Category: news

A National Institutes of Health study found the corona virus can live on cardboard for 24 hours and 2 to 3 days on plastic and stainless steel (1).  I have not heard anyone sneeze or cough in public since the coronana virus surfaced yet it took only days to travel 50 miles to reach my area.  The people who load and unload cartons that are delivered are a possible vector for the rapid spread.  Shopping while wearing a glove on my sound hand and using a credit card instead of cash (see previous post) was not just paranoia.  Thank God I rehearsed because initially I made mistakes.

Initially I grabbed the handle of my car door with the glove I had pushed the shopping cart still on my hand.  Whatever was on the glove was now on the handle.  Now I can quickly put the glove in the plastic cup in my car door.  I made it easier to put the blue foam covering my hemiplegic thumb in an isolated place.  The weather got warm so I can no longer put my credit card in my coat pocket.  I put the card in a tiny purse and hung it from my big purse.  The arrow points to the velcro closure which is easy to open one-handed.  The tiny purse hangs in front of my stomach where it is harder for someone to open it without me noticing.  homeafterstroke.blogspot.com

1.  https://www.9and10news.com/2020/03/12/national-institutes-of-health-releases-study-on-how-long-coronavirus-lasts-on-surfaces/

During an uncertain time as we realize the impact of the COVID-19 outbreak on the local communities, here are a few questions and answers regarding the virus and ways in which we can reduce spread:

Why is it called novel “coronavirus”?

Coronavirus is named for its appearance of the virus’s outer membrane on electron microscopy, which resemble a crown.  These zoonotic (animal derived) viruses were first discovered in the 1960’s and likely makes up approximately 15% of all colds.

The designation of “novel” comes from the fact that the virus is genetically distinct and emerged from animals and was capable of infecting humans, and then made the jump to human to human infection.  Scientists call the phenomenon of a virus being able to infect another animal as a “spillover.”

There are four major strains of coronavirus that cause common colds during the respiratory virus season.  COVID-19 is different from these in that it possesses different features on the viral outer layer that is foreign to our immune system.

Our bodies come across viruses frequently and our bodies have innate (meaning built-in) and adaptive (developed) mechanisms to protect us from them.  With COVID-19, the virus has not circulated in humans before, so the protections that normally dampen the response to infections are not present.

Therefore, there is an imbalance of managing this, resulting in increased viral stealth and an increased inflammatory response.  The body knows something is wrong but it cannot temper the response.  A mixture of these interactions contribute to varying severities of infection that could lead to a threat on life.

How is a virus spread?

Like most respiratory viruses, COVID-19 is spread in respiratory droplets.  Just to illustrate the magnitude of spread, take one simple cough.  One cough can spread thousands of droplets into the air at up to 50 miles an hour for 6 feet.  The size of the droplets measures from 10 microns to 100 microns. Just to give you an example of size of 10 microns, it would 100 droplets of this size together to make it visible (e.g. 1mm).  If the virus is 100 nanometers (or 0.1 micron) a droplet can have from 100 to 1000 viruses riding within it.  A single cough then is capable of shedding millions of copies of a virus.

How far the droplets can be spread depend on their size and wind currents – the majority of which fall within six feet, the space that doctors advise for social distancing.  There is no compelling evidence that the virus is easily transmitted in the air, or airborne.  Likely, as with all viruses, there is a continuum.  Small droplets known as droplet nuclei can travel on air currents for longer distances or float in the air.  Although people likely have a personal cloud of droplets around them, it is unlikely that this virus can be transmitted easily beyond 6 feet.

Studies have demonstrated that COVID-19 can remain viable, or “infectious” for 2-3 days and perhaps several days on surfaces.  This is not likely to constitute the main mechanism of spread and is also not unlike other respiratory virus characteristics.

The important thing to communicate is that the virus operates by natural laws and although new to our immune system, as we gain greater information of its mechanisms and employ rapid testing to mitigate risk and target containment, the chain reaction that is this outbreak can be blunted and interrupted.

How can I prevent the spread or protect myself from a virus?

General measures are still helpful to try to reduce the risk of getting this virus. Respiratory viruses notoriously difficult to protect against. The CDC estimates that between 10 million and 50 million people get the flu yearly. Nevertheless, an increased vigilance in these practices may still provide some protection:

• Good hand-washing with soap and water for 15-20 seconds or the use of alcohol-based sanitizers
• Social distancing and avoiding anyone who is coughing or sneezing. If you are sick, ensure that you are practicing measures of social distancing, handwashing and sneezing/coughing into your arm sleeve and not shaking hands.
• “Corona elbow-bump” or ankle hit, instead of shaking hands. These are now “in” and accepted ways of showing respect, acknowledgement and affection.
• Avoid touching the face, nose, eyes or mouth, which could lead to ingestion of the virus particles.
• Wipe contact surfaces down before and after use, e.g. in the gym or in a common area or avoid touching your face or washing your hands after use.
• Wash you hands before preparing food and before eating.

Can I get a viral infection after handling a package from someone who was infectious or that was delivered from a country where there is a high caseload?

COVID-19 is predominantly spread by respiratory droplets, where millions of viruses can be spread in one cough.  As other respiratory viruses, it can be transmitted by shaking someone’s hand who is infected and had coughed, sneezed or touched his/her face, touching a contaminated surface or an inanimate object (fomite) that have infected respiratory droplets.

It is unlikely that the virus can survive on absorptive surfaces such as cardboard for very long or in packages for longer than several hours, so it would be unlikely that the virus could be spread effectively in this fashion.  Some studies of coronaviruses (including those that cause the common cold) as well as other the coronaviruses SARS and MERS have shown that viruses are capable of remaining infectious for 2-3 days, and in some cases several days.  Fortunately, they are easy to wipe off with alcohol-based solutions, dilute bleach and other cleaning solutions.

If a delivery person is dropping off a package and is infected, there is a conceivable risk of transmitting viruses, if he/she coughs or sneezes on the package.  This is an exceedingly low risk to the general public.  Handwashing throughout the day is always recommended during the cold virus/flu season, in addition to avoiding touching the face, eyes or nose when out in public.

What are the signs of symptoms of viruses, including COVID-19?

Respiratory viruses infect mucosal surfaces in the respiratory tract, usually from nose to bronchial airways and sometimes even the lower respiratory tract. The more severe presentations are seen where a virus causes damage to the respiratory tissue, a process known as viral pneumonitis or viral pneumonia. Many viruses can cause this type of infection, including influenza, adenovirus, respiratory syncytial virus and COVID-19.

The common cold mostly causes cough, nasal congestion or runny nose and possibly a sore throat. It is not uncommon to have some tiredness and low to high temperatures for any of the respiratory viruses. Some people will have nausea and diarrhea.

The most common symptoms of COVID-19 include fever, cough and tiredness. If you have these symptoms, you would not be able to know if this was COVID-19 or another respiratory virus, without a specific test, a PCR on nasal secretions.

Most people will have only mild to moderate symptoms from COVID-19 that will improve after a few days of staying home, resting, keeping well hydrated and nourished. In those that are of advanced age and/or who have high blood pressure, heart disease, lung disease or diabetes, they may have a worse presentation that may require advanced care, including hospitalization. A smaller amount will die from the disease.

If I have a viral infection, when should I go to the emergency department or clinic?

The concern of severity of infection can get anyone worried about their health. We hear daily the amount of those that have died from COVID-19 and not influenza. The CDC estimates that as many as 30,000 people have died in the United States from influenza this season 2019-2020.

If you are experiencing cold symptoms that are minor, that is you feel tired and achy and are coughing a little, you can stay home and allow time to recover. If you are experienced a fast heart rate, recurrent fevers and increasing problems with breathing – “catching your breath”, “having difficulty breathing” or being “concerned about my breathing” are key words – then you should seek further care in your local emergency department.

We are currently not screening everyone with cold symptoms, reserving this for those who have severe enough illness to be hospitalized for now. With the amount of cases now reported in the community, there is likely local spread. Nevertheless, in people that are being tested, various viruses are likely to show up, like influenza A/B, respiratory syncytial virus (RSV) and metapneumovirus. With the upscaling of testing, it is likely that we may be able to test even those that have mild to moderate symptoms to better address the outbreak and target quarantine measures.

• Unless your symptoms are as described above, it is recommended not to go to the local clinic or emergency department, where a respiratory virus could get transmitted to those that have chronic heath conditions and at risk to have more severe infection.

What should I do about my travel plans?

With the report of cases of more than 1400 cases in the United States (March 12, 2020), families are beginning to wonder if they should change their spring break or other trip plans.  The United States has enacted nationwide measures and various states have declared local emergencies to protect the public. Large events are being canceled as a means of interrupting viral transfer in the name of social distancing.

With this increased awareness, families are trying to balance between canceling plans to protect themselves or following through with the plans and possibly putting themselves at risk or contributing to further spread. The spread of disease in this outbreak is extremely volatile and could require in a sudden shift in plans as events are canceled.

The following are some considerations for your decision:

• Did you purchase travel and/or flight insurance?
• Is your ticket purchase (e.g. an amusement park) only for “same day” or can it be transferable for a later time? Review all of the policies for cancellation of the event, and contact the venue, park or hotel to discuss exceptions,etc.
• How flexible are you to the possibility of sudden changes in your plans?

As for the risk of attending these events:  The risk of acquiring any respiratory virus is increased with proximity and likelihood of coming into someone who is infected, such as in social activities.  Common practices of social distancing and avoid contact of infected surfaces or inanimate objects (fomites) cannot be assured in an amusement park, for instance.  The same is true with access to hand washing.

Here are a few measures that families can take to prepare themselves for their trips:

• Have hand sanitizer and handwipes available for use while traveling.
• Instruct children to cough and sneeze into their sleeves and not their hands – and other practices to avoid touching the face, nose or eyes.
• Check on outbreak information at the specific location or closest city to it before you embark. Disney just announced today that it’s closing the California park because of COVID-19.

Families can take certain precautions in advance of surprises.  COVID-19, as with other respiratory viruses can have a major effect on people of advanced age or with chronic conditions such as hypertension, heart disease, diabetes and lung disease or who are immunocompromised.  The majority of travelers require no further preparation than what they would do to protect themselves from viral infections during the cold season.

I hope this information is found to be useful.  Please share this with your friends and please feel free to comment.  This will be placed in the Health Information section as well as COVID-19 resources.  Thank you for reading this.

The novelty of the novel COVID-19 outbreak has passed. Sure our imagination that drums up images of viral apocalypse and global chaotic destabilization are simmering. Although the fears are transforming into measured preparedness, there still remains an allure of uncertainty with how this outbreak will affect the rest of the world.    In the wake of this recent outbreak, the global public health community and the world in general is left with many important questions.  In real-time, the community has had to develop a blueprint to testing, containment and risk mitigation.  While the United States and countries in Europe are reporting higher case loads, some important lessons can be gleaned from the early part of the epidemic:

Emerging Lessons:

1.  Containing the Transmission of a Respiratory Virus is like trying to hold water in your hands.

When the nCoV-19 (COVID-19) outbreak was declared in Wuhan, China in late December 2019, about three weeks of potential transmission for the index cases had occurred.  The first wave of cases were close contacts and healthcare workers.  The virus was transmitted to others through coughing, sneezing, talking, kissing, or from contaminated surfaces or objects.

Just one cough sends out thousands of respiratory droplets, varying from 10 to 100 microns in size, at a speed of 50 miles an hour to a distance of a meter or more.  If you sneeze when you have the cold, you are sending out 40,000 droplets of 0.5 to 12 microns at a speed of 100 m/s.  Imagine that if viruses, such as COVID-19, are 100 nanometers (0.1 micron), hundreds can surf on these droplets and easily become sprayed onto objects or surfaces at a closer distance, while droplet nuclei (<5 microns) may spread distances of a few meters or may even follow air currents still further.

These infectious secretions can easily then enter the mouth, nose of eyes of a passersby or get ingested after touching the face from surface or fomite transfer.  Studies support the concept of a “personal cloud” of infectious particles supplied by coughing and sneezing and air currents around an infected person.  With so many viral particles, transmission of an infection to multiple people becomes easy.

The Wells evaporation-falling curve of droplets  From Annex C. Respiratory droplets.

2.  Case Fatality Rates (CFR) are always overestimated in the beginning of outbreaks

An outbreak requires constant reassessment.  Imagine trying to isolate and contain an outbreak, while at the same time trying to identify the pathogen, confirm cases, protect those at risk, and consider treatment and vaccination options – all in real time.

Epidemiologists can draft a case definition early on, but if the outbreak is from a novel pathogen, cases are defined by syndromic presentation first until more specific tests become available.  The public health system and the general public have sensitive ears for case fatality rate, the amount of those dying from a specific infection over the amount of those infected.

Case fatality rates (CFR) depend on knowledge of all affected cases, which for respiratory virus is usually not possible.  The problem is that most patients that have mild infection may not get tested.  On the other hand, some serious cases may not go attributed to the infection.  As we are learning, even later into the outbreak, e.g. in the US, outbreak investigation and containment largely depends on the availability of tests kits.

In China, the Wuhan COVID-19 outbreak had an attributable CFR of 4%. These original rates are higher than what has mostly been seen in secondary outbreak countries, such as South Korea.  One-third of the caseload was determined by syndromic definition rather than specific testing.  Many more may have not been tested.  The more people that are tested including those mildly symptomatic or asymptomatic, the closer we get to understanding the true CFR.

Enter South Korea.  When COVID-19 was reported in South Korea, great strides were made to identify cases.  On Tuesday March 3rd, Moon Jae-in declared “war” on COVID-19.  This comes after an outbreak of MERS in South Korea where tests kits were not readily available, and 38 people died.  By March 4th, South Korea has already tested more than 140,000 people for COVID-19, even providing a “drive-through” testing option.  South Korea has detected 6,593 cases with 43 total deaths.

If you take into account a sensitivity of 95%, there may be 5% false negatives, this would equate to a CFR of  43 deaths/6,593 x 100% = 0.65%.   This represents the unadjusted CFR based on the positive tests.  However, there is a false negative rate of 5%, so taking into account all of those tested (158,456 – 6,593),  the adjustment could be as low as 0.2%.  Although there is a possibility that the numerator may not be correct, it is less likely to shift, as there isn’t another definition for “death” but it could not capture the attributable deaths from COVID-19.

The WHO declared that the case fatality rate of COVID worldwide has been 3.4%, which appears to be an gross overestimate.  However and importantly, even with the calculated CFR from  South Korea, the rate is likely to be twofold higher (or greater) than what is encountered with seasonal influenza yearly.  When determining risk, the Wuhan data closely correlated advanced age and those with chronic diseases with increased CFR.  So the adjusted case fatality rate is likely to be higher in these at-risk groups and lower in the general population.

*This is coming from the China outbreak – Expect a similar mortality distribution though needs adjusted from other underlying risk factors

Think of a virus as a chain reaction.  Anytime a virus can spread easily and only cause some deaths, sometimes considered a “sweet spot” in disease transmission, it is likely to have a significant impact.  When a virus kills off its hosts too quickly or is transmitted by a different route (e.g. Ebola with infected blood and secretions), it is impactful in its severity, but it can’t get around to infecting too many people.  The CDC estimates that influenza causes about 10,000 to 60,000 deaths annually (CFR 0.1%) – in the Unites States alone.  Even if the CFR for COVID-19 similar to influenza, widespread disease could be impactful on our elderly and other at-risk groups and strains health care delivery.

3.  Outbreak Containment and Risk Mitigation Strategies Benefit Greatly from Accurate Case Definition 

Efforts to contain COVID-19 improve as the case definition becomes more specific.  The original CDC case definition was more rigid, since the outbreak was related to the specific outbreak city, Wuhan.  As is always the case, coming up with an accurate definition up front can be difficult in real-time.  The Chinese government imposed strict lockdown measures, which crippled the cities and was meant to interrupt further transmission.  It became apparent, that low grade transmission and milder cases continued both inside China and to other countries.

Chinese scientist defined the genome of the novel Coronavirus shortly after declaring the outbreak, allowing for the development of testing.  Once testing became available, it was as if an invisible menace could be seen.  In the South Korea outbreak, people were readily tested, so active recommendations for quarantine could be given.  Truly it is important to recognize the efforts of the South Korean government and medical community to contain and test the population.  This testing may have contributed to the lower case fatality rates, by identifying at-risk people and keeping them free of disease.

With the further spread of COVID-19, a country will be able to gain a greater control on the outbreak through greater testing.  This provides knowledge of active cases, so that voluntary quarantine can be put into affect.

4.  Protecting Healthcare workers, Care givers and High Risk Populations is a key strategy 

With the SARS outbreak in 2002, we were reminded that the ability to provide healthcare relies on its personnel.  During that epidemic, one-fifth of all cases were healthcare workers.  As the outbreak of COVID-19 continues, some people will require medical attention and report to the hospital – maybe not even knowing that they have the disease.

As the caseload increases in the United States, the at-risk definition will increase.  It may be necessary to wear personal protective equipment with anyone who exhibits a viral infection.  Healthcare workers will be a greater risk of acquiring the illness.  When healthcare workers are unable to attend to patients because they are sick, healthcare delivery is consequently impacted.

It is clear that there is a higher case fatality rate with the elderly and those with health condition.  When an infected person, whether it is a healthcare worker, patient or visitor comes into a population of those at risk, you see a perfect storm for severe disease and fatality.  Recently, the Life Care center in Kirkland, Washington had a spate of 13 deaths from COVID-19.  it is incumbent on long-term care facilities to develop strategies to prevent any further outbreaks of COVID-19 in such high-risk settings.

5.  With any viral spillover, there are always two outbreaks: Infectious Disease and the Infectious Fear. 

An outbreak is an unpredictable process.  It can sometimes burn out, even as we are still learning of the risk factors of its spread.  As for a respiratory virus outbreak, it is easily transmitted, often leading to relatively silent spread.  Containment strategies are often too late.  As information emerges from the virus, speculation can create narratives that lead to fear, panic and rapid decision-making.

Reports from the news are often related to deaths and how the viral infection is changing regular life and can be sensationalistic.  Online authors and presenters are shaping the news and narratives.  The images of the strict containment measures in China tempt us to think about self-preservation from an unknown invader.  These fears shape behaviors:  cancelling flights, stocking up on masks, cancelling conferences.  While it is not wrong that containment measures can help, defining cases can lead to more targeted containment without crippling the flow of a functioning society.

In the unknown of the COVID-19 outbreak, the stock market has seen great losses and is showing volatility.  Imposing mass quarantine and containment efforts can have real effects on the economy and productivity.  Canceling major conferences can lead to losses that can affect multiple sectors.  Even if you decide not to cancel your European trip, strict measures could be applied in the setting of an outbreak, that can limit or spoil your vacation plans.

Stories of vampires, werewolves and zombies go back hundreds, if not thousands of years.  The concept of some unknown force overpowering humans and causing them to morph into someone or something else hits the nerve of our self-preservation instinct.  In many ways, viruses are the true vampires.  They are lifeless forces other than the primitive instincts of self-preservation and self-generation.  A virus’s consciousness is generativity – producing copies to transmit to others.  It’s  result is a destructive untangling of the fiber of society. A virus is transmitted through social interactions and an interruptions in these behaviors although may be useful,  often results in a significant fallout.

A Viral Outbreak Creates a Fissure in Human Collaboration Efforts, leaving a wake of economic and sociopolitical fallout.

Future direction:

1.  The use of already existing apps for description of symptoms to determine places for targeted testing.
2.  The coordination of an international outbreak system either through already-arranged WHO or influenza surveillance sites.
3.  Selecting specialized labs to launch testing as early as possible.
4.  More rapid protocols for vaccine development in emergency situations that do not require the rigid testing phases as those that are currently imposed by the FDA and other entities.

Summary

Managing the COVID-19 outbreak will require a group effort to stay aware of our individual symptoms and use standard precautions, to identify cases through rapid testing, to mitigate risk through targeted containment and to transform fears into preparation.

A viral outbreak in many ways is like a natural force.  The transmission

At present, with multiple people testing positive, COVID-19 has hit several areas in the United States.  Do we need to be concerned about this.

Since I was a little girl and able to understand scary stuff, my mother said that her body “manufactured” too much cholesterol. Never mind the fatty foods she ate like red meat and extra buttery toast and cheesecake, her favorite dessert. She stood by her story to the end. I was scared I would inherit the same “manufactured” condition. But I was spared even though I had a hemorrhagic stroke that was from Protein S deficiency. (Don’t get me started on a lousy gene pool).

My mother probably familial hypercholesterolemia, this news  brought you by US National Library of Medicine, a disorder that is passed down through families. It causes LDL (bad or think of loathsome) cholesterol level to be very high. The condition begins at birth and can cause heart attacks at an early age. My mother didn’t have a heart attack, but she could have had one.

Familial hypercholesterolemia is a genetic disorder. It is caused by a defect on chromosome 19. The defect makes the body unable to remove low density lipoprotein (LDL, or bad) cholesterol from the blood. This results in a high level of LDL in the blood.

This condition makes you more likely to have narrowing of the arteries from atherosclerosis at an early age. The condition is typically passed down through families in an autosomal dominant manner (that is, inheriting a disease, condition, or trait depending on which type of chromosome was affected).

And that’s probably what she meant by manufacturing high cholesterol. So I thought to myself, I’m lucky that I escaped the high-cholesterol syndrome, and now that I am a pescatarian or, as I like to say, a vegan with fish. That got me thinking: Can your cholesterol be too low? The answer scared me more.

In April of 2019, a study by the American Academy of Neurology said that low cholesterol was linked to a higher risk of “bleeding [hemorrhagic] stroke” in women.

The study also discovered that women with the lowest triglyceride levels, that is, fat found in the blood, had an increased risk of hemorrhagic stroke compared to those with the highest triglyceride levels.

“Strategies to lower cholesterol and triglyceride levels, like modifying diet or taking statins, are widely used to prevent cardiovascular disease,” said Pamela Rist, ScD, study author of Brigham and Women’s Hospital in Boston and a member of the American Academy of Neurology.

“But our large study shows that in women, very low levels may also carry some risks. [I’ll say]. Women already have a higher risk of stroke than men, in part because they live longer, so clearly defining ways to reduce their risk is important. Women with very low LDL cholesterol or low triglycerides should be monitored by their doctors for other stroke risk factors that can be modified, like high blood pressure and smoking, in order to reduce their risk of hemorrhagic stroke.

“Also, additional research is needed to determine how to lower the risk of hemorrhagic stroke in women with very low LDL and low triglycerides,” Rist said.

My head was spinning. Low cholesterol and low triglyceride are considered bad now? I wanted to find out more.

The study of 27,937 women age 45 and older participated  in the Women’s Health Study (supported by the National Institutes of Health) who had total cholesterol, LDL cholesterol, high density lipoprotein (HDL or good cholesterol), and triglycerides measured at the beginning of the study. Researchers reviewed tons of medical records to determine how many women had a hemorrhagic stroke.

With an average follow up at 19 years, researchers identified 137 women who had a bleeding stroke. Nine out of 1,069 women with cholesterol 70 mg/dL or lower, or 0.8 percent, had a bleeding stroke, compared to 40 out of 10,067 women with cholesterol 100 mg/dL up to 130 mg/dL, or 0.4 percent.

Some other factors were weighed in that could affect risk of stroke, such as age, smoking status, high blood pressure and treatment with cholesterol-lowering medications, and researchers discovered that those with extremely low LDL cholesterol were 2.2 times more likely to have a bleeding stroke.

Researchers divided the women into four groups for triglyceride levels. Women in the group with the lowest levels had fasting levels 74 mg/dL or lower, or non-fasting levels of 85 mg/dL or lower. Women in the group with the highest levels had fasting levels that were higher than 156 mg/dL, or non-fasting levels that were higher than 188  mg/dl. Researchers found that 34 women of the 5,714 women with the lowest levels of triglycerides, or 0.6 percent, had a bleeding stroke, compared to 29 women of the 7,989 with the highest triglycerides, or 0.4 percent.

The study’s key limitation was that cholesterol and triglyceride levels were only measured once at the beginning of the study. In addition, menopause was evident in a large number of the women, which prevented researchers from examining whether menopause status may be the missing link between cholesterol and triglyceride levels and bleeding stroke. More study is needed.

WELCOME TO CHECK. CHANGE. CONTROL. CALCULATOR, compliments of the American Heart association (AHA).

https://ccccalculator.ccctracker.com/

Through blood tests, CBC and Lipid Panel, and vitals like blood pressure, you can fill in the blanks on the form to see if you’re susceptible to a heart attack or stroke. Shouldn’t you know rather than guess?

Statins are effective at lowering cholesterol and protecting against a heart attack and stroke, although they may lead to side effects for some people.

The Mayo Clinic says that doctors “often prescribe statins for people with high cholesterol to lower their total cholesterol and reduce their risk of a heart attack or stroke.” But they have been associated with the onslaught of muscle pain, digestive problems, and mental confusion in some people who take them and may cause liver damage, albeit rare.

Statins include:

• atorvastatin (Lipitor)
• fluvastatin (Lescol XL)
• lovastatin (Altoprev)
• pitavastatin (Livalo)
• pravastatin (Pravachol)
• rosuvastatin (Crestor, Ezallor)
• simvastatin (Zocor, FloLipid)

 

The reason that doctors prescribe statins is that that block a substance your liver needs to make cholesterol, and causes your liver to remove cholesterol from your blood.

If you’re already on statins, talk to your doctor before stopping them. My doctor told me to stop reading articles on the Internet. Hoo, boy. Like that’s gonna happen.

If you have muscle pain, the statin you’re on may be producing  rhabdomyolysis which can cause severe pain, liver damage, kidney failure, and death. The risk is very low, and numbers are equal to a few cases per million people taking statins. Rhabdomyolysis can happen when you take statins in combination with certain drugs so ask your pharmacist.

Or statin use could cause an increase in liver inflammation. But if the increase is severe, you may need to try a different statin because all statins are not alike. Again, talk to your doctor, if you also have unusual and increased fatigue or weakness, loss of appetite, pain in your upper abdomen, dark-colored urine, or yellowing of your skin or eyes.

It also possible your blood sugar level may increase when you take a statin, which may lead to developing type 2 diabetes.

The risk is barely significant but important enough that the Food and Drug Administration (FDA) has issued a change on warning labels regarding blood glucose levels and diabetes with statin use prevalent.

Also, the FDA issues a warning on statin labels that some people have memory loss or confusion while using statins.

Everyone who takes a statin may not experience side effects.

Risk factors include:

• Being female
• Being age 80 or older
• Having kidney or liver disease
• Drinking too much alcohol
• Having certain conditions such as hypothyroidism or neuromuscular disorders including amyotrophic lateral sclerosis (ALS)
• Having a small body frame
• Taking multiple medications to lower your cholesterol

If your doctor says it’s fine, take a small break from statin and see whether the muscle aches or other problems you’re having are statin side effects. It may be just part of the aging process.

Or switch to another statin drug if that’s ok with your doctor.

Or change your dose with the doctor’s permission. Another option is to take the medication every other day, especially if you take a statin that stays in the blood for several days. Again, talk to your doctor.

More than usual exercise may increase the risk of muscle injury. And it’s difficult to know if your muscle pain comes exercise or a statin.

One more thing. Is your diet healthy enough not to produce high cholesterol and, by the way, high triglycerides? My mother, again, probably had Familial hypercholesterolemia, the inherited gene that you could help by eating healthy, exercising, and not smoking, all of which my mother did not do.

• The case fatality rate is likely lower than original estimates and varies with at-risk groups, including age and underlying chronic disease
• It is likely that occult transmission of COVID-19 has already occurred in a few areas (e.g. Washington State) in the United States
• Masks are unlikely to be useful in preventing COVID-19 disease beyond the usual prevention measures, such as handwashing, hand sanitizers, social distancing and not touching hands to the mouth, eyes and nose.
• Although person-to-person contact of COVID-19 is the usual mode of transmission, inanimate objects or surfaces could pose a risk.  The virus may survive on surfaces possibly for several days but are easily addressed with dilute bleach or alcohol solutions.
• Rapid diagnostic tests, particularly at the point-of-care, are necessary and useful tools to mitigate risk and concentrate resources and containment efforts.
• As a means of capturing all at-risk patients, the CDC recommends COVID-19 screening of any patient with severe respiratory disease and no other identifiable cause.

I have had insomnia all my life, but my stroke brought this problem to a new level.  I had a stroke in the brainstem which puts us to sleep and wakes us up. Since my stroke I have repeatedly had nights where I get only two hours of sleep per night.  When I did not sleep and did not feel sleepy for two days I FREAKED OUT so I got aggressive about addressing this problem.

Daytime routine.  I avoid caffeine after lunch time.  This meant changing to decaffinated iced tea for dinner and drinking water when I eat out at night.

Bedroom environment.  I sleep in a dark bedroom with no TV.  The alarm clock is placed where I cannot see it.  Sometimes I wake up and find I am sweating.  So I lowered the room temperature because a lower body temperature tells the brain to sleep.

Preparing for bed.  If I am sleepy at 9 p.m. I go to bed.  If I wake up in the middle of the night at least I have slept for 4 or 5 hours because I went to bed early.  If I am still wide awake at 10 p.m.
I go to war.  I turn off the TV, wash my face and brush my teeth, and come back to the living room to listen to a calming CD.  If my body aches I take Tylenol.  The constant burning in my hemiplegic foot keeps me awake so I provide a competing sensation by taking a warm gel pack to bed.

Back up plans.  (1) If I lay in bed and cannot fall asleep, I get up and eat a tiny bowl of cereal with milk.  (2) If I wake up at 3 a.m. to go to the bathroom and cannot fall asleep, I get up and turn on a calming CD or a fan at a low volume for background noise.  These strategies work only IF I realize I have been lying awake for an hour or more.

homeafterstroke.blogspot.com

I admit it. This refrain was borrowed and comes from Tim Mcgraw’s country song, Better Than I Used To Be. I love that song and realize that now, 10 years post stroke, that song could have been about mostly me. I turned the negatives that were mentioned in the song around to positive ones.
Please listen:

https://www.youtube.com/watch?v=WO0keYA21oI&list=RDWO0keYA21oI&index=1

He sings:

Hold a grudge

I used to hold grudges–like, forever. But no more. For example, there was my his-way-or-the-highway sibling and his super-controlling wife. I realized, or pretended to imagine, that they liked to have control, but I wasn’t going to be a party to that. Or my colleagues that didn’t listen to my demands for speaking without confrontation. Or my neighbors who didn’t throw the mouse in the rubbish when it came to land in our shared driveway with my two kids playing. Having no grudges means I’m free of all that negativity and that the cliche Life Is Too Short really means something.

The hearts I’ve broke

Yes, I broke some hearts because, and as my sons say, I liked men with edge because of my sheltered past, not nice guys who would have been perfect husbands and fathers. I married an edgy guy for 18 years who threw food on the floor if he didn’t like it, broke furniture in a fit of rage, once inches away from my infant son, and threatened me countless times. The other person was simply a mistake that lasted 16 years when I should have known better. There were signs, yes. But they’re both now dead to me, the first literally, the other figuratively. I found a couple on nice ones I’m sort of interested in, but time will tell if those feelings are returned.

People I let down

Sure, I let people down, and I had reasons, albeit faulty and selfish, to do so. But show me people who don’t have any regrets in their whole lives, and I’ll show you liars. From not agreeing with contentious friends to not cooking what I said I was going to bring to a pot luck supper, I let people down, so down that they stopped speaking with me. But, come on! Over politics or Shepherd’s Pie?

There’s some dirt on me

Absolutely, there’s some but not a whole lot, like the time I used my friend’s mascara when I had an eye infection on Saturday and then two days later on Monday she found out after she used that mascara the day on Sunday the day before (ouch! that was really a bad one) or how about the time I gossiped to people I knew would spill the beans about a friend’s secret drug addiction and she didn’t get the job. I did.

But I have one thing that wasn’t in the song. Patience! Do you know how I got patience where there wasn’t any before? From my stroke. Talk about a silver lining! It took a while to develop it, but now patience is with me all the time. People write to me occasionally to ask how I developed patience instead of constant anger and frustration. I practiced becoming patient because, in truth, it doesn’t come naturally, at least to me. You have to want it, and it will come, not right away but eventually.

Maybe, in time, I’ll become like that character from the television show My Name is Earl, a f-up who won $100,000 in the lottery and decides to correct all the wrongs from his past. Or maybe I’ll begin again in “it’s-never-too-late” fashion  to make the right decisions this time around.

I live alone so when the electricity goes out 2 to 3 times a year I have to handle it.  My stroke took away my ability to know where vertical is unless I can see my surroundings.  So I put flashlights in every room.  My plan worked until last night when the house went completely black while I was watching TV at 10 p.m.  I reached down for the flashlight on the floor next to my couch.  I started to freak out when I could not find it.  The electricity has gone off for hours in the past and sitting on my short couch until sunrise would be awful.  I finally found the flashlight, but after the lights came back on I put the flashlight in a different location.  I moved it to the tray on my couch that holds my remote control devices.  I also moved a second flashlight to a counter directly behind the place I sit at my kitchen table.

A previous outage taught me to put a battery operated lanturn on a cart next to my bed.  I turn the lantern on by rolling on my side and pulling the cart close too me so I can feel the on switch.

Unusual problem solving after a stroke NEVER ENDS.

homeafterstroke.blogspot.com

An Infectious Diseases Specialist Perspective for Planning for the Next Pandemic

The Emergence of the Wuhan Coronavirus 

The caseload of those infected with 2019-nCoV (aka Wuhan Coronavirus) continue to ascend in an exponential manner in China; 45 cases have now been reported in sixteen other countries in Asia, Australia and France.  In the United States, 5 cases were confirmed Monday (73 pending results), one case in Canada, and now three suspected cases in India.

What began in an animal marketplace in the bustling city of 11 million in Wuhan, China, has developed into 4,515 cases and 106 deaths in China with 976 in serious condition. Public transportation in 17 populous cities in China has been suspended, as the Chinese government grapples with trying to contain the illness.

The first case of 2019-nCoV was reported on December 31st, after a person developed symptoms three weeks earlier (December 8th), along with 27 other cases (suspected) over the course of a few weeks.  2019-nCoV has now approached pandemic proportions.   All of this is happening during one of the busiest times in China, the Lunar New Year.

Infection Characteristics: A Review of Epidemiology

In order to understand the gravity of the novel coronavirus, it is important to define some epidemiology terms:  attack rate and mortality rate.  The attack rate represents the number of people who acquire an illness divided by the number of those at risk.  The mortality rate is the number of those that have died from the infection divided by the amount of those infected.

Even when a disease has a lower mortality rate, if it has a high attack rate, it can make a severe impact.  The seasonal flu has an estimated attack rate of 10-20%.  This means about one-fifth of the US population may contract influenza during the season!  During the current flu season, the CDC estimates that there have been up to 21 million flu illnesses in the United States, with up to 10 million flu medical visits, 250,000 flu hospitalizations and up to 20,000 deaths related to the flu.

With the amount of cases of seasonal influenza, the mortality rate is around 0.1% (9 cases/100,000).  Thusfar, with the 4,515 cases reported of the 2019-nCoV, there were 106 reported deaths, making the estimated mortality rate 2.3%. This is expected to change, as more cases are identified.  If the attack rate of 2019-nCoV is similar to influenza, it will have a significant impact across the globe if it is not contained.  Diseases with menacingly high mortality rates, such as SARS (10%), Avian flu (59%), and Ebola (50-90%), have lower attack rates, meaning they were not able to affect as many.

What’s particularly more concerning is the amount of severe cases reported, which, if the number is accurate, a rate of 21% of those infected with 2019-nCoV have a more severe infection.  Though, most likely these cases are among the highest risk populations for severe disease, the very old and those with chronic diseases.

Another thing to keep in mind: When epidemiologists determine the above rates, they must ensure an accurate numerator and denominator.  Oftentimes, the first cases that are identified are the more severe cases – making the estimated mortality rate higher than it may actually be.   When you tally up the cases of milder diseases, your denominator increases, and the mortality rate consequently decreases.

An illness that can cause mortality and be spread easily requires preparation and containment strategies.

Was the rapidity of this process predictable?

The first case of 2019-nCoV was believed to have been acquired at a market in Wuhan – and was reported as a novel infection on December 28th.  There were 27 other people that were being evaluated for viral pneumonia during that time.  One day following, a report of a family cluster of six patients who flew from Shenzhen to Wuhan on December 29, 2019, started presenting with influenza like symptoms on January 1, 2020.  None of the family members had contact with markets or animals in Wuhan.  This suggests that they were exposed to secondary cases (i.e. person-to-person) by the time that the primary case was identified as having the novel coronavirus.

Given that this disease emerged during the flu season, it is not unusual that it took some time to differentiate this from the usual viral infections. The usual “shotgun” gene sequencing tests were used including respiratory viral panels.  Samples were sent for further methods to identify it as a novel coronavirus, similar to those of bat origin.

The epidemic was already well into phase 4 sustained human transmission by the time it was identified.  Given that respiratory viruses, such as influenza, respiratory syncytial virus (RSV) and coronaviruses are transmitted by respiratory droplets as little as 10 microns (micrometers), the diseases can be easily transmitted with casual contact, shaking hands, or touching contaminated surfaces or objects (fomites).  Remember these droplets can get passed not only from the secretions from sneezing or coughing, but also saliva from talking.

Any respiratory disease has the capabilities of exponential spread over a short period.  

What can one do to protect themselves from this scourge?

A simple surgical mask, when worn correctly (sealed well around the nose), can prevent particles larger than 5 microns from entering the mask.  Since respiratory droplets are larger than this size, risk of transmission is expected to be low.  Although an N95 mask offers greater protection for very small particles (0.3 microns), it is likely unnecessary to prevent transmission of 2019-nCoV.  Another important recommendation is for someone who suspects or is suspected of having the infection should comply with using a mask and washing hands after touching his/her face.

Do we need to stock up and “hunker down”?

Preparation for an apocalypse is a common theme in many popular movies and streaming series.  While 2019-nCoV is expected to make a significant wave of disease throughout the world – which is what I gather when I see the case reports double in a day – it is unlikely that it is going to have a major impact on lives.  The virus may transform as it is spreads from human to human – potentially becoming more virulent.  If that were to occur, the dynamics of the attack rate would likely change.  I don’t expect that we will see this with 2019-nCoV.

As for now, my recommendation would be to keep informed of the disease rates while reading the news or listening to the radio.  These rates are constantly being updated throughout the day.  Staying glued to this information is likely not beneficial and may be hazardous to your mental health – increasing fear and panic.

Seasonal influenza has made a greater impact and your likelihood of getting it is much greater too. So if you still haven’t been vaccinated, it is never too late.

Wuhan Coronavirus: An Emerging Global Pandemic?

Get the best out of your sleep

Good sleep is a necessity for the healthy functioning of the mind and body.  It is also one of the things that we can forcibly deprive ourselves.  Ideally, we spend one-third of our lives asleep.  Improving your sleep quality can be the first step toward stress resilience and  healthy decisions.

Could you imagine sleeping for 4 hours, then waking up to go to the gym to exercise, then going to work, and taking an extra cup of coffee to stay up?! If this happens to you, wouldn’t you skip the gym and maybe skip preparing a healthy meal? Without sleep, the brain has a lower threshold to develop stress, anger and impatience.  Driving a car after not sleeping well the night before is equivalent to driving under the influence of alcohol.  The system doesn’t just recalibrate the sleep deficit by sleeping in on a Saturday morning.

Sleep affects more than just the neurologic system.  Many first-time parents probably remember getting up at night because of a crying baby.  Most people recognize that sleep reduces memory and concentration and impairs judgement, but sleep also reduces the immune system, leads to weight gain and increases the risk of high blood pressure and stroke.  The endocrine, immunologic and vascular systems are regulated by sleep.

Here is a list of tips to ensure ideal sleep:

1. Tone down technology: Silence your cellphones and other technology and put them in a different room at a set time each evening, preferably at least 2 hours before bedtime.  The screen lights can inhibit the production of melatonin, which would otherwise prepare you for sleep.
2. Preparation: Provide yourself a 30-60 minute of winding down before lights out. Limit reading time to 20-30 minutes.
3. Make sleep a routine: Go to bed and wake up at consistent times.  Most of the time, you will sleep for 6-8 hours naturally.  With a natural routine, you will very likely not need an alarm clock.  If you do use it, stop it and get up – don’t hit snooze 5 times.
4. Your bed, the slumber throne. Limit activities to sex and sleep.  Watching TV, eating, working on the computer may affect your body’s ability to rest in bed.
5. Avoid medicating to sleep: Medications to sleep should be avoided or limited to a low dose of melatonin (2-4mg nightly).  Although the medications may sometimes “work”, they come with side effects and, moreover, are not addressing the source of the problem.  The last thing you want to do is develop dependence on alcohol, benzodiazepines or ambien, etc.  and then can’t sleep without it.  As for the other side of things, avoid any intake of caffeine after noon hours.  Avoid any stimulant medications, e.g. albuterol inhalers, immediately prior to sleeping.  One interesting association of sleep apnea is the patient who drinks high levels of caffeine during the day and then takes a sleeping medication at night.
6. Environment: Keep sleeping area dimly lit or dark.  Ambient noise should be at a minute, though white noise is acceptable.  Temperature should be on the lower side, between 60-67 degrees F.
7. Trouble-shoot for the future: If you are having problems sleeping at night and find yourself tossing and turning, thinking too much or waiting until that magic click to start, limit time in bed to about 15-20 minutes. There is usually a reason that this has happened and it is up to you to brainstorm it.  You can sit in your chair to begin to rest, meditate and then return to your bed to sleep.  The next day, think why this happened:  It could have been that maybe you exercised too close to bedtime, took too warm of a shower before sleeping, saw a stimulating program on TV, or tried to squeeze some work on the computer too close to bedtime.

If you still have trouble sleeping after following this checklist, you should consider being evaluated for sleep apnea or other conditions (parasomnias) associated with sleeping, such as restless legs, etc.