Coastal Complete Direct Primary Care

Tomorrow is DEA Take back day
This is an opportunity to dispose of unwanted, unused medications on Saturday, April 22, 2023, from 10am-2pm, and they can go to https://www.dea.gov/takebackday -locator to find a location near their home.
https://www.dea.gov/takebackday

Take Back Day The drug overdose epidemic in the United States is a clear and present public health, public safety, and national security threat. DEA’s National Prescription Drug Take Back Day reflects DEA’s commitment to Americans’ safety and health, encouraging the public to remove unneeded medications fro...

Today is the one year anniversary of our practice opening. Thank you to all the patients who trusted me and joined me in the new venture. Here’s to good health in 2022!!
Thank you from Jacqueline Miller Kolesnik and me.

Happy Holodays from Dr. Baker and Jacqueline! (And Sunnie too!)

Please get a flu shot!

This lovely lady is 100 years old! Happy Birthday to a one of a kind Mrs. Rua King!

Q: I had alpha COVID. I should be immune to delta right?

A: There are studies that show robust immunity 6-12 months after infection, with a natural waning of that immunity (as expected). The attached JAMA article shows this. But, the immunity varies based on the variant.

The CDC recommends vaccination after infection (a state referred to a hybrid immunity-natural plus vaccine)

"Unvaccinated health care workers appeared to have less protection against the delta and beta variants compared with alpha about a year after they recovered from mild COVID-19. While 88% of this group had neutralizing antibodies against alpha, only 47% neutralized delta."

the article shows a 50 FOLD INCREASE IN IMMUNITY for delta with one booster immunization.

TAKE HOME MESSAGE:
If you previously had COVID 19 Alpha, it would be prudent to get a booster vaccine for Delta.

https://jamanetwork.com/journals/jama/fullarticle/2782139

Study Suggests Lasting Immunity After COVID-19, With a Big Boost From Vaccination This Medical News article discusses the duration of immunity after SARS-CoV-2 infection.

Q: I had Alpha Covid-19. Do I need a vaccine for Delta variant?

A: the Cleveland Clinic did a study of employees and the preprint is available below. It suggests that natural immunity is similar to vaccine immunity. At this time there are mixed recommendations:
-no shot needed
-one shot as a ‘booster’
-full vaccine series

There is no clear guidance on this issue. From a practical standpoint a vaccine would be reasonable if your immune system is impaired or you live with someone who would have a rough time if infected.

We are seeing vaccinated individuals that are sick. I admitted one to the hospital last week. About 10% of the folks admitted with Covid locally have been vaccinated

Pfizer recommends a booster to those age 18 and older. This is from the company- it CDC or FDA at this time.

I know we are all tired of this. But this bug is still here and the hospitals are full.

Hang in there y’all.

https://www.medrxiv.org/content/10.1101/2021.06.01.21258176v

Necessity of COVID-19 vaccination in previously infected individuals Background The purpose of this study was to evaluate the necessity of COVID-19 vaccination in persons previously infected with SARS-CoV-2. Methods Employees of the Cleveland Clinic Health System working in Ohio on Dec 16, 2020, the day COVID-19 vaccination was started, were included. Any subject who...



Q: I thought the vaccine was supposed to fix everything? What’s going on with this Delta variant?

A: I’m sure you all are seeing things on the news right now about Delta variant and breakthrough infections. People that have gotten the vaccine are getting sick with Covid because the virus mutated and it’s just slightly different than the original Alpha strain.

Delta reproduces more rapidly and has highly concentrated virions in the secretions. When you get sick from Covid it’s due to a virus particle exposure. The more virus particles you’re exposed to the more likely you are to get sick. Even with the vaccine when you get blasted with 1000 fold increase in viral particles, occasionally your immune system has a hard time keeping up with that exposure even with a previous vaccination. This will lead to milder disease because you’re able to ramp up a immune response faster and keep it in check. But you might still get symptoms. Depending on your immune system, and lots of other factors, you might actually get really sick. About 1% of our current hospitalized infections appear to be previously vaccinated individuals (* there is no accurate data for this at this time and this number may change). 

There is a scientific explanation for the increase in infections eleven with a lot of folks vaccinated. It has to do with the infectivity number “R naught“. I did a post about this early last year to explain these numbers and how we generate a herd immunity estimate.

The R naught Is a number to convey how infectious some thing is. It basically tells us for every one infection , this number is the amount of infections that will spread to. For seasonal flu the numbers is 1.3 for Measles the number is 18. Original Covid had an R naught of approximately 2.5.
The Delta variant number is 6. 

This means it is much more contagious. And the level of vaccinated individuals to create a herd immunity state is much higher.
There is an equation that we use to calculate herd immunity:
1 - 1/R0

Doing some quick math the percentage of individuals need to be vaccinated for original Covid to develop herd is 60%. With the new Delta variant the percentage jumps to 83%.

The Delta variant has some other properties that make it different from Alpha Covid. The loss of sense of smell and taste is usually not a strong symptom. In addition it tends to have a headache sore throat and runny nose as more primary symptoms. It also spreads faster, so the incubation period is shorter. As of now it appears that it does not make anyone sicker or is “worse“ than alpha other than the fact that it’s so much more contagious.

The vaccines work. All along vaccines were intended to decrease your likelihood to die or be hospitalized from an infection. Vaccine associated milder infections are not unusual with vaccines in general. Vaccines are not perfect and from the get-go we knew that there was going to be people that were vaccinated that would get sick. The overwhelming majority of individuals who have been vaccinated will be fine even against the Delta variant. 

I was a guest on the Doctor Pod with Dr. Bill Mallon and Rhett Palmer. Here is a link if you are interested in listening.
https://www.buzzsprout.com/1768387/8805178

Dr. Nancy Baker, M.D., - Coastal Complete Direct Primary Care - Doctor Pod - Getting and Staying Healthy Together We welcome Dr. Nancy Baker MD founder of Coastal Complete Direct Primary Care"To practice good medicine, I needed a place where I could take my time to really get to know my patients and develop meaningful relationships with them. I wanted the ab...

For those in Vero who have COVID there are a few treatment options outpatient now for study based treatments.

Whole Family Clinic is doing IV monoclonal antibody infusions

Dr. Laurie Welton is doing outpatient oral Camostat (an antiviral medication) trials , IV Monoclonal antibody combination or inhaled interferon trials.

If you or someone you know has COVID, and are interested these treatments are free and they also compensate you for being in the trial.

IN ADDITION- Dr Welton has 800 doses of the Pfizer vaccine available at her clinic. You can reach out to her to schedule one if you desire vaccination.

Whole Family Health Center 772-257-5785
Dr. Laurie Welton’s office 772-299-7009

Q: I am hesitant to vaccinate my daughter because I am worried about fertility and the vaccine- what will you do about your daughter?

A: I plan to vaccinate my daughter. There is no evidence that there is any issue with fertility and the vaccine. I know that folks are talking about this and I want to explain why this started as "a thing" and why I am not worried.

"In early December, a German doctor and epidemiologist named Wolfgang Wodarg, who has been skeptical about the need for vaccines in other pandemics, teamed up with a former Pfizer employee to ask the European Medicines Agency (the European Union counterpart to the FDA) to delay the study and approval of the Pfizer/BioNTech vaccine. One of their concerns was a protein called syncytin-1, which shares similar genetic instructions with part of the spike of the new coronavirus. That same protein is an important component of the placenta in mammals. If the vaccine causes the body to make antibodies against syncytin-1, they argued, it might also cause the body to attack and reject the protein in the human placenta, making women infertile.

The coronavirus’s spike protein and syncytin-1 share small stretches of the same genetic code, but not enough to make them a match. She says it would be like two people having phone numbers that both contain the number 7. You couldn’t dial one number to reach the other person, even though their phone numbers shared a digit.

Data from the human studies of the Pfizer vaccine don’t bear out this theory. In the Pfizer trial, which included more than 37,000 people, women were given pregnancy tests before they were accepted to the study. They were excluded if they were already pregnant. During the trial, 23 women conceived, likely by accident. Twelve of these pregnancies happened in the vaccine group, and 11 in the placebo group. They continued to be followed as part of the study." (WebMD)

To be clear- we do not have long term data on this because the vaccine has existed for only 9 months. But with the science behind it, and the data we have so far I am comfortable having the vaccine, giving the vaccine, and specifically giving the vaccine to my kids.

I anticipate that the approval for Pfizer age 12-15 will come around the second week of May. https://www.uab.edu/news/youcanuse/item/11864-addressing-fertility-questions-and-concerns-with-the-covid-19-vaccine

Addressing fertility questions and concerns with the COVID-19 vaccine UAB experts explain why women should not have concerns about the COVID-19 vaccine’s impacting their fertility goals.

Congratulations to Dr. Nancy Baker on winning Woman of the Year 2020! Your work is an inspiration to us all!

The CDC is now recommending that schools can decrease the amount of distance between students and K through 12 grade to 3 feet instead of six in the classrooms. This is great news because it will promote in person learning which our children need. 

 https://www.npr.org/2021/03/19/978608714/cdc-says-schools-can-now-space-students-3-feet-apart-rather-than-6?utm_source=facebook&utm_medium=news_tab&utm_content=algorithm

CDC Says Schools Can Now Space Students 3 Feet Apart, Rather Than 6 In many places, the 6-foot guidance was interpreted as requiring schools to operate on part-time schedules in order to reduce class sizes. A 3-foot rule would allow many more schools to reopen fully.

Sharing from a colleague

In the NEJM, a study shows that serum samples taken from folks who had been fully vaccinated with the Pfizer vaccine neutralized all the concerning variants
B.1.1.7 (UK) B.1.351, (South Africa)and P.1.(Brazil). Crushed them. And the vaccine elicited CD8+ T-cell responses that recognized multiple variants( need more data.)

THIS IS GOOD NEWS*********
*waiting on data on NYC variant

https://www.nejm.org/doi/full/10.1056/NEJMc2102017?fbclid=IwAR1u4-jsu_ruHNmFjDpyIwanevPNCSXpNLC_zXIos7wLdGnrFFDMrv9pxFw

Neutralizing Activity of BNT162b2-Elicited Serum | NEJM Correspondence from The New England Journal of Medicine — Neutralizing Activity of BNT162b2-Elicited Serum

One year later there are still scientists and research physicians trying to repurpose other medications for treatment of COVID.  Keep an eye out for data on fluvoxamine, colchicine and molnupiravir.

Vaccines are great - and the best way to come out of the pandemic. However, they are not perfect, and this bug will still make some people sick.

Locally there are two infectious disease specialists doing outpatient studies on monoclonal antibody treatments and other modalities like inhaled interferon. These and other doctors will continue to work on this.

CDC has updated their guidelines today. If you are fully vaccinated they have loosened the restrictions. Please read the following if you are fully vaccinated to see how life can get back to normal.

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html?fbclid=IwAR2MbE6kA4dhV_9Hm6qAJxhY-_6lmahtB5KZhwaF9Mohh8vgtNHeAzIoU54



COVID-19 and Your Health Symptoms, testing, what to do if sick, daily activities, and more.

Governor DeSantis has now opened vaccine eligibility to firefighters over age 50, law-enforcement over age 50, and K-12 staff and teachers over age 50. There are places in Florida where CVS has been giving vaccines to preschool providers and teachers that are under 50, however they are not covered by the governors executive order.

I’ve had a few people reach out to me asking if it’s a good idea to get the vaccine. YES. These vaccines, while new, are safe and I am completely comfortable having received a vaccine and recommending them. As soon as my children are eligible I will also vaccinate them.

The more people that get vaccinated the closer we are to herd immunity. Then we get to start living life a little more normally. 

Govornor Desantis expanded the eligibility of Covid 19 vaccination to those under 65 years old that are "extremely vulnerable to COVID 19"

The Florida DOH defines those at high risk as those over age 65
Other high-risk conditions could include:
People with chronic lung disease or moderate to severe asthma.
People who have serious heart conditions.
People who are immunocompromised including cancer treatment.
People of any age with severe obesity (body mass index [BMI] >40) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk.

in addition it notes "Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications."

I STRONGLY urge you to contact your doctor and request an order if you are in one of these groups. Get a shot as soon as you are able to. Any of the three vaccines available are fine.

https://www.msn.com/en-us/health/medical/desantis-expands-covid-19-vaccine-eligibility-to-high-risk-people-under-65-at-pharmacies-doctors-e2-80-99-offices/ar-BB1e67Ff

DeSantis expands COVID-19 vaccine eligibility to high-risk people under 65 at pharmacies, doctors’ offices Gov. Ron DeSantis quietly expanded COVID-19 vaccine eligibility late last week to allow Floridians younger than 65 who have high-risk medical conditions to get the injections at doctors’ offices and pharmacies. The governor signed an executive order late Friday that allows physicians, nurses and p...

And then there were three...
This is a traditional vaccine and easier to distribute, administer (only one dose), and store. Approved for 18 and older.

This has a lower percentage efficacy than the two mRNA vaccines, but is still VERY good at preventing hospitalization and deaths.

https://www.washingtonpost.com/health/2021/02/27/johnson-and-johnson-covid-vaccine-fda/

FDA authorizes Johnson & Johnson’s single-shot coronavirus vaccine, adding to the nation’s arsenal against the pandemic Only a few million doses will be shipped in the days immediately after authorization, though production will ramp up in coming weeks, with 20 million doses to be delivered by the end of March and 100 million in the first half of the year.

I am a We Care Clinic volunteer and this quarter I am honored to be the featured volunteer physician.
https://www.wecareofirc.org/featured-doctor/

Featured Doctor | We Care Featured Doctor Meet this Quarter’s Featured Doctor Nancy Baker M.D.   Dr. Denis Saver, president of the board of the We Care Foundation of Indian River, is honored to announce that Nancy Baker M.D. has been named We Care Volunteer of the First Quarter of 2021. Dr. Baker has had a family practice...

COVID Q and A


Q: What is the deal with double masking? Is it really worth it?

A: CDC conducted experiments to assess two ways of improving the fit of medical procedure masks: fitting a cloth mask over a medical procedure mask, and knotting the ear loops of a medical procedure mask and then tucking in and flattening the extra material close to the face. Each modification substantially improved source control and reduced wearer exposure.

For my brother, who is super high risk, he wears an N95 and then a cloth or surgical mask over it. BUt if you are average risk, Just finding a good fit matters. One that doesn't sag, or gap at the sides. When I am working I use paper tape to create a seal, which doubles the efficacy of a simple surgical mask. (Plus-BONUS- stops the fogging from my goggles).

Take home message: If the mask has a better fit, then it works better. Filters, mask loop devices, or double masking all have a benefit over a simple mask.

https://www.cdc.gov/mmwr/volumes/70/wr/mm7007e1.htm?s_cid=mm7007e1_w

Maximizing Fit for Cloth and Medical Procedure Masks ... This report describes experiments conducted by CDC to assess ...

NBC news created a web site to help folks navigate the Vaccine process. You put in your age, your job and see what the vaccine rollout locally is.

In Florida For updates about the vaccine and distribution from Gov. Ron DeSantis, text FLCOVID19 to 888777 or sign up for email updates https://myvaccine.fl.gov.

Plan Your Vaccine Everything you need to know about getting a Covid-19 vaccination as the rollout extends across the U.S.

The CDC updated their guidelines on quarantine yesterday:

new criteria for managing exposures for VACCINATED INDIVIDUALS:

vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are NOT required to quarantine if they meet all of the following criteria†:
- Are fully vaccinated (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine)
- Are within 3 months following receipt of the last dose in the series
- Have remained asymptomatic since the current COVID-19 exposure
Persons who do not meet all 3 of the above criteria should continue to follow current quarantine guidance after exposure to someone with suspected or confirmed COVID-19.

***Please keep in mind this WILL CHANGE. AS more information becomes available, the length of immunity etc. , addition of the other three vaccines into the clinical arena, new variants, they may extend this.
https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines | CDC Find interim clinical considerations for the use of mRNA COVID-19 Vaccines.

COVID Q and A

Q: So the news is filled with doom and gloom reports about new variants- What does this mean for me?

A: First lets describe the variants:

B117
(the UK variant): First detected in the UK in September, the WHO says it has now spread to at least 60 countries. In the US, nearly 300 cases have been reported across 24 states. Scientists believe it is up to 70% more contagious and could be up to 40% more deadly.

B1351
(the South Africa variant): First detected in South Africa in October, it's now spread to about 20 countries. So far, there haven't been any reports of it in the US. Scientists think it is 50% more contagious, but are still gathering data to determine if it's more deadly.

P1
(the Brazil variant): First detected in four travelers from Brazil in Japan earlier this month. But researchers reportedly came across the variant in their data last year. Aside from Japan and Brazil, this variant has also been reported in Peru, Germany, and South Korea. Yesterday, Minnesota health officials reported the first case of P1 in the US from someone who'd recently traveled to Brazil. Scientists think it could be more contagious, but are still looking into it.

So now lets unpack what this means for the average person. These variants are not unexpected. Viruses mutate ALL THE TIME. Most of the time, its a nothing change and the virus behaves the same. But occasionally it changes the behavior of the virus. This is what happened in 1920 to finally get the world past the Spanish Flu- it mutated to a less deadly form, which for a virus is success (don't want to kill off all the hosts....)

These three appear to be changing the behavior of the 'original' COVID infection. The UK has it tough right now, as their variant appears to be more deadly. This is why they locked back down so severely. And why the travel to/from there is restricted right now (a smart idea IMO).

The biggest questions are these two: If you had COVID and are "immune" can the new variant infect you? and Will the vaccines protect me against the new variant?

The answer to both of these questions are unknown.

So for the average person- I recommend two stragegies
1. Get a vaccine as soon as you are offered one. (I know its a nightmare right now with logistics ramping up, but with pharmacies getting in the game I suspect it will get better soon)
2. Continue your mitigating measures (masking, social distancing, hand washing etc.) even if you have had COVID and consider yourself "immune" for a time or if you have had a vaccine.

The world will be watching and updating these situations as more information comes to light. Please remember that science is an evolving process and the advice could change based on new information (just like with masks....)

The Florida Department of Health (DOH) has launched a new telephone support line for seniors (ages 65 and above) and frontline healthcare workers to request COVID-19 vaccine appointments. The main number is (866) 201-6313 and the TTY number is (833) 476-1526.

The Florida Department of Health has created a
VACCINE LOCATOR web site.
Here is the link to look for available vaccines in your area
Keep in mind you can go ANYWHERE to get a shot. So it may be a good idea to look at adjacent counties

https://floridahealthcovid19.gov/vaccines/vaccine-locator/

Know Before You Go | Florida Department of Health COVID-19 Outbreak The Florida Department of Health is issuing 2019 Novel Coronavirus (COVID-19) updates every day to keep residents and visitors safe and aware. %

Covid Q and A from the New England Journal of Medicine

https://www.nejm.org/covid-vaccine/faq?fbclid=IwAR06AWIn4NkjNoA73jDsWhz2gNAinJvz0gEprW1BIb0dhhXUuBPThHaCTkQ



Covid-19 Vaccine Frequently Asked Questions A collection of resources on Covid-19 vaccines, including frequently asked questions, continuing medical education, published research, and commentary.

Q: There are a lot of news reports about a new "strain" of the COVID virus. What does this mean?

A: Let's define some terms that people are throwing around.

COVID is a STRAIN of the larger family of coronaviruses like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). These are all different strains belonging to the same virus family, which all have very different - but similar - effects and severities.

A MUTATION is an alteration in the genetic material of a cell of a living organism or of a virus that is more or less permanent and that can be transmitted to the cell's or the virus's descendants. In the majority of the cases, viral mutations hardly have any impact on the way the virus affects individuals.

A VARIANT is s mutation that changes the behavior of the virus in infected individuals.

Now that the terminology is clear, the new VARIANT is called B117. It is a mutation in the spike protein which is the viral key to enter the host cells. The big issue with this variant is that it appears to increase transmissibility. In scientific terms it increases the R naught by 0.4 to 0.7. This does not sound significant, but this means an EXPONENTIAL increase in cases.

There is still a lot we do not know about this variant. First of all- we don't know how long it has been in the US. The CDC does random sampling and sequencing of COVID tests here in the US which is how the case in Martin County was identified.
It is entirely possible it has already been here.

The biggest concern right now is not lethality. It is the issue that has been problematic all along- resources. Hospitalizations in the UK and South Africa where the variant appears to be dominant are surging.

TAKE HOME MESSAGE: Viruses mutate, this is expected. This variant *could* be trouble, so continue your personal mitigation measures. As the world begins to roll out vaccines we need to watch this situation closely.

https://www.theguardian.com/world/2021/jan/01/now-coronavirus-variant-us-since-october

New coronavirus variant may have been in US since October Re-analysis of 2m Covid tests raises fresh questions about origin of B117 ‘UK strain’ and suggests it may already be widespread

Govornor Ron DeSantis approved administration of the CoVID vaccine to adults ages 65 and older. While this is awesome, and I wholeheartedly agree that this is appropriate- the state of Florida received around 200,000 doses and has a population of 20+ million people. The demand far exceeds the supply. Please know that this is going to take time to implement.


For Vero Beach locals at this time there are two ways to try to get the vaccine:
1- Cleveland Clinic Indian River Hospital
Patients at Cleveland Clinic locations in Broward, Palm Beach and Indian River counties can call 954-659-5950 to schedule. Scheduling hours include: Dec. 30, 10 a.m. to 7 p.m.; Dec. 31, 7 a.m. to 7 p.m.; Jan. 1, closed; Jan. 2, 8 a.m. to 4 p.m.; Jan. 3, 8.am. to 12 p.m.; Jan. 4, 7 a.m. to 7 p.m.; Jan. 5 on, 7 a.m. to 6 p.m.
(This line has been very busy)

2-Indian River County Health Department
https://ircappointments.as.me/Vaccine
call 772-226-3900

COVID-19 Vaccine event at the Fairgrounds Schedule your appointment online COVID-19 Vaccine event at the Fairgrounds