In the news

 Will the fat lady ever sing?                

   “It ain’t over ‘til the fat lady sings,’ attributed to sportswriter Dan Cook, 1976.

            If this well-worn saying refers to the coronavirus pandemic we may never hear her final aria. SARS-CoV-2 is here to stay. It differs from the SARS coronavirus that surfaced in 2002 and MERS (Middle East Respiratory Syndrome) that was first identified in 2012. Unlike those two versions it has a low mortality rate except for elderly persons with underlying medical conditions. This strain is much more contagious and has rapidly infected more than one-half billion people around the globe in a little more than six months. In that brief period it has forever changed the world’s economy, challenged healthcare systems and profoundly altered how humans interact and communicate with each other. It will be a long time before the pandemic subsides and we can feel that life has settled into the next version of normal.

The good news is that the proverbial silver lining is already evident. Vaccine technology, accelerated by advances in genetics, may yield a SARS-CoV-2 vaccine in months, not years. Anticipating success, some manufacturers have already prepared millions of doses that can be distributed immediately as soon as their candidate is found to be safe and effective. Nothing like this has happened since Dr. Edward Jenner developed the first safe and successful smallpox vaccine late in the 18th century.

Social distancing has accelerated the move toward digital communications. There could be a reversal of the steep upward trajectory of college costs as online presentations replace lecture halls and classrooms. Zoom conferences don’t require business travel. Some healthcare providers already report that ninety percent of routine patient visits no longer take place in the office but via the telephone or computer. Devices that transmit vital signs such as blood pressure, temperature and oxygen levels are no longer Star Trek imaginings and they will proliferate.

How long will the fear of crowds affect our behavior? What will happen to events that by their nature draw large numbers of people? Will sports teams and entertainers be able to fill stadiums and arenas? Will movie theaters be able to survive when even the least tech-savvy among us have finally learned how to navigate our smart TVs to find the latest releases on Hulu, Apple TV or scores of other streaming services?

Almost no government, business, institution or individual was prepared for COVID-19. A few national leaders did foresee a pandemic scenario – Bill Gates and Marco Rubio come to mind – but no one heeded their warnings. Worse, federal and state administrations allowed stockpiles of medical supplies to dwindle. This time people and governments will listen to the prophets among us. The “prepper” movement will gain new adherents; to the mantra of “beans, bullets and band-aids” they will add “toilet paper”. Financial advisors who have warned us for decades that having one year’s income in savings was prudent no matter how difficult, will see that many families are following their advice. Fifty governors will ensure that their citizens will have ventilators, medical supplies and other essential items before the next pandemic arrives.

We might see the eventual reversal of the twin epidemics of obesity and type 2 diabetes. Early in the pandemic it became clear that the elderly were those at highest risk. It was not because of their years, it was because they had comorbidities that included overweight and diabetes and other conditions that included lung disease, high blood pressure and chronic kidney disease, all of which are almost entirely the result of lifestyle and are thus avoidable.

Physicians will develop new insights into viral diseases, how to treat them and how the human body reacts to them. They are learning how to use mechanical ventilators more effectively and how to prevent or treat the aberrant immunological response to infection known as cytokine storm.

The pandemic has accelerated research into dozens of antiviral drugs, novel applications of drugs that were developed more than a half-century ago and innovative diagnostic methods. Since the Renaissance era, wartime diseases and injuries have accelerated medical progress. This new war will do the same.

The fallout from the coronavirus pandemic will shadow us for years, possibly decades. If that view is correct, the fat lady will be waiting in the wings for a very long time.

Lifestyle

We’re all concentrating on avoiding the coronavirus and in keeping our sanity in this prolonged loss of social contacts. Routine doctor visits are being postponed but sometimes urgent problems override caution. One of the annoyances of aging, (the 17th in our series) kidney stones, is one of those. The severity of the pain that they cause is almost never life-threatening; it just feels like it.

Most kidney stones are composed of calcium oxalate and thus we can avoid them with minor changes in our lifestyle. Some are caused by a genetic biochemical defect and a few accompany gout, a painful condition of the joints.

The single most important factor in the development of kidney stones is dehydration, a condition that is common among older persons but that is almost always avoidable. When we get behind in our fluid intake the body responds by conserving water, thus making the urine more concentrated. Some of the solid materials that have been filtered through the kidneys also become more concentrated. As they coalesce they form itty-bitty (a scientific term) particles within the kidney that grow larger as dehydration persists, eventually forming stones. The tiniest leave the kidney and depart harmlessly when we empty our bladder. When larger stones exit the kidney via the ureter they encounter a couple of narrow sections and cause severe pain as they squeeze through. That’s not the end of the story. If they make it to the bladder they make the voiding process similarly painful.

The rough surface of a kidney stone that causes severe pain often scratches the walls of the ureter enough to cause bleeding. Sometimes blood in the urine is the first sign of a stone and is always an indication for a visit to the doctor.

Once upon a time doctors told patients who had suffered from kidney stones to reduce their calcium intake in order to prevent a recurrence. Just the opposite is true; taking too little calcium will encourage stone formation. The culprit is not calcium but oxalate. Oxalate is a constituent of many plant foods, especially rhubarb, spinach, strawberries and chocolate. (Sigh!)  Calcium in our food binds oxalate so that too little calcium allows excess oxalate to be absorbed into the bloodstream where there is plenty of calcium. When the calcium oxalate complex is filtered through the kidney it will precipitate out to begin stone formation if the urine is not dilute enough.

Dietary calcium is rarely a problem but persons who take large doses (more than 1,000 milligrams) of calcium, especially with vitamin D are at increased risk of stone formation. The guidelines to follow: never take more than 500 mg. of a calcium supplement at a time, never exceed 1,000 mg. per day and never take it at bedtime.

Water intake is critical but there is no magic formula. You will avoid dehydration and kidney stones if you drink enough water so that your urine is always light yellow with only a mild odor.

 

 

 

 

 

 

 

 

 

 

Pandemic Perspective #11     May 30, 2020

COVID-19 Lemonade

“When life hands you a lemon…” We all know that old saw but in spite of all the jokes and cartoons that fill our email box every day (I’m not complaining, just sayin’) it seems hard to come up with something really positive as deaths increase. Life’s lemonade may not always be so sweet but it does present us with some valuable lessons. Some relate to health, some relate to work and some relate to being ready for the next pandemic. And you can be sure that there will be more pandemics that afflict the human race unless we extinguish ourselves first.

Perhaps the greatest lesson is the most tragic. The vast majority of deaths from SARS-CoV-2 have occurred among the elderly – or so it seems. Yet stories of centenarians from around the globe who have survived the infection are popping up on a regular basis. The risk is not old age; according to the CDC nearly 90 percent of patients, including those in middle age or even younger, have one or more lifestyle-related medical conditions. A report in early April, 2020 listed hypertension in more than 70 percent of those over the age of 65. Half had cardiovascular disease; nearly as many were obese or had chronic lung disease. The great majority were overweight. Among those between the ages of 50 and 64 years those conditions were nearly as common.

With very few exceptions, such as asthma and some genetic conditions, these “comorbidities” are the result of lifestyle, not the aging process. Since the middle of the last century physicians and other health authorities have been pounding their heads in frustration, warning us that the modern American diet, high in salt and refined grains, and the lack of physical activity, are literally killing us. It is just possible that COVID-19 is the proverbial smack alongside the head that will make us more aware of what we can do to avoid the non-infectious chronic diseases that have become actual epidemics and that kill more than a million of us every year.

Obesity is a driving factor in mortality in general and infections in particular. Obesity has two immune-related effects. It lowers the ability of the immune system to protect against several infectious diseases. This has been observed in influenza as well as the current COVID-19 pandemic.

The second malfunction of the immune system is cytokine storm, in which the immune system overreacts and attacks several organ systems. Fat tissue harbors cytokines, chemicals that produce inflammation. The excess body fat in overweight and obese individuals is the source of cytokines that are associated with this uncontrolled and usually fatal immune response.

The lemonade? It’s my hope that 2020 will be a turning point, the year in which the lessons of the new coronavirus pandemic will lead to a realization that we can reverse the twin epidemics of obesity and type 2 diabetes and their lifestyle-destroying complications.

In coming Saturdays’ Pandemic Perspectives I’ll address more of the positive – and less morbid — fallout of COVID-19.

 

Pandemic Perspective #10  May 23

Uncertainty rules

The only thing certain in this COVID-19 challenge is – uncertainty. I have been collecting articles from medical journals as well as the media and the range of opinions, “discoveries” and “statistics” – a stack now two inches thick – is a tangled mess.

Don’t give up hope. I’ll have some positive comments at the end of this blog.

At the forefront is the question of openings. Protests border on rebellion. Churchgoers and barflies want to get together again – each in their separate venues of course. Big box stores and grocers allow the entry of a few patrons at a time but those same shoppers can’t go to their favorite gym. So we’re eating more and exercising less. Even our superheroes are affected!

That mask that Batman is wearing should be upside down. It hasn’t helped that government experts haven’t decided whether face masks matter or not. Their own opinions range from: only healthcare workers need to wear masks; any kind of mask works; no masks are completely effective to prevent getting infected; wearing a mask is mandatory even when going into a bank or a 7-11 store, something that would have brought out armed security or the local cops less than three months ago. Confused yet?

Vaccines are in the headlines this week. More than 100 laboratories are developing their own with recipes that are as varied as those for fruitcake. (Hmmmm! Interesting analogy.) Isn’t it amazing that something as tiny as a coronavirus is made up of so many components that a vaccine might target?  The reaction to the news about the most recent developments: maybe the vaccine won’t work. Maybe we’ll have to get a booster every three months. We might have to get two doses, each with a different vaccine. We are still 18 months away from a vaccine. We’ll have a vaccine ready for distribution in October (maybe November, maybe January, maybe…) One of the vaccines is composed of a coronavirus particle attached to an adenovirus. Adenoviruses are common causes of the common cold. Many older persons have antibodies to adenoviruses because they have lived so long and have had so many colds. Therefore they might have antibodies to the vaccine adenovirus, so that the vaccine won’t work for the people that are the most susceptible to the coronavirus. Has your head stopped spinning yet?

How long can the coronavirus stay alive and dangerous on an inanimate surface? Take your pick: 20 minutes, 2 ½ hours, 2 days, 2 weeks, three months (!). Happy news: the CDC has just announced that inanimate surfaces are not likely to be the source of infection. Whew! Recently when I bought a newspaper I gave the clerk a five-dollar bill and told her to keep the change. After all, I didn’t want to handle the bills and coins that she and dozens of other perverse virus-carriers had handled.

Can you get reinfected after you have recovered from this coronavirus? Some recoverees have been found to have pieces of virus in their throats for three months. Some (but not all) scientists say that those particles won’t cause disease. Stay tuned. They might change their minds later.

And – God forbid that you should take hydroxychloroquine or its plain vanilla cousin, chloroquine, with or without a side of Zithromax. A couple of studies show that coronavirus patients are more likely to die if they take it; other studies state that if you take it early in the illness you won’t need a ventilator and you won’t die. Doctors who have used it for decades tell us that they have never had a patient with lupus, for instance, who died with a heart complication from chloroquine. Journalists tell us that you are very likely to die of an abnormal heart rhythm if you take the drug. They don’t seem to be aware that it has been used for about 65 years to prevent and to treat malaria in millions of persons. A search of the medical literature this week came up with a meta-analysis of 86 articles regarding chloroquine side effects published up to July 2017. The median length of treatment was 7 years; the longest 35 years. Death due to cardiac complications occurred in 24 patients. (Unfortunately the abstract didn’t reveal the total number of patients in these 86 studies. Getting the full article would have cost me about 30 bucks so I passed on that. Sorry!)

There is actually some good news among all this confusion although the most useful scientific information won’t emerge for a year or two after the political chaff has been blown away to reveal the wheat. We will eventually learn what the best means are to prevent widespread disease. We will have an effective vaccine although it might require annual shots, as we need for influenza. We’re going to get pretty good at using disinfectants and cleaners. We’ll get to know our spouses and children better, and especially how to keep from pushing their buttons. Board games are coming back; we’ll all become very good at using Zoom and its counterparts. Plastic barriers at store counters will be permanent fixtures but we might see fewer influenza infections and colds next season because of them. I’ve become better at handling money, i.e., I try not to handle it at all!

I hope that you will forever be mentally positive and coronavirus negative.

 

 

 

Pandemic Perspective #9 May 16 2020

Mutations: Hollywood vs. the real world

The term mutation has a negative, sometimes frightening connotation, especially when it appears in the popular media. Books and movies that describe worldwide pandemics triggered by a single mutation in a virus like Ebola, for example, do not reflect what happens in the biological world.

Genes are composed of thousands of elements and a tiny mistake in any one of these elements can affect how that gene influences some chemical event in a virus, a bacterium or a human. In the case of certain viruses such as the coronavirus group, these changes occur frequently but only a very few of these mistakes result in anything that matters. Specifically, a single mutation is very unlikely to transform a benign virus into a deadly one. It’s more likely that a mutation will be detrimental to the virus and that viral particle will not be able to propagate.

Redundancy is a characteristic feature of living things, including viruses that are not exactly “living” (they need another plant or animal in which to propagate). Traits such as ease of transmission and lethality require more than one gene for their evolution. The kind of single-gene disastrous events described in popular films such as Outbreak are exciting but as noted by one group of virologists, “baseless.”

A study that has only been released in pre-publication form, that is, it has not yet been peer-reviewed as of this writing, states that the SARS-CoV-19 virus has undergone several mutations, one of which has increased its transmissibility, the ability to spread from one person to another. They note that this trait does not also confer a greater risk of mortality.

If there is one word that characterizes this pandemic it is uncertainty. From the early dismal projections of mortality to the revelation that it can cause a serious and sometimes fatal heart complication in children, COVID-19 may turn out to give us deeper insights into how to respond to global pandemics

 

 

In the news

“Sticks and stones…”

“…but names will never hurt me” unless I’m Chinese.

Why is there such a furor over applying the name “Chinese virus” to the cause of the current pandemic? A few months ago it was common throughout all parts of the media but now the term is being vilified as racist. Why?

For the record, I couldn’t care less about the derivation of the names of diseases or the agents that cause them. Early in the 16th century syphilis was named The French Disease, The Italian Disease, The Polish Disease and The German Disease in a schoolboyish tit for tat that military folk have engaged in for millennia.

The media seem to have no problem in referring to the flu pandemic of 1918-1919 as the Spanish Flu. Isn’t that just as racist? It didn’t originate on the Iberian Peninsula, of course but Spain had made the decision to remain neutral during The Great War. They reported the numbers of victims as accurately as the system of the day allowed but the combatants did not. The Allies and the Germany-Austria-Hungary Alliance, not wanting to hurt morale, were not forthcoming regarding their flu-related losses. By comparison, Spain’s figures were awful, hence the name Spanish Flu.

Just off the top of my head I can name quite a few diseases that were named for their place of origin or prevalence but in more than a half-century as an infectious diseases specialist I can’t remember any anger on the part of the inhabitants of those locales.

German measles, Japanese encephalitis, Mediterranean fever, Crimean fever, Malta fever, Rocky Mountain Spotted fever, Asian flu, Hong Kong flu, Zika virus, Lassa fever, West Nile virus, Ebola virus, MERS (Middle East Respiratory Syndrome) – more than a dozen apparently inoffensive place names that I can recall without referring to a medical textbook. I’m not even offended by Lyme disease, named after a small town in my native Connecticut!

Speaking of medical textbooks, here’s what I found in just a few pages of the index of my Principles of Internal Medicine, which is gathering dust since I can retrieve more up-to-date information with a few keystrokes: California encephalitis (WOW!), Rift Valley fever, African tick-bite fever, African sleeping sickness, Aleppo evil, Baghdad boil, American trypanosomiasis, St. Louis encephalitis and Russian spring-summer encephalitis. There are dozens more, of course, named after places whose inhabitants probably have never thought about complaining about the racist attitudes of the scientists who named these scourges.

Like it or not, the terms Chines coronavirus and the more exotic-sounding Wuhan virus will linger for decades. That won’t keep me from dining in Chinese restaurants or from buying products made in China (as if I had a choice).

Lifestyle

Annoyance number 14: ear wax

“Never put anything smaller than your elbow in your ear.” I have no idea when I first heard that, maybe when I was about seven years old. It didn’t take long for me to figure out that I was never going to put my elbow in there but I didn’t think about it much again until I got to medical school and learned how to use an otoscope. A few ears later I learned about the nature of cerumen, a much more sophisticated term than ear wax. Some people have almost none; some have moderate to large amounts of the really gunky stuff and some – mostly Asians – have lots of dry, hard wax that is really hard to remove.

The elbow rule is one that everyone should follow. In particular, a cotton swab does yield a little wax when you twirl it in the ear canal but it can push some farther in at the same time. Having seen a grown-up or two with bloody, broken ear drums from the overenthusiastic application of a Q-Tip I feel strongly that ear canals should be left alone. Water and ear wax almost always dry up or fall out, respectively.

How can you tell if you have an accumulation of ear wax? This is not a DIY project. Be sure to have your physician take a look during your next annual check-up. If you haven’t had a screening hearing test and you are over the age of 50 the audiologist can do it.

Can an accumulation of ear was cause hearing problems? Yes, but there’s a simple way of removing it without the risk of trauma and that I used with universal success when treating children: hydrogen peroxide. If you feel that you are accumulating an excess of wax, simply put two or three drops of plain out-of-the-bottle peroxide in each ear after your daily shower. Once or twice a week should be enough. As long as you have not damaged the ear canal with a bobby pin or similar instrument, the peroxide will not cause pain.

During my pediatric practice years I often had to remove wax from a child’s ears to rule out an ear infection. I used a metal loop called a curette. Believe me, I would have much preferred to use a cotton swab because sometimes removing a piece of wax took a fragment of skin that it had adhered to, resulting in bleeding. That frustrated me and terrified the mother.

When the curette didn’t work we used irrigation with a Water Pik, similar to the gadget that you see these days in TV ads. Yes, it works; no, you don’t need it. We did in in my practice because I had to see those eardrums right away. Peroxide is cheaper and just takes a few days even if you have lots of wax.

OTC (Over-The-Counter) solutions work too but they are unnecessary. Never use mineral or olive oil, which can lead to infection and seldom work.

At the risk of offending my medical colleagues who are still in practice – not very many of those left – it’s not necessary to make periodic visits to the doctor’s office to have ear wax removed. A little hydrogen peroxide will do the job. And if your hearing is normal, (see the May 1st blog) don’t bother.

If you’re high-tech, consider the Q-Grip, a corkscrew device that retails for $12.99 to $39.99 but before you buy, you might want to check the customer reviews.

 

Stone Age Doc’s Pandemic Perspective #8

Is the new coronavirus mutating? Several laboratories around the world have reported that it is undergoing mutation. Like so many aspects of this pandemic, there is little consensus about how that will affect infectivity, lethality, response to antiviral drugs and the effectiveness of vaccines, of which there are more than 100 now in development.

Mutations are normal in all living things from the smallest viruses to the largest animals. Some mutations have minimal effects but others can be crippling or lethal, as seen in numerous human disease conditions such as cystic fibrosis. When a mutation occurs that makes a bacterial cell resistant to an antibiotic the descendants of that cell can spread throughout the human population, making treatment more challenging.

Virologists have already identified several mutations in the coronavirus that began to spread in late 2019 but these changes appear to be minor. The new variants do appear to have a greater tendency to spread within the population but at least for now there is no clear evidence that mutant strains are more lethal. That is a possibility however, considering that some countries, like Italy and Sweden, appear to have higher mortality among infected persons than other countries.

What is the likelihood that mutations will make a vaccine less effective? The reality is that we won‘t know the answer for some time, probably well into 2021. Vaccine development involves inoculating volunteers who are later deliberately exposed to the virus under laboratory conditions. Those results are only preliminary but they may be encouraging. It is only when at least several hundred naturally exposed vaccinees are evaluated will we have fairly predictive results.

In earlier blogs I have been optimistic that there will be a SARS-CoV-2 vaccine released to the public by the end of September. That opinion is based on two factors: the large number of candidate vaccines, now more than 100 as noted above, and the hope that any mutations will not be of the type that thwart the protective capability of a vaccine.

Only time will tell.

Stone Age Doc’s Pandemic Perspective #7

Many of you have probably seen or have become aware of the 51-minute video by two emergency room physicians in Bakersfield, California on You Tube. They proposed that the current lockdown of the country, while justified very early when we had no reliable statistics, no longer is the best strategy. They soon had more than 5 million views but You Tube took down the video because, as they stated, the opinions of these physicians violated community standards.

Regarding the You Tube suppression of the First Amendment: Americans have the right to say things that are factually incorrect, stupid, nasty and vulgar. You will find all the above on You Tube, and frequent use of the F word as well. The doctors were guilty of none of these.

Are the physicians’ statistics flawed? Some of them are, but not any more so than those of W.H.O or the Imperial College. Dr. John Ioannidis, a highly respected professor of medicine, epidemiology and population health at Stanford has some interesting observations on that. (A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data.) He considers the W.H.O report “meaningless” and his calculations of the deaths on the Diamond Princess cruise ship give a fatality rate that ranges from 0.025 to 0.625% in a population of older persons. Cruise ship travelers tend to be in the older demographic and the majority of those passengers had comorbidities including heart, lung and kidney disease, obesity and type 2 diabetes.

The publication by USC and the L.A. County Department of Health (who only studied persons with symptoms, for which they do not apologize) on April 20th states that the number of infected persons could be from 28 to 55 times higher than current estimates. They also state that the fatality rate is “much lower” than had been thought.

Drs. Erickson and Massihi, the Bakersfield physicians, did acknowledge that earlier lack of the true figures did justify the early quarantines but that the most recent data do not. They are not alone. The governments of Sweden and New Zealand (the latter admittedly not at high risk because they shut down entry into their country very early) as well as several U.S. governors agree with them. Data vary from state to state and even between counties, leading to mind-boggling differences in policy. As some governors relax their restrictions some are tightening them.

It concerns me that so few persons in authority realize that exposing children to the virus could greatly accelerate the development of herd immunity. Keeping schools closed makes no sense even though the teachers, bus drivers, etc. might have the serious comorbidities of obesity and diabetes. Proper screening, which is now available throughout the country, could vastly lower their risk. On the other hand, influenza is taking a terrible toll on our children this season – more than 140 deaths by early March. With very rare exceptions, the only kids below the age of 10 who died from the coronavirus have had underlying problems such as asthma and congenital heart disease.

Could the doctors in Bakersfield have a selfish interest? Not any more so than the drug companies that will soon (I hope) start selling the coronavirus vaccine or the maker of remdesivir, just recently released by the FDA.

Is it the doctors’ intent to corner the market on testing in the Central Valley as their critics have complained? That idea gives them too much credit. Where is the Bakersfield Health Department? Isn’t that their bailiwick?

In my view this is very much a matter of the forest/trees challenge. We are keeping the healthy from developing immunity; domestic abuse and suicide are already increasing; the crime rate in New York is rising significantly. Unemployment?  A disaster for the owners of restaurants and golf courses but not for those who sell alcohol or marijuana.

As always, I value your feedback.