General Wellness

Unfortunately, the mixed, and in some cases frankly wrong and biased messaging some of our governmental and medical bodies have been putting out, or in some cases ignoring and not putting out,  have understandably made many people very leery and untrusting. This just fuels the polar, and almost religious fervor with which people entrench themselves in their beliefs when it comes to this pandemic, vaccines, medications and masking. Even as we gather information and experience, people have difficulty accepting those changes and newer recommendations. This occurs on both sides of the stethoscope, patient and doctor.

In a recent post, I mentioned the incidence of myocarditis (heart inflammation) with vaccination and Covid-19. It’s an issue I have read and heard a lot about. As a father of 2 boys in the most affected age bracket, it’s an important issue to me. I wanted to share some “newer” information. I put “newer” in quotes, because some of this is actually not that new, it has just not garnered the press and attention it deserves. We are all influenced by our biases, myself included.

It is absolutely true that myocarditis has been around for a long time and the vast majority of cases worldwide are idiopathic, meaning, no specific cause has been identified. In some cases, it is related to viral infections of many types, including the common cold, flu and, yes, Covid-19. It is also true that it has been associated with various vaccines, including the Covid-19 vaccine. Basically, any process which triggers our immune system which causes inflammation, can cause inflammation anywhere in the body, including the heart. In most cases, it is self limiting, and results in no long term ill-effects, however it can rarely be lethal as well.

As far as Covid and the vaccines are concerned, myocarditis has been seen with both situations. Some studies are showing that rates may be higher with vaccination. This may also be simply a matter of numbers since 212 million Americans have been fully vaccinated (64%) whereas only 78 million have contracted Covid. That number is certainly an underestimate given the number of people who home-tested positive and were not reported. Just as an fyi, we, in the US, are at 933,000 dead from this disease. The degree of severity has supporters on both sides of the fence as well. The type of inflammation may be different from the inflammation caused by actual infection. Some say myocarditis from Covid is worse, and some say that the vaccine induced heart inflammation is worse. In either case, the vast majority resolve quickly and without complication. Overall, the numbers of cases from vaccination are still very small.

As far as which vaccines are more implicated, the mRNA vaccine, specifically the Moderna one, seems to have the highest rate of incidence of myocarditis. It is highest after the second shot and it appears that the risk goes down with the booster. In the EU, the recommendation now is to not use Moderna in males, 15-25 years of age, the demographic most affected by this condition.

I still firmly believe in vaccines and feel that everyone should get vaccinated, however today, I would tailor recommendations to specific situations, including which vaccine to take and when to take it. Young men should avoid the Moderna vaccine if possible. Young women should avoid J&J. If you don’t have the option of choosing, I would still get whichever vaccine is available. If you had Covid, wait a few months, up to 6, but still get vaccinated. And consider how lucky we are to have such options! In China, all they have is Sinovac which is really quite poorly protective against Omicron. In other countries, they have nothing.

One of my boys received the Moderna vaccine, along with the booster, and he did fine. In hindsight, would I have guided him to get the Pfizer vaccine? Probably, but hindsight is 20:20 and there are a LOT of things I would have done differently in my life “if I knew then what I know now!” I certainly would not have dyed my hair blond with lemon juice back in the 80s!

Many people talk a lot about suppression of information accusing the CDC of censorship of outspoken doctors and scientists who are not “vaccine at all costs” advocates. This sounds a little “conspiracy theorist” but there may be some elements of truth in this. Certainly, news outlets report on items that conform to their biases (CNN vs FOX…). An example is the use of the drug fluvoxamine (Fluvox) in treating Covid as an outpatient. It is a great, cheap and safe drug used for anxiety and OCD. The mechanism of action of its benefit when it comes to Covid, has to do with an antiinflammatory effect it has, decreasing the severity of symptoms. This is similar to how dexamethasone, an antiinflammatory steroid, works. Studies have shown a 91% reduced severity of symptoms on this medication. There is barely any mention of it however in the press.

On the flip side, as far as Ivermectin and Hydroxychloroquin go, studies seem to be showing more and more that these drugs are really not providing any real Covid benefit, and in the case of hydroxy, they may have caused more harm than good. Overall. Are there individuals who took these meds and had improvement, sure, but they may have gotten better regardless. I had a vaccine hostile patient recently who was angry that Ivermectin is used routinely en masse in India and is ignored here in the US. I pointed out to her that, despite many vaccines being produced in India, the average Indian doesn’t have access to any vaccines. In addition, their water sucks and is polluted with parasites, which Ivermectin, an amazingly effective antiparasitic drug, treats. If I lived in India, I would take Ivermectin daily as well, but more so I wouldn’t poop myself to death from the parasite.

I updated some mask information earlier, some of which I was surprised to learn, but felt important to pass along. The absence of efficacy of many types of materials used to make masks is disturbing, but the benefit and increased availability of others is encouraging. How necessary are they? Well it all depends on the situation. You can’t be against vaccination, masking and any kind of restrictions all at the same time. If you are vaccinated and are in a safe environment with people you know, don’t wear a mask. If you are vaccinated and go into the grocery store which is not too busy, you’re probably safe. But in situations where you don’t know who is around you, with a population where at best 1 in 3 people around you is not vaccinated at all, with many vaccinated people no longer being “fully vaccinated” because of missing boosters, you may be at greater risk. Personally, I wear a mask all the time in public. It’s easy, not a big deal and I admit to a certain level of paranoia which I can’t shake, no matter how much I run and meditate. 

I agree that what our kids are going through with schools and lack of socialization is very concerning and damaging. In most European countries, kids in schools are not masked, but in those same countries, their vaccination rates are much better than ours, as is their capacity and willingness to test. The US  ranks somewhere around 60th when it comes to rates of vaccination! Let the kids go to school unmasked, but the price of that is better vaccination rates of all those around them. Again, you can’t have everything you want. In order to have freedom, you must also demonstrate responsibility.

Early on, Sweden was held up as a country where there were no mandates and life continued almost as usual, except it didn’t. People there are more vaccinated. They distance themselves more in public. They behave in more responsible ways, staying home when sick. They are overall slimmer and healthier than our obese population. They did also have a slightly higher rate of death early on, but the numbers overall have leveled off and ALL of their metrics are better than those in the US. They have a lot more freedom, but they also behave much more responsibly.

Perspective is also important. The death rate from cardiovascular disease, which in most cases is preventable with some simple lifestyle changes, kills more than twice as many people annually than does Covid. Why aren’t we freaking out about that? Kids are developing heart disease in their teens and even pre-teen years. In kids and young adults, the death rate from many other preventable causes are also quite striking.

This is a table showing the increased annual rates of death of car accidents (MVA) as well as suicide, homicide and drug overdose relative to Covid in different age categories:

AGE        <5    5-14    15-24    25-35

MVA        11x    10x    10x    2x

Suicide    –    6.5x    10x    2x

Homicide    10x    5x    10x    2x

Drug OD    2x    =    10x    6.5x

To clarify, the drug ODs in kids under 5 is usually related to accidental poisoning. After that, it’s all “recreational” drugs. We need to focus more on these issues when it comes to our younger, especially school and college age population, rather than have violent debates about masking and vaccines. 

I’m rambling a bit, as usual, but the lack of responsible behavior, not only by the public, but by those who we are supposed to trust to give us complete information and guidance, has been pretty disappointing.

All we can do is the best we can, given the overall amount of information and experience we have. Covid has been around now for over 2 years and we have a lot of experience and know how to prevent it and treat it, but we are still working on how we will need to live with it.

Vaccination is still our best defense against this virus as well as it’s complications, but which one you take and when you get it, is evolving information. We are fortunate we have options.

Masking is still very important but which one we wear, how we wear it and where we wear it is important. We are fortunate we have options.

Distancing continues to be important. Picking where we go and how and with whom we interact, is important. We are fortunate we have options.

Getting healthy is STILL an extremely important goal. Clearly, the more you weigh, the more anxious you are and the more chronic diseases you are dealing with, the greater your risks of contracting this virus and having a worse course if you do. Risks of long-haul symptoms are also greater. We are fortunate to have the option to improve our health. All we have to do is choose to do so.

Overall, despite this crazy pandemic and the crazy times we are living in, we are fortunate to have what we have and fortunate to have options. 

Be grateful. Live compassionately.

Stay safe and be well.

AC

Masks – What Makes Sense, And What Doesn’t

This post was written in response to 2 patients I saw last week. One who was incredibly anxious and stressed out, who was wearing 2 KN95 masks at the same time. And another, a conscientious teacher who was using 2 KN95 masks a day, meaning that they were wearing one in the morning and the other in the afternoon, throwing both out every day. They were lamenting the costs. Although they were both very careful, both practices were excessive, uncomfortable and costly. I will describe my own mask habits further on. 

First, some basics.

Masks essentially serve 2 purposes.

1. Protecting you from those around you and
2. Protecting those around you from you!

I would add an additional 3rd purpose and that is to remind us all that we are still in the midst of a pandemic and we all need to be careful.

The original purpose when they were first devised was to protect patients actually. Although the droplet theory of infection was first proposed in 1897, along with the proposal of masks was introduced later that same year, doctors have been wearing some kind of facial coverings for long before that. In the 1600s, during the Bubonic Plague, doctors used to wear elaborate beak-like masks filled with herbs and spices thought to ward off the “evil humors” which they thought caused the plague. It wasn’t the herbs, just the layers of barrier which gave a modicum of protection.

In the Orient, masks have been worn for decades. Westerners would poke fun at the mask-wearing people in the East. They wore masks not necessarily for personal protection purposes, but more because of a sense of societal responsibility. And here we are now, doing the same thing. But sadly, most people’s attitude regarding masking and vaccination is more personal or political, than interest in protecting ourselves and those around us. Furthermore, being told that we should do these things is taken more as an affront to personal freedom. But to paraphrase Justice Oliver Wendell Holmes, your personal freedom ends where another man’s nose begins, in the case of Covid-19, quite literally.

When all this started 2 years ago, most physicians, me included, did not promote the notion of mask wearing. At the time, we thought this was like the flu, probably seasonal and spread through droplets let loose by a good sneeze, cough or from a snotty door handle.

Now we know that it is aerosolized and spread just by breathing.

Do masks work? Absolutely. However, all masks are not made equal. Nor is how you wear it. In addition, more detailed studies indicate that they actually protect the wearer from getting infected more than those around you if you are infected, particularly if you are not wearing it correctly. Lastly, vaccines work better. Masks are an adjunct, just like distancing and choosing who you interact with, and where, carefully.

Just to be clear, the term “face coverings” is misleading and stupid. It’s the head-in-the-sand approach. If I wear this doily or mesh on my face, that’s enough. Maybe to follow the rules, but not to do anything useful when it comes to getting infected or spreading it.

Just to get technique over with, masks must be fit well so air doesn’t leak around the edges, both in and out. Wearing it loosely or under your nose is essentially useless, other than letting others around you know that you are an imbecile and/or are probably infected. In that sense, they are still useful since it cautions everyone else to stay away. Obviously the under-the-chin technique is just moronic. In addition, how fine it is, meaning, what size of particle does it let through, is the most important factor.

Gaiters, or the masks made from similar synthetic materials, are useless and maybe even harmful. They actually aerosolize secretions more so they make you more prone to getting a good dose of virus, or spreading it.

Cotton is next best, especially if used with multiple layers and better yet, with a polypropylene filter inside. They do have the advantage of being washable. Some still argue they are useless. But again, better than nothing and significantly better than synthetic materials.

As a surgeon, operating on people now for over 25 years, I was shocked to learn how poorly surgical masks actually perform. Only marginally better than cotton actually, and only if tightly fit!!! They do have the advantage of being inexpensive and essentially are throw-away masks. I use them, but usually as a second layer over an N95, and typically in only higher risk situations, and more to protect the N95 underneath.

N95 or KN95 (the Chinese designation and equivalent in quality), are by far the most protective, other than the full face masks/ventilators car painters or graffiti artists use or papper-style suits used in the ER or OR with acutely ill, coughing-up-a-lung patients. Other N95 equivalent designations include FFP and KF94.

Now, they are more expensive BUT you can reuse them.

A recent study was published in The National Academy of the Sciences on masks comparing N95 with and without a nose piece (meaning tight fitting around the nose, as well as tightly  fitted surgical masks). When exposed to a Covid infected person for 20 minutes, the risk of infection with a surgical mask was 10%. With an N95 without a nosepiece, the risk was 4% and with a nosepiece, the risk was 0.4%. Of course there are other variables such as the environment of the contact, ventilation… 

I’m not going to tell you what to do, but this is what I do. I perform a full head and neck exam on 20-30 patients a day, many of whom are sick, and some of them are guaranteed to have covid. Thus far, I’ve managed to dodge the bullet. I wear an N95 all day long, other than to dictate notes in my little cubby hole. I re-use my mask many days in a row. I will use an N95 for up to a week, if not longer. I do something of a rotation, putting the one I wore that day on my dashboard or on a window ledge in the sun. The virus on the surface dies within a day or 2 at the most. If you take care of it and don’t beat it up too much, there is no reason that you can’t wear it for multiple days in a row, especially if you are only wearing it here and there in stores. STOP TOUCHING IT AND PULLING ON IT TO TALK and that will reduce wear and tear. As far as my mask practices are concerned outside the hospital and office, I am struggling a bit. I still wear a mask, usually an N95, everywhere I go. It is partly to limit exposing others to me, but honestly, I have some paranoia. Essentially, I don’t trust those around me enough. At best, 2/3rds of the people around me are vaccinated. So you are always guaranteed to be exposed to the virus everywhere you go. The estimate as it is, is that 50% of Europeans and at least 25% of Americans have already contracted Omicron, whether they know it or not. Even one of my partners was recently surprised to find out that he had antibodies to the virus, which he could not get from vaccination, despite no symptoms and regular negative home tests.

Masks are important. But again, the quality and technique of wearing it are equally important. But they are not as important as vaccination.

Do we need to vaccinate kids? Absolutely. Do we need to force them to wear masks in schools? There is a huge amount of debate over this. Although it is still quite clear that kids develop less significant disease, especially with Omicron, they can still get it, and they can still spread it. In some places like Britain, they don’t force kids to wear masks in schools, but they have a much higher vaccination rate, more vigorous testing and isolation if positive and ultimately, more responsible citizens, meaning, if they are sick, they stay home and are not out there spreading virus,

There is a lot of recent data and information I have been processing lately. This pandemic seems to be turning into an endemic infection, much the same way the Spanish Flu pandemic of 1918, when millions died, turned into the seasonal flu we deal with today. I don’t think we’re there yet, especially given the many millions and even billions of people who have not been vaccinated or have not gotten sick yet.

Please be careful out there, but be practical and not fearful. The most common risk factor for being admitted to the ICU with Covid complications is being overweight or obese. The second most common risk factor is fear and anxiety. Look out for yourselves and look out for everyone else.

Please get vaccinated. I still firmly believe in our vaccines. We may not need the frequency of booster which are being recommended and getting sick from Covid does provide some significant benefit. The numbers, however, are clear that if you are vaccinated, your chances of getting sick are significantly decreased (of course not zero), your chances of needing hospitalization are 87x less and your chances of dying are close to 100% less, as compared with non vaccinated people. In addition , some recent studies have shown that vaccination reduces the risks of developing long Covid symptoms both before you get Covid and even after you have had Covid and have symptoms.

Keep working on your physical and mental health.

Stay Safe and Be Well.

AC