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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Lowering Blood Pressure with Yoga

We are always looking for methods to improve our health without adding more medications or chemicals. A research team at the Cambridge Cardiac Care Center in Ontario, Canada published a peer reviewed article in the online version of the Canadian Journal of Cardiology extolling the virtues of using 15 minutes of yoga five times per week to lower blood pressure. They added yoga to a 30-minute aerobic exercise program five days per week and saw a significant drop in participants blood pressure. They compared it to another group of aerobic exercisers who simply performed post exercise stretching.

The research team concluded that a structured yoga program after 30-minutes of aerobic exercise five days per week can lower your blood pressure and reduce your cardiovascular risk.

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?

Cannabis Smoking Can Cause Emphysema

Giselle Revah, MD of the University of Ottawa Department of Radiology published a peer reviewed study in the journal of Radiology about the effects of smoking marijuana in patients enrolled in a lung cancer screening program. Marijuana is legal for recreational and medical use in Canada.

Since the legalization Dr. Revah, along with colleagues in internal medicine and family practice, have noticed an increased number of patients presenting at a younger age with emphysema and an increased number of non-trauma related cases of spontaneous pneumothorax (collapsed lung).

Her research team looked at the screening CT scans of marijuana smokers, non-smokers and cigarette smokers. When adjusted for age and sex, 93% of the cannabis smokers had emphysema compared to 67% of the cigarette smokers and < 5% of the non-smokers. Please keep in mind all the marijuana smokers were also cigarette smokers.

Dr. Revah found that those cigarette smokers with emphysema tended to be much older than the marijuana smokers with emphysema with many of the cannabis smokers with emphysema being younger than 50 years old. There was CT evidence in marijuana smokers of extensive airway inflammation, bronchial wall thickening, bronchiectasis and impacted mucous unable to be cleared easily. The study did not examine the CT lung scans of marijuana smokers who do not smoke cigarettes as well. That study is now in progress.

The message to patients and physicians seems clear. If you smoke cigarettes, then think about an alternative mechanism of obtaining the effects of cannabis than smoking. It seems that pot smoking plus tobacco may be synergistic leading to increased and earlier lung damage.

Paxlovid for COVID is About to Get Very Expensive

Paxlovid is an antiviral medication in pill form developed by Pfizer pharmaceutical company to treat Sars2Coronavirus or COVID-19. It is designed to prevent severe disease from developing in high-risk patients. There is an alternative, but far less effective, product called molnupiravir (“Lagevrio”) by Merck. Both were developed with a funding package passed by Congress at the start of the COVID pandemic which produced the Pfizer and Moderna vaccines plus a host of monoclonal antibodies to be administered to high-risk patients as well. Those monoclonals can no longer be used because the COVID virus has found a new way to elude or resist them. There are no new monoclonal antibodies in production because the cost of development of each one is about $200 million dollars, and the Federal government has decided not to guarantee purchasing them.

The US government purchased 20 million dosages of Paxlovid from Pfizer for the bulk discount rate of $530 per treatment. Americans who became ill received it for no upfront cost. The funding for that program has run out. The Biden administration submitted a bill to the Senate in early November requesting funding for this project to continue and the Senate replied by voting to end the COVID-19 “Emergency” state. The drug Paxlovid is still being administered to adults infected with COVID and considered high-risk under an Emergency Utilization Authorization designation. Pfizer applied for full approval status to the FDA in June of 2022. So far, the FDA has not taken any action on this request. That process can take months to years.

It is expected that in January 2023 , when Federal funding runs out, pharmacies will be charging patients $2,300 for the five-day course of Paxlovid. It will not be covered by insurance. It will not be covered by Medicare Part D which by law can only cover products which have the full approval of the FDA.

The CEO of Pfizer pharmaceuticals has sent a note out to his shareholders and board anticipating huge profits in 2023 because Paxlovid will be sold at retail price. Public health officials are anticipating that the poor and seniors on fixed income will just not take the medication at that price.

As of last week, with the medication available, there were still almost 400 people in the U.S. dying daily from of COVID. Ninety percent of those deaths occurred in seniors 65 years or older who are already vaccinated.

I URGE YOU TO CONTACT YOUR CONGRESSIONAL REPRESENTATIVES and PROTEST THEIR LACK OF ACTION ON CONTINUING TO FUND THE DEVELOPMENT AND FUNDING FOR MEDICATIONS TO TREAT COVID.

Staying COVID-Safe During the Holidays

As we head into the Chanukah, Christmas, New Year’s, Kwanza season most of us are gathering with loved ones and friends to celebrate. COVID remains at epidemic to pandemic levels, depending on who you choose to believe. As posted in the Wall Street Journal on the weekend of December 3, 90% of the 300 plus daily COVID related deaths in the United States are now occurring in vaccinated individuals 65 years of age or older.

Misinformation is being spread that COVID is no more serious than influenza. The death rate currently from COVID is close to 20% higher than for the flu. If you couple this with the surge in illness from seasonal influenza and respiratory syncytial virus (aka RSV) ,emergency rooms are flooded as are walk-in clinics.

In some areas of the USA, the anti-COVID antiviral drug Paxlovid is in short supply. We no longer have the option of infusing you with safe and effective monoclonal antibodies because the virus is now resistant to the existing antiviral drug and the Federal government stopped funding the costs of developing new ones.

My suggestions are simple:

  1. Get your quadrivalent flu shot. Get the high dose product if you are 65 or older.
  2. Get your bivalent Pfizer or Moderna COVID booster shot if it’s more than two months since your last non-bivalent booster or three months since you had an infection with COVID.
  3. When indoors with people you do not know, wear an N95 mask. That would include buses, trains, airports, government buildings and other public places.
  4. If you are 65 or older and are having guests over, ask them to test with an at home quick antigen test before they arrive. If they test negative, they are far safer. If the weather permits, hold the gathering outdoors.
  5. If you are younger than 65 and are immunosuppressed, take the same precautions as those 65 and older.

When I recently discussed this with my obese, diabetic patient with end stage kidney disease awaiting a transplant, they asked me when will this be over? My answer was simply, “I do not know”.

Masks are not perfect, but they are far superior to not masking. Quick at home tests are not perfect either but they will identify those who are contagious. If you have questions, feel free to call me.

Happy holidays and a joyous and healthy New Year to you all.

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.

The End of Monoclonal Antibody Treatment of COVID-19

National Public Radio (NPR) reviewed the end of the outpatient use of monoclonal antibodies to combat SARS 2 Coronavirus (COVID last week. These synthetically produced antibodies were infused into patients infected with COVID and were at high risk to develop severe disease requiring hospitalization or death. It cost about 200 million dollars to invent, develop and then use the drug in trials to gain FDA approval for human usage. Drug manufacturers were willing to take the risk developing these products because the US government financially guaranteed their purchase.

The antibodies were synthetic Y shaped molecules which bound to the viruses spike protein rendering it incapable of invading human cells and alerting our own immune system that the virus was present facilitating the virus’s destruction. Over time, the virus learned to mutate and evade a particular monoclonal antibody rendering it ineffective. When 30% or more of the new COVID variants in a region became able to resist the monoclonal antibody, the CDC and FDA withdrew the product. Drug manufacturers continued to develop new monoclonals due to the Federal guarantee of purchase.

Bebtelivimab was the last product that worked well against COVID and on Monday, November 21, 2022 it was withdrawn as well. The Federal government stopped guaranteeing purchase of these products so drug manufacturers have now discontinued their expensive development.

Let me explain how this impacts my patients locally. Baptist Health BOCA Raton Regional Hospital had a robust outpatient monoclonal antibody program. I phoned or text messaged Lisa, the nurse practitioner program director the patient name , demographics and reason for participation and she scheduled and her team administered the drug within the seven day window required. No one became ill from the infusions. No one had to stop their usual medications due to drug drug interactions. No one progressed to severe disease requiring hospitalization and no one died. I referred at least 100 high risk patients including myself in the last 2.5 years and now that weapon is gone. No one treated cleared the virus and then had a rebound recurrent period of sickness.

So we are now left with Paxlovid and Lagevrio oral pills. One has multiple drug interactions with so many of the common medications the high risk population takes daily for cardiac, renal , diabetic and mental health it requires cessation or a reduction in dosage. The other is just not that effective. Patients taking these drugs also at times clear the virus then several days later have a mild rebound of symptoms and are contagious for a few days more.

We head into winter with an aggressive flu bug, respiratory syncytial virus in epidemic proportions and one less successful weapon against COVID-19. As I reflect on this past Thanksgiving holiday, I am grateful for the BRRH monoclonal antibody team and everyone connected with its development. I wonder what our elected Congressional officials were thinking when they stopped funding the development of these effective and safe, but expensive, products?

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.

Tidbits with Tropical Storm/Hurricane Nicole Rolling In

November tropical weather systems, either storms or hurricanes, are a rarity for south Floridians including this grizzled veteran who has spent 45 years in this area.

My office has been in the same location since 2003 but this is at least the third ownership group (landlord) we have worked with. The building and grounds are well maintained. For reasons unclear to me, when NOAA issued a hurricane warning for Boca Raton yesterday at 2 p.m., the building management insisted we vacate the building by 4 p.m. so they could prepare for the storm. I have gone through multiple hurricanes as a tenant in this building, so I know just how long it takes to prepare the building for a storm. There are no shutters to install. There is no impact glass in the office building. The storm was not projected to arrive until sometime the next day.

Nonetheless we rescheduled our last patients, sent some home early and sent our wonderful staff home at 3:45 to comply. The storm still has not fully arrived and, thankfully when it does, it will not bring hurricane force winds or tornados to the area. I now have all this extra time on my hands to catch up on reading journal articles. None of the topics truly warranted a full blog so I thought I would give you a quick smorgasbord synopsis.

  1. A small study suggested that if you perform physical exercise 30-60 minutes prior to your flu shot or COVID-19 booster shot you get an enhanced immune system response.
  2. Drinking 2-5 cups a day of coffee probably reduces cardiac arrhythmia, cardiac events and cerebrovascular events. Ground coffee with caffeine seems more effective than decaf and instant coffee.
  3. The new guidelines for vaccinating adults against community acquired pneumonia are about as clear as mud. If you turned 65 and received Prevnar 13 followed a year later by Pneumovax 23 you are probably complete. If you only received Prevnar 13 please go to your pharmacy and get a PCV 20 vaccine to complete the series. There was much disagreement on giving boosters to seniors five years after completing the vaccine series. If this confuses you all well then welcome to the club.
  4. Screening for colorectal cancer with an office based flexible sigmoidoscopy saves lives. Screening with a traditional colonoscopy is even better at getting a look at the left and right colon. Any controversy created by a recent colorectal cancer study needs to be ignored. If you are 45 you need a screening colonoscopy. If your study is normal, then you will be retested in 7-10 years. In the future, tests such as Cologuard and fecal immune globulin may permit other safe means of evaluation and screening in low-risk patients.
  5. There are some new and safe treatments for acute migraine headaches and prevention of migraine headaches. These include injectable monoclonal antibodies and receptor site inhibitors. Avoiding triggers of these headaches. Tylenol, non-steroidal anti-inflammatory drugs and triptans remain the main options for treating migraines but new and better therapies are now available.
  6. Bebtelovimab, the monoclonal antibody infused to prevent COVID-19 from progressing to severe disease requiring hospitalization may not cover some of the newer Omicron variants. It is currently still recommended by the CDC in all 50 states and is the product administered at our local hospital. That may change in the next few weeks.

Hope you enjoyed this poo-poo platter of medical knowledge. Call me if you have any questions.