Distancing, N95 Masks and Eye Covering Protect Against Respiratory Illness

To wear a facial covering or mask, or not, has been turned into a political affiliation and machismo issue in the United States instead of a scientific, medical and public health issue. A publication in the British medical journal Lancet clearly brought the issue into a medical public health category.  The “cliff notes” summary of the study is that for each meter (2.2 meters = one foot) you distance from a contagious individual, the less likelihood you have of becoming infected with that illness.  Facial coverings diminish your risk of catching the disease by about 15% and N95 or KN95 respirator masks work better than surgical masks, bandanas or cloth masks.

The study was a systemic review and meta-analysis of 172 observational studies involving SARS, MERS and COVID-19 spanning six continents with almost 26,000 participants.  Daniel Chu, MD, PhD made it clear, “The risk for infection is highly dependent on the distance to the individual infected and the type of face mask and eye protections worn. Six feet or more away is the optimal distance to maintain. While N95 masks scored best in terms of protection for health care workers, facial coverings of any type reduced the chance of infections from 17.4% to 3.1%. Eye protection reduced the risk of infection from 16% to 5.5%.”

Due to a shortage of personal protective equipment (PPE), the CDC downgraded its requirements for health care workers treating sick infected individuals  to surgical masks, cloth masks or bandanas.  Professor Raina MacIntyre, MBBS, PhD at the Kirby Institute University of New South Wales in Sydney went on to say that recommending anything less than an N95 mask for health care workers is like sending troops into battle “ unarmed or with bows and arrows against a fully armed enemy.”

Many wonder what the difference is between an N95 respirator mask and a KN95 respirator mask. They both are supposed to prevent 95% of the particles of a certain size from penetrating. If the masks are reviewed and approved and certified by USA agencies such as OSHA or the CDC, they are labeled N95.  If they are reviewed by similar agencies in China, they are labeled KN95. In most cases the product is made outside the USA even if the company is an American firm.

Key points to remember are:

• Distancing works with over six feet best for preventing person to person transmission of respiratory illnesses like Covid-19.
• Facial coverings reduce the risk of infection.
• N95 and KN95 are the gold standard for health care workers.
• Eye covering reduces infections even further. 

This is not a macho or political issue. It’s an infectious disease public health issue.  Be smart and considerate of others. Cover your mouth, cover your eyes and keep six feet or more apart.

Absence of Leadership Is Why COVID-19 Is Destroying The USA

Two articles arrived at my desk discussing the ongoing tragedy of COVID-19. One is written in the New England Journal of Medicine by Dr. Eric Schneider. Dr Schneider sees the ability to test someone quickly and reliably as the only way out of the pandemic and back to some degree of normal life without there being mass casualties and deaths. He is appalled that foreign nations with far less developed scientific communities have developed testing and contact tracing so that they can limit the spread of the disease while safely opening those societies again. 

He cites the failure of the Trump administration to heed warnings, prepare for the arrival of the virus and more importantly to produce, distribute and test the public while collecting and organizing the data as the only reason we are now left with “non pharmacological interventions (NPIs)”   Shutting down society and staying at home is our only successful  NPI option to date.  He goes on to criticize the administration for looking for that magic cure with a medication or a quick vaccine which the scientists working on them insist will take longer than the President claims it will.  While Dr. Schneider believes that NPI’s have been successful, they carry their own price of economic ruin, social isolation and a restless population now demonstrating loudly to resume commerce and normal activities even though the infection rate and death rate will be so much higher. 

An editorial in the revered British Journal The Lancet today discusses the need to revive the CDC. The editorial highlights the history of the Center for Disease Control and its role as a world leader in public health and safety.  It then goes on to illustrate how the Ronald Reagan and George W. Bush administrations, and now the Trump administration, have destroyed its funding and marginalized its role.

The Lancet editorial board first criticizes those administrations for reducing funding when the CDC was leading the fight against HIV disease worldwide. The current administration has eliminated funding and support even further.

The CDC always kept pandemic surveillance personnel in China since Asia has always been a birthplace of new serious viral illnesses such as SARS, Bird Flu and MERS. Funding elimination resulted in the last CDC surveillance officer leaving China in July of 2019.

When the current CDC Director Nancy Meissonier, MD warned the world about the COVID-19 pandemic on February 25, 2020; she was removed from White House briefings and public appearances because of her prophetic statement. “The CDC needs a director who can provide leadership without the threat of being silenced and who has the technical capacity to lead today’s complicated effor. Americans must put a president in the White House come January 2021, who will understand that public health should not be guided by partisan politics.”

PLCO Data Support Protective Effect of Aspirin in Preventing Deaths

In recent months, the US Preventive Task Force has recommended adults without diabetes or documented coronary artery disease avoid taking baby aspirin to prevent heart attacks and strokes. They believe the risk of bleeding outweighs the benefit derived. They still recommend aspirin prevention in men with known cardiovascular, cerebrovascular disease and diabetes.

The Prostate, Lung, Colorectal and Ovarian Cancer Trial (PLCO) just made the decision-making much more complex. In their study, reported in this month’s JAMA Network Open, they found that taking aspirin as infrequently as 1 to 3 times per month reduced the risk of all-cause and cancer related mortality compared to no aspirin in their study with 146,152 patient participants.

Weekly use of aspirin significantly reduced the risk of mortality from both GI and colorectal cancer and all mortality endpoints irrespective of how heavy you were. When the study looked at 12.5 years of aspirin use 1 to 3 times a month, compared to none, the all-cause mortality was reduced by 16%. The results were even more encouraging when aspirin was taken three or more times per week.

The PLCO Cancer Screening Trial involved participants aged 55-74 who were randomized to a cancer screening group or a control group at 10 United States Medical Centers. This review looked at men and women 65 years or older at baseline. While this study showed a beneficial effect of aspirin in the elderly, other recent studies have been less favorable. The ASPREE study, Aspirin in Reducing Events in the Elderly, found that individuals taking 100 mg of aspirin daily were at increased risk for all-cause mortality compared to those taking a placebo.

The decision to take low dose aspirin, or not, is something you should discuss with your physician so that you can tailor the situation and risks to your personalized needs.

Talcum Powder Does Not Cause Ovarian Cancer

Katie O’ Brien, PhD, of the National Institute of Environmental Health Sciences in North Carolina reported a study in nearly 250,000 women over an 11 year span that showed that talcum powder does not contribute to the development of ovarian cancer, The study was published in JAMA, the Journal of the American Medical Association.

The study found that in women who used talcum powder in the genital area, a total of 61 cases per 100,000 persons years was detected. When they compared that to women who never used talcum powder in that area, they found 55 cases of ovarian cancer per 100,000. The difference between users of talcum powder developing ovarian cancer by age 70 compared to nonusers was just 0.09%.

The concern about talcum powder use and cancer occurred in 1976 when asbestos was found in talcum powder. Most talcum powder is felt to be asbestos free today.

New Approaches to Early Prostate Cancer

Men today diagnosed with early prostate cancer, Gleason Stage 7 or less, have the option of a new arm of care called watchful waiting. With periodic PSA blood tests, prostate biopsies and imaging studies; urologists and oncologists can follow the patient with disease felt to be not aggressive rather than radiate the lesion or surgically remove it as was done in the past. In some cases, they can watch it even closer with an approach called Active Surveillance. This week a new research treatment was made public.

MedPage Today published work by Steve Raman, M.D., of the UCLA Medical Center on his TULSA-PRO ablation clinical trial. One hundred-fifteen men with localized and low, or intermediate, risk prostate cancer underwent ultrasound blasting of the cancer using the MRI imaging equipment to direct the therapy. In his study, prostate volume decreased from 39 cubic centimeters before treatment down to 3.8 cubic centimeters after a year. Clinically significant cancer was eliminated in 80% of the study participants and 65% had no evidence of cancer after biopsy at one year. PSA blood levels decreased by 95%. The side effects were minimal with low rates of incontinence and impotence and few bowel complications.

The study leader noted that if prostate cancer reoccurred then the modalities of repeat ultrasound treatment, surgery or radiation were still possible. In August 2019, the FDA approved the TULSA-PRO Device for use. The procedure involves placing a rod-shaped device into the urethra. The device has ten ultrasound probes which are controlled by a computer program while the patient is observed in an MRI machine. The probes shoot out sound waves that heat and destroy the tissue the sound is directed at. The procedure is an outpatient procedure which can also be used to shrink a non-cancerous enlarged prostate from benign prostatic hypertrophy.

Environmental Pollution Linked to Decreasing Lifespan and Increased Deaths

Worsening air pollution is killing more people at a younger age. We read on a daily basis about a White House sponsored movement back to the use of coal for fuel. At the same time, rules and regulations designed to keep our air and water clean are being relaxed by Administration appointees to the Environmental Protection Agency.

Instead of protecting the environment so that future generations have clean air to breathe, and water to drink, we see rule after rule put in place to protect our countries environment scraped by officials who cite economic profit and jobs over environmental concerns for future generations. When the discussion gets heated, officials cite the fact that even if we use clean energy, developing countries like China and India and third world nations produce enough environmental pollution to offset our best efforts.  The rhetoric goes back and forth between advocates for developing and exporting clean energy (solar, wind, natural gas and nuclear) versus coal products. But, what do the facts say?

A recent study published in the Journal of the American Medical Association Open Network directly linked air pollution and its contribution of fine particulate matter to the atmosphere with an increased burden of death from several causes. The researchers followed 4,522,160 military veterans in the USA from 2006 to 2016 and linked their exposure to increased particulate matter or pollution to increased deaths from nine causes including:

1. Heart Disease
2. Cerebrovascular Disease
3. Chronic Kidney Disease
4. Chronic Obstructive Pulmonary Disease
5. Dementia
6. Type II Diabetes Mellitus
7. Hypertension
8. Lung Cancer
9. Pneumonia

The increased death rate was more noticeable in persons of color living in poor socioeconomic communities. The causes of death were in no way related to accidents.

The concentration of pollutants the study population was exposed to was actually lower than the new relaxed standards the current Environmental Protection Agency has approved. Last month a similar study was presented at a worldwide meeting of the World Health Organization.

The message is quite clear.  Unless we want to see a rising death toll due to air pollution, we need to improve the air quality and ask for more stringent standards. At the same time, the USA needs to support the development of clean fuel and energy sources that we can export to developing countries so that their reliance on coal and polluting sources diminishes.

We need to do what we can to control the issue rather than continuing policies that increase the deaths of our citizens in the name of profits.

Taking BP Medications at Night More Efficacious Than in the Morning

The European Heart Journal published the Hygia Chronotherapy Trial which followed hypertensive patients in Spain for a decade between 2008 and 2018. There were 19,000 participants of whom 10,600 were men, all older than 18 and all being treated for high blood pressure.  The group was randomly selected to either take their blood pressure medications at bedtime or in the morning.  They were followed with frequent blood pressure checkups plus 48-hour ambulatory blood pressure monitoring to assess their sleep time blood pressures.

The study was performed only on Caucasian participants who went to sleep on what would be considered a normal day/night schedule.  The results were significant and important.

Those who took their blood pressure medications at bedtime saw the risk of dying from a heart or blood vessel related problem drop by two-thirds compared to those who took their meds in the morning.  Night time administration of blood pressure medications resulted in a 44% drop in heart attack risk, a 40% drop in the need for coronary artery revascularization, a 42% drop in the risk for heart failure and a 49% drop in stroke risk.  The overall reduction in risk for cardiovascular death was 45%.

This is a significant study which must now be performed in patients of color who tend to have higher night time blood pressures.  While these studies are in progress, it appears that taking your blood pressure medication before bed is the correct choice.

Healthy Aging – Adjustments for Living & Reality

For several years now my wife has been complaining that I do not hear her when she talks.  I have gone for regular ENT checkups with audiology testing and while there is clearly a drop in hearing certain frequencies, my word discrimination and comprehension put me in a position of delaying using hearing aids for another year.

I was aware I had trouble hearing my middle adult daughter’s voice frequency.  I was missing words on TV especially when foreign accents were present leading to the purchase of TV Ears which solved the problem.  Still I knew that without auditory stimulation your brain deteriorates at a faster rate.

Last year the ENT doctor sent me home with a pair of hearing aids to try.  “Your wife called and said that if you don’t try them she may find me and kill me in my sleep.”  I was so angry with my wife for interfering that I made a point of pretending not to hear her every time she addressed me and I had the hearing aides in.  Those hearing aids were returned within the 30-day trial period because I could not use my stethoscope with them in.

One year later I was back again and this time my hearing test showed some drop in my word discrimination. They suggested trying a blue tooth compatible pair of hearing aids and even took out a stethoscope to show me how my hearing was enhanced using the stethoscope thus eliminating my favorite argument.   I wore them home and frankly they are wonderful.

The next day I had an appointment for my six-month eye exam. My acuity was off and I suspected my visual field in one eye had diminished based on driving and athletic pursuits.  The test confirmed my suspicions with my ophthalmologist diagnosing “normal pressure glaucoma” in my right eye.  “We need to lower the pressure by 3% with the drops I am prescribing and if the pressure doesn’t decrease we will recommend a laser surgery procedure in three weeks.  You are not going blind, but we want to preserve your visual field.”

The look on my face advertised my disappointment.  “It’s not so bad, you have sent me hundreds of patients with this situation and we helped them all. Why are you so troubled over this?  Looking at your med sheet and problem list at least you aren’t complaining about ED.”    When I didn’t answer her there was a long pause and she said, “Oh, I am sorry if I brought up a difficult topic.”   The best I could mutter was that in geometry what was once an acute angle is now an obtuse one.”

I tried to sell the fact that my dermatologist had me on a short-term course of prednisone which was raising the ocular pressure, but she wasn’t buying that argument.  New glasses, nightly eye drops and hearing aides all in a 72-hour period.

Instead of being grateful and thankful that I had minor correctable issues, and I could afford to spend the $6000 plus dollars for hearing aides and new trifocal lenses, I was moaning and groaning about the trials and tribulations of healthy aging. It was like running into the ocean surf on a hot day preparing to dive in to the surf and cool off and an unexpected wave smacks you down and stuns you before you can dive below its crest and avoid the strong impact.  I was devastated.

It took about 72 hours to adjust.  At my regular Friday night dinner with friends my buddy said, “Steve you seem to be hearing much better tonight. We did not have to repeat anything. What are you doing?”   I told him I was wearing new hearing aids which he had not noticed.  I hear better through my stethoscope than I did before.  When I walk my dogs or take my daily walk I hear the birds chirping, the children playing, the sprinklers initiating their watering cycle. These are all sounds I had forgotten about.  At lectures and movies I am hearing clearer. The blue tooth connection to my cellphone makes calls easier to complete.  My new trifocals allow me to read up close far more easily and see distance much better.

As a physician and geriatrician, I stress eye exams, hearing tests and evaluations to determine our ability to stay independent and functional. I cannot explain why I was so resistant to applying the same principles to my own health.

My day-to-day life has improved markedly with the hearing enhancement and new glasses. I hope my patients and students will look at my stubbornness and reluctance to accept healthy age-related changes as an example of how hard we cling to our independence and how reluctant we are to give up pieces of it even when we know it is for the best.

Hypertension Guidelines Versus Life Experiences

One of the advantages of practicing clinical medicine, and seeing patients daily for many years, is you develop your own long-term study regarding certain medical health issues. In the area of hypertension, I have been taught by the best since my internship with pioneers such as Eliseo Perez Stable and Barry Materson at the University of Miami affiliated hospitals, Jackson Memorial Program, ensuring that their trainees were up to the task.

The goals and guidelines have changed. Lifestyle changes including salt restriction (sodium chloride), weight reduction, smoking cessation, reducing alcohol intake and regular exercise will always be mainstays of non-pharmacologic treatments.  We used to be taught to keep the systolic blood pressure at less than 140 and the diastolic blood pressure at less than 85.  These numbers have changed over the years, having been lowered, with everyone over 120 systolic now being classified as having some degree of increased risk of cardiac, cerebrovascular or vascular disease and hypertension.

We originally were taught to start with a diuretic and keep raising the dosage until the blood pressure was controlled or the patient developed adverse effects. We learned that when we used one medication, pushing it to its limit inducing adverse effects along the way, patients just stopped taking their medications. This resulted in a change in strategy to using several medicines each with another pathway to controlling blood pressure but all at a lower dosage which did not produce any ill feeling adverse effects.  The downside of more medications was additional costs and more pills to remember to take.  As hypertension experts pushed us to lower systolic blood pressure to 120 or less in our geriatric population I was concerned that lowering the pressure that much would again create adverse effects which were as or more troublesome than the risk  of having a BP between 120 and 140 systolic.  An article in JAMA Internal Medicine looked at this issue. They looked at patients over 65 years of age who were hospitalized for non-cardiac related problems and whose blood pressure was over 120. They studied these patients at Veterans Administration hospitals over two year period. Patients with elevated blood pressure above 120 were given more medications and higher dosages to bring their pressure down to meet the more stringent guidelines. The result was that there were no fewer cardiac events than anticipated and no better blood pressure control at a year.  In addition, these patients suffered from an increased number of re-admissions to the hospital and “serious“ adverse events within 30 days.

The new guidelines for blood pressure control may be applicable in a younger healthier population.  In the geriatric population we may need to readjust our goals to account for the physiologic changes that occur in men and women who age in a healthy manner. More specific data on why there were more re-admissions and what serious adverse effects occurred needs to be made public to determine if the effort to tightly control blood pressure is to blame.

Antibiotic Use – Independent of Physician Prescribing

A recent article in the Annals of Internal Medicine looked at individuals who took antibiotics without them being prescribed by physicians at a visit.  The authors looked at 31 published studies between January 2000 and March 2019.  The medications came from family and friends, online distribution sites, drugs prescribed for their animals by their veterinary doctors and those stored after a previous indicated use.   When asked about it, and the reasons why these patients took these medications, the main factors cited were lack of health insurance or lack of healthcare access, cost of physician visits or medications, long waiting times in clinics, embarrassment for needing antibiotics, lack of transportation and/or easy availability of antibiotics  from other sources.

We are currently going through an antibiotic resistance crisis in the world.  Most of the fault lays with agricultural industry feeding livestock tons of antibiotics to fatten them up. Patterns of resistance develop on the farms and are passed species to species.

To remedy this, the US agriculture industry, especially in chicken production, has cut back drastically on this process.  At the same time, we are requesting physicians to work with infectious disease doctors in stewardship programs to reduce their use of ineffective antibiotics and to prescribe with precision when these medications are needed.  It works. Studies are beginning to show the benefits of these programs.

Despite this, the pressure from patients to be given something when they pay for, and invest in, a medical evaluation for an infection is overwhelming. In the setting of telemedicine, as well as walk-in and urgent care centers, reviews and patient satisfaction survey results are tied to whether the patient was given an antibiotic whether it was indicated or not.

As bacteria become resistant to common and inexpensive antibiotics, pharmaceutical manufacturers are not being incentivized to produce newer more efficacious medications.  At the same time, older useful antibiotics which do not generate much of a profit are not even being ordered and stored by chain pharmacies that lose money each time the older generics are prescribed.

To begin solving this problem, an improvement of our health literacy is required. Education in schools and in public health announcements, both in print and social media, need to realistically address the issue. This education will not replace the need for access to health care and health, but it is a beginning to make individuals understand how, when and why these “miraculous” medications can and should be used.