The Medical News Report,

November,2020

#106

Samuel J. LaMonte, M.D., FACS

samlamonte@gmail.com

www.themedicalnewsreport.com

 

Subjects for November, 2020:

 

1. New Updates on COVID-19

2. Diabetes 2020Diagnosis and Therapies; Recall on some Metformin prescriptions

3. 50% of Americans will be obese by 2030

4. Can cannabis cure cancer? Medical cannabis use---current status….miracle drug or not?? Miscalculations in approving it?

5. Primary care practices shrinking

6. Anemia--Iron deficiency and Pernicious anemia-Vitamin B12; Folic acid supplement during pregnancy

7. “Snake oil” treatments

Go-fund-me accounts steer millions to snake oil treatments; Pain and Memory remedies--??? Relief Factor, Prevagen; FDA after supplement industry for bogus Alzheimer’s treatment and prevention

 

 

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.

  Thank you, Dr. Sam

 

1. New Updates on COVID-19

   The number of cases continue to rise primarily in college towns in the younger population, but they can still infect older more vulnerable people. Remember, if a person regardless of age, has underlying disease and/or obesity, will increase the risk of severity of infection, hospitalization, and death.

  Be safe and respect but don’t fear the virus. Respect each other as we cope with this pandemic. If you get exposed, please isolate and get tested (some studies say 25% will not).  

 

Remdesivir (brand name Veklury) is now FDA approved as treatment

  It is now official. FDA has approved this antiviral medication for all hospitalized patients. Prior to this, the FDA approved this experimental therapy for emergency-use authorization only in severe cases. This drug is authorized for anyone 12 years of age and older and prevents viral replication and spread in the body.

  The latest research shows that on average, the length of the illness can be reduced from 10-15 days to 5 days.

  This comes just after the WHO (World Health Organziation) declared it ineffective in improving survival, a publication without much peer review (a critical part of the acceptability of any drug study).  

  Patients need to be treated 10 days in mild, moderate, and severe cases (although some studies say 5 days is equally good). It also reduced the need for mechanical oxygenation (ventilator). An additional benefit of this antiviral….it is critical to reduce the number of illness days to preserve hospital resources.

  FDA press conference coverd by Medpage, Oct. 22, 2020  

 

The $16 trillion virus

  This pandemic created so much hardship in the world! Some people do not want to believe that China could have  curtailed this virus by closing their borders from the beginning. The WHO knew and did not warn the world because of supposed close ties to the Chinese Communits Government. With these major countries at each other’s throats, it is not too surprising the cooperation was less than stellar.

  The medical, psychological, social, and financial impact will be felt for the rest of our lives. Now the world continues to suffer from unpreparedness to face an unknown virus with such infectious capability. Some would say, public health officials should have taken their experience from SARS in 2003 (started in China), the Swine Flu pandemic in 2009, and MERS in 2012 to demand the government to better prepare for an epidemic in the U.S. Regardless, the world continues to suffer.

  Hindsight is 20/20, and it is easy to see where we and the world were caught off guard, and it should not have happened, but it did. We are catching up and doing much better with testing and treatment, and we are about to have several vaccines available by the end of 2020. Currently there has been a lack of cooperation from younger people, and the virus continues to spread as we try to reopen the country or suffer terminal financial consequences.

  The source of information for this report from JAMA cited that 25% who test positive do not isolate (mostly young people). OMG! The public must take responsibility along with cooperation from the businesses trying to rebound.

  Early on, the nursing homes were the least prepared and when COVID-19 patients were sent to back to these facilities, the death rate skyrocketed, and it still accounts for 40% of the deaths to date.

  Thankfully with the private sector and White House Task Force teaming up, quick action was taken to rectify the overwhelming needs of hospitals, providing ventilators and PPEs, etc., but it still took time.

  Rapid testing lagged greatly with the PCR test still taking 24 hours or more. However, the White House Task Force just made 100 million tests available to states with more to follow. This is critical in controlling spread of this virus and contact tracing.

  The JAMA (Oct. 20, 2020) article presented a dismal look at the financial costs of dealing with this pandemic. And we haven’t even hit flu season yet.

  60 million claims for unemployment insurance have been filed as of September. The Congressional Budget Office estimates it will cost the U.S. $7.6 trillion in lost output during the next decade. Death cannot be measured except in pain and sorrow and loss of quality of lives for those left behind. However, the economic impact on premature deaths alone is estimated to be $4 trillion.

  Economists (Harvard, U. of Chicago, etc.) estimate, even with 2 stimulus packages, 100,000 small businesses have shut down since March. That is 2% of all businesses, and 3% of all restaurants. 4.2 million of the 30 million small businesses received received emergency loans. Can the U.S. fund this pandemic disaster?

  In the graph below, look at the percentage of U.S. workers employed by small businesses in 2017 compared to 1988. This will continue to shrink with so many failed businesses. And think about the number of businesses that will only survive if the anchor businesses (restaurants) in their communities. We must support these facilities for them to survive. 25% occupancy for restaurants is not going to keep the doors open. Small restaurants are suffering exponentially.

  Our political parties can’t compromise and get out more stimulus money because of the presidential election. It will be interesting how many rules change after November 3. Suddenly, businesses will open, money will be made available, etc. You may or may not agree!

Unintended consequences revisited and Long Term Symptoms after recovery

  It will be sometime before the true impact of long term symptoms from survivors can be estimated, but it is known that a third of patients who had severe disease are still struggling with prolonged difficulty with fatigue, respiratory symptoms, and aggravation of underlying health and mental issues. Chronic lung disease created by COVID-19 may be a serious long term consequence that will shorten lives as we go forward over the next decade.

  Earlier this year, I presented a Zoom conference on COVID-19 and created slides to demonstrate the devastating unintended consequences of this pandemic. It should be pretty convincing that a shut down country is not the answer. There must be a balance between letting the virus spread and reopening it to preserve our future. After all, how are we going to pay all these trillions of dollars if we are in a depression?

Unintended Consequences

The opioid crisis is out of hand with little chance of relief with the current unemployment situation, stress to pay bills, and surviving a pandemic. America is suffering more from the consequences than the virus in many respects, in my opinion, although no one is taking this pandemic lightly with over 8 million cases and 225,000 deaths in the U.S. The good news is, 99% survive. 

  Cancer patients are extremely hard hit with COVID-19 causing a 36% mortality rate if admitted to the ICU. Blood cancer patients are at the highest risk (lymphoma and leukemia).

  If cancer patients require a ventilator, this study cited a 54% mortality rate.

  It was noted that cancer patients who require ICU admission with the flu have similar mortality rates. American College of Chest Surgeons conference, Oct. 22, 2020

  Another consequence of this virus (and this election) have been a deterioration of our social structure, stress on families and friends, domestic abuse, children exponentially suffering, divorce, separation, loss of work quality, and loss of industries completely devastated by states imposing strict rules (bars, restaurants, sports, churches, etc.) even if necessary.

  Limited visits to hospitals and nursing facilities (now open with restrictions) have taken such a toll. Not attending funerals, delays in weddings, travel, financial plans for opening of businesses, starting schools, children not maturing without social interaction with other classmates, and the delay in diagnosing serious illnesses from lack of screening is but a part of the massive impact on our country and the world. 

  It is estimated that as many as 40% of the adult population is suffering from anxiety and depression since April, 2020 (compared to 19% before the pandemic). Psychological services are grossly inadequate to handle all the cases.

  The figure of $16 trillion is estimated to be the overall cost for health outcomes with lost output which is approximately 90% of GDP of the U.S. The Great Recession of 2008 cost ¼ that amount.

  The investment for the future must include continued innovation in therapeutics, prevention through testing, contact tracing, and vaccines. Intensive research must be ongoing regarding what will come next in global pandemics. Policies must initiated with bipartisan support for these plans and cooperation between medical centers around the world.

  To recover from such a devastating virus, our country must reopen, our schools must increase face to face learning, and businesses must be allowed to reopen, BUT, it is necessary for the public to cooperate, otherwise, we are in trouble.

  It is estimated through contact tracing, 25% of those who test positive will not quarantine. OMG!

  The Rockefeller Foundation estimates that a policy of 30 million tests weekly will require an additional $75 billion bringing the cost of contact tracing to $100 billion.

  Public health measures are a key factor in getting this virus under control, but we must not cripple current industries who are bringing our country back with greater taxes and loss of industries to other countries.

  Bringing back America may seem selfish to some, but tell me how we can afford all the above costs while we don’t have an economic recovery?

  There is no room for radical socialistic thinking even if Biden wins. He must withstand the malignant nature of those who are trying to drive us into a socialistic society and worse. If Trump wins, he must work with the Democrats to provide enough stimulus for those in need, while encouraging people to get back to work, re-educate, change job types…whatever it takes.

  Businesses can’t get people to come back to work and can’t expand occupancy, and if they are making more money sitting at home, many will not return to work.

  The people of this country must adapt, and it will be painful, but we can do it with the right leadership. Who do believe can do it better? Answer with your vote.

  Who knows how best to bring our economy back? How long will it take?

 

Low tech prevention methods  

  Regardless of the lack of solid evidence that most of the low tech methods really protect, it is common sense to wear a mask, wash hands frequently, adequate ventilation, stay 6 feet between people if possible, avoid crowds (especially if high risk), and isolate when exposed or tested positive (with or without symptoms).

  The science has provided us with some evidence that most masks (not bandanas) provide some reduction of transmission of the virus. There is a caveat to that fact….wearing the mask properly!! From what I see, that is abused constantly. Do people change masks daily or more frequently. Do they wash repeat wearable masks every day?

  Keeping the politics out of the issue is in all our best interest, as we have enough division in this country already. Hopefully, after the election we will see improved compliance, more safe openings of businesses, and schools. And for God’s sake hopefully the Congress will compromise on more stimulus money.

  Regardless of how a person feels about wearing mask, etc., respect the decisions of others, obey business’ rules, and be careful when out. Remember it will also prevent transmission of the flu bug!

 

Flu has some of the same complications as COVID-19

  Both the Flu and COVID-19 are most likely to start with fever before any other symptoms. Muscle ache, fatigue, sore throat, cough, etc. may lag by a day or so. Symptoms can first appear as soon as 3-4 days or as long as 2 weeks after exposure. 40% are asymptomatic.

  Flu usually starts with cough and muscle ache and doesn’t usually involve nausea and stomach symptoms, whereas COVID-19 can. Regardless, any of these symptoms can mean either illness, and it is important to know the diagnosis, therefore, get tested for both during the cooler months.

  As discussed numerous times underlying chronic diseases increase the risk of a severe case of either illness. Obesity as an isolated issue in a healthy person increases risk and so does being a smoker.

  The flu can be very devastating requiring hospitalization and complications can occur similar to COVID-19, primarily pneumonia and heart issues including heart attacks and heart failure.

  Imagine if a person with underlying disease contracts both viruses? Will this double the chances of complications in hospitalized patients? This is unknown, but certainly will make for a more serious illness and increased risk of death. Annals of Internal Medicine, August 25, 2020

  Can I emphasize any more how important people need to get the flu shot? GET THE FLU SHOT!! Just because a person is very healthy, the flu can put a person on their back for 2-3 weeks, and is more likely to be a worse illness for younger people than COVID-19.

 

Listerine oral rinse effective in killing COVID-19; UV light and HEPA Filters for the home

  Regardless of the flu, cold weather will make infections climb, because people will be inside more and increase exposure to more individuals.

   Better ventilation of homes with HEPA filters is recommended to purify the air and decrease germs in the air as people tend to stay inside for cold weather.

  UV light kills the virus, and it is being recommended by some pulmonary specialists to buy UV light devices to sterilize the air in homes (with safety for the eyes, always following the instructions for safet).

  UV also kills flu virus. I suggest folks look into it, as it is offered by many sites. Talk to personal doctors about the wisdom of these devices.

Listerine oral rinses

  Early on there was some discussion about nasal saline sniffs and oral antiseptic mouth rinses to diminish the virus, which certainly made sense to me (an ENT surgeon). Now a study in the Journal of Medical Virology has announced that it is effective if the rinse lasts at least 30 seconds. This was a laboratory experiment and not a typical clinical study. Previously a German journal cited the same results, but not much was said about it.

  It stands to reason that Listerine with alcohol and other ingredients have always been touted to kill mouth germs that cause tooth and gum disease. Now we need more clinical studies to prove its worth in killing COVID-19 and the Flu viruses.

  For now, it seems innocent enough to gargle and rinse Listerine in the mouth when returning home after wearing a mask out in public. Be sure it contains alcohol.

  1% baby shampoo nasal sniffs

  Another experiment in this study included 1% baby shampoo as a nasal sniff, which also demonstrated a high kill rate of the COVID-19. Before snorting shampoo up the nose, I would want more verification and an actual commercially produced 1% baby shampoo, otherwise, I forsee trouble with burns, and inhalation of soap, etc.. They also stated using a Nedipot did not work.

  I have always highly recommended forceful snorting of salt water out of a cupped hand. It must be forceful enough to cleanse the mucus from the nasal lining.

  These laboratory experiments must be extended into clinical studies before their value can be assured.

 

The latest news on vaccine development

  Dr. Anthony Fauci, Head of NIH Alergy and Infectious Diseases and a member of the White House Task Force says that we should have vaccines ready for use for special groups before the end of 2020 (healthcare workers, military, first responders, nursing homes, teachers, etc. The priority will come from states.

  All vaccine’s clinical trials have resumed after a short pause due to isolated cases of complications. Independent scientists have cleared these companies to resume. They declared the vaccine safe and was not responsible for the symptoms.

  Astra Zenica, one of the pharmaceutical company working on vaccine development, stated there is good news for older people—the vaccine is creating significant antibody response even in older people which equates to solid immunity against COVID-19.

There continues to be new information in the medical journals, therefore, I will provide a mid-month update if it is warranted.

  Continue to be safe, wear your mask when appropriate, wash your hands and surfaces frequently, and socially distance as much as possible. Be smart not fearful!!

 

2. Type-2 Diabetes-- Diagnosis and new management guidelines (recalls on some Metformin products); COVID-19 connections

  For those who need a more in depth understanding of the effects of diabetes on the body’s organs, please click on: www.themedicalnewsreport.com  and go to the SUBJECT INDEX, AND SCROLL DOWN TO DIABETES, WHERE YOU WILL FIND A NUMBER OF REPORTS.

  Much of the information below came from www.emedicine.medscape.com

 

Opening remarks, statistics

  Diabetes is on the rise in the U.S. and throughout the world, while another epidemic is currently ongoing…obesity, which is closely linked to the rise in type 2 Diabetes.

  According to the American Diabetes Association (ADA) and the CDC, over 35 million American children and adults

have diabetes (500 million worldwide), which equates to 10.5% of the population. 1 in 11 Americans, and 1 in 4 over 65 years of age have diabetes. Nearly 90 million Americans have pre-diabetes. 7.2 million have undiagnosed diabetes.

 

Know the signs of Diabetes

   Individuals need to know the subtle signs (the 3 Ps)—polydipsia, polyuria, and polyphagia (increased thirst, urination, and hunger). Blurred vision, yeast infections, and lower leg numbness or tingling also is suggestive.

  For glucose to enter the cells of the body, insulin is necessary for it to pass through the cell wall.  

  Type 1 diabetics can’t make insulin while type 2 diabetics don’t make enough insulin or the insulin does not have as good effect on the body’s cells to accept glucose into the cells for energy (insulin resistance).

 

Regulation of blood sugar; cost of diabetes

  High blood sugar occurs in several ways: insulin resistance, inadequate insulin secretion, or inadequate or inappropriate glucagon secretion.

  Glucagon is the other pancreatic hormone that is produced by the alpha cells of the pancreas, whereas insulin is secreted by the beta cells of the pancreas. The balance between these two hormones allows normal regulation of the blood sugar. Glucagon is especially valuable to prevent hypoglycemia.

  Blacks and Hispanics are 50% more likely to be diagnosed with diabetes.

  Diabetes costs the U.S. $327 billion annually in health outcomes, lost time at work, medications, hospitalization, and disabilities.

  Add that financial burden to diabetics with cardiovascular disease, and this creates a most serious health problem that is affecting millions of Americans as heart disease continues to be the #1 killer in the U.S. and close to a $trillion dollar price tag. These are some of the diseases that make COVID-19 more deadly by far.

 

Who should be tested for Diabetes at 45 years of age? (earlier with more than one risk factor)

  --First degree relatives of diabetics, high risk races (Black, Asian, Latin, and Native and Asian Americans, and Pacific Islanders)

  --History of cardiovascular disease

  --Hypertension (greater than 140/90)

  --HDL-cholesterol lower than 35mg/dl and triglyceride elevation greater than 250mg/dl

  --Polycystic ovaries (secretes hormones that raise blood sugar)

  --Physical inactivity

  --Obesity

  --Patients with a skin condition called acanthosis nigracans (armpit)

 

Diagnosis of Diabetes—Blood glucose levels

--Fasting glucose of greater than 125mg/ml

--2 hour post-prandial blood sugar of over 200mg/ml

--A1c greater than 6.5%

--A random blood sugar of 200mg/ml with symptoms cited above  

 

Relationship between Diabetes and COVID-19

  COVID-19 brought the worst out in people who have chronic underlying disorders raising the risk of hospitalization, admission to the ICU, and death by 2-3 times over healthy people. 1/3 of these patients require being put on a ventilator.  

  Given the fact that 85% with type 2 diabetes also are overweight (30% of overweight people are diabetic) and have hypertension with some cardiovascular disease, the risk is even higher, and is a direct threat to even those on oral hypoglycemic agents (oral drugs that lower blood sugar). Infections also increase the complexity of treating diabetes. That certainly holds for COVID-19. 

  COVID-19 is the ultimate inflammatory infection inciting secretion of the body’s own pro-inflammatory chemicals into the blood stream which creates stress on the entire body including the pancreas (Islet Cells of Langerhan), where insulin is produced.

  Tight glucose control in diabetics is directly linked to lowering the mortality rate of diabetics with COVID-19. The blood sugar must be maintained on average of 115mg/dl and an A-1c of less than 7.3%.

Reference--The Journal Metabolism.

  1 in 10 diabetics who are admitted to the hospital with COVID-19 die within a week (that is 10% compared to the mortality of a non-diabetic at 2.7%).

  They are much more likely to develop acute respiratory distress syndrome, kidney injury, and septic shock. Treatment regimens were much more complicated because of these trends, with greater likelihood of oxygen therapy including using a ventilator in the ICU.

  Obesity, older age, and elevated C-reactive proteins in the blood (an indicator of inflammation), elevated triglyceride blood levels, and the use of insulin all were independent factors in raising mortality. Women continue to have less severe cases (24% less likely) and have a lower mortality while takng oral Metformin when admitted.

  Type 1 diabetics have an even higher mortality rate.

 

Dual therapy saves lives

  A recent study performed in Italy of COVID-19 patients with type 2 diabetes had lower mortality if their treatment included a combination of insulin and DPP-4 medication (Onglyza, Januvia, Nesina, etc.). 18% died with insulin/DPP-4 meds compared with 37% with insulin therapy alone. Diabetes Care Journal, September 29, 2020

  Comparing those whose diabetes was successfully well controlled, their death rate was 1.1% compared to 11%. Good management saves lives!!

  In another study, those people not known to have diabetes, who had uncontrolled elevated glucose levels, were also strong predictors of mortality. It is likely that many of these patients had undiagnosed diabetes.

 

Diagnosis and Management of Diabetes

 

What is insulin resistance?

  There are no symptoms of insulin resistance. In type 2 diabetes, the pancreas’ insulin is not capable of moving glucose into the cells as well as possible. This is because there are factors that make the transport more difficult, and this is called insulin resistance, which keeps the blood sugar high.

  To combat an elevated glucose, the pancreas secretes more insulin, and over time the pancreas can’t keep up and the blood sugar continues to stay elevated. Patients with insulin resistance requires insulin shots.

  Insulin resistance is part of a syndrome called the metabolic syndrome, which includes the high risk factors for increasing the risk for cardiovascular disease and mortality (hypertension, diabetes with insulin resistance, obesity, and high cholesterol). These factors are the very reason these patients are at high risk for a severe case of COVID-19.

 

  There are many conditions that tend to make insulin resistance more likely, according to WebMD, including obesity, inactive lifestyle, a diet high in carbohydrates, family history of diabetes and gestational diabetes (during pregnancy), fatty liver disease, polycystic ovary syndrome, a smoker, black, Hispanic, Native American, sleep apnea, those taking cortisone (Cushing’s disease) and other meds.

 

What is Ketoacidosis?

  When diabetics can’t produce enough insulin from the pancreas for elevated blood sugars, fat cells are broken down for the body to use as fuel. Insulin is necessary for glucose to get into the body’s cells to be used for energy. When those fat cells break down a byproduct is ketones.

  Ketones are very acid in ph, and are the reason for ketoacidosis, a metabolic disorder that causes great harm to the body. This causes many symptoms including excessive thirst, frequent urination, nausea and vomiting, weakness, fatigue, short of breath, fruity breath (ketones), and abdominal pain.

  Ketones can be detected in the urine and can be monitored. If ketones continue to increase, this can be a medical emergency and need immediate care.

  If the blood sugar is over 240mg/ml, ketones need to tested in the blood. Some glucose meters measure ketones.

  Treatment usually requires hospitalization with  intravenous insulin, IV fluids to rehydrate, and monitoring of electrolytes (insulin can drive potassium into the cell requiring replacement).

  Fortunately, for those with type 2 diabetes, ketoacidosis is rare if the blood sugar is regularly monitored. This is  especially true if patients are on insulin or taking one of the oral antidiabetic meds called SGLT-2, which can increase the risk of ketoacidosis. This particular medication, however, helps reduce heart disease in diabetics and the decision to use them must be balanced with their protective heart value vs. the risk of ketoacidosis. Annals of Internal Medicine, July 28, 2020

 

Weight loss is critical

  Obesity must addressed to help control diabetes. It is recommended that individuals lose 5% of body weight with physical activity of 200-300 minutes per week. If a person weighs 220 lbs., 5% loss would only be 11 pounds.

  Being overweight just overwhelms the capacity of the pancreas to provide enough insulin to keep the blood sugar at a normal level, thus leading to type 2 diabetes.

  Recommendations:

  a- A planned diabetic diet to lose this weight is critical and help from a nutritionist is recommended.

  b- Behavior modification aligned with a physical activity program, with long term (greater than 1 year) goals is required to be successful in this type of endeavor.

  A physician’s assistant (PA) or other healthcare personnel in the doctor’s office should assist in the guidance of the management. There needs to be a lifelong commitment to managing diabetes, as it not curable, but controllable. Tight control computes to cancel a higher mortality rate.   

  Losing weight is a very difficult task and maintaining the loss is even harder. Those morbidly obese, who are not successful could consider gastric bypass surgery, and is very successful to bring weight down and improve glycemic control. Some studies have determined surgery is no more successful that losing the same amount of weight by diet, but easier said than done.

  Many studies have shown insulin resistance improves with bariatric surgery and blood sugars come under better control even before weight loss can be attained when the surgery was performed. The mechanism is unknown.

  Some of the gastric bypass procedures are better than others. The bypass of some of the small intestine (Roux-en-Y) has been the most successful, but does have its complications. Still, it should be considered in the significantly obese.

  Another factor to consider in obese diabetics is obstructive sleep apnea. A sleep study should be performed and if significant, CPAP (continuous positive air pressure using a mask at night) should be ordered. It is very effective in helping daytime drowsiness, but not very effective in helping control blood sugars or decreasing cardiovascular disease in diabetics. With more energy during the day, it is hopeful that the individual might be more motivated to exercise and diet.

 

Treatment

  Medications are necessary for most diabetics, but the absolute beginning of diabetic control is maintaining a good diabetic diet with a specific number of calories. Calorie counting is helpful.

  Standard-release Metformin is the first line therapy increasing the dose (starting at 1000mg) over time to prevent gastrointestinal side effects, however, more is not necessarily better and has more side effects. B-12 deficiency and other causes of anemia must be monitored.   

  Normal functioning kidneys are necessary to ingest Metformin, and kidney function should be monitored since diabetic kidney disease is common. It is reported to be safe even in patients with NASH (non-alcoholic steatohepatitis), a form of fatty cirrhosis that diabetics develop.

 

How diabetic medications work

  Below are the medications that lower blood sugars, but there are different mechanisms.

1- The blood sugar can be directly reduced (insulin).

2- The liver can be controlled so that it does not release glucose as fast (Metformin).

3- Meds can stimulate the pancreas to make more insulin (GLP-1).

4- Meds can increase the excretion of glucose by the kidneys (SGLT-2).

5- Meds can inhibit an enzyme (DPP-4) that influence GLP and GIP hormones that affect the blood glucose levels (Januvia, Onglyza, Tradjenta, Nesina).

  How effective the medications are can be influenced by diet, weight, exercise, and how difficult the diabetes is to control.

  Physicians choose certain medications based on each individual’s circumstances, their weight, presence of kidney disease, hypoglycemic risk, cost, risk for side effects, and patient preference. Medications should be re-evaluated every 3-6 months.

  Most of these medications can lower glucose levels too much (hypoglycemia), and diabetics need to be aware of this and carry some form of sugar with them just in case. Glucagon, one of the pancreatic hormone, is available as a medical treatment for hypoglycemia.

 

Anti-diabetic medications

  Many of the new diabetic control drugs are extremely expensive and must be taken into consideration. These are the average costs without insurance.

a- Metformin (Glucophage)-- $4 for 30 days at Walmart

b- DPP-4 inhibitors-- $581 per month

  These meds were approved in 2006--sitagliptin. In 2007, a combination of this drug and Metformin can be used as a monotherapy or can be combined with sulfonylureas, as triple therapy. Nesina, Tradjenta, Onglyza, and Januvia are some of the brand names.

c- SGLT-inhibitors-- $530 per month

  These are newer medications and include Invokana, Farxiga, Jardiance, Steglatro. They increase the removal of glucose through the kidneys. However, as mentioned above, it does increase the risk of ketoacidosis, but is desirable if heart disease is present, since it improves heart function. These two factors must be weighed against each other, decided on a case by case basis.

d- GLP-1 agonists-- $1165 per month 

  Tanzeum, Trulicity, Byetta, Victoza, and Ozmepic are the most common. These drugs can help the body make insulin. These meds require an injection.

e- Sulfonylureas-- $50 per month

  Glucitrol, Diabeta, Micronase

  These medications have been around since the 1950s, and have largely been replaced. However, they are inexpensive, which is a huge issue. These medications increase the release of insulin from the pancreas. They can be added to Metformin.

f- TDZs—Thiazolidinediones-- $112 per month

  Actos, Avandia

  TDZs work on insulin resistance, by producing new fat cells, which are much more sensitive to body’s own insulin.

g- Insulin injections-- $332 for a vial of insulin plus cost of syringes

  Insulin is produced to directly lower glucose in different speeds:

--Rapid or Fast-acting—30 minutes

--Regular or short acting insulin—3 hours

--Intermediate—takes a few hours 8-10 hours and lasts longer

--Long acting—a 24 hour injection, but can last longer.

 Combinations of these forms of insulin are common.

Glucose Meters and Insulin Pumps

  There are metered pump devices that can monitor the glucose to inject the needed amount of insulin 24/7, but expensive. Using a blood glucose meter is an essential tool for type 2 diabetics. Insulin pumps also make it easy.

    

 

When oral hypoglycemic agents can’t maintain blood sugars in an acceptable range, insulin injections should be considered.

  New studies are beginning to recommend the earlier use of insulin to control diabetes to prevent the many complications of this disease. Using insulin may allow the pancreas to recover some of its ability to produce insulin. Some doctors may recommend starting with insulin and once control is attained, switching to an oral med may be possible.

  During stressful times or medical illnesses, insulin will likely be used to control the blood sugar, as the glucose will rise more aggressively. Certainly during hospitalizations, including treating COVID-19, insulin will be started even if the patient was taking oral medications.

  Other instances, when insulin will be necessary are: 1) surgery 2) medical emergencies such as a heart attack 3) pregnancy 4) taking medications such as corticosteroids  5) diabetic ketoacidosis.

  Long acting insulin will be most likely used initially to keep the blood sugars stable throughout the day and night. If that is not successful, short acting insulin may be added before each meal to contend with the rise caused by the calories consumed.

  The insulin pump is a good choice when the glucose levels require more than one shot per day, which can provide a metered dose of insulin 24/7. Glucose levels must be monitored 4X a day.

  Although still in clinical trials, a once a week insulin shot is probably going to be approved in the next year. That will increase the number of diabetics willing to switch to insulin (to keep from taking a shot daily).

  A diabetic diet is critical to maintain stable levels of glucose, eating the same number of calories each day and avoiding most carbohydrates.

  Carbohydrates cause the greatest rise in glucose and are to be avoided. Each carbohydrate has a glycemic index, and only carbs such as beans and whole grains, which have low glycemic indices, are recommended instead of the other obvious “white stuff”.

 

2020 new guidelines for treatment of type 2 Diabetes; some recalls of some Metformin*

*(The FDA has announced certain pharmaceutical companies have manufactured Metformin with a possible cancer causing contaminant and are recalled—please check what company makes your Metformin and call your pharmacist. There is a list on the FDA website that must be returned—Amneal, Apotex, Teva, Marksana, Granules, and Lupin Pharmaceuticals). Return it for a replacement.

  The American Diabetes Association (ADA) has recommended Metformin as the initial treatment in milder cases, however, for more severe cases, here are the new guidelines:

1) Early combination therapy is recommended if the Hemoglobin—Hgb-A1c is higher than 1.5-2.0% above normal levels (normal is less than 6.5%). It has been deemed that solo treatment with Metformin does not reduce the Hbg—A1c more than 1.0% on average.

2) Insulin should be considered early if the patient has had weight loss, has symptoms of high blood sugar (thirst, hunger, increased urination) or a very high Hgb A1c (>10%) or a very high blood sugar >300mg/ml.

(GLP-1) medications are preferred over insulin by the ADA. Examples are Trulicity, Byetta, Victoza, Ozempic. These medications stimulate the body to make insulin. However, cost is a consideration. They also may help weight loss.

3) For patients with known cardiovascular or kidney disease, the GLP-1 or the SGLT-2 meds are recommended initially.

4) If cost is a major concern, sulfonylureas and TZDs (Thiazolidinediones) may be used to lower blood sugar. Also lower cost insulin may be used. The current administration has implemented a cost-saving for diabetics on insulin.

5) If weight loss is desired or prevention of weight gain, GLP-1 or SGLT-2 meds should be considered.

Annals of Internal Medicine, September 1, 2020

 

The Management Package—team approach

   Other important aspects of management must include glucose monitoring instructions, adjusting dose of diabetic meds, goal setting, monitoring for complications, foot care, vision, neuropathy, kidney and cardiac functions, immunizations, and blood chemistry regular evaluation, and proper maintenance of ideal blood sugars (90-130mg/dl).

  Stress can interfere with blood sugars, and should be understood that maintaining those levels is critical over the long haul.

  Be aware of hypoglycemia and wear a medicAlert bracelet if diabetic.

  Conditions that can complicate diabetes include kidney disease, liver disease (fatty liver), heart failure, and age.

  Oral hypoglycemic medications can be affected by certain other medications including HIV drugs, diuretics, angina pills (nitroglycerine), and drugs to treat pulmonary hypertension.

 

3. 50% of U.S. adults will be obese by 2030

  Sad but true! Nearly half of U.S adults will be considered obese by 2030 and 25% will be severely obese, according to a published article in the New England Journal of Medicine, Dec., 2019

  The information came from researchers who provided data from 6.2 million participants from 1993-2016 in Behavioral Risk Factor Surveillance System Study.

  The highesr rate of obesity is projected to be Alabama, Arkansas, Mississippi, Oklahoma, and West Virginia at 58%. Women, blacks, and poor people will suffer the greatest.

  The consequences of increasing weight in America will have major impact on chronic disease (i.e. diabetes), injuries, cardiovascular and airway issues, orthopedic injuries, and long term care management. Healthcare costs will skyrocket no matter what type of system we are living in. The medical costs alone in 2008 for obesity was $147 billion, according to the CDC.

  Will the public respond? So far, not so much!

 

4. Can cannabis cure cancer? Medical cannabis use---current status….miracle drug or not?? Miscalculations in approving it!; medical marijuana

The August JAMA journal reported on the current status of medical cannabis use from the marijuana plant Cannabis sativa. Nearly 10% of cannabis users are using it for medicinal reasons.

  Proven benefits include spasticity for multiple sclerosis and other neuromuscular disorders, rare types of childhood seizures, and nausea associated with chemotherapy.

  As of August, 2019, 33 states have initiated policies to legalize the use of cannabis or cannabinoids for medical treatment of various symptoms. Because the feds still consider cannabis use illegal, adequate research on this plant and its compounds continues to be lacking.

  There have been some miscalculations by states when they legalized it. To date, the doses are not standardized, product concentrations are not regulated, and prescribing practices are quite variable. There has been an avalanche of users, and those who use it frequently are experiencing significant side effects, experimenting with the dose with no guidance. Most physicians do not provide any help.

 

The dangers of cannabis

  Neurotoxic effects are a well known consequence if used often including anxiety (more common in adults), paranoia, and delirium, and depression (more common in children). It also impairs memory, concentration, judgment, and motor skills. Cannabis can be habit forming. Long term use can cause chronic lung disease. Sadly, many of those who use pot, also use other substances to complicate the issue.

 

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 disorder 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. Add that to low birth babies in cannabis users during pregnancy.

  Currently, there is no database for side effects at the state or national level.

  The FDA accepts only reports from the approved cannabis drug (Epidiolex). There is a great need for states and the federal government to protect our citizens and be able to deliver credible information to the public about the dangers of cannabis. Now with the legalization of pot, there is little initiative to provide funds for research.

  A recent article in the NEJM, September 19, 2019, cited grave concern after legalizing medical marijuana from the state of Pennsylvania, who are seeing overdoses from internet THC preparations which exceed the usual dose (10mg/ml). Since these preparations are readily available without a prescription from an authorized doctor, patients are just jumping to the most readily available source (the internet).     

  The main two cannabinoids, THC (tetrahyrocannabinol—the psychoactive substance in marijuana) and CBD (cannabidiol), which by rule must have less than 5% THC and is not psychoactive (but still will show up as marijuana in a urine test for drugs).

 

Approval for chemotherapy side effects

  However, there are two compounds approved by the FDA for chemotherapy-induced nausea and vomiting and are available as an oral prescription, dronabinol (Marinol) and nabilone (Cesimet). It clearly helps nausea and vomiting, however, a recent study reports there is a cannabis hyperemesis syndrome, which causes episodic vomiting in some cases. This dichotomy has given many physicians pause to consider supporting patients using cannabis on a regular basis. If a patient develops this syndrome, they run the risk of continuing to vomit even if they stop cannabis.

NEJM Journal Watch Gastroenterology, Sept, 2016

Dronabinol also is approved to stimulate appetite in conditions that cause weight loss (i.e. HIV, and other serious chronic illnesses).

  CBD (cannabidiol) has been approved by the FDA for 2 rare pediatric seizure disorders (Dravet Syndrome and Lennox-Gastaut Syndrome). Of course, patients with seizure disorders are jumping to the use of CBD to see if it will help. The danger is stopping prescribed seizure medications to experiment with the potential CBD benefit might have. Researching journals and legitimate websites finds no good answers.

 

Seizures

  Several bogus health websites are touting it for all seizures. The dose, the interactions with other medications, side effects, value of controlling seizures (without standard anti-seizure medications), etc., are just not reliable. Testimonials and fake research (which is not controlled) are making this industry boom like no other businesses we have seen in years.

 

Chronic pain

  Chronic pain can potentially be helped with cannabinoids, but reliable research is not consistent. I have talked to people personally that are convinced that it is effective in controlling minor pain.

  The placebo effect can be very seductive in convincing people that what they are taking helps their pain. Sometimes the euphoric effect allows them to perceive pain relief differently. That is why methods of pain relief must be tested against placebos. Some research has reported as much as a 30% improvement of pain over placebos.

 

Other uses for cannabis including cancer—where is the proof?

  Intractable cancer pain, multiple sclerosis, epilepsy, and others are common conditions where these cannibinoids are being used.

  There is some research evidence that cannabinoids may have some anti-tumor benefit in animals only. However, much more research is necessary before these chemicals can be used in oncology. There is no evidence it can cure cancer. The internet is full of sites recommending THC products for cancer, giving patients false hope and taking their money.

  There are studies in mice that reported cannabinoids could bind to and activate cannabinoid receptors located on cancer cell surfaces and somehow modulate the intracellular signal pathways, which they say can trigger a host of anti-neoplastic effects.

  These effects include: 1) can induce cell death (apoptosis) 2) can block cell growth 3) can impair angioneogenesis-can stop cancer cells from stimulating blood vessel growth 4) can inhibit cell migration and spread of cancer cells (all animal studies only). The article in the JAMA also reported animal studies report that cannabinoids can work synergistically with anti-cancer drugs, but no human studies are evidence based.

  The National Academies of Science, Engineering and Medicine there was no evidence based valid studies to prove that cannabinoids can affect cancer in humans. There are, however, isolated cases in the medical literature that have cited value in brain tumors, leukemia, and others but these cases have had standard csncer therapy before cannabinoids were used.

  The internet vaguely professes great results with high grade CBD products, but with little backup of scientific proof.

  Most of the current research has been in treating glioblastomas ( a very malignant common brain tumor). 9 patients were treated with intracranial THC and appeared to shrink the tumors to some degree based on MRI scans. 21 patients were treated with cannabinoids (nabiximols-THC/CBD) with a cancer drug, temozolomide. At one year, survival rates with the combination therapy had 83% 1 year survival rates compared to placebos in recurrent glioblastoma. There is an ongoing study comparing the use of cannabinoids plus chemotherapy versus chemoradiation in newly diagnosed glioblastoma patients. It deserves research to answer these questions with peer reviewed published articles.

  Because cannabinoids have brain receptors, it was assumed that using brain tumor patients would be a logical starting place. Time will tell, but for now, there is not enough evidence to prove its value over standard therapy.

Conflict with chemotherapy, immunotherapy

  Highly potent cannabinoid products can interfere with chemotherapy increasing toxicities, and one study cited interference with immunotherapies for cancer patients.

  Patients deciding to use high doses of cannabinoids are facing as much as $7000 a month, and that is superimposed on the costs of standard cancer therapies.

  It must be remembered that many desperate patients have already been on chemotherapy and had other conventional treatments before deciding to use high doses of cannabinoids.        

JAMA Network, January 16, 2020

 

Consequences of daily use

  Patients and some doctors are to the point of recommending a trial of cannabinoids, whether by prescription or purchased illegally. So why not? Let’s study occasional versus chronic daily use of these substances.

  When daily psychoactive THC is smoked, eaten, etc. there are neurological cognitive consequences including temporary impaired learning, memory, attention, and motor coordination.

  A study at the University of Buffalo found that people in their mid-70s tolerated marijuana well and was helpful in treating pain and anxiety. Long term studies are not available in older people.  Medscape, May 6, 2019

  Chronic use is associated with psychiatric illness and addiction. There is an association also with developing one of the psychotic disorders including schizophrenia. Impairment of school work, jobs, and relationships have affected in as much as 31% of users.

  Based on the assessment of these authors from Beth Israel Deaconess Hospital in Boston, Mass., there continues to be insufficient evidence that cannabinoids are consistently valuable for most medical conditions. Yet, as many as 50 conditions are being treated with these substances.

  I am anxious to see more reputable reproducible evidence about its value and where it is of little value.

 

CBD products

 

CBD (cannabidiol) product stores are popping up all over the states, and owners are making big bucks thanks to gullibility of the American public. Businesses are touting CBD in bath bombs, skin care products and food, even ice cream. There are small cost “starter kits”. This comes from the hemp plant (not the marijuana plant). Some states are allowing hemp plants to be grown commercially, and therefore CBD is allowed.

  Americans certainly are willing to try CBD products based on the success of CBD shops opening up with every imaginable product laced with CBD. What concentration? Where is the research? Why are people so gullible? Why spend money on unproven methods?

   60+ year old adults are jumping on the wagon and have no idea if it will interfere or aggravate their existing medical issues or interact with their current medications.

  A Gallop poll found 1 in 7 Americans use CBD oil and its products. 8% of the total are over 65 years of age. Pain relief, anxiety, sleep disorders, and arthritis are just some of the reason for taking cannabis. Others are just experimenting. 4 out of 10 Americans think CBD oil should be legal.

  Even though it is freely available in Florida and Georgia, but still federally illegal. CBD products will bring in $20 billion this year.

 

  KEEP IN MIND CBD OIL WILL MAKE A URINE TEST POSITIVE FOR ILLEGAL SUBSTANCES EVEN WITH LESS THAN 5% THC, and in my pain management doctor’s office, he will not fill a pain prescription if the urine test is positive for any federally illegal substance.

Medscape Medical News, August, 2019

Legalizing marijuana;consequences

  Marijuana use has risen to 13.3% in U.S. people 18 years and older in 2014. Co-exposure to cigarette smoking and smoking marijuana can more than double the risks of respiratory illness.

  Despite the toxins from both marijuana, it is a bronchodilator, which seems to protect the lungs from some damage.

  The U.S. Surgeon General has warned about the dangers of marijuana in the young brain. Pregnant girls have been increasing usage of weed since 2002-2017=3.4-7.0%.

  Frequent marijuana use in young people have deficits in cognition, memory, and behavior….not something that is desirable in someone who is a student. 9 million young people ages 12-25 reported having used marijuana in the previous 1 month.

  Newer stronger strains of pot have been reported to cause psychosis, paranoia, agitation, and anxiety. Frequent use leads to opioid and alcohol abuse. The strength of THC continues to climb in many of these strains.

From the Department of Health and Human Services, August, 2019

  Weed has been the downfall of many a high schooler, and it continues. There is also a potentiating effect of tobacco and marijuana. Blunting, for example, is a common way for adolescents and teenagers to smoke marijuana. For those who never heard of that method (“blunting”), small cigars are burrowed out and filled with marijuana. It is well known that youngsters who smoke cigarettes are more likely to vape and smoke weed. Legalizing marijuana is going to have an even greater effect on use. JAMA Network, Dec. 3, 2019

 

5. Visits to Primary Care doctors are decreasing; Shortage of PCPs getting worse

 

Visits to primary doctors decreasing

  The number of patients seeing doctors in primary care is decreasing, and the number of visits to nurse practitioners and physician assistants is increasing, but still a net drop in going to traditional offices.

  Urgent care facilities, and even emergency departments are increasingly using NPs and PAs.

Few millennials have a primary care doctor

   Previously, I reported that millenials do not want to take the time to sit in a doctor’s office and opt for urgent care and drug store “docs” instead.

NPs and PAs are taking over much of the primary care practices

  It was thought by some that allowing NPs and PAs to join physicians allowed physicians to take care of more complicated patients and drop the cost of healthcare. However, it has not dropped. Even though NPs and PAs are paid less, the bills to see them were only $3.00 less than the doctor according to the Healthcare Cost Institute, a non-partisan, non-profit organization created in 2011. These studies came from the records of the major insurance companies.

  Most people have no problem seeing NPs and PAs, however, however, it has watered down primary care and increased referrals to specialists, which increases the cost of healthcare. I have seen very fine NPs and PAs in my doctor’s offices and feel they are providing quality care. I am still sad to see fewer medical graduates choosing primary care, the backbone of healthcare.

  17 states allow NPs to practice without supervision from a physician. That is increasing especially in smaller towns who can’t afford to keep a physician in town or even keep their rural hospitals open.

  Also there is a group of so-called PA-Physicians who are medical school graduates from foreign medical schools (primarily the Carribean) who can’t pass the U.S. medical boards to practice in the U.S. They are now being allowed to practice in Missouri only (for now) with very loose supervision from a group of doctors from the State of Missouri willing to cover their malpractice (being paid for by the state) and paid to “supervise” these people. 

Telehealth was supposed to be the answer

  Telehealth got a big boost during the pandemic, and allowed patients to contact their doctors by phone or videoconferencing. The feds promised to pay the physicians for a regular doctor’s visit, however, most of the doctors are being reimbursed at a much lower rate than promised. Shame!

  This was supposed to provide security, safety, and convenience for both patient and doctor, and it did…..but the physicians need to paid for their time. If this trend continues, this will stop most doctors from using this method.

  There is also tele-fraud occurring with this method by unscrupulous doctors who may not even be licensed. Don’t trust the internet, and if they are sending you medication directly, you may not be receiving a truly safe drug with proper dosing, etc. Therefore, I strongly suggest individuals limit their tele-exposure to their personal doctors.

Shortage of Primary care physicians getting worse

  15 year projections for the shortage of primary care and specialty physicians in the U.S. grew from 54,000 and 139,000 in the latest annual report by the Association of American Medical Colleges. The number just one year ago there was a shortfall of 46,900 and 121,900 by 2032. The access issue continues to worsen, and those without insurance or poor insurance with large deductibles will suffer the most. Rural areas are losing their hospitals in record numbers and losing their physicians.

  More than 2 out of 5 physicians will be over 65 within 10 years. Retirements are increasingly happening at younger ages, as the income and stress (burnout) of administrative duties and regulations has soured the entire profession.

  These shortages will be replaced with shorter trained healthcare professionals including nurse practitioners and physicians assistants, but with proper supervision, they provide a valuable service to be appreciated.

  COVID-19 has magnified the shortage of physicians capable of meeting acute emergencies. Patients have been fearful even going to the emergency department, suffering serious acute illnesses with delayed care.

    Even in the face of increasing supply of osteopathic physicians and well trained foreign doctors, fewer medical school graduates are choosing primary care residencies (internal medicine, family medicine, and pediatrics) in the face of a record number of slots offered. Only 41% of the internal medicine slots were chosen, and similar trends stand true for family medicine, and pediatrics.

  The main reason is low income and being in a position to either provide a relatively simple low complex practice or face needing to keep up with so many fields of medicine to keep these difficult management cases at the primary care level.

  According to Medscape, the average salary for an internal medicine doctor is $243,000 annually when the highest paid orthopedic surgeons earn about 2-3X that. 

  Of those graduating with either a medical or osteopathic doctor degree, three quarters are M.D. and the rest grant D.O. degrees. Osteopathic physicians choose primary care more often than M.D.s, as there are more openings available.

  All the slots for residency not selected by graduating medical and osteopathic students are filled by foreign trained doctors. 68.9% of foreign trained medical physicians have gone into primary care.

  Before choosing a doctor who was trained in their specialty (primary care included) outside the U.S., I would just look into their credentials and find ones who are in very reputable group practices with U.S. trained doctors. It is difficult to criticize these dedicated doctors, but if they were top notch, they would have qualified for a U.S. medical school and a U.S. residency.

  The bottom line, in my opinion, is the quality of healthcare is slipping, and it is because of the red tape running the best people out of medicine, and the totally unfair reimbursement system for primary care doctors.

  As I have stated many times, if you find a good doctor, stick with them, be kind to them and their staff, and be thankful you are well cared for!

 

6. Anemia--Iron deficiency anemia; Pernicious anemia (Vitamin B-12); Folic acid supplement and pregnancy

  Iron deficiency anemia is the most common anemia. Iron is vital to make hemoglobin, the protein pigment in a red cell. Bleeding, excessive menstrual periods, and a diet deficient in iron are the most common causes of this type of anemia. Some medications including gastric reflux meds can possibly block the absorption of dietary iron.

  The drawing below shows healthy normally larger red cells on the left and pale smaller cells in the next frame. Iron deficiency causes the red cells to carry less of the pigment hemoglobin making them pale (microcytic hypochromic).

  Cancer of the stomach, although uncommon, can occur in patients without acid secretion (achlorhydria). Some people don’t make acid and they are most at risk.

 

Checking for iron deficiency

  A CBC (complete blood count) will indicate there is a problem. However, if iron deficiency is suspected, an additional study is required to test for the iron in the blood (serum ferritin). The CBC looks at various indicators that anemia may be on the way. If anemia is present, a discussion about continued use of medications such as stomach acid suppressors would be in order and whether iron supplements should be prescribed.

 

Treatment of iron deficiency

  Ferrous sulfate can be obtained over the counter, but a prescription, even though the insurance does not cover it, may be less expensive than OTC. At CVS, for instance, unless iron tablets are on sale, a prescription will be less expensive.

   Ferrous sulfate 325mg three times a day is the recommended dose, however, constipation, darker stools, nausea, vomiting, and stomach pain can occur.

  If side effects are unacceptable, an alternative is ferrous gluconate. Vitamin C once daily (500mg), according to Medscape will help increase absorption of iron, especially if acid suppressors are necessary for reflux, etc. The CBC and serum ferritin (iron)will need to be checked in 3 months to see if the iron deficiency is improved. Medicine.Net

 

Before taking iron

  Anyone who has iron deficiency should be checked for a possible sources of bleeding, such as the gastrointestinal tract (performing a stool exam for blood prior to treatment) should be discussed with a person’s doctor. Bleeding from GI diseases, ulcers, and cancers must be ruled out including esophagogastroscopy and colonoscopy.

Medscape, Oct., 2018

 

Vitamin B12 deficiency

 

These anemic cells are slightly larger than normal red cells.

  This vitamin deficiency causes an even larger cell although it is less efficient (megaloblastic anemia), and if prolonged, can cause serious consequences.

  The body does not normally produce vitamin B-12, therefore, the diet is necessary to absorb it, but these acid suppressors can block the “intrinsic factor”, a glycoprotein produced by the stomach, which would lead to a decrease in B-12 absorption.

  In addition to weakness, paleness, heart irregularities, and even neuropathy can occur. 

  There are other causes of B12 deficiency including pernicious anemia, patients with chronic autoimmune gut diseases (Crohn’s, Ulcerative colitis, etc.). Vegetarian diets need to be watched for deficiency.

 

Treatment

  Injections of Vitamin B12 (cyanocobalamin is commercially produced) may be necessary if the stomach is not absorbing it for the above reasons or if acid suppressors can’t be stopped. People on vegetarian diets may need supplementation. The doctor should decide.

 

Folic acid prior to pregnancy may cut autism in half; critical during pregnancy

  Folic acid (vitamin B-9) is necessary for an adequate red blood count or anemia will occur. Folates are also necessary for myelination of nerves (the lipoprotein covering of nerves).   

  Folates are found naturally in certain foods, but additional folic acid is necessary in pregnant women for the baby’s welfare.

  It is well known in preventing neural tube deformities (spina bifida and anencephaly) in fetuses and all pregnant women and those contemplating getting pregnant should start prenatal vitamins and folic acid supplements.

 

Folates may prevent autism

  New research has now reported to possibly prevent autism in children if women start taking folic acid supplement just one month prior to pregnancy. It is reported to potentally cut the incidence in half, according to a study from Norway.

  If contemplating pregnancy, it would be wise to start folates, however, that is a decision for an individual’s doctor. The fetus absorbs all its folate from the mother thus requiring more intake by the mother.

  During pregnancy, folic acid 5 mg. is already recommended.

  More studies will need to confirm this study, but it is very encouraging that folates may be very important in many neurological disorders. 

  As described in the Feb, 2019 JAMA, these children whose mothers took folic acid for a month prior to getting pregnant were followed for 6 years. 0.1% of children developed autism in the treated group compared to 0.2% for those who did not take folic acid the month prior to pregnancy. That calculates to a 39% lower incidence of autism in the treated group. 

  In this study, the majority of those studied were having their first child, and those who took folic acid tended to be better educated, thinner, and did not smoke. All these factors may play a role. For those who become pregnant, even if they did not take folic acid 1 month prior to conception, also seemed to have some protection.

  Folic acid deficiency causes anemia similar to B-12 deficiency. Certain medications, nutritional deficiencies, and gastrointestinal diseases can predispose to deficiency.

  Folates are found in leafy green vegetables, beans, grains, etc. Breads and pastas are fortified with folic acid. People undergoing cancer treatment can be at risk as are those with gastrointestinal disorders and those taking acid reflux meds.

  Prenatal vitamins are also highly recommended to prevent birth defects and language delay.

Incidence of autism in the U.S.

  1 in 88 pregnancies will produce an autistic child in the U.S. according to the CDC. For the thousandth time, vaccines do not increase the risk of autism.

    

7. “Snake oil” advertising and Fraud; “Go-Fund-Me” accounts steer millions for snake oil treatments; Pain and memory remedies--Relief Factor, Prevagen-? Value 

  Certain products marketed to the public that have some health value (antioxidants being the most abused) frequently are used in other products to tout unproven remedies for certain ailments with out any scientific proof.

  Just because a vitamin, herb, supplement, etc. has value in one situation, without true authentic research, products should not be marketed for specific ailments. Even the box it comes in has to provide the statement that it is dietary supplement and not a treatment for specific medical issues. And yet, TV and internet commercials can provide bogus testimonials for specific ailments. Why does the federal government allow such nonsense?? The supplement industry has a powerful lobbying group paying big bucks to congressmen.

   Please, do not fall for these bogus treatment or preventives from testimonials. It is wasting your money and potentially causing you harm (drug interaction, side effects, etc.).

“Crowdfunding”

  Should a person donate to someone who is wanting to pay for some unproven snake oil treatment? It may come as a surprise, but this is big business, and friends and families are donating for treatments that have no medical value, can harm, and are scientifically unproven.

  On the other hand, there are thousands of people seeking help with large legitimate medical bills and needs who need help from such internet sites like Go-Fund-Me.

  A good example of a questionable treatment is stem cell treatments that insurance does not cover, such as this case below. This has been reported by healthnewsreview.org that cited research from 408 campaigns that were shared online 111,444 times on social media.

 

They looked at GoFundMe or YouCaring websites and found that many of these requests are for unproven treatments frequently in other countries. There is no proof these individuals even have a disease in the first place.

  Often there are claims that are made on these websites about the effectiveness of a treatment when there is no scientific evidence to back up the claim.

  They were very likely to not mention risks associated with these treatments. 90% of these claims stated that the procedure would be very effective from the companies providing the services, often taking a sizable slice of the money recruited.

  The campaigns studied from August to December, 2017 had sought more than $7.4 million and received pledges of $1.4 million from 13,050 donors for unproven stem cell treatments. 46% of the donations came from friends, 24% from a relative, and 35% came from strangers.

Note:  There is a website citing evidence based information about what diseases stem cell treatments actually do help:

www.closerlookatstemcells.org (nine things to know about stem cell treatments).

  These campaigns online seeking donations for patients to have unproven methods is called “CROWDFUNDING”.

  Many of these requests come for treatments not necessarily approved by the FDA and are available in other countries with fewer restrictions but also less safety.

Medpage Today, Feb. 25, 2020

DONATING TO GOOD CAUSES IS A WONDERFUL AMERICAN PHENOMENON WITH SO MANY GIVING PEOPLE IN OUR COUNTRY, BUT DO YOUR RESEARCH!!

 

FDA cracks down on illegal sales of Alzheimer’s (AD) cures

  The FDA is after companies marketing supplements and other products to prevent, treat, or cure dementia/AD.

  5 online companies are selling 58 products unproven to help memory, dementia, or Alzheimer’s disease, according to Dr. Scott Gottlieb, M.D., FDA Commisioner.

  These companies are in violation of the Dietary Supplement Health and Education Act (enacted by the U.S. Congress 25 years ago) and is greatly in need of reform and strengthening.

  The supplement industry is a $40 billion business with more than 50,000 products. Next month, I will report on the latest information on dementia and Alzheimer’s Disease next month.

  The number of memory remedies are raking in the money, and to date there is not one that has any scientific proof they help cognitive function!!!

  Prevagen is a good example, a heavily marketed unproven product. Ingredients come from jellyfish, including Apoaequorin, a protein used to study how calcium gets into cells, but no scientific proof it helps cognitive function whatsoever, according to Harvard Health Publishing at Harvard Medical School.

  The FDA must crack down on these products ripping off the public. The FDA is supposed to protect the public from “snake oil” treatments.

       

Relief Factor is another gimmick product

    Pat Boone claims that Relief Factor is the best thing since sliced bread. I looked up the ingredients for this latest snake oil potion. It is full of anti-inflammatory and anti-oxidants all known to be of some health value, but none are proven to relieve pain as a combination using scientific method.

  Contents include omega-3 fatty acids, resveratrol, a flavonoid is an antioxidant found in wine, curcumin is turmeric, another anti-oxidant, icarin, another flavonoid known as epimedium, a Chinese anti-inflammatory and anti-oxidant. There are no human studies to prove this combination of ingredients have value in protecting nerve cells from free radical induced damage (only in mice).

  This product is commonly advertised on cable television and has no scientific proven value. It is just a group of anti-inflammatory/antioxidant supplements never proven to be of value in humans who are in pain especially combined.

  Typical testimonials flood the ads popularized by Pat Boone. He should have stuck to singing.

 

This completes the November report!!

 

The December, 2020 report will include:

1. Update on Drug Crisis and COVID-19

2. Alzheimer’s Disease; Dementia—diagnosis

3. “Intelligent” knife for cancer surgery

4. Older people need to reconsider their medications and dosages

5. Management of difficult skin cancers—Moh’s surgery

 

Thank you for reading the latest medical information. I hope you voted, and God Bless America!! Also get the Flu shot!!

Stay healthy, safe, and well, my friends, Dr. Sam