The Flu Shot Lowers Stroke Risk. It’s Time to Schedule Yours.

Fall is just around the corner and its time to start scheduling your flu shot. This season we have the high dose quadrivalent vaccine for people 65 years of age or older and the Quadrivalent for those younger than 65 years of age. The vaccine takes about two weeks to provide full immunity and will reduce your chance of catching the illness.  Most importantly, it will prevent serious illness requiring hospitalization and or death. Last year influenza caused almost 45,000 deaths in the USA.

The vaccine is being given in our office. My patients should call 561.368.0191 to schedule the flu shot. You can take this vaccine at the same time as the new Omicron specific booster and near that vaccine which is being given at local pharmacies including CVS and Walgreens.

The journal Neurology published a peer reviewed article that examined whether getting a flu shot provided any additional protection beyond preventing the flu  The study, led by Francisco Jose de Abajo, MD, MPH, PhD of the University of Alcala in Madrid Spain, showed that the flu vaccine reduced the risk of stroke by 12% in those who had risk factors for cerebrovascular or cardiovascular disease. The study noted the protection began within two weeks of receiving the vaccine for both patients with cerebrovascular risk factors regardless of age.

Another study published several weeks ago noted that the risk of dementia was diminished in those patients receiving the flu shot as well.

Flu season is here. Please call the office and schedule your vaccine.

Bisphosphonates, Prolia & Forteo in Osteoporosis Treatment

When I started practicing clinical medicine in South Florida there were few if any treatments for osteoporosis. We saw the devastating effects of this condition in lean post-menopausal women in their seventies and eighties – especially those who had multiple pregnancies and smoked. In men we were more likely to see it in male smokers taking corticosteroids for an inflammatory disease.

Spontaneous collapse of their vertebrae leading to nerve compressions, brutal unrelenting pain and at times neuromuscular injuries preventing walking were common. If we measured height, we saw a decrease in height over time before these catastrophic spinal injuries occurred. We also saw a plethora of spontaneous hip fractures which occurred causing a fall with trauma. In most cases, both presentations resulted in major and extensive surgery and rehabilitation before a patient resumed their life. The only medications we had at the time for women were estrogen and progesterone which carried their own list of potential adverse effects.

The introduction of oral bisphosphonates changed that. Medications like Fosamax, Actonel, Boniva slowed down the process and, with weight bearing exercise, smoking cessation, appropriate nutrition, and luck, reversed it. These medications in pill form were tough to take and still are. They are large, poorly absorbable and require you to take them on an empty stomach while upright. Most instructions call for drinking eight ounces of water with the pill followed by another eight ounces of water after the pill then staying upright for 30-60 minutes. These pills are extremely corrosive if they get caught in your esophagus because you didn’t swallow them with water. They can upset the gastric lining of your stomach as well.

Bone Densitometry tests allowed physicians to detect and then follow serially over years the thickness of your bones. I believe due to the size of the pills and the gastrointestinal problems they can cause convincing patients to try these medications has always been a difficult prospect. Fortunately, much of the responsibility falls on the gynecologists who look for osteoporosis and osteopenia as part of their evaluation of perimenopausal women routinely.

For those individuals unable to tolerate these oral medications, or unwilling to try, rheumatologists have injectables to help the bones. Prolia (denosumab) an injectable given every six months, and Forteo, (teriparatide) a daily injectable, were developed. They too can produce side effects including back and bone pain and a host of others. The good news is they work.

In a recent study of 50,862 women published in the journal Therapeutic Advances in Musculoskeletal Diseases researchers from the University of Verona, Italy led by Giovanni Adami, found that the oral medications can reduce the risk of fracture by 30% while monthly Prolia did so by 60% and daily Forteo by 90%. The significant difference was the fact that the oral agents required one year of use before the risk of a spontaneous fracture occurred while the injectables achieved success much sooner. While rheumatologists and gynecologists surmised this was occurring, this study provides solid evidence to back up their hunches.

Take Your BP Medications Anytime You Choose To!

Two years ago, a large study called HYGIA concluded that taking your blood pressure medications at night resulted in fewer heart attacks and strokes and less death from those issues. The accompanying editorials and comments suggested that most heart attacks and strokes occurred in the early morning and the nighttime dosage helped prevent that.

As a clinician seeing patients during the COVID-19 Pandemic, I do not remember much objection to that study. As a result of it, I switched the time of my own BP meds from the morning to bedtime.

There was concern at the time that if you took your BP meds in the evening and awoke to void you might be more susceptible to falls. At about the same time, research appeared that showed that most combinations of BP medications lowered your BP but a second-generation calcium blocker, and ARB/ACEI, reduced mortality as well. I started prescribing amlodipine and losartan at bedtime and took it myself.

Many hypertension and cardiology researchers disagreed with the results, methods, and conclusions of this study. So they undertook the TIME study. 21,000 patients with high blood pressure who were assigned to take their medications in the morning or evening. The average patient age was 65 with a fair representation of diabetics, cigarette smokers (4%) and cardiovascular disease. They were followed for a median of 5.2 years with some for 9 years.

The results showed that it did not make a difference if your blood pressure was controlled, and you took the medication in the morning or the evening. There were no more cardiovascular events or cerebrovascular events in morning medication takers compared to evening medication takers. The results were contradictory to the HYGIA study.

I take two blood pressure medications. I will now take one pill in the morning and one pill at bedtime. I am sure this issue will be studied again. Until that is done, and the results are in, my advice is just remember to take your blood pressure medications every day as prescribed by your physician.

Our Pug Gigi – True Love, True Grit

We euthanized our rescue Pug Gigi last week. She joined our family five years ago, probably coming from a puppy mill. She was abandoned and left to die in an empty building where she stood at the window and barked until someone finally noticed.

Gigi was fostered by South Florida Pug Rescue and medically treated and rehabilitated. No one knows how old she was. After losing our original Pug to old age, we decided to bring some love to an animal that needed it and to provide our sweet older mixed breed dog Chloe with a friend.

On her first visit in our home, she walked over to a straw basket filled with dog toys and pulled out a squeaky toy and had great fun tossing it around and chasing it. The representative of Pug Rescue said she never had a toy and this was her first. We allowed her to take it with her back to her foster home after the first introductory visit.

The process of adopting a dog is quite lengthy and difficult. There is a home inspection. You fill out an application and need two citizens and a vet to vouch for you. In Gigi’s case, they were concerned about her kidney function. Being a physician, and reviewing their lab data, I was not the least bit concerned, nor were my consulting kidney specialists who reviewed the data with me.

We fought to adopt Gigi and won. Pug Rescue said she was gruff and not very affectionate. It took about 48 hours of play, food, long walks and petting for this formerly abused dog to trot up to my wife and I and I and cuddle and lick our hands. She returned our love, caring and attention in multiples.

We hired a professional trainer to help us teach her obedience and after a few weeks we noticed she stopped jumping onto and off of the furniture, which she was not supposed to be on in the first place. Several weeks later a neighbor noticed she was walking awkwardly having difficulty placing her rear paw. A trip to our vet and a consult to a neurologist disclosed that she had the doggie equivalent of Lou Gehrig’s disease. Genetic testing through the American Kennel Club confirmed that she had both genes for a degenerative neurological myelopathy with a prognosis of 1-2 years. The disease produced no pain, just a gradual loss of muscle function starting in the legs and moving forward. Eventually the respiratory muscles stopped functioning.

My wife and I talked about the poor animal’s horrible luck and decided to make her time on this earth as good as possible. We constructed ramps to make access easier. We did daily physical therapy. Having a swimming pool, we set aside an hour for her to swim most days. When the weather turned cold, we put her in a doggie wetsuit with her name on it and went swimming despite the cold.

Gigi thrived but her muscles continued to get weaker. First, the back legs stopped working. The tail stopped wagging. I had to support her rear on walks and make sure her rear paws were high enough off ground to prevent them from knuckling under and scraping away the skin.

For almost three years we followed this daily schedule of long walks with two dogs and me supporting Gigi’s rear followed by a trip to the pool for more exercises. It reached a point where Gigi’s only real freedom occurred in the pool when I allowed her to swim where she wanted to when she wanted to.

Throughout this process she was pain free, with a great appetite and a love for being with the family. There were some hurdles. She had a stroke a year and a half ago during a hurricane. Her paralysis resolved with exercise. She had several of urine infections too.

When her front paws started to decline, and she started having difficulty swallowing without aspirating, I knew her days were numbered. Despite this we took her and our other sweet puppy on a three-week driving vacation to visit family up and down the east coast of America. Both dogs behaved well.

Upon our return home I tried to renew our pool exercises. Poor Gigi lost her ability to stay buoyant and lost the strength in her front legs to propel herself. Her gag reflex started to decline, and meals sometimes went down the wrong pipe causing coughing. I thickened her meals like we would for a senior citizen and hand fed her. Then, last week, her front legs gave out despite me holding them up. She cracked a nail on her front paw, dropped her chin to the ground and scraped it on the pavement. I took her home, stopped the bleeding, cleaned and dressed the wounds and consulted my wife about her deterioration. It was time to end her battle before she suffered.

We called our vet and took both dogs to his clinic and put Gigi to sleep. As the vet injected a tranquilizer into her she found the strength to lift her head and lick my face with several kisses.

In my profession, I deal with life and death daily. I counsel patients and families on end-of-life issues routinely. You stay a bit detached and objective and professional. When the loss is yours, the grief sits like a basketball in your throat and chest.

We were blessed to be able to provide a loving home for five years to a creature who knew no love or care before entering our home. Despite a genetic degenerative illness, we improvised ways to give this puppy a high quality of life for far longer than the experts predicted. Those facts don’t make the sadness and loss any easier to bear. We miss her and she will always be in our hearts.

NSAIDS and Heart Failure in Type II Diabetics

The European Society of Cardiology is receiving a presentation on the increased risk of heart failure occurring in Type II Diabetics over the age of 65 years with an elevated HgbA1C level. The mechanism of the heart failure is still under discussion and being researched and it is believed to be beyond the accepted increased retention of fluid that occurs when you take an oral NSAID. The risk of developing heart failure was increased by almost 50% in Type II Diabetics 65 years of age or older. It was clearly not seen in patients with a normal HgbA1C younger than 65 years of age.

The study was led by Anders Halt, MD, a cardiologist and epidemiologist, who accessed the Danish National Health Registry to obtain his raw data. In his study it was clear that older age and elevated HgbA1C were present in those patients developing heart failure and requiring treatment and/or hospitalization. In Denmark patients were using Diclofenac Sodium and Ibuprofen primarily with few using celexocab or naproxen products.

As we age, we develop joint inflammation and aches and pains that make us reach for an over-the-counter anti-inflammatory medication frequently. This study raises the question clearly “If you are a Type II diabetic over sixty-five years of age with poorly controlled sugars should you be looking elsewhere than NSAIDs for relief”. Diclofenac sodium is no longer in oral form in the USA, but ibuprofen certainly is. The study clearly outlines the need for exploration of the mechanism of the heart failure. I believe the reason heart failure occurs must be clarified but until that occurs older Type II diabetics should be wary of reaching for an NSAID for relief of aches and pains.

Pre-Workout Caffeine and Energy Drinks May Be Detrimental to Your Health

Medical Bag, an online medical journal, looked at the practice of consuming high quantities of caffeine containing energy drinks before exercising or entering a competition and its effects on your health and performance. They followed their review of the recommendations of the European Association of Preventive Cardiology and the World Health Organization positions against consuming these drinks prior to exercise.

It was noted that in addition to elevated levels of caffeine these drinks contain taurine and glucuronolactone which can have a negative effect as well.  The high doses of caffeine may alter your susceptibility to lethal cardiac arrythmias by prolonging your QTc interval on your EKG. They also adversely alter the function of your endothelial cells which line our blood vessels and prevent random clotting within these vessels. They cite a 2019 study by Shah et al which looked at 2 popular energy drinks consumed before vigorous exercise and compared to consumption of a placebo resulting in the energy drinks prolonging the QTc intervals. This may cause arrythmias in individuals with healthy hearts but is much more likely to cause them in individuals with non-diagnosed heart issues. The caffeine and additives also contribute routinely to elevation of your systolic and diastolic blood pressure with vigorous exercise.

The energy drinks have become popular in the USA based on small studies that hinted that caffeine enhances one’s performance. The small sample size and design of the studies did not warrant that conclusion.

Energy drinks are relatively unregulated in the United States and are treated as a food not a medication.  It is far safer to hydrate with water or an electrolyte rich sports drink than a highly caffeinated beverage prior to vigorous exercise or athletic competition.

Practicing Adult Primary Care Requires Time

In September of 1979, the American Board of Internal Medicine awarded me “Board Certification in Internal Medicine” after I completed their training and testing requirements. In 2002, I took the board certification exam in the newly created specialty of Geriatrics and passed it. I answer to the titles of “Doctor,” “ Geriatrician,” “physician”. However, CMS and private health insurers instead lump me, and other medical doctors, into the broad category of “provider”. The term “ provider” is both insulting and demeaning since what I do in general internal medicine/ geriatrics is different than what a physician’s assistant or nurse practitioner does and involves several more years of schooling as well as observed and critiqued training.

Insurers added insult to injury by stripping me of my internal medicine designation and lumping me in with family practitioners, pediatricians and obstetricians. Those are all unique specialties with their own rigorous training requirements and post training testing. They too deserve to be recognized by name for their accomplishments. But how they practice medicine and how I practice medicine are not one in the same.

I bring this up as an introduction to a research paper published in the Journal of Internal Medicine that performed time/work studies and determined that to perform the preventive care, chronic issue care, acute problem care and administrative duties, when caring for 2,500 patients, a physician would have to work 26.7 hour per days. If you provided that physician with qualified support staff, and created a care team, you could reduce the required time to 9.7 hours a day.

Ten-hour workdays are long by anyone’s standards and the article didn’t specify whether the primary care provider was limited to outpatient office work or included caring for their hospitalized patients as well. At best, this team-based approach ensures that the patient spends less time face to face with their actual physician which, in my opinion, is not a positive step.

The paper cited the example of vaccinations and immunizations being something best handled by lesser trained team members and, providing patients access to educational reading material. Once again, I have no problem with trained staff administering vaccinations but as you have seen with the corona virus pandemic and monkey pox outbreak, patients have many questions about materials injected into their body and they want to speak to a physician.

As an alternative to teams seeing patients, the authors mentioned “direct pay practices” which keep their patient load to 1000 or less, charge a monthly administrative fee and only accept cash for services rendered. I propose even smaller panels of 500 patients with insurers and CMS covering the costs of membership.

Studies sponsored by a large concierge medicine franchise program, have shown that they reduce their patients’ hospitalizations, meet preventive guidelines and ultimately save CMS and private insurers money. As an independent concierge medicine physician for 18 years, I have seen similar results limiting the number of patients I care for to 400 and giving them time, availability and advocacy with a focus on prevention.

By practicing in the concierge medicine model, you retain your patients long term and develop strong relationships with them. Also, you learn quickly that taking care of fewer people, and the relationships you establish with them,  is extremely satisfying and rewarding – something which will attract future doctors to these types of practices.

The current system does not work. Independent internists found a solution 20-years ago called concierge medicine. It’s time to give that model a try. It would save private insurers and CMS hundreds of millions of dollars per year resulting from a focus on prevention and reducing costly ER visits and hospitalizations.  For employers, it would reduce absenteeism and presenteeism, improve productivity and serve as a terrific health benefit.

More on Polio & the Breakthrough Population

In a previous blog post, I pointed out that there is a case of polio in Rockland County, NY in the orthodox Jewish population. Additionally, Public Health officials have detected polio virus in the wastewater of Rockland County, Orange County and NYC . They suspect that there must be at least 100 asymptomatic patients in that population as well. Certain facts must be clarified regarding the previous blog post.

Prior to polio vaccination, the world was dealing with the wild polio virus . It was transmitted through the fecal oral route. Paralysis and life-threatening illness occurred in 1 out of 200 patients infected. Most individuals did not even know they had it.

With funding and support from the March of Dimes, Jonas Salk, MD , invented the polio vaccine in injectable form. If you received a polio injection you could not transmit the virus to the unvaccinated.

Several years later the oral Saban vaccine was developed. You took this live attenuated virus prep orally – usually on a sugar cube. Since the natural transmission of polio was by the fecal oral route, the Saban oral vaccine produced a better level of immunity but additionally led to shedding of the virus with the potential to infect unvaccinated patients. At the time this was considered advantageous leading to more immunized patients but, as rare symptomatic cases of polio developed from the vaccine, authorities switched back to an injectable vaccine in the USA. The rest of the world did not necessarily follow suit and continued to use the less expensive live attenuated oral vaccine.

The case in Rockland County is felt to be the result of patient exposure to someone shedding the polio virus from an oral vaccination overseas. If that individual had been vaccinated against polio, they would not have contracted the disease and be shedding virus to others.

In an interesting opinion article in the NY Times, Editorial Board Member Jean Interlandi forwards the argument that lack of vaccination is not a religious issue . She has worked extensively with the orthodox community promoting public health issues and believes it is the young mothers and women who need to be educated and encouraged to vaccinate their children, not the rabbi’s who lead the community.

Ms. Interlandi may be correct but local authorities and politicians have made it far too easy for this group of individuals to ignore public health recommendations and reintroduce measles and its complications, whooping cough and now polio. Offering a carrot rather than a stick may be her best advice but, in my opinion, using both options is long overdue.

Health officials agree that if you are vaccinated you are protected against this non wild form of the virus. The solution is to vaccinate the children of Rockland and Orange County against these once eradicated diseases and allow this religious minority to worship as they please if their actions do not bring risk to the rest of the general population. At this time there are no recommendations for polio boosters in adults, immunosuppressed or the elderly populations.

On the Road Home

When I last checked in we were on our daughter’s farm in Fleischmann’s, NY. Cool morning temperatures in the low fifties were a wonderful change of pace from Florida’ s heat and humidity. This was peaceful, quiet, green and serene. It was wonderful to spend time with family and to relax in the true peace and quiet of the Catskills region.

We spent several days there before heading out on winding mountain roads to Buck Hills Falls, Pennsylvania where The Dow Jones firm developed a former Quaker property for their executives. They built individual “cottages” purchased by executives with enough room to fit at least four of my Boca Raton sized home inside each cottage. There was an inn for lesser employees to visit and vacation, but it burned to the ground and has not been rebuilt. Three golf courses, a tennis complex, equestrian stables, corrals, a children’s day camp, lawn bowling and resort size community pool provide the outdoor amenities for residents and the few lucky seasonal renters.

My brother and sister-in-law rented a home for the summer which did not permit pets inside, so we rented an AirBNB home nearby. We dined on their deck each night watching the large August full moon and a meteor shower while enjoying sweater and sweatshirt weather. Spending time with our family while helping plan our nephew’s wedding scheduled next summer, and bemoaning our beloved NY Yankees major slump, occupied our time. I wish I had planned more time with my brother, but it was time to head south.

Our adult children were adamant that we keep the driving to five or fewer hours. Our next stop was a bed and breakfast on a working farm in Fairfield, Virginia. It was “pet friendly” and five hours southwest. Their advertising “app” and email instructions were clear check in arrival was 4-7PM. The owner proprietors texted us the morning before our arrival asking when we expected to arrive. We estimated between 5-6PM. We stopped every few hours to walk the dogs and use the rest room. Major truck accidents slowed down every leg of our trip.

We arrived at 5:45PM only to learn the hosts had left for a concert and we were left an instruction letter and room key. We expected to be in a first-floor facility separate from the main inn. We were instead on the second floor of the main house accessing our accommodation by climbing a wood lumber steep exterior staircase. Carrying our luggage and a paralyzed pooch up and down the steps was great exercise and the equivalent of a cardiac stress test. The staircase was so steep that our three-year-old dog was afraid to climb or descend on it.

The property was breathtaking in the Shenandoah Valley surrounded by mountains. horses, chickens, fruit and vegetable gardens and hummingbirds. Young deer, rabbits and foxes were abundant and visible just as they had been at our stops in Maryland, Berkeley Heights, New Jersey, upstate NY and Pennsylvania.

There were no food provisions or dinners or lunch available on the property . With no one to greet us we were on our own with Waze to guide us on poorly marked northern Virginia country roads. We found Frankie’s Pizza and dined on pizza and beer on our second-floor deck one night and hoagies the next.

We met our host and hostess the next morning at a sumptuous breakfast made with eggs, cheeses, butter, vegetables from their farm . The breakfast was luscious. Before arriving, we received strict written instructions to keep visiting pets off the deck, so we left the dogs in the room. When we finished introductions prior to being seated for breakfast, the hostess asked us to bring the dogs down.

As I carried Gigi down, she had a rare urinary accident on the wood deck outside. I offered to clean it up but instead received a stern lecture on the value of the items in each room and their concern about them being ruined by an incontinent dog . I was charged a daily pet cleaning fee in advance and signed a pet form guaranteeing responsibility for any damage as well upon arrival.

We were meticulous inside our accommodations at every stop with the older dog wearing two diapers lying on a waterproof mat placed on a waterproof doggie bed. I suggested she list her property as “pets tolerated” rather than pet friendly . It was the only negative incident over the course of the trip. This bed and breakfast is well worth relaxing at without pets or young children. The host and hostess were actually quite nice once you spent time with them, so we chose to overlook the previous days harsh lecture.

After two nights we drove south six hours to Asheville , North Carolina. The drive on I81 south then 26 east took us into Tennessee and through the mountains. I have been to Big Sur, the Pacific Coast Highway and the Amalfi Coast all wondrous and dramatic. The Tennessee mountains were far greener and more beautiful than anything I had ever seen.

Asheville reminded me of Boulder, Colorado or Venice, California with wealthy long haired seniors and street people. It was a great outdoors activity, sit outside and drink a beer from a microbrewery type of town. We were down the block from the Biltmore Estate and the Mission Hospital complex, a huge medical center I had never heard of. Patients from the south used it as a referral Center of Excellence.

With trendy stores, restaurants, pubs and activities I learned firsthand why it has become a retirement and vacation hub. I understood the allure of Asheville but it was not our cup of tea.

Our next stop on the trip south was Jekyll Island, Georgia. Beautiful natural beaches, with protected dunes and limited development made it a unique beach town. Inclement weather induced us to leave a day earlier for the six-hour drive home.

As we pulled into our residential community I was struck by how pretty and well maintained it was. Traveling up and down the east coast I saw impressive residential areas, but I still love my neighborhood.

Despite the divisiveness in the nation, most people we met were polite, civil and warm. We wore N95 masks when indoors in public places and most shopkeepers asked us if we wanted them to don a mask when we approached them. We refrained from asking them to put on a mask.

The vacation was long overdue and certainly recharged my battery. But it’s always good to be home.

Posture Makes a Difference in Pill Time to Action

Engineers at the Johns Hopkins School of Engineering have been creating models of human organs to investigate the way to make them most efficient. Recently they used an artificial human stomach to determine if our position at the time of swallowing a pill makes a difference in the time until onset of action of the medication. Most experts agree that oral medication doesn’t start to work until the material leaves the stomach and moves to the small intestine. For prime efficiency you want the pills to land in the distal portion of the stomach or antrum. You can achieve this by lying on your right side.

Their studies, published in Physics of Fluids, showed that dissolution was quicker by lying on your right side. Your left side was significantly slower. Being upright fell somewhere in between being on your right or left side. They showed that a person lying on their left side took almost 23 minutes for the material to dissolve and leave the stomach while that time was only 10 minutes on the right side. For patients with diabetic gastroparesis, or Parkinson’s disease, these positional differences may be even more significant.

As a physician prescribing medication for years, I never considered position an issue. Now when I get my headache and want quicker resolution, I will try the different positions and see if it makes a difference.