Move it!

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

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

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

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

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

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

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

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I want to live forever - or do I?

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

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

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

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

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

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

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

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Quo vadis, Omicron?

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

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

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

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

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

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

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

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

If you have been delaying, PLEASE get vaccinated.

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The new CDC Guidelines - are they valid?

Confused by the latest CDC guidelines on when to get out of isolation? Join the crowd. Many infectious disease experts are decrying the change while others support the new rules.

What do we know? People are most likely to spread the virus in the 1-2 days before they develop symptoms and for 3-4 days after the onset of symptoms. Vaccinated individuals do not seem to shed a lot of virus after 5 days of symptoms assuming they feel better and do not have a fever. This is not true for unvaccinated individuals, who may shed virus for 10 days or more; there is a wide range – some do not shed much after 3-4 days while others can shed virus for up to 2 weeks.

The practical political aspect of this decision is that with the much more transmissible Omicron variant, we are seeing a sharp rise in cases, with many only mildly ill, and we are seeing resulting shortages of workers. The numerous flight cancellations of the past holiday weekend were in large part due to so many pilots and other crew being COVID-positive. Hospitals are running low on doctors, nurses and other staff.

I think that it is reasonable to allow vaccinated individuals to come out of isolation 5 days after testing positive but that this should only be done when they have a negative antigen (rapid) test on the day they leave. Wearing a mask gives a little extra margin of safety.

Unvaccinated individuals should probably stick to the prior 10-day isolation. They shed virus longer (and are the people who are less likely to consistently wear masks).

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Omicron - Is the sky falling?

Spoiler alert! Our knowledge is at an early stage, and much of what I am about to say may change as our knowledge evolves – that is inherent in any new natural phenomenon.

Viruses mutate constantly – when you are producing millions of new virus particles a day, there will be random changes in the RNA sequence. Most of these mutations are minor and have no effect on how the virus behaves but some will cause the virus to be more (or less) easily transmitted and/or more (or less) dangerous to the host (us!).

Most virus mutations are given such catchy names as B.1.1.7, but when the World Health Organization deems a virus to be more dangerous and/or more easily transmitted, it is given a Greek letter name for easier communication. We are all familiar with the Delta variant that is now the dominant strain in the United States and which has caused our case counts to shoot up.

The latest “variant of concern” is Omicron, first identified and sequenced in the Republic of South Africa. It did not necessarily emerge there, but S.A. has a much better public health system than its neighbors. We should be grateful to South Africa for promptly telling the WHO and the world about this new variant. If only China had been equally open, it might have saved precious time for a response to the initial Covid outbreak.

Given the interconnected world in which we live, it is not a surprise that Omicron has spread beyond southern Africa. As of Nov 30, at least 19 countries have reported small numbers of cases. From 1 to 20 cases have been reported from Australia, Canada, Israel, Japan, Hong Kong and 12 western European countries. While there have been no cases identified yet in the U.S., I would be shocked if there are not already a handful here. While much publicity was given to two flights from South Africa to Amsterdam carrying infected people, it is now known that the variant was present in the Netherlands at least a week earlier.

What do we know about Omicron?

1.It seems to be more easily transmitted than the original virus, though not necessarily more than Delta.

2.So far, it does not appear to cause more serious disease than existing strains.

3.Existing vaccines should give at least moderate protection against getting seriously ill, though I suspect will be less effective at preventing infection.

4.The best current therapy, monoclonal antibody infusions, will be much less effective against Omicron, because they target the spike protein and this has been greatly changed in Omicron.

5.The newly approved pills, which target a different part of the virus, should be similarly effective against Omicron, though their benefit is only moderate.

What should you do?

1.If you have not already done so, PLEASE get vaccinated and get your booster.

2.I would wear a mask whenever you are in large groups indoors (theatres, stores, etc.)

3.If you are immune compromised and/or over 75, I would avoid non-essential travel

Stay tuned! We will have more and better details in the next few weeks

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Home (Safely) for the Holidays

One of the worst aspects of the Covid pandemic has been the isolation. Last year, many of us had to forego our holiday family traditions and get-togethers in the interest of safety. This year, with the widespread availability of vaccines, we hope to once again be with our loved ones around the holidays. At the same time, the Delta variant and the rising case count seen in many states makes us nervous, as do reports of break-through infections in vaccinated people. What can/should we do?

A few facts can guide our behavior. The first is that no activity in life is 100% safe. If you are travelling “over hill and dale to grandma’s house” in a car, you are accepting the risk of being injured or killed in an accident. You can of course minimize this risk by wearing a seatbelt, not driving under the influence of alcohol and obeying traffic laws. Second, while no vaccine is 100% effective, the current Covid vaccines are pretty darn good, reducing your risk of getting seriously ill by some 90%.

Here are some possible holiday scenarios and my suggestions for how to handle each:

Scenario 1: everyone attending your get-together who is eligible (is over 5 years old) has been vaccinated, including a booster where appropriate, and no one is immunocompromised or a frail elder. In this situation, I would feel free to socialize freely and not wear masks or require any tests. Go ahead: hug each other. [It goes without saying that someone who is sick should not attend!]

Scenario 2: everyone is vaccinated, but you will have a frail elder or someone who has a compromised immune system with you. In this situation you need to be more careful. Again, strictly advise guests to stay away if they are sick, but in addition, I would ask everyone coming, including children, to do an at-home antigen test the morning of the gathering and stay away if positive. [Any person testing positive should also follow through with their primary care doctor or local public health nurse.]

Scenario 3: at least some of your potential guests are not vaccinated. Here it gets sticky. If everyone else is fully vaccinated and in good health, you must decide if you are willing to accept the risk of getting infected, knowing that the vaccine you received will probably mean you will have nothing worse than a bad cold. Ask them to do a home test the morning of the event and stay away if the test is positive and/or they have any cold symptoms. You should warn all your invitees that there will be unvaccinated guests so they can decide if they want to attend.

3a: If you will have elderly grandparents or friends/family with compromised immune systems with you, I suggest you tell the unvaccinated that they would be putting others at risk and that while you hope to see them next year, they are not welcome this year. There is always Zoom.

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Medical Debt

I have not yet seen a pig fly, but I did recently see something I would have felt just as unlikely: a front-page story in the Rupert Murdoch-owned Wall Street Journal that could have been written by Bernie Sanders.

The headline read “$100,000 in debt: arbitrary hospital prices hit some hard.” It was the story of a hard-working South Dakota woman who died of cervical cancer after a long series of tests and treatments who was forced to use up all her retirement savings to pay down her medical debt. (Unmentioned was why this woman did not have the routine medical care that should prevent most women from dying of this disease that is easily cured when found early.)

https://www.wsj.com/articles/hospital-prices-arbitrary-healthcare-medical-bills-insurance-11635428943?st=qypiqn1wayhirth&reflink=desktopwebshare_permalink (may be paywall)

The article described the random and arbitrary nature of hospital pricing and how people with different health insurance plans might have dramatically different out-of-pocket costs for the same tests at the same hospital. It also emphasized how little control most people had over their medical costs. Many hospitals charge their highest prices to patients when a procedure is not covered by their insurance plan.

Standard right-wing dogma is that health care is “just another consumer choice,” whose pricing should be left to the marketplace. Omitted from this thinking are such factors as limited choice (the woman in the story lived in rural South Dakota with only one hospital anywhere close), the fact that very sick people are rarely in a position to negotiate prices and the incomprehensible pricing structure used by most hospitals.

Couple this story with research published this summer showing that U.S. debt collection agencies held $140 billion in unpaid medical bills last year and you have to ask why people are not out in the streets demanding change.

In part this is probably because medical costs hit the poor hardest: 35% of people living in households with an annual income below $24,000 reported skipping medical care because of cost versus 7% of all those with incomes under $180,000. The poor, with day-to-day worries about paying for food and utilities, are the least able to work for political change.

In the long run, we all pay. One in six patients with heart failure reported skipped or delayed medical care because of cost, and this was associated with higher overall spending because of increased hospitalizations.

The mark of a healthy society is how it cares for its most vulnerable citizens. By this measure, we are failing. When the dust settles in Washington, it is time to take up the cudgel again and fight for affordable care for all.

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