I Told My Daughter “Find Another Doctor!”

I have three adult daughters, all college graduates.  All are in long-term relationships with men,  children, dogs and careers.  I am “dad” and will always be dad.  I additionally happen to be a physician who cares for adult patients.  If they are ill or have a medical problem their first phone call is to my cell phone. If its not a phone call it’s a text message. I do not bring this up to give the impression that I am complaining about it. They are my children, I love them and always will.  Anything I can do to comfort or help them is always fine with me. 

I have stressed to them that they need to find a family physician or internist to handle their medical care  who is compassionate, available, caring, accessible and will advocate on their behalf. The older two are financially secure enough to find a concierge physician and I have encouraged that. My younger adult daughter lives about one hour south of my home and practice. She has a primary care physician under contract and on the panel of her Blue Cross Blue Shield PPO. That internist is an employee of the large medical health system that recently purchased my local community hospital. They have been purchasing doctors’ practices and putting in place hospital employed physicians with the speed and rapidity that a wildfire spreads in the dry California brush propelled by the Santa Anna winds.

My daughter called me this morning at 6:15 a.m. with a 102-degree fever, sudden onset of body aches, chills, sweats and “ a killer sore throat”   She is vaccinated against influenza but had a Flu Assay positive case in December 2022. She wondered if she could catch flu again.   

My toddler grandchildren attend daycare and pre-school and bring home febrile viral illnesses in abundance almost weekly.  Bacterial Streptococcal infections and Respiratory Syncytial Virus are epidemic locally along with flu and high risk of COVID, per the CDC and not our Florida Department of Public Health.  Her COVID home antigen test was negative so after taking some Tylenol and throat lozenges she called her family physician.  She was told to, “Go to Urgent Care.  We Don’t see sick people in the office.”

At the beginning of the Sars 2 Coronavirus pandemic most physicians were unvaccinated and unprotected against COVID-19 and we followed the advice of the CDC in referring patients to COVID-19  test sites for testing. We conducted phone calls with patients and telehealth visits. With five COVID vaccines, and an abundance of at-home quick tests available locally, most of us are now seeing sick patients in our offices again as long as we know their COVID test status. 

In my practice, pre-COVID and pre-Concierge Medicine, we always adjusted our schedules to include patients who had an acute febrile illness and were not in respiratory distress. I knew most of these illnesses were caused by viruses and required nothing more than fluids, Tylenol, cough syrup and tincture of time.  Most did have multiple medical and metabolic conditions as well which exacerbated with the infection. The purpose of the visit was to make sure the other conditions, exacerbated by the viral infection, didn’t exacerbate. To accommodate our sick patients, we started the day earlier, worked through lunch at times and stayed late if need be.

When my daughter called me from the urgent care center facing a 90-minute wait, she asked me what she should do.  I suggested she wait it out, see the physician and when she felt better find another doctor. I understand the reason for not bringing an acute COVID patient into the office. For everything else there is no excuse for only seeing “well” patients. Our job is to keep our patients healthy.  What value are we if we don’t see them when they are ill?

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Universal Flu Vaccine in Development

It’s been a more serious flu season than I have seen in the recent past. The flu season began much earlier than expected here in South Florida and was more severe even in young healthy individuals. We administered the quadrivalent flu shot to all our patients younger than 65 years old and the high dose vaccine to seniors far earlier in the season than in previous years due to the flu’s early arrival.

There has been a great deal of conjecture that in senior citizens the vaccines protection begins to decline at 90 days. With this in mind, and influenza still raging in the community, we are requesting information from the CDC on whether we should be administering a second flu shot to seniors in January 2023. The viral makeup of the flu shot is determined by research and surveillance done in Asia a year in advance of our flu season. There are 30 different subtypes and this year’s vaccine is directed against four of them. Ongoing surveillance is trying to determine the most likely strains to travel to the USA next season so they can prepare next year’s flu shots

Researchers at the University of Pennsylvania are trying to prevent the guessing game and develop a universal vaccine that protects against all 20 subtypes. They have developed a vaccine using the same mRNA technology used to develop the Pfizer and Moderna COVID vaccines. It was recently tested on ferrets and mice and was successful in preventing infection against all 20 of the possible variants. The results were published in Science as plans for human trials begin.

Dr. Ofer Levy, MD, PhD, director of the precision Vaccines Program at Boston’s Children’s Hospital, feels this new mRNA vaccine may be given to children to prime their T and B cells to react quickly and fight off a flu virus they are exposed to. The new vaccine will hopefully protect humans against any strain of vaccine.

The mRNA COVID-19 vaccines have been the source of much political backlash with “anti-vaccine advocates”, some politicians and their health care appointees using opposition to the vaccine to appeal to certain voter populations. Is it possible that a miraculous new scientific advance will again be met by inappropriate resistance?

Home with COVID

Had the entire family in from out of town this Thanksgiving. Awoke Thanksgiving Day, turned to get out of bed and felt something snap in my lower back. Since I have been fortunate to never have had back issues before, I just stretched it out over several minutes on the floor and went about my business as best I could. Walking produced sciatic pain down my right leg. I walked the dog in pain, stretched again, took some acetaminophen and let my younger relatives provide the physical work I usually do to set up tables and clean up after dinner.

It was a long weekend and while my energy level was down, I had no symptoms of an upper respiratory tract infection. None of my adult kids were ill on arrival the week before. My toddler age grandchildren, now back at preschool, are always sick with viral illnesses but their COVID tests were negative.

The last visitor left for home Sunday and that afternoon my wife said she ached all over and felt like she had been suddenly hit by a truck. A quick COVID test was negative. The next morning, a bit more tired than usual, I returned to my office to see patients. At lunch time I ran home with an influenza test and a few home COVID antigen tests. Her influenza test was negative. Her COVID test immediately showed positive, so we repeated it and it was still positive. At that point I tested myself and sure enough it was immediately positive.

Four weeks prior I would have contacted my local hospital monoclonal antibody program and we would have received bebtelivamib without having to worry about drug/drug interactions or adverse reactions. That drug is no longer available due to the virus mutating and developing resistance.

We called our internist and he prescribed Paxlovid for five days to prevent progression to serious illness in high-risk patients. My wife had to stop her calcium channel blood pressure pill, stop her cholesterol lowering pill and reduce her anti-anxiety medications to take Paxlovid. For me it required stopping a blood pressure pill and realizing that maybe my back pain was the first sign of COVID and that put me at Day 5 of symptoms which is the latest you can effectively start Paxlovid. The drug leaves a persistent metallic taste in your mouth. It wears away at about twelve hours just when it is time to take the next dosage.

I cancelled my office patients for the week knowing that my associate would see anyone that required an in-person visit. I can still return phone calls and perform telehealth visits if a patient requests it. I just do not want to transmit a disease to a healthy patient in for a routine checkup.

Some tasks you cannot hand off. I was up walking the dog this morning when I met a long-time neighbor who I respect but differ with on politics drastically. He asked how I was, and I told him I had COVID and asked him to please safely keep his distance for his safety. With that he coughed repeatedly, told me he was sick for several days and thought there was no point in testing for COVID. He clearly sounded far more symptomatic from some viral illness than I was. He said after his walk he was going to synagogue and then to work. He asked me why I bothered to take the test at all.

I referred him to an article in the day’s Wall Street Journal that claims that nine out of ten COVID related deaths are occurring in men and women 65 years of age and older and my wife and I fit into that category. There are still 300 deaths per day from COVID in the USA .

With a positive test I wanted to have every opportunity to prevent serious illness in my wife. Since I live and work in a senior citizen rich community, I didn’t want to spread the disease to others either.

Somehow as a nation we have lost our moral compass regarding age and this disease. The death toll from COVID in the older age group far exceeds that from influenza despite the claims of Florida freedom politicians. The tradeoff of keeping everything open, with no protection for seniors on buses, planes , airports, subways and office buildings seems like age discrimination to me. Changes in public policy by the national administration, CDC and public health officials in advance of the midterm elections may have helped “ save democracy” but certainly are not protecting elders like my patient population.

My wife and I will survive. After five days of Paxlovid we will start retesting with a quick antigen test. I fear for my neighbors over 65 years old who don’t have the knowledge, access or experience to recognize and treat this disease.

Low Dose Statin More Effective at Lowering Cholesterol Than Advertised OTC Supplements

At the Scientific Session of the American Heart Association, researchers presented the SPORT study (Supplement, Placebo or Rosuvastatin Clinical Trial). The study compared .5 mg of Rosuvastatin (Crestor) to multiple over the counter products advertised to lower cholesterol without the ill effects of a statin.

The products included:

  1. Placebo
  2. Fish Oil( Nature Made Fish Oil 240 mg)
  3. Cinnamon ( Nutriflair 2400 mg)
  4. Garlic ( Garlique 5000 mcg Allison)
  5. Turmeric ( BioSchwarrtz Brand 4500 mcg)
  6. Red Yeast Rice ( Amazon 2400 mg)
  7. Plant Sterols ( Nature Made Cholestoff Plus 1600 mcg plant sterols)

Nineteen-hundred adults aged 40-75 years, with no history of cardiovascular disease, were randomized to receive one of the products for 28 days. These individuals had pre-study LDL cholesterols between 70 – 189 and a 5-20% risk of developing atherosclerotic disease within 10 years.

The results showed that Rosuvastatin decreased LDL cholesterol by 37% with the supplements having no more effect than the placebo. Rosuvastatin also reduced total cholesterol by 24% and Triglycerides by 19%. LDL is the adverse cholesterol. It’s helpful to remember the phonic, L stands for “lousy”.

Plant Sterols lowered protective HDL cholesterol and garlic increased the LDL cholesterol when compared to placebo.

This study indicated OTC (over the counter) products just do not work to effectively lower cholesterol and protect against heart attack or stroke. Vitamins, minerals, herbs and supplements are treated as foods in the USA and are not inspected to ensure that what is on the label is in the bottle. Also, there is no assurance that there are no contaminants such as lead, arsenic or mercury in these OTC products.

Some will say that the length of the study was too short for the supplements to show their effectiveness. That may be a valid criticism, but it plays into the anti-science attitude being promoted which encourages sales and marketing of products over scientific testing and results.

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.

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.

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.

FDA Approved LabCorp Test for COVID-19, Influenza & RSV

The FDA has approved an at-home testing kit that can differentiate between symptoms of an upper respiratory virus being caused by COVID-19, Influenza A/B or Respiratory Synctial Virus (RSV) . It is called the Pixel by LabCorp COVID-19+Flus+ RSV Test Home Collection Kit. You obtain a nasal swab and send it directly to LabCorp for testing. The results will be sent by an app that can be downloaded to a smartphone or tablet.

Since children returned to school after a prolonged isolation due to the COVID -19 pandemic, we are seeing a large number of viral upper respiratory tract infections in this group, their parents, and caregivers. “Is it COVID-19?” is always the first concern, “but if its not COVID what is it”?  This testing will  allow patients to swab themselves and obtain a diagnosis without having to first go to the doctor for a visit.

I suspect your doctor will still wish to see you or your child prior to prescribing anti-viral therapy once the diagnosis is reported,  but this is the first at-home testing approved for all three virus types. The test can be purchased online at the LabCorp website or at pharmacies.  The retail price has not yet been disclosed.

Shampoos and Allergens

I saw my dermatologist because of an allergic skin condition he called atopic dermatitis or eczema. Dry itching crusty skin is neither fun to live with or fun to look at. He gave me a bunch of hypoallergenic “clean” soaps, creams and shampoos to try.

Ironically, while reading one of my online medical synopsis journals I came upon an article about allergic substances in shampoos. There are apparently traditional shampoos and other shampoos supposedly less allergenic and called “clean.” There are no regulations over the right to claim your product is hypoallergenic or “clean.”

In a study published in the Journal of the American Academy of Dermatology, authored by L. Ghafari and associates, they found that every clean shampoo and 99% of the traditional shampoos contained fragrances. If you are allergic to fragrances, then all of these products can produce irritation or an allergic reaction.

The researchers went to three stores and identified 85 clean shampoos and 124 traditional shampoos . The clean shampoos were less likely to use allergenic chemicals such as methlsothiazolinone than the traditional shampoos. Both types of products used chemicals that are known to be less irritating or allergenic than others, but few were actually “clean”. The moral of the review was that few of the clean shampoos were actually “clean”. If you have sensitive allergic skin then your dermatologist or allergist may have to suggest a prescription product or particular over-the-counter product that is truly hypoallergenic to prevent your skin allergic reaction.