Monday, December 19, 2022

Curing Alzheimer's? Lies, damn lies and statistics

If you flip a coin three times and all three times it shows heads, you would not be shocked. If you flipped it 50 times and it came up heads every time you would ask for a new coin! Statisticians have ways of describing the odds that something happens by chance, and this type of calculation is broadly used in medical trials.

When treatment A gives a different outcome than treatment B, this is generally accompanied by a “P value,” which expresses the likelihood that the difference was purely by chance. The commonly accepted metric that there is a real difference between two arms of a trial is a P value less than 0.05. If P<0.05, this says there is less than a 1 in 20 chance the results were not really different. The lower the P value, the greater the chance the results were not coincidental.

While many researchers worship at the altar of P<0.05, I urge caution. If you include very large numbers of patients, even small differences in outcome can be “statistically significant,” when the difference is meaningless to patient outcomes.

Let’s say you treat 10 patients with an aggressive cancer with A and 10 with B. After 3 years, all the patients given A are dead and 9 of those given B are alive. You don’t need a statistician to choose your treatment.

Instead, let us say you treat 1000 patients with A or B, and the average lifespan for those given A is 2 years and two months, while those given B live an average of 2 years and a month. Because of the large number of patients in the trial, it is reported that A is statistically better than B. Yes, but… Those given A were twice as likely to have to stop treatment for a time due to serious side effects, and spent several weeks more in hospital. Choice depends on individual values.

There is often a serious difference between statistical significance and clinical significance.

This brings me to lecanemab, the newest “wonder drug” for Alzheimer’s disease. Like several others released or in testing, this monoclonal antibody targets amyloid-beta, a protein that accumulates in the brain of patients with Alzheimer’s. I must note that experts are still not agreed on whether amyloid causes Alzheimer’s or is simply a marker of the disease.

The trial of lecanemab involved 1795 patients, half getting an infusion of the drug every two weeks and half getting a placebo. The results, touted loudly by the drug’s manufacturer showed a highly statistically significant difference (P<0.001) in favor of the drug.

When you dig deeper, the results are less impressive. Patients in both arms showed steady deterioration in mental acuity, though the decline was less for those on the drug. The absolute difference after 18 months was 0.45 on an 18-point scale, a difference, but a modest one.

A quarter of those given the drug had serious reactions to the infusion, and one in eight had brain swelling. There were two deaths in the active treatment group that remain unexplained. Potentially useful? Maybe. A game-changer? No.

Existing drugs like the cholinesterase-inhibitors (Aricept et al) also slow the decline but do not cure the disease. There is also recent evidence that this class of drugs prolongs life.

In the meantime, do things proven to help that are low cost and safe: do not drink to excess; every drink over 1/day progressively shrinks your gray matter. Eat less processed and more unprocessed food. Be sure your Vitamin D levels are in the normal range; if you do not live in the tropics, taking a daily supplement is advised. Be sure your blood pressure is below 140/80.

My bias is that chasing amyloid is chasing down a blind alley. Time will tell, but be cautious about “statistically proven” treatments of marginal clinical benefit.

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Wednesday, December 7, 2022

Doctor: would you mind saying that again, but in English?

It will come as no surprise to most of you that what doctors think they say and what patients hear are frequently not the same.

Every field has its own jargon, understood by the practitioners but not “outsiders.” Be honest: if you bring your car in for service and the service advisor says you have a bad solenoid, would you understand what this means? [engineers excepted]

A recent study published in JAMA Network Open described what researchers found when they asked a group of adults attending the Minnesota State Fair last year their understanding of common medical expressions used by doctors talking to patients.

Despite the fact that this was an educated group (90% had at least an associate degree and 65% a bachelor’s degree or higher), less than 10% correctly understood the question “Have you been febrile?” and 2% understood the statement “I am concerned the patient has an occult infection.” 11% knew what it meant when they were told “You will need to be NPO at 8 AM.”

A common cause of confusion is the frequent difference between common usage and medical meaning. In most circumstances, “positive” has a good connotation, but in “your lymph nodes were positive,” the opposite is true. Being told “your performance on the test was impressive” would make a student happy, but if your doctor says “your Xray findings were very impressive,” you had better worry.

Even doctors may miscommunicate if an abbreviation is used out of context. If one doctor says to another “the patient has MS,” does this mean they have multiple sclerosis or mitral stenosis? If it is one neurologist talking to another, the meaning will usually be clear, but if the neurologist is talking to a cardiologist, all bets are off.

How should this affect your behavior?

A good medical interaction should end with the doctor asking the patient to tell the doctor what they understood of the conversation, but this rarely happens in today’s frantic environment. You should take the initiative and tell the doctor what you believe they just told you. Do not be surprised if they say “no, that is not what I intended to tell you.” You can then hopefully get a clarification.

Remember: the only dumb question is the one you should have asked but did not. Do not leave a medical visit without being sure you know what you were told and understand all its implications.

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Tuesday, November 29, 2022

Out from the valley of the shadow of death

It has been a while since I last wrote, but there was good reason. On Sept 23, I went in to one of the country's "top ten" hospitals for a “minor procedure” that was supposed to let me out in 3-4 days. My surgeon was very well-respected. On the second post-op day I told the staff there was a problem but was reassured my recovery was normal. Late on the third day my blood pressure disappeared, a fever developed and I was rushed back to the operating room, where 2 quarts of blood were found in the abdomen, indicating a post-operative hemorrhage, and then I was admitted to the ICU in “guarded condition.” [Translation: may not make it.]

After 10 days in the ICU, I went to the surgical floor for a week and then a rehab hospital where I could not get out of bed without help. Two weeks of rehab, followed by home PT for a month and I am well on the way to recovery.

What lessons should you take from this experience?

First, let me remind you of my definition of “minor surgery:” surgery done on someone else. Something can always go wrong, so be very sure there are not non-surgical alternatives before agreeing to an operation.

Second, be your own advocate or have someone close assume that role. I was probably not insistent enough that studies were needed the day before everything went sour.

Third, be sure you have a written health care proxy and have reviewed it with your surrogate. Do you want to be on a ventilator? In what circumstances? This should be made explicit.

Fortunately, my tale has a happy ending, but that was far from guaranteed.

On another note, the newest Alzheimer’s drug has been reported to great fanfare, but I urge caution. As is all-too-often true with new drugs, the benefit was "statistically significant" but I was not impressed with the clinical benefit, and the two deaths in the trial remain to be explained. More when I have a chance to read the full paper.

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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


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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Monday, March 28, 2022

Reigning: Cats and Dogs

Pet owners know that dogs and cats are like family members and get joy (as well as the occasional pain) from their animal companions. It is well known that pet ownership went up during the Covid pandemic: the “pandemic puppy” phenomenon.

What you may not know is the health benefits that accrue to pet owners, particularly dog owners.

A recent study from the University of Michigan followed 1369 adults 65 and older, who had normal cognitive skills at entry, over six years. They found that there was less cognitive decline among pet owners. The effect was most pronounced among those who had owned a pet for five years or more. Using a 27-point test score, pet owners had an average score that was 1.2 points higher at 6 years than non-pet owners. For comparison, this is a great difference than bestowed by the controversial drug aduhelm!

Another study looked at 11,233 Japanese adults 65 and older who had no pet or who owned a cat or a dog and followed them over 3.5 years. The dog owners had half the rate of disability develop over the study period compared to non-pet owners. There was no major benefit seen in cat owners. The researchers suggested that the benefit was due to the increased exercise forced on dog owners: dogs must be walked regularly, unlike cats.

Another interesting study was done in the emergency department of a large teaching hospital in Saskatchewan, Canada. Patients coming to the emergency department with painful conditions were randomly assigned to either receive a 10-minute visit from a “therapy dog” or not. Those who had the canine visits had significantly lower pain scores after the visit, as well as less anxiety and depression.

So, when your pet chews the furniture, cut them some slack: they are doing you a lot of good!

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Thursday, March 10, 2022

Long Covid - it is not "all in your head."

If you follow the news, you are aware that some people who recover from a COVID-19 infection have persistent complaints for months after their apparent recovery. These can occur in almost every body system, but the most prominent tend to be fatigue, shortness of breath and “brain fog:” difficulty concentrating.

While an enormous amount has been written about post-acute Covid syndrome, popularly known as Long Covid, the medical profession still has more questions than answers. There are many challenges to understanding what is happening. For those who were sick enough to be hospitalized, the medium and long-term symptoms seen in Covid survivors are not that different than those seen in many patients who spent time in the ICU for any reason. In these people, “long Covid” may be a form of “post-ICU syndrome,” which has only recently been studied.

Another problem is that to date, we have no good measures to evaluate the long haulers’ complaints. There are no blood tests or X-rays that we can point and say that these explain the symptoms or that they “prove” you are truly sick. Just as with the chronic fatigue syndrome, when all the usual blood makers are normal, many doctors dismiss the complaints as being imagined.

Several recent studies have shed some light. Comparing people who have recovered from Covid with those who have recovered from other illnesses, there are more complaints of shortness of breath and of a variety of neurologic and psychologic symptoms. A large study of Chinese Covid survivors found them to have more decline in mental acuity, particularly among those who had severe acute Covid. Strengthening the idea that this was not psychological, a small study in Britain found both cognitive decline and shrinkage of the brain on MRI among people who had recovered from mostly mild cases of Covid but had persisting symptoms.

A very large study done by the VA showed that compared to people hospitalized for other reasons, Covid survivors had more blood clots, atrial fibrillation, strokes and heart failure. Most recently, a study of 10 patients who complained of shortness of breath but whose routine tests were all normal found, with more sophisticated tests, that their tissues did not take up oxygen normally, thus explaining why they had trouble exercising.

On the bright side, a British study found that only 9.5% of vaccinated individuals who had break though infection had Long Covid symptoms compared to 14.6% of unvaccinated individuals. Since vaccination also clearly reduces your chances of any symptomatic Covid, the value is even greater.

Finally, a very preliminary study in the U.S. found that enhanced external counterpulsation, a harmless but tedious treatment shown to improve circulation to the heart and brain, improved symptoms in most of the 50 patients studied.

Bottom line: 1. Get vaccinated. 2. If you have symptoms months after recovery from Covid, don’t let your doctor tell you “it is all in your head,” but ask to be referred to one of the specialized centers bringing a multi-disciplinary approach to treating Long Covid.

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Sunday, February 27, 2022

To mask or not to mask... that is the question

As you have probably read, the CDC has relaxed its mask guidance in response to the falling numbers of Covid cases and hospitalizations. What should you do?

There are several key points to consider.

The first is that being fully vaccinated is the most important thing you can do to protect yourself from serious illness. While the vaccines’ ability to prevent infection wanes, their protection against hospitalization and death has remained strong.

The second is that masks, while not a panacea, clearly reduce risk. If you are in close contact with an infected person and both of you are wearing masks, your likelihood of catching the virus is reduced by 50%.

Finally, life is inherently risky, and you can balance your tolerance for risk against other things that are important to you, as you do every time you get in a car.

There is little need for most people to wear masks outdoors unless packed together as in a stadium.

If you are healthy and fully vaccinated, and so are your family, it is reasonable to stop using a mask in most settings. I would still use one when you are indoors in crowded environments such as theatres and public transportation.

If you or a family member or close friend are immune compromised, masks are still a useful barrier to infection and should still be used in most indoor settings.

When gathering indoors with friends, if you are all vaccinated and have no symptoms, you can skip the masks. If someone in the group is immune compromised, you can add an extra layer of safety by all doing a self-test before the gathering.

One of the things that mask-wearing has done is markedly cut down both influenza and colds, which are spread the same way as Covid – the respiratory route. I may just keep wearing one in stores and such for a while longer!

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Thursday, February 17, 2022

Move it!

Just as with clothing, medicine has its fads. Coffee is good for you, then it is bad, Chocolate is harmful or perhaps it is helpful. Red wine prevents heart attacks, then it does not. Through all these ups and downs, the one thing that remains true is the value of exercise.

Regular aerobic exercise helps the joints, is one of the few activities shown to reduce the risk of dementia and can help elevate your mood. How much is necessary is unclear, and there does seem to be a point beyond which no extra benefit is seen.

Another feature that has been uncertain is whether the heart benefits of exercise require you to start young. A recent study from Italy tells us that exercise at older ages is very protective. The study looked at 3100 men and women 65 and older (60% female). Their baseline physical activity level was assessed when the study began and again 4 and 7 years later. “Active” seniors were those who engaged in at least 20 minutes of moderate or vigorous physical activity daily.

Those who exercised at 70-75 and kept it up had 50% fewer cardiovascular events than those who were sedentary throughout the study period. The benefit was greatest at preventing coronary disease, somewhat less at preventing congestive heart failure and least helpful at preventing strokes.

The benefits began at 20 minutes/day of exercise and seemed to plateau at 60 minutes. This agrees with other observations: you do not have to run marathons to gain the greatest reduction in heart disease. 40-60 minutes a day seems to get you “the most bang for the buck.”

It is also true that you do not have to push yourself beyond your safe limits. The study defined vigorous physical activity to include gardening, gym attendance, bicycling, dancing and swimming.

The take-home: it is never too late to start. If you find an activity (or several activities) you enjoy, get out there and do them every day. Your heart will thank you.

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Saturday, January 29, 2022

I want to live forever - or do I?

Do you remember resveratrol? This was the “magic” antioxidant that supposedly made red wine so healthy, and on which pharmaceutical companies spent a fortune. I always believed that the reason the French smoked more and yet had fewer heart attacks than Americans had little to do with red wine and more to do with their relaxed lifestyle: 2-hour lunch breaks at home with family and the month of August off. In any case, Glaxo Smith Kline spent $720 million on a start-up that was working on a resveratrol-like compound only to shut it down for failure to produce useful results in increasing health and longevity.

Two products that are currently being studied as anti-aging compounds are an old drug used to treat diabetes, metformin, and a newer agent, rapamycin, that is used to prevent transplanted organs being rejected. Both have shown promise in increasing longevity in animal studies.

The average human lifespan has certainly increased dramatically over the past few centuries. World-wide, human life expectancy at birth has risen from about 30 years in the mid-19th century to 73 years in 2020. The reasons for this are the dramatic reduction in infectious disease deaths through immunization and, to a lesser degree, antibiotics, safer food and water, safer work environments and better maternal care. These mean fewer people die young.

What has not changed much is the maximum human lifespan. The oldest old live to be 110 to 120 years, and this has not changed, though we are certainly seeing more centenarians. Most species have an upper limit to their lifespan in the absence of disease or trauma, and for humans, this would appear to be about 120 years.

One impediment to “anti-aging” drug development is that the FDA does not recognize “aging” as a disease to be treated and would thus probably not approve a drug targeted at extending lifespan rather than treating a specific disease. Another is the very high safety threshold such a drug would face if it were to be targeted at everyone.

The other big question is whether many of us would want to live longer if this meant living with a growing array of medical problems and frailties. The ideal drug would not necessarily make us all live to 120 but would let us get into our 80’s, 90’s and beyond with intact joints, brain, and muscle.

Both metformin and low-dose rapamycin are currently in human trials, and other products are in animal studies. No promises, but stay tuned.

Prescription for Bankruptcy. Buy the book on Amazon

Friday, January 7, 2022

Quo vadis, Omicron?

What a difference a day makes. In my December 1 post, I said “While there have been no cases identified yet in the U.S., I would be shocked if there are not already a handful here.” Of course, now 5 weeks later, a local testing center said that 93% of Covid isolates in Massachusetts were Omicron.

Much of the early information about this variant has proved true. The Omicron variant is dramatically more easily transmitted than earlier variants; no disease but measles seems to spread as easily. Fortunately, it also remains true that Omicron is much less lethal than earlier variants. While the daily case counts in the state have increased 20-fold – from 1200 positive samples/day over last summer to 25,000/day this week, hospitalizations have “only” gone up five-fold – from 500 at the summer low to the current 2500 and daily Covid-related deaths have increased 4-fold, from 10/day to 40.

The fact that it is less deadly does not mean it is harmless. A virus that spreads 10 times as easily but kills half as many of those infects will kill 5 times as many people!

The good news for those who have followed the science is that the current serious cases are almost all among the unvaccinated. Hospitalization due to Omicron is 9-10 times greater among the unvaccinated than those who have had the full series (including booster).

A recent study found that prior Covid infection gave good SHORT-TERM (3-4 month) protection against the original virus and the Delta variant, but much less protection against Omicron.

There is also the very real concern that as hospitals are over-run with Covid cases, other treatments, including elective surgeries, have had to be delayed.

What should you be doing? If you are fully vaccinated, I would go about my life using just simple common-sense precautions. Avoid crowded venues when you cannot be sure that other people there are vaccinated and wearing masks. At theatres with good protocols for enforcing mask use and checking vaccination status, I am comfortable attending performances. Wear a mask when you are inside stores, museums, etc. Do what you enjoy outside. Gather with friends and family if you know all are vaccinated.

Nothing is risk-free. Getting in a car involves risk. Without being cavalier, I think those of us who are vaccinated and careful can enjoy getting back to living.

If you have been delaying, PLEASE get vaccinated.

Prescription for Bankruptcy. Buy the book on Amazon