Tag: COVID-19

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Traveling In Pandemic Times

My parents provided me with the usual survival tactics in childhood: “don’t put your finger in the electric socket; “don’t play stickball in a busy street;” “look both ways when crossing the street;” “put a jacket on to prevent pneumonia.” But no pandemic advice. My father, born in 1921, had missed out on the Great Influenza pandemic by 3 years. He survived the depression, World War II, the Korean War, The Cold War and Stagflation, but he had no pandemic real world experience. 

Mastering COVID avoidance was easy. I didn’t go out the front door. I wiped down every delivery with Clorox wipes. I interrogated delivery workers at the front door from 6 feet away. I masked up and social distanced with friends who took science and survival seriously. My only brush with the outside world was beamed in with cable news and internet pictures.

With viral mRNA inoculated twice into my arm, the lure of travel beckoned and with it the reality and trepidation of return to the unknown. What would airports, big cities, seeing friends and family be like after a monastic-like life for almost a year?

Armed with an  N95, surgical mask and face shield barrier, I pushed the UBER request on my app for a ride to the airport. “Please roll down the front and back windows for cross ventilation,” I directed the driver, thinking viral kinetics and air exchange. He didn’t blink an eye. At the airport, Homeland Security officers donned face shields and stood behind window barriers. Driver license identity was self-swiped at a distance. The Starbuck’s line imprints on the floor were spaced 6 feet apart and baristas looked like they were part of a surgical OR team. Sipping coffee, a learned skill honed in the past, became a conundrum when faced with two masks blocking the oral route. Should I slip the masks down or up? Should I replace the mask after each sip? Should I take the masks off completely? Should I just gulp the coffee quickly and then replace the mask? Thoughts of Dr. Fauci and the CDC flashed through my head: 10 minutes of exposure, high viral load, ventilation and symptomatic patients. I headed to the far reaches of the airport terminal, separated myself from the unmasked masses, and bolted the coffee down, nearly incurring mouth burns.

Boarding the plane entered me into a strange world. The cheap seats in the back of the plane got first dibs on boarding to limit contact time. Finally, seated, I breathed a sigh of relief when the hotly debated middle seat vacancy was enforced. Anxiety returned, as the flight attendants distributed the snacks. Was it worth unmasking for a granola bar and a small package of chips? The lure of Pringles was too great and I succumbed to temptation, all the while contemplating my eulogy, “he gave his life for a a few plain potato chips.” 

The plane hovered over LaGuardia Airport awaiting the final approach. Built on a garbage dump used for Brooklyn’s excess waste, I pondered the early Queen’s denizens grappling over their microbe challenge: Salmonella and Shigella. The plane landed, the  gate opened and I marched single file, 6 feet apart, masked and into the terminal where multiple, camouflaged clad military awaited me. Did I take the wrong flight and land in Mogadishu, Somalia? No, New York City, where Andrew Cuomo’s quarantine rules were being enforced against the blasé non-Northeastern states where I was now residing. It seemed surreal to be approached by a military serviceman and servicewoman who were both armed with weapons and asked if I had a Covid 19 PCR test performed in the last 72 hours, and if so, what was the result? Things had changed.

After claiming my luggage, I entered a NYC taxi cab to the final push to Manhattan. As I gazed upon the the facial scowl of our driver, I thought it best not to bring up the cross ventilation directions again. As I entered FDR Drive, I fixated on the credit card swipe. Can COVID exist on the card? Can I Clorox the gap? “What would Dr. Fauci do?”

Walking in Manhattan, I could immediately sense the gravity and public health compliance of the borough. This pandemic was not some abstract chyron endlessly streaming on a CNN telecast. Families and friends had been stricken with serious illness and death at the beginning of the pandemic and this crystallized the importance of public health measures. Multiple restaurants had outdoor seating ensconced within a plastic dome. At night, the yellow and purple lighting from restaurant isolation tables provided an extra-terrestrial feel. 

The ordeal was worth it after ending a year absence from family. Hugging my fully vaccinated son and and elbow bumping my unvaccinated son and daughter-in-law in the social distancing expanse of Prospect Park (thank you ,Frederick Law Olmstead) was priceless.

Many years from now, when my grandchildren gather around me and ask about the Pandemic, I’ll reply, you have to carefully peel off your N-95 mask just like this, and then get the Starbucks lid under the face shield that protects your mask and..…”

  • Fortitude, NY Public Library Lion, Masked
  • Double Masked and Ready
  • Military comes to LaGuardia
  • Outdoor Dining Bubble
  • A bubble for Two
  • Social Distancing in Prospect Park
  • Atlas Masked in Rockefeller Center
  • Unmasked Dog in Upper East Side
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Gut Punch Against COVID-19

“You are what you eat.”Jean Anthelme Brillant-Savarin, a French lawyer, epicurean and father of the low carbohydrate diet, penned these words in the 18th century. As we struggle through the COVID-19 pandemic, we search for personal ways to influence our health and our immune system to combat this pestilence. Food choices are an overlooked variable that may alter our fate.

Our human engagement with infections is played out daily through our immune system. Ironically, we are dependent upon our commensal microbes that happily reside in our bodies to assist in the fight against environmental, viral and bacterial invaders.  Over one hundred trillion bacteria and untold fungi, archaea and microscopic multicellular microbes take up residence in the gut after birth.  These microbes are a virtual army responsible for innate immunity and the initial fighting response to pathogenic agents. Furthermore, these bacteria contribute forty times more genes in the gut than human genes in the entire body. The exact role of these genes is uncertain, but they may produce proteins that may influence the bodies fighting power.  It is believed this gut bacterial diversity and their metabolites protect us by establishing an intact mechanical barrier, facilitating the release of bacterial and human antimicrobial chemicals and competing with pathogens for nutrients. They trigger the inflammasome, a coordinated release of immune stimulating chemicals (cytokines) that arm the lymphocytes, macrophages, neutrophils, dendritic and plasma cells that produce the coordinated inflammatory response.  A delayed innate response can result in a virus that gains a foothold that cannot be stopped. Similar to friendly fire, an over exuberant immune response can injure tissue from toxic inflammatory chemicals long after the pathogen has been vanquished.

Older age, diabetes and obesity are clearly risk factors for severe adverse outcomes with COVID-19. The common metric of these risks are a dysfunctional immune response. A slow initial response or an unregulated and injurious inflammatory reaction can result in devastating consequences for the infected host.  The gut microbes and their genes, the so called microbiome, are fundamental for a proper defense to infectious agents. A healthy microbiota is still being defined, but with new molecular biological techniques, a diverse population of organisms is critical to drive down the middle lane of life–away from infectious disease and autoimmune/allergic disorders. Altered microbiota or dysbiosis, is the hallmark of obesity and diabetes. And our country is flush with these risks. Over 40% of the U.S. is obese, representating a four-fold increase in prevalence since the 1960’s.

The microbiota can be malleable and is dictated by food for good or bad. And, food choices in our country may have steered us into more fatal outcomes with COVID-19. Processed food, hydrogenated and trans fats, high fructose corn syrup, larger portion size with higher calories and antibiotic tainted meats have assaulted the beneficial microbes in us. Could this be one of the reasons we are the leading country in COVID-19 cases and deaths?

Social distancing and masks are first line defenses against the Coronavirus fight.  Food choices MAY be another volitional pathway to maintain health. Fermented foods can select for beneficial commensal bacteria that make-up one’s microbiota. Greek yogurt, sauerkraut, tempeh, kimchi, and miso can favor the growth of Lactobacilli and Bifidobacter genera, both known to be healthy members of the microbiome.  Germany, Korea and Japan have low per capita rates of disease, attributed to timely public health measures and widespread COVID-19 testing. Might these differences be partly explained by eating sauerkraut in Germany, kimchi in Korea and miso in Japan?  Do some long standing cultural food preferences select for a healthier microbiome that is protective for Coronavirus infection or helps to modulate an appropriate immune response?  It seems to this clinician that it’s worth a clinical study as we, the people of every culture and nation, come together to collectively look to each other for any possible clue to mitigate the ravages of this virus.

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Uncertainty to Despair to Hope and Redemption: My Professional Life Battling an RNA Virus

I feel  like I am reliving a bad dream. The race to find a treatment and/or cure to SARS-CoV-2 is reminiscent of decades of practicing gastroenterology while hepatitis C roamed the hospital wards as a death sentence for many. I found myself recently recalling a patient whose story ends with science finding a cure.  The story begins in a community hospital’s ICU.

 As I peered around the ICU curtain, I could see the outline of a motionless ill man. I was visually greeted by a panoply of colors not usually seen in human health. Yellow skin and eyes, violaceous bumps on his extremities and blue hued fingertips. As I entered the room, I recognized him as the car salesman I had spoken to several months ago discussing the pros and cons of  an SUV versus a minivan. His labs and physical exam delivered the bad news that his liver and kidneys were not working and he had vasculitis, an inflammation of the blood vessels. While he had a case that medical students study intently, private doctors rarely see in decades of practice: essential mixed cryoglobulinemia secondary to Hepatitis C. In an attempt to curtail the virus, antibodies bind to viral proteins. Excess antibody-protein complexes, instead of being  cleared from the blood circulation, get deposited in the blood vessel walls causing inflammation and sometimes closure of the vessel. He was in danger of losing his kidneys, his liver and his life. A National Institute of Health study had shown a few years earlier that the immune stimulating natural agent interferon could have a beneficial effect on Hepatitis C. Interferon was started and miraculously the bumps disappeared, the kidneys started to make urine, dialysis was stopped and the jaundice receded. He left the hospital and completed 12 months of interferon, combating fatigue, low white blood counts and depression due to drug side effects. He had been cured of Hepatitis C and had dodged a fatal complication of the virus using a toxic biologic agent.  

This early success had been a rare gold nugget amidst multiple disappointing and tragic events in my experience with the RNA virus, hepatitis C. The lessons learned from this virus are worth retelling as this is a story that parallels our current ordeal with another RNA virus, SARS-CoV-2. 

The biologic veil of Hepatitis C was heavy and was only lifted in fits and starts. In the alphabet soup of hepatitis viruses, A and B were discovered early but “C” was undetectable and given the placeholder non-A-non-B for years until special techniques were devised to recognize its presence. Infection was through blood transmission, usually through blood transfusion, sharing of needles or instruments that were contaminated with the virus and inadvertently inoculated through the skin. In contrast to SARS-CoV-2, which has a presymptomatic stage of a few days, Hepatitis C’s silent period was years or decades before disaster would take hold. Cirrhosis, or significant scar tissue in the liver could impair the sieve like blood circulation within the liver shunting blood to places it normally wouldn’t go resulting in gastrointestinal bleeding, ascites and encephalopathy. Years of infection can lead to liver cancer with a dismal prognosis. 

My early encounters with hepatitis C felt like bailing water from the Titanic while it was taking on water. I could band bleeding blood vessels, start water pills and limit salt in those with fluid overload and give antibiotics to reduce the toxin burden and reduce hepatic coma risks. But without specific treatment for the virus, we were on a slowly sinking ship. Then the drug interferon came along. It was a mixed blessing. It was toxic, causing fatigue in most and depression in a significant minority. It could lower white blood counts and damage the nervous system. It worked in only 10% of patients with the most common genotype of the virus. Most diabolically, those who needed it most were cirrhotics, and for patients with this condition, it was the most toxic and had the lowest response rate. I saw harsh drug side effects that included suicidal thoughts, absenteeism from work on the drug and plummeting white blood counts in countless patients. I questioned whether it was worth the one in ten chance that the drug would work. Slow progress (too slow for patients on the liver transplant waiting list) was the rule of the day. Ribavirin, an oral drug, used with interferon, raised the response rate to over 40% at the expense of the new side effects of anemia and potential birth defects. Most of my discussions with afflicted patients were often discouraging treatment, waiting for “some breakthrough in the future.”

The initial breakthrough came: direct acting antiviral drugs were available in 2011. They were protease inhibitors, drugs that blocked the assembly of viral proteins within the cell. The first generation protease inhibitors had novel side effects including disabling rash, headaches and mouth sores.

I came to dread the newly diagnosed hepatitis C consult. It felt like a “pick your poison” option.  I could offer an imperfect and potentially toxic mix of therapy, not unlike the oncologist administering chemotherapy to a cancer victim. 

This all changed with the synthesis of the drug sofosbuvir, an RNA polymerase inhibitor not unlike Remdesivir, an encouraging agent for SARS-CoV-2. Sofosbuvir, coupled with new protease inhibitors was the miracle I had not witnessed in my four decades rendering care to my patients. It’s side effect profile was no different than placebo and amazingly the cure rate would climb to over 98%. It worked equally well in patients with cirrhosis and the course of therapy was “weeks” rather than “years.” And, it was a cure! Patients who would have been candidates for liver transplantation saw improvement and were removed from the transplant lists. Liver cancer risks were reduced. Other non-liver conditions like heart disease, immune function and cognitive function improved with eradication of the virus. I felt my office was the equivalent of a Lourdes destination for the hepatitis C patient.

Science rendered a disease that afflicted 3.5 million Americans and killed up to 20,000 people a year to an affliction that most likely will be eradicated from the planet in our lifetime. The success of the treatment for hepatitis C can be looked upon as a template for our next RNA viral battle: SARS-CoV-2.  Hopefully, we can build from the success of the hepatitis C RNA polymerase inhibitor and extrapolate to a drug combination that can treat the disease as we wait for a definitive cure and vaccine.  Covid-19’s fate must be one that someday, when I reminisce about this time, I write another science driven medical success story.

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The Art and Science of Barriers

“Good Fences make good neighbors” is a memorable and salient line from Robert Frost’s poem, “Mending Walls.”  While the context of its meaning is a plea for the importance of privacy, it is a useful phrase for the COVID-19 pandemic as we all try social distancing as our physical defense and protective barrier from the Coronavirus. Six feet away from one another and swathed with a nose and face covering mask seems to be the barrier du jour. It has been that throughout life we must deal with barriers that represent either obstacles, as in the poetic verse of Robert Frost, or provide succor to our existence. In our current COVID-19 world, our imposed barrier, a protective mask, will be critical to manage our “new normal” prior to a transformative drug or vaccine. In essence, we need a science driven mask that is effective, comfortable and re-wearable.

Biologic barriers are present from conception. Surrounded by the amniotic membrane, we are protected from most pathogens. Upon its rupture and our ride down the birth canal we start the self versus society struggle.  Hepatitis B, polio, rotavirus, diphtheria, tetanus and pneumococcal vaccinations are our initial immune barrier. Child proofing mechanical barriers (plug locks, stair locks, edge protectors) are present during our formative years. Car seats and later seat belts protect us from motor vehicle morbidity. Science has driven these medical protections and public health measures have orchestrated their distribution to the public and their acceptances as standards of care.

Societal barriers have protected humans for eons from human aggression, accidents and microbes. The Caves of Lascaux  protected Paleolithic man, The Great Wall of China retarded invasion by the Mongols. The Roman emperor Hadrian built his namesake “wall” in Northern England to keep out the “barbarians.” Ramparts and moats around European castles in the Middle Ages slowed the devastation wrought by the Vikings. In our lifetime we put up with anti-terrorist barriers at TSA checkpoints at all U.S. airports. Physical barriers and screening techniques have been shown over time to decrease disease and death from outside threats to our well-being.

Our protection from COVID-19 now demands a barrier to our nasopharynx. We are now safely surrounded by our homes’ four walls and limited “world” contact through our UPS and Amazon delivery services. In order to integrate into society we need extra protection from the virus. A mask or “facial condom” could provide us with the protection and turn human interaction into an acceptable risk. We are now familiar with the N95, surgical, and home-made masks. We have YouTube videos of media celebrities constructing masks. Now,  “mask science” is the next logical step to assure that our efforts are working to prevent Covid-19 transmission. What we really need is some evidence based guidelines developed from a controlled study.

 The geometry is well known: N95 keeps out 95% of particles that are as small as 0.3 microns; droplets containing COVID-19 are 50 microns or less. Droplet spread is 6 feet, more if sneezing or aerosol transmission is involved from the contact. What we don’t know is what materials and layering are most effective against virus spread when used in a real world scenario.

Compliance and comfort are inextricably linked. When I donned a mask in the OR, my face felt like I was in the microclimate of Miami during the summer and my eyeglasses fogged up like winter in London. We have designers and aerosol engineers that can overcome “wearability” issues that could lead to improved compliance. We have industry and universities that have the capability of testing combinations of fabric under simulated and actual environmental conditions.  Distribution capabilities are available to send masks to every household in the United States utilizing the Postal Service.

Americans have internalized the use of seatbelts and TSA screenings in my lifetime. Introducing and complying with  a “new fence” is easier when the alternative may be a painful respiratory death. Wearing a fashionable, comfortable and effective face mask should become the “new normal.”  The design, efficacy and distribution is simply just one more barrier for science to overcome.

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Soup Saviors: Chicken and Matzo Ball Soup Stories

Chicken soup has long been an off-label medicinal treatment for the common cold and flu as long as most of us can remember. So, it seems in these troubled times of COVID-19, we are hearing of its use in both healthy and coronavirus inflicted patients. An elixir from antiquity, chicken soup and its Passover-inspired cousin, matzo ball soup, are the “magic potions” from yesteryear that have been a proven adjuvant to analgesics and cough suppressants. However an Amazon search for chicken soup brings up a dizzying array of “out of stock” and “delayed delivery” for dozens of pre-made poultry influenced self-prescribed potions.  Chicken noodle, chicken and stars, old-fashioned chicken noodle, low sodium, healthy request, chunky, cream of chicken and every conceivable form of soup on a grocery shelf is starkly absent. In fact, chicken soup is one of two most requested items on Amazon. When I took a moment to ponder why, my memory was flooded with memories of my grandmother, aunt and mother serving up large bowls of chicken soup for every childhood illness that befell me. And, to be quite frank, I almost instantly felt better after its consumption.

My maternal grandmother, Nan, unveiled her divine Matzo Ball Soup at the start of each Passover Seder. Even a “soup skeptic” like my father, devoured the contents of the bowl. I can still hear the clanking of his soup spoon on the bottom of the porcelain dish. My nuclear family had matzo ball soup anticipation throughout the year, and not unlike McDonald’s McRibs strategy, Nan would bring it out during random Erev Shabbat gatherings. While there were many proponents of Nan’s soup credentials there was not unanimous agreement. Aunt Rose’s Matzo Ball Soup was touted as the gold standard by my relatives north of the Bronx. The debate on the best soup went on for decades.

Chickens can incubate avian influenza but they can provide sustenance through their soup derivatives. The 12th century Jewish physician and rabbi, Maimonides declared the medicinal properties of chicken soup back in the 12th century. Modern science has weighed in on its medicinal values. Chicken soup can slow  the entry of white cells into the nasal cavity, explaining the improvement in airflow. Medical researchers at Mt. Sinai in Miami Beach ascertaned chicken soup challenge in humans showed an improvement in nasal mucus flow, a marker of viral clearance. Chicken soup can also improve cilia function, the hair-like projections on naso-respiratory cells that “clean up” the nasal and respiratory passages, The soup additives, onions and garlic can have antiviral effects.

As Jews celebrate Passover and recall the 10 plagues of antiquity while living through a 21st Century pandemic, let us remember the benefits and memories that our loved ones provided: the humble Matzo ball/chicken soup miracle.

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Coronavirus: ICU and the Human Factor

The summer of 1979 is permanently etched into my memory. I walked into the Intensive Care Unit at U.C. San Diego Medical Center as a newly minted intern. I walked over to ICU-Bed 1 to be introduced to my first patient, a frail teen aged boy who was tethered to a ventilator. “He is day 30 with respiratory failure from disseminated coccidioidomycosis,” my internal medicine resident informed me. “He is your responsibility now, and don’t f__ it up.” An impending wave of anxiety enveloped me as I visually tracked the unending array of IV’s, feeding tube, central line, temporary pacemaker leads and monitoring equipment surrounding his bed. Over the next 6 weeks, I quickly learned that I was a small cog in the care that navigated his course away from almost certain mortality. As the credits to a movie may roll for minutes with names that do not have an apparent effect on the finished product, so too is the list of people who render care to the ICU patient. The pulmonologist, critical care specialist, critical care nurses, respiratory therapists and anesthesiologists represent a core team. Integral to their support are those that are in the supply chain providing meds, equipment (lines, pacemakers, intubation equipment, personal protective equipment, monitors, ventilators) and those that support and repair these items. Additionally, consultative services such as cardiology, infectious disease, gastroenterology, neurology, hematology, surgery and ENT to name a few, are involved with medical and surgical issues that arise from the prolonged hospital course and many complications that arise in patients that cannot provide critical organ function. Furthermore, ICU patients consume intensive utilization of laboratory and radiology service. Ethics committee members may be involved in deciding end of life and medical futility issues. Family adjustment and bereavement may also need social work and psychiatric services to cope with these psychosocial issues. The work day of the ICU is punctuated by “crisis moments” as each patient may have a life threatening arrhythmia, mucous plug in a large airway preventing oxygenation, massive gastrointestinal bleed, pneumothorax from high ventilator pressures to name a few of the “falling dominoes” of the critically ill patient.

Universal precaution implementation is, in an ideal world, best adopted in a slow, compliant fashion with a critical care or scrub nurse equivalent monitoring the provider for breaches in technique while putting on and removing personal protective equipment. In real life, emergent events require rushed donning of masks and gowns with possible gaps in the mechanical barriers. Of course, infective risks are greater with the lack of N95 respirators and the use of less protective surgical masks. Now, let’s look at the public risks of community exposure when the family equation is factored in. At least a dozen or more providers may enter an ICU bed in a given day. Most of the health care professionals are young, have families and extended families that they interface with on a daily basis. A four person household with a dozen personnel exposed to COVID-19 and a national number of 85,000 ICU beds creates a potential exponential source of infection in the community.

More masks, more providers and infrastructure are needed now. Can this be possible? Innovation in equipment, medical therapy and healthcare delivery are possible given the resiliency of Americans devoted to the well being of the United States. Is it possible? I have faith that this can be overcome. And, yes, my teenage patient  in 1979, after 30 more days in the ICU, walked out of the hospital with a smile on his face and his health intact.