Drug Resistant Bacterial Infections and Medical Tourism

The high cost of health care in the United States including the high cost of medical insurance have driven patients to seek medical care abroad. In addition to cost, there are treatments abroad using materials and methods not approved in the USA for treatment of those conditions. These “alternative” treatments, performed without any research which is published in traditional peer reviewed journals or accepted as evidence-based, often results in adverse effects. The standards, hygiene and quality control we, as Americans, expect is just not as strict in many of these overseas cash cows.

Morbidity and Mortality Weekly Review published a review of three patients treated in Mexico with stem cells and platelet rich plasma who acquired Mycobacterium abscessum infections. This non tuberculosis organism is exceptionally resistant to known antibiotics. One woman with multiple sclerosis received the tainted injections into her spinal canal. Two other patients received intraarticular injections into an elbow and both knees. When they returned to the United States and sought treatment for these new infections, they were referred to a Center of Excellence in Denver, Colorado which treats Mycobacteria infections. The Center performed genetic gene sequencing on the infecting organisms and were able to trace the origins back to facilities in Baja, Mexico and Guadalajara, Mexico.

As a potential buyer, beware when considering medications compounded in foreign clinics and procedures done abroad that are not approved in the USA. Cosmetic procedures and dental work are especially common medical tourism procedures. However, you have to know who you are dealing with, where their products originate from and what their track record of infections and complications is.

More On Vitamin D and the Development of Diabetes

Studies about Vitamin D levels and disease have been flooding the medical and lay literature for several years. In 2011, the National Academy of Medicine declared that a serum level of >20ng/ml was sufficient to maintain skeletal health. The Endocrine Society first recommended 28 ng/ml and now raised it to 30 ng/ml. Physicians in the United States have been measuring serum vitamin D Levels through reference labs for a decade or more now despite the United States Preventive Task Force concluding there is no benefit to screening adults for vitamin D level. 

A current study in the Journal of Clinical Endocrinology and Metabolism, authored by Carolina Gonazalez- Lopez, MD and associates, used data from the British UK Biobank over fourteen years to show that maintaining a serum vitamin D3 level of 30 or greater is best to prevent normoglycemic individuals from converting to Type II diabetes.

Vitamin D is made by the kidneys if our body gets sufficient sunlight exposure. Patients with kidney disease have difficulty achieving normal Vitamin D levels.

This study and others showed that supplementation with Vitamin D orally helped individuals achieve a level which reduced the risk of developing diabetes.  In a review of this material and study, David Rakel MD, FAFP and Sun H. Kim MD, MS agreed on a target normal level of 30 ng/ml.

Oral Vaccine To Prevent Urinary Tract Infections in Development

Urinary tract infections involve 400 million individuals annually. Patients with repeat and recurrent urine infections become treatment problems because the bacteria they harbor often develop resistance to the antibiotics used to treat the infection.  To combat situations like this, an oral vaccine was developed to prevent recurrent urine infections. It is named  Uromune. A nine-year research study of its effectiveness was presented at the European Association of Urology last month.
     

The vaccine is made of inactivated whole bacteria commonly found in urine infections including E Coli,  K Pneumonia, P Vulgaris and Enterococcus Faecalis. The pineapple flavored suspension is sprayed under a recipient’s tongue with two sprays daily for three months.  After completing the initial treatment recipients are retreated at one and two years.  The study followed 89 patients (72 women), with a mean age of 56, for nine years. Forty-eight of these patients remained infection free for nine years. The average infection free time frame for treated patients was 4.5 years. The researchers reported no adverse effects.
     

This was a small study which will require a much larger sample size before the product will be approved by the European Union or Food and Drug Administration. The product has been used “off label” in Europe and Asia for several years but is relatively unavailable in the United States.

 It remains to be seen whether women with colonization of bacteria in their bladders will be able to avoid recurrent infections with a vaccine like this.  Will women with post coital inflammation and infection be able to avoid recurrent infections?  Men with enlarged prostates who don’t completely empty their bladders upon voiding share a similar problem. 

The research needs to be done but hopefully, if successful, this product will receive approval and be available by 2030.

Our Nation’s Lack of Geriatricians is a Growing Problem

Carly Stern in the Washington Post writes about a shortage of specialty physicians in geriatric medicine despite the extraordinary daily increase in patients in that age group.  The reasons are quite simple. To become a geriatrics specialist, you must first become board certified in internal medicine. This requires three years of post-medical school training in an accredited Internal Medicine program then entry into a Geriatrics Fellowship program for a few additional years. At the completion of both the internal medicine residency and Geriatrics fellowship program you must pass a national exam.

Geriatrics as a specialty has been operational since the late 1980’s.  So few internists applied for these positions that the American Board of Internal Medicine opened the test to certified internists with experience caring for the elderly. There were no academic fellowship programs at that time.  If you passed the exam and were certified, you entered a world in which a geriatrician earned about $20,000 less per year than their general internal medicine colleagues.

For reasons not entirely clear to me today, I decided to take the exam in 2002. I paid a few hundred dollars for a syllabus several hundred pages long from the American Geriatrics Society and registered for the test at a cost of about $500.  It was a two-day exam administered in a convention center of a Tampa hotel necessitating transportation costs and two nights lodging at a hotel. 

I passed the test and received my certification or “added qualifications in Geriatric Medicine” a few weeks later. I originally considered this a great accomplishment and sent a notice to all my patients and colleagues of my new status. The result was that many of my patients younger than 65 years of age decided to find another doctor. They wrote me and said they did not want to sit in a waiting room with aides and wheelchair bound patients with walkers. I proudly displayed my certificate on my exam room wall and carried on.

A few years later, due to media pressure and Congressional lobbying pressure, the American College of Physicians and American Board of Internal Medicine decided that if I wished to retain this certification I would need to demonstrate that I had made changes to my practice style and re-take the exam at an approximate cost of about $5000.   I decided these organizations were crazy and opted out. I still read the updated syllabus and take the practice tests but the financial rewards for maintaining this certification just were not worth the cost.

There are currently about 7,300  geriatrics fellowship trained physicians in the USA. That is less than 1% of the physician workforce. They still earn about $20,000 less than a general internist or pediatrician. To encourage more individuals to consider this field, the Federal government needs to make some changes.

1. Geriatric physicians need more time with their patients per visit. Coordinating care with their many specialty physicians and reviewing their multiple prescriptions for drug/drug interactions is time- consuming.  Pay geriatric physicians more for these cognitive visits.
2. Consider forgiving the educational debt of physicians who agree to stay in primary care and geriatrics for a minimum of fifteen years.
3. Consider giving these physicians an office expense stipend so they can afford to hire a RN to help them with the telephone triaging and patient care.

There is now renewed discussion of finding a pathway for practicing internists and family practitioners to become certified geriatricians. I seriously doubt physicians will consider this pathway until changes are made which allow them the time required to spend with seniors and to perform a thorough evaluation and to compensate them for their time and expertise.

With our rapidly aging society, our healthcare system must take steps to incentivize more internal medicine physicians to be trained and certified as geriatric specialists.

My Caring and Compassionate Friend Sandy

Whenever I had a patient who suffered a traumatic injury or was suffering severe pain from a chronic arthritic or rheumatologic disease and could not make progress, I called in master physical therapist Sandy. He took individuals who could not find the inner strength to work harder to get better. Through caring, kindness, compassion, professional expertise and experience, Sandy helped them make themselves whole. He never said no to my request to help a patient.

I met him at a local gym and physical therapy center 40 years ago where we were each doing volunteer health care work for public high school students. His warm  beaming smile and  gentle touch encouraged even the most discouraged to try. Over the years I have lost count of how many patients, friends, family members I have asked Sandy to perform his magic with. He always graciously did.

In the summers, Sandy travelled to West Virginia to teach physical therapy students at the University of West Virginia. He loved teaching and being close to family. We talked about his kids and grandkids frequently especially since several lived overseas. As he aged, the complications of his Type ll Diabetes and chronic kidney disease made work much more difficult for him. He retired from active practice and moved back to West Virginia to live out his life a few months ago. 

Sandy passed away in his sleep earlier this month with his wife and family nearby. He will be missed. Thanks, Sandy, for all your help teaching us all about caring, compassion, kindness and expertise.

Measles and My Adult Patients

There has been an outbreak of measles in Broward County in the community of Weston, Florida. The outbreak began in a middle school. Additional outbreaks have been reported in central Florida and now in Chicago, Illinois.

The outbreaks have occurred in non-vaccinated children who were written medical exemptions and allowed to enter the school system unvaccinated. There are no medical guidelines which clarify which medical or immunological conditions, if any, place a recipient in a position that requires them to avoid the two MMR vaccinations 4 weeks apart. There are also “religious exemptions” created by the Florida Legislature for political reasons. I have spoken  to several Rabbis, Iman, Pastors and Priests and there seems to be no religious reason to avoid the MMR vaccine in Judaism, Islam or Christianity.

Measles is a serious viral illness resulting in high fevers, cough, respiratory problems, total body rash, hospitalizations and even death. It is considered the most transmissible airborne viral illness known to medical science. It can result in severe brain damage from encephalitis and has been implicated in a delayed brain injury twenty to thirty years after initial infection. It had been eliminated in the United States. The MMR vaccine (Measles Mumps Rubella) has been administered in two doses to school children since 1957. Those persons born prior to 1957 survived a Measles infection and are felt to have natural immunity.

I have received numerous phone calls from patients born prior to 1957, and those vaccinated after 1957, to ask if they needed an additional vaccine administration. To test for immunity, we perform a blood test which measures the IgG level of antibody against measles or Rubeola. If your titer is too low, and falls below an agreed upon level, that mean your immunity is low and you are a candidate for vaccination.

The test is run by most national labs such as Quest, LabCorp and Bioreference. We can draw the blood in the office at your next scheduled visit. If you have any questions, please call me or the office staff.

Can Vaccinations Be Used as a Weapon Against Alzheimer’s Disease?

In the February 24 , 2024 issue of The Guardian, David Robson discusses the possibility that vaccines stimulate our immune systems to perform better and limit our chances of developing dementia. It is known that in most instances the blood brain barrier prevents most bacteria, viruses and pathogens from crossing over into the brain.

Some neurology experts on dementia believe that the barrier becomes more permeable as we age.  Infectious agents such as viruses and bacteria enter the nervous system and amyloid beta protein is produced to engulf and neutralize these infectious invaders. When we are younger and our immune system is functioning as it evolved to, clean up cells called microglia come along, engulf this protein pathogen contaminant and dispose of it. In older patients it accumulates, entangles neurological cells leading to inflammation and more beta amyloid accumulation and dysfunction. Researchers wondered if the immune system could possibly be activated or tuned up to perform more efficiently and reduce the chance of dementia developing from this infection neutralizing protein accumulation.
   

BCG is a vaccine developed by a physician and a veterinarian to prevent the transmission of bovine tuberculosis. They found a way to isolate the TB pathogen and grow it in a lab. They noticed that with each new generation of their TB material, the disease became less virulent. In 1921, it was tried on a human baby after the child’s mother died of TB and the baby was exposed. That child survived and the scientific finding became the basis for a cheap, easily produced vaccine that saved millions of lives from tuberculosis infection. 

In today’s world BCG is additionally used to treat bladder cancer by instilling it into the bladder. It is felt to stimulate the patients’ immune system to work more efficiently and attack the bladder cancer cells.

The idea that BCG might be used to prevent Alzheimer’s dementia is being looked at by researchers at Hadassah-Hebrew Medical Center in Jerusalem. They looked at their data on 1,371 patients treated for bladder cancer with or without BCG. Of those treated with BCG only, 2.4% developed dementia over the next eight years compared to 8.9% of those not given the BCG.

Marc Weinberg and his team at the Massachusetts General Hospital in Boston have been able to reproduce this data. They believe the risk reduction can be as high as 45%. The randomized controlled studies to examine the question of whether inexpensive BCG can prevent or limit the development of dementia are now being developed.

RSV Vaccine: Where is the Real-World Data?

Respiratory Syncytial Virus (RSV) is a viral pathogen that causes the same number of hospitalizations and deaths as influenza. The complications of infection occur primarily in the elderly, the immunosuppressed and those with chronic respiratory and cardiac conditions. There was no vaccination to prevent this illness until this past fall. AREXVY was approved for adults 60 years of age and older in May 2023 and began being injected into seniors in the fall. ABRYSVO was approved later that month and began being injected into patients as well this past fall.

Based on research  projections, for each one million doses of the RSV vaccine administered, they expected an elimination of about 25,000 physician visits for symptoms and infection, 2,500 hospitalizations and 130 hospital deaths. They additionally expected a reduction in 500 ICU admissions. However, to date, only 22% of the eligible adult population has taken the vaccine so the CDC does not have enough information to judge the vaccines effectiveness yet.

The CDC Advisory Committee on Immunization Practices (ACIP) completed a two-day meeting this last week to discuss the adverse effects, pros and cons of the RSV vaccine program so far. They noted a slight increase in cases of the neurological disease Guillan Barre Syndrome (GBS) with about 10 new cases per one million doses of AREXVY administered and 25 new cases per one million doses of ABRYSVO administered. The initial projections showed an estimate of 5 GBS cases per one million doses of vaccine administered.

Amadea Britton, MD of the ACIP advisory group said, “Due to uncertainty and limitations in the early data, there is currently insufficient evidence to confirm whether RSV vaccination is associated with increased risk for GBS in older adults or to estimate the magnitude of any increase in GBS risk after RSV vaccination.” She went on to say we must each weigh the benefits against the risk, and the benefits appear to outweigh the risks.

The committee did acknowledge that the benefit for healthy seniors, age 60 or older, who do not live in a chronic care facility or have severe cardiac, pulmonary or immunologic suppressive conditions may be far less.

I am still going to wait for more data before encouraging my healthy seniors to take the RSV vaccine. When this information becomes available, I will happily share it with my patients. For those who wish to get the vaccine due to living with pulmonary and chronic medical conditions, I prefer AREXVY at this point.

Brushing Your Teeth Lowers Risk of Acquiring Pneumonia

Patients and health care workers routinely underestimate the importance of practicing excellent dental hygiene habits and their effect on your overall health. Since childhood, parents, teachers, dental hygienists and staff have instructed us to brush after meals and before sleep. In addition to tooth decay, periodontal disease and infections are routinely associated with infections of the heart valves and serious illness.

JAMA Internal Medicine recently published a research paper that explored the relationship between hospitalized patients and hospital-acquired pneumonias. These pneumonias from respiratory equipment and organisms exposed to, and resistant to, many common antibiotics are always considered to be serious and unfortunate complications of treatmentand are even more common in critically ill patients on respirators in intensive care settings.

A recent publication examined whether brushing the teeth of individuals on mechanical ventilation (respirators) once or twice a day would influence their hospital course. The results showed that it reduced the risk of a hospital acquired pneumonia and the length of time required on a respirator. This is a simple enough action to improve the chances of recovery for patients requiring mechanical ventilation to survive. Expect to see the toothbrush used more frequently in ICU settings on these types of patients.

CDC Recommends Spring 2024 COVID Booster for Senior Citizens

The Center for Disease Control and Prevention (CDC) has recommended that senior citizens 65 years of age or older receive a second monovalent COVID vaccine immunization six months after receiving the last one in the fall of 2023.  This recommendation applies to younger individuals who are immunosuppressed as well.  If an individual contracted COVID since taking the last vaccine this past fall they are supposed to wait two months after the last COVID infection to take the vaccine.

The vaccine is needed to prevent severe disease, hospitalization and death. Most of the deaths from COVID in the last six months have occurred in men and women over 65 years of age who are not up to date on COVID vaccinations. Long COVID, a common complication of a COVID infection, is less likely to occur in individuals who are up to date with the vaccine.

The vaccine is being administered at major pharmacies such as CVS, Walgreens and Publix. You can make an appointment for the vaccine on their company websites.