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 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.