Continuity of Care Threatened by Deteriorated Communication Between Hospital-Based & Community-Based Physicians

Medicine in my area of the country has morphed into physicians who care for patients while they are in the hospital  as “in patients” or “ observational status” and outpatients.  Very few primary care physicians admit their patients to a hospital and then care for them while hospitalized. There are numerous reasons for this, mostly economic and initiated by hospital administrations and insurers, but that will be the topic of a future discussion.

In today’s healthcare environment, most hospitalized patients are cared for by hospitalists. These are physicians, nurse practitioners and physician assistants either employed directly by the hospital or employed by a group practice that is contracted to provide services at that facility.

My role as a primary care physician is to present the hospitalists with the reason why the patient is at the emergency department with past records and to provide them with the perspective needed to provide continuity of care. If I know my patient is going to the Emergency Department, I phone the ER charge nurse , review the patient’s case and ask to speak to the physician who will be evaluating them. After I have completed those two calls I send over the records via fax. 

Sadly, the ER physician I have spoken to is often not the ER physician who sees the patient. Also, the records I fax to the ER frequently are not added to the patient’s chart nor are they provided to the ER physician even though I have received electronic confirmation that they were received.

I have arranged to have one coverage team of hospitalists see my patients requiring hospital admission. I text or call that physician to alert them that a patient is on the way.  Unfortunately, the Emergency Department doesn’t always call that doctor to see the patient. In those instances, they admit the patient to the hospitalists resident team instead. I have had numerous phone calls and meetings with the hospital CEO, hospital chief medical officer, the physician leader of the emergency medicine group employed by the hospital and the head nurse in the ER regarding these issues.  My name and the covering physician’s name are clearly listed in their computers and they discuss it at staff meetings but somehow patients frequently end up on the wrong team.

As part of the hospital admission process, the patient’s primary care doctor in the community, and specialists, are usually mentioned in the information obtained upon arrival. That information is certainly included in the documents I send over to the facility. Despite this, it is rare to see a patient admitted to the resident program hospitalists program actually notify those specialists or ask them to see their patient. I call those specialists to make them aware of our mutual patient’s hospital admission so they know to stop by and check on the progress of our patients. 

I use the computer portal daily to follow the evaluation and treatment of these patients. If I have questions or concerns, I speak to the hospitalist physician about it. Upon a patient’s discharge from the hospital, I receive a fax notification from hospital administration notifying me that the patient has been sent home.  I access the discharge summary, print it out and place it in the patient’s office chart and update the medication list if changes have been made in the hospital. For this to be thorough and complete the process requires the hospitalist dictating the summary to be thorough and complete. Sometimes this occurs.

Take the case of Kathy, a 63-year-old woman born with cerebral palsy and suffering seizures.  Since her parents died, she is living with a caregiver supervised by a family member who makes all the medical, legal and financial decisions with the patient supported by funds set aside by her late parents. For unknown reasons, she tragically has had a series of uncontrolled seizures and is taken to a hospital not in my service area. To control her seizures required sedating her, intubating her and putting her on a ventilator to breathe while sedated. While unconscious from sedation she had an arrhythmia requiring starting a new medication to control the rhythm and an anticoagulant to prevent a clot from forming in her heart and traveling to her brain causing a stroke.  Her neurologist and heart specialist were never notified by that facility’s hospitalists even though they had partners who routinely visited that facility. 

Upon discharge, the hospitalist prescribed two days of the amiodarone for the new rhythm and two days of the anticoagulant Eliquis.  They suggested seeing the cardiologist for follow up but the soonest his office could see her was five weeks away.  The discharge summary made no mention of the arrhythmia. The discharge summary did not list the amiodarone or Eliquis.   

The patient’s legal guardian called me to ask about the lack of medications prescribed and basically to have someone explain to him what had occurred. To clarify the situation, my staff contacted the medical records department of the hospital and faxed them a signed authorized medical release of records . We obtained all the daily progress notes and consultation reports. These documents provided the name of the cardiologist who saw her.  It took several attempts by phone before we reached him and he explained what had occurred and clarified what dosage of amiodarone and what length of treatment he preferred and why.   

This research and clarification took hours of non-compensated time.  It was an absolute necessity to insure safe care for the patient. General internists, family practitioners, pediatricians do this daily attempting to coordinate patient care . The lack of interest by hospital administration and overworked employed hospital physicians and staff make being successful increasingly difficult.  The lack of outrage over these incomplete and lazy handoffs is infuriating.

The same families that are furious at the care they receive donate charitable funds to these institutions with few, if any, strings attached about where the money is needed and should go. With for-profit hospital and medical facilities behaving no differently than non-profit facilities and medical groups, and no pressure from the IRS, Center for Medicare Services or insurers, I see no hope for a more professional and thorough handoff of care between the community physicians and hospital-based care.

“D” is for Dandy

Recently, my local hospital received coverage in the newspaper stating its safety rating was downgraded from a “C” to a “D”.  On the same day my long-time family friend and patient who just turned 70 collapsed at his gym while working out with a trainer and lay unresponsive on the floor unable to move his left arm or left leg.  Emergency Medical Services responded to his wife’s 911 call and took him to our D-rated hospital.

The Emergency Department had been alerted by the paramedics of an inbound patient who met the acute stroke protocol so within 45 minutes of arrival his labs were drawn and analyzed and imaging studies of his brain and blood vessels were completed showing a major blockage of a major artery supplying the right hemisphere of his brain. He was intubated, sedated somewhat and placed on a ventilator and wheeled into the interventional radiology suite. The team led by a well-trained young interventional radiologist accessed the clogged blood vessel using a catheter, removed the clot and injected the clogged vessel with a thrombolytic “clot buster.”   He was transferred to the recovery area and then to the neurology intensive care unit. 

I arrived at the neurology intensive care unit just as they completed removing his endotracheal tube allowing him to breathe and speak.  He greeted me by name and grabbed my hand with his previously flaccid left hand.  I have read the biblical version of the parting of the Red Sea and the biblical version of the Jews exodus from Egypt as part of the Passover miracle story, but I cannot imagine it was any more miraculous than this recovery.  The next afternoon we walked together around the neuro ICU as he inquired about whether scheduling a golf tee time in two days was too soon.

On the heels of the pandemic, all our local hospitals are short of nursing and support staff. This facility is undergoing a major construction upgrade making it virtually unrecognizable from the facility that stood there two years ago. The safety issues brought out in the study will be addressed and corrected, I am sure.

The “D” for safety reminded me of a story my late father told me about his boyhood. His parents, my paternal grandparents, were immigrants and spoke primarily Yiddish and little English. When his older brother, my uncle, brought home a report card filled with “D “grades his father asked him in Yiddish what the D represented. He said, “D stands for Dandy Dad.”

Based on the treatment my patient and friend received at this hospital I too will say “ D” stands for Dandy.

Please Go to the ER When I Advise You to Go!

On a daily basis, I receive phone calls from patients who are suddenly ill and either want to be seen in the office immediately or wish to speak to me immediately.  We have an evaluation or “triage” protocol which teaches the staff when to immediately interrupt me and bring me to the phone after suggesting that you call 911 . When I get on the phone, patients frequently say one of the following: “I don’t want to go to the ER because the wait is too long.” or, “I don’t think the problem is serious enough to go to the ER can you please just order me an imaging study at an imaging center?” or, “Can I just go to a walk-in clinic?”.

I refer patients to the Emergency Department when their complaints and condition are such that I believe we do not have the equipment and/or trained staff to safely evaluate and treat you in an office setting. The last thing I want to do is bring you into the office, find that your condition requires a hospital emergency room and have to call EMS to the office to transport you safely to the Emergency Department. I do not enjoy going to the ER as a patient either, but sometimes it is a necessary evil .

We do not refer patients to the ER instead of the office because we don’t want to see you.  We don’t refer patients to the ER because we don’t want to stay late to squeeze your visit in. We don’t refer patients to the ER because we want to keep our costs low and not pay overtime wages to our staff.

We refer patients to the ER because evaluation and treatment of your complaints safely requires the staff and equipment present in a hospital ER. This week alone a gentleman with recurrent chest discomfort over several days refused to go. When we finally got him to the hospital his studies revealed a life-threatening coronary artery blockage  known in the non-medical press as a “widow maker.”   A cardiac catheterization and stent placement saved this individual’s life. Another patient on an oral blood thinner plus a drug to inhibit his platelet function fell and hit his head. He had a terrible headache and also refused to go to the ER. When he finally did go, a large bleed and hematoma was found and surgically evacuated to save his life. A healthy woman developed chills and shakes two weeks after surgery on an inflamed internal abdominal organ.  She refused to go to the ER. When she finally did the blood cultures drawn turned positive requiring several weeks of intravenous antibiotics  to save her from an infection which was new and had nothing to do with her recent surgery.

I don’t like to refer my patients to the ER but sometimes that is the right thing to do. Nonetheless, I get flak and pushback from patients and family when I suggest it. However, I will continue to make that recommendation every time it is in your best interest to do so.

Shared Decision Making or Covering Your Liability?

Much has been written about patient / physician relationships and sharing decision making responsibility with your patients and their health care surrogates. My concept of shared decision making involves explaining to the patient exactly what the conditions are you are dealing with and trying to remedy.  It involves outlining the choices and options to both evaluate the problem and treat it. That outline should include the physician’s preference for evaluation and treatment and why these suggestions are made. The patient then has the information to ask questions and make their decision.

In reality, that is not occurring especially the part that requires the physician to explain what options they prefer and why. What’s worse is when the patient declines the best option. The physician then documents it on the chart as “ Patient declined suggestion” to lower their medico-legal risk.

This past week’s experiences provide examples.  An 80+ year old patient of mine with dizziness for several days decided to self-refer himself to the emergency department in the middle of the night.  He had no vertigo or loss of consciousness or slurred speech or motor or sensory changes. The patient had not discussed any of these multi day symptoms with me or with his  very responsive cardiologist or neurologist.  He did call me at 3:00 a.m. Saturday morning to let me know he was in the ER. I awoke, logged into the hospital computer electronic health record system and reviewed the very appropriate and complete and thorough evaluation planned by the ER physician and staff.  

Two hours later a physician assistant observed him walking and reviewed the tests and felt he was well enough to go home. An EKG had been read as revealing changes which could be associated with acute poor blood supply to the heart muscle or ischemia.  The Emergency Room physician’s official note says he offered the patient admission to the hospital to stay and evaluate this and the patient declined.

I called the patient at a reasonable hour and, while feeling better but tired, he insisted that no one had ever suggested he stay or that there might be a cardiac problem. I have no idea if the physician actually said, “I think you should stay because your EKG has changed and that may be related to your dizziness.” I suspect that message was never delivered. Instead, the patient received the message, ”Your neurological symptoms have disappeared and the brain CT scan is normal. What do you want to do?”

A similar situation occurred the next evening when at midnight I received a phone call from a family member whose spouse had tripped and fallen in her bathroom putting her head through their dry wall.  There was a cut on her scalp bleeding profusely but she seemed to be neurologically intact.  The patient was 69 years old and had been taking aspirin for aches and pains and occasional ibuprofen. There was no loss of consciousness.

The fall was not related to alcohol ingestion or recreational drug use but probably was related to a foot and ankle orthopedic issue and knee issue that should have been addressed after previous falls. I suggested they go to the local ER and be examined.  They followed my advice and at the ER she was examined and treated. The ER doctor told her she had no neurological abnormal findings and inquired whether she wanted a brain CT scan to look for brain bleeding or injury.  The patient declined. In the official record it is stated that the physician suggested a CT brain scan and the patient declined. At no time did the ER physician say , “I think a CT brain scan without contrast would be a good idea based on your use of aspirin, your age and the trauma involved.”  

The ER physician next asked if the patient wanted her to suture the wound with staples or not. No explanation of the options and reasoning behind choosing one option or the other was advanced. The patient chose no suturing and chart was documented as a suturing offered but declined.

At the very least, patients have to ask “What choice do you think I should make and why?” It would also be acceptable to ask, “If I was your mom, what would you suggest and why?”

Has the Business of Medicine Ruined Health Care?

Early in my career if I had an elderly patient recovering from an illness or surgical procedure and their condition required an extra inpatient hospital day, I just looked at the chart and found some chronic condition still not “normal” . I wrote a note in the chart documenting it and the patient stayed put. Most of the time the reason was medical. Sometimes it was logistical, such as a family member flying in to be the caregiver and unexpectedly delayed. Sometimes it was about a hospital bed or wheelchair or nebulizer unavailable until the next day. I deferred to caring and compassion.

As we moved into the 1980’s and 1990’s, and managed care evolved, a new hospital employee position replaced the “social worker” called a “ case manager”. They would discuss “ Length of Stay or LOS” and tell us reckless spenders how much we were costing the hospital. This didn’t jive ever with the annual financial report card I received from that facility  in the first quarter of each year on patients I cared for while hospitalized. There was not a year where I had not made the facility at least $250,000 in profit and that was only from the inpatient data. I kept a copy of that report with me when I made rounds and, as an independent practitioner not employed by the institution, I had the ability to put my patient first and remind administration each time they complained.

I bring this up because I read an article in the New England Journal of Medicine this week written by a young physician complaining about how the hospital employed physicians discharged patients routinely before their evaluations were complete. He cited examples of how this practice delayed the diagnosis and life span of the patients. The author felt great compassion for the patient and the hospital based employed  physicians who are under tremendous contractual pressure to discharge quickly and keep the admission profitable. This is occurring in for-profit hospitals as well as in  not-for-profit hospitals.

At the same reading session, I read an article discussing the problems that occur when an older adult is admitted to the hospital for an illness which the authors, in retrospect, believe could have been handled while the patient stayed at home. In 40 years of practice, I know of no situation where a patient who could safely stay at home was hospitalized for physician profit.

Do you have any idea how inconvenient, inefficient and cost ineffective it is  for a physician with an office-based practice to care for a hospitalized patient ? You have to get there before daily office hours, return after office hours and handle dozens of phone calls from nurses, aides, pharmacy staff and physical therapists – not to mention family members.

“The suits”, business investors, insurers and employers, plus CMS and our elected Congressional officials, have cut the heart and caring out of medicine. I stopped going to the hospital at the  start of the pandemic when hospital officials limited who could see patients as a means to slow the spread of infection. When it was considered safe to return to the hospital, the control of administrators over care decisions had expanded so much that it was clearly uncomfortable to work there.

My physician partner, who covered my practice when I was out of town or ill, refused to  return to hospital care for just this reason. It left me without backup.  I explored returning but the care and concern by hospital staff were so different and so robotic I felt that if I returned I would end up in a shouting match trying to advocate for my patients and lose my credentials anyway.            

My local hospital was built because emergency care was not available for two youngsters who died enroute to a distant hospital in the early 1960’s. The facility was built by the community and recently sold to a major not-for-profit chain. Just prior to the sale, they  closed its pediatric unit because it  was not  profitable. However, they continue to have a profitable labor and delivery program and continue to deliver babies. If those newborns become ill they are sent to hospitals 35 – 40 minutes away. If a child is brought to the Emergency Room and requires admission to the hospital, they too are transferred to a pediatric unit in Broward County or the one in Palm Beach. This is what occurs when financial people run healthcare.

The influence of ‘ business” on medicine has even infiltrated into medical schools where students are encouraged to become employees and work shifts for balance of life reasons rather than enter their own private practice and develop lifelong professional relationships with patients.

An article from Canada talked about the importance of primary care in treating chronic illnesses. With an aging population of baby boomers, preventing and controlling chronic problems is essential to the health of the citizens and the financial health of the country. 

In Canada, with a national health system, less than 1% of the caregivers are nurse practitioners or physician assistants. You are evaluated by and treated by a physician. Hospitalists( hospital-based and employed physicians) were the creation of a bunch of residents at University of California San Francisco who, upon completing their training, had no idea what to do with their careers. Their mentors in academia detested their time away from their research while out on the wards supervising the care and training of internal medicine physicians. They hired these doctors to perform their clinical duties and responsibilities so they could continue to teach and conduct research. Hospital administrators loved the concept because by employing them and making it difficult for community based independent physicians to come to the hospital, they had a mechanism to control costs and length of stay. Insurers and employers loved them for the same reason. Nurse practitioners and physician assistants were adored for the same reason.

Hiring a “mid-level” provider is far less expensive than hiring a physician. The original wave of NPs and PAs came from experienced nurses with years of  experience in the field. Bringing them back to school for training and then supervising their postgraduate clinical experiences produced some outstanding clinicians. The new breed of mid-level providers come from students with two years of experience only. While a physician in training is supervised for a minimum of 144,000 hours, the oversight on mid-level providers is far less. Asking them to be the chronic care supervisors in the USA may help the bottom line of insurers, employers and hospital systems but it does little for senior citizens.

My advice to patients is simple.  Find yourself a well-trained independent physician who actually sees patients. Stay away from HMO plans unless it is a superior product like Kaiser Permanente. Stay away from Medicare Advantage plans. They are not the same as traditional Medicare. They cost less for patients but the price you pay if you get ill in terms of choice of physicians to care for you and facilities can be very limited.

If you can afford a concierge physician or direct pay physician with a small practice it is well worth it.  If you get hospitalized you need a savvy advocate who knows health care to be there with you.  Write your Congressman and advocate  against Medicare Advantage plans which actually cost more per patient now than traditional Medicare. If your care is switched to a mid-level provider, ask that provider how much clinical experience they had in nursing prior to entering NP or PA programs. Scrutinize them the same way you would view the credentials of a perspective physician. Lastly, ignore their online reviews. In general, online reviews are written by patients who are dissatisfied and don’t necessarily represent the overall sentiment the majority have of the provider.

The End of Monoclonal Antibody Treatment of COVID-19

National Public Radio (NPR) reviewed the end of the outpatient use of monoclonal antibodies to combat SARS 2 Coronavirus (COVID last week. These synthetically produced antibodies were infused into patients infected with COVID and were at high risk to develop severe disease requiring hospitalization or death. It cost about 200 million dollars to invent, develop and then use the drug in trials to gain FDA approval for human usage. Drug manufacturers were willing to take the risk developing these products because the US government financially guaranteed their purchase.

The antibodies were synthetic Y shaped molecules which bound to the viruses spike protein rendering it incapable of invading human cells and alerting our own immune system that the virus was present facilitating the virus’s destruction. Over time, the virus learned to mutate and evade a particular monoclonal antibody rendering it ineffective. When 30% or more of the new COVID variants in a region became able to resist the monoclonal antibody, the CDC and FDA withdrew the product. Drug manufacturers continued to develop new monoclonals due to the Federal guarantee of purchase.

Bebtelivimab was the last product that worked well against COVID and on Monday, November 21, 2022 it was withdrawn as well. The Federal government stopped guaranteeing purchase of these products so drug manufacturers have now discontinued their expensive development.

Let me explain how this impacts my patients locally. Baptist Health BOCA Raton Regional Hospital had a robust outpatient monoclonal antibody program. I phoned or text messaged Lisa, the nurse practitioner program director the patient name , demographics and reason for participation and she scheduled and her team administered the drug within the seven day window required. No one became ill from the infusions. No one had to stop their usual medications due to drug drug interactions. No one progressed to severe disease requiring hospitalization and no one died. I referred at least 100 high risk patients including myself in the last 2.5 years and now that weapon is gone. No one treated cleared the virus and then had a rebound recurrent period of sickness.

So we are now left with Paxlovid and Lagevrio oral pills. One has multiple drug interactions with so many of the common medications the high risk population takes daily for cardiac, renal , diabetic and mental health it requires cessation or a reduction in dosage. The other is just not that effective. Patients taking these drugs also at times clear the virus then several days later have a mild rebound of symptoms and are contagious for a few days more.

We head into winter with an aggressive flu bug, respiratory syncytial virus in epidemic proportions and one less successful weapon against COVID-19. As I reflect on this past Thanksgiving holiday, I am grateful for the BRRH monoclonal antibody team and everyone connected with its development. I wonder what our elected Congressional officials were thinking when they stopped funding the development of these effective and safe, but expensive, products?

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.

Disappointment in Decision-Making Regarding COVID-19

I received an email from the Chief Medical Officer at my main local hospital informing me that elective surgical and diagnostic procedures had been cancelled due to understaffing because of COVID-19 infections. He mentioned 136 employees testing positive yesterday and 36 nurses not reporting to work this morning for the day shift due to COVID. Nearby Holy Cross Medical Center has stopped delivering babies due to a shortage of staff.

I subscribe to numerous physician run newsletters that discuss expert opinions on many specialty topics. The physician writers are all at the stage of life where they and their children are young and they are grappling with in-person schooling and infection. They write about hosting large holiday gatherings and now learning that multiple attendees are ill and positive with COVID-19.

While there have been few hospitalizations so far in this young professional vaccinated group, they worry about infecting their young unvaccinated children and elderly parents with chronic illnesses. These are leaders in the health care public policy and influence pedaling industry today and their lack of discipline and ability to delay gratification has put us all in the unenviable position of having to face an absence of available medical services due to further spread of COVID-19

I have no more success with my own highly educated children who do not work in health care. My eldest child hosted a holiday gathering in Venice, California to celebrate their Christmas Canal Boat Parade and multiple attendees reported being sick four days later. She then boarded a plane to New Mexico with friends.  Upon their return, two of the three travelers are home with COVID-19

We are in a major surge of infection with a highly transmissible virus. Texas Children’s Hospital is full of children too young to be vaccinated and struggling to breathe and survive. Locally, Jack Nicklaus Children’s Hospital and Joe DiMaggio Children’s Hospital are facing similar problems.

I urge you to stay home. Wear a mask if you go out in public which is a N95 or KN95 mask or triple layer cloth surgical mask. Avoid eating out at restaurants even outside. Stay out of gyms. Stay out of country club dining rooms and card rooms. “The Board” can make those places clean but they can not make them safe from a respiratory virus with twice the transmissibility of smallpox and measles. The economy will suffer but can recover with intelligent leadership. Sadly, businesses will suffer too but they can recover. Lost children and seniors cannot be replaced.

Should I Measure My COVID Antibodies?

On a daily basis I get asked by patients to please add an antibody test to their necessary blood work monitoring chronic conditions and medications to see if they have immunity against COVID-19. Some want the information just to feel comfortable that they have responded to their vaccine administration. Some have had COVID-19 and want to see if their immunity is sufficient to avoid taking a COVID-19 vaccine or booster shot? Some who have not been vaccinated and have been ill recently but not tested just want to know if the illness was COVID-19.

The topic was just reviewed in the online journal MedPage Today. First of all, the test you order to determine if you developed immunity based on receiving the vaccine is different than the test you order to measure antibodies arising from a previous infection. Nathan Landau, PhD, a virologist with the NYU Grossman School of Medicine believes we do not yet have the data to determine if antibodies we develop from infection or vaccination are appropriate to provide immunity. “The real answer is we just don’t know. It takes time to gather that data, to know what titers people have and what their chance of getting infected is.”

To determine the level of antibody that is needed to prevent infection scientists must first perform neutralization assays or tests. These are not performed in the commercial labs that do antibody tests for COVID-19. The neutralization assay is the Gold Standard . The test is performed by taking the blood of an infected individual, isolating the blood serum and then diluting it into different strengths. The different strengths are then mixed with the live Sars2 Coronavirus in a set amount. They then observe if the virus is killed off.

 In order to kill the virus you must have neutralizing antibodies. The commercial labs only measure the total antibody not specifying how much of that is actually successful in neutralizing the live virus. The neutralization assay looks to see what dilution of the antibody kills off 50% of the virus.

For example a dilution of 1:100 means 1 milliliter of serum was mixed with 99 milliliter of saline. At this point we do not know what dilution is necessary to prevent infection. This data is known for diseases such as measles, German measles and different strains of hepatitis.

There has just not been enough time yet to make this determination but the research is ongoing and conclusions should be released soon. What is known is that the mRNA vaccines produce more immunity than the non mRNA vaccines. They also know that the antibody produced from a vaccine is superior to the immunity from infection against new variants and reinfection. The commercial tests are expensive, time consuming and use reagents affected by supply chain problems.

Relief From Migraine Headaches Erenumab (Aimovig) versus Topiramate

Patients with frequent migraine headaches, which disabling symptoms, were in the past treated with oral medications called beta blockers such as propranolol or metoprolol to prevent recurrences. Drugs such as amitriptyline (Elavil) and other antidepressants were used as well. Triptans, caffeine, acetaminophen, narcotics, and Ergot alkaloids rounded out the therapy. The headaches could be crippling and disabling for suffering patients. In recent years, physicians have added topiramate (Topamax) and injectable Aimovig (Erunumab) to the regimen.

Recently a double blinded controlled research project looked at 777 adults with at least four migraine headache days per month. To be in the study these individuals needed to have never been treated with migraine medications. Patients were randomly assigned to receive either Aimovig 70 mg, the 140 mg injection monthly or topiramate at a dosage of 50- 100 mg per day.

The study ran for twenty-four weeks. This was a phase 4 head-to-head study of the efficacy of one versus the other (Clinical Trials.gov Identifier: NCT03828539. The endpoints were at least a 50% reduction in monthly migraine days plus ability to remain in the study without leaving due to side effects from the medication.

The results and conclusion were that Aimovig injections resulted in fewer migraine headache days per month and less discontinuation due to side effects of the medication. Only about 11% of the Aimovig patients stopped the drug due to side effects (fatigue, nausea, disturbance in attention and dizziness) versus almost 40% in the Topiramate group (parasthesias, disturbance in attention, fatigue, and nausea).  The Aimovig group had a 55.4% of its participants achieve at least a 50% reduction in monthly migraine days compared with 31% in the topiramate group.

Patients with recurrent and severe headaches need a full neurological evaluation to determine the exact cause and type of headache they are experiencing. Once the cause and type of the headache are known, it is wonderful to have this calcitonin gene-related peptide receptor antagonist available to prevent migraines in sufferers of these severe headaches.