Category: Just So You Know

Eosinophilic Esophagitis

Eosinophilic Esophagitis

Patient education: Eosinophilic esophagitis
What is eosinophilic esophagitis
Eosinophilic esophagitis is a condition that affects the esophagus, the tube that carries food from the mouth to the stomach. This condition is called “EoE” for short. In EoE, the esophagus has cells called “eosinophils” in it. Eosinophils are allergy cells that are not normally found in the esophagus.
Doctors don’t know for sure what causes EoE. But they think it might be caused by allergies, especially food allergies.
EoE sometimes runs in families. It can happen in both children and adults.
What are the symptoms of eosinophilic esophagitis?
Symptoms can be different, depending on a person’s age.
Adults and teens usually have symptoms such as:
●Trouble swallowing – This is the most common symptom. People usually have trouble swallowing solid foods. Some people have pain with swallowing or feel like the food gets stuck in their throat or chest.
●Chest or upper belly pain
●Burning in the chest (heartburn) that doesn’t get better after taking medicine to treat heartburn
Children usually have symptoms such as:
●Feeding problems, such as refusing to eat solid foods
●Nausea or vomiting
●Belly pain
Is there a test for eosinophilic esophagitis?
The test done most often to check for this condition is an upper endoscopy.
During an upper endoscopy, a doctor (called a gastroenterologist) puts a thin tube with a camera and light on the end into your mouth and down into your esophagus. They will look at the lining of the esophagus and take small samples of it. Another doctor will then look at the cells under a microscope to see if you have EoE.
How is eosinophilic esophagitis treated?
Treatment usually involves diet changes and medicines:
●Diet changes – Your doctor might have you avoid foods that could be causing your symptoms. There are 3 main ways to do this. You can:
•Avoid the foods that most commonly cause EoE
•Avoid the foods you are allergic to – To figure out the foods you are allergic to, you might need to see an allergist (allergy doctor) and have tests.
•Go on a special liquid diet and avoid all solid foods
To make sure you get the nutrition you need, your doctor might recommend that you work with a dietitian (food expert). After your symptoms improve, you will be able to add foods back into your diet.
●Medicines – Doctors can use different medicines to treat EoE. One is called a “proton pump inhibitor.” This medicine is usually used to treat acid reflux, which is when acid that is normally in the stomach backs up into the esophagus. People with EoE sometimes have acid reflux, but this medicine can treat EoE, too.
Other medicines include steroids, which help reduce inflammation. (These are not the same as the steroids some athletes take illegally.) Steroids usually come in a device called an inhaler, but you don’t breathe in the steroids the way you normally would with inhaler medicines. Instead, you allow the medicine to build up in your mouth and then you swallow it. Steroids might also be given as a liquid or pill.
In some people, EoE leads to a condition called an esophageal stricture, which is a narrowing of the esophagus. The main treatment for an esophageal stricture in people who do not improve with medicines is a procedure to widen the esophagus, called “dilation.” This procedure is done during endoscopy.

COVID-19 FAQ and Answers

COVID-19 FAQ and Answers

  1. How is SARS-CoV-2 (the virus that causes COVID-19) transmitted?

Person-to-person spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is thought to occur mainly via respiratory droplets, resembling the spread of influenza. With droplet transmission, the virus is released in the respiratory secretions when an infected person coughs, sneezes, or talks if it makes direct contact with the mucous membranes. Infection can also occur if a person touches a contaminated surface and then touches his or her eyes, nose, or mouth. Droplets typically do not travel more than six feet (about two meters).

The extent to which SARS-CoV-2 can be transmitted through the airborne route (through particles smaller than droplets that remain in the air over time and distance) under natural conditions and how much this mode of transmission has contributed to the pandemic are controversial.

While SARS-CoV-2 RNA has been detected in non-respiratory specimens (e.g., stool, blood), neither fecal-oral nor blood borne transmission appear to be significant sources of infection. SARS-CoV-2 infection has been described in animals, but there is no evidence to suggest that animals are a major source of transmission.

2. What is the incubation period for COVID-19?

The incubation period for COVID-19 is thought to be within 14 days following exposure, with most cases occurring approximately four to five days after exposure.

3. What are some of the important SARS-CoV-2 variants?

Multiple SARS-CoV-2 variants are circulating globally. Some variants contain mutations in the surface spike protein, which mediates viral attachment to human cells and is a target for natural and vaccine-induced immunity. Thus, these variants have the potential to be more transmissible, cause more severe disease, and/or evade natural or vaccine-induced immune responses. Although more prevalent in the locations where they were first identified, these variants have subsequently been detected in many other countries, including in the United States:

UK variant was first identified in the United Kingdom in late 2020. This variant is estimated to be more transmissible than wild-type virus. Preliminary data also suggest this variant may cause more severe illness.

South Africa variant was identified in late 2020 in South Africa, where it quickly became the dominant circulating strain. This variant is also believed to be more transmissible than wild-type virus, and there is concern that it evades immune responses; there is no evidence to suggest it impacts disease severity.

Brazil variant was first identified in Japan in travelers from Brazil in late 2020, and subsequently widely detected in specimens from the Amazonas state of Brazil. The variant harbors several mutations, which have the potential to increase transmissibility and impact immunity.

What are the clinical presentation and natural history of COVID-19? The spectrum of illness associated with COVID-19 is wide, ranging from asymptomatic infection to life-threatening respiratory failure. When symptoms are present, they typically arise approximately four to five days after exposure. Symptoms are mild in approximately 80 percent of cases and often include fever, fatigue, and dry cough. Smell and taste disorders have also been reported in patients with COVID-19; whether these symptoms are distinguishing features is unknown. Gastrointestinal symptoms are not frequently reported but may be the presenting feature in some patients. Headache, rhinorrhea, and sore throat are less common.

Dyspnea (shortness of breath that starts suddenly) affects approximately 20 to 30 percent of patients, typically arising five to eight days after symptom onset. Progression from dyspnea to acute respiratory distress syndrome (ARDS) can be rapid; thus, the onset of dyspnea is generally an indication for hospital evaluation and management.

Pneumonia is the most common manifestation of severe disease. ARDS develops in a sizable minority of symptomatic patients and can be associated with a cytokine release syndrome, which is characterized by fever, progressive hypoxia and/or hypotension, and markedly elevated inflammatory markers. ARDS is the leading cause of death, followed by sepsis, cardiac complications, and secondary infections.

The overall case fatality rate is estimated to be between 2 and 3 percent, although it varies widely by age and the true rate is unknown. While severe and fatal illness can occur in anyone, the risk rises dramatically with age and the presence of chronic illnesses, including cardiovascular disease, pulmonary disease, diabetes mellitus, kidney disease, and cancer. For those who recover, illness is often prolonged, lasting approximately two weeks in those with mild disease and three to six weeks in those with severe disease.

5. What factors are associated with severe COVID-19?

Severe illness can occur in otherwise healthy individuals of any age, but it predominantly occurs in adults with advanced age or underlying medical comorbidities. Major comorbidities associated with severe illness and mortality include:

  • Cardiovascular disease
  • Diabetes mellitus
  • Hypertension
  • Chronic lung disease
  • Cancer
  • Chronic kidney disease
  • Obesity (body mass index ≥30)
  • Smoking

6. What are the major cardiac complications in patients with COVID-19? And how often do they occur?

Cardiac manifestations are common in hospitalized patients and occur most frequently in critically ill patients. The most common complications are listed here:

Cardiac troponin elevation, which is a biomarker of myocardial injury, occurs in approximately 10 to 30 percent of hospitalized patients. In the majority of these patients, cardiac signs and symptoms are not present and the cause of the troponin rise is not acute myocardial infarction (MI). However, patients with a clinical presentation (including history or electrocardiogram) suggestive of acute MI require prompt evaluation and treatment.

Usually, troponin elevation in COVID-19 patients is due to other causes of myocardial injury including stress cardiomyopathy, hypoxic injury, myocarditis, right heart strain, microvascular dysfunction, and systemic inflammatory response syndrome. For those without suspected acute MI, further evaluation is focused on testing expected to impact management.

The following complications may occur with or without troponin elevation:

  • Arrhythmias have been reported in approximately 5 to 20 percent of hospitalized cases, and most are asymptomatic. Causes may include hypoxia, electrolyte abnormalities, myocardial injury, and drug effects (such as QT-prolonging agents).
  • Heart failure is the most common symptomatic cardiac complication. Data on its incidence are limited; however, its presence is associated with increased mortality. Heart failure in patients with COVID-19 may be precipitated by acute illness in patients with pre-existing known or undiagnosed heart disease (e.g., coronary artery disease or hypertensive heart disease) or incident acute myocardial injury (e.g., stress cardiomyopathy or acute MI).

7. What are the major thrombotic complications in patients with COVID-19?

COVID-19 is a hypercoagulable state associated with an increased risk of venous thromboembolism (VTE; including deep vein thrombosis and pulmonary embolism) and arterial thrombosis, including stroke, myocardial infarction, and possibly limb ischemia. The risk is highest in individuals in the intensive care unit (ICU), often despite prophylactic anticoagulation. Bleeding is not common but has been seen, especially in the setting of trauma and/or anticoagulation.

8. What are the most common dermatologic syndromes associated with COVID-19?

The most common cutaneous findings reported in patients with COVID-19 include an exanthematous (morbilliform) rash, pernio-like acral lesions, livedo-like lesions, retiform purpura, necrotic vascular lesions, urticaria, vesicular (varicella-like) eruptions, and erythema multiforme-like lesions. An erythematous, polymorphic rash has also been associated with a related multisystem inflammatory syndrome in children. The frequency of cutaneous findings is estimated to range from less than 1 percent to 20 percent of patients with COVID-19.

Uncertainty remains about the strength and mechanisms of associations between reported skin findings and COVID-19. The timing of the appearance of cutaneous findings in relation to the course of COVID-19 has varied, with reports describing skin changes occurring prior to, concomitantly, or following symptoms of COVID-19.

9. What is multisystem inflammatory syndrome associated with COVID-19?

Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious condition that has been reported in patients with current or recent COVID-19 infection or exposure. It shares clinical features with Kawasaki disease (KD), KD shock, and toxic shock syndrome. Clinical features include persistent fever, severe illness with involvement of multiple organ systems, and elevated inflammatory markers. Most children with MIS-C have survived, although some have required intensive care. Pending additional information, children with clinical features of MIS-C should be promptly referred to a specialist in pediatric infectious diseases, rheumatology, cardiology, and/or critical care, as necessary. 

Persistent physical symptoms following acute COVID-19 are common and typically include fatigue, dyspnea, chest pain, and cough. Headache, joint pain, insomnia, anxiety, cognitive dysfunction, myalgias, and diarrhea have also been reported. The time to symptom resolution depends primarily on premorbid risk factors, the severity of the acute illness, and the spectrum of initial symptoms. However, prolonged symptoms are common even in patients with less severe disease who were never hospitalized.

11. Is there a way to distinguish COVID-19 clinically from other respiratory illnesses, particularly influenza?

No, the clinical features of COVID-19 overlap substantially with influenza and other respiratory viral illnesses. There is no way to distinguish among them without testing.

12. When should patients with confirmed or suspected COVID-19 be advised to stay at home? Have an in-person clinical evaluation?

Home management is appropriate for most patients with mild symptoms (eg, fever, cough, and/or myalgias without dyspnea), provided they can be adequately isolated, monitored, and supported in the outpatient setting. However, there should be a low threshold to clinically evaluate patients who have any risk factors for more severe illness, even if they have only mild symptoms. As an example, some outpatients with mild to moderate symptoms, but who have certain risk factors for severe disease, may be candidates for treatment with monoclonal antibody therapy.

Patients being managed at home should be educated about the potential for worsening disease and advised to closely monitor for symptoms of more serious disease, including dyspnea or persistent chest pain. The development of these symptoms should prompt clinical evaluation and possible hospitalization.

13. What laboratory abnormalities are commonly seen in patients with COVID-19?

Common laboratory abnormalities among hospitalized patients with COVID-19 include:

  • Lymphopenia (reported in up to 90 percent)
  • Elevated amino transaminase levels
  • Elevated lactate dehydrogenase levels
  • Elevated inflammatory markers (eg, ferritin, C-reactive protein, and erythrocyte sedimentation rate)

Abnormalities in coagulation testing, elevated procalcitonin levels, and elevated troponin levels have also been reported. The degree of these abnormalities tends to correlate with disease severity.

14. What are the major coagulation abnormalities in patients with COVID-19?

A number of laboratory abnormalities have been reported, including high fibrinogen and D-dimer and mild prolongation of the prothrombin time (PT) and activated partial thromboplastin time (APTT). Abnormal coagulation studies are mainly used to monitor clinical status and to help determine level of care. Very high D-dimer is associated with a high mortality rate. Atypical findings (e.g., severe thrombocytopenia) should be further evaluated.

15. What are the different types of tests for COVID-19?

  • Nucleic acid amplifications tests (NAATs; eg, reverse transcription polymerase chain reaction [RT-PCR]) – RT-PCR for SARS-CoV-2 is the primary test used to diagnose active COVID-19. The test is performed primarily on upper respiratory specimens (including nasopharyngeal swabs, nasal swabs, and saliva) but can also be performed on lower respiratory tract samples. Sensitivity and specificity are generally high, although performance varies based on the specific assay used, specimen quality, and duration of illness.
  • Serology – Serologic tests measure antibodies to SARS-CoV-2 and are primarily used to identify patients who have had COVID-19 in the past as well as patients with current infection who have had symptoms for three to four weeks. Sensitivity and specificity are highly variable, and cross-reactivity with other coronaviruses has been reported.
  • Antigen tests – Antigen tests can also be used to diagnosis active infection, although they are less sensitive than NAATs. These tests are typically performed on nasopharyngeal or nasal swabs.

Both NAATs and antigen tests can be used to screen patients in congregate settings, such as long-term care facilities.

16. How accurate is RT-PCR for SARS-CoV-2? Should two tests be performed or one?

A positive RT-PCR for SARS-CoV-2 generally confirms the diagnosis of COVID-19. However, false-negative tests from upper respiratory specimens have been well documented. If initial testing is negative, but the suspicion for COVID-19 remains, and determining the presence of infection is important for management or infection control, we suggest repeating the test. For hospitalized patients with evidence of lower respiratory tract involvement, the repeat test can be performed on expectorated sputum or a tracheal aspirate, if available.

In many cases, because of the limited availability of testing and concern for false-negative results, the diagnosis of COVID-19 is made presumptively based on a compatible clinical presentation in the setting of an exposure risk (residence in or travel to an area with widespread community transmission or known contact).

17. What are the indications for testing asymptomatic individuals?

Indications for testing asymptomatic individuals include close contact with an individual with COVID-19, screening in congregate settings (eg, long-term care facilities, correctional and detention facilities, homeless shelters), and screening hospitalized patients in high-prevalence regions. Screening may also be indicated prior to time-sensitive surgical procedures or aerosol-generating procedures and prior to receiving immunosuppression.

18. When is the best time to test for COVID-19 following an exposure?

The optimal time to test for COVID-19 following exposure is uncertain. The United States Centers for Disease Control and Prevention (CDC) recommends testing immediately after the exposure is identified to quickly identify infection and, if the test is negative, retesting five to seven days after the last exposure. In some cases, testing can be used to help determine the length of quarantine (eg, reduce the quarantine period to seven days if an individual remains asymptomatic and has a negative viral test within 48 hours of the planned end of quarantine).

19. Can SARS-CoV-2 variants be reliably detected by available diagnostic assays?

Thus far, yes. Most circulating SARS-CoV-2 variants have mutations in the viral spike protein.

While many nucleic acid amplification tests target the gene that encodes the spike protein, they also target other genes. Thus, if a mutation alters one gene target, the other gene targets still function and the test will detect the virus.

Most antigen tests target nucleocapsid protein, so mutations in the spike protein would not impact the accuracy of such antigen tests. 

20. Are there any COVID-19-specific therapies available for non-hospitalized patients?

Antibody-based treatments may reduce the risk of severe disease in high-risk outpatients. However, they require intravenous administration, necessitate the use of valuable ancillary services, and must be given early in the course of illness. These factors make administration operationally complicated.

Monoclonal antibody therapy – In the United States, two combination monoclonal antibody therapies targeting SARS-CoV-2 (bamlanivimab-etesevimab and casirivimab-imdevimab) are available for the treatment of non-hospitalized adults (≥18 years) with mild to moderate COVID-19 and any of the following risk factors for severe disease:

  • Body mass index (BMI) ≥35 kg/m2
  • Chronic kidney disease
  • Diabetes mellitus
  • Immunosuppression (immunosuppressive disease or treatment)
  • ≥65 years of age
  • ≥55 years of age and who have cardiovascular disease, and/or hypertension, and/or chronic obstructive pulmonary disease (or other chronic respiratory disease)

Given the limited data and intensive resources needed for administration, experts suggest not routinely treating patients with monoclonal antibodies. Nevertheless, if supporting infrastructure is in place, it is reasonable to offer bamlanivimab-etesevimab, which is recommended by the National Institutes of Health based on preliminary evidence of a mortality reduction.

SARS-CoV-2 variants may impact the clinical efficacy of monoclonal antibody therapies. In the United States, due to the increasing prevalence of variants that are resistant to bamlanivimab, this agent is no longer available as for use as monotherapy and should only be administered in combination with etesevimab. Clinicians should be aware of the prevalence of variants in their local area and the potential resistance to available monoclonal antibody therapies.

If monoclonal antibody therapy is used, it should be given as soon as possible after illness onset and positive SARS-CoV-2 test has been obtained; ideally within three days, but no longer than 10 days after symptom onset.

High-titer convalescent plasma – Limited high-quality data suggest that early administration of high-titer convalescent plasma may lower the risk of progression to severe disease in high-risk older adults (age ≥75 years or ≥65 years with specific comorbidities) with mild illness. Convalescent plasma appears to have the greatest efficacy when given within 72 hours of symptom onset.

As with monoclonal antibody therapy, high-titer convalescent plasma therapy remains investigational and should be administered through a clinical trial if available. Experts do not routinely treat COVID-19 in non-hospitalized patients with glucocorticoids, antibiotics, anticoagulation, or antiplatelet therapy. 

21. What advice should be given to patients with known or presumed COVID-19 managed at home?

For most patients with COVID-19 who are managed at home, we advise the following:

  • Supportive care with antipyretics/analgesics (e.g., acetaminophen) and hydration
  • Close contact with their health care provider
  • Monitoring for clinical worsening, particularly the development of new or worsening dyspnea, which should prompt clinical evaluation and possible hospitalization
  • Separation from other household members, including pets (eg, staying in a separate room when possible and wearing a mask when in the same room)
  • Frequent hand washing for all family members
  • Frequent disinfection of commonly touched surfaces.

22. How long patients should be cared for at home stay isolated?

For most symptomatic immunocompetent patients cared for at home, isolation can usually be discontinued when the following criteria are met:

  • At least 10 days have passed since symptoms first appeared AND
  • At least one day (24 hours) has passed since resolution of fever without the use of fever-reducing medications AND 
  • There is improvement in symptoms (e.g., cough, shortness of breath)

In some cases, patients may have had laboratory-confirmed COVID-19 but did not have any symptoms when they were tested. In such patients, home isolation can usually be discontinued using a time-based strategy (when at least 10 days have passed since the date of their first positive COVID-19 test) as long as there was no evidence of subsequent illness.

For those who had severe disease or are severely immunocompromised, the duration of isolation may need to be extended and/or testing may be needed to confirm resolution.

23. What is the significance of a persistently positive RT-PCR for weeks after illness?

Patients diagnosed with COVID-19 can have detectable SARS-CoV-2 RNA in upper respiratory tract specimens for weeks after the onset of symptoms. However, prolonged viral RNA detection does not necessarily indicate prolonged infectiousness. According to the CDC, isolation of infectious virus more than 10 days after illness onset is rare in patients whose symptoms have resolved.

There is no standardized approach to management of patients with persistently positive reverse transcription polymerase chain reaction (RT-PCR) 10 days or more after resolution of symptoms. However, such patients are generally felt to have low infectiousness, particularly after mild to moderate disease and in the absence of immunocompromised. This is why symptom- and time-based approaches for discontinuation of precautions are recommended for most patients.

24. Should I use acetaminophen or NSAIDs when providing supportive care?

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been theorized to cause harm in patients with COVID-19, but clinical data are limited. Given the uncertainty, we use acetaminophen as the preferred antipyretic agent for most patients rather than NSAIDs. If NSAIDs are needed, we use the lowest effective dose. We do not routinely discontinue NSAIDs in patients using them for the management of chronic illnesses.

The US Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the World Health Organization (WHO) do not recommend that NSAIDs be avoided when clinically indicated. 

25. Do ACE inhibitors and ARBs increase the likelihood of severe COVID-19?

Patients receiving angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should continue treatment with these agents. The membrane-bound ACE2 functions as a receptor for SARS-CoV-2, and because ACE inhibitors and ARBs may increase the expression of ACE2, there is speculation that patients with COVID-19 who are receiving these agents may be at increased risk for severe disease. However, there is no evidence to support an association of ACE inhibitors and ARBs with more severe disease, and it is also possible that these drugs may attenuate the severity of disease. In addition, stopping these agents in some patients can exacerbate comorbid cardiovascular or kidney disease and increase mortality. 

26. Should patients using inhaled glucocorticoids for asthma or COPD be advised to stop these medications to prevent COVID-19?

No, patients with asthma or chronic obstructive pulmonary disease (COPD) who need inhaled glucocorticoids to maintain control of their asthma or COPD should continue them at their usual dose. When indicated, inhaled steroids help to minimize risk of an asthma or COPD exacerbation and the associated need for interaction with the health care system. There is no good evidence that inhaled glucocorticoids increase susceptibility to COVID-19 or have an adverse effect on the course of infection. Stopping them may worsen asthma or COPD control and thereby increase the risk for complications of COVID-19, if acquired.

27. Should patients with COVID-19 and an acute exacerbation of asthma or COPD be treated with systemic glucocorticoids?

Yes, patients with COVID-19 infection and a concomitant acute exacerbation of asthma or COPD should receive prompt treatment with systemic glucocorticoids as indicated by usual guidelines. Delaying therapy can increase the risk of a life-threatening exacerbation. While the World Health Organization (WHO) and United States Centers for Disease Control and Prevention (CDC) recommend glucocorticoids not be routinely used in the treatment of COVID-19 infection, exacerbations of asthma and COPD are considered appropriate indications for use. Overall, the known benefits of systemic glucocorticoids for exacerbations of asthma and COPD outweigh the potential harm in COVID-19 infection. 

28. Have any medications been shown to prevent COVID-19?

No agent is known to be effective for preventing COVID-19. While hydroxychloroquine is being studied as a prophylactic agent, randomized trials found that it was not effective for prevention. We recommend that neither this medication nor any other be used for prophylaxis outside of clinical trials.

29. What PPE is recommended for health care workers taking care of patients with suspected or confirmed COVID-19?

Any personnel entering the room of a patient with suspected or confirmed COVID-19, regardless of COVID-19 vaccination status, should wear the appropriate personal protective equipment (PPE): gown, gloves, eye protection (full face shield preferred rather than goggles or a surgical mask with an attached eye shield), and a respirator (eg, an N95 respirator). If the supply of respirators is limited, medical masks are an acceptable alternative, except during aerosol-generating procedures (e.g., tracheal intubation and extubating, tracheotomy, bronchoscopy, noninvasive ventilation, cardiopulmonary resuscitation).

30. Should patients be advised to wear masks in public?

Yes, patients should be advised to wear masks when in public spaces (indoors or outdoors) or when around individuals outside of their household. This is consistent with recommendations from the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC). The CDC also advises that individuals who have been fully vaccinated should still wear masks in public but can forgo mask use when visiting with other vaccinated individuals or with unvaccinated members of a single household who are at low risk for severe COVID-19.

The rationale for individuals (regardless of symptoms) to wear a mask in the community is to contain secretions of and prevent transmission from individuals with infection, including those who have asymptomatic or pre symptomatic infection. Masks also reduce exposure to SARS-CoV-2 for the wearer. 

31. Does protective immunity develop after SARS-CoV-2 infection? Can reinfection occur?

SARS-CoV-2-specific antibodies and cell-mediated responses are induced following infection. Evidence suggests that some of these responses are protective and generally last at least several months. However, it is unknown whether all infected patients mount a protective immune response and how long protective effects last beyond the first few months after infection.

The short-term risk of reinfection (e.g., within the first few months after initial infection) appears low. However, sporadic cases of reinfection have been documented.

32. Which vaccines are currently available in the United States? Worldwide?

In the United States, three vaccines are available:

  • BNT162b2 (Pfizer-BioNTech COVID-19 vaccine)
  • mRNA-1273 (Moderna COVID-19 vaccine)
  • Ad26.COV2.S (Janssen COVID-19 vaccine)

BNT162b2 and mRNA-1273 are mRNA vaccines are delivered in lipid nanoparticles. Once injected and taken up into muscle cells, the mRNA expresses the SARS-CoV-2 surface spike protein. Spike protein mediates viral attachment to human cells. Expression of the spike protein induces binding and neutralizing antibody responses.

Ad26.COV2.S (Janssen) has been approved for use in the United States. This vaccine is based on a replication-incompetent adenovirus 26 vector that expresses a stabilized spike protein. This is a single shot vaccine.

Outside of the United States, vaccine availability varies regionally. One of the most widely available vaccines is ChAdOx1 nCoV-19/AZD1222 (University of Oxford, AstraZeneca, and the Serum Institute of India vaccines), an adenovirus vector-based DNA vaccine that also expresses the surface spike protein. 

Numerous additional vaccine candidates are being evaluated for prevention of COVID-19, including nucleic acid-based (mRNA and DNA) vaccines, viral-vector vaccines, and inactivated or recombinant protein vaccines.

33. How efficacious is vaccination at preventing symptomatic COVID-19?

BNT162b2 (Pfizer-BioNTech COVID-19 vaccine) had 95 percent efficacy in preventing symptomatic COVID-19 at or after day 7 following completion of a two-dose series.

MRNA-1273 (Moderna COVID-19 vaccine) had 95 percent efficacy in preventing symptomatic COVID-19 at or after day 7 following completion of a two-dose series. 

Ad26.COV2.S (Janssen) had 66 percent efficacy against moderate to severe COVID-19 and 85 percent efficacy against severe COVID-19 at or after 28 days following administration of a single dose. 

ChAdOx1 nCoV-19/AZD1222 (AstraZeneca COVID-19 vaccine) had 70 percent efficacy in preventing symptomatic COVID-19 at or after two weeks following completion of a two-dose series. 

34. How effective is vaccination against SARS-CoV-2 variants?

Many circulating SARS-CoV-2 variants contain mutations in the surface spike protein, which is the most common vaccine target. The impact of these mutations on vaccine efficacy is not well studied and undoubtedly varies by variant and by vaccine type.

Preliminary evidence suggests that both BNT162b2 (Pfizer-BioNTech COVID-19 vaccine) and mRNA-1273 (Moderna COVID-19 vaccine) retain neutralizing activity against B.1.1.7, the dominant viral variant in the United Kingdom and other countries. Both vaccines have reduced neutralizing activity against B.1.351, the dominant variant in South Africa, though the clinical significance of this reduction is not known.

The efficacy of Ad26.COV2.S (Janssen) varied by region: 74 percent in the United States, 66 percent in Brazil, where the P.2 variant was prevalent, and 52 percent in South Africa, where most infections were caused by the variant B.1.351. Nevertheless, vaccine efficacy against severe/critical disease was similar across regions.

The efficacy of ChAdOx1 nCoV-19/AZD1222 (AstraZeneca COVID-19 vaccine) against B.1.1.7 appears to be similar to wild-type virus despite reduced neutralizing activity.

As mutations continue to accumulate, there is potential for vaccine efficacy to further decline. 

35. What are the indications and contraindications to vaccination?

For patients in the United States, experts recommend vaccination with either BNT162b2 (Pfizer-BioNTech COVID-19 vaccine), mRNA-1273 (Moderna COVID-19 vaccine), or Ad26.COV2.S (Janssen COVID-19 vaccine).

  • Individuals ≥16 years old are eligible for BNT162b2.
  • Individuals ≥18 years old are eligible for mRNA-1273 and Ad26.COV2.S.

Contraindications to these vaccines are:

For the mRNA COVID-19 vaccines:

  • A history of a severe allergic reaction, such as anaphylaxis, after a previous dose of an mRNA COVID-19 vaccine or to any of its components (including polyethylene glycol).
  • An immediate allergic reaction of any severity (including hives) to a previous dose of an mRNA COVID-19 vaccine, to any of its components, or to polysorbate (with which there can be cross-reactive hypersensitivity to polyethylene glycol). Such individuals should not receive an mRNA COVID-19 vaccine unless they have been evaluated by an allergy expert who determines that it can be given safely.

The United States Advisory Committee on Immunization Practices lists history of severe allergic reaction to any other vaccine or injectable therapy (that does not share the same components as the mRNA COVID-19 vaccines) as a precaution, but not contraindication, to mRNA COVID-19 vaccination.

For Ad26.COV2.S – A history of a severe allergic reaction, such as anaphylaxis, to any of its components.

Individuals with a precaution to vaccination, as well as any individual with a history of anaphylaxis that does not result in a contraindication to vaccination, should be monitored for 30 minutes after vaccination. All other recipients should be monitored for 15 minutes.

36. What adverse effects are associated with vaccination?

The more common adverse effects for all vaccine types include local injection site reactions, fever, headache, fatigue, chills, myalgias, and arthralgia. These reactions are more common in younger individuals and after the second dose.

Anaphylaxis is a rare adverse event reported following receipt of mRNA vaccines. In the United States, 21 episodes of anaphylaxis were reported to the CDC after 1,893,360 doses had been administered (11.1 events per one million doses). Anaphylaxis is more common in individuals with a history of allergies.

37. Is there an increased risk of thromboembolism associated with the ChAdOx1 nCoV-19/AZD1222 (AstraZeneca) vaccine? Should this vaccine be avoided?

In March 2021, rare thromboembolic events following vaccination with ChAdOx1 nCoV-19/AZD1222 were investigated by the European Medicines Agency (EMA). The EMA found that the overall rate of thromboembolic disorders was lower than expected for the general population, but that two specific types of events, blood clots in multiple vessels (suggestive of disseminated intravascular coagulation [DIC]) and cerebral venous sinus thrombosis (CVST), occurred more frequently than expected. The EMA concluded that the benefit of ChAdOx1 nCoV-19/AZD1222 outweighs the extremely small possibility of DIC or CVST; vaccine recipients should be aware of the possible association and seek immediate care for symptoms suggestive of thrombocytopenia and/or thrombotic complications. 

38. Can analgesics or antipyretics be taken for side effects following vaccination?

Analgesics or antipyretics (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs] or acetaminophen) can be taken for local or systemic side effects following vaccination. However, pre-emptive use of these agents prior to vaccination is not recommended because of the uncertain impact on immune response to the vaccine. 

39. Can other vaccines be given with COVID-19 vaccine?

No, other vaccines should generally not be administered within 14 days of COVID-19 vaccine administration because there are no data regarding the safety and efficacy of co administration. However, when the benefits of vaccination are deemed to outweigh the uncertain risk of co administration (e.g., tetanus toxoid-containing vaccination as part of wound management, measles vaccination in an outbreak, repeat mRNA COVID-19 vaccination when availability is limited), vaccination within a shorter time frame is reasonable. 

40. What if the second dose of an mRNA vaccine cannot be given because of a prior reaction?

For individuals who received a first dose of an mRNA vaccine but cannot receive either mRNA vaccine for the second dose (e.g., because of contraindications), Ad26.COV2.S can be given as long as there is not also a contraindication to Ad26.COV2.S.

The CDC suggests giving Ad26.COV2.S at least 28 days after the mRNA vaccine dose. Such individuals should be considered to have received a complete AD26.COV2.S vaccine regimen. 

41. Should people who have had SARS-CoV-2 infection be vaccinated? If so, when? What if a patient acquires COVID-19 after the first dose?

Yes, individuals with a history of SARS-CoV-2 infection should be vaccinated. Vaccination can be given as soon as the individual has recovered from acute infection (if symptomatic) and meets criteria for discontinuation of isolation precautions. Pre-vaccination serologic screening is not recommended. If infection is diagnosed after receipt of the first vaccine of a two-dose series (e.g., with the mRNA COVID-19 vaccines), the second dose should still be given.

Delaying vaccination for 90 days from the time of infection is also reasonable; the risk of reinfection during this time period is low, and delaying vaccination allows other people to receive the vaccination sooner. Delaying vaccination for 90 days is also suggested for individuals who were treated with monoclonal antibodies or convalescent plasma.

42. What should I tell patients about donating blood or plasma during the pandemic?

Blood donation is particularly important during the pandemic due to concerns that the supply could become critically low. Having a history of COVID-19 is not an exclusion to donation as long as the illness resolved at least 14 days prior to donation.

Vaccination for COVID-19 is also not a contraindication to blood donation. Individuals who have received an mRNA vaccine or other non-infectious vaccine (nonreplicating, inactivated) can donate immediately; those who have received a live-attenuated viral vaccine (and those who are unsure which vaccine they received) should refrain from donating blood for a short waiting period (e.g., 14 days) after receiving the vaccine.

Persons who have recovered from COVID-19 are encouraged to donate plasma, because convalescent plasma is an investigational treatment for COVID-19. COVID-19 vaccine recipients are not eligible for convalescent plasma donation. 

I did not collect information on care of Hospitalized patients since that is not needed for this posting.

Compiled from Various sources mostly from Up-to-date and posted in public interest.

Tarun Kothari MD, FACG, FACP


What is Liver Cancer?

What is Liver Cancer?

Patient Education: Hepatocellular Carcinoma (Liver Cancer):

What is liver cancer?

Liver cancer happens when normal cells in the liver change into abnormal cells and grow out of control. The liver is a big organ in the upper right side of the belly.

Most people who get liver cancer have long-term liver disease (also called chronic liver disease). Having long-term liver disease increases a person’s chances of getting liver cancer. The most common and most serious form of long-term liver disease is a condition called “cirrhosis,” which scars the liver.

What are the symptoms of liver cancer?

Liver cancer does not usually cause any symptoms of its own. A few patients might have a lump or mild pain in the upper belly, feel full early on when they try to eat, or lose weight.

Others might have symptoms that are caused by the liver disease they had before they got cancer. Those symptoms can get worse or come back because of the cancer. They include:

  • Swelling of the belly or legs
  • The skin or white part of the eyes turning yellow

If you have these symptoms, tell your doctor or nurse.

Is there a test for liver cancer?

Yes. If your doctor suspects you have liver cancer, they will do 1 or more of the following tests:

  • Blood tests
  • Imaging tests: An MRI scan, CT scan, ultrasound, or other imaging test. Imaging tests create pictures of the inside of the body and can show abnormal growths.
  • Biopsy – For this test, a doctor will remove a small sample of tissue from the liver. Another doctor will look at the sample under a microscope to see if it has cancer.

What is liver cancer staging?:

Cancer staging is a way in which doctors find out if a cancer has spread past the layer of tissue where it began and, if so, how far.

How is liver cancer treated?

Liver cancer can be treated in different ways. Treatment depends on the stage of your cancer. It also depends on how healthy your liver is (in other words, how serious your liver disease was before you got cancer). The different treatments include:

  • Surgery – Liver cancer can sometimes be treated with surgery to remove the part of the liver with the cancer.
  • Liver transplant – A liver transplant is a type of surgery in which a doctor replaces a diseased liver with a healthy liver from another person.
  • Ablation therapy – Ablation therapy is a procedure that can kill cancer cells in the liver. It does not involve surgery. Doctors can do ablation therapy in different ways. They can kill the cancer cells using heat, microwaves, a laser, or radiation therapy.
  • Blocking the cancer’s blood supply – Doctors can do a procedure called “embolization” to block off the blood vessel that sends blood to the cancer. This keeps the cancer from growing by “starving” it of its blood supply. Sometimes, the embolization procedure is combined with chemotherapy (“chemoembolization”) or radiation (“radioembolization”).
  • Immunotherapy – This is the term doctors use for medicines that work with the body’s infection-fighting system (the “immune system”) to stop cancer growth.
  • Chemotherapy – Chemotherapy is the medical term for medicines that kill cancer cells or stop them from growing.

What happens after treatment?

After treatment, you will be checked every so often to see if the cancer comes back. Regular follow up tests usually include exams, blood tests, and imaging tests.

You should also watch for the symptoms listed above. Having those symptoms could mean the cancer has come back. Tell your doctor or nurse if you have any symptoms.

If you had a liver transplant, you will need to take medicines called “anti-rejection medicines” for the rest of your life. These medicines help keep your body from reacting badly to your new liver.

What happens if the cancer comes back or spreads?

If the cancer comes back or spreads, your doctor will talk with you about possible treatment choices. These might include the treatments listed above.

What else should I do?

It is important to follow all your doctor’s instructions about visits and tests. It’s also important to talk to your doctor about any side effects or problems you have during treatment. People who have liver cancer, especially if they have long-term liver disease, should avoid alcohol and any drugs that could be harmful to the liver.

Getting treated for liver cancer involves making many choices, such as what treatment to have.

Always let your doctors and nurses know how you feel about a treatment. Any time you are offered a treatment, ask:

  • What are the benefits of this treatment? Is it likely to help me live longer? Will it reduce or prevent symptoms?
  • What are the downsides to this treatment?
  • Are there other options besides this treatment?
  • What happens if I do not have this treatment?

Compiled from UpToDate.

What is Cirrhosis of Liver?

What is Cirrhosis of Liver?

Patient education: Cirrhosis

Cirrhosis is a disease that scars the liver. The liver is a big organ in the upper right side of the belly. Damage to the liver can cause heavy bleeding, swelling, and breathing problems.

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What are the symptoms of Cirrhosis?

Some people with cirrhosis have no symptoms. When symptoms do occur, they can include:

  • Swelling in the belly and legs, and fluid buildup in the lungs
  • Heavy bleeding from blood vessels in the esophagus, the tube that connects the mouth to the stomach
  • Bruising or bleeding easily
  • Trouble breathing
  • Feeling full
  • Feeling tired
  • Trouble getting enough sleep or sleeping too much
  • Yellowing of the skin or whites of the eyes, called jaundice
  • Confusion that can come on suddenly
  • Coma

Cirrhosis also makes it more likely that you will get infections, and it can increase your risk of liver cancer.

What causes cirrhosis?

When something harms the liver, the organ tries to fix itself. In the process, scars form. Causes of liver damage include:

  • Heavy alcohol use – People who abuse alcohol or who are addicted to it are most at risk for cirrhosis.
  • Hepatitis B or hepatitis C – Viruses cause these liver diseases. People can catch the viruses by sharing needles or having sex with people who are infected.
  • Nonalcoholic steatohepatitis (NASH) – People with this condition often don’t drink alcohol. Doctors aren’t sure what causes NASH, but many people who have it are overweight and have diabetes.

Is there a test for cirrhosis?
Yes. Tests include:

  • Biopsy – In this test, a doctor puts a needle into your liver and takes out a small sample of tissue. The sample will show how severe the damage is.
  • Blood tests – Results can show what is causing the disease.
  • Imaging – Your doctor might take pictures of your liver with an ultrasound machine or with a MRI.

Is there anything I can do to prevent further liver damage?

Yes. To help protect your liver:

  • Avoid alcohol
  • Talk to your doctor before you start taking any new medicines, including pain killers such as ibuprofen (sample brand names: Advil, Motrin), naproxen (sample brand name: Aleve), or acetaminophen (sample brand name: Tylenol). Also talk to your doctor before taking any herbs, vitamins, or supplements. Some medicines and supplements can damage the liver.
  • Get vaccinated against hepatitis A and B if you have not had the infections before.

How is cirrhosis treated?:

Treatments depend on the cause of cirrhosis, how severe it is, and what symptoms you have. Treatments fall into a few main categories, including those that:

  • Treat the cause of the disease – Some causes of cirrhosis can be treated. For example, people with cirrhosis caused by alcohol abuse can try to stop drinking. People with chronic hepatitis C or B can take medicines.
  • Lower the risk of bleeding – Cirrhosis can cause the blood vessels around the esophagus to swell or even burst and bleed. To prevent that from happening, doctors can:
  • Prescribe medicines called “beta blockers.” These medicines reduce blood pressure in the liver and help reduce the chance of bleeding.
  • Place tiny bands around the swollen blood vessels (this procedure is called “variceal band ligation”)
  • Decrease fluid buildup in the belly – In people with cirrhosis, the belly sometimes fills with fluid. To decrease fluid buildup, doctors can:
  • Prescribe medicines called “diuretics.” These medicines make you urinate a lot. People who take diuretic medicines often must also reduce the amount of salt they eat.
  • Drain the fluid from your belly using a needle (this procedure is called a “paracentesis”)
  • Implant a device in the liver that reduces fluid buildup in the belly (this procedure is called “TIPS”)
  • Treat or prevent infection – People with cirrhosis have a higher than normal chance of getting infections. When they get an infection, they can also get much sicker than people without cirrhosis. As a result, people with cirrhosis sometimes need antibiotics to either treat or prevent infection. Most people with cirrhosis should also get the flu vaccine and other vaccines to prevent common infections.
  • Treat confusion – Advanced cirrhosis can lead to confusion. Doctors usually use lactulose (a medicine that softens stool) or certain antibiotics to treat the confusion.

Will I need a new liver?

People with severe cirrhosis need a new liver. Talk to your doctor about the surgery before you get too sick, to find out if a liver transplant might be an option for you. People often have to wait for up to 2 years to get a new liver.
Can cirrhosis be prevented?

You can reduce your chances of getting cirrhosis by:

  • Getting help if you have an alcohol problem
  • Getting the vaccines for hepatitis B and hepatitis A, if you haven’t already
  • Using condoms when having sex
  • Not sharing drug needles

Compiled from UpToDate.

Iron Deficiency Anemia

Iron Deficiency Anemia

Patient education: Anemia caused by low iron

What is anemia? Anemia is the term doctors and nurses use when a person has too few red blood cells. Red blood cells are the cells in your blood that carry oxygen. If you have too few red blood cells, your body might not get all the oxygen it needs.

ANEMIA SIGNS AND SYMPTOMS Many people with iron deficiency anemia have no symptoms at all. Of those who do, the most common symptoms include:





●Difficulty exercising (due to shortness of breath, rapid heartbeat)

●Brittle nails

●Sore tongue

●Restless legs syndrome

●Pica (an abnormal craving to eat non-food items, such as clay or dirt, paper products, or cornstarch)

●Pagophagia (an abnormal craving to eat ice)

ANEMIA CAUSES Two common causes of iron deficiency anemia are blood loss (most common) and decreased absorption of iron from food.

Blood loss — The source of blood loss may be obvious, such as in women who have heavy menstrual bleeding or multiple pregnancies, or a person with a known bleeding ulcer. In other cases, the source of the blood loss is not visible, as in someone who has chronic bleeding in their gastrointestinal (GI) tract (stomach, small intestine, colon). This may appear as diarrhea with black, tarry stools, or, if the blood loss is very slow, the stool may appear normal. Donating blood can also cause iron deficiency, especially if it is done on a regular basis.

Decreased iron absorption — Normally, the body absorbs iron from food through the GI tract. If the GI tract is not functioning correctly, as is the case in people with certain conditions such as celiac disease, autoimmune gastritis, other forms of stomach inflammation, gastric bypass surgery (for weight loss), or other forms of weight loss surgery, an inadequate amount of iron may be absorbed, leading to iron deficiency anemia.

Other causes — A common cause of iron deficiency anemia in developing countries is a lack of foods that contain iron. However, this is rarely seen in adults in developed countries such as the United States because many foods contain iron, and others have added iron (breakfast cereal, bread, pasta). Iron is also available in some plant-based foods.

Pregnant and postpartum women may develop iron deficiency anemia because of the increased iron requirements of the growing fetus and placenta and blood loss at the time of delivery.

Is there a test for anemia? Yes, your doctor or nurse can test your blood for anemia. The things they most often check are the “hemoglobin level” and “hematocrit.” These show up on a test called the “complete blood count” or “CBC.”

How is iron deficiency anemia treated? The first step in treatment is to find out whether your anemia is caused by blood loss. If so, your doctor or nurse will want to find out why you are bleeding.

Blood loss can be related to stomach ulcers, bowel problems, or other issues. In women, blood loss can be related to heavy periods.

Whatever the cause of your anemia, your doctor or nurse can treat it by giving you iron. If the anemia is severe, you might need a blood transfusion. You might also need treatment for the cause of the bleeding.

People with iron deficiency anemia need to get iron. Eating foods with iron will not do enough to cure the anemia. You can get extra iron in pills or through a thin tube that goes into a vein, called an “IV.” Most people get it in pills. Your doctor or nurse will tell you how much to take, and for how long.

Iron pills can cause side effects such as upset stomach and constipation (too few bowel movements). If you have side effects, ask your doctor or nurse what to do. They can suggest ways to reduce these side effects or switch you to IV iron.

Adopted from UpToDate

Telemedicine during COVID-19 Pandemic

Telemedicine during COVID-19 Pandemic

Telehealth and its role in coronavirus Pandemic:
Telehealth is the distribution of health-related services and information via electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions.
New York State describes telehealth, for purposes of commercial products, as the use of electronic information and communication technologies by a health care provider to deliver health care services to an insured individual while such individual is located at a different site than where the health care provider is located.
While “telemedicine” has been more commonly used in the past, “telehealth” is a more universal term for the current broad array of applications in the field. Its use crosses most health service disciplines, including dentistry, counseling, physical therapy, and home health, and many other domains. Further, telehealth practice has expanded beyond traditional diagnostic and monitoring activities to include consumer and professional education. A connection exists between health information technology (HIT), health information exchange (HIE), and telehealth.
As our country responds to the unprecedented coronavirus pandemic, CMS is working rapidly to change the way we practice medicine to keep people safe. One critical innovation is the use of telehealth, which allows patients to use smartphones, laptops, and other widely available technologies to connect with your healthcare team.
For the duration of the pandemic, Medicare beneficiaries may now stay at home and use a commonly available interactive form of technology like FaceTime or Skype to have a telehealth office visit.
Some hospitals and practices have online portals available as well, but patients can also simply use their telephone. These developments are a game-changer for new and established patients, as well as their trusted clinicians
Medicare has added more than 80 new services that can be provided via telehealth, such as physical therapy, speech or hearing therapy, radiation treatment management, group psychotherapy, inpatient neonatal and pediatric critical care, and end-stage renal disease services.
During this pandemic, the option for telehealth has now been extended to home health, nursing home visits, and hospice as well. You can even make a “visit” to the emergency room through your phone. Crucially, Medicare copayments can be waived during this national crisis for all these telehealth services.
Telehealth helps doctors and other clinicians as well. It enables healthcare workers to safely work during this pandemic by greatly reducing their risk of exposure to COVID-19. And if they are quarantined, it opens the option of working from home. Telehealth allows them to continue to practice medicine, albeit in a different way, and remain available to their patients.
Moreover, this now-virtual workforce can be deployed to assess and treat patients at a distance, extending a lifeline to millions and providing convenient, continuous management of common chronic conditions like diabetes, hypertension, and more. These clinicians and therapists are helping their patients monitor illness and stay healthy during the COVID-19 pandemic.
Same is true for most of the commercial insurances including BCBS.
Providers will be paid Medicare level fees for telemedicine services even for Medicaid or uninsured patients. Commercial Insurances have already been paying for these services.

Rochester RHIO is committed to provide its services to 14 counties and 1.5 million clients its serves. Providers are able to log on to Explore query portal from their home while providing Telehealth services in these trying times. Federal and state have relaxed HIPPA guidelines for tele health services during COVID-19 pandemic. Rochester RHIO and other HIE in the NY state now are able to accept verbal consent documented in the encounter note as patient consent if provider is not sure that patient consent preexists. This has simplified the patient-provider connection from their respective homes for diagnosis and treatment at the same time maintaining safe distancing. Telehealth is here to stay as patients and providers gain valuable experience. Technology will keep improving and fees paid for the services will be further enhanced. CMS came through for their Medicare and Medicaid patients to allow access to telehealth and providers getting paid for it. Speed of decision and implementation of this program during this Pandemic was astounding. Rochester RHIO patient query portal EXPLORE is available 24/7 for patients, providers, hospitals, health systems, community based organizations, EMS, Nursing homes and from where ever patients and providers are accessing PHI.

Coronavirus: Handwashing Education Flyer by World Health Organization

Coronavirus: Handwashing Education Flyer by World Health Organization

Education * Inform * Protect * Prevent

Many Thanks to Mr.Vinod Luthra for contributing this posting to GUTCHEK

Here are suggestions on how to protect yourselves and the well-being of our residents. The Centers for Disease Control and Prevention (CDC) recommends disinfecting all surfaces, washing hands for 20 seconds or using hand sanitizer, avoid handshakes, and staying home if you are not feeling well and notify a doctor immediately.



Patient education: Coronavirus disease 2019 (COVID-19)

What is COVID-19?:  Coronavirus disease 2019, or “COVID-19,” is an infection caused by a specific virus called SARS-CoV2. It first appeared in late 2019 in the city of Wuhan, China. People with COVID-19 can have fever, cough, and trouble breathing. Problems with breathing happen when the infection affects the lungs and causes pneumonia
Experts are studying this virus and will continue to learn more about it over time.
How is COVID-19 spread?: Experts think COVID-19 first spread to people from animals in China that had the virus. But it can also be spread from person to person, like the flu.
Most cases of COVID-19 are in China. But there have been cases in other countries, too, including the United States. Most of these happened when people got the infection and then traveled to another country. In some cases, the virus then spreads to other people.
What are the symptoms of COVID-19?:  Symptoms usually start a few days after a person is infected with the virus. But in some people it can take even longer for symptoms to appear.
Symptoms can include:
●Trouble breathing
●Feeling tired
●Muscle aches
Some people have no symptoms, or only have mild symptoms. But in other people, COVID-19 can lead to serious problems like pneumonia, not getting enough oxygen, or even death. This is more common in people who have other health problems.
Should I see a doctor or nurse?:  If you have a fever with cough or trouble breathing and might have been exposed to COVID-19, call your doctor or nurse. You might have been exposed if you lived in or visited China in the 14 days before you got sick, or if you have been around a person who has the virus.
If your symptoms are not severe, it is best to call your doctor, nurse, or clinic before you go in. They can tell you what to do and where to go. If you do need to go to the clinic or hospital, you will need to put on a face mask. The staff might also have you wait some place away from other people.
If you are severely ill and need to go to the clinic or hospital right away, you should still call ahead. This way the staff can care for you while taking steps to protect others.
Your doctor or nurse will do an exam and ask about your symptoms. They will also ask questions about where you live, and whether you have had contact with people who might be sick or with animals.
Will I need tests? Yes. If your doctor or nurse suspects you have COVID-19, they will do tests on samples of fluid taken from inside your nose and mouth. They might also test fluid from your lungs, as well as your urine and stool (bowel movements). These tests can all show if you have COVID-19 or another infection.
Your doctor might also order a chest X-ray to check your lungs.
How is COVID-19 treated?:  Many people with COVID-19 have only mild illness and can rest at home until they get better. If you have more severe illness, you might need to stay in the hospital, possibly in the intensive care unit (also called the “ICU”). There is no specific treatment for the infection, but the doctors and nurses in the hospital can monitor and support your breathing and other body functions, and make you as comfortable as possible.
You might need extra oxygen to help you breathe easily. If you are having a very hard time breathing, you might need to be put on a ventilator. This is a machine to help you breathe.
Can COVID-19 be prevented?: There are things you can do to reduce your chances of getting COVID-19.
Some experts recommend avoiding travel to China or other countries where there are a lot of cases of COVID-19. If you do live or travel in one of these areas, try to stay away from people who have any symptoms of the infection. You can also protect yourself by washing your hands with soap and water often. Below are instructions on how to hand washing to prevent spreading illness
1. Wet your hands and put soap on them
2. Rub your hands together for at least 20 seconds. Make sure to clean your wrists, fingernails, and in between your fingers.
3. Rinse your hands
4. Dry your hands with a paper towel that you can throw away
If you are not near a sink, you can use a hand gel to clean your hands. The gels with alcohol in them work the best. But it is better to wash with soap and water if you can wash your hands to prevent spreading illness
You can also lower your risk of infection by avoiding animals and markets that sell animal products. Do not eat raw meat, and do not eat food that might have been in contact with animals without washing, peeling, or boiling it first.
If someone in your home has COVID-19, there are things you can to do protect yourself:
● Keep the sick person away from others – The sick person should stay in a separate room and use a separate bathroom if possible.
● Use face masks – The sick person should wear a face mask when they are in the same room as other people. If you are caring for the sick person, you can also protect yourself by wearing a face mask when you are in the room. This is especially important if the sick person cannot wear a mask.
● Be extra careful around body fluids – If you will be in contact with the sick person’s blood, mucus, or other body fluids, wear a disposable face mask, gown, and gloves. If any body fluids touch your skin, wash your hands with soap right away.
● Clean often – It’s especially important to clean things that are touched a lot. This includes counters, bedside tables, doorknobs, computers, phones, and bathroom surfaces.
● Wash hands – Wash your hands with soap and water often.
As we learn more about this virus, expert recommendations will continue to change. Check with your doctor or public health official to get the most updated information about how to protect yourself.
For more information login: 2.29.20
Watch This Video:

Corona Virus (COVID-19) Comparison with Flu

Corona Virus (COVID-19) Comparison with Flu

Let’s Get Things in Perspective

Influenza and Novel Corona Virus Comparison

There is not a day that goes by that does not have something on the news about the COVID-19 (Coronavirus).  It is scary for some who have family and friends who may have connections with folks on cruise ships, living in China, travel, etc. The number of cases seems astronomical. What is frustrating is that it is a new virus, and we do not know much about it. Let us not forget that the flu is also spreading rapidly.

What we do know for now:

Flu COVID-19 Comments
Mode of Transmission Droplet

(Gown and Mask)

Regular Room


Gown, N-95/PAPR, goggles/Face shield

Negative Pressure if available or private room with door shut and surgical mask on client

Human to human for both

Both are Viral

Incubation period (time to grow and spread 24 hours before symptoms until 24-48 hours temperature free without benefit of Tylenol or aspirin 14 days from exposure. Can spread before symptoms even occur This is why some people returning from China have been placed in Quarantine for 14 days
Symptoms Fever, cough, sore throat, runny or stuffy nose, muscle or body aches, headache, tiredness (diarrhea and vomiting in children) Fever, cough and shortness of breath along with: travel to China, contact with a confirmed COVID-19 person, or having cared for a COVID-19 person with in the last 14 days Symptoms are both similar
Diagnostic Test Nasopharyngeal swab Nasopharyngeal Swab

Oropharyngeal Swab


Blood (Gold top serum separated tube)

Flu testing done in Bath

COVID-19 goes to CDC as directed by the Public Health Department

Treatment Tamiflu or Xofluza

Plus, symptom management

Symptom management
Vaccine  Yes No

If there is a suspected case of the COVID-19 Virus, the local Department of Health  where the patient lives will be notified.  No one who is suspected of COVID-19 will be discharged without a discharge plan from the Health Department.

One must practice good Public Health:

  • If sick… stay away from others, stay home (if you have a cough, sneezing, etc., from a cold, and  you come to work, please wear a mask!!)
  • Cover your mouth when you cough.
  • Keep your hands and fingers away from your eyes, mouth and nose.
  • Wipe down work areas, as well as areas at home (cell phones, tables, door knobs).
  • Eat healthy.
  • Get sleep.
  • Wash your hands.
  • Get a flu shot if you have not already done so. (If you did not get a flu shot, remember masks are available for you to wear.)

Remember, you can help prevent the flu or lessen the effects of the flu with a flu shot. There is no shot for Coronavirus.

So, to keep things in perspective

  Influenza COVID-19 Comments
Number of cases  106,000 + cases in NYS

15, 000,000 USA cases this year

0 cases NYS

19 patients checked outside NYC

6 in NYC

ALL negative with none pending currently.

15 Cases in the US

75,282 (Global for COVID-19)

140,000 people have been hospitalized for flu in the US this year

Number of Deaths 3 Pediatric (in NYS)

(state doesn’t indicate the number of deaths for adults…. but it is there)

12,000 Flu deaths USA this year


2,012 COVID-19 global

61,000 People died from the flu in 2017-18

Adapted from:  VA Newsletter 02/20/20

Happy New Year, 2020

Happy New Year, 2020

Hi Friends,

Dawn of the New Year and new decade is here: Year 2020! Wow, did we imagine 20 years ago when Y2K was a big deal that 20 years would pass by so fast? With so much innovation, new ideas, and so many new medical advances!

I am excited to bring new insights and articles this year, and what I learn I want to pass to you. What I miss is feedback, positive and negative; it does not matter to me. I would like to improve the quality of topics and content of this blog in 2020.

Many times I wonder is it worth continuing the blog if there is no audience?
The medical world is changing so fast that it is hard to keep up with all of the changes and, at the same time, do a fact check. I like to alert my readers only to the topics and contents that are well established and accepted by majority of the medical community.

I am also delighted to report that I have been successful in patient advocacy and guiding folks as to where they can go for care at least in my geographic area of approach. This year, I will like to reach out to more folks and help.

Talk to you soon!