COVID-19: Bringing Back Precautions & Restrictions

We recently spoke with our Friday night Shabbat Dinner friends of 40 years and cancelled our dinner plans because of the aggressive resurgence of the COVID-19 Delta Pandemic. I remember our last dinner eating outside in early February 2020 on a beautiful evening wondering if we should all be together one last time before suspending our weekly meals together. We were joined by a physician friend and his wife visiting from Cleveland and they were poking fun at my concerns and over reaction to the “Wuhan Flu.” The proverbial “shit hit the fan” the next week and we went into lockdown.

One year later we were all excited lining up for the Pfizer and Moderna vaccine. We really thought that would be the solution. We really thought our leaders at the federal and state levels would stand up and promote vaccinations. We really expected community leaders, respected by people of color, including church leaders, community activists, respected community members would be out there championing the vaccine, helping at vaccination sites and getting the shot into the arms of the most vulnerable.

Several months ago, when things began to calm down, we started having dinner together again in our homes. The rate of positivity in the spring of 2021 was low and our friends masked and kept distance when indoors shopping for supplies. We felt comfortable enjoying our friends’ company once again outdoors at a few restaurants and in our homes. Then came the Delta surge and with it the relaxation of restrictions.

It reminds me of pictures of the start of the Oklahoma Land Rush. A gun was fired, and everyone rode off to stake their claim. In 2021 they made their plane flight reservations, bought their concert tickets, made their hotel reservations and resumed everything they did prior to the pandemic. They stopped tracking cases, and, in many states, they stopped looking for new genetic mutations and variants of the virus. They forgot to get the vaccine to poorer nations but left the air and ship travel paths open to anyone and everyone. They underestimated the ability of the virus to find a way to survive by changing once inside the bodies of the vaccinated and unvaccinated.

Yes, it’s true that if you are vaccinated and get infected with the virus you most likely will not require inpatient hospitalization and die but according to those who went through this you will feel miserable for quite awhile. Yes, it’s true that you probably can transmit it to others even though the data on that is still new and quite controversial including passing it to unvaccinated children and the immunosuppressed.

To make matters worse, our Governor thinks he’s Bob Barker screaming; “Come on Down” as he invites foreign and out of state residents to come visit our beautiful state, spend money, pick up the virus and bring it home to your locale. I bet Florida is the leading exporter of sickness, death and chronic illness in the world over the last 12 months and no one in our state capitol seems to care.

We are returning to a bunker mentality in our household. No more dinners out. No more social engagements with friends whose activities and travels we are unsure of. If our grandson is sent to his preschool my wife will stop being his nanny because she does not want to risk catching the virus.

As college and NFL football season approach, it is unlikely I will sit in a stadium with thousands of unmasked individuals to see my teams play. The same goes for the theater and for travel. It’s really disheartening and depressing but we will do what is necessary to stay healthy and we hope you will too.

Delta Variant, Breakthrough Infections & What You Need to Consider

As a primary care physician treating older adults fifty years of age and older, I am starting to be involved in the treatment of “breakthrough” COVID-19 cases in vaccinated adults. At the end of June 2021, just prior to the July 4th holiday, we were told to enjoy the summer if we were vaccinated. Many in my patient population took this to mean book flight and cruise reservations and begin travelling. Others started meeting friends to shop again, exercise together in gyms or eat lunch socially indoors.  Experts at the CDC felt it was safe to take off our masks indoors.  Then came the Delta variant – a far more transmissible virus. 

I first read about breakthrough cases in a peer reviewed medical journal discussing the widespread outbreak of COVID-19 in Israeli citizens vaccinated with the Pfizer Vaccine. The message was clear, if vaccinated, you can still get the viral infection with the Delta variant, but you won’t require hospitalization and you have a minimal chance of dying. 

With that news many of my patients continued resuming their lives and normalizing to pre-pandemic routines without masking or distancing in public areas.  Three weeks ago, our local hospital had no breakthrough cases. Two weeks ago, there were five. All the breakthrough cases in individuals 65- years of age, or older, or with symptoms, are invited to receive the monoclonal antibody treatment which shortens the course of the illness and the severity.   Treatment should be within 10 days of first developing symptoms. The cases are so numerous this week that there is a wait of days to get treated.

In discussing the breakthrough cases with my ill patients, they all feel miserable.  They are exhausted, coughing, some febrile with high fevers and severe joint and muscle aches. Some have lost their sense of taste and smell. They say the monoclonal antibodies help, but a week later most of my patients are too weak and tired to do much beyond their necessary activities of daily living. They call daily asking how much longer this will last.  My answer is, “I just do not know.”

I also do not know If their viral load was high enough to transmit the disease to the unvaccinated, the immunosuppressed vulnerable vaccinated patients or even other vaccinated individuals.  The experts are not sure either. Will these vaccinated breakthrough patients become “long haulers” with chronic symptoms stretching to months post infection?  We don’t know – it’s too soon to tell. 

I am also getting calls from patients who were out socially unmasked with close friends and relatives and have now received a phone call that their friends have the COVID-19 infection, and they were exposed.  These patients need to be tested for the disease a few days after exposure but, with the closure of all the state-run testing sites locally, you are limited to going to your pharmacy or some walk-in clinics for COVID testing. Take my advice, get the nasal PCR test sent to the lab which takes longer than the quick test but produces fewer incorrect results.

What I do know is this is a disease well worth avoiding.  Get vaccinated if you haven’t already done so.  Wear a good N95 or KN95 mask if you must go out in public to an indoor facility, and you have no idea who is vaccinated, and who isn’t, and who might be spreading the disease prior to developing clear cut symptoms.  Yes, this is retreating and taking a step backwards into a bunker mentality.  If you don’t believe me, just ask my COVID-19 breakthrough patients. They will tell you this is more than just a “bad flu.”

Deep Breathing to Lower Blood Pressure

A new breathing device called Resperate is being marketed to slow your breathing rate, stimulate your parasympathetic nervous system and ultimately lower your blood pressure. The device sells for $330 and has been discussed in numerous health letters the last few weeks including the Harvard Health Newsletter.

The sympathetic nervous system controls involuntary functions such as breathing, digestion, heart rate. The parasympathetic division of it can slow your heart rate, dilate blood vessels and ultimately lower your blood pressure. The Resperate device uses sensors on your chest connected to a belt device to create a slow melody for you to listen to and breathe to. You synchronize your breathing to the melody slowing your breathing with prolonged exhalations. The slow breathing stimulates your parasympathetic nervous system slowing your heart rate, dilating blood vessels and lowering your blood pressure.

The device is used four times per week for 10-15 minutes sessions and should lower your diastolic and systolic blood pressure over a few weeks. How much and for how long does the effect work is currently unknown.

Medicare does not yet cover the cost of the device but some private insurers do.  After reading about slow breathing lowering blood pressure I looked for information on breathing techniques to lower your blood pressure without requiring a breathing machine. A website viitalheartandbrain.com offered several options:

Thirty Second Method: Sit in a quiet place and relax. Set a timer for thirty seconds and begin. Take six slow deep breaths through your nose and exhale slowly through your mouth during the 30 second period. Repeat the process as often as you can. This method studied with 20,000 Japanese adults lowered BP.

Equal Breath Length Method: Begin by sitting or lying down in a quiet area and close your eyes. Inhale through your nose counting to 4. Pause and feel the air in your lungs. Exhale thorough your mouth to the count of four. Feel the emptiness of your lungs. Repeat as often as you can

4-7-8 Breathing Technique: Sit in a quiet place. Place the tip of your tongue behind your teeth. Inhale through your nose slowly counting to four. Hold this breath for a count of seven. Exhale through your mouth to a count of eight making a gentle whooshing sound. Repeat four times per session

Diaphragmatic Breathing: Lie flat on your back. Place a pillow under your neck and bend your knees up. Place one hand on your chest and one under your rib cage (diaphragm). Inhale slowly through your nose and watch the hand placed under your rib cage rise while the hand on your chest remains still. Exhale through your pursed lips while watching the hand under your rib cage descend and the hand on your chest remaining still. Repeat the process several times.

Give these relaxation techniques and slow breathing techniques an opportunity to relieve your stress and lower your BP and heart rate. In a previous post I discussed tea both green and regular tea lowering blood pressure. Try a cup after the breathing exercises for further relaxation. If tea isn’t your drink, then consider unsalted tomato juice, beet juice, prune juice, pomegranate juice or skim milk. These drinks all had a similar blood pressure lowering effect.

The COVID-19 Pandemic Continues Due to Citizen Dysfunction

Last night on the national news coverage of the Sars 2 Coronavirus Pandemic a major story dealt with the large number of children infected with the Delta variant of the virus and the severity of their illness. These children are too young to receive the vaccine.

At best, Pfizer and Moderna hope to have approval to start vaccinating young children by the end of September. These children are dependent on their parents, teachers and counselors keeping them masked, keeping them distanced and keeping them safe. This story dealt with an outbreak in Missouri and Mississippi with 10 youngsters currently on life support systems.

It is a dilemma for parents, especially working parents, about what activities to allow their children to engage in. With previous COVID-19 surges and outbreaks, experts have discussed how mild the illness is in children and how infrequently long-term and life-threatening complications occur. They stress the need for children this age to socialize and go to school and camp but that was prior to the Delta variant and other mutations and variants becoming the dominant source of infection in the USA. It is hard to tell whether the news coverage is sensationalized to promote viewership or is the Delta variant a threat to young unvaccinated children different and more severe than it was 90 days ago?

It’s time for our federal government to take a hard line with health care workers and health care facilities. All employees without a valid health reason for being vaccinated must be vaccinated or face termination. This would include hospitals, outpatient facilities, senior centers, childcare centers, etc. If the result is the facility is understaffed resulting in delays in elective profitable procedures, then so be it until the pandemic is controlled!

Commercial air traffic from regions of the country and world with low vaccination rates and vaccine hesitancy battling large outbreaks of COVID-19 should be halted until their outbreaks are under control. Vaccine passports should be encouraged – not legislated against. When an individual’s actions and decisions threaten others around them by increasing the likelihood of spread of a disease, and its accompanying economic devastation, then the issue is not about loss of freedom. It is about public health and the governments’ sworn duty to protect its citizens.

It’s time to end this Pandemic and the way to achieve that is through mandatory vaccination.

Aerobic Training Helps Blood Pressure Medications Do Their Job

We are always looking for ways to stay healthy with less medicine.  Miguel Ramirez-Jiminez, PhD of the  University of Castilla-La Mancha, Toledo, Spain presented a paper to the American College of Sports Medicine recently week and addressed this topic.

His group looked at 36 obese and overweight adults who normally did less than 120-minutes of physical activity per week. Ages ranged from 53 – 65 years with 22% postmenopausal women. They had all been taking blood pressure medications for at least eight years and all met the criteria for having the metabolic syndrome which includes hypertension, elevated blood glucose, elevated triglycerides and a large waist.

The group was randomly divided into a placebo group whose medication was stopped or a trial group who continued their antihypertensive medications for the next three days. All participants then underwent 24-hour ambulatory blood pressure monitoring. All the participants were then entered into a four-month cycling program three times a week. 

After completing the four months of cycling training the placebo group again did not receive their medications for three days while the trial group did.  Twenty-four-hour ambulatory blood pressure was then checked in both groups.

The group exercising plus taking their medications saw an average drop in blood pressure of 3-5 mm Hg in addition to the 5mm Hg noted just from the medication’s pre-exercise training. When the exercise program stopped, the extra drop in blood pressure additionally dropped. There is a phenomenon known as “post exercise hypotension” that can reduce your blood pressure for up to 24 hours after training. This is the reason experts advise 3-5 exercise sessions per week.  

The study also revealed that if you exercise aggressively, and hope to permanently stop your blood pressure medications, your pressure usually rises above acceptable levels.  Exercise is not a substitute for prescribed blood pressure medicines. The article can be found at www.medscape.com  

Eggs Are Safe & Delicious

A few years ago, while visiting my pug’s veterinarian to try and find a way to get the dog to eat while undergoing radiation therapy, he suggested, “Why don’t you scramble him some eggs? It’s a great protein source and doesn’t contribute to cardiovascular disease in canines.” I have to admit I was a bit jealous since I was avoiding eggs, using egg whites and Egg Beaters instead. Two recent studies suggest eggs are safe for humans too.,

The American Journal of Medicine, in the January 2021 edition, published a research paper by C. Krittanwong, MD and associates which looked at 23 prospective studies covering a median of 12.8 years and 1,415,839 patients. There were 157,324 cardiovascular events during the study period. “Compared with the consumption of no egg or 1 egg per day, higher consumption was not associated with significantly increased risk of cardiovascular disease events. Higher egg consumption (>1 egg per day) was associated with a significantly decreased risk of coronary artery disease compared to no egg or one egg per day.

A study with similar results was published in the March 2020 edition of the British Medical Journal in a study involving 14,806 patients over 32 years. “Moderate egg consumption is not associated with increased cardiovascular risk overall.”

The message is clear, eggs are a fine source of protein in moderation.

Nonsteroidal Anti-inflammatory Drugs Can Injure Your Kidneys

When I awaken and first get out of bed, I feel my seventy-one years of age.  Decades of weight bearing exercise including running, jogging and walking, in addition to basketball and tennis on hard surfaces, has contributed to wear and tear arthritic discomfort.  I think all the time about popping naproxen, ibuprofen or some other medicine for pain but the risk of an adverse event results in me sucking it up and working through it. 

These wonderful pain medications work by inhibiting prostaglandins involved in the inflammatory response. One of those prostaglandins also keeps the coronary arteries open. The NSAIDS can inhibit the mucous covering of the stomach leading to stomach inflammation and bleeding. 

As a physician caring for senior adults these incredible pain killers can injure the kidneys. By the time we reach 70 years of age most of us have naturally lost 70% of our functioning kidney cells. We do very well with the remaining 25% if we do not stress the kidney asking it to call on reserves it no longer possesses.

A study on the kidney effects of these drugs was published in the Clinical Journal of the American Society of Nephrology in April 2021 by physicians working in Hong Kong. They performed a retrospective analysis of kidney function in almost 2 million Chinese individuals in Hong Kong – all over 18 and with normal kidney function. The study looked at those individuals with a prescription for a NSAID for a minimum of 28 days and found a marked decrease in their Glomerular Filtration Rate (GFR) and a 94% increased risk of a decline of GFR of 30% or greater.

The study looked at ibuprofen, celecoxib, diclofenac, indomethacin, naproxen, piroxicam, sulindac and mefenamic acid. The average patient was 55 years old and 53% were women.  Their results showed that ibuprofen was the least likely to lower GFR indicating kidney injury but even it conferred a risk of 12% on GFR declining to less than 60%.

The findings of this study reinforce what we already know. A steady diet of NSAIDs will injure your kidneys.  An occasional dosage is probably still safe if you take it with food in your stomach and remain well hydrated.

We live in a society where physical exercise and activity are encouraged for health.  Long-term activity will lead to morning stiffness and aches and pains. Traditional opioid pain medications are addictive and clearly not the answer. NSAIDs were hoped to be safer but apparently not so on a long-term steady basis.

Sugary Drinks & Increased Colon Cancer

The Nurses Health Study II followed 95,464 nurses’ health from 1991- 2015. Principal researcher Yin Cao, ScD, MPH, of Washington University in St. Louis and co-researchers found that those women consuming two sugar sweetened beverages a day in adulthood had more than double the early onset colorectal cancer risk as those consuming less than one serving a week. The risk rose by 16% with each additional serving per day.

In adolescents aged 13-18, each serving per day increment was accompanied by a 32 % higher risk of early onset colorectal cancer. As adolescents reach adulthood, replacing these sugar sweetened beverages with artificially sweetened beverages, coffee or milk was associated with a 17-36% lower risk.

The diagnosis of colorectal cancer in those born around 1990, and risk of developing it, is twice as much risk of developing colon cancer and four times the risk of developing rectal cancer as in adults born around 1950. Cao and associates offered several theoretical reasons for the findings including the use of fructose corn syrup as a sweetener instead of real sugar. Fructose corn syrup is known to make changes to the intestinal wall making it more susceptible to carcinogens. And, it has been shown to cause intestinal tumors in mice.

The message is clear. Obstetricians, family practitioners, pediatricians and internists need to start asking about sugar sweetened beverages in our patient histories. Screening for colon and rectal cancer at a younger age with fecal globulin tests, Cologuard fecal genetic testing and fiber optic exams in a younger group is essential. Most importantly, we must educate teenagers and young adults about the dangers of these sugar sweetened beverages so they don’t give them to their friends and eventually their own children.

New Device Helps Stroke Victims with Hand Function Difficulties

Stroke victims often lose function of a hand. The road back to recovery involves months of physical therapy and work.

Last month the FDA approved the Neurolutions IpsiHand Upper Extremity Rehabilitation System for survivors of stroke trying to regain hand, wrist or arm function.  The system uses EEG electrodes to record your brain activity and then uses these messages to move an electronic hand brace according to the intended muscle movement. It essentially delivers your brain’s intended electrical message to the brace to retrain your limb to work.

This is a sophisticated device which will need to be fitted by stroke rehab professionals and then tailored for individual patient needs so it can be successfully used.

Making Sense of the New CDC Guidelines Here in Florida

There were almost 6,000 new cases of Coronavirus illness in Florida yesterday with the positivity rate of those tested being well above 5%. Fewer and fewer people are showing up for testing or to receive vaccine here in the Sunshine State.

The Center for Disease Control (CDC) has issued new less restrictive activity guidelines last week which suggest outdoor activities in low population densities do not require a mask. This makes great sense and I am in complete agreement. They go further and say small indoor gatherings with vaccinated individuals do not require a mask. This makes great scientific sense as well. What they do not want is thousands of individuals, whose vaccination or immunity status is unknown to be packed into a venue indoors or out without being masked. They additionally don’t recommend large private gatherings indoors of individuals whose immune status is unknown. This makes sense to me as well in Florida where the infectious positivity rate remains greater than 5%.

We know vaccinated individuals have a low probability of catching COVID if exposed. If they are unlucky enough to catch it (about 6,000 breakthrough cases are known in the USA with about 150 million already receiving vaccine) there is an even smaller chance of getting sick enough to require hospitalization or dying. They still are not sure if those infected can transmit it to those unvaccinated or those frail, immunosuppressed and vulnerable.

The Governor of Florida and his Attorney General have sued the CDC, NIH and Federal government demanding that they allow cruise ships to begin sailing again from Florida ports. My daughter and grandchildren depend on cruise industry revenue to pay their mortgage, feed and clothe the family and live. The cruise industry has gone to great expense to vaccinate its crews and restrict passenger access to those who can prove they have been vaccinated or prove they are not COVID Positive. They wanted a “vaccine passport” for passengers.

Florida responds by having its Surgeon General, pediatrician friend and political ally of the Governor with zero public health or infectious disease background declare if you are vaccinated you are not required to wear a mask anywhere anytime. The legislature, composed primarily of members of the Governors party, passes legislation forbidding businesses from barring individuals from their business based on their vaccine status. This comes well after they supported the Governor with legislation forbidding local municipalities from enforcing local ordinances requiring masks.

I want the ships to sail so my son-in-law keeps his job! The last thing we need is for Florida politics to permit a ship to go out to sea and become a center of infection, illness and death because Florida elected officials watered down the sensible guidelines the cruise industry developed to begin sailing again safely.

Florida is a gateway state encouraging visitors from Latin and Central America as well as US tourists. Brazil is embroiled in a COVID surge of infection and death . The poverty in Central America and the islands prevent knowing exactly what their status is. I am more concerned about the disease entering and leaving Florida via visitors and no rules than I am concerned with illegal immigrants bringing it in at the Texas and Arizona borders as the media and certain elements of the U S seem to be.

Vaccines have brought us so close to controlling the Pandemic. Why can’t we mask up and be patient for a few weeks more?

In my office we will continue to follow the CDC guidelines. We will wait to see if the relaxed mask recommendations of the CDC, plus the vaccine program, keep the infection rate down. Florida Surgeon General Scott Rivkes’ no mask for the vaccinated anywhere may be interpreted as no masks anywhere for everyone. It will take three to four weeks for the consequences of these announcements to make an impact. If the number of infected decreases, my physician associate and I will sit down and alter our approach based on the science. Until that time, we will require masks in our office!