COVID-19, Phase III Reopening & Influenza Vaccine

Watched the Presidential debate last evening which resembled a sequel to the movie Animal House with Chris Wallace of Fox News doing his best Dean Wermer impression. The moderator had the right and duty to allow each participant to answer the question in their allotted time and could have turned off the microphone of the offending participant but chose not to. The American Public was cheated by his ineffective leadership.

This occurred on the same day columnist Fabio Santiago, of the Miami Herald accused Florida Governor Ron DeSantis of threatening public safety by opening the state completely before the state has met any of the recommended safety benchmark goals of the CDC.

An article in the Jerusalem Times forwarded to me discussed a large series of Israeli COVID-19 survivors who developed antibodies to COVID-19 and then became ill with it within the three-month recovery period. Their presumed second round of COVID was far more serious and complicated than the first bout raising questions about whether they ever cleared the disease or not. It underscores the tremendous lack of knowledge we have about this pathogen.

I understand the frustration of small business owners, stay at home working parents who now have to supervise their kid’s education while working remotely and; the unemployed who cannot break through the inefficient computer systems to obtain the benefits they deserve and need to survive. In my mind these issues just highlight the need for a national program to fight the spread of COVID-19, protect the most vulnerable, support those out of work as well as the businesses who need to pay rent and salaries to survive while we wait for a vaccine or medication. To say that its fine to come to Florida, and safe for tourism purposes, is a lie exposing Floridians to the COVID-19 they bring from their homes and exposing their friends and neighbors to the COVID-19 of the Sunshine State.

Which brings me to the influenza vaccine. Do yourself a favor and get your influenza shot. No, the vaccine does not make you more susceptible to coronavirus as one Midwest couple read on a disinformation website. No, it is not 100% effective, but it will reduce the intensity and the severity of the disease if you are exposed to it.

We are currently experimenting with the safest way to immunize our patient population. The tenants in our building, with the support of building ownership and management, did not enforce the indoor mask mandate when we were in Stages I and II. Now the younger, more casual tenants, are even less likely to observe social distancing CDC guidelines. We are experimenting with three different ways of administering the vaccine on site, which I believe is still far safer than the exposure in a commercial pharmacy.

My advice to my patients remains:

1. Stay out of restaurants and country club dining rooms despite the efforts of management and the board to keep these places spotless. CDC studies show restaurant attendance is associated with catching the disease.

2. Stay out of gyms – both public gyms and gyms in your apartment complex. Take walks outside. Use a chlorine pool. Walk at the beach. Bicycle ride.

3. Stay out of hair salons and nail salons.

4. Cook and prepare your own food. Restaurant workers, who must come to work to get paid, are often asymptomatic spreaders of COVID.

5. Suppress the urge to use commercial air travel to visit your relatives. Airport terminals and inconsiderate and uncaring passengers are your biggest threat. If you do go, you will need to quarantine for 14 days before you see your vulnerable loved ones or; wait at least four days after arriving before being tested for the COVID-19 antigen indicating an ongoing infection.

Stay home. Wear masks when in public. Wash your hands frequently and stay 12 feet or more away from others. That is our best option for staying healthy and alive until a treatment or vaccine is available. Get your flu shot. Listen to science not politicians.

A Perfect Storm Brewing: Flu Season Plus A COVID-19 Resurgence

I was asked by a colleague what I thought influenza seasonal infections coupled with a predicted second wave of COVID-19 would look like locally? Influenza A arrives locally around Thanksgiving and peaks the last two weeks in January and first two weeks in February. I suspect it is fueled by seasonal visitors coming to Florida bringing the disease from their home locales. We see a low level of influenza B year- round in our pediatric population.

A full-page ad appeared in all Florida newspapers today sponsored by every major health system in the state including Baptist, Tenet, HCA, Cleveland Clinic, Broward Health, Jackson, U M Health, Memorial Health and others. It stressed wearing masks, social distancing and frequent hand washing.

If you get sick with mild symptoms, they encourage remote telehealth care. If you have moderate symptoms, they suggest going to their urgent care facilities. For severe symptoms call 911 or go to the ER. At no time did they suggest calling one of their employed physician offices or visiting your private doctor which is all consistent with CDC recommendations. Private independent and employed physicians just don’t have the ventilation systems, sanitizing systems, personal protective equipment or trained staff to see potential COVID patients in their offices. If a patient is positive, or a staff member converts, what is their responsibility to the next patient or to the other tenants of their building? Is a 14-day quarantine in order?

Much depends on unknown factors. How effective will this year’s flu shot be? In my area, the chain pharmacies already received their supply of influenza vaccine and have shamelessly been pushing it on customers since July. Scientific research shows that in senior citizens the flu shot immunity begins to subside 90 days after you receive the shot. Given that, if your pharmacy tech gives you the flu shot in September, then how much immunity will you have by the time the flu arrives around Thanksgiving?

Quick, accurate and inexpensive testing availability for flu and COVID 19 is an important factor as well. We have had a quick influenza test for years requiring a nasopharyngeal swab. A similar test for COVID -19 has just been released by Abbott Labs and received Emergency Utilization Authorization from the FDA. That means Abbot Labs researchers say it works and the FDA takes them at their word. This test, called “a game changer” by many, will be available in October.

When $15 per hour medical assistants start performing the test rapidly, in volume, I hope the accuracy results are similar to Abbots claims. Our health and lives depend on that. At the same time a finger stick blood drop test is heading to market to quickly detect flu and COVID -19 on the same test card. Finnish scientists and Israeli researchers have quick breathalyzer tests coming soon as well. I hope they work and get here soon. I will test everyone at the door as will restaurants, theaters, sports arenas and most businesses.

All of this information really skirts the issue. With no treatment and vaccines available yet, I expect this flu COVID-19 season to be a human health disaster. With no national plan in place and no close coordination with state and local elected and public health officials, I see the fall and winter as a time of continued disease surges and deaths while the political influence on disease treatment supersedes scientific research and public health realities. Without a coordinated program of PPE and medication distribution, coordination of testing availability and results with contact tracing and specific shutdowns of hot spots without challenges related to loss of freedoms the outlook is grim.

Protecting senior facilities without a coordinated program and funding for it will not work for residents or employees. Opening schools and day care without similar precautions, training and funding for materials and tracing will lead to hotspots as well. There are members of the student population such as special needs children who need to return too, in person, learning safely and creatively. Others need to learn remotely or be given a chance to catch up later when safe return to in person learning is possible.

Without a plan to assist renters, homeowners, landlords, small business owners, farmers, restaurateurs, etc.; any shutdown for disease will be met with overwhelming resistance. I see a bleak and dangerous health picture developing in the fall/winter creating a perfect influenza/COVID storm.  I hope I am wrong but, if right, the disease surge will overwhelm ERs and hospitals.

More Steps Per Day Associated with Milder Irritable Bowel Symptoms

The association between emotions, the brain and the intestines has always been of great interest to me. As a young medical student facing the stress of having to succeed academically, I developed irritable bowel syndrome. I have written previously about my encounters with IBS and discussed how my symptoms diminished as my coping skills improved. I have always loved to aerobically exercise for stress reduction but never really appreciated how that activity may have diminished my irritable bowel discomfort.

Toyohiro Hamaguchi, PhD, of the School of Health Sciences at Saitama Prefectural University reported on a study discussed in Plos One showing that with increased walking irritable bowel symptoms seemed to diminish. The study looked at 100 students, 78 of whom were women with a mean age of 20 years old. They were recruited for the study based on their diagnosis of irritable bowel syndrome between the years 2015-2018.

The participants were not obese based on Body Mass Index (BMI). They answered a GSRS (Gastrointestinal Symptom Rating Scale) document at the start of the study and again while participating in the study. The rating scale evaluates the severity of abdominal pain, indigestion, reflux, diarrhea and constipation. Walking patterns were then tracked using a pedometer.

They found that with increasing daily steps, the severity of the symptoms markedly decreased based on the GSRS rating scale. Based on their findings, the severity of symptoms decreases by 50% when increasing your daily step count from 4000 steps to greater than 9500.

Dr. Hamaguchi explained that “mild physical activity helps clear intestinal gas and reduces bloating. Thirty minutes of daily walking is recommended for increasing colon transit time in adults with chronic constipation. Recent research has found that inflammatory biomarkers were reduced after 24 weeks of moderate -intensity aerobic exercise”.

This is one more study showing that low to moderate intensity exercise, on a regular basis, allows you to feel better. During this Covid19 Pandemic the stress level for all is so much higher. Take a 30-minute walk at your own pace, maintaining social distancing and with a mask available if someone starts to get close . It will reduce your stress and improve your health!

I’m Dealing With the Silent Fear of Infection

I saw a patient yesterday with a cough and intermittent fevers. I believe based on her history she is a low risk for COVID-19 disease. One must treat all patients as if they have COVID-19 until proven otherwise so I wore a double mask including a N95 respirator mask, a face shield and gloves.  The face shield limits your peripheral vision and fogs up easily as do your glasses. I could feel and hear my heart pounding and racing as I got close to the patient for an exam and the sweat pouring down my forehead into my eyes stinging and burning did not help.

The visit was uneventful.  I maintained my sanitary protective field, removed my protective gear afterward, as per protocol, and washed up extensively. The weather outside was stormy with torrential rain, thunder, lightening, high winds, flooding and some hail – adding to the apocalyptic climate that now exists in the patient care arena.

Yes, I began to relax some as the visit progressed but there was always this uneasiness wondering if I careful enough?   It reminded me of 1979 before we knew what the HIV virus was and what AIDS was. I was seeing a brand-new patient in the intensive care unit of Boca Raton Community Hospital. He was the editor of an internationally known tabloid published just north of Boca Raton.

Married to a French national, he had left New York to come oversee this paper and had taken ill.   I had seen many cases of this immune system destroying disease during my residency in Miami at Jackson Memorial Hospital. This obese gentleman struggling to breath had none of the risk factors for this new disease. He denied drug use or intravenous drug use. He denied being in relations with other men.  How could he possibly have this horrible new disease with none of the risk factors. His wife was testy when I questioned her alone about private and personal areas of their relationship all necessary to determine her husband’s risk of having this immune destroying disease. She was vigorous in her defense of his very ordinary, very traditional behavior.

In those days we rarely wore gloves to draw blood. It was unheard of. We rarely put on gloves to start an IV line. With this disease things were different.  I was in a paper gown, gloves, face mask, goggles and face shield as was the young pulmonary expert I was working with.  The confinement of the personal protective gear and the warmth and fogginess of your vision led to a rapid pounding heartbeat and the same sweating I was experiencing 40 years later. It calmed down some as we got into the procedure.  I was wearing scrubs then which never left the hospital locker room. I am wearing scrubs now which never leave my office. I come to work in pants, shirt and tie and change into special scrubs plus sneakers that are kept here. At the end of the day the scrubs go into a laundry bin. 

As a physician who cares for patients, I need to take this risk. As a human being over 60 years of age I realize I am high risk for developing complications and death if I catch the COVID-19 virus. I am most afraid of transmitting it to my wife, my children, my grandchildren unknowingly. I hope they have the courage to put up with my risk taking.

Anti-inflammatory Colchicine Exhibits Major Benefits After a Heart Attack

Jean-Claude Tardif, M.D., of the Montreal Heart Institute in Canada presented a paper at the Scientific Session of the American Heart Association last week demonstrating the benefits of using colchicine to reduce inflammation after patients have a heart attack.  In a study called COLCOT, performed at 167 different health centers in multiple countries, almost 5000 patients were double-blinded and either given 0.5 mg of colchicine a day or a placebo.

All of these patients received standard post heart attack cardiac care including cholesterol lowering medicine, anti-platelet agents and blood pressure medicines in addition to the study drugs.  The patients were on average 60 years old, 80 % were overweight men with 93% having undergone angioplasty as a treatment of their cardiac disease.  Ninety-nine percent were taking aspirin, 98% were taking an additional anti-platelet agent, 99% were on a statin to control cholesterol and 89% on a beta-blocker.

The doctors conducting the study recognized that acute heart attack patients are demonstrating a high degree of inflammation at that time and are at increased risk for another heart attack, stroke or acute rehospitalization for an ischemic event.  The addition of colchicine reduced this risk by 34% when used with all the currently recommended post heart attack medications.  A new study, COLCOT 2, is being planned to see the effect of colchicine in preventing coronary ischemic events in diabetics who are at increased risk.

Colchicine is an anti-inflammatory drug originally used to treat gout and inflammation of the sack around the heart known as pericarditis.  It originally was not patented and sold for pennies.  The drug was purchased by a Wall Street investment firm, patented, and now a 30-day supply sells for more than $250.

Influenza Vaccination in Adults

It is time once again to be thinking about taking your flu shot.   A recently published study by the National Foundation for Infectious Diseases (NFID) estimated that only 52% of US adults plan to take the flu shot.  Reasons for not being vaccinated include:

  • I do not believe it works (51%)
  • Concern it would cause an adverse effect (34%)
  • Concern that the vaccine would give them the flu (22%)

Health and Human Services Secretary Alex M. Azar II said, “Each season, flu vaccination prevents several million illnesses, tens of thousands of hospitalizations and thousands of deaths.  Over recent years, on average, flu vaccination has reduced the average adult’s chance of going to the doctor by between 30 – 60%.

A recent study performed by the northern California Kaiser Permanente Group, using seven years of flu season data, shows the immunity from the shot is near perfect for the first six weeks and then begins to wane. They estimate your post-vaccination chance of getting the flu, even if immunized, increases by 16% every 28 days after the shot but is near perfect for the first 42 days.

It is believed the Center for Disease Control (CDC) will recommend in future years that adults receive two flu shots each season. One will be administered at the beginning of the season and one six weeks later.  For the moment, the CDC acknowledges the flu season begins at different times in different regions of the country and suggests you receive your vaccination about two weeks before it arrives.

In South Florida, we typically see the arrival of the Influenza A virus after Thanksgiving. It peaks the last two weeks in January and first two weeks in February. For this reason, we suggest taking the shot later in the fall.

Vaccines are inactivated meaning they are not live and cannot give anyone the flu!

Heartburn, Indigestion & Protein Pump Inhibitors

I have seen multiple adult patients with intractable heartburn, reflux, indigestion and chest pressure all related to food and digestive enzymes kicking back up the esophagus from the stomach through a lax group of muscles known as the lower esophageal sphincter.  All these patients receive a fiber optic upper endoscopy (EGD) at some point and are observed and biopsied to eliminate the possibility of ulcers, cancer, gastric polyps, esophageal cancer, potential esophageal cancer and Helicobacter Pylori bacteria as the cause.

They are all treated with weight control suggestions, avoiding a host of foods, most of which are quite healthy from a cardiovascular standpoint plus limits on alcohol, elimination of tobacco and other indulgences of adults. We ask these patients to wear loose clothing at the waistline, avoid reclining for three hours after eating and take a host of medicines including proton pump inhibitors (PPI) such as Nexium, Protonix, Prilosec.  Drugs like Tagamet, Zantac (H2 Receptor Blockers), Tums, Rolaids are far less effective.

In recent years, numerous articles have appeared in medical journals stating that protein pump inhibitors, when taken regularly, can predispose to increased and early death, pneumonia and dementia.  A large review article from a prominent GI group in Boston, and published in the New England Journal of Medicine, tried to eloquently refute these claims but the doubt about long term safety lingers buoyed by numerous lay periodicals and online internet sites sensationalizing the down sides of these medicines.

To allay the patients fears, doctors and patients work together to try and stop the PPIs and substitute the older standbys like Tagamet and Zantac but they just don’t provide the symptom relief that the PPI’s do. Patient’s face the dilemma of taking the medicine that works best and incurring the potential risks or suffering.

In a recent edition of the journal Gastroenterology, Paul Moayyedi, MB ChB, PhD from McMaster University in Canada followed 17,000 patients for three years with half the group taking PPI’s. Those taking a PPI (Protonix) for three years had no more illness or adverse effects than those taking a placebo.  L. Cohen, MD, a reviewer at Mount Sinai School of Medicine in NY, concluded that the study provided strong evidence of the safety of PPIs for patients taking the drug for three consecutive years.

The controversy will continue. I am sure next week someone will produce data revealing some additional horrible consequences of taking these medications to relieve heartburn. It will ultimately come down to individual decisions about quality of life versus potential risks because the lifestyle changes necessary to control this problem are difficult for human beings to sustain over a long period of time.

Sleep Apnea and Cognitive Impairment

Convincing a patient to undergo a sleep analysis for obstructive sleep apnea is a difficult task. During our history taking session, we ask about excessive snoring, periods of not breathing while asleep, daytime sleepiness and we look at the patient’s body habitus, weight and height. Often, the patient’s spouse or partner has complained about their snoring keeping them up. Most of the time, when I ask about this the response is, “Why go for an evaluation if I am not going to wear that mask anyway?  I have a friend who has a CPAP mask and I am just not going to do that.”

Obstructive sleep apnea and periods of apnea (not breathing) results in the lung blood vessel blood pressure rising.  We call it pulmonary hypertension.  It is different from systemic arterial essential hypertension in that traditional blood pressure medicines do not lower the pulmonary pressures.

If you examine our heart and lung anatomy you realize that the very non-muscular right side of the heart, primarily the right ventricle, pumps blood a short distance to the lungs to exchange gases and removing wasteful gases in exchange for oxygen. That oxygen rich blood returns to the left side of the heart where the very muscular left ventricle pumps it out to the body.

When the body’s systemic blood pressure rises the left side of the heart has to work harder. The muscular left ventricle is much more suited for that task than the right ventricle is suited to pump against pulmonary vessel hypertension.  The result is the right heart fails much sooner than the left side and the treatment options and medications are far less successful.  This explanation to patients is often received, digested and dismissed as hypothetical and down the road.

This week the American Academy of Neurology received a presentation by a group at the Mayo Clinic in Rochester that showed that patients with untreated sleep apnea produced an increased amount of tau protein deposition in the brain. Tau protein deposition is associated with Alzheimer’s disease.  The researchers, led by Diego Z. Carvalho, MD, are not sure if more Tau protein accumulates in brains of people with untreated sleep apnea or if Tau protein accumulation actually leads to sleep apnea?  That research is ongoing.

The lesson is that sleep apnea is something that needs to be diagnosed and treated. I am a fan of referring patients’ to sleep evaluation centers where that is the primary disease state reviewed.

While sleep apnea is one of the abnormalities evaluated, there are many other disorders of sleep that can be recognized and treated to improve patient sleep. At home sleep monitors are available as well but may be limited in diagnosing sleep apnea alone.

If you are determined to have obstructive sleep apnea then treatment choices include weight loss, laser treatment of the uvula, dental appliances to open up your airways, adjustments to your sleep position and many types of facial and nasal CPAP devices.

Most of my patients who try a CPAP mask require 8-12 weeks to adjust to it. Once adjusted to it, their quality of sleep is so good that I rarely have to convince them to keep using it.

Tdap Booster Vaccinations

Several years ago an epidemic of whooping cough (pertussis) was ongoing in affluent areas of California and Arizona. Epidemiologists from the Center for Disease Control (CDC) and National Institute of Health (NIH) descended on those areas to determine the cause of the life threatening illness to very young children.

Much to their surprise, grandparents were inadvertently transmitting it to their new and not completely vaccinated grandchildren. As youngsters, these grandparents took the suggested DPT series of shots believing they were resistant to diphtheria, pertussis and tetanus for life.

Like most things, as we get older, the immune system just doesn’t work as well. The immunity to pertussis waned and adults were catching the adult version of whooping cough in the form of an upper respiratory tract infection with bronchitis. The adult version resembled a run of the mill viral upper respiratory tract infection with a prolonged barking cough. This was just the type of infection which infectious disease experts were suggesting we do not treat with antibiotics and instead let our immune systems fight off independently. Unknown to us was the fact that even after we stopped coughing, if this was in fact adult whooping cough, we could transmit the pertussis bacteria for well over a year after we stopped coughing.

The solution to the problem was to give these adults a booster shot against pertussis when they received their tetanus shot booster. It is recommended that we get a tetanus booster every seven to ten years.

Tdap, produced by Sanofli Pasteur, was the solution and an international campaign of vaccination was begun. The campaign was successful but what do you do seven to ten years later when the next tetanus shot is due? In a study sponsored by the manufacturer, adults 18- 64, were given a second dosage 8-10 years after the first Tdap shot and tolerated it very well. Blood levels for immunogenicity taken 28 days later showed the benefit of the second shot.

The data has been submitted to the CDC and its vaccination Prevention Advisory Panel for consideration for a change in the recommendations on vaccinating adults.

Marijuana, Pain Relief and the Facts

On a daily basis patients of mine come in for office visits complaining of wear and tear injuries, as well as aches and pains, and their methods of dealing with chronic pain. As we all know, aging is a part of the normal life process.

For instance, as we approach 70 years old we typically lose three quarters of our functioning kidney cells (nephrons) but do well with our limited reserve as long as we do not constantly call on that reserve. When we take nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen to relieve pain we are challenging that reserve leading seniors to look for alternatives. Opioids, even when appropriate, have become taboo so alternatives are being searched for.

Medical marijuana has become a very hot topic recently.  It is being heavily marketed as a pain relief alternative in several forms.  However, what little legitimate research has been conducted indicates it is not very good at relieving non cancer related chronic pain.

Not a day goes by when several patients reveal they are using cannabis products obtained out of state for pain relief with no consideration of how it interacts with the medications they are already taking. Recently, strong public relations campaigns for legalizing medical marijuana have led to its legalization in different forms, in various states, even if it doesn’t work. A select group of investors have positioned themselves to make vast sums of money from a product with little documented upside and potentially unknown downsides.

At the same time that medical marijuana enters mainstream medicine there is a similar legislative and marketing push to legalize marijuana for recreational use. Once again, a well-financed lobby of investors is trying to sell the concept of marijuana being less troublesome than legalized tobacco or alcohol. In the last few weeks there have been several articles appearing in reputable medical journals and periodicals such as the Wall Street Journal, New York Times and New Yorker magazine all examining the known results of liberalizing marijuana use in three states.

First of all, today’s marijuana is far stronger and potent than the “love generation’s” weed of the 1960’s with a higher percentage of the hallucinogen THC. To that point, states that have legalized marijuana have seen a tripling of visits to the emergency department for psychotic behavior. Also, violent crime and murders have tripled in many jurisdictions. A growing body of evidence indicates auto accidents have increased as a direct result of marijuana’s use.

Medically speaking, there is little research evaluating marijuana as a drug. Many questions remain.  What is the minimal dosage to create an effect? What is the dosage that can cause medical illness? How does the mechanism of delivery affect the final effects such as smoking versus vaping versus eating the product? Beyond the stoners’ credo of “start low and go slow” there is little data to evaluate the product as a pharmaceutical drug and or how it can interact with other drugs prescribed for you.

I am far from an anti-marijuana critic. I’d just like to know what I’d be getting in to before I consider hallucinating. It seems to me that before we liberalize marijuana use, the product needs to be put through the type of research and scrutiny the old Food and Drug Administration (FDA) put a product through before it was approved for public use.