Medical Bits – Vol. 3.7: Your Health and Medical News

Professional Burnout

Personal reflections

This past week, I celebrated my 32nd Medical School graduation anniversary like most humans: working. And as most humans do from time to time, I reviewed some of the highlights that led me to share my professional and personal life with you, my patients and friends.

My father, Duilio Picone, was an Internal Medicine and GI physician, who despite working in a small town in Argentina’s hinterland, completed painstaking observations (after-hours and weekend labor of love) on his patients and published his simple research at one of the national meetings. The keynote speaker at one of those conferences, was a visiting professor from the Medical College of Virginia (MCV), who rewarded Duilio with a Research Fellowship and an opportunity to advance his professional knowledge and hone his research skills. While in Richmond, Virginia, in the early 1970’s he made new friends and had the great fortune to strike “gold” as his acquaintance with Dr. Enrique Gerszten blossomed into a lifetime friendship and “brotherhood”. As Duilio and my mom Edith, resumed life in our sleepy town of Esperanza, Argentina, their communication, letters, mutual visits and shared travel plans continued. Eventually, his children would visit us and attend school in Argentina for a few months and before my 17th birthday, it was my time to come and attend public school in Virginia to brush up on English, life in America and learn about other opportunities that probably beckoned beyond the endless sunsets and horizons of Argentina’s Pampas.

Those few months under Dr. Gerszten and his wife Ellen’s watchful eyes were life-changing. They zealously looked for all opportunities to make my experience extraordinary and to “open my eyes” to the many good things of life. They sent me to visit NYC (where one of my father’s childhood friends was Ambassador to the United Nations for Argentina) and to experience “college life” with his children and their friends, arranging to visit UVA, Yale and Harvard and as a good professor (he has won the annual “best teacher award” at the Medical College of Virginia for decades) he drilled in the message “weekends are to catch up and evenings are to study”!

After that “boot camp”, and with many of those tools, I barged ahead into medical school and decided then, that I would return for more rigorous medical training in the US. Upon graduation, I was accepted by the Internal Medicine program at MCV and overflowing with energy, dreams (and little knowledge) embarked on my journey of medical training.

As I look back, throughout the 50 years of my father’s professional life and at least the first 10-15 years of my medical life, medicine was a more “fraternal profession”. Life was a bit “slower”. Medicine was less complex. My father kept decades of “medical documentation” in alphabetized 4” x 6” cards. One card per patient, occasionally “spilling over” into two cards and seldom into three.

Medical training meant long hours at the hospital and few limits on the “on-call hours”. Physicians-in-training went home when “their work was completed”, an ill-defined concept but very clear to Medical Residents. Patients were hospitalized for longer periods and physicians were able to spend more time at the bedside, talking to their patients, researching the many clinical questions that still needed answers. There were no interruptions by “case workers” requesting prompt transfers to lower levels of care or asking for diagnostic codes to justify admissions, there were no “Hospitalists” and physicians got to know each other while conducting their hospital rounds, interacting at the “Doctors’ Lounge” and “curb-siding” (picking each other’s brains) with medical questions and learning from each other about Medicine and about Life.

After a decade at MCV, we moved to Washington and joined my current practice with the beginning of the new millennium and after another 10 to 15 years, I might have developed some symptoms of “burnout”, which are not always easy to recognize from within.

What is Professional Burnout?

It is an exhaustion of personal (emotional, physical and intellectual) resources that does not get better with rest. Some of you have read with alarm about “Professional Burnout” and by extension, “Physician Burnout”. Half of all doctors surveyed in 2019 (and before the Pandemic) reported worrisome symptoms: depression, emotional exhaustion, depersonalization, diminished sense of purpose, dissatisfaction and a sense of failure. Those reporting symptoms were twice as likely to commit serious medical errors.

Burnout rates in Medicine are more than double the rates seen in other fields, after adjusting for age, sex, level of education and weekly hours worked.

A more systematic review found anticipated variability according to definitions and specialties.

The most “stressful”, front-line specialties have a higher proportion of burnout:

Critical Care Medicine 51%

Pulmonary Medicine 49%

Internal Medicine: 46%

Emergency Medicine 46%

Family Medicine 46%

Obstetrics and gynecology 46%

Neurology 46%

Lowest rates:

Plastic Surgery: 23% – Dermatology: 30% – Ophthalmology: 32% – Pathology: 32% – Orthopedics: 34%

The Pandemic has further exacerbated this serious problem, that leads to loss of empathy, poor job performance, rising costs and potentially worse patients’ outcomes.

Much has changed over the past two decades. Physicians at hospitals work shift-hours. Continuity of care has faltered. Declining remuneration has made it all but impossible for office clinicians to follow their patients through hospitalizations. The clerical burdens have progressively increased and time- motioned studies show that for every hour doctors spend with patients, they spend 1-2 hours calling patients, answering emails, completing notes, ordering tests, reviewing results, prescribing medications, “fighting” with insurances on behalf of patients to approve medications or necessary tests and communicating with staff and colleagues. All of this work is uncompensated and it is usually completed on the doctors’ “own time”.

Studies have shown that as clerical demands rise, the burnout rates increase. Electronic Medical Records (EMR) have allowed medical systems to increase “productivity” but the flexibility of taking the work home has also led to increasing alienation. Arguably, slowly progressive displeasure with many of the changes of modern medicine (or modern life) became exponential with the widespread adoption of EMRs and “performance metrics”.

We have omitted a “big elephant” in the Burnout Room… and that is the Covid- 19 pandemic that we have covered and all have endured from the beginning.

Caring for patients with fully preventable disease has become overly taxing (and expensive) for the healthcare system and all of its members and components. When more than a 1/3 of patients with Covid-19 associated pneumonitis and respiratory failure die despite all interventions, the dwindling bank of compassion and empathy gets exhausted. Dealing with patients and families demanding unrealistic interventions when an inexpensive, safe and widely available vaccine would have prevented so much suffering becomes difficult. And when we remember that a few encouraging words from a few political “leaders” would persuade many “holdouts” it is not difficult to understand that burnout has exponentially increased. It should not be blamed on individual physicians or nurses but rather, on systemic workplace and national factors.

The concept of “National Factors” reminds me of the strenuous sacrifices by Critical Care physicians and nurses that I observed while working in Intensive Care for months. Our efforts were acknowledged and applauded by our communities and yet, when it became time to compensate critical care and physician work, the Critical Care doctors are rewarded with an 8% cut from CMS (Centers for Medicare and Medicaid Services) as they have decreased reimbursement. It is surprising to see that the tax cuts people want, have consequences. If you want to get more detail from the labyrinth of Medicare (and the rest of insurances follow CMS lead) you could review rules, regulations, codes, adjustments, sequestrations, suspensions, provisions, amendments, rules, final decisions etc. etc. HERE. For good behavior, Pulmonary and Internal Medicine doctors may get a 1% positive adjustment (YAHOOOOOOO!!!!).

As mentioned, looking back at my own trajectory, I now suspect that a few years back I was on the brink of “burnout”. You may recall that we used to work one of four weeks in the Intensive Care Unit at Sibley Memorial Hospital until 2016. The after-hours demands, constant interruptions, the frequent provision of “end of life care” instead of real Intensive Care and the endless requests foraggressive measures and solutions when sometimes, at heart, physicians felt that interventions would be futile and would likely lead to more emotional, financial and physical trauma, reached a point where my interactions with patients and colleagues suffered.

The merger agreement with a larger institution with its imposition of “improved” methods led to additional erosion of autonomy, displacing or ignoring many doctors who selflessly lent support to the institution through free participation in multiple committees and clinical endeavors, contributed to a deep feeling of underappreciation.

Frankly, I was fortunate enough to be able to restructure my professional practice and continue to do what I love, gaining more autonomy and limiting my call-hours and to a large degree, my concierge medical practice has allowed me to do that, while my long-term collaboration with Mobile Medical Care provided an avenue to continue to provide free medical care to those without the resources. I realize such alternative may not be available to some colleagues.

How to turn the tide and boost professional satisfaction?

Some mitigations are anticipated and quite obvious, like decreasing the clerical requests and time away from real clinical questions. Or using medical assistants to gather data, reconcile medications, learn about the patients’ agenda for the visit and review preventive measures. Others, more nuanced, but center on improving professional motivation and psychological health. A recent large study suggests that solutions targeting doctors (exercise classes, relaxation techniques, social hours, child care, devices to improve efficiency) do not seem to be effective. Dr. Pamela Harzband argues that we should lend a page from Organizational Psychology and cognitive evaluation theory to find other explanations and solutions.

Physicians as a group have a high level of altruism, view their work as a “calling” and enjoy high “intrinsic motivation”. But some “extrinsic motivators” (sticks and carrots) dreamt up by healthcare and hospital administrators may lead to damage of that intrinsic motivation and hasten “burnout” (physicians would recognize relative value units or RVU’s).

I encourage you to read Dr. Harzband’s perspective article. She argues that we should promote intrinsic motivation and the psychological well-being of physicians by granting more autonomy, celebrating competence and facilitating human relationships and relatedness. Of course, those are good prescriptions for all humans alike, partnering in this interesting journey we call “LIFE”.

Another excellent prescription that we should explore is Mindfulness. And if you are waiting for Amazon Care (yes, Amazon and its trillions may be adding to the fragmentation of healthcare and coming to a corner near you!) to solve your problems the way they deliver your packages. As my educated patients know, some medical problems are complex and require more than an app, a chat box and a nurse.

Are you still wondering if it is worth having a “Primary Care Physician”? You can glean my “unbiased” opinion.

What can you do limit “burnout”?

1. When visiting your doctor, make a short list of problems with bullet points.
2. If you email your doctor, apply the same principle. Short emails with bullet points that are simple to follow and may help provide a solution.
3. Be ready to accept all preventive measures, including vaccinations, as nothing is more cost-effective and safer.
4. When demanding certain treatments or interventions, keep in mind that more is not best and false positive results are a real problem that can lead to worse outcomes.
5. Remember that doctors also need time to read, to relax, to grow, to study and to recharge batteries to be effective at what they do.
6. Before you send an email or a text message or make a call after-hours or on private time, think twice and only proceed if it is urgent.
7. Respect the personal – professional boundaries. So many times, doctors are asked for opinions about medical problems by friends and families, both trivial and more serious. It is very hard to provide good advice without all the elements and details and more so when a personal relationship adds an important emotional component.
8. Develop good communication with doctors as they only want what is best for you, but may not know important bits that help fine tune decisions and recommendations.

COVID-19 VACCINATION, BOOSTERS AND OMICRON

YOU MUST KEEP IN MIND THAT INFECTION IN A PANDEMIC IS NOT OPTIONAL, AS 100% OF HUMANS WILL EVENTUALLY BECOME INFECTED (unless you are able to make a residence on the Moon, Venus, Mars or beyond).

Globally, Covid-19 is responsible for more than 5 million deaths. You realize that “attributed” deaths is often difficult to ascertain, but should remember that excess global mortality since the onset of the pandemic is approaching 20 million. Since we are dealing with a new disease, ongoing monitoring and caution are warranted, as the evolution of the virus and the rise of mutants is certain. Since the first SARS-CoV2 was sequenced in Wuhan on January 10th, 2020, more than 5.6 million SARS-CoV2 genomes have been added to the GISAID database and arranged into “clades” – groupings with a distinct common ancestor.

The rise in hospitalizations first detected in Israel over the summer, prompted their health authorities to recommend a booster dose starting with those older than 60 years of age or older and then expanding to all eligible groups. We now have data from new studies demonstrating their effectiveness against severe disease of death of 90-95% with an absolute effectiveness of two vaccines doses of 90% and a calculated absolute effectiveness of two doses plus a booster of 99-100%. Of course, the Omicron variant may change those calculations (see below).

Fortunately, most of you have already been vaccinated and “boosted”. Our region continues to enjoy one of the highest vaccination rates of the nation and in fact, Montgomery County of MD remains at the top of the 3,243 counties in the US. I don’t need to repeat to my educated patients that vaccines are safe and effective. They work. In my personal ICU experience working at several hospitals, finding a vaccinated patient with severe COVID-19 associated pneumonitis and respiratory failure continues to be rare. Despite the advent of new variants, vaccines continue to be highly effective against severe disease and death.

Almost 9 billion vaccines have now been deployed worldwide with 57% of the world population vaccinated and 37 million doses administered daily. Several new studies are able to put into context some of the few adverse effects from vaccination for physicians and their patients to make better informed decisions for those few “hold-outs” and may also help parents trying to decide if their adolescent children should be vaccinated or if those younger than 5 should be immunized once the vaccine approved for children.

In late August 2021, a study involving the largest Israeli healthcare system published their observations, demonstrating that the excess risk for the reported significant adverse events in this population of 1.7 million individuals, was many folds higher from infection with SARS-CoV2 than from vaccination.

The only exceptions were minimal increased risk of Herpes Zoster (shingles) (if older than 50, you be vaccinated with the two-shots of recombinant Shingrix Vaccine) and development of enlarged lymph nodes. Some of you remain concerned about vaccine-induced immune thrombotic thrombocytopenia (VITT), very rare (1:500,000 doses) more common in young women and easy to recognize and treat.

Several studies reported on the efficacy of vaccines and the minimal decline in efficacy with the Delta variant.

In a case-control study of almost 11,500 fully vaccinated Israeli health care workers (Pfizer-BioNTech), 1500 of them exposed to infected individuals there were only 39 breakthrough cases.

Another study published on August 2021, demonstrated a modest decline in efficacy against the Delta Variant of 5-6% but remained highly effective to prevent hospitalization and severe disease

The emergence of the Delta variant and the rise of cases in those vaccinated this past summer, prompted the Israeli health authorities to approve a “booster” or third dose (Pfizer-BioNTech), to cope with the resurgence.

The study of almost 850,000 participants (mean age 68.5, diabetes 30%, obese 33% and hypertension almost 50%) the difference in the risk of death from Covid-19 was almost 19x lower in the booster group (0.16 per 100,000 in the booster group vs. 2.98 per 100,000 in the non-booster group). Those who received a booster at least 5 months after a second dose of the mRNA Pfizer- BioNTech vaccine had 90% lower mortality due to Covid-19 in the short term compared to those not “boosted”.

A large study from the Israel Ministry of Health database reviewed almost 5 million people who had received two vs. three doses of Pfizer-BioNtech showed a decrease rate of confirmed infection by a factor of 10 to 17.

OMICRON VARIANT

In late November, new cases in South Africa jumped from <400 to > 2000. Sequencing showed a new variant later designated Omicron, which is quite different to other variants, has almost 50 mutations in its genome and it is better at getting into human cells and therefore more infectious. It appears to be 3.2 times more infectious than the Delta variant and cases are doubling every 2-4 days in the US. It has already been reported from all continents, more than 100 nations and most states.

Almost half of the near 50 mutations are in the Spike protein, necessary to enter cells and targeted by the antibodies promoted by vaccinations. No wonder it is a variant “of concern”. Those Spike protein mutations make it more infectious, but not more severe or lethal.

A study just published from the University of Hong Kong, provides a glimpse on how the new variant infects the respiratory tract and may explain why Omicron is more infectious but less severe.

The researchers found that Omicron SARS-CoV-2 infects and multiplies 50-70 times faster than the Delta variant and original SARS-CoV-2 in human bronchus and upper airway, which may explain why Omicron may transmit faster between humans than previous variants. But at the same time, it replicates 10 times slower than the original virus and much slower than Delta in the alveoli (tiny air sacs where gas exchange takes place and ravaged in severe Covid-19 cases). Another group of researchers led by led by Dr. Ravi Gupta, professor of clinical microbiology at the University of Cambridge, England reported this week that the new feared variant is less efficient at infecting alveolar cells, confirming the reported findings.

It is interesting to observe that this variant may have risen in immunocompromised individuals who are unable to clear the infection and provide a “laboratory” for mutants to continue to evolve as a low-grade infection continues to coexist with its host for months. What was anticipated by virologists early in the pandemic as a potential risk for development of more complex variants has now occurred.

It appears that ALL vaccines still provide significant protection against serious illness, but only the mRNA vaccines (Moderna and BioNTech) when reinforced with a third shot appear successful at stopping infections. But these vaccines are not widely available in other nations. In fact, other vaccines such as AstraZeneca, J&J, Sputnik and Sinopharm do not seem to limit the spread of Omicron, which has implications for the trajectory of the pandemic and healthcare systems. Unwisely, many nations are tightening restrictions to “prevent the spread of Omicron”. Traveling restrictions have been shown to be worthless and ineffective. They are usually too late, as the virus is already circulating widely and aggravate economic and personal tolls.

It appears that Omicron is 50 x less sensitive to neutralization after two doses of mRNA vaccine but a booster dose substantially reduces the risk of symptomatic breakthrough infections. And remember that your immune system uses antibodies and also cell immunity for your defense and 97% of the Omicron genetic sequence is identical to the original virus from China! Hence, your cellular immunity should work well!!!

EVEN IS LESS SEVERE, THERE IS NO REASON TO PROCRASTINATE, AS IN A PANDEMIC EVENTUALLY 100% OF HUMANS BECOME INFECTED. YOU SHOULD BE VACCINATED AND GET YOUR BOOSTER NOW

Regardless, BioNTech and Moderna are already working on a vaccine using mRNA with the new genetic alterations and tailoring new vaccines against Omicron (as they did against the Beta and Delta variants, but since the original shots remained effective, production did not become necessary). Both companies indicate a new vaccine could be available in less than 100 days. But we do not yet know if that will become necessary.

As Dr. Anthony Fauci and his colleagues from NIH-NIAID explain, over the past two decades humanity encountered four coronavirus epidemics (as discussed in prior “BITS” – SARS 2002-2003 – MERS and now Covid-19). Due to loss of habitat and closer proximity to other mammals and bats in particular, additional coronaviruses are likely to emerge. The scientific community is working on characterizing the global coronavirus universe to use this information in the design of “universal” coronavirus vaccines.

COVID-19 Variants and Mutants

There are several open-source databases tracking SARS-CoV-2 genomic sequences, but the largest and most popular is GISAID.

It was originally conceived in 2006 as a “bank” of genomic data from flu viruses, but the Pandemic has expanded its mission to promote the rapid sharing of data from all influenza and coronaviruses to help researchers understand how viruses evolve and spread during epidemics and pandemics. Scientists are able to upload the genomic sequence of the viral strain present in their communities. Their hard work has led to the sharing of more than 5.6 million coronavirus genome sequences from 172 nations, allowing researchers to track the development and movement of new variants across the planet.

Nextstrain, is another open-source consortium that follows numerous infectious diseases and updated several times weekly, tracking the global spread and flow of variants. You can read and explore more here.

The frequently updated Coronavirus Vaccine Tracker from the NYT is an excellent resource. Another excellent Covid-19 Research update from Nature. This NYT link has National and International Vaccine Rollout information.

COVID-19 Testing and Vaccines: Q & A

1.    Do we need vaccine mandates?

In my opinion, YES. We have vaccines that are highly effective, safe and fully authorized. For humans who want to continue to participate in social functions, such as public venues, concerts, sporting events, restaurants, schools or work- places, vaccination should be required. Even if we are immunocompetent and do not fear poor outcomes, it is our personal and social responsibility to assist with the creation of an immunologic wall to prevent disease transmission and the rise of new variants.

2.    Is Pregnancy a contraindication to Covid-19 vaccination?

No. In fact, a recent study confirmed no safety concerns with the mRNA vaccines and adequate protection.

The safest or most rational timing of vaccination during pregnancy has not been established, but as indicated in our prior “Bits”, best to inoculate in the second trimester, to ascertain protection to the mother in the third trimester (when infectious complications are more common) and to facilitate the placental transfer of antibodies and protection to the newborn.

3.    Do we need to continue to decontaminate surfaces?

No. As we learn more about transmission, we know that this is an airborne disease. It is highly unlikely that we can pick up an “infectious dose” on our fingertips.

4.    How long patients continue to shed live viruses?

The median time from symptom onset to viral clearance in culture was 7 days (+/- 5 days) but the median time to clearance of PCR was 34 days. The latest positive viral culture was 12 days after symptom onset. Thus, we may continue to shed the viral particles for a while, but they may be inactive and not likely to cause disease. This period may be significantly longer in immunocompromised patients.

5.    Do I need to have oxygen available in case of need?

No. There is no evidence that more oxygen is better. In fact, multiple studies have shown that only patients with persistent oxygen saturation below 89% benefit from Oxygen. This applies to all humans, including patients with COPD, emphysema, heart failure and the rest. Most people discharged home on oxygen, do not need supplemental oxygen upon re-testing 2-3 weeks later. If you are “hoarding” an oxygen concentrator, have your physician return it and use those precious healthcare funds for other beneficial treatments.

6.    Are the vaccines safe?

YES. All the vaccines approved in the US are safe, trigger an excellent immunologic response across all age groups, are highly protective and cause minimal injection-site reactions and fatigue/malaise and occasional headaches (symptoms that are generally attributable to all vaccines and due to the immunogenic response triggered by the introduced antigens). The incidence of anaphylactic reactions (mostly in those with polyethylene glycol intolerance) is below 5/million inoculations and develops within 20 minutes of administration and Vaccine-associated clotting (VITT) complications reported above occur to about 1:500,000 people and we now know how to recognize them and treat effectively. Other abnormal immune responses such as persistent body aches, pericarditis, pleuritis, myocarditis and muscle aches have been reported as indicated above, but the incidence is much lower than that caused by active infection with SARS- CoV2

7.    What is the duration of the protection elicited by vaccines?

The humoral, antibody protection was anticipated to last 6 months, but the advent of more infectious variants demonstrates that necessary neutralization titers are much higher, mandating boosters. But don’t forget that cellular immunity is a long-lasting defense and also stimulated.

8.    Can vaccines possibly aggravate pre-existing conditions?

Yes. There are few reports of flares of autoimmune and inflammatory conditions such as inflammatory bowel disease, Crohn’s ulcerative colitis and PMR reported. But the benefits of vaccination outweigh the risks by many folds.

9.    Could the messenger RNA vaccines get integrated into my DNA and cause mutations or long-lasting ill-effects?

No. This is biologically impossible. The small messenger RNA is quickly broken down and does not interact with humans’ DNA. Both vaccines have a tiny segment of mRNA encased in lipids.

10.    Asymptomatic individuals do not transmit COVID-19.

They do. Multiple studies indicate that nearly ½ of transmissions are from people not feeling ill and about a third of all infected patients remain asymptomatic.

11. Is the virus mutating such that the efficacy of vaccines is in peril?

Of course, the virus is mutating, just like any other virus multiplying in the trillions and infecting millions of As discussed, some of the mutations may lead to increased infectivity and severity of disease. SARS-CoV2 is a stable, non-segmented RNA virus. The infectivity of the virus increased early, as a result of a specific mutation carrying the spike protein D614G substitution, augmenting the virus infectivity and becoming the dominant strain causing disease in Northern Italy and the most prevalent variant throughout the world for most of 2020. New variants with heightened infectivity such as B.1.1.7; B.1.617 (Delta) and now B.1.1.529 (OMICRON) displace other less “efficient” strains. But vaccines + booster remain effective and you have received or are ready for a third vaccine “update”.

12.    Should people who recovered from COVID-19 be vaccinated?

Yes. It is not certain how long the immunity will last, and although long term humoral and cellular immunities are anticipated, the recommendation is to be vaccinated 90 days after the acute infection (mine: do it earlier!)

13.      Are people who cough or sneeze more infectious than others?

No. Transmission appears to be driven by the viral load of index cases. A higher viral load also increases the risk of developing symptomatic disease shortens the incubation period in a “dose-dependent” manner, as reported by The Lancet.

14.    When will vaccines become available for Children?

The clinical trials that led to the approval of the mRNA vaccines included adolescents ages 12-17 and later children older than 5. All should be vaccinated. Parents hoping that a vaccine would soon become available for their babies and children younger than 5, will have to wait a bit longer following an announcement that Pfizer’s two-dose regimen fails to trigger an effective immune response in kids two to five years old. Pfizer and BioNTech announced Friday that they are now modifying their clinical trial to include a third shot at least two months after the second dose.

15.    Do I need to get a booster?

Yes. The FDA has expanded eligibility to everyone older than 16 and we should all get a booster!

16. I have been exposed to someone who tested positive. What do I do?

Relax. Most people who have been vaccinated will develop a mild cold and as the Omicron variant replaces the Delta variant as the predominant circulating strain, we may see milder You should forgo social interactions, work from home and use common-sense precautions to limit the spread, but there is no need to rush to the ER or demand immediate testing. Remember that if you have symptoms, you likely have it and behave accordingly. Your peak shedding will be 5-7 days and after a week to 10 days you can resume normal functions.

17. I have tested positive or suspect I became infected. What do I do?

Relax. Most vaccinated humans need to follow the advice above and relax. Even if you have not yet received a booster shot! Do nothing. Enjoy your time at home, work remotely and find a few good books! You do not need monoclonal antibodies or the new medications (Molnupirafir or Paxlovid- Ritonavir).

18.    Where should I get tested?

Sibley Covid-19 PCR test. Contact the office for order. Results in 24 hrs. Kelly Goodman, NP Covid-19 PCR, but only on weekdays – they prefer patients of the practice.

Same Day Health – Georgetown and Capital Hill locations, offer Covid-19 PCR testing; say that they take 72 hours to provide results, but it usually only takes 36 hours

Minute Clinic, CVS – scheduling is currently difficult, but still available; receive results in 24-48 hours

Walgreens – free drive thru Covid-19 testing, get results within a variable time frame

The government has rolled out self-tests – Rapid and will be available at your local libraries.

DC Covid-19 testing sites: https://coronavirus.dc.gov/testing https://coronavirus.dc.gov/testyourself

PCR testing in Montgomery County: https://www.montgomerycountymed.gov/covid19/testing.html

All public libraries in Fairfax county offer rapid tests: https://www.washingtonian.com/2021/12/02/some-maryland-and- virginia-libraries-are-giving-out-free-rapid-covid-tests/

COVID-19 TREATMENTS

New oral treatments

Molnupiravir

This is an antiviral developed by the Emory Institute for Drug Development, made by Merck and active against influenza and many other RNA viruses. In a trial published this past week, 800 mg administered twice daily for 5 days and initiated within 5 days of symptoms onset, decreased the risk of hospitalization or death from 14 to 7% on interim analysis but from a more modest 9.7% to a 6.8% with an absolute difference of 3% on final analysis.

PAXLOVID – RINOTAVIR

Pfizer pharmaceuticals announced last week results of their oral medication, Paxlovid used in combination with the antiviral ritonavir. There are no peer- reviewed publications yet but the results are very encouraging:

• Reduced risk of hospitalization or death by 89% (within three days of symptom onset) and 88% (within five days of symptom onset) compared to placebo; no deaths compared to placebo in non-hospitalized, high-risk adults with COVID-19
• An ongoing second study in standard-risk adults showed a 70% reduction in hospitalization and no deaths in the treated population, compared to placebo.
• Approximately a 10-fold decrease in viral load at Day 5, relative to placebo
• Recent in vitro data confirm that Paxlovid-Ritonavir is a potent inhibitor of the Omicron 3CL protease, indicating that PAXLOVID will retain robust antiviral activity against Omicron and all variants to date.

COVID-19 Monoclonal Antibodies

Monoclonal antibodies are expensive engineered human monoclonal antibodies specific against the Spike protein of SARS-CoV2 and have been investigated to prevent progression of mild-moderate Covid-19 infection in ambulatory, UNVACCINATED patients.

There are many formulations and some trials have shown lower viral loads, and modestly lower rates of progression of disease. The FDA granted Emergency Use Authorization for some of them. A summary cartoon on some of the research published on the most effective ones follows.

But some caveats are necessary (as demonstrated by recent calls and emails requesting orders for administration):

1. All of these publications pertain to unvaccinated patients.
2. If you get an upper respiratory tract infection or were exposed to someone with COVID-19 and now likely the Omicron variant, that does not necessarily qualify you for Monoclonal antibody administration.
3. Bamlanivimab is ineffective against the Delta or Omicron variants.
4. Banlanivimab – Etesevimab are no longer effective against new variants.
5. Casirivimab-Imdevimab combination retained efficacy against Delta but it is anticipated to be less effective against Omicron.
6. Sotrovimab, which neutralizes most sarbecoviruses is likely to be effective against Omicron and the 500 mg may be administered as an infusion or intramuscular, which facilitates administration logistics
7. If some unscrupulous physicians ignore important details about these agents and are willing to prescribe them is immaterial.
8. We will not order them if they are not indicated.

COVID-19 – PROVEN THERAPY

It is important to emphasize what is effective and what is not!

While working in ICU, I have witnessed expensive and potentially deleterious and invasive treatments sometimes imposed by physicians and more frequently demanded by family members, despite the lack of evidence for benefit or possible harm. The Hippocratic oath reminds us: “Primum non Nocere”.

The National Institutes of Health has a wonderful resource available to all which summarizes the evidence in their NIH Covid-Treatment Guidelines, which grows steadily and now stands at over 350 pages. Another excellent review is provided by Open Critical Care (also in Spanish).

In summary:

1. Use Dexamethasone at 6 mg daily for 10 days after diagnosis of COVID- related pneumonitis.
2. Remdesivir may help patients requiring supplemental oxygen and possibly those on mechanical ventilation, but benefit is marginal.
3. A new Remdesivir oral formulation may be more effective if used earlier and before hospitalization.
4. In hospitalized patients, use IV Tocilizumab.
5. If Tocilizumab not available use Sarilumab IV
6. Use Sotrovimab in similar settings. Likely more effective w Omicron.
7. Use Casirivimab plus imdevimab SQ or IV for post-exposure prophylaxis in patients at high risk for progression to severe Covid-19 and unvaccinated.
8. Azithromycin and Ceftriaxone have not benefit.
9. Immune convalescent plasma from previously infected patients: marginal benefit.
10. Plasma exchange – plasmapheresis. No benefit, costly and invasive.
11. Insufficient evidence. Do not use
12. Interleukin 1 – 6 inhibitors. Insufficient evidence. Do not use.
13. Insufficient evidence. Do not use. Now we know that it may be beneficial in lower- and middle-income nations where intestinal parasites are more prevalent, since the regular use of dexamethasone as part of the treatment may promote parasitic hyper-infection and infestation with bad consequences.
14. Janus Kinase Inhibitor Baricitinib. Promising. Use in the right setting.
15. Anticoagulants. Only in prophylactic doses.

If you have 7 minutes daily, you can start to improve your fitness right now with the Scientific 7- Minute Workout. Get the app on your phone!

11 more minutes will get you in shape!

For core strength, try this 9-minute routine!

AND START EXPLORING AND PRACTICING MINDFULNESS! THERE ARE MULTIPLE RESOURCES ON THE WEB.

Let’s all remember that the only certainty in life, is death and the only fountain of youth proven by science and experience are exercise, laughter, humor and a positive attitude!

OFFICE UPDATES

1. We have requested mRNA Covid-19 vaccines from the local governments, but as of yet we have not been granted access. We will notify our patients if we obtain a batch of vaccines.
2. I will be away for a few days between Christmas and New Years and from January 12-18th.
3. Simran Singh, Samantha Morales, Sarah Molinari and Fiona MacNair are our capable and affable Medical Assistants and will continue to assist all of you with your healthcare need.
4. Simran Singh at simrans@chevychasepulmonary.com is my personal assistant.

Wishing you Happy Holidays and a better 2022!

We must always be ready for worse times to come, and be surprised and happy if they turn out better than expected!

Cheers!

Carlos E. Picone, MD

5215 Loughboro Rd NW, Suite 400

Washington, DC 20016

301-656-7374

cpicone@chevychasepulmonary.com

References:

https://www.nejm.org/coronavirus

https://www.cdc.gov/coronavirus/2019-nCoV/index.html

https://www.who.int

https://clinicaltrials.gov/

https://www.nature.com/articles/d41586-020-00154-w]

https://science.sciencemag.org/content/early/2020/05/12/science.abc5312

https://www.nejm.org/doi/full/10.1056/NEJMp2005630?query=featured_corona virus

https://www.youtube.com/watch?v=-Gn8oJY1VHY&feature=youtu.be

https://www.cfr.org/backgrounder/what-world-doing-create-covid-19-vaccine

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805090/ https://www.nejm.org/doi/full/10.1056/NEJMcibr2009737?query=featured_coro navirus

https://jamanetwork.com/journals/jama/fullarticle/2767840

https://www.nature.com/articles/d41586-020-00502-w

https://www.nap.edu/catalog/25914/discussion-draft-of-the-preliminary- framework-for-equitable-allocation-of-covid-19-vaccine

https://www.economist.com/briefing/2020/11/14/an-effective-covid-19-vaccine- is-a-turning-point-in-the-pandemic

https://www.economist.com/briefing/2021/02/13/vaccine-hesitancy-is-putting- progress-against-covid-19-at-risk

https://www.nature.com/articles/d41586-020-00502