The Medical News Report

#95

  December, 2019 

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

samlamonte@gmail.com

Subjects:

1. Ground breaking study on medical therapy vs. invasive techniques for ischemic heart disease

2.  Infectious Diseases Series

A. Pneumoniatypes and treatment; updates on resistant infections

B. Shingles shot-newer Shingrix vaccine

C. New Influenza drug to shorten symptoms; more info on complications of flu bug; warning about vaping and flu-like symptoms

D. Measles outbreaks continue! Complications can be severe

E. Update on HPV virus and Hepatitis B vaccinations; Immunization schedule for all adult vaccines

3. Do Lawyer ads for class action suits against drugs and medical devices do harm?

4. Red Meat is ok to consume or is it?

5. Ovarian cancer risk in BRCA gene mutation women—new guidelines

6. Drugs and Bucks!! Big Pharma—how are we going to reduce drug prices? An update!

 

Merry Christmas everyone!!

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

  Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

  Thanks!! Dr. Sam

 

1. Ground breaking study on medical therapy vs. invasive techniques for ischemic heart disease

    

Coronary artery anatomy

  Every once in awhile, a study comes along that really stirs the medical pot. In people with stable ischemic heart disease, a multi-country project found that those patients will fair as well with medical treatment, behavior modification, and diet as those having a coronary artery stent or bypass procedure. The ISCHEMIA TRIAL cited no meaningful difference between these groups.

  5200 participants were randomized to having medical treatment or a coronary stent (or bypass) if they presented with symptoms of angina or other symptoms that prompted their cardiologist to perform a stress test. When the stress demonstrated ischemic changes on the EKG, these patients were referred for either invasive management (coronary angiogram and either a stent or bypass graft surgery) or intensive medical therapy.

  If the cardiac catheterization demonstrated isolated stenosis (narrowing) of a coronary artery (not the left mainstem coronary artery-the widow maker, which carries a very high risk), they had angioplasty to dilate the narrowing and a stent placed or in certain cases coronary bypass surgery was performed. Both groups were given intensive medical treatment. See below! Below drawing 1 and 2A and 2B

 

Drawing #1

Above drawing #1, demonstrates dilating a partially blocked artery with a balloon and then slipping a metal expandable stent to keep the area open. The catheter is passed through the femoral (groin) artery up into the heart, as seen on the left portion of the drawing to perform a cardiac catheterization.

  The below drawing 2A and 2B, demonstrates a donor vein (usually from the lower leg) surgically attached from the aorta to the coronary artery placed past the blocked coronary area to perfuse the heart muscle. Below is an example of a double and triple bypass surgery, but all 4 arteries can be bypassed (quadruple bypass).

Next Page:

Double and triple bypass surgery     Single bypass surgery

    

Results of the study

At 4 years, these two groups were analyzed for cardiovascular death, heart attacks, CPR for cardiac arrest, hospitalization for unstable angina, or heart failure. Both groups had about the same number of events (15% for medical vs 13% for stent or bypass). Due to the closeness of the stats, it was deemed statistically insignificant between the two groups.  

  This is a major study presented to the American Heart Association’s annual meeting. It opens up great concern about how to treat individual patients in the U.S. with our current litigenous society and ingrained attitudes of both cardiologists and patients.

  One of the main concerns is getting patients to agree to try medical therapy and modify their lives to encourage ongoing cardiac disease to be handled in a conservative manor while worrying they might have a heart attack and die. These patients were prescribed statins where indicated and omega-3 drugs to lower triglycerides and cholesterol.

  How does a physician have success in getting patients to quit smoking, lose weight, exercise, improve their diet, and take the appropriate medications to improve their cardiovascular health without invasive intervention? With motivated patients it is clear it is possible.

  Call me pessimistic (or realistic), but when a person develops cardiovascular symptoms, and they go to the ER, and show evidence of EKG abnormalities, I wonder how many people would be willing to go the medical therapy route when they are in distress?

  Since these studies have not been published in peer reviewed journals, I think it is premature to accept these studies. Until such time that the medical community can digest these findings, I would not expect many cardiologists to buy into this somewhat radical departure from standard approaches to ischemic heart disease management. Some are even suggesting that stress tests may not be necessary in certain cases. Yet, it is encouraging to know that we as patients have the ability to change our chances of mortality…..and that is powerful information.

  It is most appropriate to discuss these findings with a person’s cardiologist and weigh the risks and benefits of both approaches perhaps before an acute event occurs. Unfortunately, patients symptomatic of heart disease (angina, etc.) may not be in a position to take the time to weigh all the issues needed to make an informed decision.   

  The main takeaway from these findings is that medical therapy really does work if a person is willing to follow a significant medical regimen. But why wait until a person is having cardiovascular symptoms to get on the “bandwagon” and take health seriously????

  Heart disease management is complicated and even though research may support considering medical therapy instead of cardiovascular intervention (cardiac catherterization, coronary stents or bypass surgery), each patient must have individualized management based on a number of criteria and the experience of their doctors. Medicine is not cookie cutter healthcare.

  When it comes down to accepting new medical information from research, most studies need independent studies to verify the same results found in this study. That will take years.

  Medical therapy is also quite complicated based on lab values, symptoms, co-morbidities, age, etc.

  For now, we have been given great news that medical therapy for cardiovascular disease really does help and prevent cardiovascular events and deaths. Everyone needs to do the best they can to help their doctors keep us out of trouble.  

 

2. The Infectious Diseases Series

A. Pneumonia

B. The new shingles vaccine

C. New flu drug

D. Measles outbreaks and vaccine

E. HPV and Hepatitis B vaccines

 

   A. Pneumonia-types and treatment; pneumonia vaccines update; update on resistant bacteria

  3 million Americans develop pneumonia annually in the U.S., and 60,000 die of the disease. 4 out of every 100 children will develop pneumonia.

  With so many respiratory infections from bacteria and viruses occurring, there is always a concern for developing  pneumonia. There are people who develop pneumonia from the beginning of their illness, especially those who are older and those immunocompromised (3.6% of the population=10 million). However, more people develop pneumonia as a complication from viruses and bacteria that start in the respiratory tract.

  Pneumonia occurs when the little lung sacs (alveoli) fill with fluid or pus. Depending on the extent, it can reduce the lungs’ capability to transfer oxygen to the body.

  Causes and types of pneumonia

  Pneumonia can be caused by bacteria, viruses, and fungi. Chemical aspiration or inhalation can cause pneumonia as is happening with the e-cigarettes (vaping) from inhalation of oils (flavored THC and nicotine oils) and other chemicals including gastric acid from reflux.

  Patients acquire pneumonia and are only somewhat ill but can still function. Patients may be somewhat asymptomatic (walking pneumonia), however if a patient  gets pneumonia in the hospital (acquired), it is usually severe.  People can get pneumonia in their community (acquired) from exposure to others who are infected.

  Higher risk groups

  Children under 2 and adults over 65 (30%) are the most prone to develop pneumonia. But this group includes childhood diseases, those on medication lowering immunity, those who have chronic disease especially pulmonary diseases (asthma, COPD, etc.) have genetic diseases, are on cancer treatments, those with HIV-AIDS, those disabled, and those in a high exposure area.

  There are many drugs being used to treat arthritis, psoriasis, cancer, HIV-AIDS, and other autoimmune diseases, that tuberculosis testing is necessary, and evaluation of exposures before treatments including areas that are known to cause fungal infections.

  Those who smoke and drink too much alcohol are risk factors as well. The biggest risk group are those getting older (over 65), primarily because their immunity begins to lessen just on age alone.

  Symptoms of pneumonia

  Fever, sweating and chills, a productive cough (producing discolored phlegm), chest pain, shortness of breath, fatigue, loss of appetite, and even nausea, vomiting, and diarrhea. They vary depending on the severity and type of pneumonia. Patients may need to be admitted to the hospital especially if not responding to oral antibiotics or have underlying chronic illnesses that prevent a successful recovery.

  X-ray evidence of pneumonia (bacterial)

     

These opacities can be scattered throughout a lobe of the lung (left) or a consolidation of a lobe (center), or in a lower lobe (right).

  X-ray evidence can lag several days after the symptoms are present and there are sounds consistent with pneumonia using a sthethoscope and other physical signs, therefore, a second X-ray may be necessary to prove the disease. By the same token, the patient will start recovering long before the X-ray clears.

 

  Other important lab tests to confirm cause

  Pulse oximetry can be placed on the finger to check the blood oxygen levels (they should be 95% or better).

  Blood tests will indicate an elevated white blood cell count indicating an active infection. Blood can be cultured for bacteria and is often performed if in the hospital and very ill.

  Sputum (phlegm) is cultured as well to identify the specific bacteria. If a bacterium is identified, several antibiotics are tested to see how effective they can kill the bacteria (called sensitivity test). This allows the physician to select or change antibiotics depending on the results of the sensitivity studies.

  There is a blood test for Mycoplasma pneumonia, a specific type of common pneumonia.

  In severe cases, bronchoscopy can allow the pulmonologist to pass a tube down into the lungs to see if there is an underlying cause (lung cancer, foreign body, or some type of narrowing).

 

  What causes the most common kinds of pneumonia?

  Flu viruses, cold viruses, RSV-respiratory syncytial virus  (most common pneumonia in babies), Streptococcus pneumoniae, and Mycoplasma pneumonia.

 

  Types and treatment or prevention

“Walking” pneumonia

  This type is most commonly mycoplasma pneumonia (called atypical pneumonia), and it occurs where there are groups of people (schools, military, nursing homes, etc.). It takes 15-20 days from the time of exposure worsening over 2-4 days characterized by cough (can come in spasms), chest pain, tiredness, sore throat, and weakness that may linger. It may also be accompanied by a rash, ear infection, and mild flu like symptoms mimicking influenza.

 

Hospital-acquired pneumonia

  Patients can bring infections to the hospital or they can get infected from the vulnerable post-op status, contamination from hospital employees, or equipment (such as a breathing machine), and not mobilizing (out of bed) adequately. These infections are more severe and can be resistant (i.e. MRSA—methicillin resistant Staphylococcocus aureus ). Bacteria infecting patients are often carried by asymptomiatic employees (called carriers) who are not infected but carry that bacteria most often in the nose.

  When patient’s blood and bodily fluids are cultured, there is a sensitivity testing that goes on to find out what antibiotics are best for an individual infection (and what are not helpful). One of the worst is example is MRSA. It requires very powerful antibiotics such as vancomycin, Zyflox, and Ceftaroline.

 

Community-acquired pneumonia

  This type of pneumonia most commonly occurs where there are groups of people such as in schools, the military, nursing homes, and those who are immune compromised, older than 65, smokers, those who have chronic lung disease (COPD, asthma, emphysema), have disabilities, diabetes, heart disease, etc.

  One of the most common causes is Streptococcus pneumoniae (or pneumococcus) and can be prevented with a vaccine in many cases. Viral pneumonias commonly occur from influenza, severe upper or lower respiratory infections (bronchitis), or in those prone to infections such as those described above.

 

Aspiration pneumonia

  When a patient presents with suspected pneumonia, the physician should question whether the patient has trouble with gastric reflux at night, as this may be the cause or a contributing factor. This can occur especially with people who have swallowing difficulty, have neurodegenerative diseases (Parkinson’s, Alzheimer’s, stroke, etc.), after anesthesia, and underlying diseases of the lung. It is also common that people who aspirate usually at night have wheezing and chronic cough, which may be confusing especially in a smoker. If a person has a severe aspiration event, pneumonia can develop within just a few days. In hospitalized patients, it can account for as many as 4-26% of patients. Foreign body aspiration in children and the elderly should also be considered.

  It is caused by certain bacteria (E.coli, Klesiella, Enterococci, Pseudomonas, etc.) in hospital or skilled nursing facilities, but in a community acquired pneumonia it easily could be Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenza, the same bacteria in other causes of community acquired disease. People on ventilators aspirate stomach contents regularly, those with a feeding tube, those who have had CPR, have underlying lung disease, etc.

  As in many pneumonia cases, X-ray evidence does not appear evident for several days after symptoms occur.  

         

As many as 60% of cases in one study of nursing home patients had some component of aspiration.

  The treatment is different if community-acquired (ampicillin-sul-bactam, carbepenem, or a fluoroquinolone). Hospital acquired aspiration pneumonias will require coverage for bacteria called gram negative bacteria (piperacillin, tazobactam, ceferine, or some of the above antibiotics). These are much more powerful antibiotics.

  Prevention is the key including diagnosis and treatment of gastric reflux at night, those who cough often, and those at risk because of certain events, procedures, and chronic underlying lung and swallowing issues, etc. Aspiration pneumonia can be fatal, so early recognition and treatment is critical.

NEJM, Feb 14, 2019

Viral pneumonias

Viruses are slightly different and usually cause a dry deep cough, tightness in the chest, fever, chills, and shortness of the breath. Antibiotics do not help. Anti-virals may be of some help (Tamiflu, Relenza, and Rapivab). If RSV (respiratory syncytial virus) is the cause in children, Virazol may be helpful. Note the two examples of X-rays below are less impressive than bacterial pneumonia. There is   without consolidation that can be seen in bacterial infections. But in the elderly the can be deadly and usually the cause of death from influenza.

    

Bacterial pneumonia

  Bacterial infections cause the most severe symptoms with high fever, green or yellow sputum, shaking chills, sweats, shortness of breath, rapid heartbeat and respiration from low oxygen levels, and sometimes sharp chest pains, including feeling very ill. Antibiotics will be discussed below.

 

Fungal pneumonia

 Although uncommon, certain fungi can cause pneumonia especially pneumocystis species in immune deficient patients.

Around bird droppings, Cryptococcus can be a culprit. Coccidiodimycosis is a cause in desert areas. Histoplasmosis is found in the Ohio and Mississippi Valley areas of the U.S. Fungal pneumonia is usually more diffuse with little pockets of infection. Fluconazole is a common antifungal used.

Rare causes include yeasts (Candida), tuberculosis, and even parasitic diseases.

 

Prevention Vaccines—2 options

 

Prevnar 13

  Prevention of this type of  pneumococcal pneumonia is the key, most commonly Stretptococcus pneumoniae, may be prevented or lessened in severity by taking the “pneumonia shot”—Prevnar 13 for those 65 or over, those under 5 years old, and anyone at high risk for pneumonia such as patients with COPD, chronic bronchitis, asthma, or heart failure.

 

Pneumovax

This vaccine is recommended for those 65 and older, children under 2 at high risk for pneumonia, all who smoke, or have asthma.

The choice of vaccines should come from a person’s doctor.

 

  Treatment of pneumonia

  Bacteria are the most common community-acquired pneumonias. This can be acquired from people coughing their infected droplets into the air. Less commonly, viruses can accomplish the same thing. People most vulnerable are those with immune deficiencies, and chronic health issues especially lung and heart.

  Choice of antibiotic depends on the pathogen. Mycoplasma pneumoniae (most commonly walking pneumonia) responds to tetracycline or doxycycline and erythromycins (i.e. Z-pak).

  The other two most common causes of walking pneumonia are Chlamydia, and Legionnaire’s disease which are sensitive to the above antibiotics. There are other bacteria that can cause pneumonia in a community-acquired or hospital acquired pneumonia, and hopefully the cultures of sputum will identify them.

 

  Antibiotics

  There are four classes of antibiotics that can be used to treat most pneumonias (outside the hospital).

1- Macrolides, which include erythromycin, clarithromycin (Biaxin), and azithromycin (Zithromax).

2- Fluoroquinolones, which include the floxin type drugs (i.e. Ciprofloxin, Levoquin), of which there are several. These are more powerful and not to be used as in children or as a first line drug. They have more complications including rupture of the aorta, hypoglycemia, rupture of tendons, neuropathies, depression, anxiety, and even suicide. When indicated, they are very effective.

3- Tetracyclines are also very effective treating walking pneumonia. Doxicycline and Minocycline are commonly used tetracyclines. They should not be used in children due to discoloration of teeth. These could be used as a first or second line treatment for adults. They cannot be used with antacid liquids or pills as they bind to them making the tetracycline ineffective.

4- Cephalosporins are very effective drugs and usually are saved for more serious pneumonias. There are 5 generations of cephalosporins based on the bacteria that most effective against.

1st generation is most effective against gram* positive bacteria, 2nd generation-target some gram positive but also gram negative bacteria. 3rd generation-mostly gram negative bacteria. 4th generation includes only one antibiotic-cefapime (Maxipime) against serious infections. 5th generation against serious infections include only one available in the U.S.-ceftaroline (Teflaro).

*gram stain defines the type of bacteria in the laboratory.

Examples of oral cephalosporins are- 1St generation-cefaclor (Ceclor), cephalexin (Keflex); 2nd generation- cefprozil (Cefzil), cefuroxime (Ceftin); 3rd generation- cefdinir (Omnicef), cefixime (Suprax).

  Vancomycin is a very strong antibiotic that is used in  MERSA, and other pneumonias that are resistant to standard antibiotics.

 

  Bacteria that cause pneumonia

  Streptococcus pneumoniae  (or pneumococcus) pneumonia is one of the most common causes of pneumonia and responds to penicillins, cephalosporins, clindamycins, and other powerful antibiotics (if first line antibiotics do not work or there is resistance to these antibiotics. As many as 30% of these cases will have some antibiotic resistant bacteria. This begs the need to culture sputum to isolate the cause. Unfortunately, often times, no bacterium grows out. If a person has taken any antibiotic, cultures of bacteria will not grow.

  Today, with resistance being an issue, a third generation cephalosporin is the drug of choice (ceftrioxone-Rocephin  or cefotaxime-Claforan) in children and adults.  Vancomycin has proven little resistance but is reserved when other antibiotics are ineffective. This is true for those who have not had the pneumococcal vaccine.

  Less aggressive antibiotics may be effective for those who have had vaccination (another good reason to ge the vaccine).

  For adults, if a person is healthy otherwise and does not need admission to the hospital, one of the macrolides (erythromycin, Azithromycin, etc.) or amoxicillins may be sufficient or a second antibiotic may be added (fluoroqunolone-Cipro, etc.).

  For adult patients with underlying risk factors cited above, a combination of macrolides and amoxicillin or a first generation cephalosporin (Kelflex, etc.) may be sufficient, or in more serious cases, a third generation cephalosporins (Rocephin) may be recommended. Also the fluoroquinolones may be necessary.

  The decision for type(s) antibiotic treatment must be decided based on all the above factors, and if there is no clinical improvement in several days, resistance must suspected and a change of antibiotic may be necessary.

  Once on antibiotics, cultures are relatively worthless.

  In communities, physicians usually know the prevailing bacterial infections causing pneumonias and the antibiotics that are most effective. This will vary from community to community (especially rural vs urban).

 

  Other bacteria that can cause pneumonia

  In addition to the bacteria cited above, Staphylococcus, Klebsiella, Psuedomonas, Haemophilus, Moraxella, and some anaerobic* bacteria can cause pneumonia. These bacteria are more commonly seen in hospital-acquired pneumonias, because these bacteria grow quite well in hospital equipment, on personnel, and can be transmitted when preventative measures are not adequately followed.

*there are aerobic and anaerobic bacteria-aerobic means they grow in oxygen medium, and anaerobic means they grow better in a oxygen depleted environment (such as an abscess, in the gut and kidneys.

Ref: The American Lung Association, WebMD, Medscape, CDC, and healthline

 

  Update on resistant bacteria

  The CDC has announced an update on resistant bacteria to standard antibiotics. Deaths due to these resistant bugs accounted for 44,000 deaths per year (2013). Due to doctors reducing the number of presecriptions for antibiotics, the death rate has drop by 18% overall. 2.8 million resistant infections occurs annually.

  Candida auris (a fungus) and Acinetobacter resistant to very strong antibiotics such as the carbapenems has topped the list of “urgent threat” alerts on a list of 18 resistant microbes which are on the threats to human health list. This includes MRSA (methicillin resistant staphylococcus aureus infections. There are 5 carbepenems reserved for these resistant infections, however, the above 2 bugs are resistant to them.

  Resistant bacteria began a few decades ago when overuse of antibiotics created resistance in certain bacteria and fungi. The next time the doctor says you have a virus and you insist on antibiotics, this is what has happened to create the crisis.

  Antibiotic stewardship is the reason some of these infections in the hospital are now under better control, but as one type of infection is better controlled, another raises its ugly head. Lancet Journal, in Medscape, November, 2019

 

B. Shingrix vaccine for shingles-Herpes zoster

The new and improved shingles vaccine has been out for about 2 years, and it was time to see how it has held up for protection, and the reactions.  2 shots of Shingrix are required (a booster 3-6 months after first shot).

  3 million Americans suffer from shingles annually, and 10-18% will experience the dreaded herpes nerve pain (post-herpetic neuralgia) which can be permanent and is debilitating. It occurs more frequently in older people.

 

1- Who needs the vaccine?

  The CDC recommends everyone over 50 years of age should get a shingles shot unless the person has some kind of immune deficiency (cancer, HIV, or are taking some type of drug that might increase the person’s susceptibility to infection). Drugs for cancer, transplants, arthritis, and other autoimmune diseases are examples. Although, those that have “low” immunosuppression” should still consider it, as cited in a recent study, that is a decision for the treating physician.

  If a person is on any drug for a serious illness, it is important to discuss with their physician before getting vaccinated.

 

2- Why do we need protection from shingles?

  For anyone who has had shingles, even if they did not have the dreaded post-herpetic neuralgia, you are in for a very painful experience for a few weeks. It is a very itchy, yet very painful rash, with blisters that appear on the skin where the specific nerve supplies sensation to the skin.

  Anyone who had a case of childhood chicken pox is vulnerable, because the herpes chicken pox virus (herpes varicella zoster) is the same virus, and it neve resolves as it lies dormant in nerve bodies and activates later in life as shingles.

  The CDC states that 99% of the population has been exposed to the chicken pox virus at one time or another whether the person had a rash or not (and harbors the virus). Performing a serologic blood test for chicken pox is not recommended by the CDC. They would recommend Shingrix anyway.

  Below is a drawing demonstrating where the virus lives dormant in the ganglia (see arrow) of the nerve(s) outside the spinal cord (a relay station that sends impulses down the peripheral nerve to the body including the skin).

Below photos demonstrates the shingles rash as seen on the chest wall and face (can cause blindness). The far right double photo shows what can happen when the facial nerve is involved (facial paralysis), involves the auditory nerve causing hearing loss, and vertigo, termed the Ramsey-Hunt Syndrome.

   

 

Having treated many of these cases, these people really suffered, and some had to be admitted to the hospital with high dose steroid and anti-viral medications (Acyclovir, Famvir, and Valtrex). Many had permanent disabilities. Facial paralysis resolved in some.

  The herpes virus most likely will appear on the chest wall and rib area nerves (can occur anywhere), but still causes extremely painful blisters that leave the skin so sensitive to touch, even wearing clothing can be intolerable. This can last for weeks or permanently.

  The nerve damage is called post-herpetic neuralgia because the herpes virus can damage the nerve as it travels from nerve ganglion outside the spinal cord down the peripheral nerve with eruptions on the skin.

 

3- Can the Shingrix vaccine be taken with the flu shot or pneumonia shot?

  The CDC has not evaluated the safety of multiple vaccines at the same time. I think most physicians do not recommend it. It makes sense to challenge the immune system one shot at a time. Check with your physician.

 

4- What if a person has had shingles before? Should they still get the vaccine?

  Yes! People who get the shingles still have the virus in their system for life and could still cause a serious infection.

 

5- Can a person get the shingles from the shot?

  The most common symptom is a sore arm at the site of the injection. A few people will have fever, and malaise, but it does not cause the shingles rash.

 

6- What if a person has previously had the other shingles shot, Zostavax?

  The CDC does not have any evidence the shot can’t be given, since the effectiveness and longevity of protection is not near as effective as the Shingrix vaccine (90% vs 50% for Zostavax).

  If a person has been given Zostavax, The CDC states an interval of at least 8 weeks be given before getting Shingrix. However, there are no studies with an interval less than 5 years.

  Zostavax effectiveness wanes considerably after age 70 (41% effective) and age 80 (18%), whereas Shingrix effectiveness is much better and shingles at older ages is much more difficult to overcome.

 

7- Who should not get the Shingrix vaccine?

  If a person has an allergic reaction from the shot or previous vaccine. Someone who has had a test negative for chicken pox will not be helped with the shingles shot. The vaccine should not be given to a person during an acute episode of shingles, is pregnant or breast feeding, or who is having an acute infection, cold, virus, etc.

 

8- Precautions

  People who have low grade immune illnesses (multiple sclerosis for instance) or on low immunosuppressive drugs, etc. should consult their physicians and discuss the wisdom of vaccination. Those who are anticipating immunosuppression or are recovering from an immunosuppressive illness can consider vaccination per the CDC.

  The CDC says that it is acceptable to be vaccinated, but it is an individual situation that must be analyzed before the decision can be made with their physician.

  Patients on chemotherapy are prone to developing shingles and it is extremely severe. Therefore, a patient should discuss getting the Shingrix vaccine before starting chemotherapy if a slight delay is acceptable

 

9- Vaccine shortage

  There is a back order for the vaccine in some states, and if a person gets the first shot, they need to schedule the second shot at the time of the first shot and be sure the pharmacy has the vaccine reserved for them 2-6 months later.

www.cdc.org/vaccines

 

C. New Flu drug approved; the latest on flu vaccines

 

Opening remarks

 

Incidence

  As many as 50 million Americans will contract the influenza virus this year cited by the CDC. Hardest hit are those over 65, because they sustain 50-75% of the hospitalizations from the flu. They also suffer the greatest risk for loss of function and permanent disability according to the CDC.

 

New drug to shorten course of flu

  Most people are aware of the somewhat valuable prescription drug, Tamiflu, to reduce the length of influenza symptoms. In fact, it is only successful in reducing the length of the illness by 1 day in most cases, is expensive, and must be taken for 5 days. Also it must be taken in the first 48 hours of the flu to be effective.

  The CDC announced that the FDA approved a new prescription medication to reduce the length of the flu and hopefully reduce the risk of complications. Baloxavir (Xofluza) was approved in April, 2018 to reduce the symptoms of the flu similar to Tamiflu. It is reserved for people at high risk for complications from the flu.

  In a comparison study with Tamiflu, Xofluza was found to be more effective. Xofluza was able to begin recovery in 72 hours as compared to 102 hours.

  This drug may only shorten the course of the flu by a day or two, but the longer the flu lasts, the more likely people  can develop complications.

  A test for the flu should be performed as soon as flu symptoms occur, especially if these medications are contemplated.

  There are always side effects from any drug, but the FDA has put out an alert that Xofluza can cause an anaphylactic reaction and sudden swelling of the airway and body (angioedema). These alerts are put out for dozens of drugs quarterly. The physician will have to decide if this new drug is for his or her patients.

Medscape, Oct. 31, 2019 

 

  High risk groups

  Those at high risk according to the CDC are those 65 years or older, those with asthma, heart disease or stroke, diabetes, cancer, HIV/AIDS, pregnant women, young children, and children with neurological conditions. Also those with chronic health conditions are included.

  Older patients can present with worsening of underlying conditions, have no fever initially, and only 31% of seniors met the criteria for a diagnosis of the flu clinically. This has diminished testing by physicians in these older patients. Those 85 and older are particularly at risk for complications that can create permanent disability and loss of function as they do not bounce back after the flu near as well.

  Warning from the CDC about vaping and flu-like symptoms 

  Another issue to consider when a person especially teenagers come down with flu-like symptoms, the physician and parent should enquire about the youth vaping. Symptoms of vaping include some of these same symptoms. In fact, after 42 deaths from vaping and over 1500 hospitalizations, the American Medical Association has called for an immediate ban on all e-cigarettes except those by prescription for smoking cessation, but that is unlikely to happen. Banning flavors is a big step, and really, only those who are trying to quit cigarettes should use them.

  For a more extensive list of high risk conditions, please log on to www.cdc.gov/flu/highrisk/index.htm

 

  Complications of the flu

  Complications include ear infections, bronchitis, pneumonia, high fever, dehydration, and worsening of pre-existing conditions especially heart and lung conditions. Pneumonia can be fatal.

  Need for vaccination; Those against vaccinations; new quadravalent vaccine now available

  Obviously, those able to be vaccinated with the flu vaccine should be getting the shot ASAP. There is a 4-6 week lag until it is fully effective.

  There is now a newer quadralent vaccine available for seniors called Fluzone High Dose providing a better immunologic reaction in older patients. The older but very effective trivalent flu shot for seniors does not include another strain of influenza virus. Discussion about these newer vaccine options with physicians is recommended.

 

Exemptions from vaccinations continue to be a stubbling block 

  The state of Florida has accepted a religious exemption for years and, unfortunately, Florida is ranked 50th as a state in the vaccination rate for influenza for children from 6 months to 17 years old. With tourism at a high level here in the flu season, the legislature needs to deal with this issue and realize that the millions of visitors are unnecessarily being exposed that can kill (12-79,000 Americans die annually) as a result of the flu.

The CDC provides the above pyramid for the annual deaths, hospitalizations, and number of clinical cases. This costs our healthcare system $millions.

 

  Symptoms of the flu

  Symptoms include fever, chills, headache, muscle ache, cough, sore throat, fatigue, and in some cases nausea, and vomiting. As discussed above, seniors may have more atypical symptoms of the flu especially with underlying serious health conditions especially heart and lung diseases. 

 

  Test for the flu—Quick-vue influenza A+B test

  This test is available in the emergency room, urgent care centers, some doctor’s offices, etc. If a person is suspicious for having the flu, and they go to any public place, they should wear a mask, as the flu is transmitted in the air. Also most doctor’s offices provide masks for patients waiting in their waiting rooms to put on to prevent spread right in the doctor’s office.

 

  Colds vs Flu

  People with a viral cold (URI-upper respiratory infection) rarely have much fever or chills, have more nasal and sinus symptoms, rarely have severe muscle ache or severe headaches, but can have a cough and sore throat. These drugs will not help a cold. And neither will antibiotics.

 

  Treatment of the flu and colds

  Symptomatic treatment with both these illnesses may include decongestants, salt water sniffs, mucus splitters (Mucinex), bed rest, salt water gargles, pain meds (Aleve, ibuprofen, aspirin or Tylenol). I have already mentioned the anti-viral agents above.

 

  Reye Syndrome

  Children should not take aspirin as it can cause Reye’s syndrome. It can cause swelling of the liver and brain with symptoms of confusion, seizures, and loss of consciousness, requiring hospitalization. The exact cause is unknown, but is associated with taking aspirin in children and even teenagers, developing the flu, chicken pox, and other viral infections. Mayo Clinic

 

D. Measles outbreaks continue; other consequences

  Most of the 1214 measles cases this year are occurring in school aged children across 31 states according to the CDC. The demands for exemptions from vaccinations also continues to rise defeating the almost eradicated disease in the precvious decade. Why? Misinformation, internet sites that scare, and celebrities that the public mistakenly listen to.

  One more time parents…….there is no link between vaccines and autism!! Some states are cracking down on these exemption loopholes thankfully.

 

Thousands are going unvaccinated

  200,000 kindergarden kids started the 2017 school year without vaccination, according to the CDC. Colorado, Idaho, Washington, Alaska, Arkansas, New Hampshire, and Kansas reported that 1 in 10 kindergardeners were unvaccinated for measles, mumps, and rubella (MMR). 6% of Florida kids are unvaccinated at the kindergarden age (12,000).

  There are usually pockets of population that go unvaccinated and have the highest rates of infection. The anti-vaccine advocates “work” these communities creating doubt in parents despite no scientific proof there is a connection to autism, according to the non-profit Immunization Action Coalition.

  State laws vary regarding vaccination exemptions…why? Is this a political issue? Some issues are national, not state, when people freely can travel from state to state. These children may be home schooled but they can’t live in a bubble.

 

Original research was a fraud!

  By now, hopefully everyone knows the European researcher who claimed the connection between autism and vaccinations did it fraudulently and was condemned by the medical profession many years ago. Parents with autistic children need only look at the many causes of this disorder, and vaccinations are not a cause. Unfortunately, the internet is full of false claims.

  Many medical professional national groups support tightening or ridding the religious exemption. There is no room for non-medical exemptions in a country whose population continues to escalate from continued increases in immigration, in my opinion.

  The American Medical Association has performed computer simulations and stated that 1 case of measles could start an outbreak of 400 cases.

  California, New York, and Maine are the only states that have now eliminated non-medical exemptions.

  Those who get an exemption must not attend school, but they can’t live in a bubble.

 

Symptoms of measles

  Remember, upper and lower respiratory symptoms and fever precede the measles rash, and the child is already infectious and able to transmit this viral disease easily through the air. Also the disease has an incubation period from 1-2 weeks before symptoms begin, and transmission can occur during that time. This is a recipe for easy spread for any infectious disease.

 

Complications of measles

  Deafness with severe ear infections, pneumonia, and brain swelling are the most common complications. It is responsible for 100,000 deaths a year globally with 7 million cases worldwide.

  A recent study in the journal Science has found that children who contract measles deplete their pre-existing antibodies on an average of 40% which increase the risk of other infections occurring.  The control group who did not contract measles retained 90% of their immunity. This makes these individuals who contract measles more susceptible to infections for years to come according to these authors.

  The 3% of the population that are imunocompromised suffer many more severe consequences of measles.

  Community immunity (herd immunity) is a concept  people need to understand. If a community is vaccinated at a very high rate, the chance of exposure is lessened and in effect help prevent exposure to those who have had necessary medical exemptions. It protects the community.

Science, November, 2019

 

E. Other updates on vaccines-HPV and Hepatitis B; Adult Immunization schedule for all vaccines

 

Human papilloma virus (HPV)

  Recently, I reported that the HPV virus vaccine (Gardasil) should be taken before sexually active to prevent this virus that causes genital, oral, throat, and perhaps other cancers.

  Vaccines should start around 11 years of age with one booster in 6 months up to 26 years of age. If the person is already sexually active, the shot can still be effective unless already infected. Infection starts to be at its highest around age 26. The number of partners greatly influences the risk of developing HPV.

  A few months ago, it was recommended until age 45, however, the Advisory Committee on Immunization practices (ACIP) has changed that recommendation to age 26 on the basis of substantially less benefit from 26-45. There are those on that committee that still feel high risk men and women who are bisexual should still get the vaccine til age 45 if they do not already have the infection.  For more information, search the CDC website.

  Although potentially effective against oral and throat cancer, the studies are not yet complete to prove its efficacy, so the vaccination continues to be recommended to prevent only genital cancers, but it is anticiapated that in time the committee will expand their indications to prevent oral and throat cancers.

  Sad as it is to report, the vaccination rates are still dismal—7.3% for girls and 5.8% for boys, but it does represent a 37% increase in vaccination rates. Parents and physicians are just not on altogether board yet.

  The studies are already proving that there are decreasing rates of oral HPV virus from 2.7% in 2010 to 1.6% in 2016 and in unvaccinated men but in unvaccinated women, the rates remained unchanged. It is hoped that there will be a continued decrease of oral HPV in large populations.

JAMA, Sept., 2019

 

Heplisav-B vaccine

  In 2018, a new option is available for hepatitis B prevention for unvaccinated or partially vaccinated people including adults age 18 and over who have a specific risk or just want protection.

  Healthcare workers and anyone working closely with the public as well as the LGBTQ community are at risk, and anyone who might get exposed to blood (the source of the virus) or have sex with many partners. Most people in other words!

  The hepatitis B vaccines require 2 doses 4 weeks apart.

 

Here is the 2019 schedule for adult vaccinations from the CDC:

 

3. Do trial lawyer ads for class action suits against drugs and medical devices do harm?

We are flooded with lawyer ads seeking the public’s business. But recently more ads for class action suits against drugs and medical devices have escalated many times with little evidence that a person can collect on the suit.

  Don’t get me wrong, there are some serious side effects from certain drugs and devices that deserve compensation in cases where the patient was not properly informed. However, many side effects occur many months to years after the FDA approved a medication or medical device. The medical drug and product industry has had to accept these suits will come and increase their prices based on the possibility. “ The price of doing business”….but the consumer pays for it.

  Pelvic mesh implants for urinary incontinence and pelvic prolapse have created serious complications (infections, extrusions, perforations of the bladder or bowel). There was fraudulent research created by the European doctor that promoted this mesh implant for thousands of women who had urinary incontinence. This researcher/practitioner was a prominent physician (with multiple seminars around the world), and he lied to physicians and the company that bought the patent (Johnson and Johnson Co.). I recently wrote on the subject in a previous report (see my subject index on my home page under incontinence).  

 

Lawsuits against Monsanto

A $2 billion judgment to a California couple is the third successful lawsuit against Monsanto for the (weed killer) Roundup (glycosate) because of its supposed cause of non-Hodgkins lymphoma, when in fact, the company and the EPA research do not link it to this type of cancer. And yet the World Health Organization has classified glycosate as a carcinogen, while it is on the shelves in America. Yet, they are still settling for big bucks!

 

Unintended consequences

  There is a downside risk for the public seeing these lawyer ads for class action lawsuits. Reports have surfaced from people who are taking a certain drug without complications, who stop the drug without consulting their doctors.

  Currently, 12 prescription medications are being targeted by personal injury lawyers according to the U.S. Chamber Institute for Legal Reform. 1335 participants were questioned and 500 reported that they were taking one or more of these 12 drugs. 50% said they would definitely or probably stop that product after seeing an ad. Many said they would reduce their dosage. Not asked but certainly a very important issue is, how many talked to their doctor about this issue and asked for an alternative medication?

 

Request from the AMA

  The AMA has voted to request that these ads have the lawyers request that patients not stop these drugs without consultation with their doctors, however, that has not happened. The FDA has reported that 32 patients quit their oral anticoagulants (blood thinners) without telling their doctor and sustained strokes, pulmonary embolism, paralysis, or death.

  In Texas, the senate passed SB 1189 the Deceptive Advertising Practices Act, and Governor Abbott is expected to sign it. It requires the ad request that people not stop the drug without seeing their doctor for discussion.

  In 2018, trial lawyers spent over $1 billion nationwide on these types of ads in 2017. Think this is big business? Can you imagine the budget for Morgan and Morgan Law Firm, now all over parts of the country with thousands of lawyers on the parole.

  Another concern is the influence of TV ads they on jurors in trials. It is impossible not to have some influence on the public, since if something is said on TV, a percentage will believe it to be true regardless of proof.

Do not stop or adjust dosage medication without discussing it with a physician.

  The bottomline….if there is a class action suit against a medical product, PLEASE talk to your doctor before changing the dose or stopping the drug about alternatives.

  Severe complications can occur with many drugs especially if the drug is suddenly stopped. A good example is developing withdrawal symptoms from anti-depressants.

  If you want to follow this issue, look for updates on The Doctor’s Advocate.  Reference—The Doctors Advocate-Second Quarter 2019

  I truly wish America could have it both ways……have drugs approved quickly without every causing side effects, and not wind up causing harm. Harm equals lawsuits in this country. It is adding another layer of cost passed onto the consumer.

  Unfortunately there is always tremendous pressure to release products and medications on a fast track, and then as soon trouble arises, the lawyers immediately start the litigation.

  When true harm has occurred through negligence, it is everyone’s right to seek legal counsel. But it is my hope people who are sought out by lawyers to join class action suits think carefully before doing so. The best example recently has been the vaginal mesh issue.

  The courts, by the way, sided with Big Pharma to keep medicine ads on the TV.         

 

 4. Red Meat is ok or is it?

  

The Annals of Internal Medicine, Oct. 2019, published a controversial journal article authored by the American College of Physicians regarding the health consequences of eating red meat and processed meats.

  A panel of 14 members, 3 community members, from 7 countries voted on the final recommendations regarding the consumption of red meat and processed meat. Included in the article was 4 systemic reviews on the health effects of these products, and one review of people preference for eating red meat and its health related consequences.

  “The panel recommends that red meat and processed meats continue to be consumed”.

  The group is called Nutri-RECS international consortium. Having reviewed their excellent research methods, I can assure everyone in this study is as legitimate as it comes. The journal article spent a considerable time explaining their legitimacy, even though they were attacked by many American organizations.

  There has been an attack on eggs, fat containing yogurt and coconut oil among other foods, and experts are beginning to question just how authentic have nutritional research studies been regarding effects on health?

  Contemporary U.S. dietary guidelines recommend limiting these products to 1 weekly consumption. The UK recommends limiting meat as well. The World Cancer Research also recommend limiting consumption. The World Health Organization has stated that meat probably has carcinogenic substances in it. The American Cancer Society strongly disagreed with the recommendations from this article. So who do we believe?

How good is nutrition research?

  The news is… nutritional research is poor at best, mostly observational and not well controlled. Yet, we have been told for years how bad meat is for us based on very questionable research methods.

  How do you follow people for years to see if they are sticking to a diet without other factors that interfere with the validity of a study. People can fib! This has been the weakness of nutritional research forever especially observational studies. There really is no answer considering the millions of dollars it takes to perform legitimate research. You can’t patent food and no one can get rich off these studies. For those who think the meat industry contaminated this research, it has not happened.

  At the end of the day, common sense about eating any foods that may be controversial should be eaten in moderation.

  Unfortunately, as I have said many times, doctors are not experts in the area of nutrition and the public needs be very careful what they read on the internet and use common sense.

  I am just reporting what is in these journal articles. It is for the reader to decide what action if any should be taken regarding the ingestion of all meat and processed meats.

  One thing I have learned over the past almost 6 years of writing this report from thousands of peer reviewed medical journals, I am convinced that the cost of really top notch research is so expensive unless there are $billions to be made (by Big Pharma), we are receiving researcher’s opinions from studies that are hard to come up with strong evidence supporting any diet, food, or effect on disease.

   I don’t listen to testimonials from anybody. Conflicts of interest are always a problem if researchers are being paid by those who would benefit from a specific outcome, and it does occur in some articles that are not well peer- reviewed. That means the researchers must stand up and answer criticism from outside experts. I will discuss trending diets in the near future including the plant-based diets.  

  Most successful diets come down to restriction of calories (if weight loss is a goal) with a large percentage of vegetables and fruits, limitations of saturated fats and refined sugars. Although weight can be lost with many diets including the keto diet, Mediterranian, South Beach, DASH diet, Paleo, Adkins diet, etc., sticking with it is the problem, because most people crave a balanced diet including meat. And in the end do they really affect our health outcomes? That needs continued study with double blind extremely controlled research.

  Without adding exercise, living a healthy life, getting adequate sleep, not smoking, reducing stress, and limiting alcohol and avoiding illicit drugs, no diet is going to work long term. It is all about behavior modification or the weight will eventually return and the cardiovascular diseases and cancers will not be modified by diet alone. In most cases, it takes medication to assist.

  It is up to the reader to decide what to eat. Moderation and Balance makes the most sense to me regardless of the type of dietary consumption a person eats!!

 

5. Ovarian cancer risk in BRCA gene mutation women—new guidelines

  I have previously reported on ovarian cancer screening, so please click on:

www.themedicalnewsreport.com/86

  For a complete discussion on ovarian cancer, please refer to www.themedicalnewsreport.com/57

 

  Ovarian cancer is hard to detect until symptoms arise, and then it is likely already advanced. CA-125, a blood test is positive in 75-80% of patients with ovarian cancer, but is not a recommended test to screen the general public for this cancer because of cost and other disorders that can raise this blood test results creating a false negative.

  Those who have the BRCA 1 and or 2 gene mutations have a very high risk of breast cancer (up to 80%) and ovarian cancer as high as 50-60%.

  Patients are turning to the internet for genetic testing to find out if they have certain genetic mutations that increase risk of certain diseases.

  Recently, the U.S. Federal Advisory group recommended that families with any member with the BRCA 1 or 2 gene mutation should be tested for the BRCA gene mutation. If positive, they should consult a genetic counselor or better still, even before asking for the tests.

  The Canadian Medical Association offered guidance regarding steps to take regarding BRCA gene testing in an article in Physicians First Watch, August 12, 2019.

 

 Among the key points were:

1) Women with known or likely family history of BRCA gene mutation should be tested for this gene mutation.

2) No screening method has reduced the mortality rate of ovarian cancer, even high risk women.

3) Removing the ovaries and tubes (salpingo-oophorectomy) can reduce the risk of ovarian cancer by 80%. For women with the BRCA 1 gene, for women who choose surgery, should be between the ages of 35-40. If the patient has the BRCA 2 gene, surgery is recommended for women 40-45 years of age.

4) Women who have their ovaries and tubes removed, should take hormonal replacement until they reach the average age of menopause (unless they have had breast cancer). Menopause begins at about age 45 and is complete by age 55, so split the difference, but take your gynecologist’s recommendations.

 

Recommendations from the American College of Gynecology (ACOG)

  If BRCA gene positive (1 or 2), patients should also be offered risk-reducing bilateral mastectomy in addition to removal of the ovaries and tubes according to ACOG.

  BRCA 1 and 2 gene mutations account for 24% of ovarian cancers and 4% of breast cancers.

  1 out of 40 women with Eastern European ancestry (Ashkenazi Jewish) will have one of the BRCA gene mutations.

  ACOG (in 2017) recommends that women with a positive BRCA test should be tested for CA-125 blood test (or a transvaginal ultrasound) and women ages 25-29 should have semi-annual breast examinations and annual mammography, but optimally an MRI of the breasts. At 30 years of age, women should alternate mammography with an MRI every 6 months. This is for those who do not choose surgical removal.

  ACOG also recommends anyone considering genetic testing, seek consultation with a genetic counselor. They are not plentiful, so getting started with them beforehand is a good idea. If a woman finds out they are BRCA gene positive, and then seeks consultation, they may wait for some time before getting an appointment, and then contending with the anxiety of knowing they have a positive test.  

  23 and me genetic testing can test for BRCA 1 and 2 genes for $249. It does not appear to be included in the $99 or $199 tests. Before buying the saliva test, talk to the doctor about the best way to screen for these gene mutations.

 

6. Bucks and Drugs--Big Pharma—how are we going to reduce drug prices?

I have discussed drug prices many times, and continue to harp on our need for the Congress to negotiate Medicare prices for pharmaceutical and medical devices to begin reforming healthcare. (I remind you, Congress did negotiate prices for Medicaid, but Big Pharma agreed to the price reductions only if they kept their hands off Medicare. The VA also negotiates drug prices and save 40% over what private insurance and Medicare pay).

Healthcare dollar waste

  A recent report from a JAMA study, stated that 25% of the healthcare dollar is being wasted--$800 billion of the $3.8 trillion is wasted on 3 factors:

1) administrative complexity with no cost saving strategies.

2) overpricing of drugs by Big Pharma and hospitals.

3) lack of care coordination. Unless we must accept socialized medicine, we must demand for our politicians to deal with these issues with a bipartisan effort . Greed has become an epidemic. As stated in this editorial, “waste has become the other man’s revenue”.  

  Big Pharma always defends their prices because they need that revenue for research, while they spend more money on marketing than they do on research.

  The marketing expenditure of the top 10 drug companies account for 50% of the total budgets. Dollars spent on research is 17% according to a website called True Cost of Health-Care.

  On average, the U.S. is paying 42% more in pharmaceutical costs than other developed nations!

  The administrative costs in the U.S. are far too high because of federal regulations that were worsened by the Obama administration’s attempt to control costs. But the Republicans have yet to provide the American people anything better (yet). However, I still can’t see any reason not to take the good of any plan (even Obamacare) and get rid of the bad, if our country is ever going to get costs under any control. The big cost comes from pre-existing illnesses. Most of us are fed up with which political party “wins” the fight on reform. We want results!

  The cost of insulin and oral anti-diabetic meds are out of control, and many diabetics are rationing their meds letting their blood sugar go sky high. Horrible!! In fact, insulin itself is backordered in some areas, because some of the companies making it were fraudulent and broke too many rules.

  It is time we must call our congressmen and tell them, if they want our vote, they must quit being a slave to Big Pharma and work together (both parties) to reform healthcare in some reasonable fashion.

  The U.S. spends 17.8% of GDP on healthcare, whereas other Western countries spend between 9.6% and 12.4%. But there is a massive difference between what is covered in those countries and what is allowed in the U.S. To drop our % of GDP to those levels, we would have to ration care that no American could stomach. Medicare must be reformed.

  I have recently discussed the options for reform including single payer, but any sensible reform must include automatic negotiations with Big Pharma.

  Why must we all suffer by going to a socialized system, when we could get the drug companies to work with us and keep our current system with some sacrifice and reform.

   After all, 90% of the U.S. is insured, so all of this pain comes from our desire to insure the remaining 11.1 million residents (not including illegal immigrants).

  Expanding Medicaid was tried but 14 states (mostly Republican run) did not expand and lost out on federal subsidy. I think that should be looked at again very seriously. However, it is up to the states and not the federal government, because states will pay a bigger share of the costs as the years go by.

  The closure of more and more rural hospitals is also putting additional strain on those in smaller communities. 75% of Alabama Hospitals are in the red (in deficit), and those people are struggling to pay for drugs, traveling many miles to healthcare facilities. 58% of American families report they have delayed or did not seek medical care because of the cost. (ProCon.org)

  Federal subsidies are used to pay for drugs in all federal healthcare systems, trying to keep costs down, but between high deductibles, copays, and the part D system for Medicare drugs has not helped enough. Perhaps, the feds should pay a bigger share but that would raise the % of the GDP even higher and the federal debt. 

  There are no easy answers, but drug reform is a good start.        

This completes the December report and the year 2019.

 Next month, the January 2020 report will be:

1) Effectiveness of CPAP, alternative treatments for sleep apnea

2) Medical Updates:

    a) Rotovirus, Norovirus, and Hepatitis A outbreaks  

    b) Safety and benefits of gastric reflux medications

    c) When to stop screening for cancer

    d) Atrial fibrillation—the Watchman procedure

3) Cancer immunotherapy

4) Update on asthma medications

  As always, stay healthy and well, my friends, and enjoy the holidays, and Merry Christmas and Happy Hanukkah.

Dr. Sam