Monkeypox

Does it appear as if we are beginning the plagues that struck Egypt in the Bible? Just as we seem to be learning to live with COVID (though that virus may not be done with us just yet), along comes monkeypox. What is it? How worried should you be?

The most notable poxvirus is the life-threatening smallpox, which has been vanquished after millennia in which it was a leading cause of death. Related viruses are the cowpox virus that Jenner used to make the first vaccines and the vaccinia virus used to make modern smallpox vaccines.

Monkeypox is a similar virus, and has probably been around for a long time, but was largely confined to central and western Africa, so was not studied by western scientists. It is so-called because it was first detected in laboratory monkeys (in Denmark), but its usual hosts are small African rodents and other small mammals. There are two forms of the virus; the one seen in the Congo basin causes more severe illness, with about a 1-2% death rate in humans, and is more transmissible. The current outbreak appears to be of the less severe West Africa strain. No deaths have yet been reported in the current outbreak.

Before this year, cases outside Africa were rare, and usually seen in returning travelers. The U.S. had an outbreak in 2003. A shipment of Gambian pouched rats infected prairie dogs housed in the same facility, and these were then bought as pets and infected their owners.

2022 is different. As of this writing, some 1500 confirmed cases have been reported from 31 countries around the world, with 60% of these in Spain, Portugal and the United Kingdom. Most of these have been traced to large gatherings such as raves, where people mingled closely. Some 50 cases have been verified in the U.S. and over 110 in Canada (most in Quebec). The virus is primarily spread by direct contact with skin lesions but can also be spread by contact with sheets or clothing that have been in contact with skin lesions. While still debated, it may be spread by large respiratory droplets.

The usual illness is fever, chills, muscle aches, sore throat and swollen lymph glands, and then comes the rash. The rash begins as flat moles, which then form blisters and then pustules. It can be all over or confined to a small area.

In the current outbreak, most cases have been in men who have sex with men, and the rash has been in the genital and rectal area. Unless the doctor treating such a patient thinks of monkeypox, they are more likely to diagnose a more common sexually transmitted disease such as herpes.

Should you be worried? Probably not yet. Unlike Covid-19, which spreads primarily through small respiratory droplets and can easily be spread even when the carrier is not sick, monkeypox is mostly spread by direct contact with a sick person, so you do not need to worry about catching it in stores or concerts. Casual contact is not a high risk.

Treatment is focused on treating symptoms. Some vaccines and antiviral medicines are available that help, but these can only be obtained from the CDC.

My biggest concern is that if private doctors and public health officials are not vigilant, the virus may become established world-wide and no longer be confined to Africa.

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The PCP - soon to follow the dodo and carrier pigeon?

The Institute of Medicine defined Primary Care in 1996 as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Whether the focus is on the individual or the community, good access to primary care is associated with more timely care, better preventive care, avoiding unnecessary care, lower costs, and lower mortality.

Most experts feel that in an ideal medical care system, about half of physicians would be in the primary care fields of family practice, general internal medicine and general pediatrics. Where does the U.S. stand? About a third of American physicians now practice primary care, but fewer than a quarter of recent medical school grads chose a primary care specialty, and the Council on Graduate Medical Education projects this number will soon drop to under 20%.

Why the disconnect between what the nation needs and what we have? There are many possible explanations, but as always, “follow the money.” According to the Association of American Medical Colleges, the average medical school debt for 2021 graduates was $203,062. It will not shock you to learn that specialists earn more than primary care doctors, but the magnitude may be surprising. In 2020, the average salary of primary care physicians was $260,000 and that of all specialists $368,000, 42% more. When broken down by field of specialization, the disparities are even greater. In 2021, the average family medicine specialist earned $255,000; the average orthopedist $$557,000 and the average cardiologist $460,000.

When a newly minted MD looks at their debt load, which is more appealing: pediatrics, with a 2020 starting salary of $196,000 or dermatology, where the average is $394.000? In addition to the obvious fiscal push toward specialty care, there are less-easily quantified but important non-monetary factors. Medical students are exposed predominantly to academic specialists and sub-specialists during their clinical rotations, and the message is often “you are too smart for primary care.” When role models are specialists who know everything there is to know about a limited field, that becomes an easy position for the student to envision for themselves.

Another factor is the “burn-out” that many students encounter during their rotations. All physicians deal with ever-increasing paperwork demands, but the burden is disproportionately heaped on primary care physicians. A recent survey asked doctors in different fields to estimate the hours they spent per week on paperwork. The range was from a low of 10 hours for anesthesiologists and ophthalmologists to 18.9 for Internists. It is the PCP who must spend the most time feeding the maw of the electronic medical record (EMR) with meaningless clicks to document items that have minimal benefit to the patient.

What is the way out? The huge discrepancy in earnings must be narrowed. A model that appeals to PCPs is the “concierge” model, which allows them to see fewer patients, give better quality care and earn more. Unfortunately, this is not available to most Americans. The rate setters must give more reward for thinking and talking to patients and less for procedures. The hundreds of “quality measures” doctors are required to document must be limited to those that have been proven to improve outcomes. Less time spent “treating” the EMR will allow more time spent with the patient. Students need more PCP role models during medical school.

In the meantime, if you have a good PCP, be grateful.

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Avocados, coffee and wine

Two articles in the press caught my eye last month. One reported that eating avocados twice a week lowered your risk of heart disease by 20% and the other that drinking 2-3 cups of coffee daily lowered your risk of death and heart disease by 10-15%. Since I need my two cups of coffee to get going in the morning but have never eaten avocados, I had to dig a bit deeper.

Both these studies, it turned out, were observational studies.

The gold standard for testing the value of a new treatment is the controlled trial. You take two groups of people who are similar in all respects and randomly give one half of the group treatment A and the other half treatment B. You then compare the results and if the results are substantially different, you can assume this is because A or B is better.

When the treatment is something people cannot do by themselves, this type of trial is straight-forward to design and conduct. When you are looking at diet, exercise, smoking or other habits, things get a lot harder. To compare the effects of eating avocados twice a week or not, you would have to control the subjects’ diets 24/7, clearly impractical. For this type of comparison, people are recruited and asked to do or not do things, but the researcher cannot control their actual behavior, or their usual behaviors are ascertained by questioning them.

Many large groups have been studied over the years in observational trials, and much useful information has been learned by following their health outcomes, but findings from such studies are almost never proof that the behaviors caused the outcomes.

The classic example of this misunderstanding about observational trials is the effect of post-menopausal estrogen use. For decades, almost every doctor believed that taking estrogens after menopause prevented heart disease. Why? Because women who took estrogen had much less heart disease. Only after the Women’s Health Initiative trial seemed to refute this did doctors pause to think that women who took estrogen were different in many other ways from women who did not. They smoked less, exercised more, saw doctors more often and were generally more health conscious. It seemed they were healthier to begin with.

More recently, the “fact” that light to moderate alcohol consumption benefits heart health has also been questioned. Researchers looked at over 371,000 people in the United Kingdom Biobank. They found, as expected, that light to moderate drinkers had the lowest heart disease risk. They also found that this group tended to have healthier lifestyles than abstainers: they smoked less, ate more vegetables and were more physically active. Taking the lifestyle factors into account eliminated any beneficial effect that could be attributed to their drinking habits.

Bottom line: observational studies may suggest harms or benefits but rarely if ever can they prove such effects. If you enjoy avocados or your morning coffee, go on consuming them, but I would not depend on either to keep you forever young.

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Reigning: Cats and Dogs

Pet owners know that dogs and cats are like family members and get joy (as well as the occasional pain) from their animal companions. It is well known that pet ownership went up during the Covid pandemic: the “pandemic puppy” phenomenon.

What you may not know is the health benefits that accrue to pet owners, particularly dog owners.

A recent study from the University of Michigan followed 1369 adults 65 and older, who had normal cognitive skills at entry, over six years. They found that there was less cognitive decline among pet owners. The effect was most pronounced among those who had owned a pet for five years or more. Using a 27-point test score, pet owners had an average score that was 1.2 points higher at 6 years than non-pet owners. For comparison, this is a great difference than bestowed by the controversial drug aduhelm!

Another study looked at 11,233 Japanese adults 65 and older who had no pet or who owned a cat or a dog and followed them over 3.5 years. The dog owners had half the rate of disability develop over the study period compared to non-pet owners. There was no major benefit seen in cat owners. The researchers suggested that the benefit was due to the increased exercise forced on dog owners: dogs must be walked regularly, unlike cats.

Another interesting study was done in the emergency department of a large teaching hospital in Saskatchewan, Canada. Patients coming to the emergency department with painful conditions were randomly assigned to either receive a 10-minute visit from a “therapy dog” or not. Those who had the canine visits had significantly lower pain scores after the visit, as well as less anxiety and depression.

So, when your pet chews the furniture, cut them some slack: they are doing you a lot of good!

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Long Covid - it is not "all in your head."

If you follow the news, you are aware that some people who recover from a COVID-19 infection have persistent complaints for months after their apparent recovery. These can occur in almost every body system, but the most prominent tend to be fatigue, shortness of breath and “brain fog:” difficulty concentrating.

While an enormous amount has been written about post-acute Covid syndrome, popularly known as Long Covid, the medical profession still has more questions than answers. There are many challenges to understanding what is happening. For those who were sick enough to be hospitalized, the medium and long-term symptoms seen in Covid survivors are not that different than those seen in many patients who spent time in the ICU for any reason. In these people, “long Covid” may be a form of “post-ICU syndrome,” which has only recently been studied.

Another problem is that to date, we have no good measures to evaluate the long haulers’ complaints. There are no blood tests or X-rays that we can point and say that these explain the symptoms or that they “prove” you are truly sick. Just as with the chronic fatigue syndrome, when all the usual blood makers are normal, many doctors dismiss the complaints as being imagined.

Several recent studies have shed some light. Comparing people who have recovered from Covid with those who have recovered from other illnesses, there are more complaints of shortness of breath and of a variety of neurologic and psychologic symptoms. A large study of Chinese Covid survivors found them to have more decline in mental acuity, particularly among those who had severe acute Covid. Strengthening the idea that this was not psychological, a small study in Britain found both cognitive decline and shrinkage of the brain on MRI among people who had recovered from mostly mild cases of Covid but had persisting symptoms.

A very large study done by the VA showed that compared to people hospitalized for other reasons, Covid survivors had more blood clots, atrial fibrillation, strokes and heart failure. Most recently, a study of 10 patients who complained of shortness of breath but whose routine tests were all normal found, with more sophisticated tests, that their tissues did not take up oxygen normally, thus explaining why they had trouble exercising.

On the bright side, a British study found that only 9.5% of vaccinated individuals who had break though infection had Long Covid symptoms compared to 14.6% of unvaccinated individuals. Since vaccination also clearly reduces your chances of any symptomatic Covid, the value is even greater.

Finally, a very preliminary study in the U.S. found that enhanced external counterpulsation, a harmless but tedious treatment shown to improve circulation to the heart and brain, improved symptoms in most of the 50 patients studied.

Bottom line: 1. Get vaccinated. 2. If you have symptoms months after recovery from Covid, don’t let your doctor tell you “it is all in your head,” but ask to be referred to one of the specialized centers bringing a multi-disciplinary approach to treating Long Covid.

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To mask or not to mask... that is the question

As you have probably read, the CDC has relaxed its mask guidance in response to the falling numbers of Covid cases and hospitalizations. What should you do?

There are several key points to consider.

The first is that being fully vaccinated is the most important thing you can do to protect yourself from serious illness. While the vaccines’ ability to prevent infection wanes, their protection against hospitalization and death has remained strong.

The second is that masks, while not a panacea, clearly reduce risk. If you are in close contact with an infected person and both of you are wearing masks, your likelihood of catching the virus is reduced by 50%.

Finally, life is inherently risky, and you can balance your tolerance for risk against other things that are important to you, as you do every time you get in a car.

There is little need for most people to wear masks outdoors unless packed together as in a stadium.

If you are healthy and fully vaccinated, and so are your family, it is reasonable to stop using a mask in most settings. I would still use one when you are indoors in crowded environments such as theatres and public transportation.

If you or a family member or close friend are immune compromised, masks are still a useful barrier to infection and should still be used in most indoor settings.

When gathering indoors with friends, if you are all vaccinated and have no symptoms, you can skip the masks. If someone in the group is immune compromised, you can add an extra layer of safety by all doing a self-test before the gathering.

One of the things that mask-wearing has done is markedly cut down both influenza and colds, which are spread the same way as Covid – the respiratory route. I may just keep wearing one in stores and such for a while longer!



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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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