Hurricane Dorian: Staying Focused as the Storm Moves In

As Hurricane Dorian moves through the Atlantic Ocean towards the United States and the Florida peninsula, there is no respite or escape from the constant barrage of news updates and suggestions being offered on TV, radio, print news, internet news outlets and social media.  The fierce image of the tightly curled storm is displayed everywhere.

I have been through quite a few storms starting in 1979 when the builders in our unfinished community loaned us plywood to board up our windows with concrete anchors ruining our exterior stucco finishes forever. Fourteen hours of work with a saw and hammer and screw drivers and I was too exhausted to notice the storm gracefully curled out to sea sparing us.

For Hurricane Andrew we had no shutters or knowledge, just luck. Masking tape was on the windows since no one had shutters.  A few pillows and pool floats were over the windows in the room we were closest to as we slept on the tile in a window free hall. Post-storm I volunteered to provide medical care in Dade County and was in a Ford Van that was broadsided at a Kendall intersection killing two in the other vehicle that ran what used to be a stop sign.  The impact sent our van tumbling over and over until we ended up right side up in someone’s driveway with our seat belted volunteer medical crew mercifully just frightened and sore.

Then there was the year that, as the storm passed and a curfew was in effect, we went to bed as it got dark with the power out and the windows open. The dogs started howling and there was loud knocking on the door.  I grabbed a flashlight and baseball bat and was greeted by a police officer at the door looking for “Dr. Reznick”.   ““They need you in the ER.“ he said.   “How can that be?  We have a coverage arrangement and no one is supposed to be called during the storm or immediately after?”

The poor officer told me the new administration had cancelled the plan and called into FEMA and was given a military reserve medical unit to cover the hospital.  “You are the first doc I have been able to find on my list of 20. Don’t worry about the curfew. If they stop you just show your hospital ID or driver’s license.  You’re good to go.”

I got dressed as did my wife and we threw the dogs into the car and headed for the hospital.  Every streetlight was out. Trees were down. Traffic signals were not working so each intersection was a treacherous four way stop sign situation.

As I turned onto Meadows Road my headlights lit up a big tree across the road and, off to the side, a roadblock with two military personnel in full battle gear signaling me to stop and roll down my window.  I showed my hospital ID and they told me I needed hospital ID for my passenger to proceed.  I told them it was my wife and she and the dogs would wait in the doctor’s lounge while I attended to the ER patient.

He said they were not permitted to accompany me to enter the facility area.   I told him to step aside or shoot us or get run over but I was going forward which I did. An MP met me at the entrance to the doctors’ lounge and, in language not repeatable in mixed company, I told him what he and his CO could do.  They backed off.

When I got to the ER I learned that one of my ocean front condo commando patients, who refused to heed the evacuation order, took the elevator down from the 18th floor to the lobby to view the storm. The power went out as he toured his lobby and he was trapped there.  He called 911 and was rescued by first responders and brought to the hospital because they had nowhere else to deposit him. Turns out he was constipated so they called me in to admit him.  I handled the administrative duties, told the new administrator what I thought of his decision to suspend our decade’s long program of collegially covering the hospital and each other’s patients and trudged home.

The FEMA medical team was sent packing the next morning as the medical staff chastised the administration for their poor decision making. This was one of administration’s first decisions which changed and ruined the community feeling of our small facility forever.

Staying focused prior to the storm is the hardest part.  Patients call in anxious and harried from the preparations and endless threatening updates and news flashes. Listening to the chronic complaints of your most anxious and worried patients and trying to sort out what is new, what is pertinent, what is important while your mind tries to stray to storm survival mode is a skill you are always trying to perfect.

The remaining shutters we use for the few remaining non-impact windows are ready to go. The windows have been sprayed with wasp and hornet spray so that we don’t get stung when the shutters and noise disrupt the hornet nests that pop up daily – which happened years ago. The work gloves are ready as are the work boots.  The WD40 is in great supply to make sure the Kevlar storm screen anchors easily screw in and out of their mooring holes.  We have three weeks of water and lights and batteries and nonperishable food.  The cars are full of gas. My wife is making extra ice for reasons I am not entirely certain of – but it cannot hurt to have it. The dogs have extra food ready.  Our quick escape “go bags” are packed and by the exits. Now all we can do is wait.

I head out for the office being extra careful on the wet and windy road because every driver is paying attention but distracted. The fender benders and aggressive driving due to anxiety have begun. Focus and stay safe.  That is the goal.

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Alzheimer’s Disease – More Insight

The August 1, 2019 issue of the journal Neurology carried a report of a team of researchers who have developed a blood test that can detect the presence of amyloid in the brain with 94% accuracy.  Amyloid is one of the chemical constituents found to be tangling up the neuron nerve communication pathways in humans with Alzheimer’s disease.

The article emphasizes this is currently a strict research tool. It is not a laboratory test that your physician or clinic can order or use to detect this form of dementia early. The results of the blood test correlate well with imaging studies currently in use. It is one small step in the investigation of the causes of this progressive, and fatal, heartbreaking disease and hopefully will allow us to evaluate Alzheimer’s at its earliest stages.

In a journal specifically dedicated to this disease entitled Alzheimer’s and Dementia, researchers at the University of California, San Francisco discussed the increased tendency of patients with Alzheimer’s disease to nap and sleep inappropriately and ineffectively. Previously it was felt that this inappropriate sleep pattern when observed was in fact a risk factor and marker for the development of the disease.

Lea Grinberg, MD and her co-authors feel it is a symptom of the disease instead. They believe that the disease process has already destroyed or inhibited those neurons (brain nerve cells) responsible for wakefulness and alertness. In the absence of this stimulation, patients nap and sleep ineffectively and inappropriately.

Imaging of these areas is difficult to obtain because of their location in the skull and brain but, on detailed studies, more tau protein deposition in these wakefulness areas is visualized.   This concept now allows researchers to zero in on other brain chemicals associated with wakefulness, alertness and sleep as a potential form of treatment of Alzheimer’s disease in addition to those chemicals in the cholinergic system that most medications attack.

Toxic Seaweed Washing Up on Florida Beaches Poses Health Problems

Local papers have been carrying the story of large amounts of seaweed washing up on Florida beaches and the cost of keeping the beaches clean.  A recent edition of the Miami Herald shows a photo of six women in bathing suits on the beach standing in the thick seaweed that washed ashore the previous evening.

In the July 12, 2019 issue of the Journal of Travel Medicine, Dr. Andrea Bogglid of the Tropical Division of Medicine Unit at Toronto General Hospital and Dr. Mary Elizabeth Wilson of the Harvard T. H. Chan School of Public Health, discussed the fact that the seaweed causes health issues. The seaweed is the Sargassum weed probably originating in Brazil. When it decomposes it releases hydrogen sulfide toxic gas which can cause palpitations, shortness of breath, dizziness, vertigo, headache and skin rashes.  The authors note that since 2011, larger than normal amounts of the brown seaweed have been washing ashore in Florida and the Caribbean Islands.  They report almost 11,000 case of the toxicity reported from the seaweed on the islands of Guadalupe and Martinique in 2018.

Part of the problem is that local governments tend to treat the seaweed as a sanitation issue rather than a health threat. Physicians have little experience in diagnosing and treating the problems the seaweed can cause to those exposed.  In most cases when patients seek medical help the diagnosis of Sargassum Toxicity due to prolonged exposure is a diagnosis of exclusion. Treatment is simply supportive with fluids and medicines to treat the symptoms.

It is believed tourists and those contracted to clean up the mess are at risk. The researchers, along with marine biologists, are suggesting aggressive cleaning up of the beaches with workers wearing appropriate protective gear. They also suggest hotels placing physical barriers to the seaweed in designated swimming areas to prevent their guests from contact and exposure.

Collusion or Conspiracy?

A 67 year-old woman with a high stress job had a vigorous disagreement with her neighbors last week. She developed severe substernal chest pain and called 911 fearing a heart attack. She is thin, has never smoked, has normal blood pressure and normal cholesterol. She is not a diabetic and runs on a treadmill for two hours at five miles per hour with an elevation for two hours four times a week. She has few risks for developing heart disease.

The ER staff was quick and efficient. An EKG revealed changes consistent with a multivessel involved heart attack. Her cardiac isoenzymes were elevated and abnormal confirming muscle injury. The ER doctor called her PCP and the cardiologist on call. This experienced interventional heart specialists on call, has worked with and cared for many of the PCPs patients. He came right over, explained the options to the patient and, with her agreement and the PCPs blessing, took her to the heart catheterization lab to perform an angiogram to find the blockages and restore blood flow to the heart muscles.

To his surprise her arteries were perfectly normal with no blockages. The heart muscle was pumping weakly exhibiting the appearance of an octopus swimming through the sea proclaiming the unusual heartbreak stress syndrome known as Takotsubos cardiomyopathy. With rest, time and reduction of stress; she was projected to recover fully in days to weeks.

She was monitored overnight and observed until her heart enzymes were normalizing, her heart rhythm was normal, and; she could walk around the room easily. She was medicated with a low dose aspirin, a low dose of a beta blocker to blunt the stress induced surge of chemicals that caused the heart damage and mild antianxiety medicines. She was advised to cancel her work schedule for two weeks, cancel a cruise scheduled for the upcoming weekend and see a psychologist for stress reduction.

She opposed each of these suggestions and demanded that I call her relative’s cardiologist for a second opinion. The very type A characteristics that led to her stress, anxiety and illness was creating the request for a second opinion. The diagnosis and treatment were straight forward.

I called her cardiologist to explain the request never expecting the reaction I received. He is successful and experienced but when I brought it up he became anxious, angry and defensive. Why? He said he was leaving the case! I begged him not to and called the cardiologist she requested for a second opinion.

“We do not do in-hospital second opinions because we wish to maintain collegiality. Let her call my office when she is home and we will see her as an outpatient.” She called that office for an appointment and was told the next appointment is in six months. I called three other groups and received the same answer of no second opinions on inpatients to maintain collegiality.

As a primary care, physician my decisions are questioned and second guessed daily. Dr Google, Dr Cousin in NY or Boston, retired neighbor doctor offer opinions on my care regularly. It comes with the territory.

An anxious fit senior citizen suffering a frightening and unexpected heart malady should be able to obtain a second opinion without threatening the egos or collegiality of professionals. I called the medical staff office and hospital administration for help and was told to work it out with my colleagues.

As we examine our dysfunctional health system, we are quick to blame insurers, big pharmacy and government interference. Medical doctors are not without blame.

Glucosamine – Heart Disease and Osteoarthritis

Glucosamine associated with chondroitin Sulfate is a supplement taken for joint health and to relieve joint pain. Several studies have shown unclear results regarding its efficacy in arthritis, but it has been shown to be safe.

A study in the Annals of Rheumatologic Disease suggested it reduced the symptoms of knee pain from osteoarthritis by modifying the inflammatory response not suppressing the symptoms as non-steroidal anti-inflammatory drugs do.  In the MOVES trial, glucosamine was compared with Celebrex (celecoxib) for relief of knee pain in osteoarthritis. At six months the two were noted to be equivalent in reducing pain. Glucosamine did not produce the gastrointestinal side effects that Celebrex and other NSAIDs can while reducing pain.

In an editorial, written in the online journal Primary Care, Dr. David Rakel looked at 466,000 patients entered into the United Kingdom Biobank database who took glucosamine products for arthritis. They were followed for seven years.  Over that period, the glucosamine users had a 15% lower incidence of cardiac events than non-users. Smokers showed a higher reduction in cardiac events – almost 37%.  They attribute this to a reduction in systemic inflammation as evidenced by a decrease in the inflammatory marker levels of C Reactive Protein in glucosamine users.

In general, glucosamine is usually taken at a dose of 750 mg twice a day.  It is combined with chondroitin which increases the viscosity of the synovial (joint) fluid. Glucosamine helps retain fluid in the joint. It usually takes about six to eight weeks to see a positive effect.   For reasons that are not entirely clear, it works best in lean individuals rather than obese ones.

Glucosamine is made from Crustacean shells so those people with a shellfish allergy should avoid it.

Is TMAO the New LDL CHOLESTEROL?

Prevention of heart disease has centered on smoking cessation, controlling blood pressure, achieving an appropriate weight, regular exercise, control of blood sugar and control of your cholesterol.  Despite addressing and controlling these items individuals still have heart attacks and strokes and vascular events. Researchers are now directing their attention to a dietary metabolite of red meat called trimethlamine N-oxide or TMAO.

Recent peer reviewed and published studies have shown an association between high blood levels of TMAO and increased risk of all-cause mortality and cardiovascular disease.  A 2017 study published in the Journal of the American Heart Association found a 60% increased risk of a major cardiovascular event and death from all causes in individuals with elevated TMAO.  Other research has linked high TMAO levels to heart failure and chronic kidney disease.

Our bodies make TMAO when choline and L-carnitine are metabolized by our gut bacteria in the microbiome. Red meat is particularly high in L-carnitine.  A study group at the Cleveland Clinic found that red meat raised the TMAO levels more than white meats or non-meat protein. They also discovered that red meat allowed more bacteria in the gut microbiome to be switched to producing TMAO. Of interest was the fact that the amount of fat in the food, particularly saturated fat, made no difference on the TMAO levels obtained.   Stanley Hazen, M.D. PhD, section head of preventive cardiology at the Cleveland Clinic, feels the TMAO pathway is “independent of the saturated fat story.”  The important issue to Dr Hazen is the presence of the gut bacteria to produce the TMAO from foods eaten.

Not all scientists buy into the TMAO theory of cardiovascular disease because of the relatively high level of TMAO found in many fish.  Some experts believe the beneficial effects of omega 3 fatty acids in fish offset the negative effects of TMAO. The leading researcher on TMAO says it is an evolving study and he is supported by experts who believe TMAO is “atherogenic, prothrombotic and inflammatory” per Kim Williams, M.D., chief of cardiology at Rush University Medical Center in Chicago.

There is even a blood test to measure TMAO levels developed by the Cleveland Clinic and available through Quest Labs.  Do not get too excited about asking your physician to order it on your blood because it requires eliminating meat, poultry and fish plus other food items for several days in advance of the test.

For many years researchers at the Cleveland Clinic and Emory University recognized that 50% or more of heart attacks occurred in men who followed all the risk reduction guidelines including stopping smoking, controlling blood pressure and lipids, losing weight and getting active. Perhaps the answer as to why will be in the TMAO research and the solution will be changing the gut bacteria or their ability to convert L-carnitine to TMAO.

Tick-Borne Powassan Virus Infections Are Increasing

As we begin the summer months, and people spend more time outside, we experience more tick-borne illnesses. Mention tick-borne illnesses and you immediately think of Lyme Disease which is the most common tick-borne disease in the United States.

A new tick-borne illness is emerging in the same geographic area that Lyme Disease is seen.   Powassan Virus (POWV) has increased from two cases reported in 2008 to well over 30 reported in 2017.  Two cases have been reported recently in New Jersey, including one fatality.

In Lyme Disease the tick attaches to the human body for 36-48 hours prior to the bacterium being transmitted to humans. In Powassan Virus this occurs within the first 15 minutes that the tick latches on. The incubation period can range from one week to one month with patients experiencing fever, vomiting, headache, weakness, loss of coordination, confusion, difficulty speaking and or seizures. The virus affects the central nervous system and can cause encephalitis and meningitis. One in 10 cases is fatal.  Recovery with permanent neurological damage can occur.

There are no medications or vaccines available to prevent or treat POWV infections. Treatment is supportive. Scientists believe the increase in ticks and POWV is a direct result of climate change.

Prevention is the key especially if you are going to be in an area known to have ticks. Experts suggest:

  1. Wear long sleeves and pants with socks pulled up over the bottom of the leg pants.
  2. Wear light colored clothes so ticks can be spotted on your clothing
  3. Use insect repellant with at least 20% DEET. Spray it on the exterior of your clothing and apparel
  4. Upon returning inside perform a thorough tick check.

This is an infection and virus most practicing physicians know very little about. There are no telltale warning rashes as in Lyme Disease.  Until more is known, prevention is the best option.