EverythingHealth

Covid Saliva Testing - Cheaper is Better

noreply@blogger.com (Toni Brayer, MD) — Fri, 04 Sep 2020 00:32:00 +0000

Saliva testing for Covid-19 may just be better than nasal swabs and cheaper too. It's preliminary, but Yale University has published a letter in The New England Journal of Medicine that showed saliva testing from the mouth picked up more positive Covid-19 patients than nasopharyngeal swab testing.

The patients they studied were already hospitalized and had tested positive for Covid-19. They re-tested them with nasal and saliva tests and found at 1 to 5 days after diagnosis 81% of saliva samples were positive compared to 71% of the nasal swabs. And at 6-10 days after diagnosis, 76% of the saliva samples were positive, compared with 65% of the nasopharyngeal swab specimens.

This is important because of the shortage of medical supplies, inability to self test nasal swabs, and the ability of using common and available reagents in the saliva test. If one reagent is out of stock (or price gouging is going on), another can be used. Yale is sharing their protocol so others can replicate it, similar to "open-source" in tech.

The Yale SalivaDirect test should help with test cost, availability, ability to test in schools and businesses and the ability to self-test. Now all we need is a point-of-care (POC) test that gives us an instant answer like a home pregnancy test. This is being studied at the University of Illinois and I look forward to their results.

Imagine that! Developing something to benefit others with scientific integrity! Way to go, Yale!

Covid-19 and Convalescent Plasma

noreply@blogger.com (Toni Brayer, MD) — Wed, 26 Aug 2020 22:26:00 +0000

This week, President Donald Trump announced the emergency use authorization (EUA) for convalescent plasma to be used to treat Covid-19. The "groundbreaking therapy" was announced at the White House after he accused the deep state at the FDA of delaying approval of therapeutics to hurt his re-election campaign.

Folks, this is politics getting mixed up again with science. The real question is: Is convalescent plasma effective in treating Covid-19?

Health experts are saying the early results are promising but we don't yet know if it works. Convalescent plasma is taken from the blood of people who have recovered from Covid-19 infection and have developed antibodies. If it works, those transfused antibodies will help the recipient of the plasma fight off the infection.

Currently there are fifteen randomized controlled clinical trials (and 54 other studies) looking at the effectiveness and one has shown preliminary success when given to patients under 80 who aren't on a ventilator within three days of diagnosis. These trials are at large academic centers and the studies have had some difficulty getting patients enrolled as they need to volunteer for a trial. Not all patients with Covid are near a trial center.

The bottom line is this; Convalescent plasma has been shown to help seriously ill people with other viral infections. It may be useful for serious Covid patients but we cannot say for sure who would benefit until the trials are completed. It is probably safe but the EUA may limit enrollment in the clinical trials which would give us the data we need.

If I had severe Covid-19 and was going downhill in the hospital, I would want to be given convalescent plasma. But I have no idea if it would help or not.

Your Blood Type Doesn't Affect Covid-19

noreply@blogger.com (Toni Brayer, MD) — Sun, 23 Aug 2020 00:24:00 +0000

We are at least eight months into the Covid-19 new pandemic and we are quickly learning about this virus and how it affects our bodies. A few weeks ago there were reports that a person's blood type might protect them from getting the infection. We now know this is not true. But first, a quick tutorial on human blood type.

Each of us inherits our blood type that is carried by an antigen on our red blood cells (RBC). The RBC is the largest quantity of blood cells in our body and is mainly designed to carry oxygen to our tissues. Each of us is either Type A, Type B, Type AB or Type O with a protein that is either positive or negative and is called Rh factor. We know that these types are critical in blood transfusions and receiving the wrong type of blood will cause a severe reaction. Every time a person is administered blood they get a "type and cross" that checks the blood type and makes sure the proper transfusion is given. People with Type O blood have no antigens so they can be given to all blood types and are called the universal donor.

It is nice speculation that a blood type might be Covid protecting but the peer-reviewed data does not show any difference.

Harvard Mass General just reported on an observational study of 1289 Covid positive patients. They ranked them for race, age and co-morbidities and wanted to know if blood type had any effect on the severity of the Covid illness. They looked at admit, ICU admit, intubation and death and found that there was no difference between any of these outcomes and a patient's blood type.

Because we know inflammation plays a role in severity of illness, they also looked at markers of inflammation and blood type and found no difference.

Scientists will continue to learn more about Covid and how it behaves and why certain people have worse outcomes. For now it's not blood type.

Don't Believe Mr. Pillow Guy

noreply@blogger.com (Toni Brayer, MD) — Wed, 19 Aug 2020 19:49:00 +0000

I'm rather disappointed that I even need to write this blog. But this is the age of "Anti-Science" and it seems there are a lot of impressionable people - people who would believe a Mr. Pillow huckster- about how to deal with the Covid-19 pandemic. So let me spare you reading and give you the cliff notes to this blog:

DO NOT TAKE OLEANDRIN TO PREVENT OR CURE COVID-19.

Nerium Oleander is a highly toxic plant. I grew up with Oleander bushes as yardscapes because they produced lovely flowers, could be trimmed into hedges and grew like weeds. But even I knew, as a child, that they were poisonous and all parts of the plant are dangerous if ingested by animals or humans.

This should not even be a story, except that The My Pillow Guy, Mike Lindell, inventor, businessman, entrepreneur and friend of Donald Trump, claims he is inspired by the Bible to promote Oleandrin as a preventative and a cure for Covid-19. He has invoked Dr. Ben Carson, Secretary of HUD as a proponent also to give credibility to his claim. Lindell is newly on the board of Phoenix Biotechnology, a company that is making the substance as a nutraceutical, meaning it can be promoted without the oversight of the FDA.

"Its the miracle of all time", boasts Lindell, "the media is trying to take away this amazing cure." Lindell claims he and friends have taken the substance and that there are peer-reviewed studies that show its success. '

There are no such studies.

This would hardly make news, except for the fact that President Donald Trump stated he is "looking into it" and that Lindell is his good friend. Given the Hydroxychloroquine scandal that distracted scientists and confused the public during a lethal pandemic (172,000 U.S. deaths today, August 19, 2020), the fact that we are again being told about a dangerous and unproven remedy is truly shameful.

Five Conditions That Are Risky for Covid-19

noreply@blogger.com (Toni Brayer, MD) — Wed, 29 Jul 2020 06:06:00 +0000

Why do some people get severe illness and even death with Covid infection, and others develop a mild illness or no symptoms at all? One of the answers to that question is the five associated conditions that we now know lead to severe Covid -19 infections. These five underlying conditions increase the risk for severe Covid-19 and they are highest in counties in the Southeastern United States and in more rural counties and urban areas.

People with one or more of these conditions had hospitalizations that were six times higher, ICU admissions that were 5 times higher and deaths 12 times higher that people without the conditions.

High risk conditions for severe Covid-19:

Chronic kidney disease (CKD)
Chronic obstructive pulmonary disease (COPD or Emphysema)
Diabetes
Heart Disease
Obesity, defined as having a body mass index (BMI) 30 or greater

Now get this! In the United States the median prevalence of any of these 5 health conditions is 40.7%. Some Counties were over 50% prevalence.

Obesity -30%
Diabetes - 11.4%
COPD - 6.9%
Heart Disease - 6.8%
CKD - 3.4%

The United States has close to 150,000 deaths from Covid-19 and that number is predicted to increases over the next four weeks. Today we reported 54,448 new cases.

This is the time to really take stock of our health infrastructure and personal health. Every one of the conditions listed above is preventable with nutrition and what we eat.

We should start with National policies to address food deserts in communities where fresh fruits and vegetables cannot be found and every block has a liquor store and a fast food drive-through. Its shocking to realize so many Americans get their groceries at the Dollar Store.

Thirty million children get subsidized school lunches. We could start there and quit serving high fat carbs that are on the outdated "food pyramid".

American School lunch

In France the school lunch is a vegetable starter, a warm main course served with a side of grains or veggies, cheese and dessert.

French school lunch

Every community has vacant space with weeds and blight. These could be turned into organic community gardens, providing food and education. Community centers should offer free cooking classes for adults and children (with masks and social distancing, of course).

We should think of food as medicine. It starts with brutal acknowledgement of the problem and instituting public policy and funding to start making changes. Not so hard!

I Have Gout - Now What?

noreply@blogger.com (Toni Brayer, MD) — Wed, 15 Jul 2020 23:16:00 +0000

Any Doctor will tell you that in medicine, things come in threes. As expected, I diagnosed three cases of gout this week. If you have been told you have gout you may wonder "Now what?"

Gout can affect anyone and it usually occurs quite suddenly, often at night. It is caused by uric acid crystals that deposit suddenly in a joint, most commonly the big toe, but any joint can be affected. Patients describe deep throbbing pain that is very intense and sometimes even a sheet touching the joint can cause exquisite pain. The pain is worse within the first 12 hours.

Uric acid is present in our blood and gout occurs when the urate levels are too high and deposit crystals in the joint. Uric acid is made from purines that are broken down from certain foods such as steak, seafood and organ meats. Alcohol and juices sweetened with fructose are also causes of excess purines. Usually uric acid is excreted in the kidneys but if there is an excess in the blood or if the kidneys can't excrete fast enough, the crystals lodge in the joint and cause gout. The joint becomes red, painful and swollen.

If you have a first gout attack, your doctor can get a blood uric acid level and usually make the diagnosis. If there is confusion, a sample of the joint fluid will show gouty crystals under a microscope. Pain is relieved with Nsaids and ice on the joint.

To prevent a gout attack in the future consider these factors noted by the Mayo Clinic:

Diet. Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, which increase your risk of gout. Alcohol consumption, especially of beer, also increases the risk of gout.
Obesity. If you're overweight, your body produces more uric acid and your kidneys have a more difficult time eliminating uric acid.
Medical conditions. Certain diseases and conditions increase your risk of gout. These include untreated high blood pressure and chronic conditions such as diabetes, metabolic syndrome, and heart and kidney diseases.
Certain medications. The use of thiazide diuretics — commonly used to treat hypertension — and low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.
Family history of gout. If other members of your family have had gout, you're more likely to develop the disease.
Age and sex. Gout occurs more often in men, primarily because women tend to have lower uric acid levels. After menopause, however, women's uric acid levels approach those of men. Men are also more likely to develop gout earlier — usually between the ages of 30 and 50 — whereas women generally develop signs and symptoms after menopause.
Recent surgery or trauma. Experiencing recent surgery or trauma has been associated with an increased risk of developing a gout attack.

Gout was once called the "Disease of Kings" or "Rich Man's Disease" as this old painting shows. Only royalty could afford meat and alcohol. You can manage recurrent gout attacks with diet and if that doesn't work, prescription medications that block excess uric acid.

Why I Don't Check Covid Antibodies in Patients

noreply@blogger.com (Toni Brayer, MD) — Tue, 14 Jul 2020 17:28:00 +0000

We are (at a minimum) 5 months into the worldwide Covid-19 pandemic that has upended all of our lives. We have been told "testing, testing, testing" is needed and will be our way out to get back to normal. There is still massive confusion about testing so let's try and make some sense out of it.
First some definitions:

The Covid-19 nasal or throat swab test - This is the test that we are promised "Anyone can get" and most of the time it will reliably diagnose Covid infection. These tests are now provided in labs, drug stores, drive through testing and some specialized medical offices. Because they deal with patients who might be infected, the front line testers have to have full PPE to protect against the virus. Depending upon the test, the results are ready between 24 hours and up to a week. This test has up to a 20% false negative rate, meaning it will say there is no infection, even if a person is infected. The test has to capture the virus when it is most active to be positive and the test has to be processed correctly to give accurate results. If a person has symptoms that are suspicious of Covid with a negative test, they should have a follow- up test before it is considered accurate.

This test tells you if you have Covid-19 at that point in time.

The Covid-19 antibody blood test - This test uses special chemiluminescent immunoassay technology or lateral flow assay technology to test blood samples and see if a person has antibodies showing current or past infection with Covid -19.

This test is currently very problematic and I do not recommend patients get this test as it does not function as an "Immunity Passport" and allow a person to feel safe with Covid. There are many hundreds of these tests that flooded the market when the FDA originally let them be sold without strict guidelines. Even the ones that are now approved do not give us the information we need.

We don't know what positive means because it can pick up other corona viruses
We don't know if having the antibody confers immunity and we don't know how long immunity would last.
We don't know if a person who had Covid-19 could get it again
Most insurance is not covering this test

The current antibody test is useful for public health experts to figure out the prevalence of the virus, the hot spots and the fatality rate. But even those studies need to be very carefully done to capture the entire population since we know Covid-19 is disproportionate in it's infection rate and severity.

Patients often ask for the antibody test because they want to travel, visit grandparents, return to school, return to work or just know if they are personally safe. I wish we could give them that answer but it's not yet ready for prime-time.

Burn Care. What You Should do at Home

noreply@blogger.com (Toni Brayer, MD) — Mon, 13 Jul 2020 00:45:00 +0000

Approximately 500,000 patients In the United States seek medical care for burns each year and 92% are treated as out-patients, according to the American Family Physician. Burns are classified by depth.

Superficial burns are called first degree. They are localized to the outer (epidermal) layer and are painful, red and dry. These burns do not blister and they take about 3 days to heal. A bad sunburn or quick stove burn is a first degree burn.

A first degree burn. Ouch

Partial thickness burns are called second degree. The epidermal layer is destroyed and they are very painful and usually blister. Most will heal within three weeks or sooner.

2nd degree burn with blister

2nd degree burn and after healing

Deep partial thickness burns involve the reticular dermis underneath the epidermal layer and they are usually dry. These are third degree burns. They take more than three weeks to heal and often cause loss of skin and scarring. Deep partial thickness burns should receive immediate medical attention and sometimes even need skin grafting.

Deep third degree burn

Full thickness burns extend through the entire dermis and into underlying fat and connective tissue and require admission to a burn center for treatment. Surgical intervention and skin grafting are needed.

For all types of burns the first thing to do is minimize the extent of burning, clean the wound and address pain. For scalds or sunburn remove the clothing immediately, including watches, belts, jewelry and diapers. Actively cool the burn surface with running tap water for at least 20 minutes. Ice should not be used because it causes the vessels to constrict and may increase the tissue injury. Using regular tap water (instead of sterile water) does not increase infections. Superficial burns do not require dressings for healing but covering the burn with wet gauze and aloe vera cream can help with pain.

What if it's a 2nd degree burn with blistering? If it is a small blister just leave it. It it is large and causing pain it is OK to puncture it or remove the blister, allowing the dermis underneath to heal.

There are pros and cons with every topical antibiotic cream used in burns. If you are treating at home, mupirocin (Bactroban) is the best for antimicrobial coverage and it can be used on the face. It does require a prescription. Even vaseline can help seal in moisture while it heals. The burn should be checked frequently and a new dressing applied.

At the emergency department they will often used advanced dressings that are kept on the burn for 14 days and it is especially helpful with children.

Remember to give pain medicine like acetaminophen (Tylenol) or Nsaids (ibuprofen, Motrin) early for superficial and partial thickness burns.

If you aren't sure how deep the burn is, or it covers a large portion of the body, go to the ER. Inhalation, electrical or chemical burns need professional treatment. Burns to the face, hands, feet, major joints, genitalia need professional treatment.

Hydroxychloroquine for Covid-19 is Dead

noreply@blogger.com (Toni Brayer, MD) — Sun, 24 May 2020 03:34:00 +0000

Physicians and Scientists everywhere, led by Anthony Fauci, have been saying "Lets wait for the data on Hydroxychloroquine as a treatment for Covid-19". Well, we now have that data and it is irrefutable that Hydroxycholorquine and Cloroquine, with or without a macrolide antibiotic (Azithromycin), does not work for Covid-19 and, in fact, causes increased death.

In case you are wondering about the guy who says "Hey, my uncle has been taking it and he got better in six hours", or "Hey, I know lots of people who take it every day and they are just fine", let me explain this Lancent study for you.

The researchers studied 671 hospitals on six continents involving 92,036 patients. They looked at hospitalizations from Dec 20, 2019 through April 14, 2020. Patients who were given Remdesivir were excluded. The mean patient age was 53.8.

They formed two groups, a control group given standard treatment and a Hydroxychloroquine or Chloroquine group with and without receiving azithromycin. In every single group, the mortality was higher in the Hydroxychloroquine/Chloroquine/Azithromycin groups. Every. Single. Group.

This is the scientific method. Anecdotes are fine but they don't really give us safety or efficacy information. Not only does Hydroxychloroquine not work, it caused decreased survival. That is the final nail in the coffin and we don't need to speculate that this is a "game changer" anymore.

People are free to do what they want as long as it doesn't hurt others. They can believe the liberals are blocking doctors from giving life-saving treatments. They can believe something they read online instead. All we can do is give valid information, backed by rigorous science.

Covid Fatigue...the Good and the Bad

noreply@blogger.com (Toni Brayer, MD) — Fri, 15 May 2020 21:07:00 +0000

We have entered a new phase of the global Covid-19 pandemic. After 9 weeks of shut-down in some areas, twenty-four hour a day news, and our lives completely disrupted, many are entering into a phase of Covid Fatigue.

The adrenaline rush that has sustained front-line caregivers is starting to wane and the grind of wearing uncomfortable PPE and seeing the virus described as a hoax makes crawling out of bed an effort. Essential service people like food supply chain (farmers, pickers, packagers, processors, transporters, stockers and grocery clerks) have been doing double duty, caring for children, managing their own lives as well as going to work every day with fear. And this includes police, firefighters, sanitation workers, food prep, cleaners, your local cable guy and everyone working from home too. Covid Fatigue is part depression, part anxiety, part fear with a hint of hopelessness thrown in.

"Will this ever end? Will I have a job? Will I be homeless? Should I close my business? Will I get an education? Will I ever see grandma again?" Unanswered questions cause overwhelming fatigue.

The current state will end. These questions will be answered and some pieces of normal will return. But this crisis has changed us forever and since we are in the middle of it, we cannot know exactly how. Here are a few ways I believe we will be changed and they are all good:

We won't go to work or school sick any more. There isn't a doctor I know that doesn't go to work sick as a dog and see patients when they should be home resting. Because of our lack of national sick leave policy, many people work sick. This will change and it's high time. And we need to push for employee rights immediately so people have paid sick leave. As voters, we must insist upon this.

A light is shined on the need for universal health coverage. The government is patching holes now by covering Covid testing (although the details are murky and providers aren't sure they will be paid). What about Covid treatment? What about the vaccine and the other health problems that lead to a worse outcome with Covid infection? We can no longer ignore the health disparity and need for healthcare for all. As voters, we must insist upon this.

We should no longer ignore the funding of Public Health. In other more enlightened countries, public health infrastructure was available to stop the virus spread with less disruption than the US. Our scientific and protective government agencies are needed. Period. End of Discussion.

People are learning to cook at home again. This is a healthy trend and could lead to more home vegetable gardens, less CRAP diets (Calorie Rich And Processed) and a focus upon nutrition. Covid is especially cruel to people who are overweight, have hypertension, diabetes and liver disease. All of these co-morbid conditions can be prevented or improved with diet. The more we learn to home cook, the better control we have with what we eat. And we need a national focus on communities with "Food Deserts" ie: no fresh grocery stores. As voters, we must insist upon this.

The air is clean. For people who have known nothing but smog and grey sky and polluted waterways, seeing what is possible and enjoying fresh air should make us demand change. We know how to avoid pollution. Do we have the will to continue it?

Animal Shelters are empty. Could this be the end of puppy mills? People taking time to care for pets is a win-win for the animals and our emotional health.

There are many more benefits and lessons learned. Think of others. The universe is giving us messages and though the learning is painful, we need to listen.

Antibody Testing for Covid- Not So Fast

noreply@blogger.com (Toni Brayer, MD) — Fri, 08 May 2020 18:51:00 +0000

Image from The Verge - Vox
I wrote a couple of weeks ago about the importance of having antibody testing for Corona Covid-19 as a pathway forward for resuming activity and work. Antibody tests are now being offered at urgent care clinics, private doctor offices, Labcorp labs and by the time you read this, there may be home antibody tests offered from ads online.

I'm getting many requests a day from patients who think they had Covid if they had any illness from December onward. "I want to know if it is Covid and if I am immune." It is vitally important for us to know who has had the virus, who is immune from future exposure and who is safe for asymptomatic passing of the virus. But...and this is a big BUT...antibody testing today is NOT READY FOR PRIME TIME.

Let's break this down. Why?

The FDA has relaxed its usual standards and has permitted emergency use authorization for antibody testing. This means Neighbor Joe can get some funding, throw some reagents together and develop an antibody test that may have no standards for reliability. There are now over 90 tests on the market and we don't know if they work. On May 4, the FDA acknowledged fraudulent tests and are requiring data showing accuracy within 10 days. It is unknown how they can police all of the tests out there.

Robert Gallo, co-founder and director of the Institute of Human Virology says "I'm waiting for the ultimate good test".

For antibody testing to work in a disease that affects 2-3% of the population, we need a test with at least 99.7% specificity. That means we need too know it is giving results for Covid-19 and not cross reacting with residual viral RNA from another Corona virus like the common cold.

Here is what we don't know about Covid-19:

We don't know at this time if the presence of antibodies to Covid-19 grants immunity or for how long.
We don't know if a person can be reinfected
We don't know if serum therapy from patients who have had the virus can be given to very sick patients to help them recover with antibodies
We don't know how many false positive antibody results there are when we look at infection rates.
We don't know how many false negative antibody results there are when people had the virus but the test is negative.
We don't know if the formation of Covid antibodies varies by age. (In the common cold virus, people over age 60 form more antibodies). We don't know how many antibodies are optimal to have.

The FDA usually insists on rigor before they approve things. As consumers and patients, we should appreciate these standards. Otherwise we have the chaos that is plaguing us now and causing undue anxiety and confusion.

We need to give scientists the time to do their jobs and these questions will be answered. Can we live with uncertainty? Covid -19 is teaching us how. We need to listen.

The Hype About Coconut Oil Benefit Is False

noreply@blogger.com (Toni Brayer, MD) — Sun, 03 May 2020 01:30:00 +0000

The benefits of using coconut oil has been hyped online, in the press and in diets with stories of its benefits for health. If you google coconut oil you will see it being touted for weight loss, antimicrobial effects, calorie burning, improving good cholesterol, reducing seizures, and boosting brain function in Alzheimers.

This shows just how misled the public can be with fads and brilliant marketing by the industry. The coconut oil and related industries have been very successful in calling coconut oil a natural, healthful product. Their marketing worked! The New York Times commissioned a survey in 2016 that showed 72% of the public said coconut oil is a healthful food. Actually studies from as far back as 1955 show coconut oil is not a heart healthy oil. And here is more evidence based truth:

Clinical trials (Reported in JAMA, April 8, 2020) showed that coconut oil, compared to other vegetable oils, increases low density lipoprotein cholesterol. Low density lipoproteins (LDL) are the bad parts of the molecule that increase cardiovascular risk. Many other studies in the past have shown the same outcome, but somehow the public is not getting the message. Coconut oil in the diet offered no improvement to weight, blood glucose or inflammation markers.

Much of the coconut oil marketing and allure relates to misconceptions about lauric acid, a saturated fatty acid that makes up about half of coconut oil's fatty acid content. Proponents of coconut oil argue that as a medium-chain fatty acid (MCFA), it bypasses the liver and can be used for energy production rather than getting into the liver and affecting cholesterol synthesis. But that is not how lauric acid works and it is absorbed in the gut and goes into the liver.

So what does all of this mean? Simply said, coconut oil is not a healthy oil, it is high in saturated fats and using it will increase cardiovascular disease risk.

Coconut oil is fine for removing makeup and conditioning your hair. Coconut water does not have fats and studies show it is equivalent to water in rehydration and performance of athletes. It won't hurt or help you.

The Nine Symptoms that Go with Covid-19

noreply@blogger.com (Toni Brayer, MD) — Mon, 27 Apr 2020 23:59:00 +0000

The Centers for Disease Control and Prevention (CDC) have added to the list of symptoms that reliably go along with Corona Covid-19 infections. The nine symptoms are:

Chills
Shortness of breath
Fever
Cough
Rigors (shaking chills often followed by sweating)
Headache
Muscle pain
Sore throat
New loss of taste or smell

One or more of these symptoms are reliably present in documented Covid infections and can be a guide for patients to watch out and isolate early if any of them occur. A patient doesn't have to have all of the symptoms, but as the infection progresses more may occur. Fatigue is also often what patients report and we are also seeing blood clots, chest pain and and pressure.

I've answered a number of questions from patients who have GI symptoms like diarrhea, abdominal cramping and nausea and wonder if it is Covid-19. Those symptoms alone are not likely to be Corona Covid-19. The Corona virus is specific for the respiratory tract and symptoms always involve the lungs.

I hope that many people have contracted the virus and are asymptomatic (no symptoms at all). Although that can sound risky for passing it to others, those asymptomatic people should have some immunity going forward.

We keep hearing about testing testing testing as the way to open up society. A reliable (that word should be in caps: RELIABLE) antibody test to show who has been exposed to the virus in the past and cleared it from their system, is critical for getting our lives, jobs and society back.

Loss of Taste and Smell common with Covid-19

noreply@blogger.com (Toni Brayer, MD) — Fri, 24 Apr 2020 00:07:00 +0000

Over the past month doctors and researchers are gaining more information as we make our way through the novel Corona Covid-19 virus. We now know that a high number of patients diagnosed with Covid-19 have a sudden loss of smell (anosmia) and/or taste as a presenting symptom. Some of these patients have no other symptoms and remain otherwise well, yet testing shows they do, in fact, have the virus.

The American Academy of Otolaryngology-Head and Neck Surgery CEO, Dr. James C. Denneny, believes the symptoms could be an early warning signal and patients with acute onset loss of smell or taste should have a high index of suspicion for Covid-19 (also known as SARS-CoV-2) infection.

Since Covid-19 is extremely contagious, any early hints that someone could be carrying the virus would be a clue to get tested and go into quarantine.

The CDC puts out a weekly report called Morbidity and Mortality Weekly and in a study of 5000 healthcare workers who reported symptoms, 750 (16%)s wrote loss of smell or taste as an "other" symptom. Similar symptom trackers using a smartphone app showed similar numbers (18%).

Other viruses like influenza and corona virus can also affect smell and taste so these symptoms alone are not enough to diagnose Covid infection but coupled with fever, fatigue and cough, the predictive value is high. The reason for this sensory loss is not known, but there may be ACE 2 receptors on the olfactory mucosa and recent studies have shown these receptors are the entry pathway for the virus.

My hospital and clinics have incorporated the taste and smell question into our screening tool for testing. I want to note that we are still NOT doing serum testing for antibodies to Covid-19. The current tests are nasal swabs that show active infection or not.

Leaving WHO is a Huge Mistake

noreply@blogger.com (Toni Brayer, MD) — Wed, 15 Apr 2020 20:17:00 +0000

Donald Trump's declaration that the United States would stop funding the World Health Organization in the middle of a global pandemic sent shock-waves through the medical world.

Less than twelve hours later, the American College of Physicians (the largest medical specialty organization in the United States with members in 145 countries worldwide) declared grave concern that this decision will undermine the effort to make progress on the Covid-19 pandemic. The ACP stated, "We urge the President to immediately restore U.S. funding to WHO, and for Congress to take appropriate action to ensure the continued funding."

In case you wondered, the United States pays about 1/5 of the budget ($400-500 million according to Trump), which sounds like a terrific deal to me.

What does the WHO do? Why does it matter if we participate?

The World Health Organization consists of more than 7000 people from 150 countries that work together promote health, keep the world safe and serve the vulnerable.

The Who promotes safe childbirth, fights female genital mutilation and helps women with obstetric fistula. It is working on eliminating cervical center and has a major role in eliminating polio worldwide.

The WHO has led the fight against Ebola outbreaks and other health emergencies that ravage the globe. They have worked on health conditions from asthma to Zika, hepatitis and malnutrition. Their expanded program immunization, set up in early 1970, with the help of UNICEF, Gavi, the Vaccine Alliance, and others, brought lifesaving vaccines to millions of children. Other innovative partnerships have produced effective vaccines against meningitis, Ebola and the world's first ever malaria vaccine.

Jeremy Konyndyk, a senior fellow at the Center for Global Development, and a director for foreign disaster assistance at USAID said, "In terms of cutting funding, it is deeply counterproductive to US interests because the US has an interest in stopping this virus everywhere. Until it is stopped everywhere we remain vulnerable here. The WHO has a super important role to play in that."

If you want to see what the World Health Organization does, check out their website. It is impressive. I can't speak strongly enough on the colossal folly of cutting of their funding and what it means for all of us who are fighting this Covid-19 pandemic and for improving health worldwide.

WHO website: click here: /

Most Covid-19 Hospital Admissions Have Underlying Conditions

noreply@blogger.com (Toni Brayer, MD) — Mon, 13 Apr 2020 19:38:00 +0000

Corona Covid-19 Virus is scary. We remain concerned that the hospital admissions and death rate in the United States continues to rise, even though we are seeing some "flattening of the curve" in some areas that put in early stay-at-home measures.

But the great majority of people will not be hospitalized and will recover from this infection. Let me emphasize that.

The great majority of people will not require hospitalization and will recover from this infection.

We have information from the Centers for Disease Control and Prevention (CDC) that helps us understand what is happening. The hospitalization rate is 4.6 per 100,000 population and almost 90% of those hospitalized have some type of underlying condition; hypertension, obesity, chronic lung disease, diabetes or cardiovascular disease.

As reported before, patients age 65 and over are most likely to have one or more underlying condition (94.4%) but even younger individuals between ages 18-44 had co-morbidities (85.4%).

These findings show why it is important to practice preventive measures (social distancing, hand washing etc) because it protects others who have health conditions. It is also why the vast majority of people with Covid-19 infection can recover at home.

Antibody Testing Is Our Path Back to Work

noreply@blogger.com (Toni Brayer, MD) — Fri, 10 Apr 2020 17:47:00 +0000

The world has been sheltering in place for over a month now and everyone wants it to end. There is much speculation about when cities in the US could start functioning again. I've had a number of patients and friends ask about antibody tests to see if one has actually had Covid. Most everyone can remember a "cold" or "sore throat" that they had since December and now wonder "Did I really have Covid-19?"

The answer to that will be provided with a serologic (blood) antibody test. By taking a few drops of blood (not nasal swabs) we will be able to see if a person has built up antibodies to the virus. That would mean they were at one time infected. We still don't know what level of antibody provides protection against catching it again, but if Covid-19 follows other viruses, it should be one-and-done, at least for a couple of years, which gives us time to develop a vaccine.

A number of studies are ongoing in humans to answer the question of who has antibodies, how long they last and how protective they are. Here is what an antibody test can tell us if we could test a majority of our population:

The true infection rate and when 60% of the population has been infected we would have "herd immunity" and a very low incidence going forward.

The true mortally rate. Up until now we have been guessing. If it is much less than regular influenza we can get back to work.

Who has antibody and is safe to work and travel

Protection of health workers by showing who is at low risk to care for Covid-19 patients.

Information about the virus and how it spreads and how contagious it is.

Over 70 test developers are working on a serologic test right now as confirmed by the FDA, with the majority based in China. According to the LA Times, a company in Irvine, Ca, Biomerica, has shipped samples of its 10-minute disposable serology tests to the Middle East and Europe.

Los Angeles County started testing 1000 randomly selected residents today to see if they have antibody to Covid-19. Stanford University says they are offering widespread serologic testing but how a doctor or person could access it is still a mystery.

If we are going to win the war on Covid-19 and protect the population and get this Country back to work, we need a plan. That plan should not come from cities or states and we won't get the full benefit of testing if it is hap-hazard. We need the US Government to develop wide-spread testing and roll it out now. It should be our #1 priority.

Covid Virus Challenges of Sub Clinical Infections

noreply@blogger.com (Toni Brayer, MD) — Mon, 06 Apr 2020 22:17:00 +0000

The New England Journal of Medicine (NEJM) reported a letter to the editor today (April 6, 2020) from scientists in South Korea describing the challenges of dealing with early infection in patients who do not show symptoms.

Remember that South Korea started testing patients very early and tracking patients they tested. The first confirmed case of Corona Covid-19 was on January 20, 2020. They started testing people who had traveled and by Feb 10 there were 28 cases of laboratory confirmed Covid Virus ranging in age from 21 to 73. Only twenty of the patients developed early symptoms and only 8 of the 20 started with a fever. Some patients reported severe sore throat and some had only a mild cough.

They were able to track all of these patients who had recently traveled and see how they transmitted the virus. Patient 3, who had no symptoms, transmitted the virus infection to Patient 6, who in turn transmitted it to patients, 10,11 and 21. Patient 12 contracted the virus during a stay in Japan after he was exposed to a person with confirmed Covid-19. (He was not quarantined because he had no symptoms and they did not know about the exposure at that time) Patient 12 appears to have subsequently infected Patient 14.

Three of the 28 patients they followed remained asymptomatic and still were able to pass on the virus.

The scientists say, "Early detection of Covid-19 is difficult because of its apparent subclinical (no symptoms) nature in some persons."

There have been other reports and speculation of asymptomatic transmission but this is the first I've seen of the contact tracing and proven contagion in patients who never developed symptoms.
The real game changer will be when we have an immunoglobulin test that shows us who has been exposed and has antibodies, (IgM and IgG). These tests are being developed now and are different than the diagnostic tests currently being used to detect the virus.

We know that people are most infectious early and when they start with symptoms. But some people are asymptomatic and can still be infected and pass the virus.

Will Telemedicine Be The New Normal

noreply@blogger.com (Toni Brayer, MD) — Mon, 06 Apr 2020 00:45:00 +0000

The technology for telemedicine (video visits with your doctor) has been around for decades. Sutter Health was the first hospital system in the West to install the electronic ICU (eICU) where critical care physicians and nurses could do remote video monitoring of all patients in ICU beds and jump on problems before they became serious (drop in blood pressure, restless patients, changes on oxygen, or other critical markers). We have wearable technology for patients to transmit their blood glucose levels, EKGs and even sonograms but despite the technology and hype, none of this has been adopted on a wide scale.

So why has it taken so long for patients and doctors to adopt this technology and use it every day instead of relying on last century visits to the doctors office? Why does a patient in a rural community need to drive for hours and wait months to see a specialist in a big city?

The Corona Covid-19 Virus will revolutionize telemedicine and I don't see us ever going back.

We are in the midst of the pandemic with not enough professionals, PPE or capacity to take care of everyone at once. In their wisdom, CMS (Center for Medicare and Medicaid) relaxed the rules and are now allowing doctor and other caregivers, both in and out of the hospital setting, to see patients using telemedicine and telephone visits and (note the caps here) TO GET PAID FOR IT.

We are also seeing states allow physicians to practice across state lines, another barrier removed.

Billing codes, payment and ability to cross state lines are the game changers!

For the Covid pandemic, video visits have provided safety to patients and office staff by limiting exposure to sick people. Most doctors can tell a lot by talking to and seeing a patient. We can see how sick they are, how well they are oxygenating, if they are struggling emotionally or physically and if they need immediate attention or can wait. Home thermometers and wearable watches and blood pressure monitors can give us vital signs. This virus is worse on the elderly and video visits can same time and expense. Virtual visits don't require transportation, moving disabled people, parking expense, other family members or delayed appointments.

Telemedicine will not replace doctors nor will it replace hands-on physical exams. But now that patients are familiar with it and doctors can get paid for their time I predict it will be here to stay once the pandemic has quieted down.

Finally!

Ventilators and Corona Covid-19

noreply@blogger.com (Toni Brayer, MD) — Sun, 05 Apr 2020 00:22:00 +0000

We are hearing about the need for ventilators during this Corona Covid-19 surge time so thought I’d explain how ventilators work in this crisis and why there is such a demand. It’s important to remember that the Covid-19 virus has no treatment. When a patient is admitted to the hospital we provide supportive care. That means we help the patient stay alive long enough for their own immune system to mount a defense and eradicate the virus.

Supportive care is provided by intense nursing with IV fluids, oxygen, anti-fever drugs, blood pressure support, anti-blood clot drugs and close monitoring for decompensation. Covid patients decompensate (get worse) very quickly and can develop a condition called ARDS (acute respiratory distress syndrome). This is a life-threatening pneumonia where fluid leaks into the lungs and does not allow the alveoli (pulmonary cells) to exchange air.

When patients go downhill and their blood oxygen saturation (O2 sat) falls, they will need mechanical ventilation to breathe for them for they will quickly die. Each of these patients needs a ventilator and experienced specialists, nurses and respiratory technicians to manage it. The patient is transferred to the ICU or critical care unit and is given special drugs to relax them or even put them to sleep so they don’t try to breathe on their own. (There is currently a shortage of these drugs). The patient is intubated with an endotracheal tube that is placed in the mouth down through the bronchus so oxygen can be mechanically delivered to both lungs. A feeding tube is placed in the mouth and esophagus down to the stomach to provide nutrition. The patient can no longer speak.

The mortality rate for patients with ARDS prior to the current Covid crisis was up to 45% depending upon age, underlying condition and time on a vent. The ventilator just buys time and keeps the patient alive while their lungs recover.

We are still gaining knowledge and statistics for Covid-19, but the majority of patients that need a vent do not survive. These patients need ventilators for a longer period of time and the longer a patient is on a vent, the worst the outcome. These are the most critical of all patients and the 24/7 resources required to care for them are extensive.

The need for ventilators, hospital ICU beds, medication, professionals (doctors, nurses, respiratory techs, critical care experts) are all in dire short supply. Small rural communities may have only 0-3 critical care beds and no critical care specialists. They routinely transfer very ill patients to larger hospitals in big cities. When those hospitals are full there is no place for patients to go.

Flattening the curve is an attempt to keep the health care system from being overwhelmed. Imagine the need for hospital ventilators and ICU care doubling daily. Ten becomes 20 and 20 becomes 40-80-160.

The system crashes very quickly. There is no community, no matter how small, that can escape this crisis.

This is why we want you to stay at home.

PPE Is A Massive Problem

noreply@blogger.com (Toni Brayer, MD) — Fri, 03 Apr 2020 21:06:00 +0000

I was shocked to receive an email from a friend today with a story that sent chills down my spine.
Everyone knows there has been a shortage of PPE (personal protective equipment) that puts health providers at risk of contracting the contagious Corona Covid-19 virus. Yesterday (April 2) at the White House briefing it was reported that 200,000 N-95 masks were sent to New York and millions of masks and other PPE will be sent across the nation. When I received this email, I realized that response is totally inadequate. The doctor referred to in this email is being kept completely anonymous because he fears his position as a resident would be impacted if the hospital or identifying information were known.

Considering the recent firing of U.S Navy Captain Crozier after he asked for help for his stricken men, this doctor is not being paranoid to want anonymity.

Read this plea and then ask yourself if we are doing enough.

"Dear Toni,
My brother is on the front line in _____________, and the hospital he is at is entirely Covid-19. They lost a doctor today and are losing patients daily, today, they lost a young _______year old with no co-morbidity.

They have no masks, no eye shields and no aprons. They are using garbage bags as protection. They are out of sanitizer as well. I shipped him some yesterday and am shipping more tomorrow for other staff at the hospital.

He has health problems himself and is resuscitating patients several times everyday, as I'm sure being at the frontlines yourself, you can well imagine.

He has an 8 year old child and we are all so scared for him and the others working long hours without any protection and full exposure.

We in the family are appealing to all our friends in the medical field to help us find supplies that we can ship to them at the hospital. Do you happen to have or know someone from whom we can get N-95s, aprons and eye shields? Any number will help, considering they have none now.

Thanks for listening and considering."

I think this letter speaks for itself. I can attest to the authenticity.

Covid Test Negative? Not So Fast

noreply@blogger.com (Toni Brayer, MD) — Wed, 01 Apr 2020 19:55:00 +0000

Now that we are expanding testing for Corona Covid-19 Virus, many patients are confused when they feel sick but get a negative test result. They have all the signs of Covid infection with fever, cough and malaise but the test came back negative. The Washington Post reported on a woman who was hospitalized with presumed Covid pneumonia but her test was repeatedly negative. What is going on?

Every clinical test we use in science and medicine has a sensitivity and a specificity. This tells us how good the test is in diagnosing who has the disease (true positive) and how many people with the disease we missed (false negative). Doctors know that tests with high sensitivity are pretty good at giving us accurate results for Covid-19 to show us the patients who have the virus.

With the Covid Virus we have many many tests that are being used and each of them, depending upon how they are testing and how they were developed in the Petri dish, have different values. None of these tests were previously tested on humans because THIS IS A NEW VIRUS.

If a test is very sensitive it means it will catch all of the true positives in people being tested (a true positive rate). We don't know the sensitivity of the myriad of tests being used but we think it is between 75-99%. That means 25-1% of the patients will have a false negative test and will test negative even if they have the Covid-19 Virus.

The specificity of the test tells us who tested negative for the disease but they don't actually have it (true negative).

We are most interested in patients who test negative but really have Covid-19 (A false negative), because we want them to really isolate and not spread the disease.

The results of the tests we are using now can be affected by a number of factors. Testing too early. Poor swab technique. Lab error. Transport error. Or just the test itself. We know we are going to be wrong a certain percent of the time.

If you think you have Covid-19 because you have the symptoms, and your test came back negative, you should presume you are positive and quarantine for 14 days. (from the beginning of your exposure or symptoms). This may sound extreme but it is the safest way to proceed.

There is no need to be re-tested if you are not worsening or needing hospitalization.

One thing that has held true in this pandemic is that the majority of patients who have severe illness or die are older or have other medical conditions or are healthcare workers. The response to the virus depends upon the viral load (amount of exposure) and a persons own immune defense.

Life In The Hot Zone

noreply@blogger.com (Toni Brayer, MD) — Tue, 31 Mar 2020 00:23:00 +0000

This Cartoon was created by Alex Thomas, MD for the Annals of Internal Medicine. It shows what many physicians are experiencing as the CDC and hospital organizations change the protocols on a daily basis to deal with the Corona Covid-19 Virus pandemic. Doctors feel like they are human fodder.

(click on the image to see it larger)

Hydroxychloroquine and Covid-19

noreply@blogger.com (Toni Brayer, MD) — Sat, 28 Mar 2020 23:20:00 +0000

Thanks to a shout out by President Trump that Hydroxychloroquine would be a "game changer", this drug is all over TV and web as the possible treatment for Corona Covid-19. Because this virus HAS NO KNOWN TREATMENT, the FDA is fast-tracking pharmaceuticals and vaccines. There are at least 22 known studies ongoing to test the effectiveness in humans and Corona Covid-19. Here's what we know (today, March 28, 2020) about Hydroxychloroquine:

As a drug used to treat rheumatoid arthritis and lupus, Hydroxychloroquine works in a complex manner on cells and proteins to down regulate the immune response.

It is also used to treat uncomplicated plasmodium malaria but is not effective against all malaria strains.

The brand name for rheumatology use is Plaquenil and it can be found in the urine three months after taking. It has a very long half life.

The Journal of Antimicrobial Agents reported a study of 26 patients receiving Hydroxychloroquine. Six patients were lost to follow up, but of the 20 who remained there was significant effectiveness in clearing the virus, even in patients who were asymptomatic. Azithromycin was added to six of the patients and they showed a greater response than Hydroxychloroquine alone.

Some studies are showing that the drug can work in cell cultures against Corona Covid-19.

Two clinical trials in the U.S. are looking at whether Hydroxycholorquine can prevent Covid-19 in health professionals exposed to the disease.

In past studies, Hydroxychloroquine was found to be not effective for treating dengue, chikungunya and influenza viruses.

Serious adverse effects include cardiac arrhythmias due to prolongation of Q-wave, blurred vision due to changes in the retina, nausea, vomiting and headache. As with any medication, the list of side effects is long but the most worrisome is the change in the heart rhythm, which can be fatal.

Millions of Americans currently take drugs that can interfere with Hydroxychloroquine and cause side effects, liver dysfunction and prolonged Q-T syndrome.

Patients who are dependent upon this drug are finding shortages because of stockpiling and hoarding. Nevada governor, Steve Sisolak, has blocked the use against coronavirus to protect the patients who need it. Pharmacies are directed to fill only one month at a time for patients with "legitimate medical purposes".

The run on Hydroxychloroquine is driven by fear as patients are experiencing a pandemic and want hope.

Doctors are being overrun with messages to prescribe this medication to patients and to tell the CDC to "cut the red tape and make it available to everyone". According to the LA Times, these messages are sponsored by a conservative organization founded and funded by wealthy supporters of Donald Trump.

Health Professionals and experts are saying "Hydroxychloroquine is not a harmless panacea for Covid-19".

When doctors do not have a treatment for patients that are in critical condition, we often use therapies that are not yet "evidence-based" with controlled studies, but may have some benefit based on smaller studies, anecdotal reports or laboratory evidence. This is happening with Covid-19 patients that are in ICUs as we attempt to save lives. We try everything!

This is very different from prescribing untested drugs to healthy or mildly ill patients.

It is my strong hope that Hydroxychloroquine, Azithromycin and other therapies will be effective. We will find out very soon.

What Patients Get Wrong About Covid-19 Virus

noreply@blogger.com (Toni Brayer, MD) — Thu, 26 Mar 2020 21:48:00 +0000

There is so much information, pop-ups, social media and gossip about Corona Covid-19 Virus, it is not a surprise that patients have some erroneous beliefs. It is an evolving situation and we are learning new things every day. Here are a few beliefs that people have wrong:

1. Only older people ( Old Boomers) get serious illness
Wrong. As of March 16, the CDC reported the cases of hospitalized patients in the U.S. were:
Over age 85 - 9%
Age 65-84. - 36%
Age 55-64 - 17%
Age 45-54 - 18%
Age 20-44 - 20%
< Age 19 -<1%

Until March 16, 80% of all deaths were in people over age 65. Note these numbers are rapidly changing as the incidence grows.

2. Any Symptom could be Corona Covid Virus
Wrong. Covid Virus is always respiratory and its main action is in the lungs and bronchioles. The virus contains glycoprotein spikes that attach to receptors and enter cells in the lower respiratory tract of humans. The symptoms include cough, fever, fatigue, shortness of breath, headache, sore throat and rarely diarrhea. If a patient does not have a cough or shortness of breath, it is not Covid.

3. Homemade and cloth masks protect against Covid Virus
Wrong. There is a worldwide shortage of Personal Protective Equipment (PPE) and the only masks that have proven effectiveness for this virus are Fitted N-95 masks.
Although the CDC has relaxed recommendations for using cloth or homemade masks, it also states "protection capability is unknown". There are no studies that show reusing N-95 masks is safe and the barrier protection is known to deteriorate over time. Are homemade masks better than nothing? Yes, probably.

4. If I have symptoms of Corona, I should be tested
Under normal circumstances we should be testing everyone with symptoms so we could track the virus, understand the contagion period, refine the epidemiology and prepare for future epidemics. But these are not normal times. With the lack of PPE, health resources and quick turnaround test results, we are not testing mildly symptomatic patients at this time. This should change and we should be testing everyone so we can track the virus and get back to normal.

Stay tuned......