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Category: COVID-19

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.”

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


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.


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.

Why Oxygenation in Covid-19 is a major problem

April 21, 2020 7:27 am

Covid-19 is a respiratory virus. The majority of patient may experience no or minimal symptoms. But small subset of those infected will unfortunately progress to have significant pulmonary dysfunction. Some will even require mechanical ventilation. Oxygenation in COVID 19 patients with severe symptoms is altered. This is the due to the changes caused by the virus.

Normal Physiology

Oxygen (O2) is exchanged with Carbon Dioxide(CO2) in the lungs. The CO2 is exhaled and the O2 is taken up by the blood. This high O2 continuing blood is then pumped to every single organ. With complete distribution network of capillary vessels, every cell then gets access to the O2 rich blood. Hemoglobin is the carrier that transports the O2.

The O2 is removed and dissociated from the Hgb  depends on a number of variables.  Each red cell Hgb has four binding site for the oxygen. The  affinity and strength of each one of those four units for oxygen changes based on a number variables. These are CO2, Acidity (PH), DPG and temperature.

Model of 2,3 DPG

Oxygen Dissociation Curve

The oxygen dissociation curve has a long “S” shape. On the low end of oxygen in the blood most of the Hgb site are occupied. As the oxygent level increase there is little change to the saturation.

Normally the relationship of the blood in the lungs (horizontal axis) and the amount of the O2 in the red cell (vertical axis) is following the red line. When the amout of oxygen insired is 25mmhg  the blood saturation is at 50% (A). The blood saturation is nearly 100% when room air is inhaled (C). Room air has PO2 of  75mmHg.  Note that there is very little change in blood saturation (SaO2) by increasing the PO2 from 75 to 100 mmHg (the red line is horizontal between 75-100).

Another way to look at this: If you increase the PO2 from 25 to 50 (doubling)  the Saturation goes from 50 (A) to nearly 85(B). Whereas increaseing the PO2 from 50 to 100 (doubling) only mober the Saturation from 85(B) to 100(C). This shows the efficiancy of system to be able to deliver the most amout of oxygen to the tissue even with the low level of oxygen present in the lungs.

As the Green and the Blue lines demosntrate the balance can change by changes in CO2, Acidity (PH), DPG and temperature.


When it comes to COVID-19 illness there may be a number of factors in play. Most patients with pre-existing conditions already have changes that may shift the curve to the right (high fever and high Co2). Furthermore, obesity, asthma and other conditions may decrease the ability to clear the lungs of secretions and mucus may contribute to decreased oxygenation. Additionally, there is significant inflammation associated with the chemicals released in COVID-19 (cytokines). These can cause devastating changes to the ability to exchange oxygen in the lungs.

Oxygenation in COVID-19 severely symptomatic patient can deprive oxygen from organ. This can  progress to organ failure.  One of the most common organ systems to fail is the kidneys which may require dialysis.

Symptoms of Coronavirus

April 15, 2020 8:10 pm

Symptoms of Covid-19 are broad. Thus a subset of patients present with different symptoms.


As the table demonstrates, there is not a clear clinical picture to distinguish betweem Covid-19 and other similar upper respiratory conditions early on. This is why testing is critical for the entier population. This will lead to identification of those at risk. Furthermore, It will also help with early and selective vacination when one becomes available.

Covid-19 Pandemic and Obesity

April 12, 2020 7:44 pm

We have now seen several articles with data collection regarding patients with obesity and COVID-19 being at greater risk of hospitalization.  We can look at metabolic syndrome associated with obesity as a risk factor also.

We have all been in physical isolation due to Covid-19 pandemic. The strategy of minimizing contact has worked. The data is clear when comparing information from states that instituted an aggressive containment plans compared to those who have not. This shows a sigifnicat flattening of the curve in California for example.

The CDC publishes the Morbidity and Mortality Weekle Report (MMWR) . The latest publushed summary (as of date of publucation of this blog) provides an insight to the risk factors of hospitalization.

The above table outlines the underlying conditions of those hospitalized with Covid-19.

Concerning to see that a respiratory virus is more likely to hospitalize those with Obesity, Diabetes and hypertension at a higher rate than lung and pulmonary related conditions.

Let us recognize that this is only a summary collected data. Therefore, there are limitatation to making any assumption of conclusion based on this information.

With those limitation aknowldged, and relying on our obesity related comobidities, we can make a few conclusions:

Not surprising, Obesity as with other diseases, compounds Covid-19 exposure and infection. Diabates is also a risk factor. There are no indepth information available on the diabetic patients. There is now data showing superior outcome of diabetes resoultion with weight loss surgery compared ro medical treatment.