About stoneagedoc

Pediatric infectious diseases specialist, author and public speaker. After 35 years in clinical practice including 40 years in academic pediatrics I now share that experience in helping others to enjoy a long, healthy life without the burden of chronic disease.

 

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.

 

Upcoming presentations

May will be another online-only month for OASIS and other presentations unless things change rapidly. It will be some time before San Diegans will want to come together in the libraries and other venues where we have met in the past.

There is an upside, however, in that there is no longer any geographic limit to senior learning. The http://www.stoneagedoc.com blog has had visitors from all over the world who are now able to access OASIS’ learning programs. You can feel free to let your friends anywhere in the world to join us.

Thursday, May 21st 10:00 a.m., Body fat: all that jiggles is not the same sponsored by OASIS. To register see their web site at http://www.SanDiegoOasis.org. (Don’t follow this link, but go via Google.) It’s location, location, location. Fat behaves differently depending on its location in the body and it’s not the same for men and women. Body fat has taken on a new significance in the age of COVID-19.

Thursday May 28th, 10:00 a.m. Keto diet insights sponsored by OASIS. To register see their web site at http://www.SanDiegoOasis.org. (Don’t follow this link, but go via Google.) The ketogenic diet (“keto diet”) is centuries old but it has become widely popular, driven by the current epidemics of obesity and type 2 diabetes. This presentation explores the difference between the keto and low-carbohydrate diets, their advantages and limitations and how to benefit from their best features.

 

In the news

But is it really news?

With some exceptions, what our grandparents read in the newspapers or heard on radio newscasts was accepted as truthful. Although the term “fake news” is heard often, it seems that misinformation exploded with the rise of the Internet. How do we protect ourselves from that, especially in regard to the COVID-19 pandemic?

I have long recommended that we should be skeptical of scientific reports that don’t emanate from sites with the suffix .edu or from institutions with a healthy reputation, such as the Mayo Clinic, Cleveland Clinic or the National Institutes of Health. To be sure, they can be sources of error but almost never deliberate misinformation.

China’s reputation is bleeding, especially in matters concerning the pandemic. Several medical journal articles from China have been retracted although the reasons are not clear. A report from Medscape.com on April 29th                                                 described the China problem, at least part of which is political.

Much of what seems to be misinformation is simply the result of inadequate data or reliance on past but not relevant experience. The vaccine issue is an example. We are rapidly moving toward the release of a vaccine against the new coronavirus but there are two issues that take time to be resolved. The first is safety. It sometimes takes many thousands of vaccinations to reveal that hazards exist, as in the example of a neurological disorder, Guillain-Barré Syndrome, which is a one-in-a-million risk of the influenza vaccine. (Full disclosure: the connection between GBS and flu vaccine is still being disputed.)

Second, it’s possible that coronavirus vaccine protection is not long-lasting. Resolution of this issue will not only require recruitment of large numbers of people but it will be necessary to expose vaccinees deliberately or naturally to the same virus. Deliberate exposure requires fairly large numbers of subjects; natural exposure requires time. It’s likely that we will need to be immunized every year, like the influenza vaccine, to have at least some protection.

Lifestyle

Aging Annoyance # 13: loss of hearing

           This is one of those stealth annoyances that creeps up on us so slowly that we don’t recognize it. Of course, our mothers warned us about it when we turned up the music to the let’s-irritate-the-adults level.

Another factor is denial – no one wants to admit to being “hearing-impaired.”

Hearing loss has many causes and it can begin early in childhood. Much of it is due to exposure to loud noises, a fact that military veterans and competitive shooters can attest to. The damage is subtle – with every noise attack we lose a few cells of the inner ear until the reduction in hearing reaches recognizable levels.

Everyone should receive a screening test for hearing loss at the age of fifty. Repeat screening is recommended every five years, especially for persons with higher risk such as playing in a rock band, exposure to military weapons, etc.

You are probably wondering about ear wax. I’ll address that in the next blog in two weeks.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stone Age Doc’s Pandemic Perspective #6

Wheat, chaff and hydroxychloroquine

There are two elements of the coronavirus pandemic that are not usually encountered in the world of medicine. One is the disturbingly rapid swings in the the opinions and conclusions of those that have the most experience with this particular disease. An example is the shift in intubation and ventilator strategy. Some practitioners have claimed that the use of ventilators actually increases mortality. In another example small trials of chloroquine/hydroxychloroquine (for simplicity I shall refer to them both as chloroquine although the hydroxy version appears to be somewhat safer) have given results that range from no effect to moderate improvement to lifesaving.

The other element is even more disturbing: the caustic, often vulgar attacks on the concept of using hydroxychloroquine, by the media, especially those directed against the president. My association with the medical field began 66 years ago, before I entered medical school. In more than six decades I have never witnessed such anger and hostility over a treatment regimen. Never.

Here are some things to consider as you try to make sense of this confusion. Chloroquine has been around since before the average American was born. It has two main uses, treatment and prophylaxis of malaria, and reducing the symptoms of several autoimmune conditions such as lupus and rheumatoid arthritis. Its ability to inhibit the replication of coronaviruses and thus to reduce viral load has fueled scores of studies, including a clinical trial initiated by the NIH and Vanderbilt University Medical Center. The fact that two reputable institutions as well as hundreds of hospitals throughout the world are applying clinical trials to this medication should have silenced the media’s singularly vitriolic criticism.

Many of you have probably Googled this topic. You might want to compare the headlines of entries that emanate from medical institutions and journals with those of the media. I will not name them but urge you to draw your own conclusions.

Chloroquine has an excellent safety record but NOT in persons with underling heart disease. As noted in the following paragraph, the people who need it the most are often those with sick hearts. Appropriate dosage for a short term in healthy individuals, such as those receiving it for malaria prophylaxis during travel very rarely causes problems.

More than 90 percent of persons who have died from COVID-19 (that’s not really the name of the virus but please accept my shorthand and that of most publications) have pre-existing medical problems. They include heart disease, high blood pressure, lung disease, kidney disease, immune deficiency, diabetes and obesity. The last is extremely common but rarely commented on in the media, as I noted in a previous blog. Obesity and diabetes both disrupt the immune system. The result is often cytokine storm, the outpouring of inflammatory chemicals from fatty tissue – and the more fat the more harmful cytokines – that literally destroys healthy organs. Those organs include the heart and the lungs that are already sick; MOST persons over the age of 70 have damage to one or both. Is it any surprise that the mortality in nursing homes is so terribly high? Do you really think that any medication can make much difference?

Although this virus began its devastating journey in the autumn of 2019 it is not yet three months since it began its rampage in the United States. I am therefore not surprised that there are so many unanswered questions. I am surprised at the remarkable speed with which our scientists and corporations have developed and distributed tests for the virus and viral antibody. I expect that a vaccine and an antiviral drug will be available sooner than most people think.

I welcome your feedback.