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.

Prescription for Bankruptcy. Buy the book on Amazon

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.

Prescription for Bankruptcy. Buy the book on Amazon

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.

Prescription for Bankruptcy. Buy the book on Amazon

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.

Prescription for Bankruptcy. Buy the book on Amazon

It is not "Mental Health," it's the f...ing 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.

Prescription for Bankruptcy. Buy the book on Amazon

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.

Prescription for Bankruptcy. Buy the book on Amazon