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.

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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.

Misleading News on Colonoscopy for Colon Cancer Screening

I rarely take issue with research which is peer reviewed and published in prestigious medical journals but a study published in the New England Journal of Medicine regarding screening for colon cancer created more havoc and uncertainty about the worthiness of screening with a colonoscopy than is appropriate.

Michael Bretthaur, MD, PhD of the University of Oslo in Norway invited almost 85,000 adults aged 55-64 in Europe to participate in a screening colonoscopy or serve in a control group with no screening. Only 42% of those invited took the colonoscopy. Based on the large numbers in the study, the conclusion was that the procedure did little to reduce death from colon cancer over a 10-year period. This conclusion was noted by the international media and played up with the idea that maybe screening colonoscopy isn’t such a great tool? NBC and CBS nightly news covered it that way. CNN actually led with a misleading headline about it.

If you actually looked at just the data of those who had the procedure, it appears that colonoscopy reduced the incidence of colon cancer by 31 % and the risk of colon cancer related death by 50%. The message should have been “If you were screened with colonoscopy your chances of dying from colon cancer were reduced by at least 50%.”

There were problems with the study. The health care providers doing the colonoscopy were not as accomplished at finding polyps as the physicians who perform the study in the USA. The 10-year follow-up period of who developed colorectal cancer is considered too short a window for this particular disease which probably requires a 15-year observation window. The research team conducting the study will now be following the participants for another five years to correct this flaw. The numbers and conclusions are expected to change with the additional five years of data.

No sane person wants to prep for a colonoscopy and have the procedure. However. it is one of life’s necessary prevention evaluations. The media’s presentation of this study added great doubt to its efficacy. People will undoubtedly skip colonoscopy screening due to the way newspapers and TV news shows covered this study.

Colonoscopies save lives and by removing precancerous polyps with malignant potential save suffering too. I just had my colonoscopy. I hated every minute of the prep. The bowel cleansing preparation continued to upset my system for twelve hours post procedure. That said, it was worth every second of feeling uncomfortable to prevent a miserable disease.

Artificial Sweeteners & Cardiovascular Risk Increase

Mathilde Touvier, MD, and colleagues of the Sorbonne Paris Nord University published an observational study in the British Medical Journal online edition showing a link between consumption of artificial sweeteners and cardiovascular disease. Their study looked at total daily consumption of artificially sweetened drinks and consumption from foods as well as sweetener added from packets to food or beverages.

The study included over 103,000 French adults who were followed for an average of nine years.  The participants consumed on average the equivalent of 100 ml of diet soda or one individual packet of tabletop sweetener (42.46 mg/day). These individuals had a 9% increased risk of a heart attack, stroke, need for a cardiac catheterization and angioplasty or transient ischemic attack compared to those who did not use artificial sweeteners.

The researchers could not find a “safe daily dosage” below which the sweeteners did not increase risk. They did note that the higher the consumption of artificial sweetener the higher the risk of a cardiovascular event.  Aspartame intake was associated with an increased risk of cerebrovascular events while acesulfame potassium and sucralose increased the risk of a coronary event. It is felt that these sweeteners influence insulin sensitivity ultimately resulting in increased risk for a disease event.

A synopsis of the study was published in the online journal MDedge Internal Medicine.  This article included an opinion by researchers who published studies supported by the artificial sweeteners industry which dispute the methods and conclusions of Dr Touvier’s study.

Until the answers are resolved, it appears avoiding artificial sweeteners is as good an idea as avoiding too much sugar. I prefer limiting sugars at 16 calories per teaspoon compared to risking the potential ill effects of artificial sweeteners.

Artificial Sweeteners: Good for Weight Loss but Possible Increased Cancer Risk

J. L. Sievenpiper, MD, PhD of St. Michaels Hospital in Toronto, Canada and his associates published a review article in the Journal of the American Medical Association Network Open which looked at 17 controlled studies aimed at showing that using artificial sweeteners led to loss of weight, lower Body Mass Index (BMI) and reduction in cardiovascular risk factors. One week later, Charlotte Debras, a PhD candidate at the Sorbonne, and her colleagues published in PLoS Medicine a study showing that several of these products result in an increased risk of cancer. They noted that aspartame and acesulfame potassium carried the increased risk while sucralose did not.

Consumption of certain artificial sweeteners caused a 13% increased risk for developing obesity-related malignancies including colorectal, stomach, oral, liver, esophageal, breast, ovarian and prostate cancers. A 15% higher risk of obesity-related cancers was seen for aspartame alone and a 22% increased risk for breast cancer. They then looked at those consuming low doses of these sweeteners. They still faced a higher risk of cancers. Sucralose products did not carry a higher cancer risk at any dosage.

The message is clear. If you must consume artificial sweeteners, Sucralose is the best choice. Sucralose is used in Splenda and NutraSweet. The authors, from Paris, made it clear that they hoped a larger study of this issue would be undertaken to confirm their findings.

COVID – “It’s only like a cold or a mild flu.”

Talking and writing about the pandemic and Sars2 Coronavirus got old months ago. At this point in time, most of my patients have received three doses of a vaccine and many have survived breakthrough cases of COVID. Fatigue at having to deal with this highly transmissible virus has led to a relaxation of everyone’s approach to this disease. Over and over, I hear friends, patients and neighbors tell me they refuse to put their lives on hold and hibernate for a virus that will at best give them a cold or mild flu. I am a bit more wary of that assessment.

Medscape Cardiology, an online medical journal summarized an article that appeared in Nature Medicine citing that the risk of a cardiovascular event such as a heart attack or stroke was 4% higher in the 12 months after contracting the COVID-19 virus. Researchers at first thought these numbers would apply to older patients with cardiovascular risk factors such as diabetes, high blood pressure, hyperlipidemia, obesity etc. This increased risk occurs across the board in young and old, smokers and never smokers, Caucasians and people of color as well as males and females. The research was done using Veterans Administration health data. Sicker hospitalized COVID patients had a higher risk than non-hospitalized patients, but the risk did not exist in similar groups who had no evidence of COVID infection. The actual immediate symptoms of infection may be mild and brief for the vaccinated, but the 4% increased risk of cardiovascular events is quite large considering the number of Americans who have been infected.

At this point in time, patients are deciding on their own to obtain a fourth shot which can raise your antibody levels but not necessarily prevent a breakthrough infection. Children five and under still don’t have access to a protective vaccine. Long term COVID is now more common with fatigue, post exercise exacerbation of symptoms, brain fog and now documented dysfunction of oxygen transport from arteries to tissue and veins and autonomic nervous system dysfunction. Recent studies have shown chemical abnormalities of the spinal fluid in patients with “long” COVID and brain fog.

I believe we have much to learn about this coronavirus and its long-term effects on humans. I will continue to advise wearing an N95 mask indoors, avoiding indoor crowds, maintaining distancing and continuing efforts to avoid infection. Relief is coming soon from new antiviral pills, monoclonal antibodies and variant specific vaccines Please don’t let down your guard in the meantime.

Dementia – Multiple Trials & Interventions to Delay Cognitive Decline

There have been multiple studies presented at scientific meetings recently that look at what influences the development of dementia and what may delay it. We have known for years that anything that interferes with sensory input to the brain can lead to increased risk of dementia. Improving hearing with hearing aids was found long ago to improve your chances to avoid dementia as you age.

A recent study published by Cecelia Lee, MD MS in JAMA Internal Medicine revealed that individuals undergoing improvement of vision with cataract surgery reduced their risk of dementia significantly. The study looked at over three thousand patients undergoing cataract surgery and or glaucoma treatment between the years 1994 and September 2018. Patients were evaluated every two years during the study with Cognitive Abilities Screening Instrument (CASI) and those with scores indicating a cognitive decline were referred for more detailed testing. Although having cataract surgery reduced your risk of dementia treating glaucoma, it did not provide the same risk reduction for dementia. There were numerous theories on why cataract repair helped based on the type and quality of light reaching the retina and brain, but it was an improvement to normal in another of our senses.

Another study looked at the effect of taking a daily multivitamin on the risk of developing dementia. This study funded in part by Centrum Silver and called the COSMOS trial looked at 2262 men and women all older than sixty-five with a mean age of seventy-three. They were evaluated before entry into the study with cognitive tests and again every year for three years. Those taking a multivitamin exhibited a “slowing of cognitive aging by 60%”. Taking a multivitamin seems like an easy inexpensive intervention to preserve cognitive function and hopefully these results will be confirmed and reproduced in future studies.

Recent studies looked at the benefits in maintaining brain volume and cognitive function when drinking coffee and tea containing caffeine. The studies showed that coffee drinkers benefitted more than tea drinkers but they both benefitted in reducing the risk of cognitive decline. A recent publication took the research a step further by having test subjects drink several cups of coffee and several cups of tea per day. The benefits of drinking both beverages on the same day were far greater than drinking individually.

    Last but not least , a study executed by the Cleveland Clinic Genomic Medicine Institute under the direction of F. Cheng, PhD, looked at insurance data to determine if taking Viagra (Sildenafil) modified your risk of developing Alzheimer’s disease (one form of dementia)  The study over a 6-year period suggested that Viagra users were 69% less likely to develop Alzheimer’s disease than non-Sildenafil users. This study, which was announced and covered extensively on television news and the print media, resulted in more phone calls to my office than the other studies. This was an observational type of study and further research is needed before prescribing this medication for this preventive reason.

Of interest to me was the fact that most of the men who called asking for Viagra after reading this article were on other medications for other medical illnesses that prevented them from safely using Sildenafil products.

Alcohol & Gastrointestinal Cancer

For many years now we have been taught that adult consumption of alcohol in moderation is an acceptable life practice. We have been told that women can safely drink one alcoholic beverage per day, if not pregnant, while men can drink two per day. Of course, driving a car or handling machinery while under the influence is not acceptable. We were also taught that our alcoholic beverages were highly caloric and that they, in fact, were considered “empty” calories providing little if any nutritional benefit.

Unfortunately, the purchase and consumption of alcoholic beverages during the COVID-19 Pandemic has markedly increased as a result of isolation, stress and quarantine.  We have also seen individuals binge drink large quantities of alcohol and even seen individuals become toxic with alcohol poisoning. Moderation and being responsible are always stressed with regard to alcohol consumption.

A study in JAMA Network Open may make us reconsider those ideas. This study looked at the adult South Korean population from 2009- 2017 who did not have a gastrointestinal cancer diagnosed. They followed almost 12,000 adults aged 40 or older with 40% agreeing they drank alcohol. Participants were divided into mild, moderate and heavy drinkers based on the volume of alcohol consumed. They were then followed and compared to the non-drinking portion of the group for the development of GI cancers.

The study found that the frequency of drinking is more of a risk factor for developing GI cancers than the actual volume consumed. In fact, among mild drinkers, those who had an alcoholic drink 3-4 nights a week had a greater chance of developing a GI cancer than those who drank heavily but less frequently.

In life nothing comes without a price. The question I raised and have not received an answer to is “Just how high is this risk?” Is the risk of developing a GI cancer with a cocktail with dinner equivalent to the risk of being killed in an auto accident on a major highway? Is a cocktail with dinner riskier than smoking a pack of cigarettes per day, or sky diving?

Until someone can present the data in a manner that I understand the true risk, it’s difficult to develop a health recommendation. Were these results an outlier unique to the Korean population? When I know based on evidence, I will let you know. Until then “cheers.”

Should I Measure My COVID Antibodies?

On a daily basis I get asked by patients to please add an antibody test to their necessary blood work monitoring chronic conditions and medications to see if they have immunity against COVID-19. Some want the information just to feel comfortable that they have responded to their vaccine administration. Some have had COVID-19 and want to see if their immunity is sufficient to avoid taking a COVID-19 vaccine or booster shot? Some who have not been vaccinated and have been ill recently but not tested just want to know if the illness was COVID-19.

The topic was just reviewed in the online journal MedPage Today. First of all, the test you order to determine if you developed immunity based on receiving the vaccine is different than the test you order to measure antibodies arising from a previous infection. Nathan Landau, PhD, a virologist with the NYU Grossman School of Medicine believes we do not yet have the data to determine if antibodies we develop from infection or vaccination are appropriate to provide immunity. “The real answer is we just don’t know. It takes time to gather that data, to know what titers people have and what their chance of getting infected is.”

To determine the level of antibody that is needed to prevent infection scientists must first perform neutralization assays or tests. These are not performed in the commercial labs that do antibody tests for COVID-19. The neutralization assay is the Gold Standard . The test is performed by taking the blood of an infected individual, isolating the blood serum and then diluting it into different strengths. The different strengths are then mixed with the live Sars2 Coronavirus in a set amount. They then observe if the virus is killed off.

 In order to kill the virus you must have neutralizing antibodies. The commercial labs only measure the total antibody not specifying how much of that is actually successful in neutralizing the live virus. The neutralization assay looks to see what dilution of the antibody kills off 50% of the virus.

For example a dilution of 1:100 means 1 milliliter of serum was mixed with 99 milliliter of saline. At this point we do not know what dilution is necessary to prevent infection. This data is known for diseases such as measles, German measles and different strains of hepatitis.

There has just not been enough time yet to make this determination but the research is ongoing and conclusions should be released soon. What is known is that the mRNA vaccines produce more immunity than the non mRNA vaccines. They also know that the antibody produced from a vaccine is superior to the immunity from infection against new variants and reinfection. The commercial tests are expensive, time consuming and use reagents affected by supply chain problems.

Zinc For Colds This Season?

Two weeks ago, my wife was doing her weekly childcare activity of love watching our two toddler grandchildren while our adult kids were on a business trip. The 3.5-year-old had brought home a viral respiratory infection the week before, gave it to his one-year-old brother and both kids were now in the tail stages of recovering from annoying but not serious illnesses.

In today’s world, coming home from school with a sore throat, runny nose and malaise means tea and honey, warm soup and a COVID-19 test. Both kids were negative but several days later my wife, then I, had similar symptoms. My wife’s symptoms settled in her sinuses and 10 days later her doctor put her on antibiotics and nasal spray. I was fortunately much less symptomatic but still have some nasal congestion and dry cough. We have a commercial preparation of a zinc product to prevent and reduce the symptoms of these infections but did not get around to taking them. In the past the literature wanted us to take these lozenges every two hours and I was not going to set an alarm at night to wake up to suck on a zinc tablet.

Jennifer-Hunter, PhD, from the Western Sydney University and associates studied the questions about zinc products’ effect on preventing and abating the common cold and published their findings in the online version of the BMJ Open on November 1, 2021. They looked at 28 randomized controlled studies with 5,456 patients. Their results showed that oral or intranasal zinc did prevent about 5 infections of those exposed per 100 persons when compared to a placebo. They found that if you challenged healthy individuals with a human rhinovirus inoculation the sublingual zinc did not prevent a clinical cold. Those who continued the zinc tended to have resolution of symptoms two days earlier than those who took placebo. For those who took the zinc prep there were more episodes of nausea and mouth and nose irritation.

I appreciate the science and think I will pass on the zinc for now and stick with avoidance of sick individuals plus chicken soup, tea and honey when I catch the virus anyway.