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Invermectin: Knowing what we don’t know.

People have asked me why I have been unusually silent on the use of “Ivermectin” the supposed wonder drug for preventing and treating COVID.

The answer is simple: Just like most business people would not advise investing in something they don’t understand, I don’t believe doctors should prescribe a drug unless they know is likely to work for the condition for which it is prescribed and also that it is likely to do more good than harm…especially when there is a good alternative that we know actually works (steroids).

Also, since this drug is really meant to be used as a worming medicine in dogs and horses, and since my patients are not dogs and horses, I have remained mute on a subject which I feel most human doctors know little about…. I have been especially reluctant to prescribe or agree that it should be used when the WHO says it should not be used outside of a (good) clinical trial. In fact, alarm bells rang for me when even the manufacturer of the drug themselves  said it should not be used for COVID 19… and surely they would love it if it was in widespread use as this would mean more profit for them?

I have been trying to learn about it of course…I have read about it. I have even taken part in webinar discussions with other doctors about whether we should be using it.  After all, they said, it seems that it is almost “in the water” in India and it has been widely used in Egypt. So what’s the harm right?

Well, please let me share with you what I have learnt:

I said doctors should not be prescribing drugs unless:

1.They know they work for the condition prescribed

2.They do more good than harm

3.There is not a better known alternative that works.

UNLESS OF COURSE THE USE IS PART OF A CLINICAL TRIAL TO ANSWER THESE QUESTIONS.

Unfortunately, one of the biggest “trials” claiming the effectiveness of Ivermectin against COVID, The Elgazzar trial out of Egypt has recently been found to have major discrepancies in it’s data, according to an article published in the Guardian UK. The data flaws were actually uncovered by a medical student who went so far as to wonder if the data had been faked. This led to the trial being withdrawn from the website “Research Gate” where it was released. If you are interested here is a link to that Guardian article.

https://www.theguardian.com/science/2021/jul/16/huge-study-supporting-ivermectin-as-covid-treatment-withdrawn-over-ethical-concerns?CMP=Share_iOSApp_Other

In the meantime, Cochrane did a review of 14 randomized controlled trials (the gold standard in trials) and found no scientific evidence to recommend Ivermectin for COVID 19. Cochrane is an independent, international organization that reviews medical research. Interestingly they excluded both the Egyptian trial and another big Argentinian trial because they did not think the trials were of good enough quality to be included.

The good news is that there are 2 very good quality trials still ongoing that may provide us with the answer we would of course like to hear: These are the The PRINCIPLE trial out of The University of Oxford, which is looking at whether taking Ivermectin keeps people with COVID 19 out of hospital, and the other is the ACTIV- 6 study being run by The National Institute for Health.

What I find so fascinating is the fact that the Elgazzar study was so widely quoted despite glaringly obvious data discrepancies! This just goes to show, that when we are in desperate times, aka a Pandemic, that even doctors will believe what we want to see – so let’s not make that mistake again! Let’s wait to see, in a calm manner what the real data, which is being properly measured in a clinical trial, shows us, rather than relying on anecdotal evidence from people, some of whom have no medical background what so ever who are selling Ivermectin in Trinidad and Tobago.

Maybe, we will find out that Ivermectin does work, but unless we do, let’s remain calm and take what we know about please. If we had no other choice, I could maybe understand its use, but the fact is we DO have alternatives.

What we DO KNOW is that Vaccinations DO keep people out of hospital. So don’t take Ivermectin to prevent COVID 19 instead of a vaccine please!

We also know that steroids save lives in severe COVID if taken at the right point in the disease for Cytokine storm only. If taken too soon for mild disease they can actually make things worse. Short courses of steroids do not cause the long term harm that we often hear about. Therefore you should only take them when told to by a doctor.

And remember, the most important thing your doctor can know is what they DON’T know! It is the first step to finding the truth.

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So What is the “Sinopharm” Vaccine and Should you Take it?

This is a COVID 19 vaccine made by the Chinese state company “ Sinopharm”. It’s real name is BBIBP-Cor V. It is not to be mixed up with other commonly exported Chinese COVID 19 vaccine called the “Sinovac” vaccine.

Does it Work?

Trials by the same state owned manufacturer have given it an efficacy rate of 79%. On May 7th the WHO approved it for emergency use in people over age 18, and claimed an efficacy estimate of 78.1%. I am not sure what if any additional tests they have done on it. They did state that it had not been tried in very many people over the age of 60, but they have no reason to believe that it will not work in these age groups also. Research as yet, has not been published in peer reviewed journals.

How does it work? 

They basically take dead coronavirus that cannot make you sick, and cannot replicate and use it to trick your immune system into making antibodies and memory T cells to it. That way, when you meet the virus for real, your immune system will remember it and mobilize its army before the virus has time to make you ill. This is a very traditional way of making vaccines, and unlike the MRNA vaccines like the Pfizer vaccine, is not new.

How many doses is it? 

2 doses and it can be stored in the fridge.

What are the likely side effects?

Similar to all vaccines, the most common side effects are a slightly sore arm the next day; tiredness, headache and mild fever. All vaccines carry a risk of allergic reaction but there is no reason to think this risk might be higher for this vaccine.

How many people have had it so far? 

There have been 65 million doses given so far. It has been used by the following countries: UAE, Peru, Dubai, Hungary, Egypt

It is not to be mixed up with another privately made Chinese vaccine called SinoVac which has not had such good results. In Brazil and Chile, Sinovac has been estimated to have an efficacy rate slightly above 50%, prompting consideration of a 3 dose vaccine. 

Do I think you should take it? 

Well, as it is a traditional type of vaccine and the WHO tells us it works, then, in the absence of another choice, then yes, I do.

Why? Because the longer we have un vaccinated people, the more chances the virus has to spread; the more it spreads the greater the chance of mutations. So we have to use what we have, as fast as we can. This is an emergency. We cannot reject the life-raft we have, hoping for a better one to come along, because by then it may be too late. 

In the end, I suspect the World will benefit from having many different COVID 19 vaccines, with different advantages and disadvantages, as like, with the virus itself, our ability to react to its mutations depends on the availability of different choices and diversity. Natural selection depends on diversity and therefore so must our arsenal of vaccines.

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So I’ve finally had my first dose of the Astra Zeneca COVID 19 Vaccine

So as a healthcare worker I finally got my first dose of the Astra Zeneca vaccine on Saturday! I feel like I have won the lottery, and I was so happy to have seen many of you there also…

So how did I feel after?

Well, truth be told on Sunday I had a mild fever and a few aches and pains, but honestly, I think that’s a small price to pay for being able to protect myself and my patients…..and by contributing to herd immunity I am helping to protect the wider population, aka our parents and grandparents. Speaking of parents, as over 60s, mine also got theirs and felt fine!

According to GAVI, the vaccine alliance, there have been about 190 million Astra Zeneca vaccines administered worldwide so far.

I know that there has been a lot of worry about blood clots with this vaccine, but let me put this into perspective for you:

Just being pregnant increases the risk of a clot 4-5 times above the non pregnant state. A woman on the combined oral pill has on average about three times the risk of a clot as a woman not on the pill (but note that this is less than the risk of a clot while pregnant). The risk of getting a clot with the vaccine is far, far lower than either the background risk from being pregnant or the risk from being on the pill. 

So would you not have had your children because of the risk of a clot? …because this risk is lower than that. And I know many of you take the pill, or have taken the pill, and this risk is lower than that too!

The WHO has issued an interim advisory that a causal relationship, while plausible, has not been confirmed.

Now, this isn’t to say that you must not be on the lookout for warning signs of a clot, or that you should not take individual advice if you have had a clot in the past, or are known to have a genetic condition which increases, your chance of clotting…of course you must check with your doctor in these cases!

However the vast majority are far more at risk of death or serious disease from getting COVID 19 itself, than from the small risk of this vaccine.

My advice: if you are eligible, call your local health center and get your shot!

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January is Cervical Health Awareness Month!

Cervical Cancer is one of the commonest and yet the most preventable cancers in Women worldwide.

We are so lucky to have a good screening test to help us detect precancerous changes in the cervix. – The “Pap” test introduced in the 1940s has reduced the incidence and mortality of cervical cancer by 77% in the USA.  In the UK The incidence has fallen by 44% and death rates by 70% since introducing screening for cancer of the cervix.

Rates of precancerous lesions in younger women have dropped even further since the introduction of the Human Papilloma Virus (HPV) vaccine.

Cervical Cancer, believe it or not, is catching! 99% of cervical cancer is caused by the high risk strains of the Human Papilloma Virus, most  commonly types 16 and 18 which are preventable. HPV is spread by sexual intercourse.

For this reason, Many countries including the USA, UK and Australia have national vaccination programs to vaccinate teenagers before they are likely to become sexually active. The aim of this is to prevent Cancers – of the cervix, penis, throat and anus!

Have you thought about discussing HPV vaccination with your adolescent? Cancer prevention could be the greatest gift you give to them.

Have you set a good example by to your daughters by having your smear test?

The Smear test is recommended for all women ages 26-64 and is done in office.

To celebrate Cervical Health Awareness Month book your smear test or consultation about the HPV vaccine on 221-3983 or by booking online at www.amesmedicalservices.com

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Long Covid

Long COVID

 

What is it?

 

Much like Chick V, the virus which causes COVID 19, SARS -CoV-2- can leave longer lasting symptoms in about 10% of people. We say these “post acute” Covid symptoms are symptoms going on longer than three weeks after the start of symptoms. The symptoms can last for months, up to 12 weeks. (Then known as “Chronic Covid” ) People suffering with Long Covid are not necessarily still infectious.

 

Common symptoms include Fatigue, breathlessness, cough, low grade fever, muscle pain and headaches as well as depression. These can come and go.

 

We are not entirely sure what causes the prolonged symptoms but it is likely to be multifactorial. Long lasting symptoms after an infection are not unique to COVID 19.. ,Many viruses can cause chronic fatigue, for example and many can cause a post infectious  Immune or inflammatory response which can affect many organs including the lungs, brain, muscles/joints or nerves. There is also likely to be  a Psychological component also.

 

What should you do if you have ongoing symptoms? 

 

See your doctor for an examination and if appropriate some baseline Investigations to rule out secondary causes for your symptoms/complications of COVID 19. For example your doctor may need to rule out: Anaemia, secondary pneumonia/chest infections requiring antibiotics.; inflammation of the heart or also even heart failure in severe cases. If you were hospitalized and are breathless they may also want to rule out a clot in the lung for example.

 

Once these have been excluded, rest, limitation of caffeine, monitoring of oxygen levels where appropriate, and possibly graded exercise therapy, and psychological support can help people feel better.

 

For fatigue, once your doctor has said it is ok, then 4-6 weeks of self paced light exercise such as walking can help.

 

When is it generally safe to return to exercise?

 

If you were reasonably active before COVID 19, then after mild illness – try one one week of stretching before attempting light cardiovascular exercise such as walking. Increase your rest periods if you get tired in between.

 

If anyone has been hospitalized, or required oxygen they should see their one doctor for an individualized assessment.

 

Patients who had heart  involvement need a cardiac assessment with Blood pressure, pulse, ECG pulse oximetry and review with doctor before resuming exercise.

 

If you are allowed to exercise, then usually light graded exercises, over 4-6 weeks helps people to recover from the fatigue, brain fog and depression that can follow COVID 19.

 

Psychological Support can help especially if you are suffering with depression, the death of a loved one or the loss of a job or income.

 

Peer-peer support groups have been known to be helpful. Perhaps consider starting one on Facebook?

 

Fever usually responds to paracetamol, although as I mentioned above see doctor to r/o secondary infection.

The good news is that if you are kind to yourself, and allow rest and positive thoughts, most people recover slowly with the above measures…hopefully by 12 weeks or so!

Here are some helpful links:

How to conserve your energy – RCOT

Long Covid Support Group | Facebook

 

 

 

 

 

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Minor Surgery Available at Ames Medical Services

 

Did you know that we do minor surgery?  

 

If you have a lump or bump that you want removed, we can do a minor procedure under local anaesthetic, right here in our new treatment room. 

 

We also remove ingrown toenailsabscesses and do cyst and comedone extractions too! 

 

Have a pesky wart or verruca or skin tag that won’t go? We can freeze it off with Liquid Nitrogen, in a procedure called Cryosurgery that involves no cutting! If you are interested, you can watch a video of it being done by Dr Ames here:  https://www.youtube.com/watch?v=VOKdjNiKOy8

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When is a Duck not a Duck? The Pitfalls of COVID-19 Testing

So, you had a cough and cold and you were worried about COVID….but you went and got a rapid test and its negative so all is good right? Wrong! 

No test is perfect and this is to help you understand some pitfalls of Covid testing.  

Let’s start with the rapid “blood” test. This is looking for antibodies to the virus, and not directly for the virus itself.  

When we get the virus for the first time, it may take a while for our immune system to mount a response and produce antibodies.  

If the test is done too soon, for example before symptoms start, or even in the first 2 weeks after getting it when you may even have symptoms, it may read negative when you are in facet positive, a so called “False negative”! Then you might be falsely reassured and unwittingly go round infecting others.  

 

So, an antibody test MAY be useful after your symptoms have passed, and if you never managed to get the proper “throat swab” PCR test and you are wondering if in fact it was COVID you had! 

 

What if you wait, do the antibody test more than two weeks after your symptoms started and you have antibodies Does that mean you are now “immune” to COVID? 

 

Er, we are still not so sure. It seems that antibody levels wane after 3 months or so, so we are not sure how long that immunity may last…. this is also complicated by the fact that there are different strains of COVID and it may be that the virus mutates very so often, just like the Flu, so your immunity may be short lived! 

 

On top of this, some people can fight of the virus with a different part of the immune system that doesn’t use antibodies. So you might actually have fought off the virus successfullyand may even have immunity that we can’t measure on the test, but then have no antibodies.  

 

Confusing right?  

 

What about the “swab” or fancy RT-PCR  test? 

 

The swab tests for actual virus particles in the nose/throat.  It is not 100% either!  No test is I am afraid.  The swab is most accurate if done days 3-5 of symptoms.  If done in asymptomatic people right after exposure, it may be too early to get a positive result. Similarly, if taken very late in the illness like day 10, the chance of picking up the virus starts to fall.  

 

It is very specific and moderately sensitive. So, what does that mean? Well, it means that if you get a positive result it is likely to be a true positive, but a negative result is less reliable. So, we tend to believe the positive results, but if a person has a negative test, that doesn’t automatically mean they are truly negative and that they don’t have COVID 19 and are not infectious. 

 

That’s why in very suspicious cases you will see us asking for 2 negative tests. ..That’s because if it looks like a duck, and quacks like a duck and flies like a duck it is probably a duck…especially if it comes from an area where there is known to be a flock of ducks living. (Like say, you shot it in the middle of a swamp) So, if someone plucks a feather from that duck and analyses it and tells you it is not a duck then would you believe them?   

 

Similarly, if a person has been exposed to someone with COVID 19, and they then develop the classic fever cough, anosmia etc, OR we know that we are in the middle of a Pandemic or local spike and someone gets a cough and cold, we have a high suspicion of COVID and just one negative test is not going to reassure us.  

 

To complicate things, we will shortly be going into the “Flu Season” and it’s hard to tell the difference clinically between the Influenza virus and COVID 19! But that’s for a whole other discussion.  

 

In short, please don’t just take yourself off for a test without consulting a health professional who is up to date with testing and timing and symptoms. The test may not mean what you think it does, and you may even need a completely different test! 

 

 

 

 

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Finally Some Good News: A COVID -19 Update TT

 

Good News! We can isolate at home if we have COVID -19! No need to go into hospital if we are well enough to stay home. 

I know this is a huge relief to all of you right? Everyone wants to be in their own bed if they are feeling under the weather!

So what do you do if you think you have COVID 19?

 

First of all don’t panic! The main symptoms are:

 

  • Fever more than 38

 

  • Dry cough

 

  • Runny nose

 

  • Sore throat

 

Sometimes:

 

  • Body aches

 

  • Diarrhea

 

Sneezing is not normally a major feature but can be present.

 

If you have any of these

 

1.Do not go out

 

2.Isolate yourself from your family and household (see our Instagram page for a leaflet on how to do this

 

3.Seek Medical advice via Telehealth, or a hotline rather than coming in, so you do not infected others. If you are extremely unwell with shortness of breath, for example, and you believe you need emergency help then proceed directly to your nearest public health facility. You can call me to find out where to go if you are unsure.

If I think you need testing I can either refer you privately for accredited PCR testing or send you to be tested via the Public health.

I can also arrange a sick note or quarantine note.

If you are well enough to stay home, you can stay home with Pandol, Fluids etc. People with underlying illnesses like Diabetes, Lung, Heart or Kidney disease should have individualized advice

You will need to stay at home from 14 days from the start of your symptoms.

4.Make a list of all those you have had CLOSE contact with. A CLOSE contact is defined as less than 6ft for 10 minutes or more. It is not someone you passed casually in the corridor at work.

 

What to do if you have been exposed to someone with known or suspected COVID 19:  Remember exposure is defined as less than 6ft for 10 minutes or more, as above…

 

  1. Don’t panic
  2. Stay home and quarantine for 14 days unless you are told otherwise by a qualified doctor. Monitor for any of the above symptoms. Seek medical advice if they develop.
  3. Seek medical advice as to whether you need to be tested.

 

Any questions or suggestions for further leaflets let me know!

 

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Sleep in the time of COVID: Part 1: Struggling to Sleep

My Prescription for Sleep during the lockdown:

 

It can be tempting to relax our regular sleep routine while in lockdown…especially since we are not going to work, or working from home. .But this lack of, or change in routine can sometimes exacerbate insomnia. Many of us barely know what day it is far less the time! We need to try to maintain our normal sleep rhythms.

Many of us are also not able to exercise as we usually would, and our body is missing those endorphins. This coupled with increased anxiety over this crazy situation we are in, can really affect our sleep…and lets face it, when we can’t sleep…we feel even more anxious and crazy! Think about it: The Japanese used to use sleep deprivation as a form of torture!

 

 

As much as possible try to stick to a regular bed time, and still set an alarm for waking up, as well as one for going to sleep

 

Resist the temptation to nap during the day

Exercise in the morning at home and not after 5pm. Exercising too late in the day can make some people feel “reved up”

Watch out for “workout ” drinks and supplements. Many of them contain Caffeine or taurine or “Green tea extract” or “Coffee bean extract” These all are basically stimulants and can keep you up at night!

Avoid Cigarettes especially before bed.  Nicotine is a stimulant.

Try to limit yourself to caffeinated beverages in the morning only, and certainly not after 3pm.

Avoid an alcohol night cap if you are struggling to sleep…alcohol can interrupt our normal sleep patterns

Dinner time is important. Try to eat at least 2-3 hours before bedtime. Going to be too full can increase heartburn which can wake you up at night with pain or a cough. Remember: Breakfast like a King, Lunch like a Prince, and Dinner like a Pauper.

What you eat is also important. Foods high in Tryptophans like Turkey and chicken can help promote good sleep.

 

Practice good sleep hygiene: Ideally the bedroom should be for sleep and sex only….but if you are forced to stay there because you are in isolation then keep a window open, and leave the curtains open during the day to let natural light in.

 

If you are in isolation Try to have a desk and comfortable lounge chair in the bedroom so you resist the temptation to spend all day in bed. 

 

At night, limit noise and increase darkness by using black out curtains or an eye mask and ear plugs if you need to.

 

DO NOT look at any screens like TV, Computer,  phone or tablet an hour before bed. The bright light breaks down our natural melatonin.

 

Have a wind down ritual: A warm shower, doing a crossword or planning what you are going to do/wear  the next day can help your brain understand it’s time for bed.

 

Sometimes medical conditions like depression, anxiety, pain, hot flushes and night sweats and restless leg syndrome can interfere with our ability to fall asleep. If you think you may be experiencing any of these, talk to your Doctor. Further updates will give more information on medical conditions which can affect your sleep.

Certain medications like Steroids and Diuretics are best taken in the morning to avoid interfering with sleep. Another common problem is Migraine tablets or “Multi symptom day tablets” – These sometimes contain caffeine. If they do, try to use these only during the day or use some without caffeine if this affects you. The common decongestant “Phenylephedrine” can also make children and some adults feel “hyper”

 

 

If you are still struggling try two Camomile tea bags in hot water and allow to draw for six minutes. You can add honey to this if you are not Diabetic. Camomile actually works on the same receptors int he brain as sleeping tablets!

 

 

You can also try 5mg of Melatonin, available over the counter, an hour before bed. This has been shown to be even more effective if you are over the age of 55.

Look out for my next update which will be on how to deal with waking up at night.

Night Night and Sleep Tight!

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