The Medical News Report
Samuel J. LaMonte, M.D., FACS
Subjects for September, 2020:
IMPORTANT REMINDER!!!! PLEASE READ!!!
I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.
The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns. You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.
Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.
Thanks!! Dr. Sam
Great news regarding convalescent plasma treatment
The best news is finally coming from some of the treatments that were promising. Now there are several studies that prove that patients who developed COVID-19 have high levels of immune factors to combat the virus for other infected and sick patients who are given transfusions of the plasma (the liquid portion of blood) from these recovered patients. There has been as high as a 35% improvement in mortality rates using this life saving plasma. We are winning! PLEASE DONATE PLASMA IF RECOVERED, AS ONE DONATION IS ENOUGH TO TREAT 4 PATIENTS.
Get the flu shot!!! Make sure children are vaccinated, and discuss the pneumonia and shingles shot with your doctor! Preventative checkups are lagging because of the pandemic, and there needs to be a more robust attempt to notify the public about screening exams, vaccinations, and how important the role of prevention plays normally, but even more in the face of a pandemic. That requires funding.The last thing an individual needs is to develop an illness that could be prevented during this crisis. Weight management, good nutrition, and exercise are the building blocks of prevention.
As we continue to face spread of the virus because of a lack of compliance to follow the rules by 18-34 year olds, I wonder how many people are still complying as well. This age group dominates the surge experienced in the South and other areas. Are people still washing their hands for 20 seconds, still maintaining social distance, cleaning surfaces, and wearing masks?
Thankfully, most businesses are requiring masks to enter the establishment, as it should be, and 39 states have some kind of mandate, which they are allowed to do. Whatever it takes! But the economic impact must be kept in mind.
The Occupational Safety and Health Administration can permit businesses to require masks for customers. However federal mandates can create a problem with legal challenges, according to JAMA Network, August 10, 2020.
The CDC derives its authority from the Public Health Services Act of 1944. It, however, has changed its direction on recommendations regarding the pandemic, creating confusion and room for criticism.
Politics contaminates the entire landscape….so sad. There will always be a debate about how much the federal government can control our lives. Also state power is still part of the fabric of our constitution.
I will report on Flu/COVID-19 this fall, and the CDC does not recommend sick patients seek a flu shot until recovered, primarily to protect healthcare workers from being infected.
Lastly, it is the public health department’s responsibility to look out for our health with little regard for the financial impact on our country, and the leader’s responsibility to keep our country running. This difference creates controversy. We need a country to behave and we will get through this.
It is a different world now, and will have a long lasting impact on how people view the world, each other, priorities, and travel, retail, etc. Add hurricane season to the mix, civil unrest, and the fact that we have had this virus interfering with our lives for over 6 months, and now face potential complications of a Flu/COVID-19 season this fall, provides a perfect storm for a rough 4th quarter.
Our resilience is certainly being tested, but we must persevere and obey the recommendations and mandates and pray we are provided a safe and effective vaccine early next year.
I would like to honor those healthcare workers who died because of or with COVID-19 complicated by underlying disorders—386 in the U.S. and 2012 globally (clearly an incomplete list!
Here are several items below that have come out in the medical literature and healthcare organizations.
Guidance from the American Academy of Pediatrics for children
As children go back to school with various options, the Academy of Pediatrics has recommended cloth face coverings for all children 2 and older. If there are vulnerable family members at home, they recommend consideration for face coverings even at home on those vulnerable. This is a lofty recommendation to expect face coverings in the home 24/7. Distance, cleaning, and hygiene make much more practical sense, but it is no surprise organized medicine will lean on the side of caution.
Childcare centers who really adhere to the rules are experiencing minimal spread. Good news!!
New reporting requirements for children started August 1
Over the past 4 weeks, there has been a 90% increase in positive cases in children (180,000), although most of have minimal or no symptoms, reported by the Pediatrics Academy. This reporting was enacted August 1, so expect more numbers.
This represents 1-9% of the total cases depending on the state (only 11 states reported) according to the Academy of Pediatrics. The younger people (18-34) are the primary individuals who are testing positive (most are asymptomatic or having minimal symptoms), and they would be the likely individual to infect their children. Hospitalization is still rare compared to adults.
The workforce is requiring weekly testing of employees, otherwise, we would not have realized the surge was happening.
How long this rise in numbers of cases continues remains to be seen, but will impact decision making for type of schooling. Children might be better off away from family, since home is the primary source of transmission, regardless of age.
It will be a challenge at best for households to comply with rules for outside the home. Look how much suffering has already occurred from social isolation, quarantine, and lack of normality.
New saliva test for diagnosing COVID-19 FDA approved
The FDA has approved a new saliva test for pandemic, which could cut the cost of diagnosing infections. The emergency use authorization is for SalivaDirect, and can collected in any sterile tube for testing. Coronavirus Resource Center
Honey superior for upper respiratory infections
A recent report stated that honey outpaced all other supportive type treatments for cough severity and frequency. This might be an easy addition to all who develop cough from any form of infection including COVID-19. Honey has always been the perfect food and now may actually have scientific proof it helps in treating respiratory disorders. Pediatric and Adolescent Medicine, August 18, 2020
Certain masks are of minimal value
Certain masks have been found to effectively reduce the transmission of the virus—N-95, KN-95, surgical masks, polypropylene, and hand-made cotton masks were able to reduce the droplets of mucus from the airway.
Bandanas and fleece were found to provide little protection. This study came from a study in Science Advance Journal.
Droplets were tested in 14 different masks with participants talking through the masks. The droplets that escaped through the mask were passed through a laser light and recorded while speaking words.
The N-95 mask was still the best protection. Bandanas are counterproductive and disburse droplets in a larger surface area allowing more droplets to pass through the covering. Science Advance, August 7, 2020
Don’t keep using the same mask, and wash the ones that can be.
Long term heart failure from COVID-19
Heart damage from COVID-19 is common in severe cases and a significant number of deaths occur from heart failure. A new study on autopsies showed considerable invasion of the heart muscle with viable coronavirus found. Now a follow up of 3 months after discharge of a group of patients who had an MRI of the heart found considerable damage not only in those with heart disease but even in as high as 20% of patients who did not have known heart disease. Surveillance over time may be necessary to follow these findings.
COVID-19 patients may develop full blown diabetes
It is well known that diabetics are significant risk for a more serious case of COVID-19, but now research reports claim that some patients who apparently were not diabetic before becoming infected, developed insulin dependent diabetes.
The virus’ influence on our metabolic and immune system is well known and the pancreas can be attacked as well from T-cell immune markers (cytokines, etc.). NEJM, August 20, 2020
Symptoms after recovery
80% of those hospitalized survive, as does 60% of those admitted to the ICU, but death rates continue to decline with newer treatments.
People who are diagnosed with sepsis (pathogens in the blood) have similar statistics to those with heart faliure. This will be discussed at length in a report on sepsis later this year.
87% of patients who recover from the virus still have symptoms of fatigue, cough, and loss of smell if it was part of the original symptoms.
For those who had severe disease, the psychological consequences are even more devastating including a high incidence of PTSD, depression, and anxiety.
Cognitive impairment is also an issue in 16%, according to a very recent report in JAMA. Close surveillance with telehealth and other methods are necessary to follow these patients, since a percentage will require re-hospitalization within a few weeks due to the underlying diseases that might worsen.
This creates some controversy, since the CDC does not recommend testing after recovery now. It clouds the issue of when a person could consider whether they are still infectious.
The CDC states that after symptoms stop or a person has gone 10 days from the onset of symptoms, they can consider them free of transmission. This includes an incubation period of 3-4 days.
With such a high percentage of people having symptoms for 1-2 months after recovery, but it is known that people who recover do not have viable virus after 14 days, even if symptoms persist. We must trust the science on this.
Death from or with COVID-19—causes inflation of the numbers.
There has been a great discrepancy of the number of deaths from the beginning of counting deaths from this virus. It has medical and political ramifications. The media hypes the number scaring the public unnecessarily. The experts in public health are paid to overcautious
People who die of any disease and happen to test positive on autopsy can sign the death certificate of COVID-19 related.
Playing a role in a death is much different than causing the death. The government is paying hospitals more for a COVID death.
Did anyone ever calculate how many people that died of COVID-19 were about to die of their underlying disease?
Medpage, July 14, 2020
The young people just won’t follow the rules
What is it going to take the younger people to obey the rules for the virus? Start with the people who are responsible for them.
A Georgia summer camp with 600 kids mostly 6-18 tested positive after just 1 week at camp, and 6-10 year olds were the highest percentage of those who tested positive (44%). This was reported by Medscape.
The counselors, all very young people, failed in providing masks to the kids, did not have adequate ventilation in the cabins (16-26 kids in some of the larger cabins), and did not keep the kids socially distanced. This is just one example of why we are failing as a country to follow the guidelines. Where is the discipline?
It appears that only those who are at higher risk are behaving properly, while the younger generations are cavalier in following the guidelines.
More evidence on asymptomatic infected individuals
A recent report on asymptomatic infected individuals in South Korea (isolated in a community center) stated that of those who were exposed and tested positive, 20% developed symptoms over the next few days (these are termed pre-symptomatic individuals).
Those symptoms that appeared were mostly respiratory --sore throat, runny nose, productive cough, reduced smell and taste, and various gastrointestinal symptoms. All but one individual remained out of the hospital with mild symptoms.
These asymptomatic individuals had a similar viral load in their bodies compared to symptomatic patients. This reinforces the need for anyone exposed to isolate until they have tested negative or have quarantined for at least 14 days. JAMA Internal Medicine, August 6, 2020
Follow up on Influenza/COVID-19
Only 45% of individuals were vaccinated against influenza, which prevented an estimated 4 million cases of flu, 58,000 hospitalizations, and 3500 deaths in 2018-2019. Fewer flu cases preserves the capacity for hospitals to concentrate on caring for COVID-19 patients and other serious disorders.
This year, with recommendations from the WHO for the content of the flu vaccine for the Northern Hemisphere and authorized by the FDA, has announced that the vaccine will contain Influenza A (H1N1) and (H3N2) and Influenza B. This will include a trivalent and a quadravalent vaccine (the 4-vaccine contains an additional influenza B component), including a higher dose vaccine (Fluzone Quadravalent).
Approved for people over 65 is a vaccine called Fuad Quadravalent.
Discuss these different options with the pharmacist or personal physician.
It will offered by the end of October, however, this is another discussion point, as last year, flu season started earlier than usual (early October) with peaks in January.
Those who should take the vaccine as a priority are:
These are the recommendations from the CDC. Healthcare professionals and those with or are in contact with children, or are employed where there is higher than normal contact with others should strongly consider the vaccine. For more information, search on CDC.gov.
Flu vaccine decreases the risk of illness by 40-60%. Sadly, childhood flu vaccine rates dropped 21% since the pandemic. Children can get very sick with the flu and transmit it quite well. PPEs, hand washing, and sanitizing surfaces should be just as effective in preventing flu as COVID-19 and can make a big difference in all ages.
The media should spend their time supporting vaccination and common sense precautions rather scare tactics. Parents must police their own children or we will suffer the consequences.
Obviously there is no experience with flu and COVID-19.
JAMA, July 28, 2020
Unintended consequences from COVID-19
I have reported on the massive side effects created by the shutdown and isolation of the American people. Many feel it is a greater threat to the future of our country than the virus. Here are the numbers:
Medical practices under financial distress
With reports now published, the medical profession is hurting just like every business. As many as 20% of offices are finding it extremely difficult to keep all of their employees (causing furloughs), are seeing fewer patients because of protective issues, and increase in costs for PPEs, and many are on the brink of losing their practices with the federal funds (Provider Relief Fund) coming to an end to support them. Physicians close to retirement are retitng early, and primary care practices are most hard hit. Telehealth calls are now helping some, but access to care takes another hit. Medscape, August 19, 2020
More information on the psychological impact of the virus
At the end of June, 2020, there were 169,000 people who reported moderately to severe depression and anxiety. This was publishe by Mental Health Association, who had a voluntary mental health screening program. Based on this questionnaire, an additional 18,000 individuals were found to be at high risk for psychosis in June alone. These numbers are 500% moere than before the pandemic.
The most profound psychological effect occurred in those under the age of 25. Loneliness and isolation were the 2 biggest factors in their deterioration. Grief, loss, and financial distress were right behind the above factors.
25,000 of these voluntary participants stated they had suicidal ideation or self harm.
The balance between reopening the country and being safe has never been as critical.
For young people, transitioning to college was a big factor and getting back to school was also a concern. Many who left the “nest” have been forced to return to the “nest” creating not only problems for the individual but their families who feel they must let them return.
These facts should reinforce the healthcare profession screening for depression and anxiety, as recommended by the USPSTF (U.S. Preventative Services Task Force).
6 cancers caused by HPV
The HPV virus (human papilloma virus) causes oropharyngeal ( mouth and throat), cervical, vulvar, vaginal, penile, anal cancer, and recently a 7th cancer has been added (esophageal). Although there are more than 100 strains of HPV virus, only a very few cause cancer (strains 16,18, 21)
Below are major changes in cervical cancer screening guidelines and who should receive the HPV vaccine.
Some cancers on the rise
Anal and oropharyngeal (oral and throat) cancer is rising, while cervical cancer incidence is already starting to drop thanks to the vaccine and screening. About 80% of oropharyngeal cancers are HPV positive. Even some laryngeal and esophageal cancers are HPV positive.
According to JAMA Otolaryngology, May 7, 2020, oropharyngeal (throat) cancer outnumbers cervical cancer with 13,000 cases annually (all HPV cancers 33,000 annually).
All men are at risk, but it is known that men having sex with men do have more genital cancers caused by HPV, and people with greater than 11 lifetime partners are at higher risk.
With over 33,000 HPV-caused cancers annually, it is very clear, parents must get their children vaccinated as early as 11-12, and can catch up to age 26 (was 45). It can prevent 90% of these cancers, since the vaccine lasts for most of a person’s life.
American Cancer Society New Guidelines
A. Cervical Cancer Screening
1. Cervical cancer screening should start at age 25 instead of 20 every 5 years until age 65.
2. HPV testing (a genetic test of cervical cells) replaces Pap smear (cytology test) unless it is not available.
3. Co-testing with HPV and Pap smear acceptable alternative.
4. If Pap smear cytology is the only available test, testing should occur every 3 years.
5. Women over 65, if negative tests for 10 years, may choose to discontinue testing.
For more in depth information, click on www.cancer.org
B. ACS revises HPV vaccination schedule guidelines—Gardasil
Public awareness is crucial regarding protection during sex and vaccination of the young before sexual contact occurs.
The American Cancr Society has clarified their HPV vaccination schedule for children and younger people. The vaccine needs to be received before being exposed to the human papilloma virus through intimate contact.
This virus affects up to 20% of Americans and rarely causes any symptoms. It is most likely contracted with oral-genital or genital-genital contact.
ACS recommends the HPV vaccine:
1) the vaccine should be administered at 9-12 years of age with healthcare providers offering the vaccine series at age 9-10. If doctors do not bring this vaccine up to parents, there is less likelihood they will receive the vaccine. Parents must be proactive.
2) Clinicians should inform patients aged 22-26 who have not been vaccinated, that vaccination given later is less effective but still may be effective, because the person may not have been exposed to the specific strains that cause cancer.
3) ACS states it is imperative the vaccine be received unless there are medical reasons not to.
CA-Cancer J Clin, July 8, 2020
HPV vaccination can prevent 93% of oral infections, as long as the person has not already become infected.
For those younger people now getting vaccinated, there is already studies that prove it will drop the incidence of genital cancers greatly in future decades. It is hoped in the future that it will reduce the incidence of oropharyngeal cancers.
JAMA-Otolaryngology, May 7, 2020
One HPV shot may be enough—Big News
Recent studies suggest that one vaccination shot may be adequate to protect women from cervical cancer and other genital cancers.
Education about the link between cancer and this virus remains low (70% surveyed did not know the link existed).
The CDC estimates that 33,700 genital cancers occur annually from the HPV virus. Getting vaccinated at the recommended age of 11-12 is strongly recommended to all girls and boys. Catch up vaccines are also recommended up to the age of 26.
Since 1979, a law was passed requiring drug manufacturers to stamp a date of expiration. A column in the Pharmacology Today Magazine may have shed some light on this subject. This is the date that manufacturers must guarantee full potency and safety of the drug distributed.
Most of the data on this subject came from a military study, who requested guidance from the FDA. The military had a large stockpile of drugs and wanted to know if they should toss them out at great expense or could be still used. Of the 100 drugs analyzed, 90 medications were deemed safe and effective even after 15 years.
So what is up with this subject today? This article felt that most over the counter and prescription medications are ok to take, but there is no guarantee that the potency is 100%. So if it 90%, what to do? Ask the doctor, but don’t expect them to tell you an answer in many occasions. They don’t want the liability. Use common sense.
There are exceptions to the rule such as tetracycline, aspirin, insulin, nitroglycerine, and liquid antibiotics.
Expiration dates from manufacturers are very conservative in predicting that date. Are expiration dates nothing but a ploy by the manufacturer to sell more drugs?
It was recommended that if the drug was a vital life saving type of medication and was a few years over the expiration date, it might be prudent to buy a new bottle or get a new prescription just be on the safe side. Otherwise, it would be an individual’s decision to make.
Aspirin degrades, and when the bottle smells like vinegar, it is time to toss them.
What about the longevity of generic drugs vs brand names? These generics are required by law to be the exact equivalent. However, how well are they monitored?
In the end, I would ask a pharmacist. At least, if a medication has just recently reached the expiration date, based on the article I read, it would be reasonable to assume that the medication is still good to take, at least until a person could get to the doctor and be sure that the medication is appropriate for the illness or disorder currently under concern.
More important, don’t take other people’s medication!
A large class action lawsuit against Johnson and Johnson’s talcum powder as a possible cause of ovarian cancer. What woman hasn’t used powder on their genitals, and yet with little scientific proof, the pharmaceutical company decided not to spend billions on defending their companies and agreed to a settlement to a class action suit. It was found there are trace amounts of nationally occurring asbestos in the talc. A recent study reported on January 7, 2020 by JAMA found no association between the two. A pooled U.S. sample of 253,000 women (median age 57), stated that 38% reported use of talcum powder and 22% of that group frequent use, and 10% long term use.
61 cases of ovarian cancer per 100,000 persons occurred for those who ever used talc, and 55 cases per 100,000 for never users. Reporting bias of frequency of use is an obvious weakness. And because of this slight difference, it is costing J&J $2 billion. 40% goes to the lawyers, a standard cut.
In the report from 4 different research projects concluded there was not a statistical difference in these groups. Previous small studies have shown a very weak link to ovarian cancer and talc.
All of this came to the surface, when trace amount of asbestos were found in some samples of talcum powder. Because it is a carcinogen, the legal profession jumped on the opportunity.
2213 developed ovarian cancer out of the 257,000 women studied. As expected talc products were used commonly by this group. Older women were more likely to report use of talc. Black women were more unlikely to use talc genitally. There was no clear dose related evidence or frequency of use.
Talc is known to contain trace amounts of asbestos in nature. Many cosmetic products contain talc to some degree.
Experimentally talc with or without asbestos can cause an inflammatory reaction in ovarian tissue. Pelvic inflammatory disease (PID) increases the risk of ovarian cancer as does chlamydia disease. More research is ongoing regarding this subject.
Remember the millions of dollars paid out for silicone breast implants because it wrongly linked to arthritis and immune diseases (there is now an extremely rare lymphoma that can occur around the implant). After the implant companies paid out huge sums, legitimate research was performed and found no link to these immunologic diseases from silicone breast implants.
Risk Factors for Ovarian Cancer
There are certainly legitimate risk factors for developing ovarian cancer such as BRCA gene mutations, certain familial cancer syndrome, and behavioral factors (smoking, alcohol use, obesity, having children later in life, never having a child, in vitro fertilization, using estrogen after menopause, family history, those who have had breast cancer, and age alone are risk factors according to the American Cancer Society.
I have discussed many of the psychiatric disorders, but need to report a new classification of psychiatric disorders. It puts things in nice boxes but diagnosing these disorders is not that easy, as there is overlap in these disorders.
This classification is only one of the groupings of psychiatric disorders, because all psychiatrists do not agree. The American Psychiatric Association uses the DSM-5 (2013) classification and is based on signs and symptoms, which closely mimic how the rest of medicine would classify disease.
These classifications are closely linked to the insurance codes for reimbursement. For the rest of medicine, all we want is some simplified classification to understand. That is why I provide this list simplified as it may be. It is a good reference.
After several years, there has been ongoing concern that smoking e-cigarettes as a teenager or younger would lead to becoming a regular smoker of tobacco products.
A JAMA report in February, 2019 studied this issue and cited the results of several studies that concluded that e-cigarettes are clearly a gateway product to becoming a smoker.
Many naïve young people do not know or care that there can be more nicotine in e-cigarettes (the amount is not regulated as it is in cigarettes).
The flavors of e-cigarettes attracted the young to the product, as anticipated by the tobacco industry, who owns a share of the industry and is quite enthusiastic since the number of adults smoking is decreasing, the e-cigarette industry plans to hook enough young people on nicotine in e-cigarettes until they can legally buy cigarettes, which has been proven.
The study reported that if a young person smokes e-cigarettes regularly, they are 4X more likely to become a smoker later in life. It estimated that the e-cigarette users will be responsible for between 15-20% of future smokers.
There are three factors cited that attract the youth to e-cigarettes—1) high peer acceptance 2) flavors and 3) perceived safety. Ease of access, regardless of laws, and less irritating to never smokers, are other factors.
Vitamin E acetate is the culprit in injuries from e-cigarettes
Vitamin E acetate is known to thicken e-cigarette liquids (mostly in black market e-cigarettes) and has been found to be the common denominator is a high percent of those who are becoming sick, develop lipoid pneumonia, and die. This holds true for marijuana liquid (THC) as well, which can be used in the cartridges of e-cigarettes
It should be noted that when youth turns to e-cigarettes, they are 2-4 times less likely to start smoking cigarettes.
As young people age, and theoir nicotine addiction continues to strengthen, many choose to continue their nicotine addiction with real cigarettes. This transition occurs since smoking cigarettes is perceived as “cooler and more mature”. Peer pressure plays a role as well, as people who smoke tend to socialize with smokers.
Some states have made e-cigarettes illegal below the age of 21 or have banned them, and it will be interesting if they will move to cigarettes, use dip or oral tobacco, turn to blackmarket vaping products, or just wise up and quit.
Those who have had lung injury should be followed closely for future lung disease. Certainly they are at significant risk for further complications and should be seen by a pulmonologist. Also access to abuse services, psychological counseling, etc. should be considered.
Marijuana and pregnant women
A recent study published in Nature Medicine (August 10, 2020) stated their findings show a 1.5X greater risk of autism spectrum in their babies if marijuana was used regularly. The Canadian study included 500,000 pregnant women who had a 50% increase in the autism spectrum disorder. This study occurred before marijuana was legalized in Canada. That is disturbing.
Chantix is best for smoking cessation
Varenicline (Chantix) in a recent study outpaced other forms of smoking cessation methods, including nicotine gum, patches, and bupropion (Wellbutrin). According to the U.S. Public Health Service. The chance of being successful in quitting smoking cigarettes is less than 10%, but with Chantix it doubles the chances. E-cigarettes have never been approved as an option for smoking cessation.
Chantix was highly recommended for patients who have other so-existing psychological disorders over Wellbutrin, since it has significant anxiety side effects since it is an anti-depressant.
A minimum of 12 weeks treatment is recommended.
The U.S. Public Health officials also recommend using nicotine patches in conjunction with Chantix and found these were the most successful at quitting.
American J. Respiratory and Critical Care Medicine, July 15, 2020
Not only does smoking cigarettes and e-cigarettes
This completes the September report!
Next month, the October report will include:
1. Prostate Updates
A.Prostate cancer—surveillance (watch and wait)
B.New procedures for enlarged prostates
2. New information on how pain works in the brain
3. Primary dysmenorrheal—painful periods
4. Life expectancy rises for the first time in 4 years
5. Are generic drugs really safe?
6. Sepsis (bugs in the blood)
Stay healthy and well, my friends, Dr. Sam