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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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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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Dairy may not be as beneficial as we have been led to believe. Stock Photo
Does calcium really reduce risk?

By David Dunaief, M.D.

Dr. David Dunaief

The prevalence of osteoporosis and low bone mass increase dramatically as we age. According to the Centers for Disease Control, over 48 percent of those ages 65 and older in the U.S. are affected by low bone mass, and 16.4 percent by osteoporosis (1).

Why do we care? Because they may lead to increased risk of fracture and, subsequently, lower mobility, which may have significant quality of life impacts (2). That is what we know. But what about what we think we know?

For decades we have been told that if we want strong bones, we need to consume dairy. This has been drilled into our brains since we were toddlers. Dairy has calcium and is fortified with vitamin D, so it could only be helpful, right? Not necessarily.

The data is mixed, but studies indicate that dairy may not be as beneficial as we have been led to believe. Even worse, it may be harmful. The operative word here is “may.” We will investigate this further. Vitamin D and calcium are good for us. But do supplements help prevent osteoporosis and subsequent fractures? Again, the data are mixed, but supplements may not be the answer for those who are not deficient.

Holes in the dairy paradigm

The results of a large, observational study involving men and women in Sweden showed that milk may be harmful (3). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. There was also an indication of increased mortality based on dosage.

For every one glass of milk consumed there was a 15 percent increased risk of death in these women. There was a much smaller, but significant, 3 percent per glass increased risk of death in men. Women experienced a small, but significant, increased risk of hip fracture, but no increased risk in overall fracture risk. There was no increased risk of fracture in men, but there was no benefit either. There were higher levels of biomarkers that indicate oxidative stress and inflammation found in the urine.

This study was 20 years in duration and is eye-opening. We cannot make any decisive conclusions, only associations, since it is not a randomized controlled trial. But it does get you thinking. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation and ultimately contribute to this potentially negative effect, whereas other foods have many-fold lower levels of this substance.

Ironically, the USDA recommends that, from 9 years of age through adulthood, we consume up to three servings of dairy per day (4). This is interesting, since the results from the previous study showed the negative effects at this recommended level of milk consumption. The USDA may want to rethink these guidelines.

Prior studies show milk may not be beneficial for preventing osteoporotic fractures. Specifically, in a meta-analysis that used data from the Nurses’ Health Study for women and the Health Professionals Follow-up Study for men, neither men nor women saw any benefit from milk consumption in preventing hip fractures (5).

Calcium disappointments

Unfortunately, it is not only milk that may not be beneficial. In a meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food on a daily basis (6).

The researchers did not differentiate the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In fact, in four clinical trials the researchers actually saw an increase in hip fractures among those who took calcium supplements. A weakness of the large multivaried meta-analyses is that vitamin D baseline levels, exercise and phosphate levels were not considered.

Vitamin D benefit

Finally, though the data is not always consistent for vitamin D, when it comes to fracture prevention, it appears it may be valuable. In a meta-analysis involving 11 randomized controlled trials, vitamin D supplementation resulted in a reduction in fractures (7). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, there was a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures in those 65 years and over. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Just because something in medicine is a paradigm does not mean it’s correct. Milk may be an example of this. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements, there seemed to be no significant benefit. Of course, the patients in these trials were not necessarily deficient in calcium or vitamin D.

In order to get benefit from vitamin D supplementation to prevent fracture, patients may need at least 800 IUs per day, which is the Institute of Medicine’s recommended amount for a relatively similar population as in the study.

Remember that studies, though imperfect, are better than tradition alone. Prevention and treatment therefore should be individualized, and deficiency in vitamin D or calcium should usually be treated, of course. Please, talk to your doctor before adding or changing any supplements.

References:

(1) cdc.gov (2) JAMA. 2001;285:785-795. (3) BMJ 2014;349:g6015. (4) health.gov. (5) JAMA Pediatr. 2014;168(1):54-60. (6) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (7) N Engl J Med. 2012 Aug. 2;367(5):481.

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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Even as public health information in other areas of the country are climbing at alarming rates, threatening to create a strain on health care on other health care systems that is all too familiar to Long Islanders, the COVID-19-related numbers have remained low enough to keep Suffolk County on track for a Phase Three reopening this Wednesday.

Phase Three will allow for indoor dining at restaurants, for groups of about 30 to convene and for more personal care businesses, like massage parlors and spas, to reopen with limitations on capacity, occupancy and services.

The number of people who have tested positive for the coronavirus was 44, which brings the total to 40,908. The percentage of people testing positive was at 1 percent.

The number of people who have tested positive for the antibody is 17,833.

The number of people afflicted with COVID-19 in the hospital fell by four to 106. The number of people in the Intensive Care Unit increased by two to 31.

For the second day in a row, one person died from complications related to COVID-19, bringing the total to 1,963.

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Many Illnesses Carried by Ticks Share Symptoms with COVID-19

A deer tick is a common type of tick on Long Island. Stock photo

With summer close by and as New York State continues to relax shutdown restrictions, residents will naturally want to get some fresh air. But while open spaces like parks and nature preserves provide a temporary reprieve from the COVID-19 pandemic, they are also home to ticks. These arachnids can carry Lyme disease and other serious tick-borne illnesses. Experts say this is the time when ticks are most active and when their numbers increase. 

“We have already passed a month of tick activity here on Long Island,” said Jorge Benach, distinguished Toll professor of Molecular Genetics & Microbiology and Pathology at the Renaissance School of Medicine, Stony Brook University. “With minimal contact because people were staying indoors due to the pandemic, we have seen less cases.” 

Benach said that could change in the coming summer months, especially with an already large tick count this year. Currently, we are entering the second phase of tick season, which is when the arachnids are in the nymph stage and are harder to spot.

“For some reason Long Island has a heavy population of ticks,” Benach said. “It has the perfect environment for them and they really thrive.”

Three species of ticks call Long Island home. The deer tick can carry Lyme disease, anaplasmosis and other illnesses, while American dog tick can carry Rocky Mountain spotted fever. The lone star tick can transmit tularemia and ehrlichiosis. 

“The lone star tick, we believe, is the most aggressive of the three species, and we didn’t know it existed until 1980,” the distinguished professor said. “And then it somehow found its way to Long Island.”

A 2019 study, headed by Benach and Rafal Tokarz, assistant professor of epidemiology at Columbia University, with co-authors from SBU and Columbia, found prevalence of multiple agents capable of causing human disease that are present in three species of ticks in Long Island.

Another concern this season is that tick-borne illnesses like Lyme disease and anaplasmosis have symptoms that overlap with those of COVID-19, including fever, muscle aches and respiratory failure, but without persistent coughing. 

“It is true that they have overlap in the initial symptoms, but once you get past that first stage it should be easier to diagnose if that person has a tick-borne illness,” Benach said. 

Tick-borne diseases are usually treated with antibiotics. The effects range from mild symptoms that can be treated at home to severe infections that if left untreated can lead to death in rare cases. 

The distinguished professor stressed the need for people to be aware of ticks when they are in certain areas outdoors. 

Repellents and wearing long-sleeve pants and shirts can be good deterrents for ticks. Other tips include walking along the center of trails, washing and drying clothing when you come home and keeping pets from areas that could be tick infested. 

Benach said there is a misconception that humans get ticks from dogs. Instead, it is more likely one gets a tick from being in the same space as your dog.

“You should be checking yourself, and if you spot a tick get it off as soon as possible,” he said. “If you develop any symptoms or illness contact your doctor.”

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Suffolk County has created a new website to connect jobless residents with shops that need workers.

And so it begins.

The Suffolk County economy, stalled for over two months as Long Island tried to contain the spread of a deadly virus, has restarted, entering Phase One of a gradual reopening process today.

Calling the reopening a “new beginning,” County Executive Steve Bellone (D) said on his daily conference call with reporters that the county was “up to the test in every way imaginable.”

To bring employers and employees together, Bellone announced the start of a virtual career and talent portal that is part of the Department of Labor. The portal will link job seekers with Suffolk County businesses that need workers.

Bellone called the site a “one stop shop” that will do everything virtually, enabling employees to see job postings in real time. Veterans will get first priority for these jobs, as the county wants to honor those who have served the nation with a 24-hour hold on these postings. Residents can access the site through SCNYForward.info.

Amid the opening, the viral numbers continued to move in a positive direction for the county.

Hospitalizations declined by 30 to 305 as of May 25. The number of people in the Intensive Care Unit also declined by 12 to 94, which is the first time since March that the number of people in the ICU with COVID-19 was below 100.

Hospital capacity remained well below 70 percent, with 65 percent of beds available in hospitals and 60 percent available in the ICU.

In the last day, nine people have left the hospital to continue their rehabilitation and recovery at home.

The virus continues to claim the lives of residents. In the last day, 10 people died from complications related to the coronavirus as the number of people who died from COVID-19 in Suffolk has reached 1,861.

On the first day of reopening, the county executive said he hadn’t had any negative reports about people violating any ongoing restrictions on businesses or social distancing rules.

With contact tracers in place and the county monitoring public health, Bellone didn’t anticipate the county backsliding into another version of New York Pause.

The contact tracers should “give us the ability to target our response,” the county executive said, “rather than what we had to do at the beginning of the outbreak.”

Bellone said the county had learned important lessons on the other side of the viral peak, which should put it in a solid position to monitor any pockets of positive tests.

“I’m certain we are going to do this safely as we open up,” Bellone said.

Separately, Bellone urged the federal government to invest in infrastructure projects on Long Island, including a sewer project.

The county has one of the largest infrastructure projects for sewers in the region in decades, Bellone said.

“With federal investment in infrastructure, we would create jobs, boost our economy, improve water quality, a win-win for everybody,” Bellone said in a statement.

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Protesters hung signs on their cars at a May 1 rally. Photo by Lorraine Yovino

Protesters in Commack May 1 made it clear that they wanted New York to get back to business.

A protester in Commack joins others in asking for all nonessential businesses in New York to be reopened. Photo by Lorraine Yovino

Dozens lined up in front of the Macy’s parking lot at the intersection of Veterans Memorial Highway and Jericho Turnpike rallying for New York to open up its economy. For weeks, after an executive order from Gov. Andrew Cuomo (D), businesses deemed nonessential such as clothing stores, hair salons, barbershops, casinos and more were mandated to shut their doors to customers to slow down the spread of the coronavirus.

The rally was organized through the Reopen NY Facebook page, and similar events have been held across the country in the last few weeks.

These protests have taken a politically partisan edge, with many wearing “Make America Great Again” hats and waving “Trump 2020” signs in support of President Donald Trump (R).

Protesters held signs while others hung them on their cars. One read, “If it’s forced, are we free. Reopen NY Now.” Another sign said, “Small business is essential.” One car had an “Impeach dictator Cuomo” sign on its window, while a protester held a sign that read, “Stop the spread of tyranny.” One woman held two signs where one read, “All jobs are essential” and the other, “Hey Cuomo, domestic violence and poverty does equal death.”

Among those lining the street, some wore masks while others had no face covering. Children were among the protesters with their parents, many holding signs as well.

Setauket resident George Altemose attended the event with friends from the North Country Patriots, a conservative group that rallies on the northeast corner of Bennetts and North Country roads in Setauket every Saturday morning.

“I was there because of the ongoing COVID-19 problem, to show my support for President Trump and to express my disapproval of the misguided policies of Governor Cuomo, Mayor De Blasio and other politicians that are counterproductive in our battle to restore our normal lives,” Altemose said in an email after the rally.

He said he was pleased that he attended the May 1 rally.

“It was a most refreshing and uplifting experience to gather with hundreds of like-minded friends and neighbors in Commack, and to enjoy the enthusiastic responses from the passing motorists, the majority of whom took the time to wave, blow their horns and give us the “thumbs up” sign,” he said. “It looks like Nov. 3 will be a day to remember.”

For Altemose, the protests were about more than the closings. He said he has taken issue with a few of Cuomo’s mandates, including that nursing homes must admit those afflicted with the virus, “even though they are not hospitals and are not even close to being equipped to deal with a problem of this nature and magnitude.”

Altemose applauded the president’s performance during the COVID-19 pandemic.

“President Trump has provided outstanding leadership from the earliest possible day of this crisis, including the placement of responsibility where it belongs,” he said.

Lorraine Yovino, from Hauppauge, said in a phone interview after the protest she was delighted to see so many people show up for the rally.

“The whole atmosphere was so positive and so hopeful,” she said. “It was just a very happy, hopeful group. I was so pleased to see so many young people too.”

Yovino said she has attended rallies in the past including the March for Life protests in Washington, D.C. and others in Albany. She heard about the May 1 rally through friends.

She said the Macy’s parking lot turned out to be an ideal place for everyone to park and protest as the lot was empty, unlike the Target parking lot in the next shopping center which was full.

“It’s unfair that the Target salespeople are considered essential, while the Macy’s people are nonessential,” she said. “One group gets a salary to support their families, and the other group is impoverished.”

While Yovino said she understands that there was not much information known about the virus at first, she said she feels experimental treatments, such as the anti-malaria drug hydroxychloroquine may be helpful to many. Though it has shown in cases to help treat the virus, it is still largely untested and has shown to cause heart issues in some who use it.

“It’s no longer justified to put American citizens into poverty and not let them go to work, not let them open their businesses, not let them support their families,” she said.

Yovino said she believes Trump has been doing a good job when it comes to dealing with COVID-19, and people need to ask more questions regarding the local elected officials’  response to the pandemic.

“My heart is going out to so many people who are unnecessarily having their freedom taken away,”
she said. “Their constitutional rights are being trampled on.”

Earlier this week, Cuomo said that businesses in the state will begin opening after the May 15 pause deadline. However, the first nonessential businesses to open will be in areas with lower density in upstate New York, with those in the city and Long Island to follow at a later date. Currently, Suffolk and Nassau counties have not met much of the criteria set by the U.S. Centers for Disease Control for any kind of reopening.

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Despite the worrisome sign that net hospitalizations rose for a second straight day in Suffolk County, the area has still met one of the qualifications for a phased reopening.

The U.S. Centers for Disease Control and Prevention has recommended that hospitals in an area have a three-day moving average where the number of hospitalizations from COVID-19 declines.

Over the last day, the number of hospitalizations from the coronavirus rose by 18, after inching up by four on Monday, bringing the total to 835 people. The number of people hospitalized with COVID-19 on Sunday had declined by 38, which means the three day moving average was a decline of over five people.

“The fact that we’ve had two days in a row of increasing hospitalizations is definitely something I’m concerned about,” County Executive Steve Bellone (D) said on his daily conference call with reporters. He doesn’t “want to see that trend continuing.”

For the second consecutive day as well, the number of people who were discharged from the hospital increased at a slower pace than it had in the last few weeks, with 37 people heading home to continue their recovery.

“Is this an indication that the people that are in the hospitals, which would be common sense, are people who are more sick?” Bellone said. He suggested that would be “logical,” although he doesn’t have any specific indication behind the numbers about why the net hospitalizations have climbed amid conspicuously lower discharges.

While Gov. Andrew Cuomo (D) has discussed a phased reopening of the state on May 15, when New York Pause ends, the decision of when to open different regions will depend on the data from those area. Upstate, for example, hasn’t been hit as hard as downstate areas like Nassau and Suffolk County.

“We are doing the work to prepare for that reopening downstate,” Bellone said. While the county executive is hopeful Suffolk County could open as soon as possible, he said the county would have to hit a range of metrics to make that possible.

These measures include a 70 percent or lower use of hospital beds, which is about where the county stands now. That, however, does not include elective surgeries, which, once they start picking up again, will require some hospital bed usage.

Additionally, the number of new hospitalizations in Suffolk County will need to be 30 or lower based on a three-day rolling average. Over the last 24 hours, the number of new hospitalizations from COVID-19 was 50.

“We’re not there yet,” Bellone said.

Amid ongoing testing throughout the county, including in seven hotspot testing sites, the number of new positive tests climbed to 715 to 38,252. The percentage of positive tests is 34.6 percent.

On the positive side, the number of people in the Intensive Care Unit declined by seven, as the number of intubations also fell.

“That’s a very good sign,” Bellone said.

The number of people who have died from complications related to coronavirus climbed by 23, bringing the total to 1,296.

“We know the terrible grief and tragedies that this virus has wrought upon our community,” Bellone said, as residents “haven’t been able to grieve in the way we are accustomed to as a community.”

The American Red Cross is providing crisis counselors who can work with families, supplying emotional and spiritual support.

Residents who would like to receive confidential help can log in to www.redcross.org/nyscovidfamilysupport where they will fill out a nine-question form. Alternatively, residents can call 585-957-8187.

Bellone said New York State and Northwell Health tested 700 police officers yesterday at the Suffolk County Police Academy for the presence of antibodies to the virus.

Suffolk County Police Commissioner Geraldine Hart said the police would use the information to track the location of positive cases to see if there are hotspots within the department.

Finally, Bellone is launching a new space on the county site where residents can share positive stories, at www.suffolkcountyny.gov/dashboardofhope. He is encouraging people to share positive stories about teachers this week, during National Teacher’s Week. Residents can share good news or can link to facebook, twitter, or videos.

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Two weeks have made a huge difference for the health care community in the fight against COVID-19.

On April 10, hospitals throughout Suffolk County were struggling as 1,658 residents needed medical help to cope with the symptoms related to COVID-19. At the time, the Army Corps. of Engineers was racing to construct a hospital extension at Stony Brook that might handle more cases if the county continued on its trajectory.

Fortunately, the number of hospitalizations turned around, falling for the first time two days later, beginning a trend, with a few rises here and there, of fewer hospitalizations.

Indeed, over the last day, the number of people in Suffolk County hospitals declined by 143 people to 1,175, which means that, from the peak, the number of people separated from their homes and families has declined by over 29 percent.

This is “ great news,” County Executive Steve Bellone (D) said on his daily conference call with reporters. Bellone has been in the unenviable position of sharing details about the numbers of people who have been sick or who have died each day. The reduction in hospitalizations is a “huge jump, which is much higher than we’ve seen over the past few weeks,” he said.

Indeed, looking back to the dark days when the county became an epicenter for the virus, Bellone said his team had to discuss where to create a makeshift morgue, in the event that those who died exceeded the county’s capacity.

The county had considered using an ice rink as a temporary facility. Bellone nixed that, recognizing that children would eventually skate on that rink again. Instead, the county found an old processing facility, which they hoped they wouldn’t have to use but “unfortunately we have.”

As the Army Corps. of Engineers completed the construction of the Stony Brook Hospital Extension, Bellone again hoped the county wouldn’t need the additional hospital beds. So far, that has been the case, which, the county executive said, is a tribute to the residents who have respected social distancing rules and who have endured economic hardship as they have shuttered their businesses and remained at home.

The hospital extension is “empty today because of what everyone has been doing, because of the sacrifices that are being made right now,” Bellone said. “We have seen the incredible courage and bravery that has been displayed by health care workers and first responder agencies who have put themselves at risk. That is the reason why that hospital stands empty today.”

Gov. Andrew Cuomo announced new testing initiatives for those “essential” employees, including restaurant workers, grocery store workers, banks, laundromats and gas stations, just to name a few examples. The governor added it could be used for health care workers.

Testing of this kind is largely going to be handled by pharmacies. Cuomo said he will be signing an executive order allowing 5,000 independent pharmacies access to the testing.

In the last 24 hours, the number of people who have been discharged from the hospital has increased to 147, which is “another great number and a positive sign,” Bellone said.

The Intensive Care Unit has also experienced a drop in the number of patients, with a decline of 25 to 453.

The number of ICU beds currently available is 179, which is more than four times the number of beds available on April 10th, when the ICU had a low of 43 remaining beds in that unit.

Over the last 24 hours, the number of residents testing positive for Covid-19 has increased by 891 to 32,185, Bellone said. In total, the six hotspot sites have now conducted tests on 1,916 residents.

While the public health trends have been improving, the number of families who have suffered irretrievable losses through the pandemic have also passed a horrific milestone. Over the last 24 hours, the number of people who have died was 49, which means that one Suffolk County resident passed away each half hour. The total number of dead in Suffolk County from complications related to coroanvirus has climbed over 1,000, reaching 1,042.

The number of people who have died “continues to be staggering,” Bellone said, as he offered his thoughts and prayers to those who mourn the loss of family, friends, and neighbors.

Bellone’s office continues to look for personal protective equipment to help first responders and health care workers who are looking to heal and provide comfort to those afflicted with the disease. Bellone’s office has received another 100,000 ear loop masks and 3,000 face shields as a part of the county’s procurement order.

Continuing a process that began yesterday at a Stop & Shop in West Babylon, Bellone distributed cloth face coverings that he received from the federal and state governments to seniors at Leisure Village, Leisure Knolls and Leisure Glen. He was joined by Sarah Anker (D-Mt. Sinai).

“People were very happy to receive those face coverings,” Bellone said. “It’s important to distribute those out to the most vulnerable in our community.”

Bellone said the distribution plan for those face coverings would also include people who live in hotspot communities.

“We will be working with community-based organizations to identify need,” Bellone said.

For those looking to get back on the links, Bellone said golf courses will reopen starting on Monday, in line with the state policy. Golfers will be expected to follow social distancing guidelines and will need to spread out tee times by 15 minutes. Golfers can not use carts.

“If you want to come out, you have to walk the course, follow the additional guidance that is in place to reduce contact and help prevent transmission of the virus,” Bellone said.

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Immune system regulation is complex and involves over 1,000 genes

By David Dunaief, M.D.

Dr. David Dunaief

Autoimmune diseases affect more than seven percent of the U.S. population, most of them women. More than 80 conditions have autoimmunity implications (1). Among the most common are rheumatoid arthritis (RA), lupus, thyroid (hypo and hyper), psoriasis, multiple sclerosis and inflammatory bowel disease. 

In all autoimmune diseases, the immune system inappropriately attacks organs, cells and tissues of the body, causing chronic inflammation. Chronic inflammation is the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you are at high risk for acquiring others.

Drug treatments

The mainstay of treatment is immunosuppressives. In RA, where there is swelling of joints bilaterally, a typical drug regimen includes methotrexate and TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab). These therapies seem to reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors, such as TNF-alpha. Disease-modifying anti-rheumatic drugs (DMARDs), a class that also includes Plaquenil (hydroxychloroquine), may slow or stop the progression of joint destruction and increase physical functioning.

However, there are several concerning factors with these drugs. First, the side effect profile is substantial. It includes the risk of cancers, opportunistic infections and even death, according to black box warnings (the strongest warning by the FDA) (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections.

It is no surprise that suppressing the immune system would result in increased infection rates. Nor is it surprising that cancer rates would increase, since the immune system helps to fend off malignancies. In fact, a study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Tangentially, there is also concern that these drugs might make those who contract COVID-19 more susceptible to severe symptoms and consequences. On the flip side, some are being studied to determine whether they can improve outcomes for others by suppressing immune system overreactions. 

Second, these drugs were tested and approved using short-term randomized clinical trials, but many patients are prescribed these therapies for 20 or more years. 

So, what other methods are available to treat autoimmune diseases? These include medical nutrition therapy using bioactive compounds, which have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression and supplementation.

Nutrition and inflammation

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. While I have not found studies that specifically tested diet in RA treatment, there is a study that looked at the Mediterranean-type diet in 112 older patients where there was a significant decrease in inflammatory markers, including CRP (5).

In another study, participants showed a substantial reduction in CRP with increased flavonoid levels, an antioxidant, from vegetables and apples. Astaxanthin, a carotenoid found in fish, was shown to significantly reduce a host of inflammatory factors in mice, including TNF-alpha (6).

Fish oil

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (7). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory, such as NFkB.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (8). When treating patients with autoimmune disease, I typically suggest about 2 grams of EPA plus DHA to help regulate their immune systems. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood thinning effects.

Probiotic supplements

The gut contains approximately 70 percent of your immune system. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (9, 10).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor, TNF-alpha (11). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Fiber

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (12).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (13).

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Dysfunction results in inflammation and potentially autoimmune disease. We know the immune system is highly influenced by bioactive compounds found in high nutrient foods and supplements. Therefore, bioactive compounds may work in tandem with medications and/or may provide the ability to reset the immune system through immunomodulatory effects and thus treat and prevent autoimmune diseases.

*Especially in this time of COVID-19, do not alter your medications, in other words, stop or start medications, without discussing it with your physician first. It is much more important to control the autoimmune disease than tot worry about drug effects on the immune system. 

References:

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Am J Clin Nutr. 2009 Jan;89(1):248-256. (6) Chem Biol Interact. 2011 May 20. (7) Am J Clin Nutr. 2009 Aug;90(2):415-424. (8) Drugs. 2003;63(9):845-853. (9) Gut. 2003 Jul;52(7):975-980. (10) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (11) Gut. 2002;51(5):659. (12) Arch Intern Med. 2007;167(5):502-506. (13) Nutr Metab (Lond). 2010 May 13;7:42.

Dr. 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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