pandemic.

That's kind of the point. ME/CFS is poorly understood and likely has many causes not directly stemming from viral illnesses. If it existed prior to Covid in seemingly large numbers, it seems pretty likely that people with pre-existing ME/CFS have now decided it's Long Covid, or that the same poorly defined causes have now impacted more people.

As I’ve stated elsewhere, many LongCovid cohorts are finding that 30% of them have hEDS which is technically considered rare (1/5000) but is actually not rare somewhere between 2% and 1% of general population. Many of those people would have got ME/CFS anyway from some other cause. Also because it’s indistinguishable and there is a stigma attached to ME/CFS many people are claiming to have LongCovid instead. In my view the only difference is the quantity of afflicted people is much higher.

I read one study that compared brains scans of people before and after covid and found brain damage. I don't recall it but maybe you want to dig it up on Google.

I think you mean this one? https://www.nature.com/articles/d41586-022-00503-x

The effect is basically non-existent in people under age 55. And I'd love to see them do a follow-up study since the scans were done fairly soon after infection recovery whereas there's decent evidence that for some people full recovery might take many months.

Sure, it needs to be studied more. But it's not encouraging.

It’s a threshold for a genetic predisposition, once you’re past the threshold it’s a crapshoot for how bad it gets.

Behold the Long Covid Experts of the Hacker News Comment Section! Check your expertise and empiricism at the door; we have enough contrarianism, anecdotes, and spurious correlation to explain everything!

Right, I'll open my digital newsletter then where the information is crystal clear and made by experts who clearly proved they know their shit a few years ago when things went bad.

If you think you know where the experts are at then please tell us so we can test your hypothesis.

I had Covid more than a month ago. While the illness itself was pretty short-lived - a maximum of 102F fever for a couple of days at most - the post-Covid fatigue has been very debilitating.

Even a month later, I just don't feel like there's any real power in my body. Like if I'm walking and want to launch into a sprint, my legs simply don't feel like they have the power to do so.

I've also had brain fog where I forget things and mispronounce words and names.

Weird disease.

Are you vaccinated?

Yes, two doses of the Oxford Covishield vaccine

There is a long covid, long lockdown and long vaccination. These maybe difficult to distinguish when you had all three. Me and my spouse got long vaccination, we went to Costco to get vaccinated with Pfizer and side effects started just after that. More than a year passed and we are still not back to normal.

Posting at 11am ist. Let's see how long until this is flagged

Since when is it weird to have side effects from the vaccination? Not sure why you're acting as the misunderstood wannabe conspiracy theorist here.

Did you test in that time? Could be that you caught the virus before the vaccination did its thing which takes at least a few days (they say two weeks but it's probably a gradient and different for different people).

No, I felt healthy at that time. I had covid 6 months earlier and it was quite awful.

I only glanced through the article but did some searches, it didn't seem to mention anything about which variants or omicron. I have heard that the latest variant (the most infectious but the least severe didn't have a risk or as big of a risk of long covid?) Anyone have data on that?

Long Covid is merely a small part of a broader story of chronic inflammation and how millions and millions of people are suffering from invisible autoimmune consequences of lyme disease, STDs, and long forgotten colds and flus that triggered lifelong inflammatory reactions.

It's the hidden cause of most cancer, a major driver of the obesity epidemic, and is surely subtracting more years of life from more people than the covid pandemic ever did. I'm optimistic that we'll have the diagnostic criteria and awareness in the medical field in the future where we will be able to diagnose, measure, and treat chronic autoimmune inflammation rather than debating whether or not everybody's faking it.

Disclaimer: Some people are definitely faking it. I know it. You know it. Everybody knows it. I'm not disputing that. If we can start understanding it as chronic autoimmune inflammation, for which there can be solid diagnostic criteria, rather than as "long covid" or "chronic lyme disease" or whatever, we can separate the legitimately ill from the disability scammers.

When you talk about hopefully being able to diagnose in the future, is your view that there are large groups of people with chronic inflammation that isn't showing up in any existing inflammatory diagnostic methods like blood tests or various types of imaging?

I believe that the diagnostic methods for testing chronic inflammation can and must be improved, and that chronic inflammation deserves far more R&D investment than it currently receives.

Not talking to you specifically, but sure glad that because a few people are faking it we can ignore a huge human health issue instead!

Wow that sure takes a load off, time to relax and drink some inflammation increasing alcohol!

It's always the elephant in the room with invisible illness.

How do we distinguish between effects of "long covid", "side effects from vaccine" or some other cause?

Also, do we trust these people to tell us the truth?

Well, I was member of the long covid slack group for almost a year before the vaccines were even available. It appears to be caused by the spike protein in some way, most people get it from infection, and some from the vaccine.

Is it possible that folk get recognized "brain fog" from the crazy news blasting + a "severe cold" (for those that survive).

Like, a mild COVID is coupled with fear and isolation and media-bombs.

Could the weeks of mental stress cause a measurable affect (or effect?) for months after?

The news was no more crazy in 2020 than 2019; your hypothesis would suggest that "long COVID" should have already been "going around" before COVID, just without that name. Which — given the stats in the article — it wasn't.

In 2019, the news wasn’t telling everyone they were complicit in killing Grandma, and didn’t have a live grandma-death-counter on every screen.

News prior 2020 were not covering health issues in 90% top articles. It's almost as if you report about terrorism all the time people are suddenly scared of terrorism and they don't feel safe, if you report about deadly virus they somehow feel less healthy over time.

Don't forget the riots and food/toilet paper shortages, that also happened in 2020.

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