Hello, Covid, my old "friend"

We’ve come to see you once again. (Cue Simon and Garfunkel)

The pandemic is behind us, and life has mostly returned to normal, but Covid has not disappeared. Instead, this summer has seen an increase in cases and in such measures as virus detection in wastewater samples.

Thanks to widespread vaccination and the immunity conferred by infection and recovery, we have not seen the huge numbers of hospitalizations and deaths that we did in 2020-21.

Covid is still a serious threat, particularly to the elderly and those with immune deficiency, and it has shown a remarkable ability to mutate into variants to which we are not fully immune. There has been a whole alphabet soup of new variants, and the original vaccinations you received will offer only limited protection to the current virus.

The FDA has recently approved a new vaccine and ordered the old ones taken off the market. The new vaccine is not perfect – the virus mutates too quickly – but should provide better protection and will be widely available in September.

While Covid is not “seasonal” the way influenza is, I expect an increase in infections as we get into colder weather and people congregate indoors.

What should you do?

If you have had a case in the last 3-4 months, the natural immunity this provides suggests you put off getting vaccinated until later in the fall.

If you have been lucky enough to avoid Covid over the summer, getting the new vaccine as soon as it is available is suggested, particularly if you are over 65.

Also, there is good evidence that wearing a mask in crowded indoor environments is helpful, as well as such commonsense advice as staying home when you are sick and using good hand-washing practice. This will reduce not only Covid, but other respiratory viruses.


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Getting the most out of a doctor visit

By now, most of us are all too aware that the doctor visit is becoming shorter and that the doctor seems to interact more with the computer than with you. It is frustrating to leave a visit that may have been made months in advance with your questions unanswered.

How can you get the most out of a medical appointment? The key is preparation.

Before you set out, you should have made sure that you have the correct date and time, that the doctor is on your insurance plan, and that if you need a referral, you have it.

Leave enough time to get there even if traffic backs up. Yes, you will probably have to wait, so bring a magazine.

If this is a new doctor, bring a list of all medicines you are taking, any medication allergies you have, major family history, recent test results and surgeries and hospitalizations you have had.

Key to a satisfactory visit is to know what you want from it. If you are scheduled for a follow-up of chronic health problems but you have a new symptom that worries you, get that out up front and not when the doctor has their hand on the door.

Bring notes and take notes. Have a written list of things you want to discuss in the order of priority you want to cover them.

It has been repeatedly found that most of what a doctor tells you is forgotten by the time you get to your car, so take notes of what you are being told. Doctors tend to slip into medical jargon, so do not hesitate to ask that they repeat something you do not fully understand.

It is very helpful to have a close friend or family member with you to act as a second set of eyes and ears, but be sure they understand what you want them to do and do not let them take over the visit. (Speaking of ears, if you need hearing aids, be sure to have them in for the visit!)

Be honest with your doctor. They have seen and heard it all, so any habits you have of which you are not proud, be upfront. Keeping secrets is not going to get you optimal care.

At the end of a visit, tell the doctor what you understood them to say and what is planned. It is rare that a problem is solved at one visit, so be clear in your mind if further testing is needed as well as what you should do if things do not go as expected. Be sure you know what to do before you leave.

If you are not comfortable with what you are told, do not hesitate to ask for a second opinion. This should not be threatening to a good doctor. In the case of a serious diagnosis, second opinions often change the diagnosis and/or the treatment.


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A new test for colon cancer

Late in July, the FDA approved a blood test to detect colon cancer. What does this mean for you?

Colon cancer is the second most common cause of cancer deaths in adults, behind only lung, and an estimated 53,000 people will die of colon cancer in the U.S. this year. At the same time, colon cancer should be almost completely curable if found very early and surgically removed.

Finding cancers in people without symptoms is called “screening,” and good screening tests are only available for a small number of cancers. Good screening tests should pick up cancers early, should be negative in people without the disease and should be proven to reduce death rates in screened populations.

For colon cancer, the gold standard screening test is the colonoscopy. It will detect both cancer and pre-cancerous polyps, most of which can be removed during the procedure. It is very sensitive – if the person has done a good clean-out “prep,” very few polyps or early cancers will be missed. It does not give false alarms – if your colon is normal, the endoscopist sees this and you can generally go 8-10 years before your next test.

The downsides are cost and the “ick” factor.

A recent report on the cost of cancer screening showed that fully 60% of the cost of all cancer screenings was spent on colonoscopies. The test requires a whole team, a special room like an operating room, anesthesia for most people having the test and costs thousands of dollars.

As Dave Barry so colorfully described, ((https://www.miamiherald.com/living/liv-columns-blogs/dave-barry/article1928847.html) the thought of a colonoscopy is repulsive to many of us, and the dietary and laxative preparation required is a turn-off for many.

The alternative has been to check the stool for hidden bleeding, the so-called FIT test. If done every year, this has a reasonably good pick-up if positive tests are followed by colonoscopy. More recently, a stool test looking at cancer DNA markers has been approved. It picks up about 85-90% of colon cancers but only about 40% of large polyps.

The newly approved blood test looks for circulating cancer DNA and was shown to detect about 83% of cancers found on colonoscopies. It had a “false positive” rate of 10%, meaning 10% of people with a positive blood test had no cancer. And it was poor at finding pre-cancerous polyps. Only some 13% of people with such polyps had a positive test.

The big advantage of the new test is ease – most of us are used to having blood drawn at a medical visit and do not mind having this done. No preparation is needed. The cost is dramatically lower than a colonoscopy. The biggest disadvantage is that it is not as good as a colonoscopy. It will miss most pre-cancerous polyps.

My take: if you have insurance that covers colonoscopy, gather up your courage and just have it done.

If the alternative is not getting screened, do the blood test.


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Shingles: more than just a rash

Some 95% of U.S. adults had chickenpox when they were children. Chickenpox, scientifically called varicella, is usually an annoying but not dangerous illness in children.

What makes the illness treacherous is that the causative varicella-zoster virus can go into a dormant phase, hiding out mostly in nerve roots near the spinal cord. When our immune system is weakened by stress, illness, medications or simply aging, the virus can spread out from the nerve root along the nerve.

This recurrence of virus along the course of a nerve is shingles.

The clinical course of shingles is usually very stereotyped. With a patient who is a good observer, I can usually diagnose it over the phone.

Stage one is an itching or burning pain localized to a band around one area of the body with nothing visible. To many, it feels as if they burned themselves when they did not.

The next phase sees them break out with blisters in the same area. It can be on any part of the body, head to toe, but is virtually always only on one side, right or left.

The blisters scab over and eventually dry up, but this may take weeks. Particularly in older people, the pain may linger for months or years after the rash has gone. This is called post-herpetic neuralgia and is very distressing.

If the involved nerve is one of the nerves of the face, the eye may be affected, and this can be a sight-threatening issue.

To fight back, we have treatment and prevention.

Two anti-viral drugs, acyclovir and famciclovir, are useful in shortening the course of the illness and in preventing post-herpetic neuralgia. To be effective, they should be given early, ideally within a day of the rash appearing. If you break out with what may be shingles on Friday, do not wait until Monday to seek help.

Vaccines are available that reduce the likelihood of getting shingles. The older one, Zostavax, is about 65% effective and the newer one, Shingrix, is over 90% effective. While Zostavax is easy to get: one shot, minimal side-effects, the more effective Shingrix requires two shots and is more likely to give you a day or two of flu-like symptoms.

There have been recent studies suggesting that vaccination reduces the risk of dementia, possibly by preventing the re-emergence of the varicella-zoster virus dormant in the brain.

Since most children are now vaccinated against chickenpox – the vaccine came out in 1995 – we can hope that shingles will follow polio and smallpox into “mostly of historical interest.”

In the meantime, most older adults should get the shingles vaccine. If getting Shingrix, don’t schedule your shot the day or two before an important event.


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