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.

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.

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.

Polio is Back

One case of polio with neurological complications has been detected in Rockland County , NY. The virus is now present in the wastewater of NYC , Rockland and Orange Counties. Public health authorities believe there are 100 or more cases in that area with symptoms not yet present but the infected shedding the virus.

The disease was detected in a population of ultra-orthodox Jewish residents who do not believe in vaccinations. Statistics released today show that less than 60% of the eligible children in those two counties have been vaccinated against polio. With the disease now being found in the wastewater of NYC, Public Health authorities are considering giving boosters to children ,the immunosuppressed and the elderly. Those decisions are pending.

I remember polio. My friend’s older siblings died from polio. My best friend’s older sister wore a brace on her leg and used a crutch to walk. My maternal grandmother’s best friend caught polio while pregnant. She survived it but we sat with her thirty something daughter born with no legs on the beach daily in the summers. We had crude elementary school level jokes about the disease. “Johnny i see you brought your father’s iron lung to school today for show and tell. What did he have to say about it?” Johnny answered, “ Uggggh”.

I remember the excitement when we received a notice from P.S. 253 that the NYC Public Health Department was going to vaccinate all elementary school children against polio. We lined up in the gym excited to be vaccinated with a shot in the arm. There was no discussion of long-term adverse effects of the vaccine. There was no talk about how effective the shot would be.

When my brother and I became ill that winter with fever and viral illness no one contemplated whether this was a breakthrough case of polio with no neurological consequences or death due to vaccination. We did not have the technology available to determine that anyway. We just knew we would not end up paralyzed, on an iron lung for life or die from polio.

As an adult I have spent years defending the right of religious groups to practice their religion in the privacy of their homes and communities. Isn’t that what America is supposed to be all about?

Growing up in a beachside residential community on the tip of Coney Island called Sea Gate, I witnessed this same community rent and purchase dilapidated multi dwelling structures and use them as summer retreats at the beach . I defended their rights to their privacy despite the fact that if I went out to wash and clean the car after sundown on Friday evening I would be verbally abused or even have objects thrown at me for disturbing their view of the Sabbath.

I still support their right to worship as they please, but not at the expense of violating reasonable public health vaccination recommendations which puts the general population at risk. Their community now has a voting bloc and financial strength to prevent the local enforcement of vaccination mandates. If G-D didn’t want humans to develop medications against dreaded diseases, then it would not have happened.

It’s long since overdue for public officials and health officials in NY City and State to charge these individuals with child abuse, throw them and any leaders who support them in jail and make it clear that if they want their rights to live and pray in peace in the community, they need to start thinking about more than just themselves.

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.

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.

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.