Saturday, September 10, 2022

The new Covid boosters

As you must be aware, the U.S. FDA recently approved (on August 31) a new booster shot against Covid-19, The bivalent vaccines, which are updated boosters, contain two messenger RNA (mRNA) components of the virus: one of the original strain of SARS-CoV-2 and the other, one that is common between the BA.4 and BA.5 lineages of the omicron variant of SARS-CoV-2, the most recent strains of the virus that are circulating.

Should you get one? Some facts:

The first is that the mRNA vaccines have been remarkably effective. While they do not necessarily mean you will not catch the virus, they dramatically reduce your chances of getting very sick or dying from it. Hospitalization rates were over 10 times commoner in unvaccinated people. Vaccinated people who are sick enough to require hospital care are overwhelmingly the elderly and those with multiple other medical illnesses.

While any vaccination helps, the best protection is offered by having the original two shots plus 1 or 2 boosters.

If you have not had your 3rd or 4th shot, the new vaccines will now be the only ones offered.

While the new vaccines have been shown in mice to produce good antibodies against the current Omicron strains, their effectiveness at preventing disease in humans has not been fully studied.

My take: if you have been fully vaccinated – 4 shots – I would be in no rush and would wait for more human studies to be reported. If you have not yet had your boosters, get one!

Also: everything we know tells us that this winter is likely to be a bad flu season. There was severe influenza in the southern hemisphere during their just-finishing winter and that is often an early warning about what we will experience.

The much-discussed mask wearing of last winter had a spin-off benefit: much less respiratory illness in general, including influenza. As people have begun to stop wearing masks, this extra layer of protection will be gone.

Get your flu vaccine before the end of October.

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Friday, July 29, 2022

Foods as medicine

As you know from reading earlier posts, the effects of different foods on health can be difficult to interpret. Rarely do studies get to compare people who are exactly alike except for their consumption of the substance of interest. Avocados may be good for your heart, or it may simply be that people who eat avocados eat a healthier diet overall. Hence the often contradictory headlines - coffee is good for you/coffee is bad for you – that populate the press.

I have thus been very interested to find several recent studies with robust data behind the health claims.

First bananas. A British group treated almost 1000 people with a hereditary tendency to colon cancer (Lynch syndrome) with a “resistant starch” powder made from bananas or a placebo for 4 years and followed them for at least 10 years. The supplement group had a similar rate of colon cancer but dramatically fewer cancers of the pancreas and upper GI organs: 5 vs. 21.

Another study looked at the value of cocoa-based chocolate compared to white chocolate and placebo in elderly patients with advanced cancer in palliative care. After 4 weeks, the group given dark chocolate had better calorie and protein intake and overall better nutritional status than either the white chocolate or no chocolate groups. They also had improved functional status.

Finally: prunes. Prunes are known to contain large amounts of antioxidant compounds. Researchers at Penn State gave post-menopausal women 55 to 75 either 6 prunes/day, 12 prunes/day or no prunes for 12 months. All 3 groups were given daily calcium and Vitamin D. Not surprisingly, the group assigned to 12 prunes/day had a high (41%) drop-out rate, presumably because of excess bowel movements, but only 10% of the 6-prune group and 15% of the no-prunes group left the study.

After a year, the groups taking prunes had much lower levels of inflammatory markers in their blood. More important to the women in the study, the placebo group had a significant fall in their bone mineral density while the group who took 6 prunes/day had no drop.

So, good data showing that bananas, dark chocolate and prunes have proven health benefits. Enjoy!

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Thursday, July 14, 2022

Do I really need that test?

A 2019 study estimated that overtreatment and “low value” testing costs the U.S. between $75 and $100 Billion annually. Why should you care? You should care because this means that the cost of your health insurance and your out-of-pocket costs go up to pay for this unnecessary treatment and testing.

We will leave treatment to another post and focus on over-testing. Unnecessary or low-value tests are those which are very unlikely to make you live longer or feel better.

Such over-testing is ubiquitous, but one area is “routine” pre-operative testing. Clearly if you have evidence of bad heart or lungs and are being asked to have a risky surgery, your doctor may need tests to determine if you can safely undergo surgery. That, however, accounts for only a tiny fraction of pre-op testing.

The vast majority of pre-operative testing is done on relatively healthy people who are about to have low-risk surgery such as hernia repairs or cataract extractions. Decades ago, the American College of Cardiology and the American Heart Association, in conjunction with the anesthesiology societies, published guidelines recommending against pre-op stress testing for most patients, and even advised against routine ECGs. While some hospitals have tried to reduce such testing, the overall impact of these recommendations has been minor.

In many cases, asking a few questions, such as “can you walk up 2 flights of stairs without problems” will avoid the need for most heart and lung testing before surgery.

Why do so many unnecessary tests continue to be ordered? Some of the incentive is financial. Doctors and hospitals are paid more when they do more. As long as this perverse incentive continues, there will be pressure to do more. Research has demonstrated that doctors who own MRI machines order many more MRI studies. If I were paid by the word to write, you can bet this post would be much longer.

The other factor is cultural. Doctors have been conditioned to believe that “It cannot hurt to get more information.” While an occasional extra blood test may not cost much or harm you, some invasive tests carry risk, and the added cost and inconvenience of any test is not trivial if you take off time from work or drive a distance. Another under-appreciated factor is that many “routine” tests turn up unexpected minor abnormalities that are not significant, but which require other tests to prove this.

What can you do? Before agreeing to any test, ask how the results will change your treatment.

For anything but blood tests or plain X-rays, ask if there is any risk to the test.

Ask if there are simpler alternatives.

Ask if there is any harm in waiting a bit. Many illnesses are self-limited, and the doctor will often be certain you have nothing serious but orders tests “to be sure.”

If the recommended test is invasive, such as cardiac catheterization, consider asking for a second opinion before you agree to have it.

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Wednesday, July 6, 2022

Protect your brain!

Dementia is probably the most feared illness to which older adults are prone. While we cannot do anything about the biggest risk factor, aging, there are many other risk factors that are under our control.

I mention aging because the likelihood of dementia rises rapidly as we get into our 70’s and beyond, and the only way I know of to prevent getting older is to die young, which I do not recommend.

So-called “mind games” have been much touted but there is little evidence they do any good.

The “modifiable” factors that increase the odds of dementia include physical inactivity, cigarette smoking, depression, low education, obesity, diabetes, high blood pressure and hearing loss. It has been said that anything which is good for the heart is good for the brain, and that certainly applies to many of these factors.

Stopping smoking if you are a smoker will add years to your life and improve the quality of your life. Treating hypertension and diabetes will lower your risk of both heart attack and dementia. Losing weight obviously helps numerous health issues, from heart disease to arthritis, as well as dementia. If only I had a magic bullet to make this easy.

Depression and hearing loss share the common factor of increasing isolation. Treating depression and getting hearing aids both allow more social participation, which in turn decreases the risk of dementia.

I have saved the best (studied) for last. Innumerable scientific studies have shown that regular physical activity lowers the risk of dementia and pushes it out later if it occurs. This does not mean you have to run marathons. Walking, gardening, pickleball or line dancing are all helpful.

How exercise works is becoming clearer. Studies in mice have shown that exercise creates more neurons and synapses (the connections between neurons). There is also evidence in mice that exercise reduces the inflammation that harms brain cells. More recently, a study of older Chicago residents followed closely over decades has found similar benefits in the human brain. There was a strong correlation between being more active physically and healthier brains with less inflammation. None of these seniors formally “exercised,” but activity monitors were used to see how often they moved versus sat.

Bottom line: get off the couch and walk, do housework or play with the grandchildren. Move that body for at least an hour a day. Your brain will thank you.

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Tuesday, June 14, 2022

Monkeypox

Does it appear as if we are beginning the plagues that struck Egypt in the Bible? Just as we seem to be learning to live with COVID (though that virus may not be done with us just yet), along comes monkeypox. What is it? How worried should you be?

The most notable poxvirus is the life-threatening smallpox, which has been vanquished after millennia in which it was a leading cause of death. Related viruses are the cowpox virus that Jenner used to make the first vaccines and the vaccinia virus used to make modern smallpox vaccines.

Monkeypox is a similar virus, and has probably been around for a long time, but was largely confined to central and western Africa, so was not studied by western scientists. It is so-called because it was first detected in laboratory monkeys (in Denmark), but its usual hosts are small African rodents and other small mammals. There are two forms of the virus; the one seen in the Congo basin causes more severe illness, with about a 1-2% death rate in humans, and is more transmissible. The current outbreak appears to be of the less severe West Africa strain. No deaths have yet been reported in the current outbreak.

Before this year, cases outside Africa were rare, and usually seen in returning travelers. The U.S. had an outbreak in 2003. A shipment of Gambian pouched rats infected prairie dogs housed in the same facility, and these were then bought as pets and infected their owners.

2022 is different. As of this writing, some 1500 confirmed cases have been reported from 31 countries around the world, with 60% of these in Spain, Portugal and the United Kingdom. Most of these have been traced to large gatherings such as raves, where people mingled closely. Some 50 cases have been verified in the U.S. and over 110 in Canada (most in Quebec). The virus is primarily spread by direct contact with skin lesions but can also be spread by contact with sheets or clothing that have been in contact with skin lesions. While still debated, it may be spread by large respiratory droplets.

The usual illness is fever, chills, muscle aches, sore throat and swollen lymph glands, and then comes the rash. The rash begins as flat moles, which then form blisters and then pustules. It can be all over or confined to a small area.

In the current outbreak, most cases have been in men who have sex with men, and the rash has been in the genital and rectal area. Unless the doctor treating such a patient thinks of monkeypox, they are more likely to diagnose a more common sexually transmitted disease such as herpes.

Should you be worried? Probably not yet. Unlike Covid-19, which spreads primarily through small respiratory droplets and can easily be spread even when the carrier is not sick, monkeypox is mostly spread by direct contact with a sick person, so you do not need to worry about catching it in stores or concerts. Casual contact is not a high risk.

Treatment is focused on treating symptoms. Some vaccines and antiviral medicines are available that help, but these can only be obtained from the CDC.

My biggest concern is that if private doctors and public health officials are not vigilant, the virus may become established world-wide and no longer be confined to Africa.

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Saturday, May 28, 2022

The PCP - soon to follow the dodo and carrier pigeon?

The Institute of Medicine defined Primary Care in 1996 as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Whether the focus is on the individual or the community, good access to primary care is associated with more timely care, better preventive care, avoiding unnecessary care, lower costs, and lower mortality.

Most experts feel that in an ideal medical care system, about half of physicians would be in the primary care fields of family practice, general internal medicine and general pediatrics. Where does the U.S. stand? About a third of American physicians now practice primary care, but fewer than a quarter of recent medical school grads chose a primary care specialty, and the Council on Graduate Medical Education projects this number will soon drop to under 20%.

Why the disconnect between what the nation needs and what we have? There are many possible explanations, but as always, “follow the money.” According to the Association of American Medical Colleges, the average medical school debt for 2021 graduates was $203,062. It will not shock you to learn that specialists earn more than primary care doctors, but the magnitude may be surprising. In 2020, the average salary of primary care physicians was $260,000 and that of all specialists $368,000, 42% more. When broken down by field of specialization, the disparities are even greater. In 2021, the average family medicine specialist earned $255,000; the average orthopedist $$557,000 and the average cardiologist $460,000.

When a newly minted MD looks at their debt load, which is more appealing: pediatrics, with a 2020 starting salary of $196,000 or dermatology, where the average is $394.000? In addition to the obvious fiscal push toward specialty care, there are less-easily quantified but important non-monetary factors. Medical students are exposed predominantly to academic specialists and sub-specialists during their clinical rotations, and the message is often “you are too smart for primary care.” When role models are specialists who know everything there is to know about a limited field, that becomes an easy position for the student to envision for themselves.

Another factor is the “burn-out” that many students encounter during their rotations. All physicians deal with ever-increasing paperwork demands, but the burden is disproportionately heaped on primary care physicians. A recent survey asked doctors in different fields to estimate the hours they spent per week on paperwork. The range was from a low of 10 hours for anesthesiologists and ophthalmologists to 18.9 for Internists. It is the PCP who must spend the most time feeding the maw of the electronic medical record (EMR) with meaningless clicks to document items that have minimal benefit to the patient.

What is the way out? The huge discrepancy in earnings must be narrowed. A model that appeals to PCPs is the “concierge” model, which allows them to see fewer patients, give better quality care and earn more. Unfortunately, this is not available to most Americans. The rate setters must give more reward for thinking and talking to patients and less for procedures. The hundreds of “quality measures” doctors are required to document must be limited to those that have been proven to improve outcomes. Less time spent “treating” the EMR will allow more time spent with the patient. Students need more PCP role models during medical school.

In the meantime, if you have a good PCP, be grateful.

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Tuesday, April 19, 2022

Avocados, coffee and wine

Two articles in the press caught my eye last month. One reported that eating avocados twice a week lowered your risk of heart disease by 20% and the other that drinking 2-3 cups of coffee daily lowered your risk of death and heart disease by 10-15%. Since I need my two cups of coffee to get going in the morning but have never eaten avocados, I had to dig a bit deeper.

Both these studies, it turned out, were observational studies.

The gold standard for testing the value of a new treatment is the controlled trial. You take two groups of people who are similar in all respects and randomly give one half of the group treatment A and the other half treatment B. You then compare the results and if the results are substantially different, you can assume this is because A or B is better.

When the treatment is something people cannot do by themselves, this type of trial is straight-forward to design and conduct. When you are looking at diet, exercise, smoking or other habits, things get a lot harder. To compare the effects of eating avocados twice a week or not, you would have to control the subjects’ diets 24/7, clearly impractical. For this type of comparison, people are recruited and asked to do or not do things, but the researcher cannot control their actual behavior, or their usual behaviors are ascertained by questioning them.

Many large groups have been studied over the years in observational trials, and much useful information has been learned by following their health outcomes, but findings from such studies are almost never proof that the behaviors caused the outcomes.

The classic example of this misunderstanding about observational trials is the effect of post-menopausal estrogen use. For decades, almost every doctor believed that taking estrogens after menopause prevented heart disease. Why? Because women who took estrogen had much less heart disease. Only after the Women’s Health Initiative trial seemed to refute this did doctors pause to think that women who took estrogen were different in many other ways from women who did not. They smoked less, exercised more, saw doctors more often and were generally more health conscious. It seemed they were healthier to begin with.

More recently, the “fact” that light to moderate alcohol consumption benefits heart health has also been questioned. Researchers looked at over 371,000 people in the United Kingdom Biobank. They found, as expected, that light to moderate drinkers had the lowest heart disease risk. They also found that this group tended to have healthier lifestyles than abstainers: they smoked less, ate more vegetables and were more physically active. Taking the lifestyle factors into account eliminated any beneficial effect that could be attributed to their drinking habits.

Bottom line: observational studies may suggest harms or benefits but rarely if ever can they prove such effects. If you enjoy avocados or your morning coffee, go on consuming them, but I would not depend on either to keep you forever young.

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