Passover and the COVID-19 Pandemic

Passover has never been one of my favorite holidays. As a child with nuclear families still within walking distance the work of changing dishes and silver ware, disposing of the chametz and cooking for 15 or more people made the event not very likeable. The seder’s were long while being conducted in a foreign language (Hebrew).  Even the attraction of having thick sweet red wine as a minor and getting a cash reward for finding the hidden matzo, were not enough to overcome the long tiring nature of the meal and storytelling.

It’s now 2020 and the world is suffering through a plague of its own. The numbers of sick and dying are simply numbing and force you to slow down and remember that each statistic represents a human being. This is someone’s loved one.

With that said my family is following the guidelines of staying home and social distancing. That will mean my grandson, who lives 60 minutes away with my daughter and wonderful son in law, will be having their holiday dinner in their home. They have been distancing for over three weeks now with no trips into the community except to walk the dog and to see her obstetrician.

My daughter lives in the zip code with the most cases in South Florida and she comments constantly that her young affluent neighbors fail to obey most of the restrictions and guidelines announced by the Governor and the Florida Department of Public Health and the CDC. Her sisters in Venice, California and Berkeley Heights, New Jersey will do the same. They are social distancing, staying home sharing their seders’ via Zoom. They will have company with their cousins in Boston, one working in a hospital with the Harvard School of Public Health and Washington, DC at Washington’s Children’s’ Hospital. Their parents from Naperville, Illinois will be in on the computer seder as well. We have no idea how this will turn out but, unlike usual years where I lead the seder service or split it with Uncle Alan, this one will involve assigned roles per Aunt Meryl.

The traditional food will be different as well. The days of me coming home from school and running to my maternal grandmothers’ apartment to see the white fish swimming in her bathtub prior to her making her own gefilte fish are long gone. In recent years, it has been finding the correct Jewish deli that makes its own fresh gefilte fish and chopped liver but even that is on hold due to the coronavirus outbreak.

If there is fish it will come from a jar. Without the chicken to make chicken soup our matzo ball soup will come from a can as well. The matzo will be real. The concord grape Manischewitz wine will be real. The Passover Farfel or a potato nick will be real and there are no dry Passover dessert cakes or macaroons. This year my daughter’ s birthday fell prior to the holiday so we are all spared her complaints that the holiday prevented her from having a “real” birthday cake.

This is not the year for community or restaurant or country club seders. This is the year to stay home, be thankful for your loved one’s health and look forward to better healthier times.

Immune Boosting Foods – Lessons from a Dietitian on the Front Lines

Allison Pingel is a registered dietitian working with the Moffit Cancer Center to provide patients with the nutritional knowledge they need to stay healthy. As we know, COVID-19 is a severe threat to those individuals with an impaired immune system. Allison talks about building a strong immune system by eating correctly on a consistent basis.

The construction of this strong immune response does not occur overnight but occurs over time when you give your body the correct nutrients. She is quick to point out that there are no scientific studies that document or prove that vitamin supplements are a good substitute for foods which provide these building blocks naturally. “Fruits and vegetables are a more economical and nutritious way to obtain your necessary vitamins and minerals as well as other nutrients that are helpful including fiber.”

“Foods high in Vitamins A, C D, E and zinc support the immune system.” She cites broccoli, berries, garlic, ginger and spinach as products containing high amounts of these vitamins which assist the body in fighting infections. She encourages yogurt and nuts as plentiful sources of probiotics and zinc, which she considers essential for building a strong immune system. Additionally, she is a strong advocate of fruits and vegetables. One and a half cups to two cups of fruit per day, plus 2-3 cups of vegetables per day, are helpful for building a strong immune response.

While eating correctly to build your immune system is essential, so is some regular exercise and activities that are social and put you in touch with others in a safe manner. As spring descends on our country, it’s a fine time to take a walk or ride a bike and say hello to your friends and neighbors from a safe distance. Just make sure you adhere to your community’s stay-at-home restrictions.

The COVID-19 pandemic is frightening but with healthy eating, regular exercise and safe social interaction we will prevail and come out of this crisis stronger.

When Can I See My Grandchild? Social Distancing – Today’s Norm

I have a neighbor down the block who is a talented internist, administrator and teacher. On his resume is a stint as the Chief Medical Officer at a large urban hospital and director of the medical doctor training program as well. We walk our dogs at a safe social distance daily and update each other on the latest news on the Coronavirus in Florida.

We are also both relatively new glowing grandparents of two-year-old boys living in Dade County. Both boys brought home a viral illness 10 days ago and, quite frankly, with no testing available, we do not know what they had. The only important item is that they both recovered, and their parents are not sick.

“Do you have any idea when I can safely see Hank,” he asked rhetorically? “The CDC told me he needs two negative Covid-19 tests at least five days apart to make sure it is safe for someone over 60 years to safely take that risk. It’s difficult enough to obtain testing for acutely Ill patients so why would I waste them in this situation”?

Initial papers out of Wuhan, China demonstrate that when a sick person recovers from this infection, they continue to shed live virus for days or even weeks. Researchers either are not sure, or do not yet know, if those viral pieces can cause illness in some other susceptible host. They are not sure how someone is still contagious after recovering?

Hopefully this information will be available soon. Until we know for sure I would advise high risk patients to stay away from recovered Covid-19 patients for a few weeks.

Tonight, my wife and I will drive down to South Miami for a family BBQ. My son-in-law, daughter and grandchild, plus their dog Mia, will be on one side of a fence in a covered area. We will be across from them separated by a fence using our own gas grill. We will stay separated by a minimum of 10 yards and prepare our own food.

We will talk in person, tell some stories, sing some songs and then make the long drive home.

 

Hugs, kisses and rides on my shoulders will have to wait for another time.

Life’s New Reality with Coronavirus aka COVID-19

We are bombarded daily with news about the spreading infections with CoronaVirus or Covid-19. With television, the Internet and other news mediums; the quantity, quality and accuracy of information can be overwhelming.

This single stranded RNA virus has managed to invade most of our populated continents and is now moving into communities. There is more we do not know about this pathogen than we do know.

Public health officials which include the Trump Administration, the CDC, the NIH and local health departments have been extremely tight-lipped on the clinical course of the hundreds of US citizens evacuated from infected areas and quarantined for 14 days.

We do not know if there are any telltale historical or clinical markers to tip us off as to whether the patient in front of us with a cough and low grade fever might have a run of the mill seasonal viral infection or Covid-19.

And, it is still unclear,

  • How long the virus stays alive on a surface and remains infective.
  • How long the incubation period is and how long in advance of demonstrating signs of infection asymptomatic patients can transmit the disease.
  • What role, if any, children, who seem to be less vulnerable to the disease, play in the transmission of the disease as asymptomatic carriers?
  • How a relatively healthy nonsmoking adult in their 30’s to 50’s will do if they catch the disease?

The recommendations on testing from the administration and CDC have been unrealistic based on the lack of availability of the testing labs and kits in affected states. This will improve with time, but will it improve to the level of the “quick, never get out of your car, drive-through testing” being done in South Korea? That story, covered by CNN, was both enlightening and disheartening. Enlightening by illustrating how government can institute a plan quickly and efficiently.   Disheartening realizing that with all our wealth and expertise in the United States we are not doing something similar.

The recommendations about prevention are commonsense. Do I really need to log onto the CDC website to learn that I need to wash my hands, avoid touching my face and stay home if ill?

The selfishness and entitlement of the American public make even asking these minimal changes in our pattern to be a major inconvenience and intrusion into our privacy. I see the Ultra Rock Festival in Miami and the Calle Ocho street festival have been cancelled smartly to prevent infection. At the same time restaurants are jammed, servers and food preparation individuals without sick leave and health insurance still show up at work ill, to serve and prepare food, and many chronological adults balk at giving up their restaurants, bars, clubs and shows to prevent the spread of disease.

Posters suggesting we stay six feet away from others are plastered on buses and train platforms of mass transit systems where if you can stay 6 microns away from another transit passenger it’s as if you are travelling in the First Class section.

If we are all fortunate, Covid-19 will ultimately be an annoyance in the low risk population. We will develop fast and effective ways to detect it and then, with knowledge of how it spreads, we will be able to provide advice on how to protect others.

I am just not sure today’s American public has the will, the determination or the sense of community, altruism and sacrifice of lifestyle needed to prevent a major health and economic crisis.

INFORMATIONAL RESOURCES:

Corona Virus – Update

I have been receiving multiple calls and inquiries from patients concerned about travelling within the continental United States and exposure to Coronavirus or its new name, Covid-19. To date, there have been NO cases identified in the general population outside the high-risk groups whose exposure came in China or from exposure to sick individuals who caught their illness from someone who had been to China. While the quarantine has slowed the spread of the virus here in the continental United States, there are still many unknowns such as:

  1. What are the different ways it is transmitted?
  2. Can asymptomatic persons transmit the disease before they become ill and how far in advance of symptoms can they be contagious?
  3. How long can the untreated virus live and transmit the disease on a surface such as a tabletop or doorknob?
  4. How aggressive is this virus? What percentage of the patients who contract the illness get minimally ill? What are the unexpected risk factors for severe complications? Why is the illness sparing children – for the most part?

If you have travel plans in the USA, I suggest you go. Given the season, it’s far more likely to contract illnesses such as cold or influenza.

When you travel, as always, wash your hands frequently and keep them away from your face.  Wipe down surfaces with antiviral commercial preparations frequently.

If you still haven’t received your flu shot, get one now!  Consider a second seasonal flu shot if it has been more than 3 months since the original one. However, expect to pay for the second shot since most insurers do not cover it.  Also, most pharmacy technicians will say you don’t need it.

Do not hesitate to call me if you are my patient and have any questions.

Staying Alive and Dog Ownership

A recent article published in the Journal of Circulation and Cardiovascular Outcomes looked at the effect of owning a dog on survival and mortality. The authors looked at research studies published between 1950 and May 2019.  They reviewed studies that evaluated dog ownership with all-cause mortality and cardiovascular related deaths. The studies looked at almost 4 million patients and 515 events.

Dog ownership was associated with a 24% risk reduction for all- cause mortality when compared to non-ownership with six of the studies showing a significant reduction in the risk of death. Those individuals who previously had a cardiovascular event had an even more pronounced reduction in the risk of death of all causes. When they reviewed the issue of cardiovascular death risk in dog owners who had a previous cardiac event, the risk reduction for cardiovascular death was 31%.  They reviewers dog ownership is associated with lower risk of death over the long-term, which is possibly driven by a reduction in cardiovascular mortality.

Two years ago my wife and I lost our treasured Pug of fifteen years, “Pug sly” and his sweet mix breed partner “Chloe.”  Losing these two a year apart was like losing beloved family.  We adopted a rescue Pug and then young pup who had been returned to its breeder.  At our first dog checkup with the new pets and our vet my wife expressed concern that at our age the dogs might out-live us. Our vet told us that if that were to occur, and no family members wanted the dog, he and his family would adopt them and care for them. He said that practice is common in many practices and they encourage senior citizens who can provide a loving and caring home to not worry about that aspect of continued care and adopt a dog.  While there is no data on this topic, I suspect pet ownership of cats and birds and other domestic animals requiring care and love confers similar benefits.

PLCO Data Support Protective Effect of Aspirin in Preventing Deaths

In recent months, the US Preventive Task Force has recommended adults without diabetes or documented coronary artery disease avoid taking baby aspirin to prevent heart attacks and strokes. They believe the risk of bleeding outweighs the benefit derived. They still recommend aspirin prevention in men with known cardiovascular, cerebrovascular disease and diabetes.

The Prostate, Lung, Colorectal and Ovarian Cancer Trial (PLCO) just made the decision-making much more complex. In their study, reported in this month’s JAMA Network Open, they found that taking aspirin as infrequently as 1 to 3 times per month reduced the risk of all-cause and cancer related mortality compared to no aspirin in their study with 146,152 patient participants.

Weekly use of aspirin significantly reduced the risk of mortality from both GI and colorectal cancer and all mortality endpoints irrespective of how heavy you were. When the study looked at 12.5 years of aspirin use 1 to 3 times a month, compared to none, the all-cause mortality was reduced by 16%. The results were even more encouraging when aspirin was taken three or more times per week.

The PLCO Cancer Screening Trial involved participants aged 55-74 who were randomized to a cancer screening group or a control group at 10 United States Medical Centers. This review looked at men and women 65 years or older at baseline. While this study showed a beneficial effect of aspirin in the elderly, other recent studies have been less favorable. The ASPREE study, Aspirin in Reducing Events in the Elderly, found that individuals taking 100 mg of aspirin daily were at increased risk for all-cause mortality compared to those taking a placebo.

The decision to take low dose aspirin, or not, is something you should discuss with your physician so that you can tailor the situation and risks to your personalized needs.

Talcum Powder Does Not Cause Ovarian Cancer

Katie O’ Brien, PhD, of the National Institute of Environmental Health Sciences in North Carolina reported a study in nearly 250,000 women over an 11 year span that showed that talcum powder does not contribute to the development of ovarian cancer, The study was published in JAMA, the Journal of the American Medical Association.

The study found that in women who used talcum powder in the genital area, a total of 61 cases per 100,000 persons years was detected. When they compared that to women who never used talcum powder in that area, they found 55 cases of ovarian cancer per 100,000. The difference between users of talcum powder developing ovarian cancer by age 70 compared to nonusers was just 0.09%.

The concern about talcum powder use and cancer occurred in 1976 when asbestos was found in talcum powder. Most talcum powder is felt to be asbestos free today.

Making Sense of the Corona Virus Outbreak in China

The news media has been extensively covering the outbreak of a new virus that causes upper respiratory symptoms. What is known is that it probably originated in bats in a cave and passed through animals and is now infectious to human beings.

The first cases were reported as originating in a fish market in Wuhan, China that illegally sold exotic animals as well. Sources have reported on this new illness for months with much of the information being suppressed by the Chinese government.

Wuhan, China is home to a first-class, state-of-the art virology research lab. That lab’s main researcher has been urging infectious disease experts to evaluate these corona viruses for years while receiving little reward for her efforts. She reports that the previous epidemic of SARS is caused by a corona virus as well.

At this point, researchers from the World Health Organization (WHO) and the US Center for Disease Control (CDC) are attempting to obtain enough information to evaluate how much of a threat this new illness represents. We do not yet publicly know the exact incubation period. We do not know the length of time an individual is a contagious carrier prior to symptoms developing. Some have claimed you are contagious for about two weeks before symptoms appear. This is not consistent with a Vietnamese visitor to Wuhan who returned home ill and his family in Vietnam were all ill with the new coronavirus within three days. We do not know how aggressive this disease is yet.

Are the fatalities from it primarily in the infirm, very young and very old or does the disease strike down the fittest and healthiest as well? Are the deaths in China due to the lack of availability of modern health care, respiratory treatments and medications?

More information should be forthcoming soon. An evacuation of 200 Americans from Wuhan this week, to a military base in Riverside, California, for a voluntary quarantine should provide valuable data. These frightened but responsible individuals will be monitored and treated and studied.

Of interest to me was an article in the NY Times weekend edition by a “medical historian” who outlined the lack of success in containing infectious diseases we have had when no medications or treatments for these diseases existed. As I read it, I kept thinking that while the quarantines were certainly not 100% effective, what data exists to predict the infection severity and mortality that would have occurred if the quarantines had not been put in place?

As a doctor who regularly sees individuals with acute upper respiratory illness, I am comfortable with the CDC’s initial recommendations of avoiding travel to China, hand washing, wearing a mask and taking a travel history on your patients presenting with upper respiratory tract symptoms.

For those of you looking for more information on the new Corona Virus I suggest accessing the online infectious disease newsletter produced by the University of Minnesota School of Medicine called CIDRAP at http://www.CIDRAP.com. They cover this illness, Ebola, SARS, MERS (Middle Eastern Respiratory Syndrome) Bird Flu, food poisoning outbreaks due to infectious agents and other infectious diseases worldwide. If you read that newsletter you will be informed, and frightened, by the reality of what is out there.

Blood Test Detects Gastrointestinal Cancers

David Wolpin, M.D. MPH of the Dana-Farber Cancer Institute discussed with online periodical MedPage Today the results of his research on detecting gastrointestinal cancers with a simple blood test. The test is not yet commercially available and is still in its developmental stages. The blood test did not detect cancer in 2000 cancer free individuals but did find it in the 135 GI cancer patients being evaluated at the Dana-Farber Cancer Institute. In most cases they were able to pinpoint the location of the malignancy in the GI tract based on the testing used. The more advanced the cancer, the more accurate the blood test was.

The report was part of a larger study named the Circulating Cell-Free Genome Study. This is a multi-center trial looking at over 15,000 individual patients from over 142 different medical institutions. The hope is that as the sophistication and accuracy of the test are improved, the ability of physicians to detect cancers early would improve as well.

Dr. Wolpin reminds us that most cancers that occur in the gastrointestinal tract are difficult to find and screen for and are detected at an advanced stage. He hopes that lives can be saved by finding the cancers early with a simple blood test.