Tuesday, December 26, 2023

All Fall Down

As children, we played Ring Around the Rosie, ending with “ashes, ashes, we all fall down.”

When small children fall down, it is fun. When older adults fall down, it is anything but fun. Over the course of my career, I saw many frail but independent elders fall, breaking a hip, and ending up in nursing homes for the rest of their lives.

The leading cause of injury and injury deaths among adults 65 and older is falls. At the last census, 14 million older adults – 28% of those 65 and older – reported falling during the prior year. In 2021, 38,742 older adults died due to falls.

How can you avoid adding to these dismal statistics? There are many things you can and should do!

You can do things to your body. Work on balance. An excellent way to do this is to sign up at the Y or your local Senior Center for Tai Chi – an exercise program focused on balance. At home you can do simple exercises on your own, such as standing on one leg – just Google “balance exercises.”

Increase your muscle strength with resistance exercises, including squats. This will both improve your leg strength, which reduces falls, and strengthen your bones, so you are less likely to sustain a fracture if you do fall.

Speaking of bones, do you know your T-score? Women in particular, but older men as well, should be checked for osteoporosis at least once. If your bones are very thin, your fracture risk is higher and you can discuss options with your doctor for improving this.

Beware of medication! Some medications can make you unsteady either by lowering your blood pressure too much or by directly impacting your brain. Sleeping pills and sedatives are a major culprit. A “med review” to look for any that can be stopped should be a regular event with your doctor.

Many simple things can reduce your risk of falls. When going up or down stairs, hold on to the banisters. Have adequate lighting, particularly at the bottom of stairs. If your vision is less than perfect, put bright tape on the last step so you do not miss it.

Be sure that any small rugs have non-skid bottoms or a non-skid pad under them.

Be cautious with ladders. Do not climb any higher than you would feel safe falling. DO use small ladders rather than chairs to get something down from a high shelf – ladders are designed to stay upright when you stand on them; chairs are not. Keep things used often on lower shelves.

Add grab bars to the shower. Closing your eyes to keep soap out of them can make you unsteady.

Both at home and in hotels, have a night light to help you safely navigate from bed to bathroom.

Be proactive! Do not be a statistic!

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Sunday, December 17, 2023

Cannabis: panacea or poison?

First, some vocabulary. Cannabis is synonymous with marijuana, and refers to a plant, the chemicals in the plant and products derived from the plant. THC, tetrahydrocannabinol, is the primary psychoactive compound in cannabis. Cannabidiol (CBD) is also psychoactive but does not have the euphoric effect of THC. CBD sold is usually derived directly from the hemp plant, a cousin of marijuana, or manufactured in a laboratory. The cannabis plant contains more than 500 chemicals, many not well understood.

Cannabis use has increased dramatically over the past decade. Once illegal throughout the U.S., cannabis is now legal for medical use in 38 states and the District of Columbia and for recreational use in 24 states and D.C. A Gallup poll in 2019 found that 14% of adults had used cannabis during the preceding year and a 2021 survey found this had increased to 21%.

Seniors are the group who are increasing their use most rapidly. In 2007, only about 0.4% of people age 65 and older in the United States reported using cannabis in the past year. That number rose to almost 3% by 2016 and in 2022 it was over 8%.

Another group who use cannabis heavily are those with cancer. A recent survey of cancer survivors found that almost half were current or past users.

What are the benefits of cannabis? Because cannabis is still classed at the federal level as “Class 1” – a drug with no currently accepted medical use and a high potential for abuse (along with heroin and LSD) – it is hard to do research into its medical benefits. Much of what we know comes from observations rather than controlled trials.

Granting that the evidence is soft, cannabis seems to help reduce chemotherapy-induced nausea. It also has antiseizure effects and has been used in patients with epilepsy not responding well to traditional drugs. It can be useful in reducing pain in chronic pain sufferers, and may be a welcome alternative to narcotics. Patients with multiple sclerosis report less spasticity and pain. Finally, patients with inflammatory bowel diseases report better quality of life with cannabis use. It may be useful in treating insomnia.

The downsides are numerous. Inhaled cannabis, the most common way it is used, has adverse effects on the lungs similar to the effects of tobacco smoking. While THC acutely dilates airways, chronic use makes asthma worse. Several asthma deaths have been linked to inhalation of marijuana. Inhaled cannabis increases the risk of lung cancer.

Recent reports at a national cardiology conference found increased risk of heart attacks, strokes and congestive heart failure in regular cannabis users. Women who use cannabis during pregnancy have a 25% increased risk of adverse pregnancy outcomes.

Some regular cannabis users develop severe vomiting requiring hospitalization and IV fluids.

Cannabis impairs driving ability and is clearly linked to increased motor vehicle accidents, though it is not nearly as bad as alcohol in this regard.

While many or most users are looking for the relaxation effect of cannabis, psychiatric side-effects including panic attacks and psychosis are common. Psychiatric problems are particularly common in adolescents, and there is good evidence that cannabis use by young people interferes with brain development.

Bottom line: if you have a problem that is not responding to traditional medication, cannabis may help but its use comes with risk. Adolescents and young adults should not use cannabis, nor should pregnant women. No one should use cannabis before driving or doing other risky things requiring alertness.

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Thursday, December 7, 2023


The holidays, Christmas, Hanukah, Kwanza or just “the holiday season,” are for most of us a time for family get-togethers, singalongs, gifts and joy. For people living alone, or struggling with depression, the expectation that they should be happy simply adds to their pain. This season is thus for some a time of increased risk of suicide.

Last year the U.S. experienced a new high in “deaths of despair,” including suicides. In 2022, almost 50,000 people lost their lives to suicide. While all age groups are affected, the highest suicide rate was in men 75 and older. Also striking is that over half of these deaths were carried out by guns.

How can we reduce these horrible events?

If you are contemplating suicide, please reach out. No matter how it may seem, you are not alone. In Massachusetts, you can call 833-773-2445. Most states have a chapter of The Samaritans. From anywhere in the U.S., you can call 988. All of these services are anonymous, free and available 24/7.

If you have guns at home, be a responsible gun owner – keep them locked up.

If you are worried about a friend or loved one, reach out. Talking about suicide does NOT “put the idea in their head.” Talking, and more important, listening, is incredibly helpful. Initiating the conversation is not easy. Make sure they feel safe in being open. Start with something like “You have seemed very down recently. I am worried about you. Would you like to talk?” When it seems appropriate, it is OK to ask “are you considering suicide?”

If they are open to discussing their feelings, be prepared to listen deeply: maintain eye contact, reflect back their words and acknowledge their feelings. Don’t interrupt and/or try to talk them out of their feelings. While you may feel things are not that bad, they do.

Suggest they get professional help or call one of the hot-lines. If they are not ready to do this, tell them you will be available to talk more. Ask them to promise you they will not act on their impulses without more talking.

If they do not want to talk, tell them you will be available when they are. Share your concerns with others in their support network; there may be someone else with whom they feel more comfortable.

Finally, if you feel the risk is very high and they refuse to seek help, reach out to emergency services on their behalf.

Sunday, November 26, 2023

Weight loss drugs - are they for me?

Last year, Denmark published statistics on its Gross Domestic Product with and without Novo Nordisk, the giant Danish pharmaceutical company that markets Wegovy – that is how much money is rolling in to the manufacturer of the wildly successful obesity drug.

Why are Wegovy and friends such a hit? What should you know about these drugs?

America is suffering an epidemic of overweight and obesity – some 70% of us are either overweight (BMI>27) or obese (>30). Excess weight contributes to the development of hypertension, diabetes and heart disease and losing 5% or more of body weight has been demonstrated to lower the risk of cardiovascular disease.

The problem is that losing weight is hard. For most of us it goes well beyond “will power.” The determinants of weight are complex, and include genetics, environment and habits. The food industry with its high fructose additives and advertising are also culprits.

Enter the holy grail – the search for a safe and effective drug that will help people lose weight.

Drugs for weight loss have been around for a while, and include phentermine, orlistat and Contrave.

Phentermine is an amphetamine that has been shown to produce about 6% of body weight loss after 6 months of use, but has the expected side effects of anxiety, racing heart and insomnia. Orlistat decreases the body’s absorption of fat and leads to about a 5% weight loss; it has a number of bowel side effects including leaking of stool, though is otherwise safe. Contrave combines naltrexone, an opioid blocker, and bupropion, an antidepressant. About half of those using it lose at least 5% of body weight after a year. Side effects include seizures, behavior changes and suicidal thoughts.

So, modest weight loss and serious or annoying side effects with these older agents.

The new kids on the block are GLP-1 agonists – drugs that mimic the effects of glucagon-like-peptide-1. They send a signal to the brain that you are full and also slow the stomach emptying. These drugs have been used to treat diabetes since 2005. Because they must be injected, they never captured much of the diabetes market.

What has turned the GLP-1 agonists into blockbusters is their dramatic effects on weight. In different trials with different products, subjects lost 12-20% of their body weight after a year. Most recently, a trial of semaglutide in very high-risk patients – in their 60’s with established cardiovascular disease – showed that those on the drug had 20% fewer events (heart attack, stroke or cardiovascular death).

There are now three products on the market: Wegovy (semaglutide), Saxenda (liraglutide) and Zepbound (tirzepatide – a GLP-1 agonist plus another). Given the vast market potential, more will follow.

What is the downside? First is cost. Wegovy retails for $1349/4 weeks; Zepbound for $1060/4 weeks; Saxenda about $1300/4 weeks. And note that these drugs must be taken indefinitely! In trials, those who stopped the drug after a year regained most of the weight they had lost by a year after stopping.

Nuisance side effects including nausea, diarrhea and constipation are common. More serious side effects including inflammation of the pancreas or gallbladder, kidney injury and suicidal thoughts have been reported in less that 1% of people taking them.

Are they for you? If you are seriously overweight and have other conditions such as diabetes, high blood pressure and/or heart disease, and if you have made your best effort at losing weight without medication, definitely discuss their use with your doctor.

Remember that weight is a life-long issue, and commit to using dietary changes and exercise as part of your life.

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Sunday, November 19, 2023

I am sick. Where should I go?

In the “old days,” say the 1950’s and 60’s, getting sick was much simpler. If you did not feel well, you called your doctor and either went to his (and 90%+ were male) office or he made a house call. Now, the set of choices is overwhelming – but where you decide to go can have a major impact on your health and your wallet. Your choices include:

The Emergency Department (ED). Pros: always open, prepared to handle just about anything acute that you may have. Cons: usually no idea who you are or your underlying health issues; very expensive – even if you have good insurance, there is usually a high co-pay; little continuity of care, and, unless you are critically ill, a long wait, often a very long wait.

Urgent care center. Pros: extended hours including weekends; can handle most minor emergencies; usually have X-ray and lab; less expensive than ED. Cons: Not 24/7, so be sure to check if they are open; no continuity of care; moderately expensive.

Pharmacy-based drop-in clinics, usually nurse-staffed. Pros: weekend hours; can handle most “minor” illnesses well; usually less expensive that the prior two. Cons: limited diseases that can be handled; little continuity; limited lab or X-ray available.

Your doctor’s office: Pros: they know you and can generally avoid over-testing; continuity of care automatic; least expensive. Cons: limited hours; may not be able to see you quickly.

So, what should you do?

As the ubiquitous phone message says, if you are having a medical emergency, hang up and dial 911. If you are experiencing chest pain, sudden shortness of breath, severe abdominal pain or are bleeding profusely, you belong in the ED. Calling 911 will get you there more safely than driving and will assure you are seen more promptly. Ambulance patients are almost always seen before those who drive themselves or are driven. Most insurance covers emergency ambulance transport (but not “convenience” rides).

If you need urgent attention but are not severely ill – think foreign object in your eye, a deep cut that will need suturing or a red swollen arm on a Saturday – the closest Urgent Care Center is probably your best bet.

For the myriad other “minor emergencies” that need prompt attention such as a bad sore throat, an earache, a possible urinary infection or a very itchy rash, try your doctor’s office first. If they are unable to see you, a convenience clinic at the local pharmacy will probably be able to help you at lowest cost and least waiting. These are the kinds of problems that do NOT belong in the ED.

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Sunday, November 12, 2023

Medical Bills and how to fight them

Years ago, when I would visit with my in-laws, after the initial pleasantries, my mother-in-law would bring out a shoebox full of paper and say “Edward, do I owe anyone any money?” In the box were dozens of undecipherable pieces of paper, many of which were marked “This is Not a Bill,” even though they looked like bills. Things have not gotten better.

Medical billing is notorious for being very hard to understand and full of errors. The average person, faced with a gigantic bill, is likely to throw up their hands and pay it, but do not be in too much of a hurry to do so.

The first step is to request an itemized bill, to which you are entitled. This will list all the things the doctor or hospital is charging you for. While the bill should list the items, sometimes you will just get a listing of CPT (Current Procedural Terminology) codes – 5-digit numbers that are medical shorthand for the things done. It is very easy to use Google to get the English translation of, say, 99285 into “Emergency Visit, high complexity.” Very often you will see things listed that were simply not done, and a call or letter should ask to have these removed.

You should also use your common sense to evaluate how well the service for which you are billed matches the service you received. Using the same example, if you are being charged $800 for a 99285 and you went to the Emergency Department with a swollen ankle that was wrapped in an elastic bandage, you should insist the charge be reduced. A high complexity visit is meant to cover caring for a victim of a major auto accident or a patient in coma, not a 10-minute visit for a simple problem.

If the billing department will not reduce the charge, demand a copy of your visit. If the notes reflect a simple visit, repeat your demand and threaten to take the issue to your insurance company or the state department of consumer affairs.

Finally, it is always worth asking for a discount. Uninsured patients are usually charged the “list price” for a service while Medicare, Medicaid and every commercial insurance company gets a substantial discount off these prices. You will very often get a discount of 25% or more just by asking.

It is your money. Don’t part with it without a fight.

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Monday, October 30, 2023

Time to sign up!

All Medicare recipients, and most people enrolled in health plans through their employers or the Affordable Care Act, have the opportunity to sign up and/or change plans during the annual Open Enrollment Period. For Medicare, this is Oct 15 through December 7, 2023.

While I am sure you have many things you would rather do than review your health insurance options, PLEASE set aside time for this critically important task.

Why is it important? Once you choose a plan, you are generally locked in for a year. If you find in March that you have a condition you want treated by “Dr. X,” but Dr. X is not in your health plan, you are out of luck. The fall open enrollment period is your chance to ensure that your needs are best met in 2024.

In the early days of Medicare, there was very little choice and life was much simpler. Now you have the major option of “classic” Medicare or Medicare Advantage (MA). In addition, if you opt for classic Medicare, there are options for the “fill-in” plans that cover Medicare’s deductibles.

This year, for the first time, over half of Medicare enrollees are in MA plans. These plans, run by commercial health insurance companies and heavily marketed, offer benefits not covered by traditional Medicare, such as payment towards hearing aids and eyeglasses, and even gym memberships. Their major downside is limited choice of doctors and hospitals. There have also been allegations that some plans have denied or delayed needed care. There is no free lunch, and plans that lure you in with lower out-of-pocket costs (and are run by profit-making companies) need to cut costs somewhere.


1.Even if you are happy with your current MA plan, read the plan information carefully to see what has changed. Plans can and do change what they cover each year. Be sure you know what medications will be covered if your plan provides drug coverage, and what your medicines will cost you. Check if any doctors you are seeing will no longer be covered. Ditto a hospital you prefer to use.

2.Double check with your doctors’ offices to be sure what plans they will be accepting. MA information is often out of date with their list of participating doctors.

3.Be sure your plan and your health needs are a good fit. A plan that covers your fitness club membership may have been inviting when you felt healthy but may no longer be the best fit if you have a new serious illness and the best doctors and hospitals for this condition are “out of network.”

4.Take the time to look at alternatives. Since both plans and your health needs change, there may be a plan that is a better fit. Check the plan ratings on medicare.gov.

5.Ignore the hype and read the fine print. You will be barraged with advertising and sales pitches. Regard these with the same skepticism as you would any other advertising.

Finally, maintain good health habits. Do not smoke or drink; exercise and eat a health plant-focused diet. The healthier you are, the less you will need to worry about what services your plan covers

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Tuesday, October 10, 2023

RSV - should I get vaccinated?

Respiratory syncytial virus (RSV) has traditionally been thought of as a disease of infants. As many as 80,000 babies under 5 are hospitalized annually in the U.S. with RSV, mostly in the winter, and some 300 die. Until very recently there was little that could be done to prevent RSV.

A monoclonal antibody has recently been approved that was 80% effective at reducing hospitalizations in infants, but it costs $495/dose.

Also new are two RSV vaccines for adults that were shown quite effective, and this availability has focused attention on RSV in older adults.

The “usual” winter respiratory virus about which we have worried for years is influenza. There is quite a bit of variability in influenza from year to year, with estimates of 140,000 to 700,000 flu hospitalizations and 12,000 to 52,000 deaths annually over the past decade. Flu vaccine efficacy has been quite variable but vaccination is universally recommended.

For the past 3 years, Covid has pushed flu out of the headlines, and it is unfortunately still with us.

Estimates for RSV for the same 10-year period are that 60,000 to 160,000 older adults are hospitalized each winter with RSV and 6,000-10,000 die. A CDC analysis of a large sample of adults over 60 found that while RSV was much less common as a cause of hospitalization than flu or COVID, patients with RSV tended to be sicker.

The two recently approved vaccines both reduced the rate of RSV illness requiring medical attention by about 85%. The advisory committee recommended the vaccine for pregnant women to protect their newborns and for adults 60 and older.

Like all new vaccines, there are unanswered questions. There seemed to be a small but real increase in neurologic side effects (notably Guillain-Barré, a temporary paralysis) in vaccine recipients and possibly a small increase in atrial fibrillation. For the frail elderly, the benefits clearly outweigh the risks. For healthier seniors it is less clear.

Cost may be an issue. The vaccine costs $200-$300. It is covered under Part D of Medicare, not Part B like flu or Covid shots. Not all private insurances cover it.

If you are older with heart or lung disease, I would definitely recommend it. If your general health is excellent, the decision is a personal weighing of risks and benefits.

By the way – masks reduce the spread of all respiratory illnesses. And if you are sick and coughing, do everyone a favor and stay home until you are better!

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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 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.

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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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