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Can Vitamin C Prevent COVID-19?

The outbreak of COVID-19 has created a global public health crisis. Our knowledge continues to be limited about the protective factors of this infection. Therefore, preventive health measures that can reduce the risk of infection, and halt the progression and severity of symptoms and complications related to COVID-19 are desperately needed. In the midst of the COVID-19 pandemic, health promotion measures, such as proper nutrition, physical activity, rest, and stress reduction measures have been advocated.  More recently, attention has been shifted to vitamin supplementation as a means to keep American’s health and immune system in optimal status.

Source: https://www.heart.org/en/healthy-living/healthy-eating/add-color

Adequate intake of micronutrients is critical for optimal health, growth and development, and healthy aging. However,  the Dietary Guidelines for Americans 2015–2020 highlight low-consumption of important nutrients including vitamins A, C, D and E, calcium, magnesium, iron, potassium, choline and fiber, with variations by age groups.1   Vitamin C has recently gained attention as a potential micronutrient in the prevention of COVID-19.  Vitamin C has been known for promoting the oxidant scavenging activity of the skin, potentially protecting against environmental oxidative stress, enhancing chemotaxis, phagocytosis, and microbial killing.2

Based on previous evidence, oral vitamin C (2-8 g/day) may reduce the incidence and duration of respiratory infections and intravenous vitamin C (6-24 g/day) has been shown to reduce mortality, hospital length of stay, and time on mechanical ventilation for severe respiratory infections3-4

Given the favorable safety profile and low cost of vitamin C, and the frequency of vitamin C deficiency in respiratory infections, trials are currently underway to determine its effect in hospitalized patients with COVID-19.4-5  Although there are currently no published results of these clinical trials due to the novelty of SARS-CoV-2 infection, there is pathophysiologic rationale for exploring the use of vitamins such as Vitamin C in this global pandemic.6

Source: https://www.heart.org/en/news/2019/07/01/low-vitamin-d-in-babies-predicts-blood-pressure-problems-for-older-kids

While we await for results from these trials, we need to continue being vigilant, and adhere to a varied and balanced diet with an abundance of fruits and vegetables and the essential nutrients known to contribute to the normal immune system functioning.  Vitamin C supplementation could present a safe and inexpensive approach to prevention of respiratory diseases, and perhaps aid in COVID-19.7

Avoidance of deficiencies and identification of suboptimal intakes of these micronutrients in targeted groups of patients and in distinct and highly sensitive populations could help to strengthen the resilience of people to the COVID-19 pandemic. It will be also important to highlight evidence-based public health messages, to prevent false and misleading claims about the benefits of vitamin supplements. It will also be important to communicate the exploratory state of research on micronutrients and COVID-19 infection and that no diet will prevent or cure COVID-19 infection. Frequent handwashing and social distancing will continue to be critical to reduce transmission during this pandemic.8

 

References:

  1. Blumberg JB, Frei B, Fulgoni VL, Weaver CM, Zeisel SH. Contribution of Dietary Supplements to Nutritional Adequacy in Various Adult Age Groups. Nutrients. 2017;9(12):1325. Published 2017 Dec 6. doi:10.3390/nu9121325
  2. U.S. Department of Health and Human Services. U.S. Department of Agriculture [(accessed on 15 March 2017)];2015–2020 Dietary Guidelines for Americans. (8th ed.). 2015 Available online: http://health.gov/dietaryguidelines/2015/guidelines/
  3. Holford P, Carr AC, Jovic TH, et al. Vitamin C-An Adjunctive Therapy for Respiratory Infection, Sepsis and COVID-19. Nutrients. 2020;12(12):3760. Published 2020 Dec 7. doi:10.3390/nu12123760
  4. Carr AC. A new clinical trial to test high-dose vitamin C in patients with COVID-19. Crit Care. 2020;24(1):133. Published 2020 Apr 7. doi:10.1186/s13054-020-02851-4
  5. Zhang J, Rao X, Li Y, et al. Pilot trial of high-dose vitamin C in critically ill COVID-19 patients. Ann Intensive Care. 2021;11(1):5. Published 2021 Jan 9. doi:10.1186/s13613-020-00792-3
  6. Jovic TH, Ali SR, Ibrahim N, et al. Could Vitamins Help in the Fight Against COVID-19?. Nutrients. 2020;12(9):2550. Published 2020 Aug 23. doi:10.3390/nu12092550
  7. Allegra A, Tonacci A, Pioggia G, Musolino C, Gangemi S. Vitamin deficiency as risk factor for SARS-CoV-2 infection: correlation with susceptibility and prognosis. Eur Rev Med Pharmacol Sci. 2020;24(18):9721-9738. doi:10.26355/eurrev_202009_23064
  8. Richardson DP, Lovegrove JA. Nutritional status of micronutrients as a possible and modifiable risk factor for COVID-19: a UK perspective [published online ahead of print, 2020 Aug 20]. Br J Nutr. 2020;1-7. doi:10.1017/S000711452000330X

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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A Roadmap for Understanding COVID Vaccines

Yes, we are still in the middle of the COVID pandemic. With the help of more people getting vaccinated and mask mandates in effect, a post-pandemic world is no longer a mere imagination. While waiting for the pandemic to be over, there are some doubts about whether the COVID vaccines should be cleared to facilitate a faster transition back to normal life.

  1.  What are the leading COVID vaccines?

    Figure: Overview of the diverse types of vaccines, and their potential advantages and disadvantages (Dong et al. 2020).

Currently, two COVID-19 vaccines are authorized and then recommended for use in the United States–the Pfizer-BioNTech COVID-19 vaccine(Polack et al. 2020) and the Moderna’s COVID-19 vaccine(Baden et al. 2020). Both of the vaccines used a cutting-edge technology, the messenger RNA (mRNA) vaccine which has been developed in the 1990s.

As of December 28th, 2020, three other COVID-19 vaccines are undergoing large-scale (Phase 3) clinical trials in the United States: AstraZeneca’s COVID-19 vaccine(Knoll and Wonodi 2021), Janssen’s COVID-19 vaccine and Novavax’s COVID-19 vaccine(Sadoff et al. 2021). Both the AstraZeneca COVID-19 vaccine and Janssen’s COVID-19 vaccines (Johnson& Johnson) used a weakened adenovirus vector strategy to tackle the spike protein on the SARS-CoV-2 virus. The weakened virus vector serves as a “Trojan horse” to deliver “information” to the cells in order to stimulate the memory of immune defense against SARS-CoV-2 virus. The adenovirus-based vaccines are relatively less foreign to the public, currently they are used against a wide variety of pathogens such as Mycobacterium tuberculosis, human immunodeficiency virus (HIV), and Plasmodium falciparum. The AstraZeneca COVID-19 vaccine has already authorized to use in Europe on January 12th, 2021 and possibly obtains approval in the United States early 2021. On January 29th, Johnson& Johnson announced its interim clinical Phase 3 trial results and a single-shot Janssen COVID-19 vaccine is on the way for FDA approval.

Novavax COVID-19 vaccine, a protein subunit-based vaccine, just announced its interim UK Phase 3 clinical trial results on January 28th, 2021. It shows promising protection to the SARS-CoV-2 virus, as well as the UK and South Africa variants. The company has already signed purchase agreements with many governments including Australia and Canada.

Two other vaccines– Russia’s sputnik V vaccine and China’s COVID-19 vaccine developed by Sinovac Biotech are also the lead runners in the vaccine race. The sputnik V vaccine which has obtained authorization to use in Russia back in November 2020, just published its Phase 3 data on February 2nd(Logunov et al. 2021). It’s an adenovirus-based vaccine, similar as the AstraZeneca COVID-19 vaccine and Janssen’s COVID-19 vaccine.

China’s COVID vaccine used a relatively well-understood technology: an inactivated SARS-CoV-2 virus. The inactivated virus vaccine approach has been implemented for a wide range of vaccines such as polio vaccine, hepatitis A vaccine, rabies vaccine and most flu vaccines. So far it received some inconsistent results from Brazil, Indonesia and Turkey and it’s not applicable in the United States. Overall, the efficacy is encouraging (50.38% to 91.25%) and requires more data to reach a more consistent result.

  1. How to understand the efficacy?

It’s a numbers game or is it? The high efficacy (95%) data released from Pfizer and Moderna at the end of last year received with great applause. The 70% protection starting after a first dose from AstraZeneca seems less impressive. The AstraZeneca COVID-19 vaccine confirms 100% protection against severe disease, hospitalization and death in the primary analysis of Phase 3 trial suggesting a total success. The recent Phase 3 trial results from Johnson& Johnson’s single-shot vaccine shows 72% effective in the United States and 66% effective overall at preventing moderate to severe COVID-19, 28 days after vaccination. The efficacy number simply cannot be interpreted as the higher the better. Like all of the clinical trials, compounding factors need to take into consideration. Their vaccine impact may depend on sex, age, genetics, geography, the timing of assessment of the end-point, the percentage of population affected by new variant compared to the original variant.

The thing matters the most is to reduce hospitalization and death. So far most of the leading vaccines have showed great promise. At the current stage, whatever vaccine is available to you could protect you from getting serious disease and prevent the virus spread to your loved ones one way or another. Herd immunity could finally be reached if enough people are getting vaccinated in the near future.

  1. mRNA technology: what is it? And is it safe?

Considering mRNA vaccine is the new kid on the block, it’s understandable that certain hesitancy and reluctance towards getting vaccinated. mRNA therapy has been developed and used to target certain types of cancer for more than twenty years. It has recently been used to target SARS-CoV-2 virus. The nucleic acid fragment of SARS-CoV-2 virus spike protein is packaged in a lipid nanoparticle. Like how most vaccine works, it tricks your body to formulate a defense memory using a small piece of information from the virus. When the actual attacks occurred, you are protected with a pre-programmed defense mechanism already. It does not change your DNA. It just helps your body to remember what it feels like to successfully combat the virus. Some of the side effects from clinical trials could be another reason to cause hesitancy. Don’t blame the messenger. The individual response elicited by the vaccines is just a small fraction of what you might experience when the real attack occurs. Some extreme allergic responses, a few reported in a million cases are rare. The chance is as similar as winning a Powerball or Mega Millions lottery. At the end of the day, the benefits still outweigh the risks.

  1. Early progress and new variants

Israel’s vaccination program shows encouraging outcome, results from a recently published preprint(Chodick et al. 2021). It’s in agreement with the Phase 3 clinical trial results from Pfizer. Data collected by Israel’s Ministry of Health shows a 41% reduction in confirmed COVID-19 infections in people aged 60 and order. Close to 90% of that age group has been administered with the first dose of Pfizer’s 2-dose vaccine. For people aged 59 and younger, the infected cases and hospitalization are also dropped.

Viruses like SARS-CoV-2 mutate all the time. There are 3 concerned variants: the UK variant (B.1.1.7), Brazil (P.1) and South Africa (B.1.351) have already been found in the United States. With the surge of new variants of SARS-CoV-2, the effectiveness of the COVID-19 vaccine also dropped. Some new data from Johnson& Johnson and Novavax suggest that the COVID-19 vaccines can prevent a lot of mild and moderate cases, and are still very effective against preventing hospitalization and deaths. Other company such as Moderna, has already developed booster shots to combat new variants. If most of the population got vaccinated, it will stop the virus’s replication and ultimately stop mutation completely. The recommended measure is to vaccine as many people as possible at current stage.

In conclusion, no matter which vaccine you got or are going to get, as long as it’s approved and authorized by the FDA, the chance of having effective protection is still very good. At the end of the day, the benefits outweigh the risks.

Reference

Baden, Lindsey R., Hana M. El Sahly, Brandon Essink, Karen Kotloff, Sharon Frey, Rick Novak, David Diemert, et al. 2020. “Efficacy and Safety of the MRNA-1273 SARS-CoV-2 Vaccine.” New England Journal of Medicine. https://doi.org/10.1056/nejmoa2035389.

Chodick, Gabriel, Lilac Tene, Tal Patalon, Sivan Gazit, Amir Ben Tov, Dani Cohen, and Khitam Muhsen. 2021. “The Effectiveness of the First Dose of BNT162b2 Vaccine in Reducing SARS-CoV-2 Infection 13-24 Days after Immunization: Real-World Evidence.” MedRxiv, January, 2021.01.27.21250612. https://doi.org/10.1101/2021.01.27.21250612.

Dong, Yetian, Tong Dai, Yujun Wei, Long Zhang, Min Zheng, and Fangfang Zhou. 2020. “A Systematic Review of SARS-CoV-2 Vaccine Candidates.” Signal Transduction and Targeted Therapy. https://doi.org/10.1038/s41392-020-00352-y.

Knoll, Maria Deloria, and Chizoba Wonodi. 2021. “Oxford–AstraZeneca COVID-19 Vaccine Efficacy.” The Lancet. https://doi.org/10.1016/S0140-6736(20)32623-4.

Logunov, Denis Y, Inna V Dolzhikova, Dmitry V Shcheblyakov, Amir I Tukhvatulin, Olga V Zubkova, Alina S Dzharullaeva, Anna V Kovyrshina, et al. 2021. “Safety and Efficacy of an RAd26 and RAd5 Vector-Based Heterologous Prime-Boost COVID-19 Vaccine: An Interim Analysis of a Randomised Controlled Phase 3 Trial in Russia.” The Lancet, February. https://doi.org/10.1016/S0140-6736(21)00234-8.

Polack, Fernando P., Stephen J. Thomas, Nicholas Kitchin, Judith Absalon, Alejandra Gurtman, Stephen Lockhart, John L. Perez, et al. 2020. “Safety and Efficacy of the BNT162b2 MRNA Covid-19 Vaccine.” New England Journal of Medicine. https://doi.org/10.1056/nejmoa2034577.

Sadoff, Jerald, Mathieu Le Gars, Georgi Shukarev, Dirk Heerwegh, Carla Truyers, Anne M. de Groot, Jeroen Stoop, et al. 2021. “Interim Results of a Phase 1–2a Trial of Ad26.COV2.S Covid-19 Vaccine.” New England Journal of Medicine. https://doi.org/10.1056/nejmoa2034201.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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To Vaccinate or Not Against COVID-19 During Pregnancy: A Pregnant Cardiology Fellow’s Humble Perspective

When news of the approval of the Pfizer vaccine surfaced, I felt a sense of anxiety. There was no data on pregnant women in the COVID-19 vaccine trials. As a medical professional, we have been trained to apply for evidenced-based medicine and baseline patient characteristics of trial participants to the patients we plan to treat. But what if your pregnancy status was not studied in the trial during a global pandemic? How might you weigh the unknown risks of the vaccine to your growing fetus with the risk of COVID-19 infection while pregnant?

Making the Decision

A few days passed when I received an email from Occupational Health that my cardiology fellowship program would be part of the Phase I distribution of the vaccine. The following day, my midwife conveyed to me that the OB department would align with the American College of Obstetrics and Gynecology (ACOG) Practice Advisory Statement:

“ACOG recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups.”

I felt a sense of relief that I would not be prohibited from getting the vaccine if I chose to do so yet also felt a sense of panic when I read the following:

“Vaccines currently available under Emergency Use Authorization (EUA) have not been tested in pregnant women. Therefore, there are no safety data specific to use in pregnancy.”

As a trained medical professional and protective mother, the overwhelming number of daily decisions we make to ensure the safety of our babies are overwhelming- no sushi, no wine, no retinoids or other harmful active ingredients found in our beloved skin care regimens, no hot tubs… I could go on.

However, the challenge of navigating the emotions of fear and uncertainty about the vaccine became incomparable to the following facts:

mRNA Does Not Alter Your DNA

These vaccines are not live virus vaccines and do not use an adjuvant to augment the efficacy of the vaccine. It does not enter the nucleus or alter human DNA.

Risk of Exposure

My job involves routinely interacting with patients and performing aerosolizing procedures, which places me at increased risk for exposure to COVID-19.

Symptomatic Pregnant Patients Infected With COVID-19 Are at Increased Risk of Severe Illness

This includes hospitalization in the intensive care unit (ICU), the need for intubation and mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and death.

I decided that getting vaccinated was safer than getting COVID-19. I also consulted with my partner who is also my husband and the father to our developing fetus. Although ultimately it was my decision to make, I felt comforted knowing he was 100% on board with me proceeding with vaccination based on the above as well.

Getting Vaccinated and the Side Effects

I received both doses of the Pfizer vaccine, the first dose at 20 weeks and the second dose at 23 weeks gestation. With the first dose of the vaccine, I only experienced arm soreness that peaked on day two. With the second dose, I experienced a mild headache and mild bilateral upper extremity soreness but with two doses of acetaminophen, I continued to work at full capacity and performed intraoperative transesophageal echocardiograms without issues.

I am now 25 weeks pregnant and feel a sense of pride that I made this decision to protect myself and my unborn child. I have received many texts and messages inquiring about how I made my choice. Questions such as “would your decision change if you were in your first trimester before organogenesis was complete?” or “would you get vaccinated while trying to conceive?” were a few memorable ones. I firmly believe it is your right as a woman to make this difficult decision when there is no safety data available.  Personally, yes, I would have still made the decision to vaccinate.

Lastly, I will join many of the other scientists and advocates out there who demand that pregnant and lactating women be included in future vaccine research trials http://vax.pregnancyethics.org/prevent-guidance. Track records of vaccine safety should exist for expectant mothers to help guide and improve vaccination rates.  Here is to hoping for a better year that allows each and every one of us access to the COVID-19 vaccine no matter what country, gender, pregnancy status, lact

ation, status, or employment status we bear.

Stay safe and stay healthy,

Kyla Lara-Breitinger, MD, MS

References:

https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19

https://s3.amazonaws.com/cdn.smfm.org/media/2632/FDA_final.pdf

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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Coronavirus Disease 2019 Vaccine

Coronavirus disease 2019 (Covid-19) has been declared a pandemic by the world health organization (WHO) on March 11, 2020. Since the outbreak, the WHO reported more than 70 million confirmed cases, and 1.5 million deaths globally. In the US, nearly 300,000 lost their lives and currently, we are facing another surge of cases with a record-breaking 3,124 new deaths in a single day last week. Over the past year, scientists, physicians, and pharmaceutical companies did phenomenal efforts to develop a safe and effective vaccine.

Finally, on December 11 2020, The Food and Drug Administration has issued an emergency use authorization (EUA) for Pfizer and BioNTech’s coronavirus vaccine (based on a 17 to 4 vote with one abstention). It is important to note that an EUA is not equivalent to FDA approval. As the latter requires safety data for at least six months. The FDA clearance occurred in a record-breaking time frame for a complicated process that usually takes years. This EUA makes the United States the sixth country to clear the vaccine after Bahrain, Canada, Saudi Arabia, Mexico, and the United Kingdom. In this blog, I will review the data behind the EUA.

The study behind the FDA’s EUA was a multinational, phase 2/3, Placebo-controlled, observer-blinded randomized trial. Between July 2020, and November 2020, 43,548 participants (16 years and older) who were healthy or had stable medical conditions underwent 1:1 randomization to receive vaccine or placebo (saline). Of which, 36,523 received two doses (21 days apart) and completed the 2 months follow up. There were 8 cases of Covid-19 with onset at least 7 days after the second dose among the vaccine group and 162 cases among the placebo group. Hence the vaccine was 95% effective in preventing Covid-19. Moreover, among the 10 cases of severe Covid-19 with onset after the first dose, 9 occurred in the placebo group and 1 in the vaccine group.

Figure 1: Efficacy of the vaccine against Covid-19 after the First Dose.

Each symbol represents Covid-19 cases starting on a given day; filled symbols represent severe Covid-19 cases. The inset shows the same data on an enlarged y-axis, through 21 days.

The noted side effects were short-term mild-to-moderate pain at the injection site, fatigue, and headache. The incidence of serious adverse events was low and similar in both groups (0.6% in the vaccine group and 0.5% in the placebo group).

Figure 2: Safety outcomes of the vaccine.

The Vaccine works simply as it contains a small piece of the virus’s mRNA that instructs cells in the body to produce the virus’s distinctive “spike” protein. After receiving the vaccine, the body will manufacture a piece of the COVID-19 virus named spike protein, which does not cause disease but triggers the immune system to learn to react defensively. Given the novel mechanism, theoretically, it carries no risk of infection, as it only codes for a piece of the virus. It is also important to note that currently, it is unclear how long the vaccine will provide protection, nor is there evidence that the vaccine prevents transmission of SARS-CoV-2 from person to person.

Given the promising results and the EUA, Pfizer is planning on shipping 2.9 million doses over this week and 100 million doses of the vaccine by next March. The pharmaceutical giant has a deal with the U.S. government, under that agreement, the vaccines will be free to the public. Understandably, the distribution will be in phases with the most critical workers and vulnerable people being on top of the list. At this point, strict monitoring of any side effects will be enforced at all sites. Apart from the approved vaccine, Moderna’s vaccine utilized a similar technology and is currently under review by the FDA and could obtain an EUA soon. Other pharmaceutical companies such as Johnson & Johnson, Oxford, and AstraZeneca, are in late-stage trials and their vaccines could be authorized in the near future. This Vaccine is the light at the end of the tunnel which gives humanity hope to reach an endpoint to this pandemic. In the meantime, we must practice social distancing, trust the data, and get vaccinated!

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Reflections of 2020: adaptations and lessons learned

2020 came, a pandemic hit, and 2020 left. It was an extraordinary year in which words such as unprecedented, exponential and social distancing forced their way into our ordinary vocabulary. Hopefully, we won’t have to live another year like that in our lifetimes, but let’s exercise some cautious optimism in that respect. It took a toll on everyone, both physically and mentally, but perhaps the brunt of it was borne by essential workers, notably those involved in healthcare. Many had to work extra hours, often at the expense of time spent with loved ones, often young children. Many of us have not been able to visit family in almost a year, due to travel restrictions or for fear of transmitting the virus to elderly parents and relatives. Many have suffered setbacks in training and professional development. We are all tired – COVID fatigue is real. We all had it bad, in some way or the other, but in the face of adversity lies the opportunity: the pandemic forced us to adapt, and it looks like the lessons we learned last year are certainly applicable for the immediately foreseeable future.

COVID 19 served to magnify existing global healthcare disparities, triggering important conversations around it, and with that, hope for rectification. It saw the more widespread adoption of telemedicine as an integral component of healthcare delivery.  It made the scientific community realize the importance of good quality research and clinical trials and the benefits of sharing knowledge and collaboration.

In pathology class at medical school, we are taught cellular responses to stress and toxic insults. Adaptations are one of them:  Robbins pathology defines them as reversible functional and structural responses to more severe physiologic stresses and some pathologic stimuli, during which new but altered steady states are achieved, allowing the cell to survive and continue to function.1

COVID-19 forced adaptations at a far greater magnitude, and we are now at the altered steady state of what we call a “new normal”. Just as much as the pandemic forced healthcare systems to adapt to the crisis, it presented an opportunity for introspection and re-evaluation of our lives on a personal level, and there are important lessons I’ve learned in the process.

Communication: Just as with telemedicine, 2020 also saw us embrace social media in a way we hadn’t before. Indeed, in an increasingly digital global landscape, many of us had to depend on virtual interactions as being the primary and often the sole form of interaction. In addition to public social media handles, many physicians took to their private accounts to combat misinformation, providing an important channel for public health messaging among friends and social circles outside of medicine. With the advent of vaccines, this appears to be even more important in breaking down important information and allaying fears related to its side effects.

Adaptations in learning: Also virtually, we learnt to modify methods of learning, with conferences and meetings adapting to virtual platforms and regular educational content being far more widely available. Paradoxically, this has perhaps resulted in increased exposure and visibility of especially early career physicians, with opportunities for global networking and collaborations. Not too different from the times of in-person conferences, we now look forward to “meeting” friends on webinar platforms, with the camaraderie and friendly exchanges with colleagues in healthcare probably being more therapeutic than the educational content itself.

Building a support network: Perhaps my greatest learning from the last year is the importance of friendship, support, and mentorship. While we’ve been trained to adapt and be strong, this is a pandemic none of us have been equipped for. We’re used to being care-givers, not receivers, but in remembering that we’re also human and vulnerable, it is only healthy to actively seek out and lean on one’s support network: this can be family, friends, sometimes colleagues: to talk, chat, cry it out, or rant.

Mentorship: We have all faced challenges that were unprecedented and it was more than just training that was affected. Navigating through the uncertainties of early career practice can be challenging even in the most ordinary of times; hence the perspectives, solid life advice, and clarity provided by good mentorship during pandemic times cannot be understated. Additionally, the stress of working in a pandemic can give rise to inopportune moments, and I couldn’t be more grateful for mentors that have cut me slack, forgiven the shortcomings, and taught me resilience. It’s a lesson in maturity that I hope I can pay forward in my dealings with junior physicians as well.

Gratitude: Count your blessings and force yourself to do this.  Pause to celebrate the small victories.

As far as the science of adaptations goes, Robbins pathology will also tell you that when the stress is eliminated, the cell can recover to its original state without having suffered any harmful consequences.1 While it looks like we’re in for a few more challenging months before the “stressful” triggers might show any signs of waning, my optimistic takeaway is precisely the hope of this recovery to its original state, or at the very least, some semblance of a better new normal.

2020 is the year that taught me resilience, and it is a testament to our ability to adapt and pivot. I’m sure we’ve all found different mechanisms of adaptations that work for each of us, and I’d love to hear yours!

References

  1. Kumar v, Abbas AK, Aster JC. Cellular Responses to Stress and Toxic Insults: Adaptation, Injury, and Death. In Robbins & Cotran Pathologic Basis of Disease. 10th ed. New York, NY: Elsevier; 2020.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Hopes for 2021

As 2020 concluded with all of the unprecedented events, with the tragedies people had to suffer and are still suffering from, with all the good and bad, we enter the New Year of 2021 with some hope; hoping for better health, better strategies to combat what we are dealing with in this pandemic, and being more responsible for each other.

COVID-19 Pandemic

COVID-19 pandemic has changed how we live our lives, and the impact of this pandemic will likely last at least a few years, if not more after the pandemic is over. There are a lot of “unknowns” about COVID-19 infection, including the long-term effects of this infection and the effectiveness of some medications, that we will get to encounter and manage in the next several years.

COVID-19 Vaccine

With multiple effective vaccines discovered recently, healthcare workers were given priority to get the vaccine, followed by more vulnerable patients, including the elderly and those with significant comorbidities. The Centers of Disease Control and Prevention (CDC) website provides helpful information on the currently available vaccines in the United States (US), Pfizer, and Moderna, including their storage, preparation, and expected side effects (Link is provided below) [1].  The hope is that by the Spring of 2021, 75% of the population in the United States will be vaccinated.  Moreover, efforts by international organizations, including the World Health Organization (WHO), to distribute the vaccine to all countries are ongoing [2].

COVID-19 New Strains

We have seen the discovery of new strains of COVID-19 infection in the United Kingdom and, most recently, the US. These new mutant strains of COVID-19 may not be covered by the available vaccines, as such, the vaccine is an additional layer of protection, with the other protection measures, including social distancing, masks, and hygiene, which may be the most important way to prevent the spread of these new strains at this point of time.

With all that being said, our hopes for a “normal 2021” depend on how we handle the COVID-19 pandemic, we may not see everything going back to normal in 2021, but we can work on making the initial right steps now so that we have less grief, less “loss,” fewer travel restrictions, with healthier and happier upcoming years!!

Special thank you to my sister, Rawan Ya’acoub, an assistant professor of Doctor of Pharmacy/Clinical Pharmacology at the University of Jordan in Amman, Jordan, who helped me write this blog, and for all of her support.

 

References

  • S. COVID-19 Vaccine Product Information: https://www.cdc.gov/vaccines/covid-19/info-by-product/index.html
  • COVID-19 vaccines: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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COVID Fatigue

Anesthesia alert! This overhead call alerting pending intubation can be heard bellowing throughout the hallways of my medical center several times throughout the day and is seemingly the soundtrack of COVID-19. My typical routine is to pause, make sure it’s not sounding the alarm to my patient’s room, and then continue with my workday.

It has been 304 days since the WHO has declared COVID-19 a pandemic. COVID numbers at my medical center continue to rise, and although the vaccine is widely available to hospital staff, we are continuing to see some of our highest numbers since the beginning of the pandemic.

As a general cardiology fellow on the advanced heart failure service at a high volume mechanical circulatory support and transplant center, we really get to know our patients while taking care of them during their index hospitalizations. For the past two weeks, I’ve gotten to know one patient in particular. She presented in cardiogenic shock, was stabilized on inotropes and a balloon pump, with plans for upcoming destination therapy LVAD implantation.

Every day when we come to her bedside, she is on FaceTime with her partner. Today, the day before her LVAD implantation, we walked to her bedside, and once again she was on FaceTime with her devoted partner. She is obviously loved. Considering that she was going for LVAD the following day, we spent a bit more time explaining the procedure in-depth to the patient and her partner. After discussing all of the technical details, she timidly asked “Do you think my partner could come to spend the night with me tonight? I just need to see my love and it’s been so long.” You could see the tears begin to drop from her face and her partners.

Donning and doffing, wearing the N95, not knowing what anyone looks like without their mask; things have become routine. Health-care workers have adapted so well to the ever-demanding challenges of practicing medicine in the era of COVID-19. We’ve made guidelines, adjusted our practice, established routines, and found ways to provide quality medical care in the darkest of times. We’ve become oddly accustomed to these necessary rituals in order to protect ourselves, our loved ones, and the patients that we care for.

But none of this is normal.

At that moment, when we told our patient that the person who loved her the most in this world could not sit with her the night before a life-altering surgery, it became dramatically apparent to me that all of this is abnormal. The weight of 304 days of pandemic sat heavy in my heart and the sounds of endless anesthesia alerts echoed in my head.

Depression and burnout were prevalent in the healthcare field even before the pandemic. COVID-19 has undoubtedly placed an added burden on all healthcare providers. I implore people to take time off if you can, spend time with family if able, and be thoughtful of your mental well being because this past year has been anything but normal.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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Smallpox to COVID-19: We’ve come a long way!

The history of humankind has never witnessed an infectious agent deadlier than Smallpox. It is thought to have first appeared in Asia or Africa thousands of years ago, before spreading to the rest of the world. This virulent disease was causing hundreds of thousands of deaths each year during the 16th, 17th, and 18th centuries in Europe alone; and when Europeans brought it to Mexico in the 16th century, it killed nearly half of the previously unexposed Aztec and Inca population in less than 6 months.1,2 In the early 1700s, Lady Mary Montague, the wife of the British Ambassador to Turkey, and a disfigured Smallpox survivor, was fascinated by the smooth skin of the ladies at the famous Turkish Baths. A face with no scars was a rare sight in Smallpox-devastated England at the time. “The small-pox, so fatal, and so general amongst us, is here entirely harmless, by the invention of engrafting”, she wrote home in her notable letter.3 She had witnessed the primitive form of vaccination, which was then called inoculation. Turkish mothers would gather their children at Smallpox parties, where an old lady would tear the skin of healthy kids and smear a small sample of the virus (typically from a recently infected child). The kids would then develop a mild form of illness that recovers with no scarring and gives them long term immunity. Lady Montague used this technique to protect her son and has been credited for bringing this historical discovery back to England and advocating for its widespread use despite major opposition from the British medical community at the time (Figure 1). Subsequently, in 1796, Edward Jenner developed the much safer technique of vaccination using Cowpox instead of the Smallpox virus.4 Two centuries later, Smallpox was completely eradicated!

Figure 1: The painting Lady Mary Wortley Montagu with her son, Edward Wortley Montagu, and attendants attributed to Jean Baptiste Vanmour (oil on canvas, circa 1717). © National Portrait Gallery, London: NPG 3924.

What is most remarkable about this story is that the practice of Smallpox inoculation was introduced in Europe only in 1721 by the relentless efforts of a concerned and enlightened mother, despite being successfully used in Oriental countries such as China, India, and Turkey for centuries. In other words, one half of the globe was deeply suffering from an illness that killed millions of people over the years, while the other half held the secret to its prevention. And it was only when knowledge was exchanged between the two halves that humanity finally defeated one of its deadliest historical enemies! There has never been a better moment to relive and celebrate the magnificent product of worldly human collaboration than these days, as people around the globe started receiving their first doses of COVID-19 vaccines. A deadly virus that took the world by surprise and killed more than 1.5 million people, now, only a year later, has more than one vaccine with proven efficacy. It is amazing how far we have come along since the times of Smallpox! The obvious difference is the power of science and research, yet, another big and equally important difference, is how well connected our world is right now. This unprecedented connection is what allowed us to have a global response to this pandemic and unite our efforts to create a solution (Figure 2). Two Turkish immigrants develop a technology in the labs of a Germany-based biotech company to be quickly adopted by an American Pharmaceutical giant, which tests it and subsequently mounts a large-scale distribution process around the world —among other fascinating stories. As much as we seem deeply divided nowadays, due to political and ideological differences, in fact, over the history of humankind, there has never been a time where the world population was more united! Maybe we clearly see our major differences simply because we have never been this close! And our closeness and continued collaboration are what will get us through this! It is too early to declare victory, and things are far from perfect, but it’s a good time to pause and appreciate our progress!

Figure 2: The global effort for COVID-19 vaccine development.
Image credit: Judith Kulich, Cody Powers, Amit Pangasa, Kristyn Feldman, Parul Rewari and Samaya Krishnan. COVID-19 vaccines: Who might win the race to the global market? Published May 13, 2020. Available online on: https://www.zs.com/insights/covid-19-vaccines-who-might-win-the-race-to-the-global-market

References:

  1. Hopkins DR. The greatest killer: smallpox in history. vol. 793. University of Chicago Press; 2002.
  2. Razzell P. The conquest of smallpox: the impact of inoculation on smallpox mortality in eighteenth century Britain. Caliban Books, 13 The Dock, Firle, Sussex BN8 6NY; 1977.
  3. Lady Mary Wortley Montagu, “Lady Mary Wortley Montagu on Small Pox in Turkey [Letter],” in Children and Youth in History, Item #157. Available online: https://chnm.gmu.edu/cyh/items/show/157 (accessed December 27, 2020). Annotated by Lynda Payne
  4. Lindemann, Mary. Medicine and Society in Early Modern Europe. Cambridge University Press. p. 77. ISBN 978-0521732567; 2013.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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COVID-19: Healthcare Workers vs The Vaccine

The mid-December rollout of two FDA-approved COVID-19 vaccines coincided with a surge in US infections, as we surpassed 21 million cases and 300k deaths. Amidst the hope for a recovery from the virus, that has captivated the world for the past 10 months, the vaccine rollout was met with stiff resistance from many Americans. Of these, healthcare workers comprise the largest group of those refusing vaccination (albeit, healthcare workers also comprised the majority of people offered the early doses). This theme has persisted over the past few weeks. I will review some of the ideas behind the refusal of vaccine acceptance.

First, the headlines (taken from Forbes):

  • Last week, Ohio Gov. Mike DeWine said he was “troubled” by the relatively low numbers of nursing home workers who have elected to take the vaccine, with DeWine stating that approximately 60% of nursing home staff declined the shot.
  • Joseph Varon, chief of critical care at Houston’s United Memorial Medical Center, told NPR in December more than half of the nurses in his unit informed him they would not get the vaccine.
  • Roughly 55 percent of surveyed New York Fire Department firefighters said they would not get the coronavirus vaccine, the Firefighters Association president said last month.
  • The Los Angeles Times reported that hospital and public officials in Riverside, Calif., have been forced to figure out how best to allocate unused doses after an estimated 50% of frontline workers in the county refused the vaccine.
  • Fewer than half of the hospital workers at St. Elizabeth Community Hospital in Tehama County, Calif., were willing to be vaccinated, and around 20% to 40% of L.A. County’s frontline workers have reportedly declined an opportunity to take the vaccine.
  • Nikhila Juvvadi, the chief clinical officer at Chicago’s Loretto Hospital, said that a survey was administered in December, and 40% of the hospital staff said they would not get vaccinated.

Distrust For The Government Among Black/LatinX

Frontline workers in the United States are disproportionately Black and Hispanic. It is no surprise to my readers, as mentioned briefly in my AHA recap article(s), that structural racism is (and has been) a pervasive force within healthcare. “I’ve heard Tuskegee more times than I can count in the past month — and, you know, it’s a valid, valid concern,” said Dr. Juvvadi. This forms the crux of the argument made by minority frontline workers against receiving the vaccine. A recent survey by the Kaiser Family Foundation found that 29% of healthcare workers were hesitant to receive the vaccine, citing concerns related to potential side effects and a lack of faith in the government to ensure the vaccines were safe. Furthermore, dissenters question the involvement of Black/LatinX participants in the clinical trials that led to the development and deployment of at least two FDA-approved vaccines at the time of this article. Dr. Juvvadi told NPR that “there’s no transparency between pharmaceutical companies or research companies — or the government sometimes — on how many people from.” In an op-ed published in the New York Times last week, emergency physicians Benjamin Thomas and Monique Smith wrote that “vaccine reluctance is a direct consequence of the medical system’s mistreatment of Black people,” exemplified by the unethical surgeries performed by J. Marion Sims and the Tuskegee Syphilis Study, that highlight “the culture of medical exploitation, abuse, and neglect of Black Americans.”

Altruism and Others More Deserving

Medicine is an inherently altruistic field, one that requires a dedication to the service and betterment of others. This theme has largely affected the sentiment concerning the acceptance of the COVID-19 vaccines. In an op-ed published earlier this week by Marty Makary MD MPH, a professor of surgery and health policy at the Johns Hopkins University School of Medicine, the case for delaying vaccination is made. Dr. Makary states:

“After a summer of corporate statements pledging that Black Lives Matter, America’s vaccine rollout is creating inequities stemming from a ruling class making rules to favor themselves. In the first two weeks after the FDA authorized the life-saving vaccine, hospital board members, spouses of physicians, cosmetic surgery receptionists, and young firefighters have been getting the vaccine ahead of our society’s most vulnerable. Low-risk Americans with access and power are cutting in the vaccine line and, by doing so, are essentially telling our society’s most vulnerable members ‘your life matters less.’”

Dr. Makary shares his experience as a physician who performs surgeries on COVID-negative patients in a sterile environment with the highest infection control precautions accounted for. Furthermore, he weighs his personal risk of having a complicated course of COVID-19 infection versus that of his elderly patients, many of whom have multiple comorbid medical conditions. He argues that low-risk healthcare workers, including those who have already been infected, defer their vaccination in order to allow for higher-risk individuals to receive a potentially life-saving intervention. This highlights the chasm in Medicine between altruism and self-preservation. Is it possible to do both?

I end with a quote from Dr. Makary, expressing his views on the matter:

“I’m not criticizing clinicians who get the vaccine — my personal decision might be different if I spent more time in the ICU, took more ER calls, or was at high risk of being a silent carrier of the virus, putting my patients at risk. But that’s not me. Given my very low personal risk of mortality and my very low risk of getting the virus in my clinical work, I have joined a growing chorus of healthcare workers who have taken a pledge to not get the vaccine until every high-risk American has been offered it first.”

Thank you for reading, and please feel free to reach out to me with comments or questions on Twitter @DrDapo.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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The Inequity of the COVID19 Vaccine Distribution: The rich countries hoard vaccines while the poor countries struggle to get them

Last week at Cedars-Sinai, we received an email asking its employees interested in getting the vaccine against COVID19. I was very excited about this since it means a lot of things at once. The development of safe mRNA vaccines in a short period shows how much technology has advanced and highlights the importance of working together as the companies that manufactured the vaccines were not in a race against each other but against the virus. On the other hand, getting a notification that I was soon going to get vaccinated against this virus that has changed our world was pure joy, that sadly faded away.

As I told my friends and family the excitement that I was having because I would be vaccinated soon, all they did was ask me, but when are we going to get the vaccination for us? For our healthcare workers, grandparents, and grandmothers? We have heard in the USA with optimism how the government has secured millions of doses for its people, and it only makes sense that a government wants to put their citizens first but, at what cost? Where does the solidarity with other nations reside? These questions made me dig deeper into an issue that gets shadow by the hype of us getting vaccinated.

The People Vaccine Alliance, an international watchdog that includes Amnesty International, has warned that some countries have bought enough COVID vaccine to immunize their populations more than once. It highlights Canada as the top country on this matter that has reported over 400.000 cases of COVID19 has secured enough vaccinations to immunize its population at least five times. In contrast, poorer countries will only be able to vaccinate one in ten people. The Alliance data also showed that the deals that have been done between the governments and the eight leading vaccine candidates’ risk of leaving behind middle-low and low-income countries, as rich nations hoard on vaccine deals.1

A clear example of the disparity between the rich and the poor has been the Moderna and Pfizer vaccines’ inequitable deals, which have shown on their preliminary data to have the highest efficacy rate. Due to their promising results, the vaccine lots have been bought in a staggering 96% for Pfizer and 100% for Moderna by rich nations. With those impressive figures, the gap between the have and the have nots will stretch even further. The Director-General of the World Health Organization, Tedros Adhanom, warned during a press conference “Every government rightly wants to do everything to protect its people, but there is now a real risk that the poorest and most vulnerable will be trampled in the stampede for vaccines”.2

Nonetheless, international efforts have been made to achieve global vaccination, such as COVAX. This compact, composed of 189 countries, amongst which the USA and Russia resonate for their absence, has high and middle-income countries committing to provide funding to ensure access to vaccination and equitably manufacturing them. In contrast, poorer countries have signed to secure vaccines for their population. This effort will also be backed up by agencies such as the Bill and Melinda Gates Foundation.3 Efforts by the Oxford/Aztreneca are also of great importance to allow developing nations to get the vaccine, as they have pledged to five more than half of its doses to developing nations. Unfortunately, this would only reach 18% of the world’s population.4

I concur with Melinda Gates’s denomination of this phenomenon as vaccine nationalism, with the populist premise of “our citizens first,” that suffice its purpose of improving the polls for political gains. However, these actions go against one of the most powerful lessons this pandemic has taught us, the sense of community and working towards the benefit of all.

I firmly believe that vaccine allocation for a health crisis like this should prioritize global immunization for healthcare workers and elderly patients, rather than prioritizing country of residence or origin. It is not acceptable to have an effective vaccine, not reaching healthcare providers on the frontlines of developing countries fighting this virus without this indispensable weapon. In contrast, rich countries rely on an excess of vaccines and immunize low-risk citizens first.

This pandemic has shown us how fragile humanity. Now more than ever, the rich countries and their economic capacity must set an example of global leadership and outline a sensible policy that focuses on a global perspective rather than an exclusive, nationalistic one because this crisis won’t be over until everyone gets vaccinated.

 

References

  1. International. A and https://www.amnesty.org/en/latest/news/2020/12/campaigners-warn-that-9-out-of-10-people-in-poor-countries-are-set-to-miss-out-on-covid-19-vaccine-next-year/. 2021.
  2. https://abcnews.go.com/Health/rich-countries-hoarding-vaccine-report/story?id=74623521 A.
  3. https://www.cnn.com/2020/12/13/world/coronavirus-vaccine-developing-world-intl/index.html C.
  4. https://www.bbc.com/news/health-55229894 B.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”