The President’s Paragraph

Coffee Talk

by Angela Self, MD, TCMS President

This article was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.

Sometimes you just need to grab a cup of coffee, sit under a tree, and contemplate nothing at all. Years before I started coffee blogging, I remember watching an episode of 60 Minutes where a segment was on “living into your 90s” by Leslie Stahl (the episode aired on May 4, 2014). I was still a toddler in my appreciation of coffee, and this episode was one of the things that propelled me to look further. Some of the commonalities that these 1,600 nonagenarians shared were physical activity (average 45 minutes a day, but at least 15), moderate alcohol consumption (those who had one to two drinks a day lived longer than those who did not drink), and coffee consumption of one to three cups a day (not more). At that time, I clung to the coffee part of the study. Now, I am realizing how far behind I am in alcohol consumption.

As the story goes, coffee was first discovered in Ethiopia by a goatherd named Kaldi. He played music for his goats each day and they would come running to follow him home. One day they did not come, so he went looking and found them playing, bleating, butting heads. He wasn’t sure what was going on but noticed they were eating leaves and berries from a plant. They refused to come for hours, but they made it home eventually. He was concerned the plant might be poisonous, but the next day the goats ran to the same area and started eating from them again. Kaldi, after seeing that the goats were not ill from the plant, decided to try it himself. That is how Mark Pendergrast tells the tale in Uncommon Grounds. The Ethiopians got creative with how they consumed this energy-giving substance that heightened alertness, a very desirable property, and thus the coffee drink was introduced to the world.

Coffee was first traded to the Arabic people by the Ethiopians. Arab Sufi monks would drink coffee to stay awake for midnight prayers. Coffee was banned more than once in that society in the 1500s, but this did not discourage people from drinking it privately. The business of “coffee growing” got quite political, and because growers tried to keep their sacred plants from being shared, there were coffee beans and trees that were smuggled from one country to another in the 1600s. The beverage was becoming popularized in Europe, and in the early 1600s it was an exotic drink used by the upper class. By the 1650s it was being sold on the streets in what sounds like coffee trucks, offering coffee and other beverages. The first coffee shop to open in Italy was reportedly Caffè Florian in Venice in 1683. This café became a place of “relaxed companionship, animated conversation, and tasty food.”1

The properties of coffee make this beverage magical—I mean, medicinal. I appreciate that reflux can be exacerbated by coffee with relaxation of the lower esophageal sphincter, and that it can keep susceptible people awake at night. However, I would rather focus on its healthy properties. Studies have been done that suggest coffee can lower the risk of cancer of the prostate, liver, endometrium, colon, and mouth.2 It is also recommended for nonalcoholic fatty liver disease because it can possibly decrease fibrosis. Caffeine comprises two to three percent of the coffee content and is present as a salt of chlorogenic acid. Tannin comprises another three to five percent. The antioxidants in coffee fight inflammation, which Rubin and Farber taught me was the basis of disease.

There are 70 species of coffee (Coffea), but the two main ones that are cultivated are Coffea arabica (75 percent) and Coffea canaphora (25 percent), and there are multiple thousands of varieties or varietals. The plant is indigenous to many countries, including Ethiopia, Brazil, Mexico, Guatemala, and Vietnam. I have tried coffee from many countries and a couple of my favorites are Costa Rica and Rwanda. I really like that Rwanda has a large female-run co-op that was started in 2009 when 85 female coffee farmers pooled their resources to form the Gashonga Cooperative (fair trade certified). I first fell in love with the body and flavor of this single-origin coffee at Oak Lawn Coffee Company (sadly, it is now closed), where they served the tasty espresso from a Denver roaster, Commonwealth Coffee Roasters. I even traveled to Denver to get another sip of this juice from the gods only to learn that Commonwealth was one of a handful of similar excellent coffeemakers: Allegro, Sweet Bloom, Little Owl . . . (perhaps just read my blog on that Denver trip at coffeebyangela.com).
 

To sum it up (I think Allison is knocking on my door), coffee is healthy for most people when consumed in moderation. It contains antioxidants, caffeine, and tannin, among other natural chemicals. It has done more to bring people together in this country than anything I can think of, even music. I believe that it staves off diseases and can even contribute to a longer life.2

Also, I just like it and I think it tastes much better than beer. So, cheers, and I hope we can enjoy a cup together soon!

References

1. Pendergrast, Mark. Uncommon Grounds: The History of Coffee and How It Transformed Our World. New York: Basic Books, 2010. 

2. http://www.cancer.org 

Where Do SARS-CoV-2 Monoclonal Antibody Therapies Fit in COVID-19 Management?

by Catherine Colquitt, MD
Tarrant County Public Health Medical Director

This article was originally published in the November/December issue of the Tarrant County Physician. You can read find the full magazine here.

With local hospitals and emergency responders struggling to meet the space and staffing challenges brought on by the COVID-19 Delta variant, monoclonal antibody infusions (and subcutaneous injections when applicable for REGEN-COV) are being used to treat early COVID-19 infections. These are effective options in persons who don’t require hospitalization for COVID-19, aren’t hypoxic (or, if chronically O2-dependent, aren’t needing to augment their percentage of supplemental O2), or even as postexposure prophylaxis for persons at high risk for severe disease and poor outcome if they contract COVID-19 after an exposure. 

The science underlying the development of the three monoclonal products granted Emergency Use Authorization (EUA) by the FDA capitalizes on the importance of the COVID-19 spike protein as a means of host cell entry. When viral particles are tagged by SARS-CoV-2 monoclonal antibody therapies, the monoclonal antibody-tagged viruses can’t enter host cells and replicate.  

The mRNA vaccines, encoded for the COVID-19 spike protein and currently in wide usage, target the same essential viral spike protein by stimulating the host to transcribe the spike protein mRNA. They mount an immune response to that transcribed viral spike protein which the host’s immune system will then remember and repeat (anamnestic response) when COVID-19 viral particles present the spike protein to the now-vaccinated host’s primed immune system.1 

Three SARS-CoV-2 monoclonal antibody formulations have been granted EUA by the FDA, though the first monoclonal SARS-CoV2 product (the coformulation bamlanivimab and etesevimab) is no longer authorized in the U.S. because of the decreased susceptibility of Beta and Gamma COVID-19 variants to it.2 Two combinations remain in use— the coformulation monoclonal casirivimab and imdevimab (REGEN-COV), which binds to nonoverlapping epitopes of the spike protein, and sotrovimab (XeVudy).  Both are given under EUA’s for mild to moderate COVID-19 infections in persons 12 years or older weighing at least 40 kg and at high risk for severe COVID-19 infection.   REGEN-COV use in postexposure prophylaxis is also granted under its EUA for COVID-19-exposed persons not yet fully vaccinated and for persons who are vaccinated but regarded as unlikely to respond well to COVID-19 vaccinations.3 Locally, only REGEN-COV is in use at present.   

Comorbidities to consider in deciding who to refer for SARS-CoV-2 monoclonal therapy after onset of mild to moderate illness (early is best but both products are approved through day 10 after symptom onset) include:

  • Age 65 and older
  • BMI over 25kg/meter squared 
  • For 12 to 17 years old, BMI over 85th percentile for height and age
  • Pregnancy
  • Chronic kidney disease
  • Diabetes mellitus
  • Immunosuppressive disorder or treatment
  • Cardiovascular disease, including hypertension and congenital heart disease
  • Chronic lung disease, including COPD
  • Moderate to severe asthma
  • Interstitial lung disease
  • Cystic fibrosis
  • Pulmonary hypertension
  • Sickle cell disease
  • Neurodevelopmental disorders such as cerebral palsy or other conditions “conferring medical complexity such as congenital abnormalities and genetic or metabolic syndromes, and medical-related technology dependence such as tracheostomy, gastrostomy or feeding jejunostomy, mechanical ventilation, etc.”4

Data supporting the use of both SARS-CoV-2 monoclonal products currently in use is persuasive if primary outcomes of all deaths and hospitalizations through day 29 after administration of the products is the measure. For REGEN-COV there was an absolute reduction in death and hospitalization of 2.2 percent and a relative reduction of 70 percent in the treatment group versus placebo. For XeVudy, using the same primary outcome measures of all-cause mortality and hospitalization through day 29, the treatment group experienced a 6 percent absolute reduction and an 85 percent relative risk reduction compared with the placebo group.5

Some special considerations for the use of SAR-CoV-2 monoclonal products: 

Variants: So far both products are rated as efficacious against variants available to test, including Delta and Mu, though this is a rapidly changing field of study. 

Vaccinations Against COVID-19: Contraindicated in the 90 days following monoclonal administration due to theoretical concerns regarding a blunted immune response to COVID-19 vaccination.

Monitoring After Infusion: For one hour in a health care setting. 

Drug Interactions: None so far identified.

Pregnancy: Monoclonals can be used in pregnancy and should certainly be considered when a pregnant woman has additional risk factors (beyond pregnancy alone) for severe COVID-19 disease.

Reactions to SARS-CoV-2 Monoclonal Products: Injection site reactions (pain, redness, swelling, pruritus, injection site ecchymosis) in approximately 1 percent and infusion related reactions such as urticaria, pruritus, flushing, pyrexia, shortness of breath, chest tightness, nausea, vomiting, and, rarely, anaphylaxis. In general, the REGEN-COV current dose of 600mg of casirivimab and 600mg of imdevimab is significantly better tolerated than the previously higher dosed formulations. 

Lactation: No data yet available.

Hepatic impairment: No dose adjustment needed.

And please remember – COVID-19 monoclonal therapeutics are not a substitute for COVID-19 vaccination! 

Locations of Tarrant County Infusion Centers: 

JPS Urgent Care Center   

1500 S. Main Street, Fort Worth , Texas 76104

Call 817-702 1451 for appt.
          
North Central Texas COVID-19 Regional Infusion Center 

815 8th Avenue, Fort Worth, Texas 76104 

Call 800-742-5990 for appt 

Medical City Healthcare
(https://medicalcityhealthcare.com/covid-19

Additional Infusion Center resources are available at www.tarrantcounty.com or by phone at HHS Protect Public Data Hub
(1-877-332-6585 in English and 1-877-366-0310 in Spanish). 

Sources

1. http://www.covid19treatmentguidelines@nih.gov, updated 8/4/2021 

2. Fact Sheet for Health Care Providers and Emergency USE Authorization (EUA) of Bamlanivmab and Etesevimab (REVOKED) 

3. https://www.fda.gov/drugs/drug-safety-and-availability/fda-authrozies-regen-cov-monoclona-antibody-therapy-post-exposure-prophylaxis-prevention-covid-19 

4. Fact Sheet for Health Care Providers and Emergency Use Authorization (EUA) of REGEN-COV 

5. Fact Sheet for Health Care Providers and Emergency Use Authorization (EUA) of Sotrolivumab

TCMS Gold-Headed Cane and Installation Celebration

Physicians, join us as we honor our 2020 and 2021 Gold-Headed Cane Award recipients and 2021 and 2022 TCMS presidents:

Teresa Godbey, MD – 2020 Gold-Headed Cane Award Recipient

Angela Self, MD – 2021 TCMS President

Susan Rudd Bailey, MD – 2021 Gold-Headed Cane Award Recipient

Shanna Combs, MD – 2022 TCMS President

The celebration will take place at the City Club of Fort Worth on December 9 from 6:00-9:30pm. If you plan to attend, please RSVP by November 30. You can do so here, or you can contact Melody Briggs at mbriggs@tcms.org.

We hope to see you there!

A Love Letter to the Community

by Rachel Marie G. Felix, OMS-II

This article was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.

by Rachel Marie G. Felix, OMS-II

If everything I’ve learned in medical school thus far, my favorite realization has been that I love people. Given the fact that we live in a society rooted in individualism, becoming aware of this fundamental truth of mine was not as straightforward as it sounds. Especially when being part of the medical field, where there is constant pressure to compete, accomplish extremely taxing feats, and be the best all-around people we can possibly be at all times. From a young age, those who pursue medicine are conditioned to hyper focus on their individual accomplishments. However, through guidance from my extraordinary mom, support from my childhood loved ones, and interactions with my incredible classmates, I’ve come to truly understand my “why,” and it’s all for the community.

With a jam-packed schedule and overflowing course material, during the first few weeks of medical school I knew I had to take time to contemplate who I was and what I wanted from life, or else I would risk losing myself to the grind. And from deep reflection and unlearning during the Black Lives Matter movement, I realized that I thrive when I am able to contribute to the joy and wellbeing of those around me.

What came from living daily in this truth was life altering. I found myself soaking in every conversation shared with my mom and truly learning the depth of her selflessness. I challenged myself to go on a medical mission trip to help those with limited access to healthcare and was overwhelmed by both the support from my family and friends and the gratitude from those we were able to serve. I would even go to campus completely open to meeting new people and end up having such enjoyable conversations. This would lead to sessions of vulnerability and genuine connection, leaving me feeling enriched by the opportunity to appreciate the different sides of each classmate-turned-friend.

As I made a point to cherish each interpersonal opportunity, I realized just how fulfilling every day can be when we immerse ourselves in community. Yes, we can say we show appreciation for our communities through volunteering or even through our careers, but intentionally showing how much we care for one another as a regular practice is a lifestyle that I highly recommend. While there are many outside influences that can cause us to get caught up in our own worlds and participate in a zero-sum game, the truth is, there is abundance in the shared human experience. We are each beautifully complex and different beings with something unique to contribute to one another. So when one of us wins, we all win.

Conversely, we all hurt when one of us hurts. As made obvious by the pandemic, a flourishing community depends on the health of its people. So dear reader, I hope you are able to appreciate the unparalleled opportunity we have to positively impact those around us as healthcare professionals. Moreover, I hope you see how valuable both you and your patients are in creating a thriving community and allow every interaction—inside and outside of the clinic—to reflect that.

JPS Health Network Names New President and CEO

The JPS Board of Managers has announced the appointment of Dr. Karen Duncan as the administrator for the Tarrant County Hospital District, to serve in the role of president and chief executive officer for JPS Health Network, effective January 1, 2022. The move follows outgoing president and CEO Robert Earley’s retirement announcement two weeks ago.

“It is a testament to the strength of JPS that we found the right person to lead the health network into the future within our own ranks,” said Dr. Charles Webber, chairman of the JPS Board of Managers. “Dr. Duncan has been a steadfast champion of providing our community with the care they need and deserve, and I look forward to her leadership.”

Duncan currently serves as the network’s chief operating officer, and has been with JPS for five years. In that time, she has been responsible for transforming the community health network of medical homes and clinics, and most recently has steered the implementation of the JPS Future Plan, the bond-supported development of healthcare services and sites throughout the county.

“JPS is on the right track, and Dr. Duncan has been an integral part of that,” said Dorothy DeBose, incoming chair of the JPS Board of Managers. “We are fortunate to have a leader of her caliber ready to continue the great work we’ve already seen. We will work closely with her to design a succession plan for the organization that recognizes the current need for stability while continuing JPS’ growth.”

“I am both humbled and honored to serve as CEO of such a highly esteemed and accomplished healthcare system,” said Duncan. “JPS is well positioned to lead the transformation of healthcare delivery in Tarrant County and to improve lives within the many communities we serve. I look forward to working alongside a committed Board, a strong executive and leadership team and an amazing JPS team.”

Just last week JPS Health Network received top marks for patient safety and quality measures from the Leapfrog Group, the latest in a growing list of accreditations and honors for network which include Best Hospital for America by Washington Monthly and the Lown Institute and Outstanding Healthcare System by D CEO Magazine.

COVID-19 Vaccine Clinics for the Week of November 6

Tarrant County Public Health hosts numerous pop-up COVID-19 clinics across Tarrant County each week in partnership with public and private organizations listed below. Each site has the Moderna and Pfizer vaccines and at times the Johnson & Johnson. Vaccination are now available for children ages five and older at all of the TCPH locations. Booster doses continue to be available for those:

In addition the to the vaccination opportunities below, the cities of Arlington, Fort Worth, Mansfield, North Richland Hills, Hurst, and Tarrant County College have also added opportunities for vaccinations that are listed on our vaccine finder website.

TCPH would like to continue to partner with businesses, churches and other organizations in the community who are interested in hosting a COVID-19 pop-up clinic. It’s easy and free to host a clinic. Those interested can sign up for a public or private event at VaxUpTC.com.

Pop-Up COVID-19 locations:

Rep. Chris Turner and Commissioner Devan Allen
Saturday, Nov. 6: 10 a.m. to 2 p.m.
Bowie High School
2101 Highbank Drive
Arlington, TX 76018

Watauga Fire Department
Monday, Nov. 8: 8 a.m. to 12 p.m.
7901 Indian Springs Road
Watauga, TX 76148

La Gran Plaza
Monday, Nov. 8: 10 a.m. to 6 p.m.
4200 South Freeway
Fort Worth, TX 76115

Hurst Fire Station
Tuesday, Nov. 9: 10 a.m. to 6 p.m.
2100 Precinct Line Rd
Hurst, TX 76054

Immaculate Heart of Mary
Wednesday, Nov. 10: 11 a.m. to 3 p.m.
108 E. Hammond Street
Fort Worth, TX 76115

N. Richland Hills Fire Station 5
Wednesday, Nov. 10: 2 to 7 p.m.
7202 Dick Fisher Drive S.
North Richland Hills, TX 76180

Sundance Square Pavilion
Friday, Nov. 12: 11 a.m. to 7 p.m.
Near the intersection of 4th and Main Streets
Fort Worth, TX 76102

Northwest Public Health Center
Monday to Friday: 8 a.m. to 12 p.m. and 1 to 5 p.m.
3800 Adam Grubb Road
Lake Worth, TX 76135

Bagsby-Williams Health Center
Monday to Friday: 8 a.m. to 12 p.m. and 1 to 5 p.m.
3212 Miller Ave.
Fort Worth, TX 76119

Southeast Public Health Center
Monday to Friday: 8 a.m. to 12 p.m. and 1 to 7 p.m.
536 W Randol Mill
Arlington TX, 76011

Main Public Health Center
Monday to Friday: 8 a.m. to 12 p.m. and 1 to 6 p.m.
1101 S. Main Street
Fort Worth, TX 76104

Southwest Public Health Center
Monday to Friday: 8 a.m. to 12 p.m. and 1 to 5 p.m.
6551 Granbury Road
Fort Worth, TX 76133

Watauga Public Health Center
Monday to Friday: 8 a.m. to 12 p.m. and 1 to 8 p.m.
6601 Watauga Road
Watauga, TX 76148

COVID-19 causes respiratory illness with cough, fever and shortness of breath and may lead to bronchitis and severe pneumonia. For more information go to coronavirus.tarrantcounty.com or call the Tarrant County Public Health information line, 817-248-6299, Monday – Friday 8 a.m. to 6 p.m. and Saturday – Sunday 10 a.m. to 2 p.m.

COVID-19 Child Doses of Pfizer are Now Available in Tarrant County

Pfizer’s COVID-19 vaccine, Comirnaty, for children ages 5 to 11 years old is now available in Tarrant County. Parents and legal guardians should first talk to their pediatrician or local pharmacy to obtain their vaccination. Tarrant County Public Health will also be offering the children’s vaccine for those who cannot obtain it elsewhere.  

The Pfizer COVID-19 vaccine received final approval for use with children from the CDC on Tuesday, Nov. 2, 2021. On Oct. 29 the vaccine received its Emergency Use Authorization from the EPA. The EPA and CDC reviewed extensive data from trials to ensure the vaccine is safe for younger children. Critical points found during the studies include:

  • Effectiveness: Immune responses of children 5 – 11 years of age were comparable to those of individuals 16 through 25. In addition, the vaccine was found to be 90.7 percent effective in preventing COVID-19 in children 5 – 11.
  • Safety: The vaccine’s safety was studied in approximately 3,100 children age 5 – 11 who received the vaccine and no serious side effects have been detected in the ongoing study.
  • Dosage: The dose is just one-third (10 micrograms) of the dose for those 12 years of age and older (30 micrograms).

Children age 5 – 11 will receive two doses, 21 days apart, similar to those in the older groups already vaccinate. If a child cannot receive their second dose at 21 days, they are encouraged to get their second dose as soon as possible. Once the series has begun, there is no reason to restart; just finish up when it is possible. At this time, a booster dose is not recommended for children. 

“The more than 204,000, 5 to 11 year-olds in Tarrant County will now be able to receive a COVID-19 vaccine and help reduce the spread across our community,” said Tarrant County Public Health Director Vinny Taneja. “The fastest and easiest way to get a vaccine will be through the family pediatrician or at the local pharmacy. Public Health will offer the vaccine at each of its clinics across the County for those who need it.”

While younger children do not typically have severe outcomes when they contract COVID-19, they do act as spreaders taking it from home to school or from school to home, school to sports, school to daycare. In Tarrant County, there have been six deaths of people under the age of 18.

To find a COVID-19 vaccination clinic in Tarrant County, visit its website at www.tarrantcounty.com/vaccinefinder.

The COVID-19 vaccines are free to the recipients, whether they are insured or uninsured.

COVID-19 causes a respiratory illness with cough, fever and shortness of breath and may lead to bronchitis and severe pneumonia. For more information, go to coronavirus.tarrantcounty.com or call the Tarrant County Public Health information line, 817-248-6299, Monday – Friday 8 a.m. to 6 p.m. and Saturday – Sunday 10 a.m. to 2 p.m.