Driving Up the East Coast on Vacation

The Pandemic resulted in me not taking a vacation for three years. A quick trip by plane to NJ in June for a high school graduation was cancelled when COVID infected the graduate’s immediate family. The party was pushed back to August but a paucity of dog sitters to watch my disabled failing pug while we were gone complicated trip plans. I consulted our vet who just suggested we take the pups with us in the car . My three adult daughters thought my wife and I were crazy for planning this vacation but here seven days later on a wooden deck on a mountain top in Upstate NY enjoying the shade, low humidity and cool breezes.

It’s great to leave Florida by car. No flight cancellations. No lost luggage. My wife and I split the driving and stop every few hours to walk the dogs and use a clean rest room ourselves. We listen to my wife’s radio choices while she drives and vice versa.

I belly laughed up the coast because she loves comedy greats on Spotify. I laughed to comic routines by Jack Carter, Jan Murray, Hennie Youngman, Robert Klein , Robin Williams, Redd Fox and other greats I had not heard in decades. We stay in dog friendly highly recommended chain hotels which are clean, serve a breakfast and have helpful friendly staff.

At stops in Beaufort , South Carolina, Richmond , Virginia and Rockville, Maryland there is no such thing as a corona virus pandemic. We were the only ones wearing masks, eating outdoors exclusively and avoiding crowds indoors. Until we arrived here high in the Catskill Mountains the weather was Florida-like, hot and humid.

On the road I stopped to see my niece, her husband and infant little girl . My niece is a pediatric hematologist, he’s an anesthesiologist and Aria is just a beautiful captivating 18-month-old. I learned how these young docs feel about medicine and how they try and balance both professional and personal responsibilities while my niece learns that being a mom really is the toughest job in the world. I was able to see their new home and the life they are building . It was a rewarding uplifting experience to see those you love happy, healthy and living their dream.

I also got to break bread with my business associate and friend who for fifteen years has directed practice advertising, website improvement, newsletters and blogs. We usually see each other a few times each year but communications have been by phone and Facetime since the pandemic began. Getting together face to face just reaffirmed why I like and respect this gentleman.

We are currently in a farmhouse in Upstate NY, which my daughter and son in law are renovating. It’s breezy, cool, serene and plush outdoors. We are planning our return trip south with overnight stops every five hours.

See you all soon.

COVID-19 Burnout

I was supposed to be visiting the NY Metropolitan area this week to celebrate a family high school graduation. Children and family were traveling from all over the country for this celebration when the parents of the graduate contracted COVID-19. The graduate stayed healthy and attended the ceremony and all post ceremony celebrations. Our family gathering was postponed, and my wife and I stayed home cancelling our flights and hotel reservations. The infected group were all vaccinated months ago and young, healthy and placed on Paxlovid . They are recovering. The fact that all will recover is what is important in a scene played out in homes across the globe all dealing with COVID and family gatherings.

At the same time this was occurring the FDA approved a Pfizer three-shot vaccine and Moderna two-shot vaccine protocol for COVID for children six months to five years old. It provided great joy in my south Miami daughter’s household since her four-year-old son has been attending pre-school and summer camp with no real protection other than a mask. My grandson has been the only child in his class and group wearing a mask indoors and the school psychologist asked my daughter if he could remove it because it was a barrier to playing with the other children.

The vaccine for young kids is not a foolproof shield but at least provided protection against serious illness. The FDA approval was a great comfort to parents hoping to have their kids vaccinated prior to the start of the next school semester in August. Then, the Governor and Florida Surgeon General announced Florida was not ordering the vaccine because they believed healthy kids did not need it despite all the infectious disease, public health and virology experts reviewing the data and approving the vaccine. Morale fell to a new low.

The very next day the Governor announced that doctors and pharmacies could order the vaccine through the Florida Shots website and had that option all along. That is not the way we ordered the vaccine earlier in the pandemic. We ordered it though the Florida Department of Health.

Supporters of the Governor blamed this ordering confusion on “big government bureaucracy”. If that is the case, then why not just announce from the beginning that pharmacies, doctors and health systems can order the vaccine through the Florida Shots website?

In the political gamesmanship of placing barriers in the way of our youngest and most vulnerable children being vaccinated, did the Governor forget that most physician offices do not have freezers capable of storing the vaccine at -90 degrees Centigrade? Also ignored was the plight of those who have relied on their county or city health department to provide the vaccines for their children for years and now those public health facilities will not have the vaccines.

My office was bombarded this week with calls from patient’s testing positive for COVID-19, all with mild symptoms of fatigue and upper respiratory viral symptoms. The current treatment options are to supply supportive care such as fluids, cough medicine, Tylenol and rest or prescribe the Pfizer pill Paxlovid. The Paxlovid must be started within five days of onset of symptoms.

So many patients walk around with cold symptoms for several days before home testing that it’s difficult to start the medicine within the five day window advised by the manufacturer. Paxlovid interacts with so many popular and common prescription medications for seniors which must be discontinued and washed out of your system prior to starting Paxlovid that they can’t start the medication on time.

The best option, in my opinion, remains receiving an infusion of the monoclonal antibody Bebtolivimab within seven days of onset of symptoms. Boca Raton Regional Hospital has a program that gets you in within a few days but several patients have been so anxious and worried that they would not wait for an appointment. Several called private services to come to their homes and treat them with monoclonal antibodies. These companies have popped up out of nowhere and their reputation and reliability are relatively unknown. Are they really administering Bebtolivimab? At least at the hospital I know the product is the real thing and the monitoring staff is well trained and experienced.

Also, several patients have insisted on Paxlovid and stopped their blood pressure, cholesterol and antidepressant medicines. Two of them took the Paxlovid and improved, then rebounded with a positive test and return of all symptoms several days later. They all recovered in a few days, but the potential rebound is another reason I prefer offering the monoclonal antibody infusion.

I have not mentioned the Merck oral medication Lagevrio ( molnupravir) because it used new technology involving disrupting the genetics of the virus. I would like to see the adverse effects of this drug and its efficacy and safety profile after being on the market for twelve or more months prior to considering it.

COVID remains a “bummer”. We are in a much better place to prevent serious illness than we were three years ago but human behavior, the demonizing of science for political gain and the resilience of this virus continue to wreak havoc on my life and those around me.

FDA Approved LabCorp Test for COVID-19, Influenza & RSV

The FDA has approved an at-home testing kit that can differentiate between symptoms of an upper respiratory virus being caused by COVID-19, Influenza A/B or Respiratory Synctial Virus (RSV) . It is called the Pixel by LabCorp COVID-19+Flus+ RSV Test Home Collection Kit. You obtain a nasal swab and send it directly to LabCorp for testing. The results will be sent by an app that can be downloaded to a smartphone or tablet.

Since children returned to school after a prolonged isolation due to the COVID -19 pandemic, we are seeing a large number of viral upper respiratory tract infections in this group, their parents, and caregivers. “Is it COVID-19?” is always the first concern, “but if its not COVID what is it”?  This testing will  allow patients to swab themselves and obtain a diagnosis without having to first go to the doctor for a visit.

I suspect your doctor will still wish to see you or your child prior to prescribing anti-viral therapy once the diagnosis is reported,  but this is the first at-home testing approved for all three virus types. The test can be purchased online at the LabCorp website or at pharmacies.  The retail price has not yet been disclosed.

A Dose of Reality. Rejoining the World

My wife and I flew to Chicago this past weekend to attend a wedding of a dear niece. The pandemic resulted in three previous postponements of this wedding. It was postponed for so long that there is now a family addition of a lovely eight month-old daughter.

The trip involved leaving the state of Florida for the first time in three years due to COVID and flying commercially to a busy airport and then taking a taxi to a busy downtown hotel. If that wasn’t scary enough for a couple living in isolation for two years, the wedding included 175 guests meeting inside for a Friday night reception and then a Saturday service and reception. All rules, recommendations, and suggestions for preventing the transmission of, or acquiring, COVID were basically ignored by the parents (all four professionals with post doctorate degrees), the maid of honor (graduate of an Ivy League public health program and director of an internationally recognized COVID response program) and the bride and groom (both practicing physicians).

My wife and I planned to wear our masks on our flights to and from Chicago which was easily accomplished. We planned to eat outdoors only which could not happen due to two days of pelting rains, gale force winds and temperatures in the low forties. Downtown Chicago was young, maskless and completely oblivious to the fact that a COVID pandemic was ongoing. All these young adults were talking about is how they were still working remotely due to COVID, but they were populating bars, clubs, restaurants, theaters, sports venues maskless with not a care in the world about this contagious and fickle disease. To say it was different and a bit overwhelming would be an understatement.

The Friday night reception for attendees in an overcrowded undersized private room of a large Chicago blues club resulted in us saying hello, having a drink and quickly leaving. The wedding was less crowded and cramped but there was no pre-function COVID testing. Several of the guests on the bride’s side had refused vaccination. I saw one masked guest at the wedding, a young female pregnant physician. Every precaution we had taken for the last three years was ignored – throwing caution to the wind.

All my adult daughters and their guys flew in for the festivities and it was just wonderful to be with family. The parental hosts for the wedding were warm and loving and they knew how to throw a great party. I was concerned about the consequences of being with large groups of people inside despite being vaccinated against COVID and receiving two booster shots. We flew home Sunday night getting into our residence around midnight.

I tested for COVID daily for several days. No one in my immediate family contracted COVID. We know of only one guest who turned positive the day after the wedding, and she was one of the non-vaccinated attendees. The weekend of the wedding the COVID positivity percentage in Chicago was less than 2%.

I have no idea if we were just lucky or if the vaccines and boosters work well. With the positivity rate in Broward County now 21.7%, I suspect we will soon find out

Pfizer Pill “Paxlovid” & Post-Treatment Relapses

The introduction of the Pfizer antiviral pill Paxlovid to treat COVID-19 infected patients, within five days of contracting the disease, was supposed to be a “gamechanger.”  Reviewers compared it to Tamiflu, the antiviral pill used against influenza and taken twice a day for five days.

The rollout and distribution of Paxlovid have been a problem from day one. Pharmacies objected to their reimbursement for distributing the product and doing the labor-intensive paperwork required because it is an Emergency Utilization Authorization (EUA) product – not yet FDA approved. In addition, it interacted with so many commonly taken medications that use the CYP3A4 pathway, including common antihypertensive and antidepressant drugs. The result is that very few pharmacies agreed to stock it and distribute it. The Federal government established an online locator of pharmacies that distribute it but often the pharmacies listed do not have it in stock when you call them to prescribe it.

This week a new wrinkle and complication appears to have been discovered. Patients treated with Paxlovid within the first five days, and completing the twice a day course, are now relapsing on days 9 and 10 post-infection. Quick at home antigen tests are turning positive in some. Viral loads are being detected and mild symptoms are returning. These relapsed patients still may be able to spread the infection.  

Pfizer representatives are suggesting we treat these patients with a second five-day regimen. The FDA has not yet advised treating for a second round. At this time the issue of post Paxlovid relapses needs to be studied. Those projects are now under way.

For this reason, until more is known about Paxlovid treated COVID relapse, our first line treatment for high risk COVID infected patients will be referral to the Baptist Health Boca Raton Regional Hospital Monoclonal Antibody program. Their use of bebtelovimab within seven days of infection continues to prevent the disease from progressing to the serious form.

My patients with any questions about this, should call the office at 561.368.0191.

COVID-19 Ba2 Variant: My Medical Office

There has been an increase in patients infected and testing positive for COVID-19 in our area. For those who have been vaccinated, and received the boosters, if you get this new variant your symptoms will likely be similar to a cold and flu.   

Typically, most people will not get sick enough to require hospitalization or the intensive care unit. However, as with any serious illness, there are always exceptions.  Recently, we lost a patient who was vaccinated and had received the COVID-19 boosters. He was taking an immunosuppressive medication for a serious skin issue but still his loss is a horrible reminder of how fickle and deadly this illness can be.

At this time, we require our patients to be vaccinated and have received a booster. For those individuals over 50 years old, or immunosuppressed, who have taken the three shots, four or more months ago, we encourage you to take a fourth shot. Local CVS , Walgreens, Publix are administering the vaccines by walk in at some locations or by appointment. You can schedule an appointment online by accessing their websites or calling them. If you cannot use a computer, call my practice and we will try to set up your appointment for you if you are my patient.

We will continue to ask our list of questions as a screening process to determine if a  face-to-face office visit in needed. The questions come from the CDC, the University of Minnesota School of Medicine Department of Infectious Disease with M. Osterholm, MD as chairperson and from the cruise ship industry. With two staff persons over 65 years old, and two living in multigenerational households, we are entitled to know the risks to our staff in advance of a visit. We are taking these precautions for the safety of our staff and their loved ones.

PATIENTS WHO TEST POSITIVE:

  1. Patients who test positive, with no symptoms, will need to quarantine at home for five (5) days per CDC guidelines. If they have no further symptoms after five days, they may resume their lives but wear a mask around others for an additional  five (5) days.
  2. Those who test positive and develop symptoms should quarantine for at least five (5) days and until symptoms are gone for at least 24 hours. They should be wearing a mask around others for 10 days from the start of symptoms.
  3. Those who test positive with symptoms and consider themselves high risk patients need to call the office. Sotravimab monoclonal antibodies are still being administered in Florida until the number of COVID cases caused by the Ba2 mutant is > 50% of all cases in the state. Baptist Health Boca Raton Regional Hospital still has an active monoclonal antibody infusion program. When Sotravimab is removed from use due to ineffectiveness, we can prescribe the oral medications Paxlovid ( if you are not taking any of the medications contraindicated with it) or the Merck pill Molnupiravir. If you are ill and have questions please just call us.

Testing locations are a real issue. The state sites at FAU runway and South County Civic Center have apparently been shut down. If you have questions about where to test call the office please.

We are actively seeing patients in person in the office Monday through Friday in the safest environment we can provide. Just because people wish to pretend that the pandemic is over doesn’t make it so! We recommend that when indoors, in public places, you continue to wear an N95 or KN95 mask if you do not know the others around you. With the Ba2 variant being so much more infectious and transmissible than previous variants you need to consider whether going to your gym, indoor dining and indoor clubs and theater are in your best interests.

Recent peer reviewed published studies show that those infected with even mild COVID not requiring hospitalization or treatment carry an increased risk of heart attack or stroke for at least the next 12 months. Controlled diabetics lose control in 40 % of the infections and those with pre-Diabetes on the borderline convert to full blown type II Diabetes in 40% of the infections even if mild.

At the current time, we are only accepting vaccinated individuals for our complimentary meet and greet sessions and as new patients. Patients who are not vaccinated and have at least one booster (unless they have a documented medical condition preventing vaccination) will not be retained when their annual membership is due for renewal. If you have any questions, suggestions or comments please call the office and stay safe!

Before You Travel Please Learn the Covid Rules for Your Planned Stops

I received a phone call last week from a long-time senior citizen patient who was in London, UK with his wife and two traveling friends on a long delayed pleasure trip. His wife and friends both had just tested positive for COVID-19 and were denied access to commercial airlines scheduled to fly them home the next day. My patient had tested negative.

They phoned their hotel and extended their stay for several days. My patient asked me for medical advice about treating COVID-19 for his wife and two friends – both not patients. All were vaccinated and had taken a booster shot already. None were terribly ill.

I told them that in Florida we would prescribe the Pfizer pill Paxlovid, the Merck pill Lagevrio or send them to the local hospital as an outpatient to receive an injection or infusion of the latest monoclonal antibody that was effective against the Omicron and Ba2 variant strains. I had no idea what services were available in London but suggested that the hotel concierge must have a private physician who attended to sick hotel guests. If that was unfruitful, I suggested calling the United States Embassy and see where our State Department personnel go for emergent health care.

The hotel concierge sent a private physician who came over, took a history, examined them and pronounced them fit but infected. He suggested treatment with rest, cough medication if a cough developed, Tylenol if a fever or aches and pains developed, warm clear fluids and call again if they developed breathing difficulty. He suggested they retest in five days and if negative get on with their lives.

After the hotel physician visit, my patient called again from London. He asked us to prescribe Paxlovid or Lagervio for him in Boca Raton, pick it up for him and ship it to London via overnight FedEx. I explained to him that he was not infected, and the drug was in short supply plus, there was only one pharmacy in West Palm Beach and one in south Fort Lauderdale distributing it (we have since learned there is one in Boca Raton as well).

The pharmacy said the drugs should be started within five days of testing positive and having symptoms to be effective and they made it very clear shipping it across state lines or internationally was illegal. Shipping it violated United States and United Kingdom laws.

The patient and I spoke daily and thankfully no one in his travel group became very ill. On Day four, my patient tested positive for COVID-19 putting his wife and travel group in the position of having to decide whether they all stay behind and wait for his negative test or whether they travel home separately?

Another patient spoke of his upcoming scuba diving trip to the Maldives. His itinerary took him through the United Arab Emirates and he was very upset that the Middle Eastern airline he was flying insisted on a negative COVID test a day in advance of his flight home. He could not find a testing site in the Maldives that fulfilled the requirements of his air carrier or the UAE.

We are in the middle of a worldwide pandemic. Just because you want it to be over doesn’t mean it is over. I suggest you review your itinerary for overseas travel carefully. Know all the rules for the countries you are flying to even if it is for a layover.

I additionally suggest you research what type of restrictions and care are available at that locale. Just because we have medications to give to COVID infected patients to prevent progression to more serious disease in the USA doesn’t mean those medications or equivalents are available or approved in other nations.

 If you must go you might consider joining an air ambulance service which guarantees to transport you home safely if you become ill while traveling. Make sure your contract specifies you will be transported to the care center of your choice not the closest facility that can provide the service.

We are all sick and tired of COVID-19 related rules regulations and restrictions. We all want to regain the freedom to travel as we please but it’s just not that simple. If you travel, please learn the rules and restrictions for your destinations in advance and make sure the care you need is available if you become infected.

COVID – “It’s only like a cold or a mild flu.”

Talking and writing about the pandemic and Sars2 Coronavirus got old months ago. At this point in time, most of my patients have received three doses of a vaccine and many have survived breakthrough cases of COVID. Fatigue at having to deal with this highly transmissible virus has led to a relaxation of everyone’s approach to this disease. Over and over, I hear friends, patients and neighbors tell me they refuse to put their lives on hold and hibernate for a virus that will at best give them a cold or mild flu. I am a bit more wary of that assessment.

Medscape Cardiology, an online medical journal summarized an article that appeared in Nature Medicine citing that the risk of a cardiovascular event such as a heart attack or stroke was 4% higher in the 12 months after contracting the COVID-19 virus. Researchers at first thought these numbers would apply to older patients with cardiovascular risk factors such as diabetes, high blood pressure, hyperlipidemia, obesity etc. This increased risk occurs across the board in young and old, smokers and never smokers, Caucasians and people of color as well as males and females. The research was done using Veterans Administration health data. Sicker hospitalized COVID patients had a higher risk than non-hospitalized patients, but the risk did not exist in similar groups who had no evidence of COVID infection. The actual immediate symptoms of infection may be mild and brief for the vaccinated, but the 4% increased risk of cardiovascular events is quite large considering the number of Americans who have been infected.

At this point in time, patients are deciding on their own to obtain a fourth shot which can raise your antibody levels but not necessarily prevent a breakthrough infection. Children five and under still don’t have access to a protective vaccine. Long term COVID is now more common with fatigue, post exercise exacerbation of symptoms, brain fog and now documented dysfunction of oxygen transport from arteries to tissue and veins and autonomic nervous system dysfunction. Recent studies have shown chemical abnormalities of the spinal fluid in patients with “long” COVID and brain fog.

I believe we have much to learn about this coronavirus and its long-term effects on humans. I will continue to advise wearing an N95 mask indoors, avoiding indoor crowds, maintaining distancing and continuing efforts to avoid infection. Relief is coming soon from new antiviral pills, monoclonal antibodies and variant specific vaccines Please don’t let down your guard in the meantime.

During the Pandemic: Medical Advice Is Challenged & Questioned While Patience is Thin

I, like most of the western civilized world, have had my fill of the pandemic. I see patience short both in the general population and in the medical community. The problem is that everyone seems to have lost their perspective and the value of education, experience and caring.

I received a phone call from a relatively new patient. He and his wife are recovering from breakthrough Covid-19. They are well past the point of being required to quarantine whether you use the original 14-day recommendation prior to vaccines, the revised 10-day program or the 5-day program. They still have deep, barking coughs. They do not have a fever, nor are they short of breath and they are not complaining of difficulty breathing. The cough keeps them up at night sometimes and produces clear to yellow phlegm. I advised patience, warm clear fluids, tea and honey, cough syrup and time. The patient asked for a Z-Pack (zithromycin , an antibiotic). I explained this was a viral illness not requiring an antibiotic and that the cough might be present for weeks to come. The message was poorly received.

Today as I was leaving the office the patient called back. He said that the stress of this all had stirred up his angina. He felt like he had an elephant sitting on his chest. I again asked if he was having trouble breathing and he said a bit more. He was not wheezing. He was talking comfortably on the phone. The symptoms associated with the pain did not include nausea, vomiting or massive sweating which sometimes are seen with an ongoing heart attack. The description of crushing chest pain like an elephant on the chest was sufficient to require an evaluation at a cardiac center. I suggested he sit down, take a nitroglycerin if he had one with him and call 911 immediately. He declined. He said it is probably just bronchitis and “If you don’t want to see me because of Covid issues I will just find a clinic to go to.” He told me he had heard on the news that there were no hospital beds and he didn’t want to wait for hours in an emergency room.

This patient has a history of high blood pressure, high cholesterol and had previously had a mini stroke . I explained that his complaints needed a cardiac center with heart rhythm monitoring, a quick lab to monitor cardiac enzymes and defibrillators with advanced cardiac life support trained personnel.

I called him back an hour later to see how he was feeling and what he decided to do. He was on his way to a clinic. “Must be bronchitis and if you won’t see me they will.”

As the pandemic rolls on there are no suggestions, recommendations or advice given that is not challenged and questioned. Sometimes I have to remind myself that we are on the same team, with the same goals of keeping you independent, healthy and feeling well.

I would expect with 20 plus years of schooling and training, and 40 plus years of experience and continuing education, my patients would remember we are on the same team and trust my professional experience rather than their own, or that of others, when it comes to the best interest of their health.

My interests and intent are to keep you healthy and well. However, there are medical conditions that cannot be safely seen in the office. A potential heart attack or ongoing stroke, a loss of consciousness, inability to breathe or unstoppable bleeding are a few of the conditions which require an ER not a walk-in center or physician’s office. When I suggest that a patient be seen in the emergency department I am doing so in the best interests of the patient!

I am not quite certain why when the advice is given, based on the information the patient and family provide, it is received with such skepticism?   I just know that skepticism and pushback are far greater now than they were before Covid appeared. 

Seaweed as a COVID Treatment?

A type of sea algae known as ulna, or sea lettuce, is being tested to see if it can be used as a medication to treat SARS 2 Coronavirus. In the past, other forms of seaweed and algae have been successfully used as anti-viral agents. For this reason, researchers have tested ulna against the corona virus in lab test tubes.

They first extracted ulvan, a chemical in the sea lettuce, and then placed it in test tubes with living cells and live Coronavirus. The cells exposed to ulvan did not get infected with coronavirus. The cells only exposed to the virus did become infected. The ulvan used in this experiment came from algae grown in the lab. The native algae sea lettuce is a normal part of the diet of individuals in Japan, New Zealand and Hawaii.

The researchers used two different methods to extract the ulvan from the seaweed sea lettuce. One method produced a product that showed 10 times more anti-viral effectiveness than the other. The next step is to test this product in animals and if successful in human trials. Those experiments are being developed for further study.

After reading this article I wonder if there is any less COVID infection in the population that regularly consumes this sea lettuce and, if infected, are the clinical symptoms and presentations milder?