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POTS, a debilitating heart condition, is linked to COVID and, to a Data taken from Kwan et al.12 and Shaw et al.6. From these results, we can conclude that POTS might be occurring at a higher-than-expected frequency following COVID-19 vaccination, although at an overall rate lower than the frequency of POTS occurring following SARS-CoV-2 infection. Unable to load your collection due to an error, Unable to load your delegates due to an error, Quantitative sudomotor axon reflex test revealed normal response in the forearm (. Kokorelis C, Malone L, Byrne K, Morrow A, Rowe PC. Can cause muscle twitching etc. Sue, Hi Ali We found that most POTS-related diagnoses increased after COVID-19 vaccination to a greater degree than non-POTS-related diagnoses (Fig. 285, 352366 (2019). A number of physicians and patient groups subsequently reached out to us with their experiences and observations, which included increased patient presentations with POTS-like symptoms after COVID-19 vaccination. doi: 10.7759/cureus.31006. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Immunol Res. Ali I was teaching someone else to use the VAERS reports, and I found the information you were seeking. Long COVID has a wide range of symptoms, most of which overlap with symptoms of chronic fatigue and POTS: Breathlessness; Brain fog Of the vaccinees, 62%, 31%, 7.0%, and <0.10% received BNT162b2 (Pfizer-BioNTech), messenger ribonucleic acid (mRNA)-1273 (Moderna), Ad26.COV2.S (Johnson & Johnson), and other COVID-19 vaccines (ChAdOx1-S, CoronaVac, and NVX-CoV2373), respectively. But there are various treatments for POTS that have been effective for many patients.. The study, published online Monday in Nature Cardiovascular Research, expands on sporadic reports of POTS occurring after COVID-19 vaccination by addressing the issue in a large cohort, Kwan told TCTMD. Additionally, POTS odds (1.3, n=4,526) were higher than CPC diagnoses odds (1.2, n=33,590) but lower than those for new POTS diagnoses post-COVID-19. Rev. Early July I started experiencing dizziness, wooziness when I got up to let the dog out. Twenty-nine (93.5%), one (3.2%), and one (3.2%) received Pfizer, Moderna, and Oxford vaccines, respectively. Posted in: Medical Science News | Medical Research News, Tags: B Cell, Cell, Coronavirus, Coronavirus Disease COVID-19, covid-19, Diabetes, Fatigue, Glycoprotein, Heart, Heart Rate, International Classification of Diseases, Mast Cell, Myocarditis, Primary Care, Research, Respiratory, Ribonucleic Acid, SARS, SARS-CoV-2, Severe Acute Respiratory, Severe Acute Respiratory Syndrome, Syndrome, Vaccine. I am not sure where to direct you next, although your cardiologist might have access to current information in their medical journals. Owned and operated by AZoNetwork, 2000-2023. Among the post-SARS-CoV-2 vaccination cohort of 284,592 individuals, the average age was 52.0years, 57.0% were women, and 63% were Whites. Toshniwal Paharia, Pooja Toshniwal Paharia. HR 165 at peak. . News-Medical. We therefore cannot exclude the possibility that the incidence of POTS and POTS-associated diagnoses was overestimated. News-Medical, viewed 04 March 2023, https://www.news-medical.net/news/20221214/What-is-the-relation-between-COVID-19-vaccination-and-new-POTS-related-diagnoses.aspx. I have only had 1 brief flare up. This case report is clinically relevant to better understand the pathophysio 2022 Nov 2;14(11):e31006. Probably had it for years but no dx. My GP put me on Oomneprazole(sp?). Internet Explorer). Slider with three articles shown per slide. Both COVID-19 and Vaccination Raise the Risk of POTS 12, 669010 (2021). In a recent study published in Nature Cardiovascular Research, researchers assessed the association between POTS (postural orthostatic tachycardia syndrome) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and coronavirus disease 2019 (COVID-19) vaccinations. CV Risk Factors or Preexisting CVD: Whats Worse for COVID-19? Nous, Yahoo, faisons partie de la famille de marques Yahoo. Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance. News-Medical.Net provides this medical information service in accordance This suggests that those with symptomatic COVID-19 infection were more likely to develop POTS in general, and that the risk of post-infection POTS is much higher than post-vaccination POTS in this cohort12. Epub 2021 Mar 30. Although POTS was previously recognized as a condition that can develop after SARS-CoV-2. Findings could enable clinicians to develop approaches to reinforce learning, in hopes of hastening further injury. Every flu season, Chung expects to meet new patients as many as half of all patients with POTS previously had a viral or bacterial infection but hes never seen an influx of patients like the one he is seeing now. Postural orthostatic tachycardia syndrome (POTS) has been observed following SARS-CoV-2 infection. Despite the good research around POTS and the evidence around autonomic nerve damage, says Chung, symptoms may be diagnosed as psychological. No relief. A lot of people with chronic fatigue and heart palpitations end up in physiatry clinics because they are debilitated. Clin Auton Res. volume1,pages 11191120 (2022)Cite this article. Although POTS was previously recognized as a condition that can develop after SARS-CoV-2 infection2, data on its potential development after vaccination have been scarce. The site is secure. Instead of getting eyerolls and no help they listened and tested. POTS After COVID The pandemic is already starting to increase awareness around POTS. Whatever side of the covid/vaccine side you are on people actually died . The conditions with the highest post-SARS-CoV-2 vaccination odds of new diagnoses were POTS, dysautonomia, myocarditis, urinary tract infections, and mast cell activation syndrome. sharing sensitive information, make sure youre on a federal We also recognized that by comparing the incidence of POTS-related diagnoses against the incidence of common diagnoses that are not POTS-related (for example, urinary tract infections, gastroesophageal reflux disease and hypertension), we could provide a benchmark that can account for healthcare engagement. Pour en savoir plus sur la faon dont nous utilisons vos donnes personnelles, veuillez consulter notre politique relative la vie prive et notre politique en matire de cookies. Alan C. Kwan, Joseph E. Ebinger, Susan Cheng, Jlia Arany, Victor Bazan, Roger Villuendas, Tetsuya Akaishi, Tamotsu Onodera, Tadashi Ishii, Shigeru Shibata, Kazuo Kobayashi, Hiromi Rakugi, Hannah E. Davis, Lisa McCorkell, Eric J. Topol, Benjamin A. Satterfield, Deepak L. Bhatt & Bernard J. Gersh, Prakash G. Kulkarni, Amul Sakharkar & Tanushree Banerjee, Mateusz Soliski, Agnieszka Pawlak, Jan J. ebrowski, Miguel A. Fernndez-Rojas, Marco A. Luna-Ruiz Esparza, Jonathan Alcntar-Fernndez, Nature Cardiovascular Research Prioritizing facilities located in counties with a high Social Vulnerability Index (SVI) ranking to help increase health equity in COVID-19 vaccination is recommended. Enter long COVID. Potential POTS association with COVID-19 vaccination weaker than with Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. Kwan, A. et al. Continued studies is the the only way to get down to the truth and find treatments that work. 2023 Feb;62(2):92-95. doi: 10.1177/00099228221113609. To obtain The main analysis was repeated with the second vaccine dose as the index study exposure and using cluster bootstrapping. -, Garg RK, Paliwal VK. Res. Kwan told Dador research also showed that the COVID-19 vaccine actually offers substantial protection against POTS. Its less clear how vaccination might be causing POTS, but it could be related to an inflammatory reaction to the spike protein generated by the mRNA or other components of the vaccines, he said. When clinically indicated, usually for substantial or persistent symptoms, medication therapy, such as beta-blockers or ivabradine, were prescribed as tolerated for tachycardic response and midodrine for orthostatic intolerance, they add. Still, their age was marginally higher (average age of 60 years, 47% were women, and 59% were Whites). This is a summary of: Kwan, A. C. et al. Calked my Gastroenterologist for more and he does not like to use it long term. POTS was more likely to be diagnosed than a collection of common primary care diagnoses (OR 1.10; 95% CI 1.03-1.17), although there was a stronger association between vaccination and myocarditis (OR 2.57; 95% CI 1.02-6.77). I tried to get into UTSW- SW Dallas. Study shows COVID-19 rates were likely forty-times higher than CDC estimates during BA.4/BA.5 dominant period in the U.S. New cell-based assay shown to rapidly profile drug resistance to three widely used SARS-CoV-2 main protease inhibiting drugs, Rebounding of COVID-19 symptoms and viral load are common among untreated COVID-19 patients, 25% of COVID-19 patients have lasting reduction in lung function, I have had COVID twice. 1) and was reported in the literature after immunization with Gardasil, a human papillomavirus (HPV) vaccine, in 2010 and, more recently, after the administration of COVID-19 vaccines6,7,8. Blitshteyn, S., Fedorowski, A. Second, it clearly demonstrates that POTS and POTS-associated comorbidities occur more frequently after COVID vaccination than before, and much more frequently than myocarditis, which, despite increasing at a higher rate after vaccination, remains a rare post-vaccination complication. POTS spiked during COVID-19, and patients could wait years to see a Third shot of Moderna is 50mcg. Beta Blockers were discussed but concern it would drop my blood pressure that was normal. For some patients, recovery from acute SARS-CoV-2 infection may involve continuing, recurrent, or new symptoms and clinical findings that persist for weeks, months, or longer. doi: 10.7759/cureus.34236. In the USA, the pre-pandemic prevalence of POTS has been estimated to be in the range of 500,0003,000,000 people, affecting predominantly women of reproductive age and roughly 1 in 100 teenagers3. A case of transient POTS following COVID-19 vaccine. Researchers analyzed data on nearly 300,000 patients from the Cedars-Sinai Health System in Los Angeles County from 2020 to 2022 who had either received at least one dose of a COVID vaccine. In this interview, AZoM speaks to Rohan Thakur, the President of Life Science Mass Spectrometry at Bruker, about what the opportunities of the market are and how Bruker is planning on rising to the challenge. 10 Myths Told by COVID Experts and Now Debunked + More Johns Hopkins' medical concierge services offer complimentary assistance with appointments and travel planning. He did suggest I speak with my cardiologist first(because of possible side effects). Cardiovascular specialist Alan C. Kwan, MD, is an investigator with the Smidt Heart Institute at Cedars-Sinai. Ive had POTS for years. Jerry s. on Twitter: "@washingtonpost How many of those suffering from The current proposed pathology for POTS is an inability to regulate blood volume. 1 cause of, CBS 2 recently interviewed cardiovascular specialist Alan Kwan, MD, an investigator with the Smidt Heart Institute at Cedars-Sinai, about a recent study suggesting that a COVID-19 infection can increase the risk of developing new-onset diabetes by, ABC 7: Syndrome POTS in Rare Cases Can Be Associated With COVID Vaccine, As Well As Virus Itself, ABC 7 recently interviewed Cedars-Sinai cardiovascular specialist. News-Medical. 71, 235248 (2020). Would you like email updates of new search results? Never got vaccinated. Over 20 months post vaccine Dysautonomia and a new acquired auto immune disease. The investigators found that the risk of developing POTS after vaccination is less than five cases per million doses. examined the frequency of new POTS-associated diagnoses POTS, dysautonomia, fatigue, mast cell disorders and EhlersDanlos syndrome before and after COVID-19-vaccination12. No other problems since Pfizer vaccine in March if 2021. A coordinator will follow up to see if Mayo Clinic is right for you. Thank you in advance! I got the vaccine and since have been diagnosed with small fiber neuropathy. Nat. CAS We recognized that pharmaco-epidemiology studies had previously used self-controlled designs, wherein patients serve as their own control3. Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA. COVID Long Haulers Illuminate Overlooked Medical Condition Request free assistance: The program was among the first-of-its-kind in the U.S. in 2020, and medical institutions across the country approached the team for guidance on developing their own ambulatory post-COVID-19 clinics. He and his colleagues note that standard POTS treatment starting with conservative therapies like salt tablets, hydration, structured exercise programs, and compressive stockings have been used to manage these patients. Kwan, who treats POTS patients in a specialized clinic at Cedars-Sinai, said he hopes his research will help connect POTS patients to a specialist for proper care. Occupational therapy has benefited Johns Hopkins patients for more than 100 years and continues to advance for optimal patient care. I have now lost 18 pounds since January. No significant lasting flares for either of us. Researchers suspect that vasomotor denervation causes dilation of the blood vessels, leading to reduced preload to the heart, which triggers an increase in the central sympathetic nervous system response. Europace 19, 12111219 (2017). TCTMD is produced by the Cardiovascular Research Foundation (CRF). . So sweet of you, thanks Sue, I did the same thing and also found this. The COVID-19 pandemic has profoundly affected worldwide health through both acute illness and the long-term effects of infection. Please note that medical information found The likelihood of getting diagnosed with postural orthostatic tachycardia syndrome (POTS) increases after both COVID-19 and vaccination against SARS-CoV-2 infection, although COVID-19 itself poses a greater risk, observational data suggest. Nat. I have now been in bed for about 8 months except for going to the Dr. 5 days latter I try to get to my car to drive to a dr appt and I pass out in the garage for 9 minutes. The risks of POTS after COVID-19 vaccination and SARS-CoV-2 infection: its worth a shot, https://doi.org/10.1038/s44161-022-00180-z. 2022;Epub ahead of print. As of mid July, they cant see me till late August 2023. Living with POTS, a long-hauler symptom of COVID-19 - TODAY Similarly, mechanistic studies investigating POTS following SARS-CoV-2 infection and COVID-19 vaccination are needed to determine causation and delineate the underlying immune-mediated mechanism, possibly involving the spike protein and/or formation of autoantibodies to G-protein-coupled receptors and other targets in the cardiovascular system and beyond13. Experts speculate that COVID-19 antibodies may be targeting the autonomic nervous system, which can cause POTS after an infection. Hi Ali - I looked and I looked - and I failed. Since the introduction of COVID-19 vaccines in the USA in December 2020, vaccination against SARS-CoV-2 has remained the most effective and influential global public health strategy to mitigate the pandemic. In total, 686 individuals received POTS-related diagnoses post-COVID-19 and had similar demographic profiles as the overall SARS-CoV-2 infection population. Res. Hello, I have been advised that those of us with POTS can have autoimmune reactions to the COVID vaccines. COVID-19 Dysautonomia. POTS Syndrome and COVID-19: Connection, Symptoms, Treatment, Outlook Compilation of the top interviews, articles, and news in the last year. The study is based on a large series of approximately 300,000 vaccinated individuals from one geographic territory in the USA (Los Angeles County), with 0.27% new post-vaccination POTS diagnoses compared with 0.18% in the pre-vaccination period, giving an odds ratio of 1.52 for post-vaccination POTS diagnoses12. Even without clear mechanisms to explain the findings, the medical community should be aware of the potential links between COVID-19 and vaccination and POTS, Kwan said. Unauthorized use of these marks is strictly prohibited. Comparing a 90-day period before exposure and a 90-day period after exposure, in fact, the probability of receiving a POTS-associated diagnosis was more than fivefold higher after a bout of COVID-19 than after vaccination (OR 5.35; 95% CI 5.05-5.68), according to researchers led by Alan Kwan, MD (Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA). Thank you! while also discussing the various products Sartorius produces in order to aid in this. SARS-CoV-2 vaccinations elicit immune responses to the SARS-CoV-2 S (spike) glycoprotein. Potential POTS association with COVID-19 vaccination weaker than with COVID-19 infection. shows that anti-SARS-CoV-2 vaccination can increase the incidence of POTS, although at a much lower frequency than the viral infection itself, and indicates the need to study the link between this dysfunction of the autonomic nervous system and the SARS-CoV-2 spike protein. Elvira Forte, Associate Editor, Nature Cardiovascular Research. 9, 43 (2020). We avoided Moderna which has 100mcg of mRNA for shots 1 and 2, while Pizer had 30. Tran, V-T., et al. Alan C. Kwan, Joseph E. Ebinger, Susan Cheng, Jlia Arany, Victor Bazan, Roger Villuendas, Tetsuya Akaishi, Tamotsu Onodera, Tadashi Ishii, Shigeru Shibata, Kazuo Kobayashi, Hiromi Rakugi, Anna Irene Vedel Srensen, Lampros Spiliopoulos, Anders Hviid, Hannah E. Davis, Lisa McCorkell, Eric J. Topol, Benjamin A. Satterfield, Deepak L. Bhatt & Bernard J. Gersh, Mateusz Soliski, Agnieszka Pawlak, Jan J. ebrowski, Nature Cardiovascular Research The authors noted that only 25 new cases of myocarditis, the best-characterized COVID-19 vaccine adverse event, occurred in the cohort, 7 before vaccination and 18 after. Current POTS reported: 66 VAERS Events, 69 to ER, 33 Hospitalized, 4 deaths. Correspondence to ISSN 2731-0590 (online). 2023 Cedars-Sinai. Google Scholar. History of POTS: 610 VAERS Events, 148 to ER, 29 Hospitalized. Side effects and immune reactivity would naturally be worse with Moderna. I appreciate reading this. Increasing COVID-19 Vaccination upon Discharge Blitshteyn, S. Eur. Thus, we examined the extent to which new diagnoses of POTS are increased following COVID-19 vaccination in our health system, a large quaternary care system in Los Angeles. But the condition isn't well understood, and many patients are dismissed as having anxiety, delaying diagnosis. Coll. Officials decided to keep the current rules in place until that date to give health care facilities and local public health agencies time to prepare for the change and adjust safety policies. Cardiovasc. Please use one of the following formats to cite this article in your essay, paper or report: Toshniwal Paharia, Pooja Toshniwal Paharia. 2021;12:624968. doi: 10.3389/fneur.2021.624968. These scenarios include patients who begin having POTS symptoms during the acute phase of COVID-19, and patients who dont present with POTS symptoms until weeks after the acute phase. As POTS is a frequently under-recognized condition that can cause substantial debility in affected patients4, greater understanding of POTS in general is required to improve overall awareness and rates of appropriate diagnosis and treatment. The https:// ensures that you are connecting to the Complete your request online or contact us by phone. Two sequencesymmetry analyses were performed with different retrospective cohorts of individuals who received COVID-19 vaccinations and those with COVID-19 history. Vous pouvez modifier vos choix tout moment en cliquant sur le lien Tableau de bord sur la vie prive prsent sur nos sites et dans nos applications. Get the facts about COVID-19 vaccines - Mayo Clinic Effect of age and gender on sudomotor and cardiovagal function and blood pressure response to tilt in normal subjects. Accumulating all POTS-associated diagnoses in one group gave slightly lower odds. I will not be getting any further booster shots. As COVID-19 vaccines will continue to be necessary for the foreseeable future, pharmacovigilance regarding off-target effects will improve our ability to engage patients in a balanced discussion on the relative benefits versus the risks of vaccination. He also aims to uncover if there is something about the condition that makes people more susceptible to developing POTS, including with regard to the diseases effect on autoantibodies or on the sympathetic nervous system. Vaccination Still Best Option for Protection, Asked about potential mechanisms to explain the findings, Kwan said POTS is typically thought of as an issue with the autonomic nervous system, which maybe damaged by COVID-19. "There does appear to be a small signal associating COVID-19 vaccines with POTS occurring after the vaccine . 8600 Rockville Pike Little-Known Illnesses Turning Up in Covid Long-Haulers https://doi.org/10.1038/s44161-022-00180-z, DOI: https://doi.org/10.1038/s44161-022-00180-z. The investigators found that the risk of developing POTS after vaccination is less than five cases per million doses. Vaccine FAILURE, on every level. | Page 194 | irate4x4 The OR value of post-vaccination diagnoses of POTS-associated conditions vs. CPC conditions was 1.1, with comparable results obtained by clustered bootstrapping. Individuals with POTS-related diagnoses (n=1,924) post-SARS-CoV-2 vaccination had similar vaccination and demographic profiles as the vaccinated population. I suggest that any of us with these issues consider sticking with Pfizer. Can the gut microbiota and metabolome explain variation in anti-SARS-CoV-2 vaccination responses in immunosuppressed IBD patients? What is the relation between COVID-19 vaccination and new POTS-related diagnoses?. Bisaccia, G. et al. Disclaimer. Get the most important science stories of the day, free in your inbox. My POTS is getting controllable. Went to an electrophysiologist who confirmed I have POTS and said it is directly related to my GI problems which were definitely a result of the Covid 19 virus. Sheldon, R. S. et al. POTS is a clinical syndrome that manifests with orthostatic intolerance and postural tachycardia1. Vaccines (Basel). Sign up for the Nature Briefing newsletter what matters in science, free to your inbox daily. Muscle Nerve. COVID-19 vaccine injured doctors are finally starting to speak upand We hope that our results feed back to the community in a positive way and spur further research to solve the issues presented to the medical community as a whole by the COVID-19 pandemic. And in a broader context, its important to raise awareness about POTS itself within cardiology because there are treatments, there are ways to help these patients feel better, Kwan said. Most patients have trouble getting a diagnosis, which can take years, he said. (2022, December 14). 2022, Kwan, A. C. We hope that our results can offer an evidence-based context of understanding for patients who experience POTS-like symptoms after COVID-19 vaccination, as well as their healthcare providers. The majority of patients in the Post-COVID-19 POTS clinic seem to have had very mild cases of COVID-19, and some were asymptomatic cases, he says. Chen, G. et al. Once diagnosed, many patients face . J. Intern. Large Cohort Study Finds Possible Association Between Postural Sorry, I misunderstood your concern. I was diagnosed 9 months ago, 4 hours away from my house, at a large university hospital. Chanlder, R. E. et al. Epub 2022 Jul 26. FOIA A.C.K. Please enable it to take advantage of the complete set of features! This site complies with the HONcode standard for trustworthy health information: verify here. I will look further to see if there is a way to tease this out of the VAERS data. On the contrary, two POTS-related conditions, fatigue and EDS (Ehler-Danlos syndrome), showed lower odds. In patients with hyperadrenergic variants, clonidine was given or considered, Kwan et al note. In the SARS-CoV-2 population, for most conditions studied, post-infection rates were higher than post-vaccination rates (Fig. The risks of POTS after COVID-19 vaccination and SARS-CoV-2 infection: its worth a shot. I had Covid 19 in January 2022. government site. Came back the next day and said I might have POTS. Rare Side Effects of COVID Vaccines Myocarditis and the COVID-19 Vaccines. COVID-19 infection, vaccine linked to POTS heart disorder, study suggests Concerning POTS-related diagnoses, post-COVID-19 risks were 5.4-fold greater compared to the risks post-SARS-CoV-2 vaccinations. We cannot guarantee that the information provided will be timely and accurate or that physicians on the list are accepting new patients, or that they accept insurance. Accordingly, patients studied received clinical care that was reviewed to be consistent with guidelines recommendations, and referral to local experts in managing POTS was often pursued in cases that warranted consideration for more specialized evaluation and therapies., Todd Neale is the Associate News Editorfor TCTMD and a Senior Medical Journalist. I was very sick for about 4 months. Svetlana Blitshteyn. Kwan AC, Ebinger JE, Wei J, et al. I looked and I looked and I failed. Julie Wu. Stay up-to-date with breaking news, conference slides, and topical videos covering the spectrum of CVD. Find out about the different types of COVID-19 vaccines, how they work, the possible side effects, and the benefits for you and your . POTS patients- vaccine or no vaccine? | Page 2 | Mayo Clinic Connect By midday I did not have these symptoms. It doesnt quite bring it to the point of being able to tell an individual patient, This is what your specific odds of POTS are after a vaccination, but we believe this essentially brings some validity to the observation that POTS may occur after vaccination, though notably at a significantly lower rate than after [COVID-19 itself].. Most (62%) received the shot from Pfizer/BioNTech, 31% the one from Moderna, 7% the Janssen vaccine from Johnson & Johnson, and less than 0.1% a mix of other shots. Second, the general awareness and diagnostic vigilance of POTS and access to adequate diagnostic modalities are decisive for POTS incidence reliability. Postural orthostatic tachycardia syndrome (POTS) and other - PubMed Connect with thousands of patients and caregivers for support, practical information, and answers. Epub 2022 Jul 23. exploring the link between the COVID-19 vaccine and a debilitating heart condition known as postural orthostatic tachycardia syndrome (POTS). By continuing to browse this site you agree to our use of cookies. 2021;69:205211. Google Scholar. Covid-19 vaccination can curb the effect of long COVID on patients By December 2020, the program had received a flood of referrals for patients exhibiting symptoms similar to those of POTS, after Chungs colleagues from comparable programs across the country were reporting that they, too, were receiving a large number of patient referrals dealing with POTS-like symptoms. Given the complex design of our study, which was intended to account for potentially important confounders, the estimated risks are reported in relative terms; that is, after exposure relative to before exposure or POTS-related diagnoses relative to non-POTS-related diagnoses.