Self-advocacy is one of the best things you can learn to do for yourself (or advocate for your loved one). It can also be one of the most difficult.
I was tired after 9 hours from multiple projects when, pre-coronavirus pandemic, I went to a famous vegetarian restaurant with a person I was going to interview, which also served vegans (of which I am one). I was told they had excellent food (first-rate grub is not at all uncommon for Portland) and we were seated when the server handed us the menus.
My anxiety kicked in when I saw the printed menu. Though the lighting wasn’t dim, the items were too small to read and my double vision went off from fatigue, both of which made for impossible reading.
It was a small place, and I could have asked him to read the menu to me, but it was embarrassing and awkward. I closed the menu as if I read it, and so did my interviewee, motioned the waiter that we were ready to order, and asked the server instead, “I’ll have that dish with tofu,” upon which, being confused about which dish I meant, he rattled off several dishes with tofu, and I chose one.
|Almost the actual size|
Enter OrCam Read (albeit six months later), the magnificent marvel which is five inched long, less than an inch wide, who reads anything to you from the printed page. It is totally portable, and you could zero in to only part of the document, like for a newspaper or read the whole page of a book. I got one on a loan to write this blog post because my heart is with stroke and other brain injury survivors whose after-effects, except for the lucky ones, include visual deficits.
The two founders are: Prof. Amnon Shashua holds the Sachs chair in computer science at the Hebrew University of Jerusalem, and his field of expertise is computer vision and machine learning, and Ziv Aviram who holds a B.Sc. in Industrial Engineering and Management from Ben-Gurion University. They both have a healthy history in safer ways to observe the environment, and that led to OrCam Read.
Impressive indeed. But I wanted more. I sometimes, to this day, have double vision.
The instructions say, “OrCam Read is a personal AI [Artificial Intelligence] -driven device for people who have mild or low vision, reading difficulties, including dyslexia and reading fatigue, and anyone who is consistently exposed to large amounts of text – at work or school, or for leisure.”
Aside from the restaurant where I would have used OrCam Read, it doesn’t need WiFi so no disruptions for pilots on airplanes or captains on ships. One could even use it to read books for enjoyment or serious stuff like final exams. The battery in constant use lasts about four hours.
Not only does OrCam Read have screen selection, but there’s a laser pointer, too, if you want people to read a chart or bullet points during a presentation.
1 year warranty
Oded Tsin, the Business Development Manager for OrCam, said, “Once you press the trigger button, the first button next to the +, the laser guidance will appear. You can keep holding the trigger button and aim toward the script. Once you will release it, the device will capture the image and read to you.
So OrCam Read couldn’t be easier. I tried it a bunch of times with the loaner. I used it to read a book for an hour and it took the stress of double vision out of the mix. I used OrCam Read to read a printed newsletter from Stroke Awareness Oregon and it did a perfect job. I even used OrCam Read to read an invitation to a baby shower! It’s a sure bet that it will work every time.
Now for the cost for which you can pay it out according to your needs: $1990 and it’s not covered by any type of insurance (though it ought to be). Perhaps your organization can buy OrCam Read to share among those with visual deficits.
“A child looked after by seven nannies is without one eye.” Russian Proverb
“Too many cooks spoil the broth.”
On this first week of the new interns, I wanted to share with you about the importance of becoming generalist specialists, and how patients truly benefit from having an astute primary care physician.
As a student, I once worked with a cardiologist who had his own primary care patients. When he first started out his practice, he didn’t had start out in a thriving practice. After several years, his cardiology practice picked up, though there were still some primary care patients that he saw. It was interesting to see that he would refer out many things to other physicians. If the patient had diabetes, he would refer them to an endocrinologist. For routine pap/pelvic examinations, he would refer them to a gynecologist. Some of his patients with have more than three physicians for various needs. He would treat the high blood pressure and atrial fibrillation, but often would focus on these issues over general health concerns during the visits.
After I completed medical school and began residency, I gained a greater appreciation of the importance of a generalist in the care of a person. The medical school I attended had a strong emphasis on primary care for health management. In small town Ohio, where access to specialty medicine meant delays in being seen, these doctors often managed the complete healthcare of their patients. This became the substrate of my growth as a physician toward a training in comprehensive care as an internist.
What would it be like for a person to be seen by different physicians in the emergency medicine department only for more urgent needs? Or to see a doctor for each system without a primary care physician? Do too many physicians hurt the patient’s care?
One way of looking at a primary care physician (PCP) is a collaborator of care. After seeing the same physician for a few visits, a patient is on their way to developing an important bridge into their medical care. The physician may function as a window to understanding how behaviors can be obstacles in health. With the rapport developed, a patient can earnestly describe his or her health concerns to a physician who is aware of the prior medical history, medications, habits, and challenges.
A PCP is the “forest for the trees” specialist – a “generalist” specialist. He/She may have knowledge of a patient’s history that can better assist them in health conditions, with a multi-disciplinary whole-patient approach. As an internist, it was quite common that a patient would schedule an appointment with me to go over the specialist’s recommendations, before they started a prescription. Not only did they want to keep their PCP up-to-date with health issues, they wanted to have me look over the medication options and confirm the plan with them.
A PCP is not a reflexive med-prescriber who renews prescriptions written by prior physicians or other specialists; s/he is not a pain or sleep medication writer without stepping in deeper into the expectation of treatments. A PCP probably should keep the greatest guard for new-patient visits or ER new patient follow-ups, when medications at higher risk of abuse are involved and “doctor shopping” behavior is suggested. This includes checking the controlled substance prescription database and discussing the medication history with their prior provider.
A physician must find a balance of being a collaborator yet not an enabler to someone’s harmful behaviors, including poly-pharmacy. A lot of friction could be prevented, if a patient and physician were to have these conversations in the beginning visits. If ulterior motives exist, the patient may not reschedule a follow-up visit and continue to look for a provider that will prescribe the medication.
One visit format that I would see patients is a “medication renewal” visit. This typically means that they would come in for new prescriptions of the same medications. Yet, they are not the “same” person. Our bodies change as we age, so that medications for a younger age may be potentially more harmful at an older age. Or the patient wants the refills but doesn’t want to talk about the behaviors that are antagonizing the health conditions.
I had a thirty-five year old patient come in once who had a very straight forward request: he needed me to refill his albuterol for his asthma, lipitor for his lipid abnormalities, and zoloft for his depression. This shouldn’t be too long of a visit, I thought.
A deeper dive into his history revealed that his father had had a heart attack in his late forties. He also reports he enjoyed a “good old American habit” of drinking beer nightly, sometimes four to six a night. He was taken aback when I asked further about the habit. He was not aware that the amount of alcohol he consumed could contribute to all three health issues. I pointed out that not addressing the alcohol problem, which would be considered alcohol dependence, would be like trying to put out a fire while there is still a gas leak.
On a second visit, he brought his girlfriend and we performed a health assessment, a blood pressure check, and reviewed his blood tests which were basically normal. He wondered if he should be on blood pressure medications. We talked about the role of the alcohol habit again; she was also concerned. He became defensive and said, “how come you bring this up each visit,” and that he “enjoyed this American past-time.”
He could not or would not acknowledge that his dependence was an obstacle to his health, including his mental health. He straightened it out in his mind by taking three medications.
As a primary care doctor, it was my obligation to discuss these issues with my patients. Along with this comes a review of the purpose of each medication, and placing a hierarchy of importance to them, in the hopes of stopping many of them (check out the poly-pharmacy section). Many medications have side effects and drug interactions, which are not always checked by the prescribing specialist. Some medications may be more harmful than helpful. I have been known to find several medications that are either duplicates or high-risk for harm and toss them in a garbage before the patient leaves (PHI protected bags). The patient reaction is one of both concern and relief.
Another point: since chronic disease is a result of a multi-systemic imbalance, many diseases, for which we have separate treatments, are inter-related. The medications are only producing a side-effect that has an activity toward reducing the severity of the problem, but not without other, less tolerable side-effects. No medication has a guarantee on health that eating a natural diet and keeping an active lifestyle do. There is no greater joy as a physician than to providing health empowerment and seeing a patient improve their health.
Below are some of the potential consequences of having many physicians and how a PCP can mitigate harm and enhance care:
- Multiple prescribers of one or more medications can lead to polypharmacy and drug interactions. One risk factor to over-prescribing is more than one prescriber. I once saw an established patient in the clinic who was prescribed an anti-anxiety medication by a cardiologist. The medication instructions were “off,” and not only was I not a prescriber of benzodiazepines, She was taking a it four times a day “as needed”, and she needed it each time. She became increasingly anxious. These medications can trigger anxiety when dependence develops. She came to see me for a follow-up visit and I discovered that this was prescribed by her specialist. I instructed her of a safe way to come off; and asked the cardiologist if he intended to work with her on this dependence and tapering. To avoid this, collaborative communication is key.
- Lack of integrative care and responsibility. Although a specialist may have prescribed a medication, there are times when patients may find it more challenging to get in to see that specialist and depend on a PCP instead. Without one, there is a bottleneck to getting seen and having more acute issues addressed. It is a common practice that with multiple physicians, there is a greater risk of focused care without tackling the behavior aspects and other risk factors. The PCP serves as the quarterback for the patient’s treatment plans.
- Increased risk of medication and treatment errors. This problem occurs a lot with patients who see urgent care or emergency care doctors for their general health issues, that may become more acute. For instance, a patient that has asthma develops a viral infection and has an exacerbation. Without detailed records of a person’s history and an inappropriate setting to discuss health factors, sometimes a patient may be treated with a “just in case” approach or given a medication without knowledge of underlying health issues. For instance, I saw a patient hospitalized for acute renal failure and delerium after he was given three times his adjusted dose of valacyclovir (used to treat shingles) for his decreased renal function. The doctor prescribed the usual dose for the condition, but, in this patient, it quickly reached toxic levels in his body.
I hope that this encourages you to enjoy the doctor-patient relationship, whichever side you are on. There are so many important benefits of having a health coach as a physician, one that will not only help you along your rough patches of disease but one that will help you find your way to health.
Please share this article if you found this useful, and stay tuned for future posts on Perspectives in Medicine.
“There are, in truth, no specialties in medicine, since to know fully many of the most important disease a (person) must be familiar with their manifestations in many organs. Sir William Osler.
Did you know that we more bacteria on and in us than we have cells that make up our body? Estimates of bacteria to human cell ratio varies from 1:1 to 10:1. Our bodies are a chimera of human and bacteria. Just in the digestive system alone, or the “Big Colon” there are 100 trillion bacteria populating it. One teaspoon of stool outnumbers the stars in the Milky Way Galaxy.
The microbiome helps our body in more ways than we realize. Our bodies have adapted to this internal and external environment that abuts our cell lining. The microbiome has earned a designation of “honorable organ,” with its weight of 2-6 lbs. Other important organs weigh about the same (LIKE THE BRAIN!).
Meike (MI-KAY) is a microbial journalist reporting the events that occur in and on our body. She introduces children to a universe of bacteria on each and every one of us. She explains what are factors that promote harmony and how bacteria can cause infection. She introduces children to the microbiome in each of the systems of the body.
Children will familiarize themselves with the microbiome and some of the ways that bacteria grow. The story will open their eyes to how our health affects our microbiome and how we can be stewards of it. The book has a few fun features in it, that I am sure kids will love, including cute bacterial caricatures and artwork, a gallery of the microbiome bunch, and a sneak peak of the sequel, which I am sure will leave your child fascinated.
About the Authors:
The book was written by Christopher Cirino and Alicia Scheffer-Wong, a long-time frined and colleague. Back in college, we were microbiology majors and lab-rates together. I am grateful to have collaborated with her on this. Already decades in our careers, I am an infectious diseases specialist and Founder of Your Health Forum and Alicia is an entrepreneur and microbiome expert (POOP!) with her company Floragraph Inc.
Please support our cause to make microbiology exciting (we already know that it is important!) and accessible to children and adults alike.
The book can be purchased on Amazon either in a Kindle Ebook ($6) or paperback ($9).
PICK UP YOUR COPY!!!
As an OT I did not know how tiring a.m. care is because I never watched a stroke survivor do one task after. Here is why bathing leaves me feeling refreshed instead of exhausted and frustrated.
Washing. I do not struggle to soap up a washcloth one-handed or chase a bar of soap after I drop it. I pour shower gel on a nylon poof and knead it a few times to get it soapy. To wash my sound arm, I use a gross grasp in my affected hand to hold the nylon poof. I do not struggle to wring out a washcloth one-handed. I hang the nylon poof on a suction-cup hook, hose it down, and let it air dry. I use shampoo suds to wash my face.
I press down on the nylon poof that is resting on my thighs to squeeze out suds so my sound hand can soap up my crotch. Before I could hold the shower hose with my hemiplegic hand,
I used my forearm to press the shower hose against my stomach to rinse my crotch. Water runs downhill. This freed my sound hand to deal with the nooks and crannies. If my husband was alive I would still want to bathe this private part of my body.
Drying. My towel rack is next to the shower so I can reach it while sitting on my shower chair. I drape the towel over one shoulder while I dry my arms and trunk. When I get out of the shower I stand to dry my crotch with the towel draped over my shoulder. My shoulder carries the weight of the towel so it is easy for my sound hand to manipulate the free end. I never hold up my affected leg to dry it. I don a terrycloth bathrobe which dries my buttocks and thighs and I let my calves air dry while I brush my teeth and comb my hair.
Dressing. For the 1st year after my stroke, dressing was easier if I rested after bathing. I laid on the bed in my bathrobe with a towel under my wet hair and listened to music on the radio. homeafterstroke.blogspot.com
I have been reading e-books on Hoopla to pass the time while sitting at home during the covid-19 pandemic. I recently reread My Antonia by Willa Cather. This book brought back fond childhood memories of my father driving across Illinois and Iowa to visit my grandparents before there were interstate highways. State highways built before World War II wove through miles of wheat fields that moved in the wind like ocean swells. When we came to an intersection we could see cars for miles in all directions because the land is so flat. One of Cather’s characters described the land this way – “I wanted to walk straight through the red grass and over the edge of the world which
could not be far away.”
When I moved east to New Jersey I freaked out for years when I drove on narrow state and county roads with sharp curves. Not being able to see on-coming traffic around a bend was unnerving. For years I also missed seeing the horizon at sunset. I have gotten used to the closed-in landscape of the densely populated east coast, but the open vistas of the middle-west still thrill me.
I am grateful that a stunning writer who won a Pulitzer Prize helped me reconnect home and
happy memories. homeafterstroke.blogspot.com
Currently over 4,700 covid-19 deaths in New Jersey have occured in long-term-care facilities so
I am very motivated to do what it takes to stay in my home. For example, my cleaning lady has not come for 6 weeks because of the pandemic. When I smelled dust and started to sneeze I felt compelled to try vacuuming until it is safe for Isabel to be in my home for two hours.
I vacuumed years ago so I already knew 2 tricks. (1) Vacuuming is exhausting because it requires stepping forwards and backwards abruptly a hundred times so I vacuum only one room a day.
(2) I knew tripping on the cord was a huge fall hazard. Thankfully I can hold the cord out of my way. I rest the cord in my partially curled hemiplegic fingers and use shoulder abduction to hold the cord away from my body.
I discovered 2 new tricks to make vacuuming easier. (3) I do not step forwards and backwards.
I stand still and move the vacuum forward and backwards only one arm’s length. Then I take two steps sideways to clean a two-vacuum wide path before moving forward. Most of my falls have happened when I step backwards but I feel stable when I step sideways. (4) Instead of vacuuming in parallel rows the way people cut grass, I start by vacuuming around the perimeter of the room and gradually work towards the center. Making 90 degree turns is easier than 180 degree turns. homeafterstroke.blogspot.com
Summary: The COVID-19 Pandemic is an unprecedented event that requires a rift in the societal fabric in order to stop its spread. This forced isolation, along with the threats on financial and health security, can create pressures on those already with a history of depression and anxiety and lead to challenges in those that don’t.
Here are seven tips to nurture your mental wellness and create resilience during this uncertain time of social distancing. Not only will these strategies help you to maintain some normalcy through these times, they just might help you excel.
The COVID-19 pandemic has been responsible for widespread upheaval. Literally overnight, we have been asked to change our behaviors, stay at home other than essential trips out, and wait for this pandemic to pass. Trips, social events, religious gatherings, and restaurants have been canceled or closed. We have been asked to work from home and hold teleconferences instead of physical meetings. For many of us, these are the very ways that we define our social and support network.
Constant reporting of new case numbers and new virus-related deaths has been both emotionally distressing and overwhelming throughout the world. When paired with shelter-in-place orders and the inevitable time spent confined at home, this unprecedented global event has placed tremendous stress on some of the population’s most vulnerable. Current events are making it harder for everyone to protect and promote mental health. Absent of key resources and often unable to receive the same support and social engagement that’s typical of their daily lives, those with diagnosed and chronic mental health issues are finding themselves in an increasingly dangerous space. The good news is that even in times like these, there are still multiple ways to create the conditions for resilient mental health.
Who’s At Greatest Risk Of Experiencing Mental Health Issues During The COVID-19 Pandemic?
Right now and for the foreseeable future, everyone is at risk of experiencing deep depression, anxiety, and stress. So much of what’s going on in the world is impossible for people to control. This sense of helplessness invariably fosters feelings of hopelessness, even in many who have formerly enjoyed consistently good mental health, general mood balance, and overall high life qualities.
However, there is also a very large number of people who are especially prone to mental distress at this time. This includes people who by choice or by circumstance were already spending significant amounts of time alone and in virtual isolation such as: elderly adults with age-related mobility issues, those with agoraphobia or fear of leaving the home, and disabled individuals who largely live in confinement. Those at greater risk for mental and emotional distress at this time additionally include people who are presently battling drug or alcohol addiction, those who have dealt with substance abuse or addiction in the past, recent divorcees, widowers, those grieving close friends, and those with a history of trauma and who may also be living with post-traumatic stress disorder.
Stressors to Mental Health During Quarantine:
A recent review article from Lancet by Samantha Brooks et al. entitled The psychological impacts of quarantine and how to reduce it discussed several risk factors that provoked a greater risk of mental health issues. It is with hopes that identifying the triggers to depression and anxiety can help us to construct ways to mitigate these risks.
- Longer duration quarantine (>10 days) or duration uncertain: Associated with poorer mental health, e.g. PTSD, avoidance behavior and anger.
- Fears of Infection. In one review, those who were concerned tended to be parents with young children or pregnant women.
- Frustration and Boredom. A change in usual behavior even routine things like shopping or social networking can create a sense of boredom and isolation.
- Inadequate Supplies Concerns. This includes the ability to get regular medical care and prescriptions.
- Inadequate Information. In studies, participants raised the greatest concerns when there was unclear messaging from public health authorities or a concern for lack of transparency. Some concern with adhering with quarantine protocols was a predictor of post-traumatic stress disorder in one study.
- Financial Factors. Many people have been asked to modify their work routines such as working from home and, in certain cases, have even lost their jobs. Those with a lower financial safety net, such as those with high debt to income burden, are particularly at risk.
The seven simple strategies that follow can benefit anyone who’s feeling the pressure of world and economic events, and who’s struggling to maintain mental health in the face of prolonged and mandated social distancing and social isolation.
- Get Outside And Get Moving
Most shelter-in-place orders that are presently being enforced are not intended to prevent people from going outside entirely. Instead, these orders have been designed to limit gatherings and activities that bring large numbers of people together. Moreover, in addition to not restricting solitary outside activities, or outside activities involving two people or fewer, many of these orders have been issued by municipal bodies that are actively encouraging people to get outside and exercise. The general understanding is that too much time spent indoors and leading a highly sedentary lifestyle is not beneficial for anyone at any time.
Pick a time each day to get outside and get moving. This can be as simple as taking a short walk around your neighborhood or going for a ride on your bike during the early morning hours or late afternoon. Although there are fewer recreational areas still open for enjoyment, there is also far less traffic on the streets. You can use this as an opportunity to better appreciate your neighborhood without the hustle and bustle of moving vehicles and busy consumers.
A short walk or bike ride will lift your spirits and give you the opportunity to re-center your thoughts. It can also make you feel more connected to the world around you. Outside exercise can even be as simple as taking your yoga mat out into the yard or onto a patio or balcony. It might be a good time to get outside to a local park and practice the calming art of Shinrin-yoku, or forest bathing. In addition to benefiting from conscious and structured movement, you’ll have the benefit of fresh air, sunlight, and a restored sense of normalcy.
- Continue Interacting With Others Via Social Media And Other Online Platforms
Now is a great time to start making use of social networking platforms. If you haven’t leveraged them before, these are great spaces for reconnecting with distant family members, childhood friends that you’ve lost contact with, and loved ones that you normally communicate with in other ways. Video chat platforms such as Skype can give you the benefit of both speaking to and seeing the people who normally fill your life, and who provide you with the social stimulation and engagement that’s absolutely essential for maintaining good mental health.
- Brighten Each Day With Exploration, New Learning, And Other Enriching Activities
For many, the COVID-19 pandemic has provided a very bittersweet silver-lining; massive amounts of free time. For those who are no longer working or having to physically commute long distances to their jobs, as well as those who are no longer attending in-person classes at school, this event offers countless opportunities to engage in new forms of learning and exploration. If you’ve ever wanted to make your own sourdough starter, crochet a blanket for a brand new or aging family member, teach yourself a new language, or pick up the cello, piano, or guitar, now is a great time to do it. These activities are personally enriching. More importantly, efforts to promote personal growth often give people greater hope for the future.
- Engage In Art Therapy
Now is also a time to break out your adult coloring books, or, better yet, start with a tabula rasa mentality and create your own work. Art is one of the most therapeutic activities that you can engage in. It’s immersive, cathartic, and relaxing. When you’re focused on drawing or coloring in the lines, choosing complementary colors, and achieving a very specific aesthetic, you cannot simultaneously dwell on all the outside problems that are beyond your realm of control. Creating art in any form can be both meditative and restorative. This is additionally a good time for art appreciation. Take advantage of online museum tours, free or discounted art or cooking classes, and other arts-related resources. Use online videos to start practicing and exploring martial arts, or start reading and writing poetry. Keeping a journal is also a great way to begin organizing your thoughts, analyzing your own emotions, and venting about your personal discomfort among other things. If you ever dreamed of writing your memoirs, the present moment is offering the perfect opportunity.
For those of you interested in using this form of expression and participating in an ongoing exhibition of art inspired by these current times, see the art that is posted on Instagram Hashtag #Cov19_art. I would like to compile the art, poetry, photography and writing into book that documents the psyche of these times and celebrates our perseverance.
- Unplug And Unwind
For all the resources, information, and assistance that the Internet is able to provide during this crisis, it can be just as harmful as it is beneficial. This is especially true when people spend too much time on the web, and when they spend too much time immersing themselves in activities and ideas that foster stress. While staying informed is vital, you must limit the amount of news that you’re reading. Nothing is currently so dire that it requires minute-by-minute updates. Set a special time for logging in and gathering essential information from trusted news sources. Then, set a special time for turning your phone off, logging off your computer, and turning off your TV. Whether you have diagnosed mental health issues or believe yourself to be in excellent mental health, too much information can lead to overload and can leave you feeling deflated, detached, depressed, or excessively anxious.
- Make Sure That You’re Getting Enough Quality Sleep
Getting poor-quality or insufficient sleep at this time is a bad idea. Not only will this undermine your efforts to maintain good mental health, but it can also lead to a flagging immune system. If you had a nighttime ritual before, try to stick to it. Moreover, don’t try to mute your emotions or lull yourself to sleep with increased indulgence in alcohol. Some areas under quarantine are reporting as much as a 40 percent increase in alcohol consumption since the institution of stay-at-home orders. Rather than promoting good sleep, alcohol actually reduces overall sleep quality, and shortens the amount of time that people are able to remain asleep.
Try reading a book or meditating before going to bed, taking a warm shower, and turning off all electronics and Internet-connected devices. If necessary, sip a warm cup of chamomile tea or a large mug of warm milk and honey. Making deep and restful sleep a top-priority is one the best things that you can do to promote physical and mental health at this time.
- Practice Mindfulness And Conscious Directing Of Your Thoughts
No other world event has highlighted the value and importance of mindfulness than the COVID-19 pandemic. With so much going on around you, it can be difficult to not let feelings of anxiety and panic set in. There is enough fear and stress in the present movement to exhaust anyone’s ability to mentally process current world circumstances. As such, there is no need, reason, or benefits in worrying about possible problems that might lie far ahead in the future. Practice focusing on the moment. Enjoy what you have you right now and work on fostering a mindset of gratitude. If you’re tired of being stuck alone at home, remind yourself that there are some people who have no homes to take shelter in. Give yourself permission to only worry about and deal with the problems that you’re immediately facing. Practicing mindfulness can help alleviate negative emotions about past events, while also limiting anxiety about what the future might hold.
The state of your mental health should be a key concern right now. Actively promoting good mental health and proactively protecting your general sense of well-being is critical. With greater mood balance, proper stress management techniques, and a focus on enriching and expanding yourself, you can successfully survive the mental and emotional ravages of this global pandemic, and any other unexpected life events.
Key Points Answered in this Article
1. What constitutes a spillover?
2. What are the contributing factors?
3. How does SARS-CoV-2 cause infection in human pneumocytes
4. What are the contributing factors to more severe disease.
The United States prepares itself for the impact of COVID-19 that will likely be unprecedented. Although we can say that most people who become infected will have a milder disease, we cannot always predict who is at greater risk for a severe outcome. Particular attention goes to healthcare workers, lower-income communities, and people with advanced age and chronic health conditions. To those unfortunate ones who develop severe disease and require hospitalization, the US health system faces shortages of ventilators, personal protective equipment (PPE), bedspace and the even the healthcare workers to attend to them. Worst-case scenarios project hospitals to become flooded with those who have severe disease, particularly if cases were to occur with the same momentum as Italy or China. The hope is that through the social distancing measures recently implemented, we may be able to blunt the outbreak peak and prevent overburdening our healthcare system.
The general audience has had access to many resources on COVID-19, such as the CDC, WHO, health blogs, video posts, and primary literature. As we face this outbreak, never before has the nation’s working knowledge of viral infections been greater. Since the outbreak was declared in December, we have had three months to learn more about this virus.
This post will go one step further into understanding the contributing factors to a viral emergence and how this likely is not the last outbreak we will have in the coming years. What happens when a virus infects our bodies? What occurs inside that leads to a certain presentation of a disease state? Although COVID-19 is shrouded in mystery, it adheres to natural rules, many of which we still need to define. The mechanism by which a pathogen causes an infection is a clue to how it can be defeated.
Viruses are Host and Cell-specific, until they cross species.
Viruses are intracellular pathogens that are species- and cell-specific. This means that they are usually only capable of infecting one animal. Though there may be some fluidity to this concept. A virus can reside in an animal, whether it is actively infecting the animal or not. An animal virus is called a zoonotic virus, and the animal carrying it is a reservoir. In viral zoonotic spread, mammals (e.g. bats, primates, etc) are the most common reservoir followed by birds. When the conditions are right and several barriers are able to be breached, viruses can jump species, infecting other animals including humans. The process by which a virus jumps species and causes human infection is termed a spillover, an example of which is our current COVID-19 pandemic.
Over 75% of new or emerging diseases originate from animals. From 1940 to 2004,Jones et al. (2008) determined that there were a total of 335 emerged diseases, 60% originating from animals. In most outbreaks, human behaviors shaped the conditions that made it possible. The principal factor relates to human encroachment into animal habitats. It is no coincidence that an acceleration of outbreak has occurred in the last sixty years (fourfold increase) in the setting of a massive population boom. Eerily, a Times article describing spillovers written in May 2017 was entitled The World is Not Ready for the Next Pandemic.
“We cut the trees; we kill the animals or cage them and send them to markets. We disrupt ecosystems, and we shake viruses loose from their natural hosts. When that happens, they need a new host. Often, we are it.” David Quammen, author of Spillover: Animal Infections and the Next Pandemic writing in New York Times.
From the 1800’s, it took approximately 127 years for the population to increase by one billion, i.e. from one to two billion, an achievement that only took thirteen year intervals over the last several decades to achieve 7 billion. The population growth may be a driving force for disputes over settlements, habitat invasion, the use of exotic animals as a food source in the setting of growing food insecurity, or the trade and introduction of exotic animals to be used as products or pets. Certain features directly related to the virus, including mutations, deletions and recombination, enable the virus to survive and then flourish within an introduced animal.
Adapted form Nat Rev Microbiol. 2017; 15(8): 502–510.doi: 10.1038/nrmicro.2017.45
Ingredients for a Spillover Event.
Although outbreaks are infrequent events, current conditions may allow for an increased risk. For a virus to jump species from an animal reservoir to to human to human spread, usually several conditions would need to be met. First, animals infected with a virus need to be stable and have persistent shedding of virus, while not succumbing to it. Second, the animals would need to be in close proximity to humans. Next, an exchange of infected fluids, such as saliva, mucus, feces or blood, or the ingestion of an animal allows for a sufficient amount of virus to be introduced into the new animal by its usual infection route. While inside the human, some of the virus must possess a specific (enough) receptor mutation to allow for avidity (or connection) of the virus to a host receptor to gain entry into the specific cell. Finally, it must be able to propagate and infect other cells, without being identified and neutralized by the host’s innate immunity. Once it is able to survive and replicate within the human host, it must be able to be transmitted from one human to another. If any of these conditions are not sustained, a spillover does not occur.
From the “Street Light Diagram,” yellow (level 2) is intended to connote caution. Red (level 3) indicates higher risk of pandemic potential, but certain viral and non-viral kinetics (e.g. population density, behaviors) prevent easy transmission. These factors influence the basic reproductive number (Ro), with an Ro of greater than one to allow for risk of exponential growth. The black (level 4) designation is related to epidemic spread. For a detailed list of RNA viruses that are recognized as causing infections in humans and their respective levels, refer to Woolhouse M. et al (list).
Of particular concern are the 180 and counting (2 newly identified per year) RNA viruses capable of infecting humans, the majority (89%) of which are zoonotic. Examples of recent RNA viruses that have emerged include HIV, influenza virus, NIPAH virus and the Coronaviruses SARS, MERS and SARS-CoV-2. RNA viruses may more easily jump species, because of their tendency to mutate and adapt more easily when introduced. Not all RNA pathogens that cause infection in humans from animals are capable of being spread from human to humans. The majority of zoonotic RNA viruses are restricted to level 2 (approx 107 out of 180 species). An example of this would be avian influenza (H5, N2 or H9, N2), which does readily not cause human-to-human transmission. It may be related to the cell type infected, the sialic acid receptor, which is in the upper respiratory tract of poultry and lower in humans. This is fortunate because it has an estimated case fatality rate of 14-30%. Level 3 spread is seen only in about 73 species and spread is limited in 26 of these RNA viruses. The remainder (47 Level 4 RNA viruses) can spread human to human, causing epidemics..
Very rarely, a virus may already be able to adapt to a human and lead to an outbreak, termed “off-the-shelf” viruses. More likely, viruses eventually adapt from repeated animal to human transmission and evolve to be more transmissable between humans (Level 3 to Level 4). HIV probably crossed over from chimpanzees to humans in what is now the Democratic Republic of the Congo in the 1920’s, possibly from hunters who ate “bush meat” or had cuts and wounds contaminated with chimpanzee blood infected with Simian immunodeficiency virus (SIV), a milder disease which does not alter the lifespan of the infected animal. The ability of HIV to cause a prolonged infection and be transmitted via various routes including bloodborne and sexually enabled it to become a level 4 pathogen and reach global transmission.
The SARS-CoV-2 emerged likely from bats with the possiblity of a secondary animal reservoir the pangolin. Bats are known carriers of coronaviruses and have been determined to be the likely reservois for SARS and MERS. Andersen et al. published a recent correspondence entitled the proximal origin of SARS-CoV-2. The authors discusss several possible and contributing scenarios. On account of a 96% identical genome with a sampled bat coronavirus, bats were likely the original reservoir of SARS-CoV-2. However, SARS-CoV-2 may have evolved the protein stucture of the S-spike to allow for better binding to human ACE2 receptors from pangolin through natural selection. It is possible that a polybasic cleavage site (necessary for cell-cell fusion) may have evolved after being introduced into humans.
From Spillover to Infection and Disease
When COVID-19 emerged from an animal source and was capable of human to human transmission, humans had no prior memory of this virus. The immune system was caught off-guard with minimal defense. As a virus infects cells and increases its numbers in the host, the disease develops, a time when a person presents with signs and symptoms. Even in the setting of a novel virus, most of the way a disease manifests is due to the host inflammatory response and not because of a distinct genetics, appearances (e.g. receptor sites) and other characteristics of a virus.
A virus is an obligatory intracellular pathogen, meaning it can only thrive within cells. A specific virus infects a specific type of cell. Hepatitis C virus infects hepatocytes; BK virus infects the transitional cells of the bladder; influenza virus and coronaviruses infect type I and type II pneumocytes in the respiratory tract; HIV infects CD4 lymphocytes and Langhans cells. The specificity of cell-type is not accidental and relates to a lock-and-key mechanism that a virus has with the cell it infects. Think of it as a parasite requiring the mechanics of the host to build more copies of itself. It enters the lining of the respiratory tract and attaches onto cells by means of a receptor interaction. Specifically, this is between an outer membrane receptor of the virus (Spike glycoprotein (S)) and a receptor(s) on the host cell. The virus then enters the cell by a process known as endocytosis.
Upon entry, the virus hijacks the cell’s ability to read nucleic acids and produce proteins. COVID-19 is a positive strand RNA virus, with the viral RNA serving as a messenger RNA, leading to the production of hundreds of copies of virus RNA and proteins in a single cell (known as replication). These copies self-assemble and form multiple viruses, or progeny. This results in stress on the cell and cause changes in the cell membrane (membrane rearrangements), damages the infected cell, and go on to infect other cells.
The extent to which a virus can infect cells in known as its pathogenicity. The speed at which a virus can spread through the body and infect other cells is known as the virus lifecycle. In the case of viruses, typically thousands of copies can be generated in a period of a day and lead to significant inflammatory changes in the body as a response to infection.
ACE2 as a SARS-CoV-2 receptor
The S receptor on the SARS-CoV-2 binds to a specific receptor that lines the cells of the lung tissue, as well as heart kidney, endothelium (the inner lining of blood vessels) and the intestines, known as the Angiotensin-converting enzyme 2 (ACE2) receptor. This interaction is a required step for viral entry into the cell. Using a mouse model, an increased expression of the ACE2 receptor allowed for more viral entry into the cells and resulted in greater disease severity. Further studies will have to sort out the speculation that medications such as ACE inhibitors, Angiotensin receptor blockers (ARBs), ibuprofen, or thiazolidinediones, all of which upregulate ACE2 receptors would potentially worsen COVID-19 disease. As for now, it does not appear to be the case. In the realm of vaccine and therapy options, it remains to be seen if blocking these receptors, for instance through antibody therapies, or providing a vaccine that triggers antibodies to the S receptor would alter pathogenesis of the virus.
How does our immune system recognize these invaders?
The evolution of the immune system occurred in the face of the continuous onslaught of microbes from the environment.The human immune system consists of innate and adaptive immunity.
Innate Immune System
The innate immune system is the first branch to respond to a viral assault. The components of the innate immune system include cells, such as natural killer cells, dendritic cells, monocytes and neutrophils, and complement proteins. The innate system senses changes that occur to the cell from viral products and cell damage (Pattern Recognition Receptors). This triggers the release of interferons (IFN), which promote inflammation (activate molecules known as cytokines) and reduce virus replication. The cytokines signal special cells, known as natural killer and dendritic cells, which destroy infected host cells to reduce the spread of the viral infection. The PRRs also trigger a process known as autophagy, in which an infected cell degrades itself to reduce (or the intent to reduce) further infection.
The complement system consists of several proteins that form a complex, leading to cell breakdown (lysis). They can also signal certain cells such as activated macrophages to engulf infected cells, a process known as opsonization.
Adaptive Immune System
Adaptive immunity requires antibody production and cell-mediated mechanisms. Some natural antibodies may already be circulating for a given virus that can provide some initial immunity (known as IgM class antibodies). These are generated by antibody-producing white blood cells known as B cells. Otherwise specific cells known as Activated macrophages can engulf cells to produce antigen that express more pathogen-specific antibodies by B cells. The dominant antibody types in humans are IgM, IgD, IgG, IgA, and IgE, each of which has specific roles in the immune response. The IgG is involved in the memory responses and form to neutralize a virus.
Another white blood cell line, known as T lymphocytes (T cells), are produced in a small gland known as the thymus, which is inside the front part of the chest (behind the sternum and in between the lungs). These T cells provide cell-mediated immunity. Specific cells are produced that have receptors for a given pathogen and can neutralize them.
From Infection to Disease
When a person becomes infected with a virus or bacteria, there is a period of time at which s/he is symptomatic. The term that is used from onset of the infection and expression of the disease is known as incubation period. Various viral infections have different incubation periods. For instance, influenza’s incubation period is one to four days; COVID-19 may take one to fourteen days (average of 6) to show symptoms. During the prodromal phase, the person develops early symptoms of a viral disease. This could be the beginning of nasal congestion, sore throat, cough and tiredness. After a threshold is reached and enough cells become infected, a more sizable inflammatory response is generated. It is at this time, the person becomes symptomatic.
During the invasive phase, the number of circulating virus intensifies, while the body responds to the infection with a maelstrom of inflammatory markers. The severity of the presentation correlates to the intensity of infection and the inflammatory response. Eventually, the inflammation subsides as neutralization of the virus as a result of the immune system. It is at this point that a person’s symptoms gradually resolve.
Viral Disease: It’s all about inflammation
In approximately 80-85% of those infected with SARS-CoV-2, only a mild disease is seen. In the remaining, a severe infection can lead to hypoxia (low oxygen levels) and need for mechanical ventilation. Owing to increased cellular damage, the subsequent inflammatory response may pose a threat on life.
Risk Factors: In a study of clinical course and risk factors for mortality in COVID-19, risk factors were identified in almost half of the patients, with hypertension, diabetes and coronary heart disease. Smoking likely leads to a two-fold risk of more severe disease than a non-smoker. Advanced age is also a significant mortality risk. From the Wuhan epicenter data: 80+ years, 14.8%; 70-79 years, 8%; 60-69 years, 3.6%; 50-59 years 1.3%. This is likely on account of dysfunctional innate immunity, IL-2 signaling (not down-regulating) and T-cell mediated immune system with aging. What still remains unknown for COVID-19 infection is whether there exist genetic determinants (as seen in other viral diseases) that lead to a greater risk of a more severe infections. This could explain why we are hearing reports of severe disease in the “otherwise healthy” youth.
Pathogenecity and Inflammation Contribute to Disease Manifestations. The extent to which someone presents with more severe disease relates to an interaction of amount of cell destruction from viral burden and host response. Below is a depiction of the contributing effects of Viral Pathogenicity and Host Inflammatory Response in disease. Increased viral infection burden is likely an important contributor to a greater immune response. It may be that type 2 pneumocyte infection in the lower respiratory tract may cause a greater cytokine release than infection in upper respiratory cells.
The most common symptoms on admission were fever and cough, sometimes with sputum production and fatigue. Interestingly, the average time of presentation of respiratory complaints, such as shortness of breath, is approximately 7 days and need for invasive ventilation is 14.5 days (range 12-19 days), suggesting that the latter part of infection may be when greater inflammation develops “cytokine storm”. The most frequently observed complication was sepsis, followed by respiratory failure, ARDS, heart failure and septic shock.
**The shortness of breath (“Dyspnea” in blue) started around day 7 in both groups**
Laboratory Findings for Hospital Management
There is a significant inflammatory response in more severe infections of COVID-19. Patients may develop ARDS, which is the leading cause of mortality. Several findings of the disease support a hypercytokine, hyperinflammatory response that contribute to a more severe presentation. These patients have a persistent fever, low white blood cell count, elevated cytokines (IL-2, IL-7, IL-6, GM-CSF, Interferon gamma and others), an elevated ferritin, and an elevated D-dimer.
In an unprecedented move, the FDA has granted emergency authorization for the use of hydroxychloroquine along with azithromycin based on early clinical data that there may be a benefit of hydroxychloroquine in reducing viral load and inflammatory state. We await further progress in other therapeutics and vaccine trials, many of which are now underway.
The COVID-19 outbreak was a spillover event of a novel coronavirus from an animal reservoir that led human to human transmission. Further research is required to understanding the way the infection can lead to various disease manifestations, including who may be susceptible to more severe presentations. Hydroxychloroquine along with azithromycin may provide some benefit in treating those with severe disease. As for now, we await for the results on the treatment and vaccination fronts.
References are embedded in the Text
Simon A, Hollander G, McMichael A. Evolution of the immune systen in humans from infancy to old age. Proceedings of the Royal Society B. 22 Dec 2015.
Zhou F, Yu T, Du R, Fan, G, Liu Y, Liu Z et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. Vol 395, issue 10229, p 1054-1062. 28 Mar 2020.
These strategies are related to my daily routine. They are examples of what stroke survivors can do to protect themselves. Your risk of catching the corona virus is probably different from mine but I think we can agree that a stroke creates enough drama for a lifetime.
Washing hands with the backwards rule: With the soap dispenser facing away from me, I push down on the nozzle with my palm and catch soap with my fingers. After I scrub my hands, I run my soapy thumb over the top of the handle before I rinse. I started washing my hands this way years ago when I handled raw chicken. I did not want to leave chicken fluids on the bar of soap and soap dish.
Paying: Many infected people do not cough so the rapid spread of the corona virus cannot be explained by lots of people spraying germs in the air. We do not know how long the corona virus lives on environmental surfaces. For now I pay with a credit card instead of handling coins that hundreds of people have touched. It is cold enough to wear a coat so I put this credit card in my coat pocket rather than dig through my purse to find it.
Shopping cart: It is easier to push and steer a shopping cart with both hands. However, physical exertion makes my hemiplegic thumb bend fully so I don a piece of foam to stop my thumb nail from cutting into my skin. I use a Kleenex tissue to take the foam off when I get in the car and then I isolate it in a special location.
Handles and keys: Some people wipe the handle of a cart before they start shopping. This does not protect them when they touch cans and boxes touched by employees who stock the shelves.
We do not know how long the corona virus lives on environmental surfaces. I currently have 2 cuts on my sound fingers so before I get out of the car I don a thin vinyl glove used by beauticians. It is one size too large so it is easier to don. I remove the glove after I get the cart to my car. My sound hand is clean when I open the car door, pull my car key out of my purse (green wrist band), and put my hand on the gear shift handle and steering wheel. I throw the glove in a bag in my car. My sound hand is clean when I pull out my house key (purple band) and open my front door. I wash both hands when I get inside.
Touch screens: Before the corona virus I refused to use a filthy touch screen to order a meal and then pick up food with my sound hand. Ordering in person is slower but safer as long as I use a napkin to handle the menu which is never washed. If a transaction forces me to use a touch screen, I use the back of a knuckle which I never stick in my ear, nose, or mouth.
Touching my face: On the news a reporter touched her face 13 times in one hour while using a computer even though she was trying not to. Transferring germs from our hand to our eyes, nose, or mouth is a common way to get sick. The news story concluded that it is really hard to stop this unconscious behavior. Any suggestions would be welcome. homeafterstroke.blogspot.com