Masking For COVID-19 Prevention

I have been wearing a mask every time I leave my house to do anything other than exercise outdoors for the last 2 months. It’s hot. It makes my nose itch. The skin on my face gets tight and irritated. Why do people pay money to have their faces steamed as a facial treatment?!

I don’t like wearing a mask. But. If everyone wears a mask, it will save lives. There is good data supporting universal masking for COVID-19 prevention.

Researchers at Texas A&M and UC San Diego looked at epidemiological data and how the outbreak responded to different control strategies. They found that the strategy that impacted the outbreak the most in both Italy and New York City was universal masking.

China was confusing because they implemented everything at once. Social distancing, stay-at-home, contact tracing and masking were all started at the same time. In Italy and New York City, however, masking requirements were instituted some time AFTER the physical distancing requirements. This makes it possible for researchers can see the relative contributions of these measures.

It turns out the single measure that made the most difference in bending the curve was universal masking. The curves representing the outbreaks in Italy and New York City were identical, including the bend that occurred when masking was instituted. The lockdown/stay-at-home orders in Italy and NYC occurred right at the beginning of the outbreaks and may or may not have impacted the outbreaks’ course.

Credit: www.pnas.org

COVID-19 is a respiratory illness. It is transmitted by aerosol primarily, not by contact. Masks decrease the production of aerosols by catching droplet when the wearer breathes, coughs and sneezes. The virus particles are very very small, too small to be stopped by tightly woven cotton or other fabrics. However, the virus isn’t shed by itself. It’s shed in droplets of mucus that ARE large enough to be stopped by the fabric.

A second benefit of masking is it decreases people’s tendency to unconsciously touch their faces. Hand washing, use of hand sanitizer and disinfecting commonly touched surfaces like light switches and doorknobs decrease contact transmission. But even if you do touch a contaminated surface like a doorknob, you have to touch your eye, nose or mouth in order to get infected.

Recommendations from health authorities like CDC and WHO change based on the latest and best information. In some cases recommendations change quickly and are contradictory. This is simply because the state of understanding of COVID-19 is new. New research findings are coming out so frequently that it is hard to keep up.

We (and the health authorities) are doing the best we can with the information we have. When we know better, we do better. However, the data is coming pretty clear that universal masking for COVID-19 prevention is an important measure.

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Tanning Beds And Skin Cancer

Summer is coming, and so now I’m starting to see teenage girls coming in abnormally brown. There’s a lockdown, you can’t travel, and it’s Cleveland. I know you’re not laying out in the backyard. If you’re tanned, you’ve been in a tanning bed.

For twenty years I’ve been talking to patients and parents about the dangers of tanning beds. The most important risk (although not the only one) is the link between tanning beds and skin cancer.

The good news is that indoor tanning is becoming less common. Educational and public service programs seem to be raising awareness of the dangers. However, millions of adults still use indoor tanning beds every year, increasing their risk of skin cancer.

Credit: CDC.gov

There is good news about tanning bed use in teens. It is clear from surveys that use among teenagers is going down as well. But it is still obvious that tanning bed use is problematic in young women and teens.

Indoor tanning increases the risk of melanoma skin cancer by 15% after only ONE session. Use before age 35 increases the risk by 75%. The damage is cumulative, the more it is used the higher the risk.

If tanning is so dangerous, why do people do it? There is a lot of misinformation about indoor tanning out there. Tanning salons promote questionable health benefits and minimize the risks. Tanning beds often provide very high UV exposure, sometimes as much as 15 times the exposure one would receive from the sun.

One of the misconceptions is that indoor tanning is a “safe” tan. Young women in particular believe that a tanning bed is less dangerous and can provide a “base tan” before being outside in the sun. Research is clear however that the tanning process requires DNA damage. Whether one is tanning indoors or outdoors, it is NOT safe and increases the risk of skin cancer.

The only known benefit of UV exposure is the production of vitamin D in the skin. However, the level of UV exposure received in indoor tanning is complete overkill for vitamin D production. Vitamin D supplements are much safer and more effective for getting to a normal blood level of vitamin D.

Both indoor and outdoor tanning increase the risk of skin cancer, but tanning beds are much more dangerous. Wearing sunscreen, sunglasses and light-weight light-colored clothing, avoiding sun exposure during peak hours and taking a vitamin D supplement is the best approach to protecting your skin AND your health.

QUESTION: Do you use tanning beds?

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Vitamin D and COVID-19

Wintertime in Cleveland really sucks. Snow. Cold. Gray skies. Did I mention snow? Colds and flu. This year’s winter has really taken the cake, though. COVID-19 has shut down the world, it seems.

I’m finding it really fascinating to read some of the explosion of research about COVID-19. Researchers are furiously trying to figure out what distinguishes those who are prone to more severe cases of this illness from those who have only mild symptoms.

A number of risk factors have emerged. Some are obvious, like diabetes and chronic lung disease. Others are making the medical community scratch their heads, like hypertension.

Recently a protective factor has emerged: vitamin D. It turns out that those with mild cases of COVID-19 are more likely to have normal vitamin D levels than those that have more severe cases or who are critically ill. What’s the link between vitamin D and COVID-19?

We know that vitamin D is important in supporting immune function and decreases your risk of getting colds and flu. Where does vitamin D come from, anyway?

Vitamin D is made in the skin in response to UVB light from the sun. UVB is blocked by clouds and by the atmosphere, so exposure is low in the winter in the higher latitudes and during the rainy season in the tropics. People with darker skin (such as people of African and Asian descent) make less vitamin D in their skin with a given amount of sun exposure.

There are not many dietary sources of vitamin D. Most dairy milk in the USA is fortified with added vitamin D, but there is not much in there. Most dairy milk is fortified to 100 units per cup. Given that it seems most adults need 2000-4000 units of vitamin D every DAY, you definitely can’t rely on dairy milk to get what you need.

So we’re left with supplementation. The best way to make sure you’re getting enough vitamin D is to have your doctor check a blood test. Current guidance is that your level should be around 50 to be optimal.

Black, Hispanic and Asian Americans have higher morbidity and mortality from COVID-19. Older adults have worse disease. These groups also generally have lower blood levels of vitamin D. I don’t think this is a coincidence.

If you can’t get to your doctor to get tested just now, that’s OK, you can definitely add a vitamin D supplement. Click here to see which one I take and trust for my family.

There is a lot of fear right now surrounding the COVID-19 pandemic. Making sure you are getting enough vitamin D every day is a simple thing that will help improve your health and support your immune system, and may help reduce your risk of a severe illness if you do contract COVID-19.

QUESTION: Do you take a vitamin D supplement every day?

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How To Have A Successful Virtual Visit

This is a really weird time in America. Everyone is staying at home. Restaurants and bars, museums, malls, zoos, movie theaters, parks and playgrounds are closed. Hospitals are empty of “elective” cases like knee replacements and spine surgery. At the same time, in many areas the health care system is completely overwhelmed by COVID-19.

Doctors’ offices are empty of patients. My practice is only seeing patients online. I have unfortunately gotten pretty comfortable doing something I never wanted to do – the virtual visit.

virtual visit

I was taught in medical school and residency that good medical care requires an examination. You can’t come to a reliable diagnosis if you can’t examine the patient. For over 20 years that has been “reality” for me.

Now I can’t examine anyone. It is extremely uncomfortable for me as a physician to have to diagnose someone’s illness based only on their symptoms. To know why someone is coughing without being able to listen to their lungs and heart is very difficult! To diagnose a UTI without checking a urine specimen is tough!

The very real danger is in overdiagnosing. Treating the earache caused by a viral infection with fluid in the ear is fairly simple, and doesn’t need antibiotics. However, if I can’t see the eardrum, I’m tempted to treat with antibiotics “just in case” it’s a bacterial ear infection. Antibiotics are potentially dangerous and only useful in certain cases.

But virtual visits are where it’s at right now, and they are safer for my patients, for me and my staff, and for all our families until the risk of this infection has subsided to some sort of “new normal.”

So how can you make sure that, if you need to do a virtual visit with your doctor, it’s as safe and effective as possible? Here are a few pointers:

  • If you are vomiting and unable to keep food or liquids down, or have chest pain or shortness of breath, you will likely need to be seen in the office, urgent care or ER. If you are severely sick you probably should bypass the virtual visit altogether and get checked out in person.
  • Do the visit on a laptop or desktop computer, not your phone or tablet if possible. Interfaces are more glitchy with the smaller electronics. (Also, your doctor doesn’t really want to look up your nose which is what happens when your phone or tablet is on your lap!)
  • Make sure your computer has the webcam, microphone and speaker (or headphones) all enabled.
  • Make sure you are not sitting with your back to a light source, like a lamp or brightly lit window. The light should be in front of you, behind the computer, so the light falls on your face.
  • You should have a home blood pressure meter available to take your blood pressure and pulse and show it to the doctor. If you have a known history of high blood pressure you need to have one of those, it’s a good time to get one. They’re available at your drugstore or on Amazon.com. Wrist meters are not as accurate as the ones that go on your upper arm.
  • While you’re ordering medical supplies, make sure you have a thermometer to take an oral temperature. The forehead scanners used in hospitals are very expensive – oral thermometers are cheap and accurate.
  • I love meeting your pets and your kids (and seeing what you’ve done with the place!) but please make sure they’re not going to be disruptive of the visit.
  • Be aware of and understand the limitations of the visit. There is an inherent risk of a missed diagnosis which is larger in a virtual visit (because there is no physical examination) than in an in-person visit.

I have high hopes that we will be able to start seeing patients in the office again soon. But the virtual visit probably isn’t going to go away. There are instances when it makes a lot of sense. Mental health follow ups. Reviews of lab results. Stable blood pressure follow ups when the patient has a reliable home blood pressure meter. (In fact, some of my patients would be better off having their BP checks at home!)

In this super weird time the virtual visit is what I would consider a necessary evil. We need to make sure we’re doing everything possible to make your online visit as safe and effective as possible.

QUESTION: Have you had a virtual visit with your doctor? Was it a good experience?

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Who Should Be Tested For COVID-19

As a physician working for one of the big local healthcare systems, starting Monday I will have the ability to order outpatient testing for the coronavirus. University Hospitals of Cleveland and the Cleveland Clinic are both offering drive-through swab testing with a doctor’s order.

Credit: bangordailynews.com

I’m anticipating a LOT of phone calls on Monday. Before you call, I want to go over the guidelines for who should be tested for COVID-19.

The very first question that will be asked when someone calls is “ARE YOU SICK.” This sounds silly but the worried well are going to want to be tested. I was at Costco Friday morning, am I at risk? I work in healthcare, am I at risk? Yes, of course. But I do NOT need to be tested because I am NOT sick.

The symptoms of COVID-19 include fever, cough, and shortness of breath. If you have a runny nose and cough, but no fever, you have a cold and do NOT need to be tested. And you don’t need to go to the doctor, urgent care or emergency room either! Stay home, drink fluids, rest and wash your hands until you are feeling better.

Suppose you do have a fever and a cough. If so, I guarantee that anxiety is going to make you feel short of breath! The next question is, have you been exposed? At this point, if you have not traveled and have not been in contact with a known or suspected case of COVID-19, and are well enough to stay home, you do NOT need to be tested. The exceptions are healthcare workers and those at high risk (like cancer patients and those 65 and older with multiple medical problems).

If you or a family member have any of THESE symptoms, you need to call 911.

  • Shortness of breath
  • Chest pain, pressure or discomfort
  • Bluish discoloration around the lips or fingernails
  • Confusion or difficulty waking up

If you need to call 911, let the dispatcher know what’s going on so they can give the paramedics and ER a heads-up and be prepared.

Social distancing, closing schools, avoiding large groups, good handwashing and sanitizing surfaces will help slow the spread of the virus. It’s inevitable that some people will be infected, and knowing who needs tested is important. We don’t have unlimited ability to test the general population. Just because you are scared and MIGHT have been exposed is not a reason to get tested.

If you need more information about this infection, here are some good resources for facts, not hype or hysteria:

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How To Wash Your Hands

I was browsing the health news reports to get an idea of a topic for this weekend’s post. Literally every post is about the coronavirus outbreak and its spread to numerous countries.

While this is very important, unfortunately I’ve already written about this topic. I have seen a number of posts this week on social media about proper hand washing, and decided this was a good time to review the right way to wash your hands.

Everyone from Mayo Clinic to the CDC has put out guidelines about how to wash hands correctly. I have included a video at the end but here are the steps:

  • Wet hands with warm water
  • Use regular soap. Antibacterial soap actually increases the risk of staph infections and is not recommended.
  • Lather the hands thoroughly and rub them together. Get between the fingers, the tips, and the thumb.
  • Continue to rub the hands for 20 seconds. This is the time it takes to sing the Happy Birthday song or the Yankee Doodle song through twice.
  • Rinse the hands thoroughly under warm water.
  • Turn off the tap with a paper towel, NOT your clean hands
  • Open the bathroom door with a paper towel, NOT your clean hands

Studies have shown over and over that good hand hygiene is critical in preventing infection. This is true not only in hospitals and doctors’ offices but in the general public as well. Especially with the growing concern about coronavirus infection, proper hand washing is a critical measure everyone can and should take to reduce their risk of illness.

QUESTION: Are you washing your hands correctly?

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Wuhan Coronavirus

OK, everyone is talking about the Coronavirus infection that started in Wuhan, China and is spreading throughout the world. What do you need to know about it?

This infection was first reported in late 2019 in Wuhan, China. A number of the first cases were reported in people who had connections to a large seafood and animal market, but later cases seemed to clearly show person-to-person transmission.

The infection is now here in the United States, and not everyone who has tested positive for the virus has been to China. Clearly the virus can pass from person to person. As of Friday, 1/31, there have been seven cases in the United States.

Wuhan Coronavirus is a respiratory illness that causes fever, cough and shortness of breath. Serious cases can involve pneumonia. Symptoms can be mild to severe. There is no vaccine, although scientists are working to develop one, and as of now there is no widely available treatment. A combination of medications designed for influenza and HIV seems to be helpful though.

Right now the best way to stay safe from this virus is to avoid infection. Travel to China has been restricted by the State Department. People returning from the Wuhan region of China are being quarantined.

If you have been to China and are sick with a respiratory illness, please see the doctor right away and tell the doctor immediately that you were in China. Follow sensible precautions like washing hands, covering coughs and disinfecting surfaces in your home.

The Wuhan Coronavirus can be deadly. About 2% of cases in China have been fatal. Compared to influenza, which kills about 1 in 1000 people who catch it, this is much more dangerous but also much more rare. 360 people have died in China from Coronavirus, compared to over 34,000 people who died in the United States in the 2018-2019 flu season.

Be aware of Wuhan Coronavirus. Don’t travel to China until the State Department announces it is safe. If you have traveled and get sick, see the doctor and make sure they know your travel history. Take sensible precautions. And don’t panic.

QUESTION: Are you worried about Wuhan Coronavirus?

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Cardiac Rehab After Heart Attack

If I tried to make a list of all my patients who have had a heart attack in the past year, unfortunately I probably would be here awhile. We are NOT good at identifying patients at risk, and many patients refuse treatments and lifestyle changes that are proven to reduce their risk of a heart attack.

AFTER a heart attack, though, we have a very good idea what will reduce the risk of having another one. Sadly, only a very small number of patients take advantage of one of the best measures to reduce the risk of an encore performance: cardiac rehab.

Cardiac rehab consists of 36 one-hour sessions which are covered by Medicare and most if not all commercial insurance. The sessions include

  • supervised exercise training
  • counseling on diet
  • counseling on stress management
  • smoking cessation (if needed)
  • guidance on other measures for heart-healthy living

Researchers at the CDC in Atlanta looked at heart attack and heart failure patients covered by Medicare and found that only 24% of the patients even started cardiac rehab. Of those, on average patients completed only 25 sessions, with only 27% attending the recommended 36 sessions.

Older patients, patients of color, sicker patients and women were less likely to go to cardiac rehab. The study wasn’t designed to figure out why this was seen. However, I can imagine transportation and family support may have been a problem with the older and sicker patients. Access to care is always a problem with patients of color and in this instance doesn’t surprise me. Women in general put their own needs last, and I can definitely see female patients being less likely to attend an extended series of rehab sessions. I can’t even get them to go to 12 physical therapy sessions to address an excruciating musculoskeletal injury!

Cardiac rehab reduces the risk of death in the period after a heart attack. It improves quality of life, mood and functional status. It also reduces the risk of hospital readmission. Every patient with a heart-related hospital stay should be offered (and should take advantage of) cardiac rehab.

If you or a family member find yourself diagnosed with a heart condition, ask your cardiologist or family doctor whether you qualify for cardiac rehab. If you do, GO. Go to ALL the sessions, go until they tell you not to come back anymore. Your heart will thank you!

QUESTION: Did you know about cardiac rehab? Do you know anyone who would benefit from it?

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Measles Outbreaks In The Pacific

Fever, rash, cough and congestion. These are the hallmarks of measles. Before the beginning of the measles vaccination program in the 1960s, there were 3-4 million cases of measles annually in the United States, almost 40,000 people were hospitalized, over 1000 people developed permanent disability from measles encephalopathy, and almost 500 people died. Every year. Most of these cases happened in children.

Now with vaccination rates falling, we are again seeing outbreaks of measles. Right now, there are measles outbreaks occurring in the South Pacific. It’s estimated that only 30% of the population of Samoa, for instance, have been vaccinated against measles, and they are in the midst of a terrible outbreak right now. Other countries are sending medical supplies, doses of vaccine and health care personnel to help deal with this outbreak.

Samoa is a country with about 200,000 people. 3,149 cases of measles have been reported, 197 people are hospitalized and 42 have died. To give some idea of the magnitude of this outbreak, we can compare to the United States, which has a population of 327.2 million people. This size of an outbreak in the US would result in 5.2 million cases, 322,000 people hospitalized, and 68,712 deaths. Most of Samoa’s deaths have been in children under 4 years of age.

Think about that. Imagine a United States in which almost 70,000 infants, toddlers and preschoolers were killed within a month’s time. Bearing in mind that those deaths are preventable, this outbreak in Samoa is a heartbreaking tragedy.

The good news for the USA is that vaccine coverage overall is still above 90%. However, there are 11 states in which coverage is under 90% and there are pockets where vaccine coverage is much, much lower. Amish people reject most modern medical innovations (including vaccines). Many California communities have vaccine coverage rates at about 50%. This is much lower than what is required to prevent outbreaks of measles.

Measles is the most contagious illness we know. It is a serious illness and potentially fatal. The vaccine is safe, so safe that in 1.5 million people vaccinated in Finland from 1982-1992 no deaths or serious permanent adverse reactions were reported.

If you are not immune to measles and are exposed, you have a 90% chance of getting sick. This is in comparison to influenza, which has about a 50% transmission rate. Parents who choose not to vaccinate their children are making a choice to leave them unprotected against a serious, possibly fatal, horribly contagious illness that is still endemic in parts of the world.

No vaccine is perfectly effective, but the MMR vaccine is pretty close. It eradicated measles, mumps and rubella in Finland in the 1980s with a 12-year, 2-dose vaccination schedule.

Measles is still present in the world. The MMR vaccine is the most effective weapon we have against this illness. Please be sure to vaccinate your children.

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Mental Health Professional Shortage

Tiffany came to see me as a new patient this week. She is a very nice young woman with a number of very big problems. She is a single mother to two daughters, one of whom is autistic. As a working mom, she has to juggle childcare and all the other household tasks. Her ex-husband is behind on child support and only rarely takes the girls for weekends. He has trouble managing their autistic child’s behaviors.

It probably won’t surprise you that Tiffany is REALLY stressed. She isn’t sleeping, and her anxiety is becoming harder to manage. She came in this week asking for a referral to a psychiatrist.

If you’ve been following me for a while, you probably know part of me started to do a quiet little happy dance on the inside as I was listening to my new friend. She was in the absolute perfect place because I have so many tools to help her. The one that I DON’T use often (and just sits dusty on the shelf almost all the time) is a psychiatry referral. I don’t need it except in rare cases.

It’s a good thing, too, because psychiatrists aren’t exactly thick on the ground in northern Ohio. In fact, most of the country has a severe mental health professional shortage.

Researchers found that this shortage is impacting how people get care for mental health problems in a big way. They looked at claims for mental health vs. physical health problems. The researchers found that people chose to go out of network and pay a larger share of the cost of treatment for their mental health problems.

While the researchers didn’t speak to patients directly and didn’t ask why they went out of network, it’s pretty obvious to me. Those of us in primary care know it takes months to get an appointment with a psychiatrist. Insurance companies often have only a handful of choices for in-network care, and many psychiatrists don’t take insurance at all because reimbursement is very low. If someone is severely sick or a danger to themselves or others, they are directed to the ER where they may be hospitalized. Otherwise they wait.

Here is my prescription for fixing our mental health care shortage:

  • Every single person needs to have an established relationship with a primary care doctor. This means a family doctor, general internal medicine doctor (NOT A SPECIALIST) or pediatrician for little kids. If you are reading this and don’t have a primary doctor, GET ONE. See him or her annually for your physical at a minimum. If you don’t like your primary doctor, get a new one!
  • Be aware of your lifestyle and its impact on your mood. Sleep, exercise, your spiritual practice, diet, ALL will impact your mood. Take small steps to improve your lifestyle before your mood starts to suffer!
  • If you start to feel stress is getting to you, see your primary doctor before things get bad. Don’t wait until you’re so sick you can’t function at all!
  • Consider seeing a counselor. Cognitive behavior therapy (CBT) is as effective as medication for mild-to-moderate depression and anxiety symptoms. It’s hard work, and requires a special kind of courage to unpack what’s going on in your life, but so worth it!
  • Psychiatrists need to send patients with depression and anxiety who are improved and in remission BACK TO THEIR PRIMARY DOCTOR for management. There is no excuse for psychiatrists to continue seeing patients who don’t need them. This will free up space in their schedule for patients who are truly in need of specialty care.

So what did I do for Tiffany? First I asked her to make an appointment with a counselor. I also asked her to start some nutrition therapy with a good multivitamin, B complex and magnesium supplements. Because she was really struggling I started her also on a low dose of an antidepressant and a gentle non-habit-forming sleeping pill.

As food for thought, we discussed the recent research showing diet’s impact on depression and anxiety and I gave her some suggestions. We’ll continue to discuss this in the future. I’m sure when I see her back in a few weeks she will be feeling better and much more in control.

I can’t fix the things going on in Tiffany’s life that are difficult for her. Divorce, single motherhood, working motherhood, and a child with a chronic illness are real stressors. However, depression and anxiety make hard things just that much harder. Treatment is effective, and doesn’t require a visit to a psychiatrist.

QUESTION: Did you know there is a mental health professional shortage?

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