Flu Activity at Its Local Height. Flu Shot Effectiveness Set at 48%.

The most recent epidemiologic data from the Center for Disease Control states that this year’s flu shots reduced a patients chance of catching the flu by 48% compared to no vaccine at all. The party line is that those individuals who were vaccinated and still contract Influenza A or B get a milder version. In this week’s Morbidity and Mortality Weekly Report, Brandon Flannery, PhD, of the CDC and associates believe the flu vaccine is about 43% effective against influenza A and 73% versus Influenza B. Most flu infections this season have been caused by Influenza A (H3N2). This particular virus has the ability to change its genetic composition frequently thus making updates to vaccines necessary more frequently than current manufacturing methods can accommodate.

We are heading into the peak weeks of Influenza A infection in Palm Beach County, Florida. Individuals with flu and upper respiratory tract infection type symptoms should see their doctor. An Influenza Nasal swab test can determine if you have the flu. It takes about fifteen minutes to learn the test result after obtaining a nasal swab. If you have the flu we can place you on a dose of Tamiflu to cut the duration and symptom spectrum of the infection. We can also recommend a ten day course for family members and intimate partners as an effective prevention against the disease. Call the office if you have any questions.

Zika Update

Zika is an infectious virus introduced to Florida by individuals who traveled to South and Central America plus the Caribbean Islands and were infected by the bite of an aegypti mosquito or a close relative of that mosquito. They then brought the infection back to the USA. The disease has an incubation period of less than two weeks and generally produces a mild illness that most adults do not even know they have. Fever, aches and pains, a fleeting rash, headache and conjunctivitis are common symptoms. Once infected the disease can be transmitted from human to human by body fluids during sexual activity. It can additionally be transmitted when an infected individual is bitten by a mosquito and then it bites a human being. Fortunately the mosquitoes have a flight range of about 100 yards. It is the mobility of infected human beings causing the geographical spread of the virus more than mosquitoes. The virus infects a male’s semen and can remain infectious for about six months. This has led to the suggestion that infected men use condoms when having sex for six months post infection.

The disease is mild in adults but the body’s response to infection has produced a neurological ascending paralysis known as Guillan Barre Syndrome (GBS) at three times the expected rate of this diseases occurrence.  GBS is painful and can affect our respiratory muscles necessitating the use of mechanical respirators and ICU care for survival. The disease is most dangerous in pregnant women causing permanent brain and developmental damage and death in developing fetuses.

At the current time treatment is supportive. There are lab tests to detect an infection using blood and urine specimens. A vaccine to prevent infection is under development with early success noted in rhesus monkeys. Prevention at this point involves practicing safe sex, avoiding mosquito bites using repellant and appropriate clothing.  The mosquito spreading Zika bites during daylight hours. Spraying to reduce the mosquito population is an ongoing strategy being hampered by poor funding. An experimental project to introduce sterile genetically engineered female mosquitoes is being hampered by lack of funding and citizen concern about potential dangers of releasing mutated mosquitoes.

President Obama asked Congress last spring for 1.9 billion dollars to fight Zika but Congress adjourned without providing any funds. The CDC used other funds to begin the research and fight against Zika but is rapidly running out of funds.

Glucosamine and Chondroitin Sulfate Preserves Knee Cartilage in Osteoarthritis

My brother in law is a well-respected researcher and biochemist. Thirty years ago he treated his post exercise aching knees with glucosamine and chondroitin sulfate and felt better. Since then he is a fan. Although he is a firm believer in the scientific method and double blind controlled research studies, we could not find any research to support his observations.   The discussion then turned to, “it helps me and it doesn’t hurt me so why not?”

In a double blind study sponsored by the National Institute of Health known as GAIT, 1500 or more patients with osteoarthritis and a painful knee were randomized to either receive glucosamine and chondroitin sulfate, each substance individually, Celebrex or placebo for six months. The results showed neither led to reduced pain.

Several other studies were as non-conclusive. In the few studies where pain was reduced the study methods and design were criticized and the results were felt to be questionable as were the conclusions of the researchers.   There was nothing positive to say about glucosamine and chondroitin sulfate until a recent study by Martel- Pellitier, Canadian researchers published in Arthritis Care and Research those individuals who took the combination for six years or greater tended to preserve their knee cartilage better than those who did not.  While the knee cartilage was maintained there was no difference in pain or complaints of symptoms between the treated and non- treated group. They believe that by preserving knee cartilage over time there may be less necessity for that joint to be replaced eventually.

I am sure over time this will be studied as well. In the meantime glucosamine and chondroitin sulfate seems to have little toxicity and ultimately my brother in law may be on to something positive.

How Tightly Should We Control Blood Pressure in the Elderly?

A recent publication in a fine peer reviewed medical journal of the SPRINT study proved that lowering our blood pressure to the old target of 120/80 or less led to fewer heart attacks, strokes and kidney failure.  There was no question on what to do with younger people but to lower their blood pressure more aggressively to these levels. Debates arose in the medical community about the ability to lower it that much and would we be able to add enough medication and convince the patients to take it religiously or not to meet these stringent recommendations?

There was less clarity in the baby boomer elderly growing population of men and women who were healthy and over 75 years of age. The thought was that maybe we need to keep their blood pressure a bit higher because we need to continue to perfuse the brain cells of these aging patients.

A study performed in the west coast of the United States using actual brain autopsy material hinted that with aggressive lowering of the blood pressure, patients were exhibiting signs and symptoms of dementia but their ultimate brain biopsies did not support that clinical diagnosis. In fact the brain autopsies suggested that we were not getting enough oxygen and nutrient rich blood to the brain because of aggressive lowering of blood pressure.  Maintain blood pressure higher we were told using a systolic BP of 150 or lower as a target.

A recent study of blood pressure control in the elderly noted that when medications for hypertension were introduced or increased a significant percentage of treated patients experienced a fall within 15 days of the adjustment in blood pressure treatment.  This all served as an introduction to a national meeting on hypertension last week during which the results of this same SPRINT (Systolic Blood Pressure Intervention Trial) strongly came out in favor of intensive lowering of blood pressure to 120/70 to reduce heart attacks, strokes and mortality in the elderly and claimed even in the intensive treated group there were few increased risks.   On further questioning however by reclassifying  adverse events in the SPRINT trial to “ possibly or definitely related to intensive treatment, the risk of injurious falls was higher in the intensive vs conventional treatment group.”

What does this mean in the big picture to all of us?  The big picture remains confusing.  It is clear that lowering your blood pressure aggressively and intensively will reduce the number of heart attacks and strokes and kidney disease of a serious nature.  It is clear as well that any initiation or enhancing of your blood pressure regimen puts you at risk for a fall. You will need to stay especially well hydrated and change positions slowly during this immediate post change in therapy time period if you hope to avoid a fall.  Will more intensive control of your blood pressure at lower levels lead to signs and symptoms of dementia due to poor perfusion of your brain cells?  With the SPRINT study only running for three or more years it is probably too early to tell if the intensive therapy will lead to more cognitive dysfunction.

Antibiotic Associated Colitis Increases Risk

At least a half dozen times per week patient’s call with symptoms of a viral upper respiratory tract infection or present to the office for a visit with symptoms and signs of a cold.  These illnesses are caused by small viral particles which do not respond to antibiotic treatment.   Your body’s defense system attacks these viral particles and over a period of hours to days defeats them.   Despite years of ongoing public health announcements and handouts by doctors and nurses and attempts at patient education you find yourself negotiating with strong willed patients who want a “Z Pack” or some other antibiotic which they do not need.  “I know my body,” they argue.  “My northern or previous physician knew to always give me an antibiotic, why won’t you?”

The answer is quite simple. They do not work to shorten the course, intensity or duration of your illness. They do in fact put you at risk of developing complications of antibiotic use. When your infection requires the use of antibiotics to restore health, it is worth taking these risks. When you do not need the medication it definitely is not. This was confirmed by an article and research presented by E Erik Dubberke, MD of Washington University School of Medicine in Saint Louis, Missouri commenting on Medicare Data about the death rate associated with antibiotic related colitis infections due to Clostridia Difficile.  Bacteria normally reside in our large intestine and promote health and digestion.  When we prescribe an antibiotic it kills off the healthy and beneficial bacteria as well as the infection related bacteria. This destruction of healthy bacteria creates an environment conducive to “opportunistic “bacteria normally suppressed by the normal flora to invade and take over your gut. The resulting fever, cramping, diarrhea with blood occurs as the intestine become inflamed with colitis. One of the common opportunistic pathogens is Clostridia Difficile.

Dr. Dubberke looked at Medicare data and compared 175,000 patients older than 65 years of age and diagnosed with Clostridia difficile infection and compared them to 1.45 million control patients. He found that those with clostridia difficile infection had a 44% increased risk of death. When comparing admissions to nursing homes for treatment there was an 89% increased risk due to antibiotic related colitis care.

Antibiotics are wonderful when appropriate. They will always carry a risk of a side effect, adverse reaction or complication which is a risk worth taking in the correct setting.  It is clearly not worth the risk when your doctor tells you that it will not work.

How Much of Yourself Can You Give to Others?

I have been practicing general internal medicine for over 35 years in the same community. I have many patients who started with me in 1979 and are now in their late eighties to early nineties.  Predictably and sadly they are failing.  Not a week goes by without one or two of them moving from general medical care to palliative care, very often with the involvement of Hospice for end of life care.   Medicare may now compensate for discussion of end of life issues but anyone practicing general internal medicine or family practice has been discussing end of life issues appropriately for years with no compensation. It just comes with the territory.

Most of us still practicing primary care thrive on being able to improve our patient’s quality of life and our major compensation can be hearing about their interactions and social engagements with family and friends.  It is an accomplishment to see you’re 90 year old with multisystem disease for years, dance at her great grandchild’s wedding.  No one who cares for patients longitudinally for years is that dispassionate that they do not give up a piece of their heart and soul each time they lose a patient or have one take a turn for the worse.   When I lose a patient, if time permits, I will attend the funeral or family grieving gathering during the mourning period.  Everyone gets a personal hand written letter. Completion of the circle of life and then moving on is part of the process.

I think physicians’ families take the brunt of this caring and I am sure mine does. As much as you want to have time and patience and sympathy and empathy for your loved ones, the work truly drains your tank and reserve. When you answer the questions of the elderly and their families over and over, often the same questions, it drains you.  Unfortunately, I believe my elderly failing mother is cheated the most by this process. Last weekend when making my weekly visit she was complaining again about the same things, asking the same questions that have repeatedly and compassionately been addressed by my brother and I. My wife interjected that I sounded angry and annoyed. I was. I told her that unfortunately all the compassion and understanding in me had been drained already today and I needed time to recharge.

I saw the widow of a patient who expired last month in his nineties. I had offered to make home visits and they were declined several times by the patient and his spouse. His last week of life he asked to receive Hospice care and they assumed his care.  I called the surviving spouse and wrote what I considered a personal letter of condolence.  His wife told me she was disappointed in me for not coming up to see him one last time. I apologized for not meeting their needs but wondered inwardly, how much can I give and still have something left for myself and my loved ones?

PCSK9 Inhibitors Not All They Are Cranked Up To Be

For months now physicians treating patients with elevated cholesterol have been looking forward to learning how to use the new monthly injectable PCSK9 inhibitor medicines that were touted to dramatically lower LDL cholesterol and cause far fewer side effects. They were designed to be used in patients with a hereditary form of elevated cholesterol traditionally very hard to control with oral statin medications and for statin intolerant patients with coronary artery disease.

The drawbacks to the new medication is its costly nature running more than $1,200 a month with many insurers, including Medicare, not yet covering it. There were additional concerns that the lowering of LDL cholesterol was so dramatic that it may cause problems in other organ systems that require cholesterol for certain functions.

The April 3rd edition of the University of Pennsylvania’s online Medical Review known as MedPage Today revealed data from Steven E Nissan, MD, of the Cleveland Clinic on the use of evolocumab (Repatha) in the phase III GAUSS -3 trial. This study looked at statin intolerant patients who had failed on two previous statin drugs or were unable to raise the statin dose from the minimal available level.  This study compared the effects of Repatha to oral Zetia (ezetimibe) at 22 and 24 weeks.  The study clearly showed that Repatha lowered LDL cholesterol levels by about 55% compared to ezetimibe at 17%.  The level of LDL cholesterol level was similar to results of the other cholesterol lowering PCSK9 inhibitor alirocumab (Praluent).

What I found most interesting is not that these expensive new injectables worked well but that 20% of the statin intolerant patients had similar muscular aches and pains and complaints with this new non statin injectable. Less than one percent of the patients on the new injectable in the study actually stopped the drug due to the muscular pains.

At this point my practice is still investigating the new injectables. Part of that investigation is determining which insurers will pay for the use of the drug and which will not.  In the past I have waited a good year for a new type of medication to be out on the US market to observe the true adverse risk profile before prescribing it. This promising injectable monoclonal antibody to reduce LDL cholesterol will be treated no differently.