Walnuts Lowered LDL Cholesterol in Seniors

Emilio Ros, MD, PhD led the Walnuts and Healthy Aging Study (WAHA) looking at healthy seniors in Loma Linda, California and Barcelona, Spain. He followed 636 patients who were randomly assigned to a walnut supplemented diet or walnut free diet.

Senior Citizens who ate a diet supplemented with walnuts lowered their LDL cholesterol significantly.  The walnut supplemented group exhibited a reduction of total cholesterol of 8.5 mg/dl with an LDL cholesterol reduction of 4.3 mg/dl.  Triglycerides and HDL cholesterol were not affected. In addition to lowering cholesterol, Dr. Ros said other studies showed a positive result in lowering blood pressure. 

Christie Ballantyne MD, chief of cardiology at Baylor College of Medicine, and director of cardiovascular disease prevention at Methodist DeBakey Heart Center, said nutritional studies are difficult to complete. The number of participants is usually small and the length of the study short. This study encompassed large numbers over two years in two different locales. 

Dr. Ros commented that adults are always wondering what can they eat as a healthy snack?  Walnuts can now be added to that list.

Influenza Season 2021-2022 is Approaching

The office has ordered enough influenza vaccine for all patients including 65 and older.  Let’s start the discussion by making it very clear that you can take the influenza vaccine at the same time you take the COVID-19 vaccine or booster. Several vaccine companies are actually producing a combination vaccine of COVID-19 and influenza but that product will not be available in the USA this fall.

The next issue to examine is when does influenza A generally arrive in south Florida? In most years we see very little influenza A prior to Thanksgiving . There is a smattering of influenza B primarily in the pediatric population year-round.

The disease arrives earlier north of the Mason Dixon Line but last season due to masking, lockdowns and school closures there was very little spread of the flu. It takes about two weeks to develop immunity after you receive the vaccine so if you are planning on traveling in October and November it pays to research when influenza arrives in the area you are traveling to and get vaccinated two weeks in advance of the trip.

In South Florida the influenza season peaks the last week in January and first weeks in February most years. Think Super Bowl weekend as the most infectious time.

We know that in those 65 years of age or older the protective effects begin to fade at 90 days. For this reason, we advise our senior citizen patients to take the influenza vaccine between Halloween and Thanksgiving. For patients over 65 who already took their flu shot at their pharmacy, we recommend a booster shot in late December or early January. For younger patients, the immunity lasts much longer and, if they choose to take the shot earlier, they should be protected for most of the flu season.

THE VACCINE IS ALREADY IN OUR OFFICE. We will officially start vaccinating in October. Seniors 65 and older will receive a version of the senior high dose quadrivalent vaccine. Younger patients will receive the traditional influenza vaccine. The vaccination will be recorded on Florida Shots – the official vaccination recording site of the State of Florida.

Eggs Are Safe & Delicious

A few years ago, while visiting my pug’s veterinarian to try and find a way to get the dog to eat while undergoing radiation therapy, he suggested, “Why don’t you scramble him some eggs? It’s a great protein source and doesn’t contribute to cardiovascular disease in canines.” I have to admit I was a bit jealous since I was avoiding eggs, using egg whites and Egg Beaters instead. Two recent studies suggest eggs are safe for humans too.,

The American Journal of Medicine, in the January 2021 edition, published a research paper by C. Krittanwong, MD and associates which looked at 23 prospective studies covering a median of 12.8 years and 1,415,839 patients. There were 157,324 cardiovascular events during the study period. “Compared with the consumption of no egg or 1 egg per day, higher consumption was not associated with significantly increased risk of cardiovascular disease events. Higher egg consumption (>1 egg per day) was associated with a significantly decreased risk of coronary artery disease compared to no egg or one egg per day.

A study with similar results was published in the March 2020 edition of the British Medical Journal in a study involving 14,806 patients over 32 years. “Moderate egg consumption is not associated with increased cardiovascular risk overall.”

The message is clear, eggs are a fine source of protein in moderation.

Safety & Efficacy of Lowering Lipids in the Elderly

I am bombarded regularly by older patients, their adult children and various elements of the media with complaints that elderly are taking too many medicines. Poly pharmacy is the word they use and the first prescription medications they want eliminated are their cholesterol lowering drugs – either a statin (Lipitor, Zocor, Pravachol, Crestor , Livalo or their generic form), Zetia ( Eztimebe) or the newer injectable PCSK9 inhibitors Repatha and Praluent. Is there an age that we should stop these medications? Is there benefit in the elderly to continue taking them? Should we start these medications in the elderly if we discover they have high cholesterol and vascular disease?

A recent study was published in the prestigious Lancet medical journal. The authors looked at 29 trials with 244,090 patients. From this pool there were 21,492 patients who were at least 75 years old. Half of them were on oral statin drugs and the others were on Eztimebe or PCSK9 inhibitors. They were followed from 2 – 6 years.

The results showed that for every reduction of LDL cholesterol of 1mmol/L there was a 26% reduction of in major adverse vascular events. These numbers were similar to those in younger patients. The data also pointed out that these patients had a significant reduction in cardiovascular deaths, myocardial infarction (heart attacks), strokes and the need for heart surgical revascularizations. It was extremely clear that if you are on a cholesterol lowering drug you should stay on that medication despite your age!

A study in JAMA internal medicine, authored by LC Yourman, answered the question of whether you are too old to start on a cholesterol lowering drug. They found that it took 2.5 years before the cholesterol lowering medicine reduced your risk of a major cardiovascular event. Their conclusion was that if you are 70 or older, and your lifespan appears to be greater than 2.5 years, you should start the medicine.

Obstructive Sleep Apnea Surgery vs. CPAP? Daytime Anti-Snoring Device?

Obstructive sleep apnea is now epidemic in a population where it runs hand-in-hand with obesity, which is also an epidemic. The consequences of untreated sleep apnea include daytime somnolence, cardiovascular, neurological and endocrine complications.   One of the hallmark signs of obstructive sleep apnea (OSA) is snoring. 

The US Food and Drug Administration (FDA) recently approved an oral device to be worn during the daytime to reduce and/or eliminate snoring. The device is called eXciteOSA made by Signifier Medical Technologies.  The device is a prescription item which will be used by sleep specialists, dentists and ENT physicians.  It has four electrodes that deliver a series of electrical stimuli to the tongue with rest periods in between. The stimulation over time improves tongue function preventing the tongue from collapsing backward into the airway and obstructing it during sleep.  The device is used for 20-minutes once a day, while awake, for six weeks and then once a week thereafter. It is designed to be used in adults 18 years of age or older with snoring and mild OSA. Think of it as physical therapy for the tongue.

The device was tested on 115 patients, 48 of whom had mild obstructive sleep apnea plus snoring. The others were all snorers. The snoring was reduced in volume by more than 20% in 87 of the 115 patients. In the group of patients with the diagnosis of OSA and snoring, the apnea-hypopnea index score was reduced by 48%

It is recommended that a thorough dental exam be performed prior to trying this device. The major side effects noted from its use were excessive saliva production, tongue discomfort or tingling, metallic taste, jaw tightening, tooth filling sensitivity.  No mention of the cost was included in the printed review.

The online journal Practice Update reviewed a JAMA Otolaryngology publication on the use of surgery to treat Obstructive Sleep Apnea versus using a CPAP machine. There are many patients who just can not wear the CPAP mask which is the first-line “gold standard” for treating OSA.  Most patients who spend 90-days adjusting to the mask sleep far better and look forward to using the device to obtain a restful night’s sleep. The study looked at patients who were at high risk for not being able to adhere to a CPAP use regimen. Soft tissue surgery to the uvula was found to reduce the rates of cardiovascular, neurological and endocrine systemic complications compared with prescriptions for CPAP in patients less likely to adhere to or use the CPAP mask. 

The takeaway message is clear. When a patient is unlikely to adhere to CPAP mask use offering soft tissue oral surgery should be offered early while treating the disease.

COVID-19, Phase III Reopening & Influenza Vaccine

Watched the Presidential debate last evening which resembled a sequel to the movie Animal House with Chris Wallace of Fox News doing his best Dean Wermer impression. The moderator had the right and duty to allow each participant to answer the question in their allotted time and could have turned off the microphone of the offending participant but chose not to. The American Public was cheated by his ineffective leadership.

This occurred on the same day columnist Fabio Santiago, of the Miami Herald accused Florida Governor Ron DeSantis of threatening public safety by opening the state completely before the state has met any of the recommended safety benchmark goals of the CDC.

An article in the Jerusalem Times forwarded to me discussed a large series of Israeli COVID-19 survivors who developed antibodies to COVID-19 and then became ill with it within the three-month recovery period. Their presumed second round of COVID was far more serious and complicated than the first bout raising questions about whether they ever cleared the disease or not. It underscores the tremendous lack of knowledge we have about this pathogen.

I understand the frustration of small business owners, stay at home working parents who now have to supervise their kid’s education while working remotely and; the unemployed who cannot break through the inefficient computer systems to obtain the benefits they deserve and need to survive. In my mind these issues just highlight the need for a national program to fight the spread of COVID-19, protect the most vulnerable, support those out of work as well as the businesses who need to pay rent and salaries to survive while we wait for a vaccine or medication. To say that its fine to come to Florida, and safe for tourism purposes, is a lie exposing Floridians to the COVID-19 they bring from their homes and exposing their friends and neighbors to the COVID-19 of the Sunshine State.

Which brings me to the influenza vaccine. Do yourself a favor and get your influenza shot. No, the vaccine does not make you more susceptible to coronavirus as one Midwest couple read on a disinformation website. No, it is not 100% effective, but it will reduce the intensity and the severity of the disease if you are exposed to it.

We are currently experimenting with the safest way to immunize our patient population. The tenants in our building, with the support of building ownership and management, did not enforce the indoor mask mandate when we were in Stages I and II. Now the younger, more casual tenants, are even less likely to observe social distancing CDC guidelines. We are experimenting with three different ways of administering the vaccine on site, which I believe is still far safer than the exposure in a commercial pharmacy.

My advice to my patients remains:

1. Stay out of restaurants and country club dining rooms despite the efforts of management and the board to keep these places spotless. CDC studies show restaurant attendance is associated with catching the disease.

2. Stay out of gyms – both public gyms and gyms in your apartment complex. Take walks outside. Use a chlorine pool. Walk at the beach. Bicycle ride.

3. Stay out of hair salons and nail salons.

4. Cook and prepare your own food. Restaurant workers, who must come to work to get paid, are often asymptomatic spreaders of COVID.

5. Suppress the urge to use commercial air travel to visit your relatives. Airport terminals and inconsiderate and uncaring passengers are your biggest threat. If you do go, you will need to quarantine for 14 days before you see your vulnerable loved ones or; wait at least four days after arriving before being tested for the COVID-19 antigen indicating an ongoing infection.

Stay home. Wear masks when in public. Wash your hands frequently and stay 12 feet or more away from others. That is our best option for staying healthy and alive until a treatment or vaccine is available. Get your flu shot. Listen to science not politicians.

A Perfect Storm Brewing: Flu Season Plus A COVID-19 Resurgence

I was asked by a colleague what I thought influenza seasonal infections coupled with a predicted second wave of COVID-19 would look like locally? Influenza A arrives locally around Thanksgiving and peaks the last two weeks in January and first two weeks in February. I suspect it is fueled by seasonal visitors coming to Florida bringing the disease from their home locales. We see a low level of influenza B year- round in our pediatric population.

A full-page ad appeared in all Florida newspapers today sponsored by every major health system in the state including Baptist, Tenet, HCA, Cleveland Clinic, Broward Health, Jackson, U M Health, Memorial Health and others. It stressed wearing masks, social distancing and frequent hand washing.

If you get sick with mild symptoms, they encourage remote telehealth care. If you have moderate symptoms, they suggest going to their urgent care facilities. For severe symptoms call 911 or go to the ER. At no time did they suggest calling one of their employed physician offices or visiting your private doctor which is all consistent with CDC recommendations. Private independent and employed physicians just don’t have the ventilation systems, sanitizing systems, personal protective equipment or trained staff to see potential COVID patients in their offices. If a patient is positive, or a staff member converts, what is their responsibility to the next patient or to the other tenants of their building? Is a 14-day quarantine in order?

Much depends on unknown factors. How effective will this year’s flu shot be? In my area, the chain pharmacies already received their supply of influenza vaccine and have shamelessly been pushing it on customers since July. Scientific research shows that in senior citizens the flu shot immunity begins to subside 90 days after you receive the shot. Given that, if your pharmacy tech gives you the flu shot in September, then how much immunity will you have by the time the flu arrives around Thanksgiving?

Quick, accurate and inexpensive testing availability for flu and COVID 19 is an important factor as well. We have had a quick influenza test for years requiring a nasopharyngeal swab. A similar test for COVID -19 has just been released by Abbott Labs and received Emergency Utilization Authorization from the FDA. That means Abbot Labs researchers say it works and the FDA takes them at their word. This test, called “a game changer” by many, will be available in October.

When $15 per hour medical assistants start performing the test rapidly, in volume, I hope the accuracy results are similar to Abbots claims. Our health and lives depend on that. At the same time a finger stick blood drop test is heading to market to quickly detect flu and COVID -19 on the same test card. Finnish scientists and Israeli researchers have quick breathalyzer tests coming soon as well. I hope they work and get here soon. I will test everyone at the door as will restaurants, theaters, sports arenas and most businesses.

All of this information really skirts the issue. With no treatment and vaccines available yet, I expect this flu COVID-19 season to be a human health disaster. With no national plan in place and no close coordination with state and local elected and public health officials, I see the fall and winter as a time of continued disease surges and deaths while the political influence on disease treatment supersedes scientific research and public health realities. Without a coordinated program of PPE and medication distribution, coordination of testing availability and results with contact tracing and specific shutdowns of hot spots without challenges related to loss of freedoms the outlook is grim.

Protecting senior facilities without a coordinated program and funding for it will not work for residents or employees. Opening schools and day care without similar precautions, training and funding for materials and tracing will lead to hotspots as well. There are members of the student population such as special needs children who need to return too, in person, learning safely and creatively. Others need to learn remotely or be given a chance to catch up later when safe return to in person learning is possible.

Without a plan to assist renters, homeowners, landlords, small business owners, farmers, restaurateurs, etc.; any shutdown for disease will be met with overwhelming resistance. I see a bleak and dangerous health picture developing in the fall/winter creating a perfect influenza/COVID storm.  I hope I am wrong but, if right, the disease surge will overwhelm ERs and hospitals.

More Steps Per Day Associated with Milder Irritable Bowel Symptoms

The association between emotions, the brain and the intestines has always been of great interest to me. As a young medical student facing the stress of having to succeed academically, I developed irritable bowel syndrome. I have written previously about my encounters with IBS and discussed how my symptoms diminished as my coping skills improved. I have always loved to aerobically exercise for stress reduction but never really appreciated how that activity may have diminished my irritable bowel discomfort.

Toyohiro Hamaguchi, PhD, of the School of Health Sciences at Saitama Prefectural University reported on a study discussed in Plos One showing that with increased walking irritable bowel symptoms seemed to diminish. The study looked at 100 students, 78 of whom were women with a mean age of 20 years old. They were recruited for the study based on their diagnosis of irritable bowel syndrome between the years 2015-2018.

The participants were not obese based on Body Mass Index (BMI). They answered a GSRS (Gastrointestinal Symptom Rating Scale) document at the start of the study and again while participating in the study. The rating scale evaluates the severity of abdominal pain, indigestion, reflux, diarrhea and constipation. Walking patterns were then tracked using a pedometer.

They found that with increasing daily steps, the severity of the symptoms markedly decreased based on the GSRS rating scale. Based on their findings, the severity of symptoms decreases by 50% when increasing your daily step count from 4000 steps to greater than 9500.

Dr. Hamaguchi explained that “mild physical activity helps clear intestinal gas and reduces bloating. Thirty minutes of daily walking is recommended for increasing colon transit time in adults with chronic constipation. Recent research has found that inflammatory biomarkers were reduced after 24 weeks of moderate -intensity aerobic exercise”.

This is one more study showing that low to moderate intensity exercise, on a regular basis, allows you to feel better. During this Covid19 Pandemic the stress level for all is so much higher. Take a 30-minute walk at your own pace, maintaining social distancing and with a mask available if someone starts to get close . It will reduce your stress and improve your health!

I’m Dealing With the Silent Fear of Infection

I saw a patient yesterday with a cough and intermittent fevers. I believe based on her history she is a low risk for COVID-19 disease. One must treat all patients as if they have COVID-19 until proven otherwise so I wore a double mask including a N95 respirator mask, a face shield and gloves.  The face shield limits your peripheral vision and fogs up easily as do your glasses. I could feel and hear my heart pounding and racing as I got close to the patient for an exam and the sweat pouring down my forehead into my eyes stinging and burning did not help.

The visit was uneventful.  I maintained my sanitary protective field, removed my protective gear afterward, as per protocol, and washed up extensively. The weather outside was stormy with torrential rain, thunder, lightening, high winds, flooding and some hail – adding to the apocalyptic climate that now exists in the patient care arena.

Yes, I began to relax some as the visit progressed but there was always this uneasiness wondering if I careful enough?   It reminded me of 1979 before we knew what the HIV virus was and what AIDS was. I was seeing a brand-new patient in the intensive care unit of Boca Raton Community Hospital. He was the editor of an internationally known tabloid published just north of Boca Raton.

Married to a French national, he had left New York to come oversee this paper and had taken ill.   I had seen many cases of this immune system destroying disease during my residency in Miami at Jackson Memorial Hospital. This obese gentleman struggling to breath had none of the risk factors for this new disease. He denied drug use or intravenous drug use. He denied being in relations with other men.  How could he possibly have this horrible new disease with none of the risk factors. His wife was testy when I questioned her alone about private and personal areas of their relationship all necessary to determine her husband’s risk of having this immune destroying disease. She was vigorous in her defense of his very ordinary, very traditional behavior.

In those days we rarely wore gloves to draw blood. It was unheard of. We rarely put on gloves to start an IV line. With this disease things were different.  I was in a paper gown, gloves, face mask, goggles and face shield as was the young pulmonary expert I was working with.  The confinement of the personal protective gear and the warmth and fogginess of your vision led to a rapid pounding heartbeat and the same sweating I was experiencing 40 years later. It calmed down some as we got into the procedure.  I was wearing scrubs then which never left the hospital locker room. I am wearing scrubs now which never leave my office. I come to work in pants, shirt and tie and change into special scrubs plus sneakers that are kept here. At the end of the day the scrubs go into a laundry bin. 

As a physician who cares for patients, I need to take this risk. As a human being over 60 years of age I realize I am high risk for developing complications and death if I catch the COVID-19 virus. I am most afraid of transmitting it to my wife, my children, my grandchildren unknowingly. I hope they have the courage to put up with my risk taking.

Anti-inflammatory Colchicine Exhibits Major Benefits After a Heart Attack

Jean-Claude Tardif, M.D., of the Montreal Heart Institute in Canada presented a paper at the Scientific Session of the American Heart Association last week demonstrating the benefits of using colchicine to reduce inflammation after patients have a heart attack.  In a study called COLCOT, performed at 167 different health centers in multiple countries, almost 5000 patients were double-blinded and either given 0.5 mg of colchicine a day or a placebo.

All of these patients received standard post heart attack cardiac care including cholesterol lowering medicine, anti-platelet agents and blood pressure medicines in addition to the study drugs.  The patients were on average 60 years old, 80 % were overweight men with 93% having undergone angioplasty as a treatment of their cardiac disease.  Ninety-nine percent were taking aspirin, 98% were taking an additional anti-platelet agent, 99% were on a statin to control cholesterol and 89% on a beta-blocker.

The doctors conducting the study recognized that acute heart attack patients are demonstrating a high degree of inflammation at that time and are at increased risk for another heart attack, stroke or acute rehospitalization for an ischemic event.  The addition of colchicine reduced this risk by 34% when used with all the currently recommended post heart attack medications.  A new study, COLCOT 2, is being planned to see the effect of colchicine in preventing coronary ischemic events in diabetics who are at increased risk.

Colchicine is an anti-inflammatory drug originally used to treat gout and inflammation of the sack around the heart known as pericarditis.  It originally was not patented and sold for pennies.  The drug was purchased by a Wall Street investment firm, patented, and now a 30-day supply sells for more than $250.