The Medical News Report

#107

December, 2020

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

samlamonte@gmail.com

 

MERRY CHRISTMAS

&

HAPPY HANUKKAH

     

Subjects for December, 2020:

1. Update on COVID-19

2. Update on the Illicit (and prescription) DRUG CRISIS during the pandemic

3. DEMENTIA-types; Alzheimer’s Disease-what is new; more preventative measures cited

SHORT REPORTS

4. The “INTELLIGENT KNIFE” for cancer surgery

5. SENIORS need to reconsider their MEDS and DOSAGE

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.

  Merry Christmas and Happy Hanukkah! Ifyou spend time with your families for the holidays, but be aware of viral spread, and be safe. 40% are asymptomatic, especially younger people under 60.

  Thank you, Dr. Sam

1. Update on COVID-19

I dedicate this update to my friend and old motorcycle buddy, Bill Ampspatcher, who died of complications from COVID-19.

Praise and thanksgiving to all the healthcare workers who have given their lives unselfishly caring for COVID-19 patients—as of Nov. 24, 836 have died in the U.S. (233,013 have been infected).

 

A. Wake up and “smell the bacon (fat)”

  Many academicians criticize the U.S. for not having better healthcare outcomes. One of my favorite authors at Johns Hopkins Medical Center (Dr. Marty Makary, M.D., MPH) has provided the stark answer to that criticism.

  After analyzing 500,000 Medicare recipients (outpatient and inpatient), he states, “ The U.S. has more obesity, people with more co-morbidities (multiple health problems), the most hospitalized of any country, the most medicated, and are the most disabled population in the civilized world”.

  No wonder we have sicker people with COVID-19 if older and have underlying disorders. Our society has fostered an unhealthy way of life with lack of exercise and little attention to sound nutrition. What would it take to change that mentality? Let me know if you have an answer.

  Many Americans eat horribly, don’t exercise, sleep poorly, stress more, are more entitled, and many adolescents and very young adults are just plain spoiled. Do parents want to be parents or friends with their children? Tough questions! People learn from their parent’s actions.

  When academicians criticize Americans, they need to be honest about why we have poorer healthcare outcomes.

  This report cited the sickest population is found in Hispanics with a 74% more likelihood of dying from their co-morbidities, including COVID-19. 45% of Hispanic men and 50% of women have obesity with the incidence of hypertension, and diabetes very high. Hispanics are followed by Asians (71% increased risk) and blacks.

  Now for some good news!! With new COVID-19 treatments, the mortality has been reduced by 80-90% even in the face of all these multiple health challenges and COVID-19.

  For a few months, the younger people (18-34) have had the highest number of positive tests, and they are filling hospital beds. Fortunately, the mortality rate is quite low. But the young also have high risk factors too.

  We now have 1 million children with positive tests having tried to reopen schools.

  There are nearly 13 million cases so far, and the Midwest and West is experiencing the highest numbers, but is leveling off. As of the end of November, 180,000 tests are being performed daily. With massive numbers such as these, the case load will appear to rise, but 2-3 months ago, there were not near the number of tests, so it appears we are in a surge, when it is because of the number of tests, and the fact that the availability of testing is much greater.

  What it really means is that when the young and middle age went back to work, they got exposed, and when the colleges reopened, they added to the list. We continue to try and control a pandemic without going under financially.

  Medpage, Nov.11, 2020

B. Operation Warp speed is a huge success-vaccine this year!

  The success of Operation Warp Speed is responsible to providing over $2 billion dollars to 2 pharmaceutical companies to create the COVID-19 vaccine in record time. The partnership between the White House COVID-19 Task Force and the private sector industry, researchers, pharmaceutical partners, and healthcare workers has brought us to a point where we will have at at least 2 vaccines (Pfizer and Moderna, and maybe AstraZenica) available this month, at least to special prioritized groups, and the latest estimate by experts have stated the general public will have these vaccines available by Spring, a miracle in itself. No time for criticism…the election is over. We must all do our part in getting through this pandemic and recovering financially.

  There are currently 40 million doses ready to go in December, if the authorization goes as planned. These doses will go to healthcare workers, first responders, and the elderly, but many more millions of doses are needed to fill even those high priority people. It will take a massive effort to provide an entire country this vaccine. It will take the rest of the winter to accomplish providing vaccines to every person with healthcare risks. The military will need vaccination ASAP as well.

  There is also good news about the effectiveness of the upcoming vaccines (95% effective) and new treatments, the death rate is staying exceedingly low (0.5%).

  There is still no room for getting sloppy about safety measures in and out of our homes (wash hands, surfaces, masks, social distance, good ventilation, minimum numbers gathering together, etc.). With holiday get togethers, we must all be mindful of the potential for even more surges, and consideration for smaller groups should be entertained. If there are vulnerable people in that group, postponing family gatherings would be smart. Tough decisions!

C. COVID-19 quick updates

  This virus’ primary target is the lung via the respiratory tract. How it affects each individual depends on an individual’s current health status, hygiene habits, exposure at work or being in crowds. Holidays will challenge our perseverance to stay safe.

  Remember, 50% of infections come from pre-symptomatic and asymptomatic individuals.

  Masks may protect others from a person spreading the disease, but a Danish study found that it did not protect the wearer from contracting an infection from others (Annals of Internal Medicine).

  However, other studies have shown some protective value according to the CDC, and could theoretically save countless lives with universal mask wearing, a very controversial concept. Masks in and of themselves should not ever be relied on as the sole method of protection (probably 40-50% effective). People often depend on masks too much! It is just one of the safety precautions.  

Antibody levels and effect on COVID-19

  Studies continue to show people with neutralizing antibodies from a COVID-19 infection show 99% of the virus is gone by 11 days, and the reason the 10 day rule* continues.

*CDC recommendations continue to be 10 days past the beginning of symptoms without fever for 48 hours (without Tylenol, aspirin, or ibuprofen).

  IT IS RECOMMENDED THAT EVEN THOSE WHO HAVE BEEN INFECTED AND RECOVERED SHOULD STILL WEAR MASKS AND SOCIALLY DISTANCE WITH PROPER HYGIENE WHEN IN PUBLIC PLACES. THE REASON, IS THAT EVEN THOUGH PEOPLE ARE IMMUNE FOR AT LEAST A FEW MONTHS, THEY MAY STILL MIGHT BE A CARRIER IN THE FUTURE AND STILL SPREAD THE VIRUS. THIS IS BEING STUDIED, BUT NO ANSWERS YET.

Home infections

  Studies continue to report 50% transmission rate in homes with one infected individual and 75% of that transmission occurs within 5 days. About half of those infected by their family member have been asymptomatic.

  People need to assume they are infected until test results are received. Waiting for test results is a dangerous time, and many do not isolate (STUDIES REPORT AS HIGH AS 40% DO NOT ISOLATE), so when exposed or symptoms begin, immediately isolate until test results are available.

Delirium can be a presenting sign of COVID-19

  28%% of 817 elderly people presented to 7 emergency departments with delirium* as one of the primary presenting symptoms, and 16% was the main presenting symptom.

  37% had none of the typical signs of COVID-19 such as cough or fever. This was particularly true for those 75 and older.

  *Delirium is characterized by alterations in consciousness, confusion, disorientation, inattention, and cognitive deficits. JAMA, November 19, 2020

What happened to Flu and COVID-19 in the Southern Hemisphere during their winter?

  There is good news from Australia (the Southern Hemisphere), since they have already gone through a combination Flu/COVID-19 winter. They report the same safety measures for COVID-19 reduced 90% of transmission of flu. Therefore, we should see a greatly reduced flu season if the public continues to follow safety measures. That finding should not prevent getting a flu shot.

Xofluza can prevent flu when exposed—NEW FINDINGS!

  Xofluza, an antiviral to reduce symptoms of flu similar to Tamiflu (but better) is already FDA approved for individuals who have early signs of flu, but now with a new study, it is also approved for individuals known to be exposed to flu and can reduce the number of cases of flu from 13% to 1% based on the study comparing it with a placebo as reported by the FDA on November 13, 2020.

  Patients 12 years or older can take this single dose, but there are restrictions for intake with any medication with calcium in the ingredients. If exposed to flu, talk to your doctor about a prescription for Xofluza. (Tamiflu was not studied).

I GOT THE FLU SHOT………………..DID YOU?

Podcast from Johns Hopkins and Texas Tech Medical Centers, Nov.7, 2020

Remdesivir controversy

  The use of Remdesivir, an effective antiviral against COVID-19, is being used under an FDA emergency use authorization throughout the U.S. with hospitalized patients. Yet, foreign studies, which often are not as solid as those in the U.S. have reported it does not save lives, and the WHO (World Health Organization) has not recommended its use. This is contrary to the decisions by the U.S.

  The reduction in number of days of hospitalizations in the U.S. allowed for its recommended use with Remdesivir. This is part of the cocktail being used, with additions of antibody medications (Regeneron, other monoclonal antibodies, etc.) and corticosteroids.

  It is not uncommon for research projects to conflict with previous studies, since the design of a study can vary widely. It is only with repeated independent research that the final answer will eventually will be determined.  

What is extracorporeal membrane oxygenation (ECMO)?

  ECMO has been used for decades, and is essentially using a heart-lung machine to run a patient’s blood out of their body to the machine for better oxygenation and returned to the patient’s blood vessels (see photo below). This is routinely performed with open heart surgery, dialysis, for heart failure, etc., but now has been used in certain serious cases of COVID-19 who can’t be oxygenated well enough with a ventilator.

The photo shows the blood going from the patient to oxygenator and back to the patient.

D. Are hospitals safe?

  The rate of transmission is quite low in medical facilities with universal mask wearing, good ventilation, and other proper use of PPEs and sterilizing techniques. However, the rate of transmission in the public sector (outside the hospitals) continues to rise in the face of those safety measures, because of the lack of adherence to recommended guidelines.

 

E. Holiday safety measures promoted by the CDC

  The CDC has defined several aspects of safety measures especially when gatherings occur. You can search: www.cdc.org/holidaygatherings

Travel restrictions from the CDC

  Depending on where a person lives and where they are going for the holidays must be considered. Please consult the CDC’s website regarding these restrictions, as they will vary from state to state and situation to situation.

  Remember 50% of infections come from pre-symptomatic and asymptomatic individuals. If you follow all the guidelines form the CDC, here is what you must do:

  Essentially, considering the concern for transmission,  holiday gatherings should be limited to household occupants only, no guest from a hotspot of infection, no one who traveled on public transportation, and gatherings should be less than 10.

  Check temperatures at the door and ask each individual if they have any symptoms of illness (especially respiratory), reject anyone with known exposure, awaiting COVID-19 test results, wash hands as soon as they enter, and provide hand sanitizer to all, use disposable dinner ware or wear gloves to remove dinnerware to be placed in the dishwasher, have one person fill plates for all, fill drinks by one person unless gloves can be used and no common liquor bottles to be touched.

  Maintain 6 feet distance, wear masks inside, no physical contact, beware of people drinking too much alcohol, and use of bathrooms should include strict hand washing and use of tissues to touch door handle, toilet, faucets, etc.

  Relatives with major health issues, frailty, recent surgery, cancer treatment, etc. should not attend!

  The length of the encounter with people continues also to be important (more than 15-20 minutes).

  In other words…..stay home….worrying about all these guidelines would ruin some family’s events! It is only one year! Knowing that a family gathering caused viral transmission to other family members and friends would potentially create significant guilt and conflict for the famly. Remember, 40% are asymptomatic.

 

F. Rapid test FDA approved

  With FDA approval (emergency use authorization) of a fast (30 minutes) test with reasonable accuracy, it is more important to distribute these tests as rapidly as possible to medical facilities, doctor’s office, etc. The wait time has become the “Achilles heel” of diagnosis, waiting days to find out (3-4 days with the PCR test).This is authorized for people ages 14 and older, who are suspected of having COVID-19. 

  The Lucira COVID-19 test is designed to be used at home and is an all-in-one test kit and will be available with a prescription for people testing ages 14 and older. Results are available in 30 minutes. A swab is inserted into the nostril and rotated 5 times in each nostril.

Hopefully, this test will be available for home use soon, but will still require a prescription, and the physician is required to report all results to the authorities. To start, it will be available in medical facilities only.

Medscape, Nov. 18, 2020

 

G. More new FDA approved treatments available

  The list grows with FDA approved treatment options with varying indications.

1-Why do men get sicker?

  A recent international study (Science, Oct.23, 2020) has shed light on why some patients get sicker than others (excluding the usual higher risk factor reasons). Those who get really sick, the virus tends to stimulate certain antibodies that disable the patient’s ability to develop an immune defense. It was found that certain antibodies turned on by the virus (called autoantibodies) cancelled out the natural defenses of the patient’s interferons.

  These autoantibodies were found to be more common in men (autoantibodies are usually more common in women causing many of the autoimmune diseases such as rheumatoid arthritis, lupus, Ms, etc.).

  This explains in part why men are more likely to get sicker. Additionally, research has proven that some of the immune responses are governed by the sex chromosome X. Since women have XX and men only one X (XY), it is hypothesized, that women have more protection from their sex chromosomes and are less prone to progressing to a more severe infection. However, also in their findings, they reported that women are 4X more likely to have prolonged symptoms after recovery for unknown reasons.

Interferons

  Interferons are the body’s first line defense against infection, especially viruses never experienced before, such as COVID-19. There is also some evidence that there are genetic mutations turned on by the virus that also cancels out the benefit of the body’s interferons. Just in time for an interferon inhaled medication.

   Inhaled interferon-beta-1a has been found to reduce severity, progression, and death in hospitalized patients, according to a study published in Lancet Journal, Nov.12, 2020 This was provided with a nebulizer once daily for 14 days and started within 7 days of hospitalization.

  Recent clinical research described above demonstrated that with COVID-19 infection, the natural response of interferons is reduced in patients with more severe viral infection especially older patients and those immunosuppressed, but now those with genetic mutations and autoantibodies stimulated by COVID-19. Providing an inhaled version of interferon-beta-1a increases the immune capabilities to fight COVID-19 with 2-3 fold better results in the participant group vs the placebo group.

  Interferons are used in other autoimmune disorders including one of the major therapies for multiple sclerosis.

  AstraZenica has been approved for emergency use for 2 new therapeutics to prevent vulnerable patients from contracting or progressing with the disease.

  Independent experts have been responsible for evaluating all these therapeutics and vaccines before the FDA makes a decision to approve for general use. Those politicians and people questioning the safety of the vaccines are doing harm to their states, friends, and families. Listen to the science!!

2--A medication to keep people out of the hospital

  Remdesivir (now officially approved) continues to show significant benefit as does other antivirals, immunologic treatments (Regeneron), hyperimmune globulin, and the corticosteroid, dexamethasone. Recently, convalescent plasma has shown mixed results. However, it is critical to keep people out of the hospital if they get mildly sick.

  The first monoclonal antibody*, bamalanivimab, has been reported to provide significant value in treating patients with mild to moderate infection (not requiring oxygen) and potentially prevent hospitalization.

*note all monoclonal antibodies’ names end in -nivimab

  Bamlanivimab has been approved for those milder cases who are higher risk to progress to a more serious case, requiring hospitalization. It has 3X better chance of preventing progression of the cases according to the studies from Lilly Pharmaceuticals and is FDA approved  for an emergency use authorization. 1 million doses will be available by the end of this year. It is very promising but there are still some hills to climb.

3—More monoclonal antibodies approved

  Two other monoclonal antibodies (casirivimab and imdevimab in combinations) for patients with mild or moderate symptoms. The news is finally getting good! This is the treatment given to President Trump in addition to  Remdesivir and corticosteroids, that was quite effective. It is given intraveneously for patients 12 years and older. This is meant for patients who do not need oxygen therapy of any kind.

4—Baricitinib (Olumniant) for hospitalized patients 

  This is another medication just FDA approved for emergency use, already used to treat rheumatoid arthritis. This oral medication (janus kinase inhibitor) used in combination with Remdesivir in patients needing supplemental oxygen during hospitalization. It was found to reduce the number of days to recovery (7 vs 8 days) with the combination.

  This janus kinase inhibitor works by attracting the inflammation pathways induced by COVID-19.

Report from the Coronavirus Treatment Acceleration Program.

  Regeneron has been approved to be distributed throughout the U.S. This has been one of the best immune cocktails produced to date.

 

H. Reflux (heartburn) meds may increase risk of severe COVID-19 infection

  There are many defenses the human body has to prevent infection. One is potentially the acid in the stomach normally secreted to digest food consumed. The stomach is one of the portals of entry for COVID-19.

  An acid pH can kill bacteria and viruses including coronavirus. However, if an individual takes a reflux medication daily, they are decreasing the normal secretion of the stomach’s acid.

  Admittedly only an observational study, the Annals of Internal Medicine, October, 20, 2020, reported that PPIs (proton pump inhibitors-Nexium, Protonix, Prevacid, etc.) taken daily have a 1.33X greater chance of contracting the virus and 1.46X greater chance of increasing severity of the virus including admission to the ICU, and 2.91X chance of secondary infections than those who do not take PPIs.

  H2 inhibitors (Pepcid, etc.) also can reduce acid as well, and they would appear to have the same effect on the potential risks of COVID-19, but this study did not include this group of reflux meds.

  Do not stop these reflux medicines without consulting the prescribing physician, even if purchased over the counter.

   

I. Continued concern for people with obesity and or other cardiovascular, kidney, and immunosuppressed individuals, and now pregnant women

  Recent studies show that one infected person in a home will infect 50% of the other people in the house if contact is prolonged (greater than 15 minutes).

  New studies continue to report that being overweight alone may be one of the most important risk factors for developing a serious case of COVID-19. Add the flu, and this is very serious.

  45 million cases have been diagnosed globally with over 1 million deaths and the mortality rate in the U.S. is still less than 0.5%.

  Age and being male are the two greatest risk factors, but being greatly overweight is the third greatest risk factor, according to a recent journal article in Lancet (November, 2020). Hypertension, diabetes, and cardiovascular disease often accompanies being overweight. Those greatly overweight have a 68% greater chance of dying than a lean individual.

Do not skip routine physical exams

  This is an excellent time to get a checkup and find out if there is yet to be discovered high blood pressure, elevated blood sugar, high cholesterol, or abnormal kidney functions. All of these risk factors can go silent for years, and studies have proven that when sick people go to the emergency departments, as many 15-20% are diagnosed with diabetes for the first time.

  In younger people, being overweight is the number one risk factor for winding up in the ICU.

  People with rheumatic diseases (rheumatoid arthritis, psoriatic arthritis, sarcoid, Sjogren’s disease, lupus, dermatomyositis, inflammatory muscle diseases, systemic vasculitis, etc.) were found to have increased risks of organ damage when infected with COVID-19. These individuals are part of those suffering from prolonged issues after recovery.

  Pregnant women (ages 15-44) have been added to the list of those at higher risk for severe disease. Those who get infected are three times more likely to be admitted to the ICU. Thanks to their younger age, these patients normally recover, however, complications of pregnancy (pre-eclampsia, eclampsia, diabetes, etc.) are at much greater risk.

  Intensive safety measures are a must, in addition to careful monitoring of the pregnancy. CDC, November 6.2020     

 

J. Readmissions to the hospital

  1 in 11 people admitted to the hospital for COVID-19 required readmission to the hospital within 2 months after analysis identifying 125,000 admissions with a 15% mortality rate, according to the CDC.

  As expected, it was those patients with underlying heart, kidney, and lung diseases. The highest number came from nursing home patients, those over 65, and those who had been in the hospital in the previous 3 months. It was stated that hospitals anticipate an additional 9% of these patients to be readmitted as stated.

 

K. Impact on a lockdown

  The CDC announced that masks in public can prevent 15% of cases and prevent lockdowns. This was by the CDC, who cited findings comparing counties who required masks and counties that did not in Kansas (6% decrease in cases vs 100% increase).

  While there are certain people who feel a lockdown will turn the tide on COVID-19, many countries have tried and failed, with many studies reporting the same number of cases.

    Yes, we continue to see more cases of COVID-19, but the mortality rate continues to be very low (less half of percent). 20% of those infected have a risk of being hospitalized with more severe symptoms.

  The negative impact on our healthcare workers, first responders, and everyday people continues to create severe stress and our entire country continues to suffer from a myriad of unintentional devastating effects on our fellow Americans with delay in care and diagnosis of serious disease, fear of seeking care, a drop in vaccinations, loneliness, aggravation of mental and physical ailments, lack of access to routine care, and PTSD is impacting our country and staffing at hospitals. Mayo Clinic reported 1000 personnel on leave for various reasons including testing positive and or being sick from the virus and other diseases.

  America is suffering permanent damage especially with efforts limiting the opening of our country, but it is at a price. As I have said many times, it is a balance in decision making between shutdown and careful reopening, because the cost will scar our country permanently.

  If you disagree with these issues, especially with friends and families, I would say, leave it alone, and remember the famous song by Tim McGraw, “Just be humble and kind”.

 

2. The Illicit (and prescription) Drug Crisis update during the Pandemic 

 

Drug Crisis and COVID-19

Introduction

  The CDC released some new data on fatal overdoses from 2017-2018, and reported that the number fell by 5.1% (from 72,000 to 68,500). This is the first year that the U.S. has seen a decrease in overdose deaths since 1999. This was almost entirely from fewer prescription overdoses mirroring the decrease in numbers of physician prescriptions.

  However, with the pandemic, need for the lockdown, isolation, job loss, major increase in psychological stress, the illicit drug market continues to be once again rising.

  More recently opioids have moved to the eastern part of the U.S. as seen above in the drawing of the U.S. In 28 states, the death rate from overdoses has more than doubled every 2 years.

Voters legalize illicit drugs

  With this crisis, and some states continue to baffle me and vote in hallucinogenic substance, psilocybin, from magic mushrooms. It is now legal in Oregon and has been decriminalized in the District of Columbia, along with other drugs. Both Oregon and D.C. have also decriminalized all currently illicit drugs including heroin, cocaine, and methamphetamine. What will happen to this crisis with legalization and decriminalizing?? I am sad the liberal attitudes of people include this issue.

Alcohol continues to be a major player in abuse

  Let us not forget alcohol is a frequent substance that accompanies prescription and illicit drugs. Many people are not suicidal until they get drunk and then the spiral begins. Alcohol and drug rehab centers must keep suicide on the radar as it continues to rise. Alcohol+ drugs + mental disorders = suicide risk! People with mental stress tend to self medicate to relieve symptoms and abuse follows.

   I had to repair shotgun blasts to faces that came from people drunk that attempted suicide. They told me they were never suicidal except when intoxicated.

  Many emergency departments are seeing a rise in non-fatal fentanyl, methamphetamine, cocaine, and heroin cases.

  Fentanyl is now the number one synthetic opiate killing people because of its potency. To detect fentanyl, a special test is required outside the usual toxicology screen. Fentanyl has been a very common drug used in general anesthesia. But the illicit market comes from China.

 CDC, July, 2019

  Reports from various emergency departments can vary widely depending on their load of COVID-19 patients. Some of the hospitals less burdened by the pandemic have reported a doubling of non-fatal opioid cases. The number of fatal cases has yet to be reported. However, there is  more liberal availability and administration of naloxone (Narcan) which reverse overdoses. Also there is a shortage of more powerful opioids from legal drug suppliers as there are for many drugs produced outside our country. Disparities in races are another factor, in that there is less access of legal prescriptions for poorer communities, since fewer people have a personal doctor. That disparity also extends to treatment access for substance abuse including *buprenorphine treatment. Even lack of public transportation has impacted access, increased financial burdens with unemployment.

  *Buprenorphine is similar to using methadone for opioid abuse. Currently a waiver is needed for a physician to prescribe this alternative opioid, which has been a huge barrier to access. This needs to be re-evaluated.

 

Unintended consequences with fewer prescriptions written

  There has been a slight reduction in opioid abuse with fewer prescriptions written, but since the CDC put out their guidelines to physicians about reducing the number of prescriptions to chronic pain patients, there have been the unintended consequences of patients being mismanaged, abandoned, or not being referred for pain meds, not to mention the major effects of the pandemic. Patients in pain who can not receive sufficient pain medication from their doctor will turn to the streets in some cases. Even fear of going to an emergency department with concern of being infected has played a role.

  Reluctance of physicians to prescribe opioids came from extreme pressure placed on them by the government at the detriment of pain relief for thousands of deserving patients. The medical organizations have also pressured doctors, considering the tarnished reputation of the medical profession.

  I have read numerous journal articles touting NSAIDs as a good substitute for opioids for patients with musculoskeletal. It is unfair to make sweeping statements other than to recommend starting with non-opioid medication, but if not adequate for pain relief, being willing to prescribe opioids.

  The national medical organizations are doing their best to steer doctors away from opioids, and that is appropriate, however, fortunately most doctors will prescribe a small amount of adequate pain medication in conjunction with taking NSAIDs, tapering the opioids over a few days with increasing NSAIDs and topical meds.

  Pain patches (Voltaren patches, lidocaine patches, patches containing capsacin) have significant value in mild to moderated cases, but there must be good judgement managing people with musculoskeletal pain. You can’t compare pain from a sprained ankle to a ruptured spinal disc.

  Muscle relaxants such as Flexeril is also valuable in these cases. Hot and cold packs intermittently are of value as well.

  In an attempt to curb opioid prescribing, there have been many patients who have suffered unnecessarily.

 

Value of Telemedicine

   Telemedicine has been a positive for many reasons especially during this pandemic. Many patients had been prescribed buprenorphine as mentioned above to combat the euphoric effect of standard opioids. Also prescriptions for naloxone (Narcan) to prevent overdoses have made an impact using telemedicine.

 

Link to suicide

  A new study has reported a new impact regsarding the link between opioid abuse, accidental overdose, and suicide. Families and friends need to be aware of the possibility that patients who are refused pain meds may attempt suicide.

  Pain changes the neuro-circuitry in the brain regarding  reward for pain relief, which can result in increased vulnerability to suicide and riskier use of opioids. There is a well-documented link between chronic pain and suicide, which are not entirely explained on the basis of an underlying psychiatric illnesses.

  Overuse is also linked to the amount of drug prescribed and underlying psychological disorders, as these can influence the reason why people may use opioids to self medicate their underlying disorders especially after 30 days of use.

  This puts the finger on doctors prescribing fewer pills and less strength when possible. Most doctors are only writing prescriptions for pain for a week or less even for post-surgical patients. There is no excuse for any physician to prescribe large amounts of opioids to any pain patient without re-evaluation of the status of the pain, what medications helped and consideration for more opioid or moving to an NSAID (Aleve, Ibuprofen, etc.)

  It is often unclear whether a suicide is intentional or not, as studies have reported only 1/3 of people leave a suicide note. If patients survive an overdose, their intent can change when questioned.

  Other factors that are linked to a higher risk of suicide include being white male, Native American, or age 41-65.

 

Withdrawal symptoms increase cravings for more opioids

  An individual known to have a previous history of opioid abuse demands the physician to constantly monitor patient’s pain levels and need for pain meds. There is a fine line between patients taking meds for actual pain and finding themselves feeling withdrawal symptoms and taking the opioids to prevent them.

  Physicians are now testing urine for drugs prior to writing an opioid prescription are given to rule out other drugs legal or illicit drugs. CBD intake will create a positive urine test and may prevent the doctor from prescribing pain meds.

  Opioid withdrawal symptoms include sweating, flushing, chills, fever, tremor, fast heart beat (tachycardia), anxiety, agitation, and abdominal symptoms. These same symptoms could also be caused by postoperative complications, therefore, the treating physician should evaluate this immediately.

 People in early recovery are extremely vulnerable to suicidal ideation because withdrawal frequently continues over a long period of time. 

 

Other factors can’t be ignored

  There is no question that as the dosage gets higher the longer a drug is taken, and the risk of overdose and suicide increase. There is also a link between being employed, having enough money to live on, legal problems, when hard times come, the pandemic, and depression occurs, etc. Crimes may be committed to get drugs, etc. which is worsened by opioids (a vicious cycle). These people need to be in rehabilitation if possible.

 

Analysis of non-fatal overdoses

  For those who had a non-fatal overdose, 6.2% died of another overdose within a year, and 9.3% within 2 years.      This information cries for careful surveillance in these high risk people and treatment if possible.

  Treatment with buprenorphine or methadone reduced mortality by 38% and 59% respectively and should be initiated in the emergency department when these people are brought in.

  Paying for drugs on the street can occur when the doctor refuses more prescriptions, and when heroin is so inexpensive and readily available, the risks skyrocket.  This vicious cycle clearly increases the risk for overuse, overdose, and suicide. 

  The availability of illicit drugs directly correlates with these issues. When crack cocaine became available (this is smoked), the addiction and overdoses rapidly escalated. When heroin became more easily available thanks to our porous southern border (and other sources), the increasing crisis clearly was linked.

The Opioid epidemic during the pandemic

JAMA, Oct. 27, 2020

  Heroin was prescribed for cough in the late 1900s.

Fentanyl Overdoses

  When fentanyl was introduced into the U.S. from China to Mexico, the number of deaths rapidly rose. People thought they were just shooting up heroin, and because fentanyl is 100 times more potent than heroin, unscrupulous dealers added the drug to heroin (to make the heroin go further) without warning their customers, and thousands of people accidentally overdosed and died.

  Veterans on these medications who were suffering from chronic pain and PTSD were particularly prone to abuse and suicide.

  There is little doubt if the U.S. could curtail drugs coming into our country, we will see a tremendous drop in overdoses and some suicides. But, let us not be naïve…it is coming in on military transports, coastal states, and now the Northeast Canadian border. We must solve the Southern U.S. border crisis for sure, because it is clearly linked, but drug rehabilitation centers is the answer in many cases, unless they commit additional crimes requiring punishment.

 

Increasing risk with certain other types of medications

  Patients with a previous history of opioid abuse disorder must be aggressively managed. Concurrent use of benzodiazepines (Xanax, Valium, Ativan, etc.), sleeping pills, and alcohol increase the risk of added abuse, overdose, and accidental suicide. These chemicals are sedatives and depress respiration, depress brain functions, and lower the dose necessary for opioids to cause an overdose or accidental suicide.

  Naloxone (Narcan) availability is also being used widely and most police officers and all medical personnel must have ready access to this drug which can reverse the effects of opioids immediately.

 

Opioid constipation

  Those who have had surgery and been on pain meds for several days after surgery have had to contend with constipation from bed rest and the effects of pain medications.

  Laxative are always the treatment of choice, however, if they are not working, suppositories or enemas may be recommended by the treating physician. They should be taken under a doctor’s supervision. Performing enemas regularly can lead to sodium and potassium deficiency.

 

New medications approved for severe constipation in opioid users

  If the usual remedies are not successful, there are new medications that are recommended for opioid induced constipation including naldemedine (Symproic) which is an opioid antagonist for non-cancer pain.

  Naloxegol (Movantik) and methylnaltrexone (Relistor) are also FDA approved and recommended by the American Gastroenterolgical Assocation.

  Since these drugs block the action of the opioid, there may be evidence of withdrawal if higher doses of opioids are being taken (reported in 1% of patients in studies performed by the drug company). 

  Prucalopride (Motregrity) is a selective serotonin receptor agonist, which increases peristalsis of the bowel.

  Lubiprostone (Amitiza) is a medication approved for these patients but also irritable bowel syndromes causng constipation.

 

Tramadol long term is addicting too!

  Addiction includes the weak short-acting opioid, Tramadol, a schedule IV narcotic (oxycodone, etc. is schedule II). Make no mistake, Tramadol (Ultram, Conzip) can be addicting as any opioid if taken over time with increasing doses.

  Physicians are using these milder opioids more frequently, but recent studies show that more patients are staying on them longer, which increases the risk of addiction and abuse. One study reported that 9% of patients are still on an opioid 6 months after surgery. Many are switched to Tramadol, but find it very difficult to stop.

 

Medication assisted therapy for Opioid Abuse

  Medication assisted therapy includes methadone, buprenorphine-naloxone, or naltrexone (Narcan). Getting patients on lower doses is critical and also by using any and all complementary therapeutic modalities available (see my series on chronic pain alternatives in previous reports—go to SUBJECT INDEX at www.themedicalnewsreport.com

 

Reference NEJM, Jan, 2019

 

New Revised Guidelines for Pain management

   Recently, the Department of Health and Human Services has recommended to pain management physicians best practices to handle patients in pain emphasizing an individualized “patient centered” approach. One of the most important issues is in dealing with tapering patients off opioids or abandoning them forcing some of them seeking street drugs (illicit opioids, heroin, and fentanyl). This is supported by many organizations including the AMA.

  With 50 million American adults experiencing chronic pain, and 20 million who have negative effects on their work, function, and quality of life, this must be addressed in a multimodal approach including opioid and non-opioid medication, nerve blocks, physical therapy, and alternative therapies (chiropractic, acupuncture, yoga, massage,  etc.), and behavioral therapy. Support from families is critical.

 

Other drugs are still a big problem

  Abuse of cocaine, psychostimulants (crystal meth), and ADHD (i.e. Ritalin) drugs are on the rise. Individuals are combining cocaine or methamphetamine to opioids, a very risky cocktail. And yet, as mentioned, Oregon and D.C. have legalized magic mushrooms and decriminalized all currently illicit substances. 

  Of the 70,000 overdose deaths in 2007, 20% involved cocaine, and 15% involved psychostimulants (methamphetamine, etc.). The CDC reports a 35% increase in recent years (2016-2020).

  75% of these deaths also included the use of opioids.

  Cocaine deaths were most often seen in females age 15-24, while psychostimulant deaths occurred in ages 24-35 most often. Blacks were the most common race dying from with cocaine, and American Indians/Alaskan Indians are the most common races suffering from psychostimulant and alcohol abuse.  Reference—CDC, May, 2019

 

ADHD drugs abused

  The increase in diagnosis of attention-deficit hyperactivity disorder (ADHD) has increased the number of prescriptions for patients. The diagnosis has doubled in some parts of the country partly due to the environmental exposure to smoking, lead, and increased screening. The majority are 13 and under. Kids sell or share their medications, or they steal them from their parents. These medications give kids a “buzz” much like amphetamines unless truly ADHD.

  11% of youth report having used prescription stimulants, and 1/3 are using it for non-medical purposes. These medications are chemically related to amphetamines.

  Ritalin is the most common medication, but Adderall, Dexedrine, and Cylert also are included in this list. There are non-stimulant alternatives for ADHD such as Strattera or Tenex, which can be used.

  Recently a new drug was approved (Vyvanase) for ADHD, which does not become active until it is metabolized in the blood, and with this delay, abuse may be reduced.

Medscape, Psychiatry, May,29, 2019

 

Screening for drugs in doctor’s offices

  The USPSTF, the task force advisory group to the federal government, announced recommendations for unhealthy drug screening in primary care offices if services for treatment are available, the first revision since 2008. This recommendation is based on 3 important findings:  

1) screening tests are now available in office practices including screening for cannabis.

2) treatment for drug abuse is now effective.

3) counseling by primary care offices has been ineffective.

  Alcohol counseling is still effective by primary care offices. Parents must be reminded to safeguard their opiods as a new study cited 1 in 7 high schoolers steal their parent’s opioids.

  Medications and behavioral therapy are effective in drug abuse cases, but must be administered by those specializing in the field of substance abuse, withdrawal, and follow up.

  10% of the population has drug abuse issues. Outcomes must improve especially when the individual is not highly motivated to change behavior. This pandemic has been a serious instrument in fueling this issue. Be aware!! See something…say something.

 

3. Dementia—types including the latest information on Alzheimer’s Disease

  

More than 3 million Americans are diagnosed with dementia each year. 5.7 million are suffering at any one time and 500,000 die every year. By 2050, these numbers could triple, according to the Alzheimer’s Association. There are cognitive and psychological components to this disease. It begins as an insidious loss of faculties, and individuals often try to hide their symptoms.

  Hallmarks of the disease, regardless of type of dementia include memory loss, difficulty communicating, forgetting where objects have been placed, confusion, disorientation, and many other cognitive issues.

  Psychological issues include depression, anxiety, changes in personality, and even psychotic symptoms and hallucinations.

Modifiable factors to prevent and reduce the progression of dementia (The Lancet Commission on Dementia Prevention)

  Dementia is caused by damage to nerve cells and their connections. Depending on the area of the brain involved, the symptoms will be different.

Alzheimer’s disease (AD)

 

History of AD

  The brain (above) shows atrophy of the cortex in comparsion to a normal brain. Note that aging also causes some shrinkage of the brain as well. Below the pink area of the brain (arrow), is the hippocampus, which shrinks more than aging or other neurodegenerative brains.

Dementia, the main feature of AD includes many different types and subdivided into primary and secondary. Secondary would include other disorders causing dementia. Dementia can be categorized by where the brain is affected, whether it is progressive, or caused by another disorder (primary or secondary). Primary dementia is a form of AD, which accounts for 50-70% of dementia. Dementia is the main feature of AD and therefore, it is crucial to understand how dementia plays the central role in 95% of AD. 7 stages of impairment are separated by the severity of symptoms.

 1) No symptoms

 2) Very mild impairment—forgetfulness blamed on aging

 3) Mild impairment—forgetfulness, memory loss, losing items, trouble managing finances, confusion, trouble managing medications, loss of concentration

4) Moderate impairment—trouble holding urine, increased memory loss and forgetfulness, inability to use the correct words, difficulty doing mental math, increased social with drawal

5) Moderately severe impairment—increased memory loss, confusion about location or previos events, needing help with wardrobe

6) Severe impairment—need assistance with dressing and bathroom, getting lost or wondering, unable to recall names of family, etc., sleep disturbance, changes in personality (paranoia, hallucinations)

7) Very severe impairment—loss of language skills, loss of awareness of surroundings, assistance with eating, unable to control urination, loss of muscle control (talk, smile, walk).

  It is now the 6th leading cause of death in the U.S. 2/3 are women. 5% develop early symptoms (40s and 50s).

  A recent study in clinical trials found that nasal mucus contained amyloid, and also found that many patients with early Alzheimer’s disease had dysfunction of smell, similar to Parkinson’s disease patients. The study compared patients with early dementia to a normal population and found higher levels of amyloid. It is hoped that this could someday soon allow an accurate nasal mucus test to detect early dementia. Scientific Report, July, 2020

 

Simple language test may predict AD

  Predicting AD could be very valuable in cases where there might be suspicion but nothing concrete. Asking everyone to take such a test is debatable and could create undo anxiety.

  A simple language test required the participant to describe in a set of pictures what was happening.

 It is premature to report anything other than it is showing promise and deserves further study and implementation if it holds up. 70% accuracy falls quite short for a test to offered to the public, but it has promise. Speech and speech patterns may have one of the keys to early prediction for select people perhaps family members of patients with AD, those with extremely early but suspicious cognitive dysfunction. EClinicalMedicine, Oct 22, 2020

 

Features of AD

  Ad patients suffer from a progressive type of dementia. The average life expectancy is 8-10 years, but can slowly progress in some for as long as 20 years. The onset is insidious with bouts of disorientation and difficulty with bouts of disorientation. As the disease progesses, the daily tasks and communication begins to slip, ultimately having difficulty caring for themselves and become paranoid and hostile. Bodily functions (swallowing, bladder, bowel become difficult to control and death can occur from aspiration of food and pneumonia, incontinence with infection and sepsis.

  A recent article in the Journal Brain stated that as many as a third of people in memory care facilities may not have progressive dementia, rather have functional cognitive disorder (FCD), which may interfere with daily life but rarely progresses. Brain, August 13, 2020

 

Risk Factors

  Elevated blood sugar, cholesterol, triglycerides, lack of exercise, hypertension, obesity, smoking, excess alcohol, lack of keeping mentally active, and insomnia or lack of 8 hours of sleep could age the brain.

  A recent publication named 10 factors that might help prevent AD—level of cognitive activity, increased blood levels of homocysteine, increasing obesity in late life, depression, stress, diabetes, head trauma, hypertension in midlife, orthostatic hypotension, and level of education. These have high level of evidence (Class A).

  Class B risks include obesity in midlife, smoking, sleep, cardiovascular disease, fraility, atrial fibrillation, and levels of vitamin C.

  Delaying the onset is a prime goal as there are no actual preventative treatments. Even though these factors may play a role, but causation cannot be proven.

Journal of Neurological Psychiatry, July 20, 2020

 

What is the cause of AD? Models, both old and new!

  Less than 1% of patients have familial AD.

  Although there is no proven cause of AD, there are 3 abnormal proteins that are deposited in the brain

1) amyloid plaques

2) tau neurofibrillary tangles

3) apolipoprotein E (APOE) 

 

Microscopic Appearance of AD

  Microscopically, there two types of protein- amyloid and tau. Amyloid in abnormal clumps called plaques and tau in neurolfibrillary tangles is found in specific areas of the brain in AD patients.

  The amyloid is found between nerve cells interfering with communication between cells, and the tau protein collects in tangles, which interfere with proper functioning of nerve cells. It is still not known if these proteins cause AD or are the result of the disease.

  A microscopic photo of amyloid plaques and the tau tangles. There is also neuronal loss, brain atrophy, and inflammation.

The old model

  It is not known if these amyloid deposits and tau tangles are cause or effect. Advocates of this model of pathogenesis believe that amyloid beta, stimulates the production of tau, found in neurofibrillary tangles. These abnormal proteins cause neuroinflammation leading to destruction of neurons, and connections between them (synapses). The APOE has a genetic link, and if a person has 2 copies (instead of 1) this gene (allele), they are 10x more likely to develop AD. 

  It remains unclear, according to an article in JAMA, July 21, 2020, how these proteins interact to produce pathology. There are several inflammatory markers seen in these patients (cytokines, chemokines, complement activation, and oxygen radicals). This neurodegeneration is most prominent in the frontal and temporal lobes of the cortex, and the limbic system. It is thought that this pathology is causing inflammation in the brain that leads to neurodegeneration. What triggers the inflammation? It is still not known.

 

The new model

  A new disease model is being hypothesized in this same JAMA article from Harvard Medical School. It is thought perhaps that an infection stimulates neuroinflammation by turning on the body’s own immune sytem (T-cell lymphocytes) very similar to COVID-19, and the herpesvirus is pointed to. It is known that there are gene variants that impair the immune response to infection and are more common in AD patients. It is thought this initiates a smoldering, recurrent reactivation of latent infection, also not proven.

  Multiple reports link herpes simplex tyoe 1 (HSV-1). DNA of HSV-1 may be found more often in brains of individuals with AD and especially prominent adjacent to amyloid plaques. This has been proven in mice, but would be hard to prove in humans.

  There is also a link between HSV-1 and those who have APOE-4 gene carriers.

  There are studies that have found that those with herpes simplex oral and or genital ulcers who are treated with antivirals ttend to have a lower incidence of dementia, although strictly an observational study.

  There other microbes linked to AD, including the shingles virus (herpes zoster), hepatitis C, helicobacter pylori,  Chlamydia pneumonia, fungal infections.

  There is a possibility that both models may be in play, but more research is necessary to prove this.

 

Blood tests on the horizon

Blood tests for amyloid and tau proteins have been coming for some time. However, they have not been able to come up with a test that has more than 95% sensitivity (accuracy in detecting the disease if it is present). It also must have a high degree of specificity (negative in in any type of dementia). These tests are not yet available. It is stated in the recent Alzheimer’s Association International Conference that these tests could be accurate enough to be available in 2-3 years as they continue to be refined.

  The above drawing demonstrates a potential screening process, starting with blood tests, and those who qualify may be a candidate for test of the cerebrospinal fluid with a spinal tap. Those who have abnormal amounts then could be candidates for a PET scan, which can quantify the tau in certain areas of the brain.

Brain scans can detect abnormalities in the brain in cases of dementia but cannot confirm a diagnosis of AD. PET scans can more specifically diagnose amyloid and tau in the brain, but still it is not known if these proteins are causing AD.

  What is needed is a blood test that can predict AD, and we are not there yet. These tests are badly needed, when it is so frustrating that we have few answers in treating these patients once they are symptomatic.

Much of the above information was taken from review on Alzheimer’s disease in a continuing education program presented on Medscape, August 14, 2020

 

FDA cracks down on illegal sales of Alzheimer’s 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 Gotlieb, M.D., FDA Commisioner. These companies are in violation of the Dietary Supplement health and Education Act enacted by 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. Prevagen is a good example of a drug from jelly fish that has never been studied to improve memory in anyone.

  

Other forms of Dementia

  Vascular dementia

  Vascular dementia is the other common form of dementia (15-20%). This can occur from a stroke, atherosclerosis, endocarditis, and amyloidosis. Structural damage occurs from blood clots, blocked arteries, and hemorrhage which can cause dementia on a vascular basis.

  Vascular dementia can co-exists with AD. The symptoms can overlap with AD, but can have short-term memory loss, wandering or getting lost, laughing or crying inappropriately (bulbar?), trouble with managing their lives, finances, inability to follow instructions, bladder and bowel difficulty, and hallucinations. Men, older people with cardiovascular disease, and blacks are higher risk.

  There is no specific treatment.

 

  Lewy Body Dementia

  The third most common form of dementia is called Lewy body dementia, from an abnormal protein (alphasynuclein) that is found in the brains of these patients. It is found in sticky clumps of this glycoprotein in the brains of patients including Parkinson’s disease. This protein has the ability to interfere with neurochemicals that have multiple functions--acetylcholine (memory and learning) and dopamine (movement, moods, and sleep).

 

 This type of dementia can overlap with AD in symptomatology, but also can have Parkinson-like movement difficulty, confusion, memory loss, loss of interest in daily activities, anxiety, and delusions.

  Lewy Body dementia is the kind of dementia found also in Parkinson’s disease with cognitive decline (memory, thinking, thought processing, problem solving, etc.) but in some ways is more devastating in Parkinson’s patients because of the associated motor impairments. About 70% will experience some signs of dementia as Parkinson’s progresses. It is felt to be the deposition of Lewy Bodies, according to the Parkinson Foundation. Over 200,000 cases are diagnosed each year in the U.S. with Parkinson’s disease.

  Medications that help parkinsonian movments may help these patients (levodopa). Donepezil and rivastigmine may also help. Melatonin and clonazepam can help sleep.

  These patients live 5-8 years and die usually from some of the secondary complications AD patients have including falls, infection, malnutrition, and aspiration pneumonia.

 

  Frontotemporal dementia

  This less common type of dementia is caused by degeneration of nerve cells in the frontal and temporal lobes of the brain. It is also associated with amyloid and tau, the abnormal proteins in AD.

  This accounts for about 10-15% of patients and occurs earlier in life (40s-50s). some consider this a subtype of AD.  The symptoms follow damage to the functions of these cerebral lobes--behavior, judgment, emotions, speech and some movement.

  Lack of empathy, inappropriate actions, lack of judgment, apathy, compulsive behavior, lack of awareness, change in eating behavior and hygiene. Movement issues can also occur.

  Antidepressants and antipsychotics may help control some of these symptoms. These patients live 5-8 years after diagnosis.

 

Other rare forms of dementia

  Rarer forms of dementia are caused by HIV, Huntington’s, Dementia Puglisitica (boxers), Corticobasal (symptoms of Parkinson’s and AD), Cruezfeldt-Jacob, dementia in children (Neiman-Pick), and medical conditions (low oxygen, acute infections, brain tumors, B1(thiamine),B6 and B-12 deficiency, acute head trauma, medication side effects, poisonings, and electrolyte imbalance.

 

Possible Treatments

 

Medications may help symptoms

  FDA approved medications may help some of the symptoms of dementia, but there is little capability of slowing the progression. There have been several drug trial failures. Memory care, cognitive therapy, and caregivers are just as necessary to keep these patients from getting into trouble, lost, hurt, or potentially hurting someone else.

  Medications—no new drugs have been approved since 2013. Medications called anticholinesterase inhibitors re the main stay of treatment. These meds block the transmission of acetylcholine in certain nerve endings. These meds act by blocking an enzyme cholinesterase, which is responsible for breaking down acetylcholine, which slows neural transmission.

Donepezil (Aricept or Namzaric)

Rivastigmine (Exelon)

Galantamine (Razadyne or Reminyl)

Tacrine (Cognex)

Memantine (reserved for advanced cases)

 

  Monoclonal antibodies are being tested in late-stage disease (solanezumab, etc.) to try and address amyloid deposits.

  Targeting tau tangles is still in the developmental stages.

  Emphasis from the latest journal articles centers on prevention rather than treatment, since there is little progress in actual slowing, reversal, or stopping the disease progression with medications. Nothing on the internet will help beyond the placebo effect.

 

Dietary Flavonols may help Alzheimer’s

  Dietary Flavonols that are present in fruits, vegetables, wine, and teas have been found to significantly reduce the risk of developing Alzheimer’s disease in observational studies. Once again, this emphasizes the value of a good diet emphasizing fruits and vegetables. Specifically the flavonols are present significant amounts in kale, beans, spinach, apples, olive oil, and tomato sauce.

  Flavonols are rich in anti-oxidants, and anti-inflammatory chemicals, however, taking dietary supplements have not been studied.

  A study at the Rush University Medical Center in Chicago, Illinois found those who had the APO-E4 gene, who had late-life good cognitive and physical activity, and who had the highest amount of flavonols intake had a 48% reduced incidence of Alzheimer’s compared to the group with the lowest intake.

 January 30, 2020 on Medscape

 

Supportive Care critical for patient and family

  Reaching out to Alzheimer and memory care facilities is critical for the support these families must have to cope with such a devastating disorder.

  Close observation for depression (and other neuropsychiatric issues), alcohol and drug abuse, and sleep disturbance is critical, and must be reported to the treating physician.

  Counseling may be necessary as the disease progresses.

 

Prevention and slowing the disease process

 The Lancet Commission Dementia Prevention separated modifiable factors into 3 stages of the dementia as suggested efforts

1-Early life—education about factors to be aware of such diet, awareness of early signs, behavioral activities that might modify dementia, including those factors needing immediate attention later in life if still present..

2-Mid-life—addressing hearing loss, obesity, and hypertension

3-Late life—smoking, depression, physical inactivity, social isolation, and diabetes.

 

Subtype of AD (progressive dysexecutive syndrome)

  There are subtypes which do not necessarily affect the hippocampus atrophy and memory centers (the main centers in AD). It is called progressive dysexecutive syndrome. Researchers at Mayo Clinic have found various defects in the brain with exclusions of the hippocampus. It tends to occur in younger people (40-50s). This syndrome could be mistaken for fronto-temporal dementia. PET scans can differentiate them. Medscape Neurology, July 10, 2021

  As iron deposits accumulate in the brain the progression of AD may occur, according to a new study. MRI scans show increased iron in the brains of AD with increased accumulation over 17 months. Whether the iron is causing the acceleration is still unknown.

Iron levels are similar to amyloid deposits. There is a gene mutation that is found with AD, and that same mutation is thought to also cause increased accumulations of iron in certain brain cells.

 

Understanding another risk factor for Dementia--Apolipoproteins

  The fat-carrying proteins (Apo-E) in our blood are involved with dementia.

  The apolioprotein (Apo-E4*) allele is the most important known single genetic factor for late-onset Alzheimer’s disease. It causes cognitive decline, shortening the time of onset to death. It does not exclusively occur in Alzheimer’s disease but can occur in other neurological conditions. It increases cognitive decline in older people who are clinically normal, and in head trauma patients. It is not yet known how it is involved even though the link is there, according to research described in JAMA Network, July 10, 2020. It should be noted that as many as 10-20% of people with this genetic abnormality are normal and do not develop dementia.

  *Apo-E stands for apolipoprotein E and is in the family of a large group of lipoproteins that bind fat to them to be transported around the human body. When there are elevated levels, they increase the risk of Alzheimer’s disease and cardiovascular disease in all humans. The mechanism has yet to be elucidated. 

  The fat is carried by chylomicra in the blood. This drawing shows how it flows through the blood and is deposited in the liver for release.

This transport particle (chylomicron) contains  triglycerides primarily, phospholipids, cholesterol, and proteins, and they are one of the 5 major groups of that transport particle called lipoproteins. These are stored in the liver and released when needed for energy.

  Summary

  We continue to lag in the treatment of such a serious disorder, and yet, research brings us closer each year. In the meantime, prevention is the best we have, and there are some very important measures to follow. Please do so!

 

4. The “intelligent knife” for cancer surgery

As a cancer surgeon who used lasers to cut many cancers out of the head and neck area, I never dreamed that there could be a “knife” that could differentiate cancer cells at the cellular level. Now there is such a knife.

In the NEJM-Journal Watch, April 21, 2020, a report from the Proceedings of the National Academy of Science.

The idealized goal of cancer removal is to not leave one cancer cell behind while sparing as much normal tissue. Currently a zone of normal tissue needs to be added to any cancer surgical excision, because it is well known that cancers have “fingers” of spread.

  Frozen sections are performed to have as much chance of total resection. The greater zone of normal tissue removed, the greater chance of harm to the area of the body. This is critical and sometimes not met with success, necessitating postop radiation, chemotherapy, etc.

  A handheld diathermy device (looks like a standard cautery unit—see above) was applied to the cervix to create a surgical “aerosol” of compounds that is attached to a tube which is fed into a mass spectrometer a nd analyzed immediately.

  This experiment was performed on normal cervical tissue biopsies removed for suspected cancer (called a cone biopsy), tissue that contained HPV virus and 21 specimens that had pathological proof of cervical cancer. The mass spectrometer were able to differentiate all 3 types of tissue.

  The authors envison a future where a diathermy wand attached through tubing is attached to a mass spectrometer and in real time can be used to remove cancers with the least normal tissue around the cancer.

  How this technology will evolve remains to be performed, and whether this application of removal of cervical cancer can be applied to other areas of the body will be determined with more research.

 

5. Older people need to reconsider their medications and their dosages

Many older people begin to reduce the quality of their diet, start losing height and weight from osteoporosis and aging, muscle wasting from inactivity, and reduced cognitive skills.

  A study reported in the JAMA May 26, 2020, that some physicians have found that if a person is on more than one antihypertensive, that one of these meds could be stopped without a rise in blood pressure (BP) over a 12 week period. Out of 569 patients, 2/3 of these patients continued to maintain acceptable BPs with reduced antihypertensive medications.

  The corollary is that other medications might be evaluated carefully to consider dropping or reducing dosage of medications, such as anti-inflammatory medications, statins, etc.

  On the other hand, evaluation of a elder’s diet and quality of posture, DEXA scan to evaluate osteopenia or osteoporosis including vitamin D and calcium levels.

  The point is, once a person reaches 80 years of age, it is wise to evaluate a person’s nutritional and medication history. I am sure most physicians are performing these tasks with the Medicare/Medicaid annual wellness exam. The only problem is not every recipient sees their primary care doctor annually or even has one.

  I discussed this issue previously, but it is such an important issue, I will expand, but please click on my website www.themedicalnewsreport.com#70

  10% of hospital admissions occur because of medication -related problems. It is estimated that 2/3 of these admissions could have been prevented if there had been adjustments in dosage or even deleting medications.

  People over 60 years of age purchase 30% of all prescription medications.

  Drug interactions increase as several drugs are consumed daily, and 40% are of over the counter (OTC) medications. The digestive tract of older people change absorption rates. Side effects of medication rise with age. Metabolism slows with age as does organ function, and this affects the medication a person ingests.

  Another important issue is elderly people forget to take their medicine properly and may take several pills when they miss (thinking they should wrongly catch up).

  With the cost of medications today, many patients do not even fill their prescriptions, never notifying their physicians. Also, if a patients develops certain symptoms and erroneously stops taking a medication abruptly, there could be serious complications requiring medical attention.

  Studies have reported that up to 1/3 of patients stop their medications without telling their primary care physicians.

  Heart and blood pressure meds, and aspirin as a preventative for heart disease, anti-coagulants, cortisone, antidepressants, drugs for ADHD, etc. all should never be stopped or have the dose adjusted except with the supervision of their doctor.

 OTC medications can be just as dangerous

  Also because of lack of regulation regarding over the counter medications, these should also be discussed, especially if people are taking more than the RDA (recommended daily allowable) recommended dose of dietary supplements.

  Another report from the Journal of the Geriatric Society, June, 2020, stated that 1/3 of older medical and surgical patients in 2 Canadian major hospitals were prescribed inappropriate medications at the time of discharge from the hospital. The most common medications were benzodiazepines without a diagnosis of epilepsy or anxiety, proton pump inhibitors (Prevacid, Nexium, Prilosec, etc.) without a diagnosis of an esophageal or gastric abnormality, and celecoxib (Celebrex) without a history of hypertension (Celebrex can elevate BP).

  Unnecessary medications increase side effects and drug interactions that could be avoided.

  It is important to question the doctor for the reason for any new medication, indications, side effects, and drug interactions. These issues multiply in older patients since they very often are taking several medications.

  Call the primary care doctor and be sure they agree with these prescriptions, their doses, and could there be safe adjustments

 

  This completes the December, 2020 report and the end of another year of reporting the latest in medical and healthcare information. Merry Christmas and Happy New Year!! God bless America!!

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

 

The January, 2021 report will include:

1. Cancer risk for children borne from mothers with fertility treatments

2. Screening guidelines for abdominal aortic aneurysms

3. Time to test thyroid function with a different test

4. Probiotics/prebiotics

5. Missed medical diagnoses

6. Management for difficult skin cancers—Moh’s Surgery