Monday, September 18, 2023

Big Pharma Cries Wolf

Over the last few weeks, as the administration has begun to implement that portion of the Inflation Reduction Act that allows Medicare to negotiate prices on 10 high-cost drugs, you have heard loud cries from the pharmaceutical industry.

They and their allies on the right claim that allowing Medicare to cut into their profits will harm consumers by reducing their incentive to develop new drugs. Does this argument have merit?

The claim that the industry should be allowed to gouge the U.S. consumer has numerous problems.

First, why should U.S. consumers be the ones to support pharmaceutical company research when their products are sold world-wide? They should establish a defensible price that covers developmental costs and a fair profit and use this in all advanced countries. Lowering prices on product sold in less-developed countries can be a humanitarian offer.

Second, and more important, the major pharmaceutical companies spend more on marketing than they do on research and could easily shift money from marketing to research should they choose to do so.

Third, they consistently exaggerate the money actually spent on research [see: JAMA Internal Medicine 2017;177(11):1575]. They also fail to credit the NIH (i.e. the U.S. taxpayer)-funded basic research that often precedes their own.

While Big Pharma does spend the lion’s share of the money needed for clinical trials, these are only done on products expected to generate big sales and profits. The basic research that is behind most truly new drugs is usually done by academic researchers with government funding or by start-ups that are bought by a major pharmaceutical company after they develop a novel product.

Finally, much of their research budgets are spent not on truly novel life-changing drugs but on "me too" copycat drugs. When a truly new drug is developed, the other companies turn their research efforts to tweaking the molecule to develop their own similar product on which they then spend money marketing it as better, with no real clinical benefit to patients. [If they sold their product at a lower price, this would be a useful addition, but this is rarely/never done. Instead, they charge a similar or higher price and bombard doctors with marketing.]

The sky will not fall if Americans do not pay 3 times what the Swiss, Germans or French do for pharmaceuticals. Write your representatives in Congress and tell them not to cave to the pharmaceutical industry.

(In the meantime, try to lower your own costs of drugs by checking out Mark Cuban’s Cost Plus pharmacy or by using websites such as GoodRx for medicines you take regularly.

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Tuesday, August 29, 2023

Covid update - behind the headlines

While most of us want to put Covid behind us, recent news headlines make that hard to do. What should you know? What should you do?

The most important fact is that, like it or not, Covid is probably here to stay. While the worst of the pandemic is thankfully behind us, Covid will join influenza as a prevalent virus against which we must take measures. Recent data shows that infections are trending up, though death rates are much lower than they were 2-3 years ago.

Second, there will be variants! Most viruses mutate, and Covid seems particularly adept at this. Mutations may make the virus more easily transmissible, more (or less) dangerous and/or better able to evade our immune response.

The recently headlined EG.5 and BA.2.86 variants have enough mutations in the spike protein that lets the virus attach to our respiratory cells that they can infect people who have been immunized and/or had prior infection. They do not seem more virulent – hence the rise in infections is steeper than the rise in hospitalizations or deaths.

We have two levels of immune defense. The antibodies produced by vaccination or prior infection are the first line of defense, and the cellular immunity the second. Even if a mutation seems able to escape our antibodies, the cellular response is often still effective.

What should you do? While vaccination is a good idea for most people, if you are older, have underlying medical conditions or are immune-suppressed, I would definitely get a Covid booster. Wait until the newer vaccine is available in late September/early October because it is targeted at mutations that more closely resemble the currently circulating variants and another shot of the old vaccine is unlikely to offer much additional protection.

What about masks? While clearly not a panacea, masks do seem to reduce transmission of most respiratory viruses, including Covid, flu and the common cold. There is little reason to use a mask outdoors or in large well-ventilated spaces, but I would encourage you to use one when in confined indoor spaces such as theatres.

Finally – please stay home when sick. We teach our children to share, but sharing your respiratory virus is not a virtue.

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Friday, August 18, 2023

Where are my meds? How safe are they?

Some 90% of the medications we take are generic. Generic drugs are dramatically less expensive than their branded equivalents and generally similar to the branded products in all but price. Unfortunately, generally does not mean always. Two large healthcare systems tested all the generics sold through their pharmacies and found that 10% had potential quality issues.

A major source of medications sold in this country and elsewhere are manufactured in India and China. The $50 Billion pharmaceutical industry is a leading source of exports and foreign earnings for India. While most Indian pharmaceutical plants are of good quality, many, especially the smaller ones, are not.

The FDA tries to inspect overseas plants whose products are imported to the U.S. In 2019, the FDA reported to Congress that India had the lowest percentage of acceptable inspections of any country. 17% of the plants it inspected had major failings. And, due to the pandemic, the number of inspections the FDA conducted fell dramatically for 2020-22.

You may recall the news stories of children in Gambia and Uzbekistan dying in 2022 due to contaminated cough syrups from Indian manufacturers. This was only the tip of the iceberg. Less dramatic but important are issues of contamination, uneven content of pills and capsules and poor formulation causing poor absorption of medication. These will not kill you, but may well make the medication less effective.

The Department of Defense is sufficiently concerned that they have contracted with an independent testing lab to test the drugs it purchases for our military and evaluate the manufacturers. Kaiser Permanente has been doing the same thing for the past three years.

What can you do? If you look at the prescription label, in small print you will find the name of the manufacturer. You can do an Internet search on the company and see where they are located and also get an idea of how ”legitimate” they seem. If you find that your medication was made by an obscure Asian company, you can ask your doctor to contact the pharmacy about changing to another manufacturer. You can also make your elected representatives aware of this issue.

A seemingly unrelated problem that has been recently making headlines is shortages of important medications. A recent survey of hospital pharmacists found that virtually all reported some drug shortages, and that 83% were rationing some medications. Key shortages have been notable in generic cancer drugs that are the mainstay of many chemotherapy regimens.

Why is this? Do you remember the baby formula crisis last year? The issue is similar: concentration in a small number of manufacturers and a convoluted supply chain. As of mid-August, 48% of the injectable medications made by Pfizer were in short supply. The generic cancer drugs are low-profit and so do not get priority when companies are deciding on what products to manufacture.

The solution here is not in our hands as individuals – it demands that the federal government strongly encourage in-sourcing manufacture of key medications. Just as we cannot depend on Asia to make crucial electronic components and ship them half-way around the world, we cannot outsource the manufacturing of crucial medications.

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Monday, July 3, 2023

Alcohol and health - the last word?

Tons of ink have been spilled on the health effects, good and bad, of alcohol consumption. Beneficial effects on the heart were discussed in the 1990’s based on “the French paradox.” A paper published in 1995 noted that there was less ischemic heart disease in France compared to the U.S. despite the fact that saturated fat intakes and prevalence of smoking were higher.

The relative immunity of the French to ischemic heart disease was attributed to their high alcohol consumption and to their intake of antioxidant vitamins, both supplied by wine. The custom of drinking wine with the meal was thought to confer protection against some of the adverse effects of the food. Resveratrol, a chemical found in grape skins, was thought to be a major factor and for a while many pharmaceutical firms investigated using it.

At the same time, the adverse effects of alcohol are numerous: liver disease, traffic accidents, gout and many cancers are all higher in heavy drinkers. A recent study from China showed that there was a higher incidence of 61 diseases among males who regularly drank alcohol.

What is the truth?

A study published this spring in JAMA Network Open looked at 107 studies of the relationship between alcohol consumption and mortality. They compared non-drinkers, light drinkers (1-2 drinks/day for men, 1/day for women), moderate drinkers (3-4/day) and heavy drinkers (5 or more drinks/day). Note that a “standard drink” is 12 ounces of beer, 5 ounces of wine or 1.5 ounces of hard liquor.

Compared to lifetime non-drinkers, occasional or light drinkers had a similar mortality while moderate drinkers had a modestly (5%) higher mortality and heavy drinkers had a 22% higher mortality rate. With very heavy drinkers a whopping 35% higher death rate was found.

Notably, women who drank any quantity of alcohol had a 20% higher mortality than female lifetime non-drinkers. (Women absorb and metabolize alcohol differently than men. In general, women have less body water than men of similar body weight, so that women reach higher concentrations of alcohol in the blood after drinking equivalent amounts of alcohol.)

What are my take-aways from this study? Do not drink because it is “heart healthy.” There is no amount of alcohol that reduces your mortality. If you enjoy a beer or a glass of wine with dinner, you can stick with it - you may be trading fewer heart attacks for more liver disease but the overall effect is neutral. If you drink heavily, please cut down. The life you save will be your own.

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Wednesday, May 31, 2023

Does a vitamin a day keep Alzheimer's at bay?

As regular readers of these posts know, I am generally not a big fan of using vitamins and supplements for healthy people who eat a reasonable diet. There is little solid data that these improve your health. A recent study has caused me to reconsider.

We all lose some memory function with aging, even those of us who will never develop dementia. Annoying “senior moments,” such as forgetting where we put the car keys or who wrote our favorite book, become increasingly common. What helps? Aerobic exercise has some benefit, while crossword puzzles, sudoku, etc. do not seem to do much. How about a pill?

A group of investigators from New York and Boston recently published the results of a trial studying the effects of a daily multivitamin (Centrum Silver) on memory in older adults. The trial was designed to test the effects of cocoa extract and multivitamins on cancer risk and cardiovascular outcomes but they used the trial to test other outcomes as well. It was a large trial: 12,666 women 65 or older and 8776 men 60 or older were enrolled.

The memory study used an internet-based battery of neuropsychological tests at baseline and repeated annually for 3 years. Importantly, the study used a memory test designed for healthy people.

You may recall the ridicule faced by Donald Trump in the summer of 2020 when he claimed to “have aced” a “really difficult test” that proved how smart he was. That test was the mini-mental status test (or something very similar), specifically designed to screen for dementia. Its weakness in studying healthy people is that it is so easy that most get high scores and subtle changes are hard to detect.

This study used a test called the ModRey test that is much harder and was designed to study memory changes in people without major memory impairment.

At both 1 and 3 years after they enrolled, people who were randomly assigned to take the multivitamin had significantly better memory scores than those assigned to placebo. The researchers estimated that the multivitamin improved memory performance over placebo by the equivalent of 3 years.

Since the treatment, an over-the-counter multivitamin, is harmless and cheap, it seems prudent to consider adding this to your daily routine. I plan to do so (when I remember).

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Tuesday, May 23, 2023

Menopause: Hot flashes or heart attack?

A new medication has just been approved by the FDA for the treatment of moderate to severe menopausal hot flashes, and I predict a barrage of television and other media advertising. In yesterday’s New York Times was an article headlined: A Movement to Make Workplaces ‘Menopause Friendly.’ Clearly a topic to be addressed.

Like most woman-specific health issues, menopause has been under-studied for years. For most of human history, women who lived long enough to pass through menopause were the lucky minority. As lifespans increased, menopause became “normal” and little but folklore was used to treat symptoms.

Menopause refers to the time a year after a woman has her last period. Perimenopause describes the years preceding, when menstrual periods may become erratic and many women begin to experience hot flashes. Each woman’s experience is different. I have had patients who will respond “I have not had a period in 6 months but feel fine,” while others have to bring a change of clothes to work. The cause of the ”vasomotor symptoms,” changes in the body's thermoregulatory system, leading to sudden feelings of heat, sweating, and skin flushing is clear: fall in estrogen. Hot flashes can occur after surgical removal of the ovaries or by medications that block estrogen, though natural perimenopause/menopause is the usual culprit.

Given the cause, the obvious treatment is estrogen, given by pill or skin patch. During the 1960’s, estrogen was widely prescribed as a panacea for all the issues of aging in women. But, a landmark study by the Woman’s Health Initiative (WHI) published in JAMA in 2002 claimed that giving hormone therapy to post-menopausal women led to more rather than fewer heart attacks and strokes, as well as increasing breast cancer risk. Prescriptions for estrogen plummeted.

At the time, I counselled my patients that the study was so flawed that it was irrelevant to them, but media coverage convinced most women that estrogen was akin to arsenic.

Why was it flawed? The study investigators set out to prove or disprove that HRT (hormone replacement therapy) prevented heart attacks. They enrolled a large number of women – over 16,600 – but were concerned there might not be enough heart attacks to result in the holy grail of “statistical significance” if they used only peri-menopausal younger women. The study group included women who were post-menopausal and 50-79 years old.

We know that menstruating women have many fewer heart attacks than men and that this protection is lost after menopause. By enrolling women who were many years or decades post-menopausal, they selected a group that were beginning to catch up to men in developing artery plaques and then exposing them to the known clot-promoting effects of estrogen. It should have been predicted that this group would have more heart attacks and strokes. How is HRT usually prescribed? It is given to women in their perimenopausal years, when they are still much less likely to have artery plaques. Much later re-analysis of the WHI data did show that the younger members of the study had fewer heart attacks when taking HRT while the older women had more.

What non-hormonal drugs can a woman take for bothersome hot flashes? Until very recently, the only approved drug was paroxetine, an anti-depressant that has been shown to reduce the severity and frequency of hot flashes. The new drug, which will be marketed as Veozah, works on the vasomotor center of the brain, and was shown in a recent study to provide superior relief to placebo. A small number of women taking it had liver test abnormalities, but side effects were generally few. The major side effect will be on the pocketbook. The drug will be marketed at a cost of $550/month, and will need to be taken for several years.

My suggestion? If your symptoms are mild, you do not need to take anything, or try soy milk.

What if your symptoms are worse?

If you are in your late 40’s or 50’s, ask your doctor about HRT. It has a good safety profile in younger women and is treating the underlying problem. Patches are generally safer than pills. If you have a history of (or strong family history of) breast cancer, HRT is not for you. In that case, see how much relief you get from paroxetine, generic and cheap. If that does not work, hope your insurance covers Veozah at a reasonable co-pay.

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Thursday, March 30, 2023

Drug-resistant shigella - how worried should you be?

Recent news stories have brought to our attention a report from the CDC that multiple strains of the diarrhea-causing bacteria Shigella have acquired resistance to the antibiotics most often used to treat the illness. The first case of extensively drug-resistant Shigella was discovered in the United States in 2016; by 2022, the strains accounted for 5 percent of Shigella infections. The drug-resistant bacteria have been found in 29 states so far. Even though shigellosis is commoner in children than adults, the resistant strain has been seen most often in adults, and is particularly common in men who have sex with men, the homeless and those with immune deficiency.

Is this important? Should you care?

Shigella is a bacterium that infects the wall of the intestine and causes nasty diarrhea, usually bloody, as well as nausea, cramps and fever. While mild cases exist and may improve without treatment, antibiotics are usually needed, as well as fluid replacement – by mouth if possible or by intravenous if you are very sick.

How do bacteria become resistant to antibiotics? Some bacteria randomly mutate to become resistant to one or more antibiotics. If exposed to antibiotics, the sensitive bacteria are killed off while the resistant ones thrive. We also know that antibiotic-resistant bacteria can share their resistance genes with other bacteria.

We live in an antibiotic-obsessed culture. People who go to their doctor with a cough and fever expect to get a prescription for antibiotics, whether they believe their illness be a sinus infection, bronchitis or pharyngitis. In the time-stressed doctor’s office, many doctors realize it is easier and faster to write a prescription than to explain why the illness is probably viral and will not get better any faster with an antibiotic.

In hospitals, patients are sicker, antibiotics are frequently given, and bacteria are readily transmitted from one patient to another, including resistant ones. These “super-bugs” are responsible for many hospital deaths.

If that is not bad enough, antibiotics are widely and often unnecessarily given to farm animals, in most cases to compensate for unhealthy conditions in which the animals are raised.

What can you do?

First, if your doctor tells you that an antibiotic is not needed, accept this. Most respiratory infections will do as well or better without one. Second, if you have any intestinal infection, be scrupulous with hand washing after using the toilet – the person you save from getting ill may be family or friend.

If you are unlucky enough to be hospitalized, do not be afraid or embarrassed to ask your doctors and nurses if they have washed their hands before they examine you. Finally, make your preference known at the grocery – try to purchase meat labelled as antibiotic-free, so that hopefully this practice will lessen.

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Tuesday, March 14, 2023

Healthcare Fraud

Healthcare fraud tends be “under the radar” for most of us, surfacing when authorities arrest those accused of such behavior or when guilty verdicts are announced, and usually in stories buried on the inside pages of the newspaper.

While it is widely acknowledged to be a serious problem, costing the government and private insurers tens of billions of dollars, it is very hard to get factual data. The numbers that reach the press are of perpetrators who are caught. The number of schemes that go undetected is impossible to quantify.

It is also a world-wide problem, not just a North American issue. The National Academies estimated in 2018 that of the $7.35 trillion spent globally on health care, some $455 billion was lost to fraud. Investigators in China estimated that 10% of healthcare spending there was wasted due to fraud.

Fraud can take many forms. The most obvious is to bill insurers for services not rendered. A New York-based cardiologist was arrested for billing Medicare and Medicaid $1.3 million for Covid testing that was never done.

More commonly, billing can be done for expensive services and equipment that are unnecessary. Companies “cold-call” people and offer braces and electric-lift chairs that will be “free” if their doctor authorizes them. One brazen scheme involved gathering homeless people who were on Medicaid and paying them small sums to go to a testing center for a panel of totally pointless but expensive tests for fabricated diagnoses.

Twelve physicians in Ohio and Michigan were sentenced to prison last year for a scheme that required narcotic addicts seeking prescriptions to undergo spinal injections, which are richly reimbursed, before getting their prescriptions.

More subtle and more widespread is “up-coding,” providing a service but billing for a more expensive one. Take the office visit. Billing for such visits can be done at one of five tiers based on the complexity of the problem and time needed to deal with it. The higher the level, the more the payment. A Massachusetts orthopedic surgeon was charged in March of 2022 for billing top-level visits for as many as 90 patients a day – meaning that in one work-day he was claiming to do over 60 hours of care! To a lesser degree, this practice is very widespread.

Technology has unfortunately made fraud easier. The typical electronic medical record allows the user to populate a note with detailed history and physical finding with a few clicks, whether or not these were done.

Telemedicine, a boon for many during Covid lock-downs, also provided a fertile field for the unscrupulous. One of “America’s Frontline Doctors,” the headline-grabbing vaccination deniers, lost her license for providing ivermectin and hydroxychloroquine after 1-2 minute on-line visits for which she billed $90. Telemedicine visits for addiction counselling are supposed to last 45 minutes. The Recovery Connection Centers of America billed insurance programs millions of dollars for visits that lasted an average of 5 minutes federal authorities alleged last month.

Why should you care? Ultimately, whether through taxes or health insurance premiums, it is your money that is being wasted. When you suspect fraudulent billing, report it.

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Thursday, March 2, 2023

Can I live to 120? Do I want to?

The Fountain of Youth is a mythical spring that restores the youth of anyone who drinks from it or bathes in its waters. Tales of such a spring have been recounted for thousands of years, appearing in the writings of Herodotus in the 5th century BC. The legend became particularly prominent in the 16th century, when it became associated with the Spanish explorer Juan Ponce de León, the first Governor of Puerto Rico. Ponce de León was supposedly searching for the Fountain of Youth when he traveled to Florida in 1513.

Modern seekers after the Fountain of Youth include tech billionaires who plan to be cryo-preserved until science finds the secret of eternal youth. Peter Thiel and Jeff Bezos have both heavily funded start-ups studying how to slow the aging process. Researchers have studied “blue zones,” where people live the longest, and are healthiest: Okinawa, Japan; Sardinia, Italy; Nicoya, Costa Rica; Ikaria, Greece, and Loma Linda, California. Not only do these places have large numbers of residents in their 90’s and older, but they remain largely free of most of the diseases associated with aging. They share common attributes of lifestyle and diet noted below.

How long can we hope to live? The best evidence is that the limit to the human lifespan is about 120 years. It is very unlikely that any intervention will dramatically change this number.

Probably more realistic, and in my mind more important, is to delay the myriad ills that we accumulate as we get older: frailty, dementia, disabling arthritis, heart and lung disease. In other words, we should hope to extend our healthy years rather than simply living longer.

How can we accomplish this? Some of this is not new: do not smoke, drink little or no alcohol, maintain a healthy weight, eat a plant-focused diet and exercise regularly. If you do all five of these, you can add 12-14 good years to your life. Being socially engaged and having a sense of purpose is also helpful.

Further study is needed, but marked calorie restriction has been shown to extend the lifespan in many species, including mice, and is now being tested in human volunteers.

The diabetes drug metformin has been touted as having anti-aging properties and is being tested in two on-going trials. It is clearly beneficial in patients with type 2 diabetes; whether that will translate to the rest of us remains to be seen.

Some 20 years ago, reports began to emerge that taking blood from young mice and giving it to old mice seemed to dial back the clock on aging for the elderly rodents. Soon after, entrepreneurs began doing this with humans without any proof that it was effective, but researchers are now testing the idea. Still in the laboratory is injecting one of several new anti-inflammatory drugs. There are some indirect markers that suggest these may work, but as yet no meaningful results have been demonstrated.

So, at this point, practice as many of the lifestyle habits listed above as you can and wait to see what science has in store. Eat well, exercise and get involved in your community.

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Monday, February 6, 2023

We are what we eat

We must eat to live. Dining is also a pleasurable activity, particularly when the food is tasty and we are eating in a companionable setting. WHAT we eat can also have a huge impact on our health and longevity. What diets are best and do dietary “supplements” have an added benefit? Millions of people believe in dietary supplements and this is a multi-billion-dollar industry.

Like skirt lengths, diets go in and out of fashion. Among the headline-grabbers over the years have been the Atkins, Scarsdale, ketogenic and Neanderthal diets, none of which have been shown to have any health benefits beyond (usually transient) modest weight loss.

Diets that HAVE been shown to reduce cardiovascular disease and cancer include the DASH diet, the Mediterranean diet and a plant-based diet. The common factor in all three is an emphasis on fruits, vegetables and grains. The Mediterranean and DASH diets add fish, some poultry and olive oil. All three dramatically reduce red meat, processed foods and sugar.

Some 80,000 different “supplements” are sold in the United States!

The more they are carefully studied, the less supplements are found to be of value. Fish oil supplements are used by millions of Americans to reduce heart disease despite multiple studies showing no benefit. Vitamin D taken by middle-aged and older healthy adults was found to have no benefit in reducing fractures. Avocados, touted after an observational trial suggested benefit, were found to have no benefit when studied in a controlled trial. One study did find mild memory benefits from a multivitamin-mineral supplement given to older adults.

Are supplements harmful? Most are not, except to your pocketbook, but some can be dangerous. Products sold for weight loss have been linked to many deaths. There is also the caveat that supplements are excluded from scrutiny by the FDA and may or may not contain what the label says.

Bottom line? Try to eat a diet rich in fruits, vegetables and whole grains. Supplement it with nuts and fish. Drink alcohol sparingly if at all. Avoid processed foods and use meat more as a condiment than as the main source of calories in a meal.

Don’t waste your money on lots of supplements. If you wish, take a single multivitamin from a reputable manufacturer.

Oh, and while I am being a kill-joy – get out and move your body! Exercise beats most pills.

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Monday, January 16, 2023

It is not "Mental Health," it's the guns!

In 2020, firearm fatalities displaced motor vehicles accidents as the leading cause of death of U.S. youth (ages 1-19). We long ago dramatically reduced infectious deaths (though vaccine hesitancy threatens to upend this victory), and the “big five” have been auto accidents, firearms, cancer, suffocation and drug overdose – accidental in the youngest and intentional or accidental in teens.

Between 2000 and 2015, firearm deaths remained steady at about 10% of all youth deaths, but this has grown dramatically since, and guns caused 19% of young peoples’ deaths in 2021.

Children, of course, are not the only ones to suffer. Between 1990 and 2021, 1,110,421 Americans died as the result of gunshots: homicidal, suicidal or accidental. The death rate has roughly doubled between 2014 and 2021. Deaths disproportionally affect males: 86% of the 1.1 million deaths were men. When looking at deaths among young people, black boys are much more likely to be killed than non-Hispanic white youth. When we look at suicides, older white males are the victims more than any other group.

Comparison with similar countries emphasizes how much of an outlier we are in the U.S. An American is 30 times more likely to die by firearm than a French citizen. Not surprisingly, in France there are 15-20 privately-owned firearms per 100 population, while in the U.S. there are 120 per 100 people. Multiple studies have shown a tight correlation of numbers of guns in circulation and gun deaths. Within the U.S., states with tougher gun laws have significantly lower firearm mortality.

Certainly, social factors – mental health issues, including depression, poverty, lack of social supports – play a role, but these are not unique to Americans. Every country has its share of sociopaths, depressed people and people angry at the world, but only in America is it so easy for these people to obtain a gun.

If someone tries to kill themselves with an overdose, there is a high likelihood they will be saved and then given help. Very few of such people die of suicide. When the method chosen is a gunshot, the “success” rate is nearly 100%.

A fanatic can kill innocents with a knife (or their bare hands), but mass killings are almost always done with firearms.

Public opinion surveys consistently show that the majority of Americans support tougher gun laws, but our federal legislators seem under the control of the gun lobby. We must convince our legislature that the will of the people is for sensible gun control unless we prefer to remain World Champions in deaths by firearm.

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Wednesday, January 4, 2023

What happened to Damar Hamlin?

The media have been focused on the tragic collapse of Damar Hamlin, a professional football player, during a televised game last Monday. Hopefully it will bring more attention to this huge problem: some 350,000 sudden deaths occur annually in the United States, though it is rare for it to happen in a fit athlete.

Some terminology:

This was not a “heart attack,” the lay term for what health professionals call an acute myocardial infarction. An acute MI typically happens to an older person who has (sometimes unknown!) narrowing of the coronary arteries and is generally felt as chest tightness rather than sudden collapse, though this can occur. It would be very rare for a fit young athlete to have coronary disease. While possible, this is unlikely to have happened to Damar.

Nor was it “heart failure,” a condition in which the heart, because of weakened muscle, cannot adequately pump blood and which usually comes on very gradually and whose cardinal symptoms are tiredness and shortness of breath due to fluid backing up in the lungs.

This was a sudden cardiac arrest, in which the coordinated electrical activity that regulates the heart becomes totally uncoordinated. The ventricles, the main pumping chambers of the heart, no longer contract rhythmically. Instead, they quiver in a totally uncoordinated manner, and there is NO effective pumping of blood. This is called VF: ventricular fibrillation. The first organ to feel the lack of blood is the brain, and hence the sudden collapse.

While the commonest cause of this in the general population is coronary disease, in young people there are commoner causes. Bostonians with a long memory will recall the tragic death of Reggie Lewis, star player with the Boston Celtics, who collapsed and died during a practice in 1993.

One possible cause of VF in a healthy person is a blow to the chest which happens to occur at just the wrong time in the heart’s electrical cycle. This is called Commotio Cordis. It tends to be more common in younger males, possibly because their chests are less muscular and a blow is more easily transmitted to the heart. It has been seen in lacrosse or hockey players getting a stick in the chest and baseball players struck in the chest by a ball. This could have caused Damar's collapse.

Another cause is a cardiomyopathy, an abnormality, often congenital, of the heart muscle. If this is very localized, the athlete may be able to perform at a high level but still be prone to VF.

A specific form of cardiomyopathy, that may have been the cause of Reggie Lewis’ sudden death, is hypertrophic cardiomyopathy: the heart is too thick and during exertion there may be severe obstruction of blood flow out of the left ventricle.

The good news is that Damar appears to have been successfully resuscitated and with luck will come out of this tragedy with minimal damage. If so, he will owe his life to the prompt recognition of what had happened, prompt administration of CPR and prompt use of an AED: automatic external defibrillator. This last is a device that allows the general public to give a life-saving electric shock to stop VF without having to wait for medical personnel to arrive on the scene.

Time is critical: the brain suffers irreversible damage if resuscitation is delayed, even if heart function can be restored.

Learn CPR. If you have any influence, see that any place where groups gather has an AED and personnel trained in its use.

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