Customer Service Has Disappeared

I write a quarterly newsletter with timely health and medical tips and mail it out to my patients. I have been doing this for 25 years now.

The content is edited by a professional and then the final copy is printed by a firm in Richmond, Virginia and mailed to the patients using first class postage. The addresses come from our office demographics of our existing patients and then those addresses are double checked by the printer using a US Postal Service address data base.

We mailed the summer newsletter from Richmond the third week in June. The last week in June almost 275 of the newsletters arrived back in our office in Boca Raton with a sticker on it saying the mail was “undeliverable addressee unknown.”   We double checked the addresses on all the returned pieces of mail then took them to the Banyan Road branch of the post office. I was told they were not delivered because the addresses were incorrect. I told them the addresses were triple checked and are correct. They told me to see their delivery department across the road, but that office was closed by 4:00 p.m.

The next day my office supervisor took the newsletters to the Delivery Division of the Boca Rio Road Post Office. She was treated brusquely and rudely – being told that the addresses were wrong. She protested and was finally told by the supervisor to remove the undeliverable labels and drop them back in the mail. The next day we dropped them back in the mail, as directed, sending them from three different post offices in the Boca Raton area. Some were delivered but 75 were returned saying they were “undeliverable addressee unknown”. We called those patients to double check the addresses and they were all correct.

I accessed the USPS customer service complaint line and a sympathetic gentleman took the information, provided me with a case number and to date nothing has been done. After two weeks I made a second inquiry and have received no answer.

I then wrote to my Congressman’s Washington office for help. I have heard nothing back. On the same day that I tried to contact my Congressman, I stopped by my local pharmacy to pick up a script for my wife called in by her physician. I used the drive through window. They asked for my driver’s license for ID and I sent it in. They never returned it and I just did not notice that until three days later when I noticed it missing from my wallet.

I retraced my steps and called the pharmacy.  I have been a customer there for 40 years and, as a physician, have sent thousands of prescriptions to them throughout that time.

“Yes”, they had my license and would gladly return it if I stopped by. I recovered my license later that day but wondered why no one from the store bothered to call my home or office to let me know they had my license? These are the same people who tell my patients I never called in their prescription when, in fact, the prescription was called-in hours ago but they have not yet listened to the messages on their system that they direct prescribers to use when phoning in prescriptions.

As the world churns through wars, political and cultural division, and ecologic weather disasters; it seems common decency and going the extra step for the public has disappeared making an already difficult life even more so.

Flu Vaccination May Guard Against Alzheimer’s Dementia

While it is early summer here in North America, most primary care practices have already ordered their influenza vaccine for the fall of 2022. Our practice will be using the “senior” high dose quadrivalent vaccine for patients 65 years of age and older as recommended by the ACIP (American College of Immunization Practices), a division of the CDC.

While experts debate when to administer the vaccine, we prefer to do it between Halloween and Thanksgiving based on when influenza arrives in South Florida and the limited length of protection seniors get from the vaccine. Flu shots can protect against serious infection and hospitalization in most cases.

Avram Bukhbinder, MD, of the University of Texas Medical Center in Houston believes the vaccine also protects seniors against Alzheimer’s disease. His work was published in the Journal of Alzheimer’s Disease recently.

His group looked at almost one million influenza vaccinated adults and compared them over time with a similar sized unvaccinated group of senior citizens 65 years of age or older. The median age was 73.7 years and 57% were women. All were free of dementia over the six year “look back period”.

They followed these groups for 46 months and found the risk of developing Alzheimer’s Disease was 40% lower in the vaccinated group. The paper did not determine why the flu vaccine lowered the risk of developing Alzheimer’s dementia. Dr. Bukhbinder hypothesized that the vaccine may have prevented severe inflammation seen with infection reducing the development of amyloid plaques and neurofibrillary tangles. An official with the Alzheimer’s Association was quick to point out that possibly those who took flu shots were more health conscious leading to less development of Alzheimer’s Disease.

Further research is warranted but this study provides an additional incentive to obtain your flu shot this fall.

Over-the-Counter Bentrio Approved for Allergic Rhinitis

With the warmer weather and outdoor activities comes more exposure to nasal allergy symptoms. This week the FDA approved an over-the-counter nasal barrier spray to combat inhaled nasal allergies. Called Bentrio, it sprays a clay mineral bentonite which is drug-free, preservative free and forms a thin protective gel layer on the nasal mucosa to prevent contact of allergens with nasal cells. If allergens encounter nasal cells, they begin a chain reaction release of chemicals which can trigger an ongoing allergic reaction for up to 14 days.

The product’s mineral bentonite coating was compared to an existing product using hydroxypropyl methylcellulose in protecting against allergic symptoms after exposure to a known pollen. The Bentrio provided similar relief over a four-hour period. Expect to see this product on the counters of US stores this coming fall.

COVID-19 Burnout

I was supposed to be visiting the NY Metropolitan area this week to celebrate a family high school graduation. Children and family were traveling from all over the country for this celebration when the parents of the graduate contracted COVID-19. The graduate stayed healthy and attended the ceremony and all post ceremony celebrations. Our family gathering was postponed, and my wife and I stayed home cancelling our flights and hotel reservations. The infected group were all vaccinated months ago and young, healthy and placed on Paxlovid . They are recovering. The fact that all will recover is what is important in a scene played out in homes across the globe all dealing with COVID and family gatherings.

At the same time this was occurring the FDA approved a Pfizer three-shot vaccine and Moderna two-shot vaccine protocol for COVID for children six months to five years old. It provided great joy in my south Miami daughter’s household since her four-year-old son has been attending pre-school and summer camp with no real protection other than a mask. My grandson has been the only child in his class and group wearing a mask indoors and the school psychologist asked my daughter if he could remove it because it was a barrier to playing with the other children.

The vaccine for young kids is not a foolproof shield but at least provided protection against serious illness. The FDA approval was a great comfort to parents hoping to have their kids vaccinated prior to the start of the next school semester in August. Then, the Governor and Florida Surgeon General announced Florida was not ordering the vaccine because they believed healthy kids did not need it despite all the infectious disease, public health and virology experts reviewing the data and approving the vaccine. Morale fell to a new low.

The very next day the Governor announced that doctors and pharmacies could order the vaccine through the Florida Shots website and had that option all along. That is not the way we ordered the vaccine earlier in the pandemic. We ordered it though the Florida Department of Health.

Supporters of the Governor blamed this ordering confusion on “big government bureaucracy”. If that is the case, then why not just announce from the beginning that pharmacies, doctors and health systems can order the vaccine through the Florida Shots website?

In the political gamesmanship of placing barriers in the way of our youngest and most vulnerable children being vaccinated, did the Governor forget that most physician offices do not have freezers capable of storing the vaccine at -90 degrees Centigrade? Also ignored was the plight of those who have relied on their county or city health department to provide the vaccines for their children for years and now those public health facilities will not have the vaccines.

My office was bombarded this week with calls from patient’s testing positive for COVID-19, all with mild symptoms of fatigue and upper respiratory viral symptoms. The current treatment options are to supply supportive care such as fluids, cough medicine, Tylenol and rest or prescribe the Pfizer pill Paxlovid. The Paxlovid must be started within five days of onset of symptoms.

So many patients walk around with cold symptoms for several days before home testing that it’s difficult to start the medicine within the five day window advised by the manufacturer. Paxlovid interacts with so many popular and common prescription medications for seniors which must be discontinued and washed out of your system prior to starting Paxlovid that they can’t start the medication on time.

The best option, in my opinion, remains receiving an infusion of the monoclonal antibody Bebtolivimab within seven days of onset of symptoms. Boca Raton Regional Hospital has a program that gets you in within a few days but several patients have been so anxious and worried that they would not wait for an appointment. Several called private services to come to their homes and treat them with monoclonal antibodies. These companies have popped up out of nowhere and their reputation and reliability are relatively unknown. Are they really administering Bebtolivimab? At least at the hospital I know the product is the real thing and the monitoring staff is well trained and experienced.

Also, several patients have insisted on Paxlovid and stopped their blood pressure, cholesterol and antidepressant medicines. Two of them took the Paxlovid and improved, then rebounded with a positive test and return of all symptoms several days later. They all recovered in a few days, but the potential rebound is another reason I prefer offering the monoclonal antibody infusion.

I have not mentioned the Merck oral medication Lagevrio ( molnupravir) because it used new technology involving disrupting the genetics of the virus. I would like to see the adverse effects of this drug and its efficacy and safety profile after being on the market for twelve or more months prior to considering it.

COVID remains a “bummer”. We are in a much better place to prevent serious illness than we were three years ago but human behavior, the demonizing of science for political gain and the resilience of this virus continue to wreak havoc on my life and those around me.

Ashwagandha Improves Quality and Duration of Sleep

The American Academy of Sleep Medicine and the Sleep Research Society held their 2022 annual meeting earlier this month and researchers presented data on the use of the shrub Ashwagandha on sleep quality and duration.

The researchers found eight studies on the topic including one which showed that after 10 weeks of therapy it took less time to fall asleep than with a placebo. Another study demonstrated “significant improvement in both quality and duration of sleep with patients experiencing an improved mood upon awakening”.

The Ashwagandha plant is native to India but is now grown worldwide and used for “stress resilience”. It is revered in Ayurvedic medicine and felt to reduce stress. The product is used to treat arthritis and treat anemia since it is high in iron. Ashwagandha is also known as Indian Ginseng, winter cherry or poison gooseberry.

Like most alternative and complimentary products, there is limited data on the product in the English research literature. Ashwagandha can cause gastrointestinal upset, nausea, vomiting and diarrhea at higher doses. It should not be ingested by children or pregnant or nursing women. There is data that it interferes with normal thyroid blood tests and should not be taken with sedatives, blood thinners or thyroid medications.

One of the major criticisms of herbal medicines in general is that they are not inspected or regulated by the FDA for purity and safety. The label often does not reflect the contents of the bottle and there are often undesirable contaminants. For this reason, I only recommend products inspected by the independent USP lab.

Ashwagandha, inspected by the USP lab is available in the USA. With insomnia being such a large problem, this product is worth thinking about.

Tirzepatide For Weight Loss

Eli Lilly product Tirzepatide recently completed a Phase III trial called SURMOUNT-1 during which overweight participants taking the once weekly 15 mg injection lost an average of 52 lbs. or 22.5% of their body weight. The drug also comes in a 5 mg dosage which produced an average 35 lb. weight loss and a 10 mg dosage which produced an average 49 lb. weight loss.

The SURMOUNT-1 study was comprised of 2,539 overweight or obese adults who had at least one other co-morbid health risk factor, but were not Type II Diabetics, including hypertension, heart disease, elevated lipids and obstructive sleep apnea. The drug was added to a reduced calorie diet and an exercise regimen. They initially received 2.5mg once a week for four weeks and then gradually increased the dosage. The study ran for 72 weeks. Those patients with prediabetes were allowed to remain in the program for an additional 104 weeks.

The major side effects were all related to the gastrointestinal tract including nausea, vomiting and diarrhea. The higher dosages produced more adverse effects. The drug outperformed Ozempic or Wegovy in head to head tests including weight loss and reduction in hemoglobin A1C. The price of the drug may be the most adverse effect costing just under $1,000 a month retail. Eli Lilly has a program for those in need to reduce the price to $25 a week.

This adds another successful weight loss medication to the field now dominated by Semaglutide drugs.

Guns and Controlled Substances

My elderly cognitively impaired patient fell at home hitting her face, jaw and left side on the corner of a cabinet. Her entire face was bloodied, and black and blue, with the bridge of her nose the only pink normal skin remaining. Her left flank was a deep purple covering four broken ribs and blood in the pleural space. Her hands and fingers were purple bilaterally. The ER sent her home without pain medication so her son called me for help.

First, I went to her medication list on my computer and researched several options for drug/drug interactions. This took a few minutes. Then I was required to access EFORSCE, the state of Florida narcotic dispensing documentation website. Failure to do so in advance of prescribing a narcotic controlled substance is a $10,000 fine and possible loss of my DEA prescribing license. I am no longer permitted by Florida law to phone in the prescription to the patient’s pharmacy. I now have to access their chart online in my cloud-based electronic health record.

I type in the medication, dosage, number of pills and instructions for taking the medication – plus refills. I have to indicate if the prescription is for “acute pain” which allows for a three-day supply or for chronic pain. I then have to look up their pharmacy’s online electronic number, enter it and hit send (I can store that number in the system for future use).

A new screen appears asking me to log in to “Mobile Pass”. I enter a User ID and Password and then a number appears on an app loaded to my smartphone. I have 30 seconds to enter that six-digit number and hit send. The process takes 5-7 minutes per prescription. No one on my office staff is permitted to do this for me.

The last controlled substance pain prescription I sent in resulted in a message that the system was not recognizing my credentials. I repeated the process and was successful the second time.

The prescription process occurred on the same day as the tragic school murders in Uvalde, Texas. I was so frustrated at the carnage, and so frustrated by my own ineptness in using the technology drafted by Florida’s State Legislature to prescribe needed medication for an injured patient, that I decided to see how long it would take me to purchase an automatic pistol with magazines of ammunition allowing me to fire multiple rounds per minute. I used Google to look it up and filled it all out in under two minutes. If I decided to use curbside service, I could pick up my weapon and ammunition in less time than it took me to prescribe Percocet for an injured victim. I don’t think our Founding Father’s meant for it to happen this way when they wrote the Second Amendment.

Treating Sepsis and the Role of Vitamin C in Patient Outcomes

Vitamin C and its relationship to the immune system and infection have been the subject of studies for years. In the past, I have written about the protective effects of Vitamin C exhibited in Scandinavian winter athletes and military troops who took a supplement daily. They developed fewer “colds” of a less severe nature than the control group who did not. Surprisingly, if Vitamin C was added once a participant showed symptoms of a cold or viral infection it did not have the same protective benefits.

The relationship between Vitamin C and severe infection came up again discussed in an abstract presented at the American Thoracic Society 2022 International Conference held this past May . Researchers looked at whether its addition to patients being treated for sepsis would be beneficial.

The researchers conducted a systemic review of PubMed, Embase and Central Cochran’s Registry and found 21 studies in which Vitamin C was introduced to patients with sepsis. They found that when Vitamin C was added to the treatment of sepsis either orally or intravenously there was a significant reduction in mortality and less need for interventions such as intubation and mechanical ventilation use of vasopressors to support blood pressure. The theory is that Vitamin C may reduce proinflammatory bio markers in severe sepsis and normalize physiologic function which in other cases might have led to an exaggerated immune response and the destruction of multiple organ systems.

Vitamin C is fairly inexpensive and is plentiful in fruits. Starting your day with an orange or a grapefruit just might be preventing infection down the road.

Coffee With or Without Sugar Reduces UK Mortality

In a nation where tea is the primary warm beverage, Chen Mao, MD, of Southern Medical University in Guangzhou, China published an article in the Annals of Internal Medicine regarding the benefits of coffee consumption in the United Kingdom. The researchers accessed seven years of data from The UK Biobank, an ongoing compilation of health data.

The study followed 171,616 UK Biobank participants who did not have cardiovascular disease or cancer when the study began. These were adults with a mean age of 55.6 years. They completed an annual questionnaire which included questions about their frequency of coffee drinking and how many teaspoons of sugar, if any, they added. Mortality data was obtained from death certificates.

Almost 76% of the participants were coffee drinkers. Just over 55 percent drank unsweetened coffee, 14.3% added a teaspoon of sugar and 6.1 % used artificial sweeteners. The groups were followed for a median of seven years during which 3,177 deaths occurred including 1,725 malignancy related deaths and 628 cardiovascular deaths.

Individuals who drank 1 – 3.5 cups of coffee per day either plain or unsweetened were about 30% less likely to die of any cause during the study period. This benefit did not extend to those who added artificial sweeteners to their coffee.

The message from this study is clear. Coffee, in moderation, is probably not harmful and may be protective. Adding a teaspoon of sugar doesn’t hurt much in terms of mortality. Keep in mind, this study looked at adding a teaspoon of sugar or about 4 grams of sugar. The average coffee shop flavored coffee has about four or more times that amount of sugar per cup.

In other coffee related studies, drinking coffee in moderation has shown benefit in maintaining brain volume and slowing cognitive decline.

Antioxidants & Dementia Risk – A New Study in Neurology

May A. Beydoun, PhD, MPH of the National Institute on Aging of the NIH in Bethesda, Maryland and associates published a study on blood antioxidant levels, food consumed and the risk of developing dementia as you aged. The study hoped to determine which foods were best to eat to limit your chances of developing cognitive impairment in later years. The researchers discovered that those individuals with the highest serum levels of lutein+ zeaxanthin and beta-cryptoxanthin at baseline were less likely to develop dementia decades later than their peers with lower levels of these protective antioxidants.

Lutein and zeaxanthin are found in green leafy vegetables such as kale, spinach, broccoli, and peas. Beta -cryptoxanthin is found in fruits such as oranges, papaya, tangerines, and persimmons. “Antioxidants may help protect the brain form oxidative stress, which can cause cell damage,” said lead author Dr. Beydoun.

The study, published in the journal Neurology analyzed 7,283 participants in the 3rd National Health and Nutrition Examination Survey who were at least 45 years old at the start of the study and were then followed for 16-17 years. The data showed the higher the serum levels of beta-cryptoxanthin at baseline the lower the risk of developing dementia. No such protection was found for lycopene, alpha-carotene, beta carotene or Vitamins A, C, or E.

This was an observational study looking at data already collected. In critiquing the study, Dr B. Hooshmand, MD, PhD and Milia Kiviipelto, MD, PhD of the Karolinska Institute, Stockholm, Sweden commented on the research noting that this was an observational study and previous studies supplementing individuals with antioxidants were disappointing and did not prevent development of cognitive dysfunction. They believe there is a more complex relationship between the foods we eat, antioxidants, socioeconomic status and lifestyle which all contribute to the development of dementia.

While there is work to be done in this field, this study certainly supported my love for a fresh orange or tangerine to start off the day. The accompanying editorial made it clear that consuming my antioxidants and vitamins in fresh fruit and produce seems to be healthier than depending on store purchased supplements.