Health

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Early diagnosis is crucial to treatment success

By David Dunaief, M.D.

Dr. David Dunaief

Diabetic retinopathy is an umbrella term for microvascular complications of diabetes that can lead to blurred vision and blindness. There are at least three different disorders that comprise it: dot and blot hemorrhages, proliferative diabetic retinopathy and diabetic macular edema. The latter two are the ones most likely to cause vision loss. Our focus for this article will be on diabetic retinopathy as a whole and on diabetic macular edema, more specifically.

Diabetic retinopathy is the number one cause of vision loss in those who are 25 to 74 years old (1). Risk factors include duration of diabetes, glucose (sugar) that is not well-controlled, smoking, high blood pressure, kidney disease, pregnancy and high cholesterol (2).

What is diabetic macula edema, also referred to as DME? Its signature is swelling caused by extracellular fluid accumulating in the macula (3). The macula is the region of the eye with greatest visual acuity. A yellowish oval spot in the central portion of the retina — in the inner segment of the back of the eye —it is sensitive to light. When fluid builds up from leaking blood vessels, there is potential for vision loss.

Those with the longest duration of diabetes have the greatest risk of DME (4). Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent loss of vision (5). Herein lies the challenge.

In a cross-sectional study (a type of observational study) using NHANES data from 2005-2008, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (6). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.

The problem is that the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder. According to the authors, there needs to be an awareness campaign about the importance of getting your eyes examined on an annual basis if you have diabetes. Many patients are unaware of the association between vision loss and diabetes.

Treatment options                                             

While DME is traditionally treated with lasers, intravitreal (intraocular — within the eye) injections of a medication known as ranibizumab (Lucentis) may be as effective.

The results from a randomized controlled trial, the gold standard of studies, showed that intravitreal (delivery directly into the eye) injections with ranibizumab, whether given prompt laser treatments or treatments delayed for at least 24 weeks, were equally effective in treating DME (7).

Increased risk with diabetes drugs

You would think that drugs to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective (backward-looking) study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (8). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. [Note that DME is not the only side effect of these drugs. There are important FDA warnings of other significant issues.]

To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.

This is in contrast to a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (9). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).

What does this ultimately mean? Both of these studies were not without weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (10). Thus, there needs to be a prospective (forward-looking) trial done to sort out these results.

Diet

The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (11). Medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. But an inference can be made: A nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy complications (12, 13).

The best way to avoid diabetic retinopathy is obviously to prevent diabetes. Barring that, it’s to have sugars well-controlled. If you or someone you know has diabetes, it is imperative that they get a yearly eye exam from an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. It is especially important for those diabetes patients who are taking the oral diabetes class thiazolidinediones.

References:

(1) Diabetes Care. 2014;37 (Supplement 1):S14-S80. (2) JAMA. 2010;304:649-656. (3) www.uptodate.com. (4) JAMA Ophthalmol online. 2014 Aug. 14. (5) www.aao.org/ppp. (6) JAMA Ophthalmol. 2014;132:168-173. (7) ASRS. Presented 2014 Aug. 11. (8) Arch Intern Med. 2012;172:1005-1011. (9) Arch Ophthalmol. 2010 March;128:312-318. (10) Arch Intern Med. 2012;172:1011-1013. (11) www.nei.nih.gov. (12) OJPM. 2012;2:364-371. (13) Am J Clin Nutr. 2009;89:1588S-1596S.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com. 

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As Suffolk County prepares to enter Phase 4 of its economic reopening, the county has reported the lowest number of weekly fatalities since March.

For for the fourth time in six days, no one died from complications related to COVID-19, which is a pattern County Executive Steve Bellone (D) said he hopes continues as the county fights to hold its hard-earned gains from the lockdown and new rules designed to protect public health.

The number of people who have died from the virus remained at 1,983.

“This is a real reflection of how far we have come,” Bellone said on his daily conference call with reporters. “All the sacrifices are ultimately about saving people’s lives.”

The number of people who tested positive for the virus was 47, bringing the total to 41,585. That represents 1.1 percent of the tests given over the last day.

Hospitalizations declined by three to 7. The number of people in the Intensive Care Unit who are battling the virus fell by three to 17. The two-day decline at the ICU was 10.

Hospital occupancy was at 68 percent, while ICU bed capacity was at 61 percent, both of which are within safe guidelines for continuing to march forward with reopening.

The number of people who were discharged from the hospital was five.

Fireworks in Port Jefferson for Independence Day 2019. Photo by David Ackerman

As the county prepares for a Fourth of July following a painful spring, county officials and health care providers reminded residents to remain safe during fireworks displays and to continue to follow health guidelines.

Steve Sandoval, Associate Professor of Surgery and Medical Director of the Suffolk County Volunteer Firefighters Burn Center at Stony Brook University Hospital, urged residents to be cautious around fireworks and barbecues.

The best way to avoid injuries is to “prevent the burn in the first place with safety tips and precautions to eliminate potential dangers,” Sandoval said in a statement.

The Suffolk County Volunteer Firefighters Burn Center offered 10 tips, which included viewing fireworks used by professionals, not leaving hot coals or fire pits, not using the stove top, fire pit or fireplace when residents are tired or have had alcohol.

“If burned, do you go anywhere but a facility that specializes in burn treatment,” Sandoval said.

The Suffolk County Police Department, meanwhile, warned residents of counterfeit oxycodone. Detectives recently seized pills that bear the markings of 30 mg of oxycodone but that were fentanyl instead, which is 1,000 times more potent than morphine. Ingestion can cause overdose and death. The department warned residents that people buying these pills may not be able to distinguish between the counterfeit pills and prescription oxycodone.

Viral Numbers

After two days without a death related to complications from COVID-19, two residents died in the past 24 hours. The total number of residents who have died from the virus is 1,983.

The number of new infections over the last day was 47, bringing the total to 41,538. Gregson Pigott, the Commissioner of the Suffolk County Department of Health Services, said new infections crossed a whole spectrum of ages and included people in their 20’s.

The county distributed 30,000 pieces of personal protective equipment over the last day.

After the success of drive in movies at the Smithpoint County Park, the county is opening a second site for movies, at the Suffolk County Community College on the Grant Campus in Brentwood. The series will include “Pee Wee’s Big Adventure” July 8, “The Karate Kid” July 9, “Matilda” on the 10th and “Back to the Future” on the 11th. Residents interested in getting free tickets can register through suffolkcountyny.gov/driveinmovies.

Pictured above, from left, Paige Hubbard, office manager; Councilman Neil Foley; Dr. Rohit Reejsinghani; Councilman Timothy Hubbard; Catrina Grefe, NP; Dr. Vishnu Seodat; Councilwoman Jodi Giglio; Councilwoman Catherine Kent; Tina Toulon, physician liaison for NYCBS; and Amanda Brown, medical assistant. Photo courtesy of New York Health

New York Health (NYHealth) recently announced the addition of family physician Dr. Vishnudat Seodat. To celebrate the opening of his two new offices — at 6144 Route 25A, Suite 19 in Wading River and 32645 Main Road, Suite 7-8 in Cutchogue — a ribbon-cutting ceremony was held at the Wading River location on June 25. 

The event was attended by the Executive Director of New York Health, Dr. Rohit Reejsinghani; Brookhaven Town Councilman Neil Foley: Riverhead Town Councilmembers Catherine Kent, Jodi Giglio and Timothy Hubbard; and members of the staff and community.

Dr. Vishnudat is presented with a Certificate of Congratulations from the Town of Riverhead. Photo courtesy of New York Health

“At the end of the day, New York Health is really about patient care and having the basis of a large group of patients with such a great practitioner in this area really compliments our group very well so we are very happy to have Dr. Seodat on board and we think this is going to be a successful operation moving forward,” said Dr. Reejsinghani.

“As a child, I developed pneumonia which led to a house call from my family physician. The physician did not accept payment from my family for the appointment due to my less fortunate financial living conditions at the time,” said Dr. Seodat. Inspired by the physician’s compassion, Dr. Seodat navigated his life so that he could become a doctor for everyone. “My journey began as a nurse and a pharmacist dispenser before traveling to New York to earn my degree in medicine.”

Working alongside him for the past two years is Adult-Geri Nurse Practitioner, Catrina Grefe, MS, RN-BC, AGNP-C. “Patients can feel confident with me as their practitioner, and I am eager to deliver high-quality care to patients on the East End,” she said.

“Supervisor Yvette Aguiar of the Town of Riverhead together with the entire town board extend their best wishes for success to New York Health Family Medicine … on the opening of your new practice in Wading River. We look forward to having your quality of business in our town and wish you great success,” said Councilman Hubbard before presenting Dr. Seodat with a Certificate of Congratulations.  

“This ribbon cutting ceremony, in my mind, signifies not only the clearing of a barrier but to open a new door and the birth of a new venture with New York Health,” said Dr. Seodat. “It offers an opportunity to expand medical care … to the East End of Long Island. I am thrilled to be given the opportunity to partner with this multidisciplinary group and I hope to set the standard for family practice and primary care in this community and many other communities on Long Island.”

To make an appointment with Dr. Seodat or Catrina Grefe, please call ​631-758-7003.

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After months in which COVID deaths robbed families throughout Suffolk County of grandparent, parents, siblings, sons and daughters, the county reported no deaths from the virus for the second time in three days.

“From where we’ve been to where we are today is a world of difference,” County Executive Steve Bellone (D) said on a daily conference call he’s conducted with reporters since the third week of March. “The last two out of three days is a good indicator of where we are and the positive direction we continue to move in.”

Bellone described the other numbers for the virus as “also very good.”

The number of new positive tests was 42, out of a total of 4,047. The positive tests represented about 1 percent of tests, which is about the recent rate. The total number of positive tests since the pandemic began in the county stands at 41,420.

The number of residents who have the antibody but haven’t had a positive test stands at 19,270.

The number of hospitalizations was one of the few figures that moved in an unfavorable direction, as seven additional people entered the hospital with COVID-19, bringing the total to 73.

The number of people in the Intensive Care Unit declined by one.

Hospital bed use was at 70 percent, with 57 percent of ICU beds occupied.

An additional six people were discharged from the hospital. The county distributed 34,000 pieces of personal protective equipment over the last day.

Finally, Bellone is hosting a webinar on July 7th at 10 am to provide information to residents interested in entering the food truck business.

“Outdoor dining has proven successful during the COVID-19 pandemic, and food trucks are uniquely positioned to adapt to the challenges posed by this crisis,” Bellone said in a statement.

Suffolk County currently has 228 mobile vending vehicles, which offer food, coffee and dessert. The webinar is a part of Suffolk Count’s Business Recovery Unit. Residents interested in attending the webinar can register here.

Bethpage Ballpark in Central Islip. Photo from LI Ducks website

The Long Island Ducks will not take the field this season, as New York State wouldn’t allow the baseball team to allow fans to attend an abbreviated season.

While Major League Baseball teams, at least for now, can make a shortened season work without fans because of television and advertising revenue, the Ducks couldn’t make a fan-free season work.

“I’m disappointed the Ducks won’t be on the field,” County Executive Steve Bellone (D) said on his daily conference call with reporters. Bellone had hoped that the state would support capacity limits, especially in an outdoor environment which would lower the risk from the transmission of COVID-19.

Bellone said the state’s decision with the Ducks shouldn’t have any impact on youth sports, in which parents are hoping to watch their children return to fields after their sons and daughters spent months away from the competition, the teammates, and the opportunity to enjoy summer games and competition.

Viral Numbers

The number of residents who tested positive for the coronavirus was 46, bringing the total to 41,386. A total of 3,312 people were tested, which means 1.4% of the tests had a positive result, which is among the higher levels of positive tests in recent weeks.

While the percentage is higher than it’s been recently, Bellone said he doesn’t put too much stock in any one day’s results.

Hospitalizations declined by six, with 66 residents now hospitalized with COVID-19. That is the first time since March that the number of people battling against the virus in the hospital was below 70.

The number of people in the Intensive Care Unit with symptoms from the virus increased by one to 24.

Hospital capacity remained below pre-set caution levels. Overall hospital occupancy was at 67%, while ICU bed occupancy was at 59%.

Nine people were discharged from hospitals in the last 24 hours.

After a day without any fatalities from complications related to COVID-19, two people died in the last day. The death toll from the coronavirus stands at 1,981.

The county distributed 5,000 pieces of personal protective equipment in the last 24 hours.

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For the first time since June 12, Suffolk County reported no deaths from COVID-19.

“I do hope and pray that it will not be another 17 days for me to be reporting zero deaths again,” County Executive Steve Bellone (D) said on his daily call with reporters. “Hopefully, this is the start of something we will continue to see.”

The total number of deaths from the virus in the county remained at 1,979.

The number of positive tests, meanwhile, was 33, bringing the total to 41,339. With 4,481 people receiving tests in the past day, the positive tests were among the lowest the county has had in weeks, at 0.7 percent.

The number of people who tested positive for the antibody who didn’t have a positive COVID-19 test was 19,074.

Hospitalizations continued to trend slightly lower. The number of people in the hospital overall fell by three to 72. The number of people in Intensive Care Units with COVID-19 also declined by three to 23.

Hospital bed occupancy was at 68 percent, down from 70 percent the day before. ICU bed occupancy was at 62 percent.

An additional 20 people were discharged from the hospital in the last day.

Separately, the county announced a plan, starting today, to walk back some protective measures put in place for Suffolk County Transit. In March, the county asked residents to use fast fare. Busses did not take cash, riders had to board from the back of the bus, and residents needed to leave the first few rows of the bus vacant to protect drivers.

Now that the county is in Phase 3, Suffolk County Transit has re-instituted front door boarding and will accept cash, even as it is encouraging riders to use the mobile app.

The county has provided protective barriers on all busses to keep the drivers safe from infection. Riders are still required to wear face coverings until further notice.

Finally, officers in the Third Precinct arrested Pablo Figuero, a convicted sex offender, last night at 10:20 pm. He was found in a parked car on Suffolk Avenue in Central Islip and was charged with Criminal Possession of a Controlled Substance in the 7th Degree. He was taken for arraignment today and will be held in jail. Bellone said he is wanted out of New Mexico.
This post was updated at 4:30 p.m. Monday.

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Suffolk County continued to keep viral numbers low. The number of new cases in the last day was 53, bringing the total since the beginning of the COViD-19 epidemic to 41,306.

The number of people who have tested positive for the antibody was 18,970.

The hospitalization figures remained relatively flat. In hospitalizations as a whole, two people left the hospital. The total stands at 75.

The number of people in the Intensive Care Unit with the virus was 26, which is an increase of 1.

An additional 10 people were discharged from the hospital.

Capacity remained at safe levels, with hospital occupancy at 70 percent and ICU bed capacity at 63 percent.

One person died in the last day, bringing that total to 1,979.

GERD is a common condition in which the esophagus becomes irritated or inflamed because of acid backing up from the stomach. Stock photo
You may avoid medications by making simple changes

By David Dunaief, M.D.

Dr. David Dunaief

Wherever you look there is an advertisement for the treatment of heartburn or indigestion, both of which are related to reflux disease.

Reflux typically results in symptoms of heartburn and regurgitation, with stomach contents going backward up the esophagus. For some reason, the lower esophageal sphincter, the valve between the stomach and esophagus, inappropriately relaxes. No one is quite sure why it happens with some people and not others. Of course, a portion of reflux is physiologic (normal functioning), especially after a meal (1). As such, it typically doesn’t require medical treatment.

Gastroesophageal reflux disease (GERD), on the other hand, differs in that it’s long-lasting and more serious, affecting as much as 28 percent of the U.S. population (2). Can you understand why pharmaceutical firms give it so much attention?

GERD risk factors are diverse. They range from lifestyle — obesity, smoking cigarettes and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Diet issues include triggers like spicy foods, peppermint, fried foods and chocolate.

Smoking and Salt

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Medications

The most common and effective medications for the treatment of GERD are H2 receptor blockers (e.g., Zantac and Tagamet), which partially block acid production, and proton pump inhibitors (e.g., Nexium and Prevacid), which almost completely block acid production (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Here, I will focus on PPIs, for which more than 100 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), and Prevacid (lansoprazole). They have demonstrated efficacy for short-term use in the treatment of Helicobacter pylori-induced (bacteria overgrowth in the gut) peptic ulcers, GERD symptoms and complication prevention and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

However, they are often used long-term as maintenance therapy for GERD. PPIs used to be considered to have mild side effects. Unfortunately, evidence is showing that this may not be true. Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year, not 10 years. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use are increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Bacterial infection risks

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

B12 deficiencies

Suppressing hydrochloric acid produced in the stomach may result in malabsorption issues if turned off for long periods of time. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. B12 was not absorbed properly from food, but the PPIs did not affect B12 levels from supplementation (9). Therefore, if you are taking a PPI chronically, it is worth getting your B12 and methylmalonic acid (a metabolite of B12) levels checked and discussing possible supplementation with your physician if you have a deficiency.

Lifestyle modifications

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (10). In the same study already mentioned with smoking and salt, fiber and exercise both had the opposite effect, reducing the risk of GERD (5). This was a prospective (forward-looking) trial. The analysis by Journal Watch suggests that the fiber effect may be due to its ability to reduce nitric oxide production, a relaxant for the lower esophageal sphincter (11).

Obesity

In one study, obesity exacerbated GERD. What was interesting about the study is that researchers used manometry, which measures pressure, to show that obesity increases the pressure on the lower esophageal sphincter significantly (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index. This is yet another reason to lose weight.

Eating close to bedtime       

Though it may be simple, it is one of the most powerful modifications we can make to avoid GERD. A study that showed a 700 percent increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four hours or more prior to bedtime. Of note, this is 10 times the increased risk of the smoking effect (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.”

Although there are a number of ways to treat GERD, the most comprehensive have to do with modifiable risk factors. Drugs have their place in the arsenal of choices, but lifestyle changes are the first — and most effective — approach in many instances. Consult your physician before stopping PPIs, since there may be rebound hyperacidity (high acid produced) if they are stopped abruptly.

References:

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014 Jun; 63(6):871-80. (3) emedicinehealth.com. (4) Gut 2004 Dec.; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 20.0. Updated December 23, 2019. Accessed June 23, 2020. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov/safety/medwatch/safetyinformation. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar.; 130:639-649. (13) Am J Gastroenterol. 2005 Dec.;100(12):2633-2636.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com. 

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County Executive Steve Bellone (D) reminded Suffolk County residents as they grapple with the mental health toll from the public health and economic crisis of the services that can help.

Residents can reach out to the Family Services League at FSL-LI.com. They can also call a hotline that is available 24 hours a day and seven days a week at (631) 952-3333.

Residents who know people who are struggling with their mental health or substance abuse that are exacerbated by COVID-19 should reach out to these services, Bellone urged.

As for the viral data, the numbers continued to move in a favorable direction for a region that is still recovering from the virus.

Over the last 24 hours, an additional 45 people tested positive, bringing the total to 41,253. These positive tests represented less than a percent of the total tests.

An additional 18,816 people tested positive for antibodies.

Hospitalizations remained steady, with one person leaving the Intensive Care Unit, bringing that total to 25.

Hospital occupancy was at 70 percent, while ICU occupancy was at 60 percent.

An additional three people died in the last 24 hours, bringing the total for the region to 1,978.

The county distributed 20,000 pieces of personal protective equipment in the last day.