COVID-19 Ba2 Variant: My Medical Office

There has been an increase in patients infected and testing positive for COVID-19 in our area. For those who have been vaccinated, and received the boosters, if you get this new variant your symptoms will likely be similar to a cold and flu.   

Typically, most people will not get sick enough to require hospitalization or the intensive care unit. However, as with any serious illness, there are always exceptions.  Recently, we lost a patient who was vaccinated and had received the COVID-19 boosters. He was taking an immunosuppressive medication for a serious skin issue but still his loss is a horrible reminder of how fickle and deadly this illness can be.

At this time, we require our patients to be vaccinated and have received a booster. For those individuals over 50 years old, or immunosuppressed, who have taken the three shots, four or more months ago, we encourage you to take a fourth shot. Local CVS , Walgreens, Publix are administering the vaccines by walk in at some locations or by appointment. You can schedule an appointment online by accessing their websites or calling them. If you cannot use a computer, call my practice and we will try to set up your appointment for you if you are my patient.

We will continue to ask our list of questions as a screening process to determine if a  face-to-face office visit in needed. The questions come from the CDC, the University of Minnesota School of Medicine Department of Infectious Disease with M. Osterholm, MD as chairperson and from the cruise ship industry. With two staff persons over 65 years old, and two living in multigenerational households, we are entitled to know the risks to our staff in advance of a visit. We are taking these precautions for the safety of our staff and their loved ones.

PATIENTS WHO TEST POSITIVE:

  1. Patients who test positive, with no symptoms, will need to quarantine at home for five (5) days per CDC guidelines. If they have no further symptoms after five days, they may resume their lives but wear a mask around others for an additional  five (5) days.
  2. Those who test positive and develop symptoms should quarantine for at least five (5) days and until symptoms are gone for at least 24 hours. They should be wearing a mask around others for 10 days from the start of symptoms.
  3. Those who test positive with symptoms and consider themselves high risk patients need to call the office. Sotravimab monoclonal antibodies are still being administered in Florida until the number of COVID cases caused by the Ba2 mutant is > 50% of all cases in the state. Baptist Health Boca Raton Regional Hospital still has an active monoclonal antibody infusion program. When Sotravimab is removed from use due to ineffectiveness, we can prescribe the oral medications Paxlovid ( if you are not taking any of the medications contraindicated with it) or the Merck pill Molnupiravir. If you are ill and have questions please just call us.

Testing locations are a real issue. The state sites at FAU runway and South County Civic Center have apparently been shut down. If you have questions about where to test call the office please.

We are actively seeing patients in person in the office Monday through Friday in the safest environment we can provide. Just because people wish to pretend that the pandemic is over doesn’t make it so! We recommend that when indoors, in public places, you continue to wear an N95 or KN95 mask if you do not know the others around you. With the Ba2 variant being so much more infectious and transmissible than previous variants you need to consider whether going to your gym, indoor dining and indoor clubs and theater are in your best interests.

Recent peer reviewed published studies show that those infected with even mild COVID not requiring hospitalization or treatment carry an increased risk of heart attack or stroke for at least the next 12 months. Controlled diabetics lose control in 40 % of the infections and those with pre-Diabetes on the borderline convert to full blown type II Diabetes in 40% of the infections even if mild.

At the current time, we are only accepting vaccinated individuals for our complimentary meet and greet sessions and as new patients. Patients who are not vaccinated and have at least one booster (unless they have a documented medical condition preventing vaccination) will not be retained when their annual membership is due for renewal. If you have any questions, suggestions or comments please call the office and stay safe!

Dementia – Telltale Indicators

In the United States, 11% of adults 65 years of age and 33% over 80 years old are diagnosed with dementia. My generation of Baby Boomers likes to pretend that todays “80” is like yesterday’s 55 years old but it simply is not true.

To combat dementia researchers are looking at numerous causes to try and reduce the number of future patients. An interesting article looked at the resting heart rate of senior citizens. Those who had a resting heart rate over 80 beats per minute were statistically more likely to develop dementia.

At the same time, the same research group was looking at resting heart rate another research group was looking at inflammatory markers that can be detected with a blood draw and be prognostic. They found an association between having a low HDL level and elevated Triglyceride level and an increased risk of developing cognitive impairment. This was especially true in individuals with Type II Diabetes Mellitus.

Researchers are looking for genetic markers that would hint at an increased risk of dementia. Others are trying to develop medications that will stop or interrupt the process and prevent or limit the disease.

In the meantime, we are left with trying to live a healthy lifestyle starting at an early age. Being active, avoiding smoking, avoiding excessive alcohol and keeping our weight and blood pressure under control will still be our best defense. Starting at any age helps but developing healthy living habits as a young adult seems to be the best choice.

PreDiabetes in The Elderly – Not to Worry

As physicians and educated adults we realize that developing diabetes increases our risks of heart disease, narrowing of our arteries or vascular disease, injury to the retina of our eyes leading to poor low vision or blindness, peripheral neuropathy or burning pains in our feet and elsewhere. We additionally have been taught the correlation between controlling our blood sugars and trying to reduce the risk of developing these complications.

In my early years in practice if a patient came in for fasting bloodwork and their glucose level was elevated above 110 on two occasions they met the legal definition of diabetes. Patients always had an excuse. “It was my birthday so I had cupcakes at work, cake and mixed alcoholic drinks at home, etc.” There were always rational reasons for being a human being, enjoying life and not being a disciplined diabetic patient.

The development of the hemoglobin A1c eliminated those excuses. It recognized that the higher your daily average blood sugar the more sugar would bind with a hemoglobin molecule and increase your hemoglobin A1C. That has given us a measure of your average blood sugar over the previous 90-days. Normal values were established as well as values in the diabetic range. The intermediate values were labeled “pre-diabetes”.

The question became “How do you keep “pre-diabetics” from becoming diabetics and risking all those complications.” Did the same rules apply to middle aged adults as to the elderly?

For the most part I counseled pre-diabetics that they had an increased risk of developing diabetes but if they stayed active, kept their weight down and improved their dietary choices they would be fine.

A research paper in Journal of the American Medical Association (JAMA) online edition now supports that position. Mary Rooney, PhD of the Bloomberg School of Public Health at Johns Hopkins University, published her data looking at 3,142 individuals 70 -90 years old with 44% being diagnosed with prediabetes. They were followed for six years.

During that time-period, only 9% of them went on to become diabetic. Thirteen percent (13%) improved into the normal glycemic range. Nineteen percent (19%) died of other causes.

The message is clear. If you are 70 years of age or older, and your hemoglobin A1C moves into the 5.7 or greater range, you are considered pre-diabetic. Stay fit and active. Keep your weight down. Meet with a dietitian and learn how to eat well and healthy, stop smoking and go for regular checkups. Diabetes will not do you in!

Scientific Reports, Media Reports and Ambiguity

Last week I read an article in a peer reviewed journal citing the benefits of a few eggs per week as part of a low carbohydrate dietary intervention for Type II Diabetes.  The information was so meaningful about a controversial food source of protein that I decided to write about it in my blog and pass it along to my patients.  Three days later the American Heart Association and American College of Cardiology discussed the increased risk of cardiovascular events and mortality in individuals consuming three or more eggs regularly. They talked about the detrimental cholesterol being concentrated in the yolk making egg white omelets look healthier than traditional omelets.

In the early 1970’s a VA study was published showing that veterans over 45 years of age who took an aspirin a day had fewer heart attacks and strokes and survived them better than those who don’t.  Fast forward almost 50 years and we have different recommendations for people who have never had an MI or CVA or evidence of cardiovascular disease compared to secondary prevention in individuals who have known coronary artery disease, cerebrovascular disease or diabetes. Throw in the controversial discussions of aspirin preventing colorectal adenomas from developing, aspirin preventing certain types of skin cancers and today’s report that suggests it may prevent liver cancer. Now three studies suggest that in older individuals (70 or greater) the risk of bleeding negates the benefits of cardio and cerebrovascular protection and aspirin may not actually prevent heart attacks and strokes in that age group.

We then turn to statins and prevention of heart attacks and numerous articles about not prescribing them to older Americans.  I saw articles on this topic covered by CNN, the Wall Street Journal, ARP Journal, AAA magazine and in several newsletters published by major national medical centers.  In each piece they caution you to talk to your doctor before stopping that medicine.

I am that seventy year old patient they all talk about.  I have never smoked. I exercise modestly on a regular basis, getting my 10,000 or more steps five or more days a week.  I battle to keep my weight down and find it difficult to give up sweets and bread when so many other of life’s pleasures are no longer available due to age and health related suggestions.

There are clearly no studies that look at patients who took a statin for 15 years and aspirins for over 20 years, stopped them and then were followed for the remainder of their lives.   How will they fare compared to patients who never took them?

I have this discussion every day with my patient’s pointing out the current guidelines and trying to individualize the suggestions to their unique lifestyle and issues. On a personal level, I still have no idea what the correct thing is to do even after discussing it with my doctors.  How can I expect my patients to feel any differently?

Eggs and Diabetes – New Information

Diabetes has been known as a risk factor for cardiovascular diseases for years. Egg consumption was discouraged by experts.   Our perception of eggs as they relate to diabetes and heart disease may have to be reconsidered based on a study published in the American Journal of Clinical Nutrition in May 2015

The Kuopio Ischemic Heart Disease Risk Factor Study enrolled 2,332 men, aged 42 -60 years old, and followed them for more than nineteen years.  Four hundred thirty-two participants developed Type 2 Diabetes.  Men who ate the most eggs demonstrated a 38% lower risk of developing Type 2 Diabetes in this study.  Higher egg intake was associated with lower levels of fasting plasma glucose and serum C – reactive protein.

The researchers published a follow up paper in the Journal of Molecular Nutrition and Food Research this year and came up with similar results stating that “moderate egg consumption of eggs can be part of a healthy dietary pattern for preventive action against Type 2 Diabetes Mellitus.” Their definition of moderate was an average of one egg or less per day.

This is preliminary data involving eggs will be discussed and battled over for years to come. What is important is that once again a modest intake of a protein in moderation is probably not deleterious as previously thought.

When dealing with diabetes, lifestyle issues such as weight control, smoking status, alcohol intake, regular exercise and simple carbohydrate intake are far more important issues to address than egg consumption in moderation.  This topic was reviewed in the latest online publication of Medscape Medical News. 

A Large Review Proves Statins Are Safe

StatinsThe online version of Circulation: Cardiovascular Quality and Outcome published a review of the safety of statin drugs. The study looked at 135 randomized research trials including 246,955 participants. Medications examined included atorvastatin (Lipitor), fluvastatin (Lescol), simvastatin (Zocor), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and trials of pitavastatin.

They found there were no differences in the rates of discontinuation of the statins because of adverse events compared with discontinuation of placebo. The same applied to elevation of the muscle enzyme creatine kinase, muscle aches or myalgias and/or the development of cancer. As the doses of these medicines increased they found the participants reported more adverse effects.

Christie Ballantyne, MD of the Baylor College of Medicine reviewed the study for MedPage, the online journal of the University Of Pennsylvania School Of Medicine, and felt the study certainly confirmed the tolerability of the statins as a class of drugs to lower cholesterol and reduce cardiovascular events. He reaffirmed the very small increased risk of statin use and developing Type II Diabetes and the need to monitor liver function blood tests while taking the drugs. He concluded these risks were well worth taking in view of the benefits to your health statins provided.

Additional Study Discusses Relationship Between ACTOS and Bladder Cancer

Laurent Azoulay, PhD, of McGill University in Montreal presented data linking ACTOS with the development of bladder cancer.  His research specifically implicated ACTOS rather than implicating the class of drugs ACTOS belongs to. His group specifically did not see this effect when looking at Avandia (rosiglitazone).  Avandia has been removed from the US market because of its cardiac toxic effects.

Azoulay and associates looked at 115,727 patients given prescriptions for these antidiabetic medicines in the United Kingdom primary care data base between 1988 and 2009.  The mean age of participants was 64 years old and they were followed for over 4 years.  Patients who had been given a prescription for the thiazolidinediones tended to be more obese, smoked and have worse control of their diabetes.  These are all risk factors for the development of bladder cancer.

ACTOS has been removed from the market in some European countries. The FDA did not restrict it in a recent review.

With the new data it will become necessary to suggest alternatives to ACTOS to my diabetic patients until the matter is completely clarified.

Statin Use and Diabetes in Older Women

Older women who take statins may be at an increased risk of developing Type 2 Diabetes Mellitus (adult onset). In a study published in the Archives of Internal Medicine, Dr Ma, of the University of Massachusetts School of Medicine, looked at the 154,000 women in the Women’s Health Initiative who did not have Diabetes when the study began in 1993.  Seven percent (7%) of them were on statins at the time through follow-up, 12 years later.  At that point, 10,242 cases of new cases of diabetes were reported. They theorize that this computes to an almost 50% increase in becoming a Diabetic if you are on a statin as compared to women who are not. Surprisingly, this occurred far more frequently in thin women taking a statin than in heavy or obese women.

The salient points taken out of this research are that women on statins need their liver enzymes monitored frequently they need their blood sugars monitored as well. The overriding message is that as physicians and patients we need to make a monumental effort to control elevated lipids by diet , exercise and weight loss without statins if humanly possible.

This also raises the question of whether we should be measuring HDL and LDL subtypes an Lpa levels on all patients before instituting statin therapy?  While this raises doubt about a popular class of drugs that are a crucial part of the prevention of cardiovascular disease, it does not yet make it clear what the clinical implications are for postmenopausal women on statins.

I will reevaluate all my female patients on statins as I see them for follow-up visits.