COVID-19: Complications

Posted Posted in Continuing Education, Elder Care, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

We knew this was coming, or at least we should have known. Several subsets of patients with complex reactions to COVID-19 (the disease from the coronavirus infection) are being recognized.  The very young, the very old, and the very sick may be predisposed to rare and intense immune responses to infection with this coronavirus.  Here is what we know so far:

  • “Cytokine Storm” can be a dire consequence of COVID-19 especially in older patients with several underlying illnesses.  Cytokines are polypeptides or proteins secreted by immune cells coming into contact with bacterial or viral antigens and/or endotoxins.  Cytokines can also be synthesized by adipose cells (one of the reasons overweight patients are at serious risk).  Cytokines include chemokines, interleukins, interferons, and tumor necrosis factors among others.  Simply put, cytokines influence the magnitude of an inflammatory immune response.  Multiple genetic factors seem to play a role.  Clinically, an older, chronically-ill patient with COVID-19 (or other infections, such as influenza) can deteriorate dramatically over 6-12 hours. Vital signs become unstable, O2 saturation drops, respiratory distress intensifies, and inflammatory markers like C-reactive protein rise.  Cardiac function is seriously compromised and liver, kidney, and neurologic function decline rapidly.  Severe clotting disorders may develop.

The outcome is poor, but aggressive efforts to suppress the massive autoimmune inflammatory response may help if initiated at the earliest stages.

  • Toxic Shock Syndrome:  This is an acute, serious, systemic illness triggered by a response to exotoxins produced by staph or strep bacteria. It was first noted in young women in the early 1980s and was linked to tampons, diaphragms, or contraceptive sponges left in the vagina.  It can occur after childbirth, abortion, or surgery.  Symptoms include a high fever, diffuse red rash resembling scalded or burned skin, hypotension and multi-organ system failure leading to shock.  Prompt and aggressive treatment involves removal of foreign bodies, debridement of incisions or wounds, IV fluids, and IV antibiotics (clindamycin and vancomycin).  IV immunoglobulin can be used.

Several patients in the New York area, who tested positive for COVID-19, have presented with symptoms similar to Toxic Shock Syndrome.

  • Kawasaki Disease:  This is a childhood illness with a dramatic presentation and complications related to vasculitis, probably of an autoimmune nature.  Each year in the U.S. there are between 3,000 to 5,000 cases, mostly in children under the age of five years.  Rare cases occur in young infants, teens, or young adults.  Occasional community clusters occur, especially in late winter and spring, without clear evidence of person-to-person transmission.  Diagnosis requires the presence of four out of five clinical findings after fever lasting five or more days.
    • Bilateral conjunctivitis — injection or intense redness without exudate, drainage, or crusting.
    • Mucocutaneous injection of the lips, tongue, and oral mucosa. Lips are red, raw, dry, cracked, and fissured.  The tongue is enlarged, red, and possibly tender.  The classic description is “strawberry tongue.”
    • Skin changes involving the hands and feet.  There is pronounced edema and erythema especially on the palms, soles, and nail beds.  Full-thickness desquamation or sloughing off of skin on the fingers, palms, soles, and toes leaves the underlying denuded skin red, raw, and tender. These changes typically begin around Day 10.
    • Polymorphous rash over the trunk may resemble measles, scarlet fever, hives, or erythema multiform.  The perineal area is often involved.
    • Cervical lymphadenopathy with at least one lymph node in the neck ≥ 1.5 cm in diameter.

The cardiac complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, pericarditis, and valvular disease.  EKG and echocardiogram are indicated at the time of diagnosis and in regular follow-up visits for at least a year.  Treatment involves high-dose aspirin and IV immune globulin.  Approximately 85 children in the New York area who are COVID-19 positive are being evaluated for this condition, now called “Pediatric Multisystem Inflammatory Syndrome.”

Cytokine storm, Toxic Shock Syndrome, and Kawasaki Disease are rare in their original forms or as complications of COVID-19.  The overwhelming majority (over 82 percent) of patients testing positive for COVID-19 remain asymptomatic or mildly ill.  The survival rate in the U.S. (rarely mentioned) is over 99.5%.

Those of us in health care must always be aware of unusual or rare complications of any illness.  But perspective is crucial, a concept lost on many in the realms of media and politics.  After all, the best way to control people is to keep them afraid.

Knowledge, perspective, and prudence:  not fun, but essential.

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Coronavirus (COVID-19): We’ll Learn To Cope

Posted Posted in Continuing Education, Elder Care, Homestudy, Psychology, Webinars

By Mary O’Brien, M.D.

Enough.  Enough with the panic, paranoia, and power grabs.  Enough with the hysteria, hoarding, and hyperbole.  Enough with the melodramatic funeral music between commercial breaks on TV.  Fear, malaise, and resignation cannot become a permanent feature of life. This is not the end of the world, and this must not be tolerated as the “new normal.”

One of the most effective antidotes to fear is perspective.  Many of us had loved ones who endured far worse situations during the Spanish Influenza of 1918.  In those days, there were no ventilators or even the ability to deliver nasal oxygen.  There were no ICUs, cardiac monitors, or even TVs.  Antibiotics, antivirals, bronchodilators, anti-inflammatory medications, and corticosteroids did not exist.  There was no such thing as a Respiratory Therapist.  It was bleak.

Ten years later, during the beginning of the Great Depression, socio-economic conditions were equally bleak.  There were no social safety nets.  Social Security, unemployment Insurance, Medicare, Medicaid, welfare, food assistance, personal and small business rescue programs were nonexistent.  Soup kitchens and bread lines were the measures of last resort.

There is another major difference between the present day and 1918, and it revolves around the media.  In 1918, people had newspapers.  Radio was in its infancy.  There were no narcissistic TV “personalities” promoting an agenda 24 hours a day.  Enough is enough.  We don’t need any more people in the media selling panic for profit.  We need facts.  We need reason.  We need sensible, constructive solutions to a serious, infectious disease.  But we cannot sit on our hands for 18 months when a vaccine may or may not save the day.

Anyone telling us we have no choice but to lock down everything is misguided.  We always have choices.  Life constantly presents us with potential risks and benefits.  People can learn how to function with reasonable safety once they have the facts.  We are not helpless, clueless children who must be grounded “for our own good.”

Death is a certainty at some point — for each of us.  It always has been.  What matters is living a life that is good, honorable, and uplifting to others.  We are told no one should determine who lives and who dies.  Yet politicians and bureaucrats proclaim which “workers” (a Marxist term) are essential and which ones are not.  That reflects a stunning level of arrogance.  The only “non-essential” job or business is the one you didn’t pour your heart and soul into.  A handful of officials (where jobs, paychecks, and pensions are secure) is destroying the lives and futures of tens of millions of other people.

We’ve learned how to cope with tuberculosis and terrorism, the Great Dust Bowl and diphtheria, threats of nuclear war, and natural disasters.  We’ll learn how to cope with COVID-19, not through fear, not through paralysis, but through prudent, innovative, courageous action.  Enough with the panic.

Let’s get on with it.

COVID-19: Clinical Observations

Posted Posted in Brain Science, Continuing Education, Elder Care, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

Every new illness brings new knowledge. Global experience with COVID-19 is revealing patterns of clinical illness which will guide our approach to treatment. Here are some of those important observations:

  • The illness in 80% of people causes mild symptoms. Many people remain completely asymptomatic. Moderate and severe illness often has two phases. Days 1‒7 are characterized by fever (above 101° F), headache, significant cough, profound fatigue, myalgias, and malaise. Between days 4‒8 some patients have nausea, vomiting, abdominal pain, and/or diarrhea. Some patients lose their sense of taste and smell. Days 8‒21 are characterized (in 15‒20% of patients) by increasingly severe symptoms, including shortness of breath, dyspnea or difficulty breathing, chest pain or tightness, tachycardia and weakness.
  • The mean interval between onset of symptoms and hospitalization is 9.1‒12.5 days. This delay in the progression to serious illness may give us a window of opportunity for treatment.
  • Clinical findings typically include a low oxygen saturation level (O2 sat) on room air. This is a key finding and levels as low as 75‒90% are being seen (95‒100% is normal).
  • Laboratory results also show patterns similar to what was observed with SARS and MERS:

o   ↓ WBC or leukopenia

o   ↓ Platelet count or thrombocytopenia

o   ↑ Liver enzymes, especially LDH around hospital days 5‒8

o   CXR typically shows streaky opacities in both lungs consistent with an atypical pneumonia.

  • Serious complications of COVID-19 include severe viral pneumonia, ARDS (Adult Respiratory Distress Syndrome) respiratory failure, cardiac injury including arrhythmias and CHF. Poor perfusion can lead to hepato-renal syndrome. Neurologic symptoms, delirium, and coma may occur.
  • There is evidence that intubation and mechanical ventilation may be causing more harm than good in some patients. One component of ventilator function, the PEEP setting (positive end-expiratory pressure) may be delivering pressures that are too high for the alveoli or air sacs in the lungs. It appears that some COVID-19 patients in respiratory distress actually need lower levels of PEEP (15‒20) as opposed to levels around 25. Some patients seem to need higher O2 concentrations delivered by face mask, CPAP or BiPAP, and not intubation and mechanical ventilation.
  • According to the CDC, two thirds of the patients who have died from COVID-19 (as of mid-April) had documented serious underlying conditions (heart disease, diabetes, asthma, renal disease, malignancy, immuno-compromise). Obesity has been a significant factor contributing to mortality. 1.9% of patients who have died had no known underlying condition.

We have only scratched the surface here. The next few weeks will reveal new insights about the illness itself and the best treatment protocols. In the meantime, do what is prudent to protect yourself and others. It may not be obvious to everyone, but tremendous progress is being made.

Blessings to all through Passover and Easter.

 

Novel Coronavirus (COVID-19): Lessons Learned

Posted Posted in Brain Science, Continuing Education, Homestudy, Psychology

We are living in historic times.  A century from now, medical personnel, civil authorities, small business owners, corporate leaders, average investors, and everyday citizens will study the lessons learned from this pandemic.  Here are just a few of the ones we’ve learned already:

  • We should all plan and prepare for crisis, disaster, or catastrophe — especially in good, stable times.  Every family and business needs to build an emergency fund of 3-6 months minimum.
  • It’s important to listen to knowledgeable, wise people (not conspiracy theorists and people on social media).  However, even the most brilliant experts can be wrong.  Predictive models are not crystal balls.  There are unrecognized variables in nearly every situation.
  • Panic never solves problems.  If it did, we wouldn’t have any problems left.  The antidote to fear and panic is perspective.  Every day in the U.S., approximately 8,000 people die from multiple causes.  Each year, we lose between 30-40 thousand people from complications of the flu.  We do not shut down the nation.
  • Bureaucracies often do more harm than good.  Their function is largely based on outdated, territorial group-think, and they cannot change or adapt quickly.  Control freaks almost always create more problems than they solve.
  • All decisions have unintended consequences.Some of them can be disastrous. “Either/or” thinking is often a false choice.  Health, both physical and mental, is heavily dependent on financial stability.  The notion that we must choose between public health or a stable economy is a false choice.  They are mutually dependent.
  • Tunnel vision is usually a mistake.  Rigid adherence to long-held principles of epidemiology can crash an economy and engender other, less obvious medical problems like cardiac events, severe depression, anxiety, sexual abuse, physical abuse, emotional abuse, child abuse, drug abuse, alcohol abuse, suicide, violent crime, and eventually societal breakdown.   It takes discipline and wisdom to see the big picture.
  • “Better safe than sorry” is not always the right choice.It’s understandable in a crisis, but it rarely addresses the root of a problem.   We can protect our most vulnerable people with selective isolation and quarantine and still move forward with life.   Sometimes we must take reasonable risks.
  • Saving a buck by reducing housekeeping staff and standards of cleanliness, especially in public places, can be horribly costly in the long run.  Many hospitals, nursing homes, and medical offices are nowhere near as clean as they were 40 years ago.  Better personal and public hygiene will turn out to be a very good thing in the years to come.
  • Living and working in overcrowded, congested areas has been a problem throughout history.   Smallpox, plague, cholera, yellow fever, malaria, and tuberculosis have taken the lives of millions over the centuries.  Flu pandemics, in many cases, have been even worse.   Perhaps this pandemic will teach us all to be more respectful of everyone’s personal space.
  • We have more everyday heroes than we realize.Celebrities are not heroes.   Nurses, doctors, respiratory therapists, pharmacists, social workers, cafeteria workers, cooks, cleaning people, truck drivers, police officers, firefighters, EMTs, grocery-store clerks, bank tellers, delivery people, postal carriers, farmers, utility crews, and millions of everyday people doing their jobs and looking after others are heroes.  They need to be honored.
  • Politicians should not control the number of hospitals, ICU beds, ventilators, or CT scanners.   Hospitals cannot be run as if they were merely ugly hotels, focused almost solely on occupancy rates.  Surge capacity in beds, staffing, and equipment is essential.   Since 1976, we have seen a 16% decline in the number of ICU beds in our country.  Prudence matters.   It always has.   It always will.

This crisis will end.  We will learn more than we can possibly imagine.  For now, be calm, be kind, be patient.  Your actions may be more heroic than you realize.

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Mindfulness and Social Connections Soothe Anxiety and Boost Immunity

Posted Posted in Brain Science, Continuing Education, Elder Care, Psychology, Seminars

By Andrea D’Asaro, MBSR

It is normal to be scared and even paralyzed in the midst of so much uncertainty around the Coronavirus (COVID-19). That’s where simple mindfulness practices can help us stay grounded and connected despite recommendations for social distancing and work at home for many Americans. Deep breathing can slow anxiety, depression and keep our nervous system stable. Reaching out to others can boost our sense of connection, increase oxytocin (the love hormone), and maintain our immunity, which can fall when stress rises.

1. Come back to the moment with five mindful breaths

It’s easy to immerse oneself in the constant stream of on-line and often conflicting information. This can also increase our anxiety. With stress, the rational part of our brain can spin out of control into survival mode or fight, flight and freeze.

Whenever you notice yourself ruminating, worrying or feeling overwhelmed, try 5 mindful breaths:

Sit in a comfortable seat with your feet on the ground (lying down or standing are also options) breathe slowly in through the nose and out through the mouth to slow the nervous system, count five breaths with in and out, counting as one. Pause at the end and check your body and mind to see if anything is different. Continue to 10 or 20 breaths, as you wish. You may want to count your five breaths on your fingers, tracing each digit while taking one breath as an additional grounding with the body.

2. Reach out to friends and boost oxytocin

Social distancing is not emotional distancing! We can increase our happiness when we make real-time connections with others and bring ourselves a spurt of oxytocin, “the bonding hormone.” Try calling distant relatives, friends and others who may feel isolated at this time, using an old-school technology–the phone! When we take the step to converse with relatives or friends, we are boosting our own mood with activation of serotonin, according to research from Stanford University School of Medicine. Such social support is associated with a decreased risk of infection and reduced stress hormones, according to research from Carnegie Mellon University.

Many senior living communities are limiting visitors and keeping elders apart from each other to avoid spread of the virus. Older people, who may not use email or social media, are already at greater risk for depression or anxiety. We know that loneliness is deadly too. Real- time phone calls allow us to hear emotion in another voice and exchange concerns and pleasantries; it’s much more engaging than texting, according to research from the University of Wisconsin.

In this time of the elbow bump, we are advised to avoid hugging. No worries, the self-hug can also enhance the oxytocin, also called the “bonding hormone”.

Try the self-hug: Open your arms wide as you take a breath in, then cross them over your chest and you breathe out. Gently grasp your upper arm with the opposite hands and give yourself some kind squeezes. If it’s comfortable for you, close your eyes and bring to mind your personal “circle of caring.” Imagine the faces of those people or pets who care deeply for you (living or decreased) around you, smiling tenderly. Or envision your favorite happy place like a fireplace or a cozy bedroom. Remember to hold your hug for 20 seconds or more for the best benefits.

3. Strengthen self-care with mindfulness

Mindfulness is all about paying attention on purpose. This means observing how you feel, what your body and mind is craving and how you may best care for yourself. Instead of reaching for social media, a new video, or a less nutritious treat, consider the best way to nurture yourself–what you might recommend to a good friend.

During these anxiety-provoking times, remember the tried-and-true stress reduction strategies. Do you best to get adequate sleep, exercise regularly, spend time in nature and employ relaxation techniques on a daily basis.

Meeting a friend for a brisk walk in nature while bringing your attention back to the moment can bring multiple benefits. You might also consider slow mindful walking where you bring attention to each foot as it touches the ground. It’s helpful to say, “heel, ball, toe” as you notice the movement of the foot against the ground. Enjoy your slow walking and remember, there’s wrong way to bring yourself mindfulness.

Prioritizing these behaviors during the coronavirus crisis can go a long way toward bolstering your immune system and increasing your psychological well-being. Caring yourself in these ways may be a new habit to build over time, so start with one practice at a time and add on as you go, with kindness. Giving yourself kindness allows you to extend it to others who are struggling at this time.

Coronavirus (COVID-19): Reason, Prudence and Common Sense

Posted Posted in Continuing Education, Elder Care, Homestudy, Nutrition, Seminars, Webinars

By Mary O’Brien, M.D.

A pattern is emerging.  Clinical and laboratory experience in several countries reveals that there are two strains of coronavirus (COVID-19).  The virus is comprised of an unstable single strand of RNA that is mutating.  This is known as antigenic drift and it is expected.  Researchers have identified an “L” strain and an “S” strain.  At present, the “L” strain appears to be associated with more severe symptoms and a higher mortality rate.  More widespread and accessible testing (which is now underway) will help us discern which strain is prevalent in various regions.

The vast majority of deaths have occurred in elderly people with significant underlying illness.  The cluster of patients in a nursing home in Kirkland, Washington, underscores the fragility of sick, elderly patients in enclosed settings.  Outbreaks on cruise ships reflect a similar pattern of transmission.  A large percentage of cruise passengers are over 50.  People don’t like to think of 50 as older, but physiologically, it is.

Clinically, patients with more serious illness have a high fever (over 101°F), a deeper-sounding cough (not a tickle in the throat), and shortness of breath.  The mortality rate in countries with good health care is around one percent.  China and Iran are impossible to assess, but mortality rates there appear to be around 3.4 percent.  Older men in China have very high rates of smoking, which is a crucial factor in both morbidity and mortality.

For now, several additional practices make sense:

  • Minimize or restrict visitors to patients in hospitals and nursing homes. Sick, elderly people need to be protected.
  • Frequent, thorough hand-washing with soap and hot water for 20‒30 seconds is best; hand sanitizers are second best. Keep your hands moisturized to avoid cracked skin.
  • Don’t eat with your fingers; don’t lick your fingers.
  • Keep your hands away from your face, eyes, nose, and mouth.
  • Sanitize your phone everyday. It’s the filthiest thing you touch.
  • Facial hair on men is a veritable Petri dish for microorganisms — especially among the nose, mouth, and chin. Now would be a good time to shave.
  • Change your pillow cases everyday.
  • Don’t waste your face masks. Surgical masks protect other people from your coughs and sneezes.  They don’t protect you from others.  Besides, many viruses penetrate our immune defenses through our eyes.
  • Toss your toothbrush at least every month, and whenever you are feeling ill.
  • Increase oral care with antiseptic mouthwash several times a day.
  • Stay well-hydrated to optimize the integrity of mucous membranes.
  • Let yourself and your patients get more sleep. Sleep is immensely important for multiple aspects of immune function.

The virus will evolve, and we will adapt.  At some point, it will resolve.  Right now, many people, especially those in the media, are overreacting.  That is always a mistake.  There has never been a substitute for reason, prudence, and common sense.  Steady as she goes.  How often can you say it?

 

Novel Coronavirus (COVID-19): Now What?

Posted Posted in Brain Science, Continuing Education, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

Everybody calm down.  Fear is spreading faster than the coronavirus at this point.  Financial markets are in turmoil over fear of a global economic slowdown caused by the virus.  Worries about lost productivity in China, reduced demand for oil and consumer goods, and disruption of travel, tech, and financial sectors have investors around the world hyperventilating.  The price of gold has reached its highest level in seven years, and the yield on the 10-year treasury is near record lows (1.37%) — both signals of a flight to safety.  Caffeine-toxic media types are nearly histrionic.  As is typically the case, the only two things missing from their breathless banter are knowledge and perspective.

Here are the facts, as of Monday evening, February 24, 2020:

  • The number of global cases of COVID-19 is around 79,000.
  • Virus-related deaths are at 2,600.  The overwhelming majority of deaths is still in China, but China is only reporting in-hospital deaths.
  • The current mortality rate is still around 2–3%.  The mortality rate of SARS was 10% and the mortality rate of seasonal flu is 0.1%.
  • COVID-19 is more readily transmissible than SARS (Severe Acute Respiratory Syndrome), but less deadly.
  • The incubation period is still considered to be 14 days.
  • Viral transmission of COVID-19 appears to occur through large droplets in respiratory secretions.  Both oral and anal swabs have detected virus (viral particles can be found in the GI tract).
  • Both SARS-CoV and MERS-CoV infect intrapulmonary epithelial cells more than cells of the upper airways. As a result, transmission occurs mostly from patients with recognized illness and usually not from patients with minimal symptoms.  COVID-19 seems to work the same way.
  • The most serious symptoms involve the lower respiratory tract and lungs, as opposed to upper airways. The resulting disease is now called “novel coronavirus-infected pneumonia” or NCIP (NEJM, Feb. 20, 2020).
  • So far the clinical breakdown of cases is fairly predictable:
    • 80% are mild illness (requiring little or no care).
    • 14% are of moderate severity.
    • 5% are critical (requiring mechanical ventilation).
    • 2–3% are fatal.
  • U.S. cases – 35 (nearly all travel-related).
  • Italy confirms 152 cases around Milan with more than 200 cases throughout the country. South Korea confirms 833 cases after testing over 20,000 people.
  • The most vulnerable patients are older individuals and those with chronic underlying illness. (CAD, CHF, COPD, DM, chronic kidney disease).

So now what?  We wait for more facts.  The headlines will reflect a frustrating level of paranoia for another 2–3 months — at least.  Universal precautions in medical settings, careful personal hygiene, and common sense are always prudent. `

Don’t panic.  Don’t dump your investments.  Don’t overdo the caffeine.  And one more thing:  Everybody, please calm down.

 

Coronavirus – An Update

Posted Posted in Elder Care, Homestudy, Nutrition, Seminars, Webinars

By Mary O’Brien, M.D.

It’s progressing. We knew it would.

The novel coronavirus, just renamed CoVID 19, has surpassed SARS in the number of deaths caused.

The number of confirmed cases worldwide is 60,081 with 1363 deaths. Nearly 99% of cases are still in China and the mortality rate remains around 2‒3%. There are undoubtedly far more unconfirmed cases in China since large numbers of people are at home with mild to moderate symptoms, or even asymptomatic infection. Inadequate testing to confirm the virus or rapidly triage and admit patients to intensive care in Chinese hospitals appears to be a serious problem.

The Chinese physician who first recognized an outbreak of SARS-like illness was targeted and arrested for “rumor-mongering.” He was even forced to recant his story. Dr. Li Wenliang contracted the coronavirus and died last week. Even his death was denied by authorities for a day. Dr. Li joins a brave, dedicated, compassionate group of heroic physicians throughout history who succumbed to the very illness they were treating. His memory will be honored.

The only way to solve a serious problem is to address it in an open, straightforward manner. Secrecy rarely solves serious problems. We’ve all heard the old dictum, “Sunlight is the best disinfectant.” Fortunately, the President’s task force on the coronavirus has done an excellent job of educating the public, securing and screening ports of entry, coordinating distribution of viral test kits to U.S. labs, evacuating Americans from China, and quarantining appropriate people with possible exposure.

The CDC, NIH, and Department of Health and Human Services personnel are working nonstop to contain the virus and develop a vaccine and potential treatment. In the meantime, supply chain disruption is affecting car companies, tech firms, and even medical supply businesses. Many of our OTC and prescription medications, including antibiotics, are made in China. The FDA has evacuated our personnel who inspect these production plants. There may well be consequences in the coming weeks and months here in the U.S.

Meanwhile, we’re in peak cold and flu season. Fastidious hygiene remains key:

  • Wash your hands – frequently and with soap and hot water for at least 20 seconds.
  • Do not touch your mouth, nose, and eyes. Viral particles suspended in respiratory droplets can penetrate mucous membranes and conjunctiva very easily.
  • Maintain at least 6 feet between yourself and others (social distancing)
  • Avoid crowds and unessential travel
  • Get more sleep than you think you need
  • Stay home if you have cold or flu symptoms (and don’t lay a guilt trip on colleagues who are sick)
  • Disinfect hard surfaces frequently. This coronavirus can apparently survive on hard surfaces as long as 9 days. Phones, keyboards, bathroom fixtures, door handles, and steering wheels are just a few examples.

Seasonal epidemics triggered by a mutated virus can be devastating, but eventually they are contained. Until then, our job is to stay calm, stay informed, and practice the time-tested principles of good patient care and common sense.

Coronavirus – Just the Facts

Posted Posted in Continuing Education, Homestudy, Seminars, Webinars

By Mary O’Brien, M.D.

Chances are good you have a lot going on this week. And there’s a lot to keep up with in the news. Bearing that in mind, here is a synopsis of the facts concerning Coronavirus.

  • Definition: Coronaviruses are enveloped RNA viruses which typically cause symptoms of the common cold. The name stems from the halo or corona-like appearance of the virus when viewed with an electron microscope.
  • Medical terminology: The current coronavirus causing illness will be referred to as 2019 nCoV (novel coronavirus 2019) in the medical literature.
  • Symptoms: Coronaviruses typically cause cold and flu-like symptoms such as runny nose, sore throat, headache, cough, fever, and malaise. Shortness of breath is often indicative of progression to a viral pneumonia.
  • Countries with documented cases of 2019 nCoV: China, South Korea, Vietnam, Thailand, Nepal, Hong Kong, Singapore, Malaysia, Australia, Japan, France, U.S., Canada.
  • Origins of current outbreak: Likely animal-to-human transmission with subsequent human-to-human transmission in Wuhan, China. Wuhan is the capital city of Hubei province and has a population of 11 million.
  • Current problems related to epidemic in China: Multiple hospitals in China are overwhelmed, with shortages of supplies including masks, gloves, goggles, disposable gowns; reports of patients being turned away. Food shortages are reported in various areas as a result of transportation bans and lock downs.
  • Containment measures in China: Travel bans now affect nearly 50 million people in China. Multiple tourist sites have been closed including some portions of the Great Wall, the Forbidden City, and Shanghai Disneyland. Movie theaters have been closed. Tour groups, cruises, and schools are closed. Many Chinese Lunar New Year Festivities have been cancelled. This week and next week comprise the busiest travel period in China and the resulting economic impact is expected to be significant.
  • Current medical measures in progress: The Chinese government is flying hundreds of physicians and volunteers into affected areas and two temporary emergency hospitals are under construction to provide an additional 2,000 beds.
  • Most vulnerable patients: Those at greatest risk include young children, the elderly, immuno-compromised patients, and those with diabetes, chronic heart or lung disease, and chronic renal disease.
  • Usual cause of death: Viral pneumonia with respiratory failure is the most common fatal complication of coronaviruses.
  • Appropriate workup in acutely-ill patients with possible exposure: Patients who have travelled in China, within the past 2‒3 weeks, or who have had contact with such an individual, who have fever, cough, headache, or shortness of breath may warrant a CXR, CBC, liver enzymes (especially LDH and AST). Coronavirus testing involves real-time reverse transcriptase PCR (RT-PCR) of lower respiratory secretions.
  • Historical perspective: Two other coronaviruses have caused serious respiratory illness in recent decades:
    • MERSCoV 2012 – Middle East Respiratory Syndrome
    • SARS-CoV 2002-3 – Severe Acute Respiratory Syndrome

MERS resulted in 2,066 confirmed cases worldwide with 720 deaths.

SARS resulted in 8,000 confirmed cases worldwide with nearly 800 deaths (a mortality rate of 10%). Deaths were reported in 37 countries.

SARS was eradicated in 2004 by rapidly identifying and isolating “super-spreaders” (patients who infect unusually large numbers of people in the general population.)

  • Prevention: Common sense and standard infectious disease principles are in order – frequent, thorough hand washing; avoid touching your face, nose, mouth, and eyes; do not travel, go to work, or socialize if you are ill; face masks can reduce transmission of virus-laden droplets from infected patients coughing or sneezing; avoid crowds; don’t share food, beverages, or utensils.
  • Current status: As of Monday 1/27 – 2,700 confirmed cases with 81 deaths. Mortality rate at present is about 3%. These statistics will evolve rapidly.
  • Recommendations:
    • Check for updates from the CDC.
    • Focus on facts, logic, and common sense.
    • Employ time-tested ID principles and protocols.
    • Realize similar outbreaks run their course (typically in winter) and eventually resolve with identification of the virus and isolation/containment of infection.
    • Get a careful history from patients. The vast majority of people with cold or flu symptoms have a cold or flu – not coronavirus from China.

Solomon and Churchill

Posted Posted in Continuing Education, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

Here we are – midway through January 2020.  Have you crystallized your vision of vitality for 2020?  Has anyone noticed you have a new routine or attitude?  Have you already given up?  Don’t be too hard on yourself.  Between coping with severe weather and assorted viruses, many people are doing well to be functional right now.  Fortunately, it’s never too late to focus on the future and take corrective action.  After all, ships and planes rely on constant corrective adjustments of their navigational systems to reach their destinations.  How much more do fallible, fatigued, and sometimes fickle human beings need to take corrective action if we’re to achieve our destiny?

Now there’s a word that gets far too little attention in our culture.  Destiny.  No doubt there are those who would roll their eyes and dismiss the concept as delusional and arcane.  But I really believe each of us has a destiny or at least a potential destiny.  The key is recognizing it and taking steady action to achieve it.  Andrew Roberts, the acclaimed biographer, describes Winston Churchill’s profound sense of personal destiny in his book, Churchill: Walking with Destiny.  An intense spiritual experience at the age of 16 implanted in the young Churchill a deep conviction that he would be called upon to save London and indeed, Great Britain, at some point in his life.

Churchill had some major failures along the way, as all great people do.  And, despite stunning successes, he was the target of relentless, vicious criticism from political opponents, pretentious journalists, and even people in his own party.  Many of Churchill’s speeches were greeted with ridicule and contempt by his detractors.  This should not surprise us.  Nothing fosters criticism more predictably than jealousy.  Those speeches would later be hailed as some of the most inspiring rhetoric in history.  Winston Churchill endured massive criticism at nearly every turn, but his sense of destiny allowed him to persevere.

The concept of destiny infuses the wisdom of the ages. Several thousand years ago, Solomon wrote a sentence in Proverbs that should be noted by individuals and nations alike.  He wrote, “Where there is no vision, the people perish.” Solomon was onto one of the great secrets of the universe.  Can there be much doubt that communism has largely collapsed because it tried to suppress the vision of its people?  Would inner city darkness and despair exist if people pursued a vision of future success?  Would many of us wallow in depression for long if a vision of great destiny propelled us forward?

If you were less than thrilled with the accomplishments and personal progress you made last year, make a change.  Change whatever isn’t working in your life.  Of course, that means changing the way you think.  It means daring to dream and develop a vision for the future.  Don’t dwell on your circumstances, change them.

The vision to see, the faith to believe, and the will to work can bring your destiny within reach.  Solomon and Churchill were onto something.  The question is, are we?