Twenty Years After 9/11

Each of us is unique. Let us think highly of one another.

It was an ordinary day for most of us on September 11, 2001. I was on duty at the Philippine General Hospital, where I had my residency training in Family and Community Medicine. At around 8 in the evening, I saw a video clip on TV showing a plane crashing into one of the towers of the World Trade Center in New York. I thought it was a movie trailer. It was not. It was reality.

Today, I am reminded of the impact this terrorist attack had not only on those who were at the scene, but for the whole human race. Some responded with fear, living with possibility of dying while inside a tall building. Others let discrimination build inside them, eyeing bearded colleagues as potential terrorists who should not be given access to any public domain. Past exposures carry a lot of weight on how we behave in the future. And the specter of death grazes our consciousness whenever we lose friends or loved ones in unexpected circumstances.

Why does disaster carry this much influence on our thoughts? It is because we are all, in one way or another, afraid of uncertainty, especially death.

When we are young, we live like we are immortal. We shrug off physical pain easily. We recover from illness faster. But when we hit old age, the reality of leaving this world sinks in. Even then, I have seen people who could never accept that they will die soon. They bargain. They beg. They petition the heavens. Losing all their ideas, thoughts, and emotions is an unbearable undertaking.

Who among those in that tower ever thought that it would be their last day on earth? Sadly, no one was able to tell. Can we predict when we will leave this planet? Unless one is suicidal, nobody can. The terrorists on the hijacked plane were probably the only ones who were ready. But then again, we could argue that they had distorted views on life and eternity.

Do we now have respect for the human race? Do we still discriminate? Are our perceptions still clouded by our differences in culture, speech, and traditions? These biases are the ones that carried hatred and brought about the ensuing carnage. In one way or the other, have we learned to treat everyone with respect and dignity?

The attitude and air or superiority, and the feeling of being bullied and subdued, elicits the kind of hatred that costs human lives. It may start within families. It can escalate between neighbors. It then brews within communities. Finally, it explodes between races.

Let us put a stop to these harmful human tendencies. It spreads easily, and when it attains its boiling point, the only way for it to cool down is to annihilate everyone in its path. Everybody may eventually be harmed once the bullied child gets into a position of power and influence. You may win the war now, but the enemy remembers and takes its time to exact revenge. It is going to be a never-ending cycle of hatred. Unless someone takes away the oxygen and says “let’s stop this inferno.”

We only live once. We will all leave this world. But when we do, let’s leave a legacy that will foster love and respect for each other’s differences. It will not just sustain us. It will keep us rational and sane. And hopefully, those that remain get to pass it on and improve along the journey.

Whatever good we can do today will extend to future generations. The only way to end the 911 attacks is to nourish and nurture the art of respect.

Perseverance

It’s Olympic Season! Although this is an unusual Quadrennial (delayed by one year) meet due to the pandemic, it does not take away from the spirit of competition. The same desire to win persists. And the inspiring stories remain the same.

Art by: M.H.

Everybody knows the golden exploits of weightlifter Hidilyn Diaz, the first Filipino gold medalist in Olympic history. But behind that triumph, only a few remember her as a young Olympian who failed in previous attempts for a medal. In 2008, she was at the bottom of the standings. In 2012, she did not complete her clean and jerk event. Her breakthrough was in 2016, and with it, came higher expectations. Those expectations became a reality in the recent Tokyo Olympics. Although the pandemic caused her to be stranded in Malaysia, this did not prevent her from pushing through and lifting a new Olympic record. 

Carlo Paalam, our Olympic silver medalist in boxing, also has a great story.  His mother left their family when he was six years old. A former scrap collector, he rose from obscurity and made us all proud by beating a former Olympic champion. He also overcame great odds by beating a Japanese fighter in his own turf. Although Tokyo is his first Olympic games, he showed that he was ready. After winning the silver medal, he recalled all those scraps he collected, and said that it symbolized all those metals he scavenged in his life. His life will now change as he is set to win millions in prize money for his performance.

What do these narratives tell us? Do they mirror our own struggles? Do we also feel victorious when someone close to us experiences a win? Do we also celebrate the success of others?

We associate ourselves with winners, and embrace their struggles. Their triumph becomes ours too. As caregivers in the health sector, no amount of remuneration can replace the joy of seeing a dying patient recover from illness. It is not the just sick who persevere, but also those in-charge of patient management. If money were the sole motivation, not a few doctors and nurses would tell you that they might have quit a long time ago.

What if there is no improvement in sight? Hospice patients face this dilemma. How does one persevere when there is no end to suffering?

The answer? Celebrate little victories. The pain-free moments. Or even just moments when pain is less. The ability to still maintain one’s quality of life despite the terminal illness. The presence of friends and loved ones.

There is also a significant contribution of teamwork in every triumph. Although weightlifting and boxing are individual sports, there are people behind Hidilyn and Carlo who made them who they are today. It was not just their trainers and coaches. Their families also provided great support. Even the whole community, the Filipino people, who cheered them on, played a role. The same is also true for taking care of the sick and dying. They must not be left alone. There must be a team of doctors, nurses, and caregivers who look after them. And their loved ones must not leave them behind.

We always have a choice whether to push through or just let life pass us by. It’s the choices we make that will ultimately determine our happiness. Perseverance pays off, both in sports, and in life.

Not Just A Number

“When we are no longer able to change a situation, we are challenged to change ourselves.”

—Viktor Frankl, Man’s Search for Meaning

I just pored through Viktor Frankl’s book, Man’s Search For Meaning for the nth time. It is an eye-opening and brain-enriching piece of work. Essentially, it tells us that finding meaning in life is one of the most important things to find out to enjoy one’s existence. This enables us to push through adversity.

Why do we go through tough exams as medical students?

Because we know that after all the hardships, we can be doctors who can make a difference in the lives of others.  Through the long hours of study and sacrifice, we see an end that is meaningful and productive. Future earnings may be a good motivation, but once a certain amount is reached, having more may no longer inspire.

Passing through this current medical crisis and the challenges and heartaches it carries is taxing to the psyche. It also exposes the different ways people react to trials. Some become numb and resigned to fate. Some become ultra-aggressive and take advantage of others. But a few find the courage to live through the pandemic by being of service to others.

Frankl tells of how the prisoners in the Nazi camps of Auschwitz were dehumanized and reduced to mere numbers for identification and segregation. The only things that were left were his belt and his eyeglasses, as all including his family was lost. What kept him going was his ability to see the world as it is and find meaning to it. Being human is always directed towards something or someone. Self-actualization is a transcendence of the human self. The fulfillment of a human need is only attained through others.

As a physician, this is what we must be able to emphasize to our patients. We tend to paint a picture of life’s beauty for those who have lost hope in living, imposing our will in the process. Probably, a better approach would be to give our patients a “new pair of eyes” to see meaning without imposing. It is indeed more therapeutic when you discover meaning by yourself. This makes you own the goal, and with the support of others, this makes the goal a shared ideal which can foster bonding and camaraderie. Maybe it’s time to shift the patient’s focus to something other than their own predicament.

Suffering ceases to be suffering once it finds meaning. We might mourn indefinitely for our loved ones who suffer from debilitating diseases and die, impacting our daily existence. When this happens, we must look for hidden tenets of wisdom to make sense of the situation. What if you were in the situation of your loved one? What would you have wanted them to do under the circumstances? The truth is, we may have to flip the page to see the other side of the passage.

We are not just numbers or pieces of DNA. Science tends to do this — reduce us to mere pieces of data to find objectivity. However, life is never fully objective and impartial, for we are human. We have feelings. It is what makes us who we are. It is the essence of our existence.

IS SINOVAC EFFECTIVE?

With the concern about the efficacy of vaccines being questioned, the timing of the medical worker outbreak in Indonesia raises valid concerns. Hundreds of health workers were said to have been infected after being given complete doses of Sinovac, a biopharmaceutical company. Some patients were hospitalized with decreasing oxygen saturation levels, which indicate a serious condition.

There are a few issues that need to be addressed in this latest outbreak. Let us try to look at them and see if we can find the answers based on the information available.

First, the World Health Organization (WHO) approved emergency use of Sinovac's vaccine as it showed at least 51% of recipients benefitted from having less severe COVID-19 symptoms, leading to less hospital stays. None of the tested patients were hospitalized for COVID-19. However, this puts into question the strain of COVID-19 that was tested in this study.

The Delta Variant, first detected in India in October 2020, poses the greatest concern, as it is said to be driving the current outbreak. This variant shows increased transmissibility and virulence. It is feared that the Sinovac vaccine is ineffective against this strain. However, there is a need to do further studies on this. Nothing is conclusive.

The second issue involves the decreased vigilance among the populace. Some of those given the full dose of the vaccine mistakenly believe that they are now immune to the disease, so they become less careful. This includes the health workers who were among the first to be vaccinated. During public holidays, the increased movement of people becomes a risk for transmission.

What is important, however, is that we follow safety protocols. Being fully vaccinated is not a license for us to lower our guard. We must still wear masks when we go outside until we are able to control the spread of this menace.

Why are there different COVID-19 strains?

Just like most living organisms, adaptive mechanisms enable us to survive in adverse conditions. For viruses, mutation is the mechanism to improve “survival” even though they cannot replicate outside a living cell – or outside the human body. Viruses are known to mutate easily. This enables them to “escape” destruction and identification by the immune system. The changes in their structure leads to the development of different COVID-19 strains. When a virus is spreading, the likelihood of the virus mutating increases. The more opportunities a virus has to spread, the more it replicates.

Some strains can still be neutralized by the currently available vaccines.  This has been proven in studies that came out this year.

According to the World Health Organization, the COVID-19 vaccines that are currently available are expected to provide at least some protection against new virus variants. This is because these vaccines elicit a broad immune response involving a range of antibodies and cells – meaning the mutants will still be neutralized by the drugs.  Alterations in the structure of the virus should not make vaccines completely ineffective. In the event that any of these vaccines prove to be less effective against one or more variants, it will be possible to change the composition of the vaccines to protect against these variants.

Should we avoid Sinovac because of this?

The simple answer is no. Science has proven the effectivity of the vaccine, despite the recent news articles stating otherwise. It is understandable to have certain apprehensions when there are doubts as to the effectiveness of prevention due to outbreaks. However, unless our health authorities say that it is unsafe or ineffective, there is no reason to doubt science. After all, it is science that will enable us to pull through this crisis.

Life After COVID-19

The coronavirus pandemic has changed our way of life. And if you were infected, there may be certain signs and symptoms to watch out for.  According to health experts, some COVID-19 patients develop long-term organ damage and have a prolonged stay in the hospital before making a complete recovery.  Most patients also report changes in breathing patterns and blood clotting mechanisms after recovering from the infection.

After COVID-19, there is a residual damage to lung alveoli and to endothelial cells that line the blood vessels, leading to persistent respiratory symptoms and excessive blood clotting across the body. Some of them succumb to eventual pneumonia and cerebrovascular disease. This so-called post-COVID syndrome happens after the initial infection of COVID-19 is over and the patient is deemed to have recovered.  Patients may have a recurrence of symptoms such as lethargy, body aches, and itchy throats.  This may have an effect on their mental state leading to anxiety and depression. It is therefore of essence to monitor patients after infection or discharge from the hospital.

Co-morbidities or other illnesses, exposures, or demographic characteristics such as smoking, diabetes, hypertension, and renal disorders also contribute to immune compromise and added risk for complications.  Gender differences have not been observed, but some studies indicate more distressing signs and symptoms among males compared to females.

It is important for COVID survivors to monitor oxygen saturation, which must not dip below 95% using a pulse oximeter.  Respiratory symptoms must also be monitored, taking note of the presence of cough or difficulty of breathing.

Temperature must also be monitored, which must not exceed 37.8 degrees centigrade. There must also be no signs of easy fatigability, sleepiness, and change in sensorium.  Patients with Diabetes Mellitus should regularly monitor their blood sugar levels.

There is a need to have a regular check-up with a trusted doctor after one week of being deemed recovered, and every 3 months thereafter.  Blood investigations may be warranted in order to screen for signs of inflammation.  Some would recommend chest imaging studies after 3 months to ensure pulmonary recovery.

The most dreaded complication would be the emergence of a cytokine storm, where immune cells attack vital organs such as the lungs and the heart. Another complication is a blood clot that can manifest as a heart attack or stroke. Therefore, blood pressure readings that fluctuate or go down must be reported at once.

Vaccination must be made available to post-COVID patients to help minimize infection and viral transmission. So far, all vaccines available in the market have shown an increase in antibodies after administration of the vaccines. There is also an increasing trend towards immediate administration of the vaccine after COVID symptoms have been resolved. This means that you no longer need to wait for a long time before you can avail of the vaccine’s preventive benefits.

However, the most important message after being infected is that there is hope. We have made great strides in the prevention and treatment of COVID-19.  We must trust that in these situations, science will prevail, and the human race will move on and learn from this crisis.

Left Behind

When a person leaves us, their lives must achieve closure. We arrange their funeral, we manage their finances, and we take care of the things they leave behind.

The job of handling personal and legal details of the dead falls on the living. It could be an overwhelming task for the inexperienced.  You may still be grieving, yet work must be done fast to facilitate a smooth transition for everyone.

But one must not carry the burden alone. Help is needed and must be provided.  Professionals such as lawyers, physicians, and accountants may need to be on-hand to give advice. It might be costly to make a mistake at times, so one must be well-versed.

Friends are an indispensable resource for unknown surprises. One may be the decision-maker, but the execution must be considered as a team event.  You may take the lead in planning, while others pitch in for execution. Even loners may find it difficult to pass through this stage in solitude.

If your loved one was confined in an institution with medical experts on hand, the medical staff can take care of the paperwork to complete the death certificate. This is important because the death certificate will allow permission to process the remains.

If someone dies at home, a medical professional must be contacted to ascertain death. You can call a doctor when you do not detect any sign of life, such as the absence of breathing or pulses. Since most often, you do not have a death certificate form on hand, you may need to contact the physician again to have the form signed on another day. That is why it is advisable to have this form handy in case you are expecting a deteriorating condition, no matter how morbid it sounds.

It is not recommended to do cardiopulmonary resuscitation on a patient who is in the terminal phase of their condition. However, it is strongly recommended to have advance care directives. The decision on resuscitation must come before the actual need to carry it out arises. Keep in mind that resuscitation is not to be offered by clinicians when it is deemed to be futile.

Immediately after the declaration of death, spend some time with the body. This is a moment of peace, quiet, and rest. Reminisce and work on accepting the inevitability of the moment. It is not bad to cry or show emotion, but it is also fine to be just a listener and a stabilizer of feelings.

Tell friends and family about the demise so they can pay their respects. One may need to go through the deceased's email and phone contacts. Inform co-workers and the members of any social groups or church the person attended and tell them to spread the word. A word of caution: never spread word on a patient’s demise unless the family gives instructions to do so.

If you know about the person’s wishes for funeral or burial, start looking at ways on how to carry it out. Contact the funeral services. Look for and secure any papers pertaining to purchased memorial lots and services. Call the funeral services once you are satisfied with the time spent after demise, so they can come over at home and prepare the body.  Call a family meeting to have the first conversation about what the funeral will look like. Will it be cremation or not?  This is critical if the deceased left no instructions.

Secure the property and belongings. Finances must be looked into, including any last wills. Don’t forget social media portals – they may need to be archived so that posers or scammers will not use them. Even pets must be cared for.  Cancel any services like phone or internet services that are no longer needed. Close all financial accounts that are available

If the deceased is employed, inform the employers. He or she may be entitled to some benefits, so make sure to do this early as it can help in your initial planning.

Doubting Thomas

In the Bible, there is the well-known story of the apostle Thomas, a man who doubted the resurrection of Christ. He tried to look for evidence by saying, “...unless I see the wounds on His hands, I will never believe.”  Of course, we know that his Master eventually showed Himself to Thomas and let him touch and feel His hands. He also said – “...you believe because you have seen Me. Happy are those who have not seen and yet believe…”

We are beset by many doubts in our existence. This may be due to our desire to make sense of the environment we are in. Humans are naturally inquisitive, looking for reasons in things. However, there are also times when we throw away all reason and jump in without thinking much. Love, for example, makes us do this.

Scientific reasoning and the instilling of doubt makes us question how things are done, and this makes us understand things better and innovate. In the case of vaccine development, we are now beset with doubts on its efficacy. There are also discrepancies in the research findings for the vaccines, but will this stop us from procuring them?

We may not have much of a choice given the existing circumstances.

Doubts are part of how we humans are wired to decipher and comprehend what is in existence. It is this inquisitiveness and critical thinking that separates us from other animals. It is also our curse, when we second guess ourselves due to external influences. Sometimes we just need to follow our gut and hope for the best.

To erase doubt, one has to find out the consistency of outcomes. Will it be the same even if the process were to be repeated? This we can see by the number of samples analyzed, or the number of witnesses who testified to the veracity of the event.  The facts that can be gathered must also be subjected to scrutiny before they are disseminated to ensure that they are authentic. This is how we are able to counter the effect of fake news.

Now, there are situations where doubt is instilled. Fake news items are one, and they can be particularly harmful to the uninitiated. The irresponsible spread of misinformation creates a scenario of disbelief that can poison the efforts of those seeking for truth. This is why those with knowledge and integrity must work doubly hard to dispel these non-truths. It is these people with integrity whom we must believe and not those who seek to spread chaos and uncertainty.

Another thing that can provide the seeds to remain doubtful is the inconsistency of decisions and outcomes. When there is a discrepancy in the things that are said and done, there will be doubts, and it would take more effort to correct the fallacy. Just think about how inconsistencies in relationships can spell doom for couples or business partners. We must make every effort to analyze these outcomes not just based on singular findings, but on how consistently they come out.

Finally, there is always a science to reason based on logical-mathematical reasoning. In the eyes of an ordinary individual, some facts may be twisted by emotions or biases. But science can remove those blinders, making the results more objective and believable. The progress that we now have in the medical field is brought about by this untiring adherence to the scientific method. If medicine did not progress to become more evidence based, who knows what kind of treatments we may be made to suffer all because of some unfounded practice?  Science has made the art of treating disease result in better outcomes.

 But science can remove those blinders, making the results more objective and believable.

However, where science ends, there is this one aspect that can erase doubt. Thomas experienced this. And we have too. The overwhelming love that we experience can erase all doubts as to what is truly essential.

And when we seek the truth, at times, we make this leap of faith. That faith is what will eventually save us all.

 

Gene Therapy In Hospice Care

As I was reading some articles on gene therapy, I was astonished at how far we have progressed in pursuing applications of this technology. Immunotherapy, oncolytic virotherapy, and gene transfer has been revolutionary, and there is no let-up in the number of researches being done. Using genetically modified cells or altered DNA sequences from different viruses, common cancers of the lung, pancreas, and prostate may be given another chance for survival. Considering that the 5-year survival rates of these diseases hover around 5 to 15 percent, any increase in the life span could mean a lot to these patients.

According to Christine Karim, “It is tremendously rewarding to see how our work, starting in the test tube, can positively impact society by creating the groundwork for new medical treatments.” The beauty of gene therapy is that it treats the problem right at its source. As current treatments have a lot of adverse effects, it offers a ray of hope for those who feel resigned to the ravages of tumor metastasis. These methods can alleviate death and suffering once they are developed and incorporated into mainstream medicine.

“It is tremendously rewarding to see how our work, starting in the test tube, can positively impact society by creating the groundwork for new medical treatments.”

— Christine Karim

 Mechanisms to decrease cancer aggression include lysis of the tumor cells, decreasing the blood supply of the neoplastic cell, and introducing genes that will restore the normal phenotype. In other words, gene therapy may not kill the cell directly like chemotherapy does, but it will cause subtle changes that will annihilate the cancer.  Gliomas, pancreatic cancer, and liver cancer are leading candidates for these types of treatment.

Just as in any new modality, there are safety concerns. Patients have died due to gene therapy in the past. While the death was not due to gene therapy for cancer, but due to a metabolic illness (a urea cycle deficiency called ornithine transcarbamoylase defect), safety remains of paramount importance. Flu-like symptoms, just like that being experienced by many who have taken the COVID-19 vaccine, are very common in gene therapy.

At present, gene therapy is being used to create recombinant cancer vaccines. Unlike for infectious diseases, these vaccines are meant to provide cure, not prevention.  The immune system is trained to recognize the cancer cells by presenting it with highly antigenic and immunostimulatory cellular debris. Cancer cells may be harvested from the patient (autologous transfer) or from established cancer cell lines. Cytokines may also be enhanced by gene therapy to recognize the abnormal cells as foreign bodies. Hopefully the genes would produce proteins that will promote synthesis of antitumor antibodies.

The challenge in the medical community is to utilize these processes prudently. They give hope, but they are not yet accepted as mainstream treatment. The issues of safety and beneficence need to be revisited, not to mention the justification of the expense involved for such novel treatments. There are stories regarding unproven alternative methods which are quite expensive, and in the wrong hands, these genetic technologies may be manipulated for selfish motives.  It is quite disturbing to think that one would take advantage of the desperation that hospice and palliative care patients are feeling, and giving them unwarranted treatments could erode their trust in the medical field.

In due time, targeted therapy for cancer will become the norm, changing the lives of patients with cancer and other chronic illnesses. We still have a long way to go to realize this, but it may be sooner than we expect. After all, the survival of the human race rests on the creativity of those who are in it.

Vaccine Hesitancy

Should I get the COVID-19 vaccine?

This might be a burning question in your mind today. With news of the COVID-19 virus having some unsavory side effects, one cannot but feel anxious whether to have it. After all, we have just been recently paralyzed with a vaccine scare for Dengue Fever that affected our belief in the vaccination program, in general.

Added to this dilemma is where the vaccine can be procured. We want to live out our lives as before, with social interactions unhindered. But fears surrounding the vaccine are circulating, and it is difficult to make a decision whether to have the vaccine or not.

In some countries, vaccination is in full swing. Some are being prioritized, such as the frontline medical personnel who are deemed most vulnerable. Though initially unsure of the consequences, they readily accepted the challenge of being the first recipients of the FDA-approved shots. In India, however, it was reported that some vaccines go to waste because people do not show up as scheduled. To address this, even unscheduled participants are now being accommodated for immunization. “Each vial has 10 doses, and if only five people are coming, either we have to deny vaccination for these five people or waste five doses,” said Tamil Nadu’s director of public health and preventive medicine Dr. T.S. Selvavinayagam.

Let us try to look into the issues and see whether they are based on facts.

First, the adverse effects being reported so far are not alarming. News on some deaths were found to be due to an underlying medical illness, not brought about by the vaccine. Most of the adverse effects are due to injection site reactions, which are expected, and which usually go away in a few days. The adverse effects of COVID-19 vaccine are mainly local ones including pain, itching, and redness (1).

Now comes the benefits. According to studies, the available vaccines have an efficacy that hovers around 90 percent or even better. Another vaccine candidate has a lower efficacy rate, but it is preferred by certain government sectors.  Could science shed more light on this discrepancy to make us have better decisions? Definitely.

Source: https://www.statista.com/chart/23510/estimated-effectiveness-of-covid-19-vaccine-candidates/

The hesitation comes from our inability to remove the noise and find what is relevant. Science will do this. It will remove the extraneous variables and focus on the truth. When decisions are based on scientific knowledge and not hearsay, you can be sure that whatever the outcome is, it will be consistent. Consistency produces results. Ask any athlete or marketing professional, and they will tell you how consistency produces the outcomes they desire.

Just believe in science. Shun the fears and unfounded factoids away. Remove the hesitation with evidence.

SOURCE:

Yuan, P., Ai, P., Liu, Y., Ai, Z., Wang, Y., Cao, W., Xia, X., & Zheng, J. C. (2020). Safety, Tolerability, and Immunogenicity of COVID-19 Vaccines: A Systematic Review and Meta-Analysis. medRxiv : the preprint server for health sciences, 2020.11.03.20224998. https://doi.org/10.1101/2020.11.03.20224998

By-Product

Everything is now online. Marketing businesses have gone to this route especially during the pandemic. It is said that most businesses today can no longer survive without an online presence.

This also included artists. We have seen most of them being more active in social media these days. Particularly for those from a major television station that just closed its doors.

Why is this so? When you are selling something, there is always a by-product of what is peddled. And this by-product can be extended to include more potential clients, more satisfied individuals, and more sales. This is called influence. And physical presence is not needed for this.

As a physician, there is a mindset that the only product that one has is the ability to heal. It may be the physician’s most lucrative business. But that is no longer true today. A doctor can create online teaching materials. Just look at Dr. Willie Ong, who earns more through his YouTube channel. Or a physician can write a book on his or her experiences. It does not have to be limited to non-fiction, but one can venture into fiction as well.

This is what we now have with the advent of technology, and even with a pandemic, one’s influence remains because our world has now become interconnected.

But with this comes greater responsibility. To ensure that only the truth comes out. To acknowledge your source of information. To make sure that your message reaches the right people. Companies and individuals must be conscious of this.
The best by-product of being a physician is influence. Just as marketing professionals try to exert influence to sell a product or service, it is actually a doctor’s influence that spurs patients to action. The mere act of going to a doctor for a medical consultation is a chore, even if it is done online. What would happen if a doctor does not recognize this reality and nonchalantly tries to rattle off one question after another without empathy? Can you make a person comfortable during a physical exam? Can a doctor truly make a patient feel her compassion even if the encounter is done virtually? How is this influence utilized to improve treatment outcomes?

This aspect of healing becomes even more important at the end of life. How can you give hope to the hopeless? How can you create an environment of joviality in misery? No amount of training can actually create this ability. It is simply inherent in a physician’s DNA. It is there. It simply has to be expressed, like a promoter unwinding the cell’s gene to unlock its potential.

We have heard of the placebo effect and its negative connotation. It is time to use the placebo effect for a positive outcome. In this day and age, when technology has started to take over most of human function, there is something that gadgets and equipment can never replace. It is the healing power of the human touch. Healing is the by-product of the physician’s heart.

Cytokine Storm

Jennifer R. Tisoncik et al. Microbiiol. Mol. Biol. Rev.2012; doi 10.1128/MMBR.05015-11

During this COVID-19 pandemic, a lot has been mentioned in popular media about a cytokine storm. It is said that most mortalities due to COVID-19 are attributed to this biological phenomenon, where the body’s immune response is overwhelmed by an infectious agent. Though mounting an immune response is the body’s normal reaction when bacteria or viruses enter the system, too much reactivity may result in organ damage and eventually death. Thus, one of the therapeutic measures undertaken to combat the cytokine storm is to slow down its progression.

The first use of the term “cytokine storm” appears to be in an article published in 1993 on graft-versus-host disease after a transplant operation. Its subsequent use in infectious disease began in early 2000, most especially when SARS-CoV 1 became a pandemic. Normally, when the human body encounters a germ, the immune system attacks the invader and tries to neutralize it. Sometimes, the army of defenders behave out of control, transforming in a “stormy” aftermath. Variants of this hyperactive immune reaction occur in an array of conditions, triggered by infection, faulty genes, or autoimmune disorders (where the body thinks its own tissues are enemies).   

The term "cytokine" is derived from a combination of two Greek words - "cyto" meaning cell and "kinos" meaning movement.  Cytokines are cell signaling molecules that aid cell-to-cell communication in immune responses and stimulate the movement of cells towards sites of inflammation, infection and trauma.  Most are produced by T-helper lymphocytes, but other cells can also produce them.

During an innate immune response to a viral infection, pattern recognition receptors (PRRs) recognize different molecular structures that are characteristic to the invading virus. These molecular structures are referred to as pathogen associated molecular patterns (PAMPs).  The binding of PAMPs to PRRs triggers an inflammatory response against the invading virus resulting in the activation of several signaling pathways that trigger gene expression. Once the gene is expressed, cytokines are generated.  

When the cytokines that raise immune activity become too abundant, the immune system may not be able to apply the brakes. Immune cells spread beyond infected body parts and start attacking healthy organs, destroying red and white blood cells, and damaging the liver. Blood vessel walls open up to let immune cells into surrounding tissues, but the vessels get porous. The lungs start to swell with fluid, and blood pressure drops. Blood clots may form throughout the body, further compromising the circulation. This is the reason why we hear a lot of those who perish from COVID-19 report signs such as bleeding, pallor, lowered blood pressure, and of course, breathlessness.  Most patients experiencing a storm will have a fever, and about half will have some sort of nervous system symptoms, such as headache, seizures or even coma.

The solution to a storm is to quiet the destructive immune response. Steroids are often the first choice of treatment, so a lot of these drugs are given. There are also medications that interfere with specific cytokines, and because of their specificity, they may produce less side effects. None of these are guaranteed cures. Factors such as genetics and other medical conditions such as Diabetes Mellitus and heart disease can complicate matters. The biggest trick in a cytokine storm is to recognize it, and treat it early. However, you have to balance the benefits of a drug with the risks. Thus, these treatments are only given in advanced disease states.

SOURCES:

Tisoncik JR, Korth MJ, Simmons CP, Farrar J, Martin TR, Katze MG. Into the eye of the cytokine storm. Microbiol Mol Biol Rev. 2012;76(1):16-32.

Sherwani S, Khan MWA. Cytokine Response in SARS-CoV-2 Infection in the Elderly. J Inflamm Res. 2020;13:737-747.

Zhang W, Zhao Y, Zhang F, et al. The use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (COVID-19): The Perspectives of clinical immunologists from China. Clin Immunol. 2020;214:108393.

Bucket List

Recently, I published my first book on Amazon Kindle. “Unrequited” is a story of life’s ups and downs, told in poetry form. As poetry seems to be a “lost literary form” in this day and age, the Shakespeare in me was jolted into completing it during this time, as I was always home.

During my interview with Mr. Anton Diaz, I was asked about my inspiration in writing the book. It is a conglomerate of various experiences, which may not necessarily be mine. Being an observer of life’s struggles and triumphs enables me to put myself in another persona – what would I do when I am in someone’s shoes? Perhaps my training as a family physician and my exposure to hospice patients helped me develop this skill.

But more than any skill, the key to writing a book is not inspiration or desire – but a determination to finish it. Setting an exact date to finish is key, and scheduling time to write is important. Word by word, page by page, the story comes to life – never mind the grammar, initially.  There is a tendency towards perfectionism, but this desire must be rejected, for no book is too perfect (except the bible, and even this is subject to debate).

What is in your bucket list?

Is it written on any piece of paper, or in an electronic file? If not, write it down. Lists or anything in print, which can be seen, has a way of spurring people into action. It also helps us remember. This is why I also love the Notes App on my smartphone. When a sudden thought comes to me and I do not have a pen, I can simply type away.

So what do you put on your list?

The movie Bucket List starring Jack Nicholson comes to mind. It may be an adventure. Or a project. An unfulfilled wish. It may not matter if it is truly attainable – this list is for inspiration. If it becomes reality – great! If not, the fact that it was written may have pushed you to go for it – and you learned through the process. You can revise the goal to something more realistic later.

What must we aim for when creating a bucket list?

Ultimately, we want to be remembered, but there must be something more to that. Extend the goal to something that does not just benefit you. It must benefit those around you. It may sound simple to you, but it may be a big deal for those whose lives you touch.

“Unrequited” is not just for me. It is for those who have struggled. It is for those who have won and lost. It is for those in the depths of despair. For those who have not been given a response. People who have gone through life and wonder what direction to take when things turn out for the worse. Its last part, “Love Is Hopeful”, brings out the goodness in all of us. For where there is hope, there is a way. And the truth is, The Way has always been there, since the beginning of time. And that is The Word.

Can Vitamin D Supplementation Reduce the Risk of Influenza and COVID-19?

Around the world, Covid-19 has been a menace. It has disrupted our lives. We may not see the world as we used to for the next couple of years. Public health practitioners, researchers, and doctors have been working overtime for a cure, but it may have to come in the distant future. Wearing personal protective equipment and social isolation is the only thing we can do against this invisible enemy. But can we do more?

There has been an ongoing clamor among certain sectors to look into the possibility of preventing infection through Vitamin D supplementation.  Can it lower viral replication rates? Several small scale studies seem to suggest that it’s worth the try. And the fact that the outbreak started during the cold season gives credence to the possible role of sun exposure and its effect on our ability to synthesize this vitamin in our bodies.

To reduce the risk of infection, it is recommended that people at risk consider taking 10,000 IU/day of Vitamin D3 for a few weeks to rapidly raise vitamin D levels in the body.

Here are some important facts that we must remember about Vitamin D, which we can remember through the acronym C.O.VI.D.:

1.     Vitamin D is important for Calcium absorption. That is why some Vitamin D supplements come with calcium supplementation. It is important to maintain bone health, especially among post-menopausal women. But you do not have to wait for menopause to shore up on your calcium stores.

2.     It is the safest fat-soluble vitamin in terms of the probability for Overdose. Hypervitaminosis D is rare, although it could be serious. And you can never overdose from Vitamin D through excess sun exposure.  It is only through over supplementation that overdose can happen.

3.     Viral infections can be reduced by vitamin D.  Vitamin D is said to act as a physical barrier and an enhancer of cellular and adaptive immunity. Vitamin D helps maintain the integrity of inter-cellular junctions.  Vitamin D enhances cellular innate immunity partly through the induction of antimicrobial peptides.

4.     It comes from Dehydrocholesterol. Yes, the cholesterol in your body that is stored underneath the skin is the initial substrate for Vitamin D synthesis in the body. The reason we need sunlight is because it activates the process leading to the formation of Vitamin D. The liver and kidneys are also involved in the process, so if you have liver or kidney failure, you may need supplementation.

As Filipinos, we are indeed blessed to be living in a tropical country. Let us take advantage of this by increasing our exposure to sunlight in the right amounts. If we cannot do this or if sunlight is not enough, we can take Vitamin D supplements in the recommended amounts. Just remember that as in most things that are beneficial, we must combine this with a healthy diet and a good amount of physical activity and rest.