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Zoom Group Meeting November 24, 2020

November 24, 2020 4:40 pm

The link to the slides is here.Zoom-Leture_11_24-2020 CDC guidelines for wearing masks are available here. Link to CDC website.   What is PCR – Polymerase Chain Reaction:   Types of Vaccines…. “The final two vaccine candidates (from Moderna and BioNTech/Fosun Pharma/Pfizer) are mRNA vaccines. What are those? First it helps to remember that DNA is the gene and RNA gives instructions for certain proteins. So an mRNA vaccine is the instructions for the SARS-CoV2 protein. Once inside the cell, the protein is made and that triggers the immune response. Just like the vector vaccines which use viruses to deliver the protein instructions, here you are delivering the instructions alone. It’s another way of getting the protein made inside of you. Is there any risk of getting COVID-19 or COVID-19-like side effects from these vaccines? When people talk about side effects of a vaccine, people often believe you’re getting a weaker version of the virus and a minor version of the disease. That is not what these things do. Most vaccine side effects — which include anything from a sore arm, to feeling warm to muscle aches — are a sign of the immune response. It’s not that you get a mild form of the disease. That’s important to be clear about. People keep a very close eye because you want to make sure these vaccines are safe.” https://labblog.uofmhealth.org/rounds/top-5-covid-19-vaccine-candidates-explained

Healthcare in US

October 04, 2020 9:44 pm

The discussion has been ongoing for years about the status of healthcare in the US. Some support universal healthcare for all; some say they are against any healthcare mandate and yet demand affordable subsidies care when needed. Then, a tiny subset of the population genuinely believes in individuals’ choice and responsibility for their healthcare and well-being. This subject of US healthcare has been studied by non-partisan groups in and outside the US at great length. The Experts at The Commonwealth Fund published a report in July 2017 which continues to be relevant today. Schneider_mirror_mirror_2017_Appendices

Zoom Group Meeting

September 21, 2020 7:10 am

We are excited to announce we will be having a Zoom group meeting Tuesday, September 22, 2020 at 7:00 PM PST.  We hope to see you online!

Registration is required. Please follow the link to the meeting registration.

Topic: Group meeting question and answer
Time: Sep 22, 2020 07:00 PM Pacific Time (US and Canada)
Join Zoom Meeting
These meetings are for general topics and/or basic question and answers.  If you need a more in-depth meeting we would suggest a video or in-person consultation with Dr. Keshishian.  You can request a consultation via this link.  Contact Us

What is Corona Virus?

September 17, 2020 1:37 pm

At a highly technical level Viruses are considered non-living materials. Viruses can not replicate and reproduce by themselves. Therfore, they need to attach themselves and penetrate a living organism to allow multiplication. Double Stranded Viruses include smallpox, Chickenpox and Herpes simplex. Single Strand Sositive Sense Virus in varies groups include HIV, and  Corona Virus. Specifically, Corona virus is a Single Strand, Enveloped Helical Virus. The classifications of the viruses are based on their shape and the mechanism of attachment to the host cell. There are differnt classification of virusrs described. Viruses have cuased more death in the human history than any other diseases. However with vaccination, and public health policies we have been able to eliminate certain deadly viruses.

Covid-19 Mutation – Please physically distance and Wear Masks

August 18, 2020 1:16 pm

Introduction:

There is evidence emerging of Covid-19 mutation. This may explain the difference between the severity and intesity of the disease presented in the those geographical locations where the disease  first.

Scientists from The Scripps Research Institute, Jupiter, Florida have identified changes in the Spike protein. This protein is used to bind the virus to host membranes. As we now know Florida is one of the few hot spots of the Covid-19 pandemic.

This has significant implications for the long term strategy needed to control transmission and manage resurrgence.

Until there is effective vaccination or effective treatment available for everyone, prevention by wearing face mask is the most efficient form to avoid transmistion.

Prevention:

The facts are that the most consistent effective preventive measures are wearing face masks and physical distancing.

There are those who may feel invincible and think that you will 1. either not get the disease or even if you get it it will 2-not affect your health.  Lets first remind ourselves that wearing a mask is more to prevent passing the virus that getting it. We should all assume that someone that we come in contact with may already have it. Would you like them to breath the virus toward you ? This then brings the second issue: We do not know what the long term health effect of the virus is for those who develop significant symptoms and those who are asymtphomatic.

The unkown:

Let’s look at other viral infections that provide either no or minimal disease condition at the time of initial exposure only to result in long term health conditions that may result in death. These include hepatitis and HIV exposures and infections. Admitedly  Coronavirus is a differnt family of virus. I am not suggesting that this will behave like other family of the viruses. We just do not have enough information to know what happens to those exposed to the virus (regardless of being asymptotic or not). Could the virus become dormant and over time result in organ injury (lung) like in the case  of hepatitis (liver). Or make a home in our body and have recurrent debilitating infections and symptoms as it is seen with Varicella-zoster virus (VZV) which causes chickenpox and the time of the initial infection and makes residence in our body to reappear later on as herpes zoster (shingles). Will we need a new strain of vaccine every year similar to the flu vaccine?

That is the crux.  We do not know because the COVID virus is new and we do not know the long term effects.

Vitamin D and COVID 19

June 13, 2020 4:40 pm

There has been extensive discussion on the importance of Vitamin D published over the last few years in regards to bone health, immune health and Calcium physiology. The importance of vitmain D and bone structure has been discussed extensively. It is also important in the absorption of Calcium. It further plays role in immune modulation.

What is new is the possible correlation of Vitamin D and COVID 19. Recently it is been shown that low vitamin D may increase the risk of a poor outcome with Covid-19 exposure and infection.

There are different standard recommendation for the Vitamin D levels.

In our practice we aim to maintain a Vitamin D level of 0ver 60 in post weight loss surgical patients.

There are a number of theories as to how the Vitamin D deficiency may play a role in this. An emerging observation is that low Vitamin D may cause abnormal and excessive blood clot formation. Mohammad et. al. in 2019 published a study on the association of low vitamin D and “…Pathogenesis of Thrombosis”

This pathologic blood clot formation in COVID-19 patients may explain the extensive lung injury and  multi system organ failure in some patient. It is also one of the reason that some COVID-19 patients have loss limbs or appendages.

Please follow all supplement recommendations based on your laboratory studies and all COVID-19 recommendations. We would recommend frequent hand washing, surface cleaning, social distancing, and wearing face masks as the most basic precautions and increase precautions based on your health status.

Vitamin D and Covid -19

May 07, 2020 9:24 am

We are all aware of the many roles that Vitamin D plays in our bodies. This includes immune function in addition to all the regulatory roles that Vitamin D plays in several physiologic reactions. There may be a correlation of low Vitamin D and COVID-19 infection increasing death risk as looked at in research articles.

Covid -19 in a subset of patience causes significant lung injury. These patients require mechanical ventilation.

Previously reported publications have suggested a possible correlation between ace inhibitors and increased risk of pulmonary complications of Covid -19. Some researchers suspect that the Covid-19 may be able to enter lung cells by the ACE receptors.

Shown is the initial entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into cells, primarily type II pneumocytes, after binding to its functional receptor, angiotensin-converting enzyme 2 (ACE2). After endocytosis of the viral complex, surface ACE2 is further down-regulated, resulting in unopposed angiotensin II accumulation. Local activation of the renin–angiotensin–aldosterone system may mediate lung injury responses to viral insults. ACE denotes angiotensin-converting enzyme, and ARB angiotensin-receptor blocker. (N Engl J Med 2020; 382:1653-1659)

Vitamin D may positively implact the receptor ACE2. This study, report clear correlation between the high death rate with low vitamin D levels in Covid infected patients. There are limitation to this study that the attached abstract outlines.

Our take home message would be to please make sure you have updated labs and that you are all taking the recommended Vitamin D based on your surgical anatomy and laboratory values, not just an average non-bariatric person recommended dose.

https://www.dssurgery.com/wp-content/uploads/2020/05/manuscript.pdf

Copper Metabolims And Weight Loss Surgery

May 01, 2020 12:31 am

Written By: Osheen Abnous, Maria Vardapetyan, Eric Baghdasaryan

Copper is an essential element to all organisms, and it is a contributor in several enzymes vital to the function of hematopoietic, vascular, and skeletal tissues, as well as the structure and function of the nervous system. 

As a crucial metal, copper plays an important role in chemical reactions throughout the human body; this includes the central nervous system. Enzymes are substances that facilitate chemical reactions. There are many copper-dependent reactions in the human body.  In humans, the major site of absorption of dietary copper is still unclear.  Copper in humans is absorbed in the proximal small bowel, duodenum, and ileum. This is after it has passed the acidic environment of the stomach.

Copper deficiency can be caused by malnutrition, prematurity, parenteral or enteral feeding without copper supplementation, gastrectomy, and excessive zinc therapy. The common causes of copper deficiency have been zinc supplementation,  and changes to the PH (acidity) of the stomach. This can be the result of the alteration of the stomach anatomy, and by chronic acid suppression by proton pump inhibitors (antacids), and similar medications. Physicians need to be alert with patients who show signs of copper deficiency or are at a high risk of developing a copper deficiency. 

It is important to raise greater awareness about copper deficiency because there is a growing number of patients undergoing surgeries for obesity, as the occurrence of copper deficiency will increase in the future. 

Studies of patients who have had weight loss surgery in the past experience common symptoms such as pain involving the feet, gait abnormality (unusual walking), lower limb weakness, and recurrent falls. Common lab results include unusually low serum copper and serum ceruloplasmin levels. In some cases, elevated zinc levels are also present. Treatment includes cupric sulfate infusion until normal copper levels are reached, which then need to be maintained for the future. Vitamin B-12 deficiency has also been reported as a possible cause of myelopathy, which is a nervous system disorder that affects the spinal cord. As stated earlier, neurological damages are often irreversible and cause permanent damage to patients. Early diagnosis from physicians is crucial for patients who have undergone gastric bypass surgery, and the sooner they are diagnosed, the less permanent damage the patient will endure.

Case Discussions:

A 49-year-old woman had gastric bypass surgery for obesity 24 years age. She presetend with increasing lower limb stiffness and numbness. Additionally she reported tingling of the feet. As her pain continued to increase, she began using a walker, and her symptoms continued to worsen. After undergoing a neurological examination, results showed that the patient had increased lower limb tone and an absent perception of vibration at the toes and ankles. Laboratory results showed that the patient had copper levels barely detectable. This included serum copper and serum ceruloplasmin levels. In addition, the patient had reduced serum carotene (vitamin A) levels. 

The patient received cupric sulfate intravenously daily through an 8-week period. After each daily infusion of cupric sulfate, the patient reported to have slight decreases in numbness and an increased tingling sensation. After the 8-week period, lab results showed that serum copper levels were normal and are needed to be maintained. Her night blindness was corrected by vitamin A injections.

In another case, a 53-year-old woman had symptoms of abnormal gait (abnormal walking) and anemia (lack of healthy red blood cells), and was seen for evaluation. The patient complained of pain in the lower legs, which would worsen over time and move up towards her thighs. As her ability to walk continued to worsen, the patient resorted to using a wheelchair. Her medical history consisted of an RYGB surgery for obesity. The only significant supplementation she received was 1000 μg vitamin B12 subcutaneously for several years. She had absent positional and vibratory sensation in the lower extremities to the knee. In addition, touch sensation was decreased. Laboratory examination revealed an elevated serum zinc level, and extremely low serum copper and ceruloplasmin levels.  

For treatment, the patient received intravenous copper over a 6-day period, was discharged home, and then received weekly intravenous copper infusions thereafter. After a month of receiving intravenous copper, serum copper levels returned to normal. In addition, the patient’s pain in the lower leg improved, but vibratory sensation remained absent in the same area. Four months after being discharged from the hospital, the patient began walking with a cane.