Vol. 232 May 1, 2020 SARS-CoV-2 is not only NOVEL; It Is WEIRD

May 1, 2020

A few not-so fun facts about the strange behavior of COVID-19 (the disease) caused by SARS-CoV-2 (the virus).

COVID-19 is proving to be so unpredictable with so many variations that it really is weird. Most other coronaviruses merely cause a mild cold. This one can be lethal.

It’s deadliness is presumed to be from a “cytokine storm”, an explosive immune response to the virus within the infected person. This “hyper immune response” causes massive vascular damage in the lungs (and now kidneys and brain and toes.), BUT the people most vulnerable to the virus are those with suppression of their immune system (the elderly, people on chemotherapy, people taking high doses of steroids). You would expect that if your immune system was suppressed you would be less likely to have a “cytokine storm”.

SARS-CoV-2 causes major damage to essential organs, but it can also cause isolated loss of smell and taste, gastro-intestinal upset, headache, aches and pains, and, most mysteriously, just purple bruises on the toes of young adult males.

It is more likely to  kill the elderly and those with chronic diseases like diabetes, high blood pressure, and autoimmune diseases, but it can kill healthy 21 year olds with no other disease. There is some evidence that the amount or “dose” of the virus one receives is the cause of this variability. Young, healthy health care workers caring for Covid-19 patients in ICUs have higher rates of serious illness presumably due to the large amount of virus shed by their patients to which the workers are exposed.

It is highly contagious because one infected person can infect 2 or 3 other people before they have any symptoms. The SARS and MERS epidemics, the two previous lethal coronaviruses we experienced, were not so contagious. Both were spread by people who already knew they were sick, so it was possible to identify infected people, isolate them, and take containment steps. Also SARS and MERS  killed their hosts (patients) so quickly that the spread of the infection to others was much less. In truth, why SARS and MERS disappeared before becoming a wider spread epidemic is not really known. (Maybe that’s where Trump got the idea of “a miracle” saving all of us from economic ruin.)

The higher death rate of infection in blacks and Hispanics has been explained by 1) assumed ethnic/racial differences, 2) the close living of tightly packed urban areas, and now 3) the greater exposure to air pollution from increased tiny particles (PM 2.5 – 2.5 millimeters in size) more prevalent in city air. Maybe all three?

Men are much more likely to die from the virus than women. Studies are now under way  to test whether female hormone administration might protect infected males. We know that women are hardier than men in many diseases, and that it may be genetic rather than hormonal, but who knows?

Originally it was thought to skip children, but recent data from China shows that it can infect and cause serious illness in children, including infants. The virus apparently does not cause infant infection in utereo,  but it is unclear whether infant infection occurs during the birth process or later by contact with the infected mother.

Rational, specific recommendations to meet a pandemic in the U.S. were developed in detail by a 2005 Pandemic Task Force  started by President George Bush after he read an account of the 1918 influenza epidemic while on vacation. It was disbanded by Trump in a cost cutting move, and its report was ignored.

Pharmaceutical companies don’t like to invest in developing vaccines. It is very expensive, and they make little or no profit. Vaccines are administered once or maybe twice in a lifetime. Big Pharma makes more money out of treating chronic diseases like diabetes, heart disease, and cancer because those patients are on medications for a long time (like the rest of their lives). Even the development of antibiotics is low profit because patients only take them for 7-10 days, and they’re cured. 

We know that three medications in combination suppresses HIV (the “AIDS cocktail”) . That treatment changed AIDS from an acute, lethal disease to a chronic, livable condition. Likewise, it may take several different medications in combination to suppress this virus.

Very rich capitalists (Bill and Melinda Gates) in the absence of  governmental funding have given millions of dollars to support vaccine and medication development for the use of the world-wide population. (“Taking money from the rich to benefit the poor” sounds like Socialism doesn’t it?) Bill Gates sounded a pandemic warning as long ago as 2015, and as recently as this week.(1)

SARS-CoV-2 infection may or may not provide protection from reinfection. Most viruses, like measles, can infect you only once because the infection causes you to produce protective antibodies that persist for years. Unfortunately other coronaviruses studied have shown that their antibodies persist only for a few months, certainly not for over a year. This obviously has implications for administration frequency of any soon-to-be-developed vaccine. 

We don’t know if SARS-CoV-2 will mutate like the flu virus does. If it does, then vaccination frequency will be like that for the flu: every year to protect against our the best guess of the strain that will appear that year.

Scientists are suspicious that this virus may become “seasonal” like influenza, despite it’s appearance world-wide in very different climates. It flourished in our winter and Australia’s summer, in our cold, wet  Northeast and in sunny, dry California.

With the current state of knowledge about this virus it seems to me that we all are enrolled in a giant clinical study while  awaiting the development of a vaccine and effective treatment. We are even dividing ourselves into “experimental groups” like Oklahoma, Iowa, and Florida that are lifting social restrictions and “control groups” like New York and Massachusetts that are not. Unlike the usual clinical study no one asked for our consent. It is just happening.

Clinical studies are very expensive for a variety of good reasons.  It is very clear that this one, though unintentional, is costing all of us a great deal. Let’s hope that some results come soon.

References:
1. New England Journal of Medicine 382;18 April 30, 2020


Vol. 231 April 15, 2020 After The Pandemic – Back To The Future??

April 15, 2020

 

“The transmission of SARS-CoV-2 could resemble
that of pandemic influenza by circulating seasonally
after causing an initial global wave of infection.”

 

 

A recent mathematical simulation study from the Harvard Chan School of Public Health suggests that our current pandemic could follow the path of the 1918 flu pandemic, i.e. recurrent surges of infections after quarantine measures are relaxed.

FACT: SARS-CoV-2 was, and is, NOT containable. Each infected person transmits the virus to 3 other people on average. Most people infected with this virus will have mild cold-like or flu-like symptoms. In fact, two other known coronaviruses are the second most frequent cause of colds. Unfortunately this coronavirus of SARS-CoV-2 can cause severe illness and even death in some per cent of the infected.

FACT: “Flattening the curve” through social distancing and isolation does not decrease the number of infected people. It’s sole purpose is to change the timeline of illness to reduce the peak demand for services for the severely ill (estimated 3% hospitalized). It is hoped that spreading that demand over time for ICU services (estimated about 1%) will reduce the number of deaths due to “lack of available resources”.

FACT: There are really only two ways to stop an pandemic, a vaccine or herd immunity. Immunity develops when individuals get infected, respond by making antibodies, get better, and end up protected from getting the illness again. Herd immunity exists when so many people have developed antibody protection that the few people who don’t have such immunity are surrounded by others who cannot have the disease again, and so can not transmit it to them. (There is a third way an epidemic stops, of course, where most people die before they can pass it on, like Ebola, but this virus is not like that.)

You have heard about herd immunity for children unvaccinated against measles (another very highly contagious virus) when they are surrounded by children who have been vaccinated against measles. Herd immunity works by lowering the risk of anyone being exposed to a person with the infection. I can remember the “last of the chicken pox parties”, another method to expedite herd immunity in a timely fashion, in my old neighborhood in the 80’s.(The chicken pox vaccine became available in 1984). An epidemiological term for herd immunity may be more intuitive, though it sounds a whole lot colder; “depletion of susceptible individuals.” The estimated herd immunity threshold for measles is 95% of the population vaccinated. The ideal is often stated as 98% vaccinated against measles.

SPECULATION: A team of scientists from Harvard using mathematical model simulations have diagramed how herd immunity might develop for SARS-CoV-2 depending on different durations of social distancing while we wait the 12-18 months necessary for vaccine development and testing. Their study of other coronaviruses (the common cold ones) indicates that a herd immunity threshold of 60% would reverse the epidemic,  BUT that different durations of social distancing could result in a HIGHER number of total cases.

I, as a pediatrician, don’t do math very well, so I’ll let the conclusions of their mathematical model simulations speak for themselves. These estimates assume rigorous social distancing and that about 80% of us will eventually be infected. 

No social distancing – 60% herd immunity reached in October, no peak delay, no “flattening of the curve”.

4 weeks of social distancing (to mid May) – peak is delayed, 60% herd immunity threshold is reached in October, total number of cases are 10% higher than “no social distancing”.

8 weeks of social distancing (to mid June) – peak is delayed, 60% herd immunity is reached in November with 15% higher number of total cases than “no social distancing”.

12 weeks of social isolation (to mid July) – markedly reduced new cases during the summer, 60% herd immunity in January,  and 20% higher number of total cases than “no social distancing”.

20 weeks of social isolation (to late August) – markedly reduced new cases through November, 60% herd immunity in February, and 20% higher number total of cases than “no social distancing.” (1)

The mathematical model predictions represent infections only, not amount of severe illness or death rates.

I know just enough mathematics to appreciate that there are lots of assumptions incorporated into mathematical modeling, just like CFO reports to Boards of Trustees, you know , as in “smoke and mirrors”, but these predictions are sobering.  The researchers suggest that periodic, intermittent relaxation of social distancing might give the best results in the long run, i.e. allow and deal with recurrent surges of infections from relaxation of restrictions until most of the population becomes immune.

“Intermittent social distancing might maintain critical care demand within current thresholds, but widespread surveillance will be required to time the distancing measures correctly and avoid overshooting critical care capacity.”

Thankfully for us mathematically impaired the study stated some conclusions in English :

SARS-CoV-2 can proliferate at any time of year.

The duration of immunity to SARS-CoV-2 is not known. If immunity to SARS-CoV-2 is not permanent, it will likely enter into regular circulation.

High seasonal variation in transmission leads to smaller peak incidence during the initial pandemic wave but larger recurrent wintertime outbreaks.

New therapeutics, vaccines, or other interventions such as aggressive contact tracing and quarantine – impractical now in many places but more practical once case numbers have been reduced and testing scaled up – could alleviate the need for stringent social distancing to maintain control of the epidemic.

Then they blur that bit of hopeful glance into the future with, of course, “virus mutation might give us a new SARS-COV every winter season just like the flu . . . until 2024”!

Enough of these not-so-fun medical facts. Let’s finish with some good news.
The recovery rates from this virus as of today are 78% in the  U.S.
For even more good news (on a variety of subjects) tune into SGN – SOME GOOD NEWS , a brand new weekly YouTube news program by John Krasinski.

References:
1. Boston Globe, April 12, 2020, Ideas Section K; includes excellent graphs of the different social distancing duration scenarios.


Vol. 230 April 1, 2020 Biden Picks His Running Mate

March 31, 2020

Press Conference

Former Vice President

Joe Biden

(Official Transcript   April 1, 2020)

BIDEN: Good morning everyone. I am glad to see all 8 reporters are sitting 6 feet from each other. I know it is burdensome, but we must work together to defeat this awful Zika. . . Rebola. . . flu . . . er, what?,  . . . I mean, you know, the Coroner virus.

Speaking of the current virus crisis . . . boy that has a nice ring to it, doesn’t it? . . . it almost rhymes . . .I would like to announce my pick of a running mate; Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Disease of NIH since 1984. . . almost twenty or . . .  er. . . many years ago.

Now before I start to answer your questions, let me give you some reasons for my choice.

Number 1: Dr. Fauci is smarter than I am, but I am taller and younger than he is.

Number 2: He is very experienced. He has worked with many Presidential administrations since he came to Washington . . . in the 1980’s as I remember. He told Ronald Reagan about the AIDS epidemic, advised two Bushs . . .  one of them gave him the Presidential Medal of Freedom . . . by the way, Ben Carson got his medal during that same ceremony, . . . where was I? Oh, yeh . .  .two Clintons . . .  yes two, remember Hilary’s Health Care Plan?. . . and, of course, an Obama or two. 

Number 3: He gives very good TV interviews, even on Fox News with Sean Hannity trying to mislead the viewers.

Number 4: His medical training has given him that special skill that all physicians must have to succeed  — “Always sound right,  and if you don’t know an answer, make one up.”  But he is more like my famous namesakes on Dragnet . . .  Sgt. Joe Friday . . .”Just the facts, Ma’am.”

Now I’ll take your questions.

[Sounds of shouting, general loud babbling, a baby crying, a chair falls over]

REPORTER:  “ Mr. Biden have you moved away from your promise to pick a female running mate?”

BIDEN: Did I say that?  When was that? . . . Oh, it was during one of those debates? . . . I wouldn’t call it a debate, and I wouldn’t call it a promise. It was a statement from which I am now socially distancing myself, and its a very timely question.  .  . .This social distancing is for the pits. I haven’t smelled somebody’s hair in weeks. . . for the record, my test was negative . . . and I will ensure that women’s voices will be heard in my administration by appointing several to my cabinet. Elizabeth Warren naturally will be Secretary of the Treasury. Kamala Harris as an experienced prosecutor would be an excellent head of the Department of Justice . . . I think she is Latino too, isn’t she?. . . I am not sure about Senator Amy Kolbuchucker from Minnesota, but she has great hair. Marianne Williamson, . . . remember her, the physic healer. . . could serve as Chief of Alternate Universes  . . .excuse me, Alternate Therapies within HHS.  Adding Senator Gillibrand to the cabinet would weigh the group too heavily towards New York, since Dr. Fauci is from Brooklyn.  I will, of course,  appoint Tulsi Gabbard as Ambassador to America Samoa.

REPORTER: “Do you have any concerns about any regrettable incidents in Dr. Fauci’s past?”

BIDEN: Not really. My staff has vetted him very thoroughly. The only whiff of scandal we found was his medical school yearbook picture where he was being lifted by two of his taller classmates so as to appear even taller than they. None of them were in black face.

 Also some people may have difficulty knowing how to pronounce his name correctly. It is pronounced as “Fow-chi” with the soft  “chi” sound common to many Italian names, . . .  and as the Senator from Nevada I wish to say that I have many Italian-American friends who are hard-working, decent citizens, but I must excuse myself from this Corleone hearing for another important committee meeting . . . oh, sorry . . . was I channeling the Godfather again?. . .  a great movie.

There is another small concern, since he is from New York City and his name ends in a vowel people may think he is associated with Rudy Giuliani. . . . but  we know that he is taller than Mike.

We have completely debunked the New Yorker Magazine stories that Dr. Fauci has recommended internal alcohol to kill the coronavirus since external alcohol really doesn’t work. In fact, he only recommended it as an antidote to the daily briefings of the White House Coronavirus Task Force. Dr. Fauci also noted that internal alcohol effects may be briefer than the briefings, so viewers may repeat a dose “PRN” (as necessary). 

REPORTER: “ Is it true that as noted in your background Press Release you just handed out that Dr. Fauci was born on Christmas Eve, and are you concerned about any back lash from Trump supporters who regard Trump as the “Second Coming.”

BIDEN: Dr. Fauci is an American. Even though he was born in Brooklyn, as I remember, there is no question about his eligibility for this office. I think that a resurgence of the Birther Movement which was so viscously directed at my close friend and mentor, Barrack Obama, . . .  there I finally got his name out there. . .  would be very unfortunate. Next question.

REPORTER: “Has Dr. Fauci made any significant contributions in fields other than virology and infectious diseases.”

BIDEN: Well let me tell you a down-to-earth, fascinating story of one of Dr. Fauci’s most recent contributions. It will be a short story, I promise. Since the Coroner virus pandemic has taken over all the headlines, editorial pages, social media memes, political cartoons, TV shows, graphic artist shops, and a lot of other things which has displaced our awareness of the Opioid Death epidemic, Dr. Fauci has developed a new attention-getting graphic to replace the familiar 1-10 faces of pain;  the 1-4 faces of Pandemic Panic levels.

REPORTER: “But face 4 is the same as face 2. Isn’t that a confusing message.”

BIDEN: Exactly

“Thank you Mr. Biden, and Happy April Fools Day.

 


Vol. 229 March 15, 2020 Beware the Ides of March

March 14, 2020

In Shakespeare’s play Julius Caesar, a soothsayer attracts Caesar’s attention and tells him:
            “Beware the ides of March.”
Caesar demands:

            “What man is that? Set him before me, let me see his face.”
When the soothsayer repeats his warning, Caesar dismisses him, saying:

            “He is a dreamer; let us leave him. Pass.”

When I started writing this blog a couple of days ago I was going to call it “A Politically Incorrect View of the Coronavirus” because I wanted to say that the virus will not be contained, that it will very shortly be community-wide,  and that we should marshall our efforts at monitoring, protecting, and treating the high risk people. But today, that is no longer “politically incorrect.” Many of our civic leaders and our leading medical scientists (Anthony Fauci, MD is my most famous medical school classmate, Class of ’66 Cornell Medical College) are now labeling COVID-19 as “community spread” , i.e. not containable through contact tracing since the sources are so numerous that we can not pinpoint a source, like the common cold and the flu.  We are now “mitigating” COVID-19, not “containing” it; just trying to “blunt the peak” on the graph of numbers of infected people.

The stakes are higher for COVID-19 (the name of the disease) then for the seasonal flu because it is more deadly to certain segments of our population. The name of the actual virus that causes COVID-19 is SARS-cov-2, and that is a real clue as to the nature of this virus given our experience with previous coronaviruses.

The good news is that the death rate is not expected to be as high as the past two coronavirus epidemics SARS (10% death rate) and MERS (35% death rate). SARS originated in Southeast Asia bats and civets (small, cat-like mammals) . MERS originated in Middle Eastern camels. SARS-cov 2 has been attributed at various times to be transmitted from bats, snakes, and now, pangolins (anteater-like reptiles with scales); all animals available in Southeast Asian “wet markets” of live animals. There is no evidence that implicates domestic dogs and cats as vectors for the virus. There is also no confirmed evidence that a mother can transmit it to her newborn during delivery.

As the number of identified cases increases (the denominator) we were hoping that the calculated death rate would decrease since the actual calculation =  #of deaths/#of cases. It appears now that the death rate could be between 1.6% (University of Bern, Switzerland estimate based on China’s CDC data) to 3.4% (WHO’s estimate from selected outbreaks), clearly at least 10 times the death rate for seasonal flu (0.1%). However, South Korea has the largest number of tested cases with cold symptoms (140,000) and their death rate is 0.6%. Of even more interest, of those 140,000 South Koreans with cold symptoms who were tested, only 4% were positive for SARS-cov-2, i.e. 96% of those with symptoms were infected with the flu virus or some other non-coronavirus.

The bad news is that about half of those in high risk populations who develop significant symptoms will require hospitalization.  80% of those hospitalized will be so sick that they will require ICU care for a number of days. The people at highest risk of requiring hospital-based medical care are those with underlying chronic diseases, called co-morbidities, like congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and those over 80 years old (a stage of life, NOT a co-morbidity thank you!).

Nearly 90% of COVID-19 cases have been in people between 30-79 years old. Less than 1% were in children under 9 years. Despite this fact that children are not the primary vector for this virus (unlike influenza), we are closing many elementary schools. In the swine flu epidemic of 2009 we closed 1300 schools for 7-14 days because of evidence that children were primary vectors for its spread. Despite the run on toilet paper resulting in empty market shelves, diarrhea is not a common symptom of the disease.

If COVID-19 is going to be as common as a cold or the flu, but has a lethal potential for select groups of people, how do we triage the people who think they have it while we wait for the coronavirus nasal swab test to become widely available?
The simplest triage diagram has just three branches in the decision tree:

  1.  If you have cold symptoms (but remember a runny nose is not a common symptom of COVID-19) — treat it like a cold with rest, fluids, and decongestants and try not to spread it to other people. (YOU wear the mask, not everybody else)
  2. If you have a fever over 101 and a cough — go see your primary care provider.
  3. If you have the above and feel weak or tired and are short of breath — the PCP may send you to the hospital.

How do people with COVID-19 die?  In the severe stage of the disease (called ARDS- Adult Respiratory Distress Syndrome) respirator machine support (a ventilator) in an ICU is usually needed. Another cause can be an overwhelming secondary bacterial pneumonia and sepsis later in the disease (similar to deaths caused by the flu) and, unexpectedly, some deaths have occurred without pneumonia or severe lung inflammation, particularly in patients with very high blood pressure or those on kidney dialysis.

Watch out for advertisements of fraudulent cures or “protections” from COVID-19. The FDA has formally warned 7 companies, including the Jim Baker Show, that their advertisements for “silver solutions” to kill the virus must stop. There is no evidence that solutions of colloidal silver can kill the virus. Vitamin C is no help either. If Purell with alcohol can kill the virus some people think that alcohol by mouth could kill it. Unfortunately alcohol does not kill the virus. Soap and water or bleach does. Do NOT gargle bleach.

The AMA has responded quickly to the epidemic and filed a request for a rush approval of a CPT code for COVID-19 testing (necessary for insurance reimbursement, hence maybe the urgency of the request). AMA President Patrice A. Harris, M.D., M.A. has said,  “By streamlining the flow of information on novel coronavirus testing, a new CPT code facilitates the reporting, measuring, analyzing, researching, and benchmarking that is necessary to help guide the nation’s response to the public health emergency.” Also as I said, health insurance companies will be asked to pay for the test.

Two surveys released this week show that the Corona beer brand is suffering from a negative buzz. A 5W Public Relations poll of 737 beer drinkers in the U.S. showed that 38% of them wouldn’t buy Corona “under any circumstances”, and another 14% said they wouldn’t order a Corona in public.  However, Corona beer and seltzer sales actually increased in February.

 


Vol. 228 March 1, 2020 Physician Speeders, Roundup Off One Hook, and Don’t Shoot the Cows

March 1, 2020

“Many people believe medical specialty choices are associated with certain personalities
leading to driving behaviors, such as fast driving, luxury car ownership . . .
and leniency by police officers.”

 


“Do As I Say, Not As I Do” –  the physician’s mantra

A study of 14,560 speeding tickets issued to 5372 physicians in all specialities between 2004 – 2017 in Florida revealed that the average speed of the ticket receivers was 15-16 mph above the speed limit. The 25% of  MD tickets issued for speeding 20 mph over the limit were labeled “extreme speed” in this study; about the same percentage as in the general population of non-MD drivers.  “Extreme speeding” was most common among psychiatrists (31%), but otherwise similar (22-25%) across specialties. Among physicians who received a ticket for speeding, cardiologists were more likely to be driving luxury cars (41%), while emergency physicians, family physicians, and pediatricians (of course) were less likely to be driving a luxury car (20%). 11% of non- physician speeders drove luxury cars. Leniency by officers (“writing a ticket with a lower fine”) towards physicians pulled over for speeding was common, but did not vary by specialty, and was similar between physicians and non-physicians. Police tended to be more lenient to Ob-Gyn physicians, older, and female drivers.

The speediest driver was a general internist clocked at 70 mph.

Quite frankly, I am surprised by the low speeds of the ticket receivers, but not much else in this study. I am certain that the ticketed speed levels would be way higher on Route 3 to Boston any morning of the week. The authors did conclude their paper, I assume with tongues firmly planted in cheeks, with “the connection between the driving behavior of physicians and patient outcomes remains unknown.” (1)

Roundup May Be Off One Hook, At Least
A sharp decline in Monarch butterflies was noted around 2005 and in a 2012 paper the idea that milkweed loss in  Midwestern U.S. corn fields was the cause. The caterpillar stage of the butterfly requires the milkweed to develop. Each year Monarch caterpillars grow up on the milkweed between those rows of corn, and then the butterflies migrate all the way down to a specific forest in Mexico for the winter.  Our corn crops, genetically modified to resist Roundup, were thriving, but the Roundup was killing the milkweed. Hence, the story went, the Monarchs are declining due to Roundup. The evil and perils of Monsanto’s Roundup became a familiar story to us.

Further studies in 2017-2019 using satellite imagery, analysis of chemicals in butterfly bodies , and more accurate counts revealed that only 2 out of 5 Monarchs came from those cornfields and that butterfly counts were stable in the Midwest summer but were declining in the Mexican winter forest. That suggested strongly that something was killing the butterflies en route. Maybe it wasn’t just the Roundup in the corn fields. Even the original “milkweed-loss” proponent backed off a bit. Currently a major study by 120 people monitoring 235 sites along the migratory route is underway to identify what is now considered the multi-factorial causes of Monarch decline. Meanwhile, the federally preserved wildlife area in the U.S. has been reduced by nearly half since 2007, and the Mexican winter-home forest has been reduced by surrounding logging operations and climate change to the size of a soccer field. Science, if not the Monarch butterfly, marches on. (2)

Don’t Shoot the Cows . . . Just Reduce Their Antibiotics.
Carl Sagan was probably the first to point out that methane gas in our atmosphere was really the only sign of true life on earth to any observer from space. We later were told that the chief source of methane on earth were cow farts, and that methane was a greenhouse gas (“bad”) enhancing climate warming. Of course, we all know that manure is an excellent fertilizer. It helps a lot of good green things to grow; good plants that grab carbon dioxide (another “bad” greenhouse gas) out of the air and trap it in organic matter. Soil stores twice as much carbon dioxide as the atmosphere can. Another plus for cows and their solid output.

A curious, enterprising,  and probably not-so-social graduate student measured the amount of carbon dioxide released into the air by different mounds of cow manure over several months. It was a sophisticated, but understandably messy, project whose methodological details are not important here. He found that the manure from cows that had not been given antibiotics released less carbon dioxide into the air, and had an overwhelming positive effect on plant growth. The manure from cows treated with antibiotics released much more carbon dioxide, and resulted in soil much less beneficial for plant growth. In fact, the type of antibiotic given to the cows made a big difference; up to a two-fold increase of carbon dioxide release by one type of antibiotic. Since U.S. livestock contributes 13 million kilograms of antibiotics a year to the environment, it is not exactly a moot point. Picking a different antibiotic might enhance the carbon-capture benefits of manure fertilizer which could help mitigate some climate change. (3) For another unintended consequence of antibiotics on wildlife check out the story of diclofenac and declining vultures in India.

References:
1. British Medical Journal, “The Need for Speed; Observational Study of Physician Driving Habits”, Harvard Medical School, Dec. 18, 2019
2. Scientific American, What’s Happening to the Monarchs, March 2020
3. Scientific American, Manure Problems, March 2020


Vol. 226 February 1, 2020 Current Controversies . . . other than impeachment.

February 1, 2020

The Battle of the Best Diets
Low-carb? Low fat? Keto? Intermittent fasting? Paleo? Gluten-free?
“The science of nutrition is confusing and contradictory. How are we supposed to figure out what to eat?”

A Stanford nutritionist’s study of 600 people, half on low carb diet and half on low fat diet for a whole year, not only found no difference in weight loss between the two groups, but also revealed wide variations in weight change in individuals within each group. Some members in each group actually gained 10 to 20 pounds! Furthermore the researches had no success in predicting which individuals would do better on one or the other diet.

“With diets, there are too many dry drunks around – people who have found a way to drop some weight and now want to force everyone else to see the light.” The only consensus about the best diet is:
1. 
reduce or eliminate added sugar.
2. reduce or eliminate refined grains, processed carbs, and processed meats.
3.
eat as many green, leafy vegetables as possible (avoid white potatoes).
(Neil Swidey, Boston Globe magazine, August25, 2019, pg. 17-20)

Vaping Illness Epidemic
“In 2019 so far there have been six deaths in the U.S. connected to vaping, as compared with more than 10,000 gun-related deaths. That can mean only one thing: EXPECT IMMEDIATE LEGISLATION RESTRICTING VAPING.”
(
Brian Pomodore, Letter to the Editor, Bos Globe September 13, 2019)

Nap for Heart Health
A Swiss study tracked 3,462 healthy adults for five years and found that those who took a nap once or twice a week had about half the risk of a heart attack or stroke. More frequent naps and naps over an hour provided no additional protection. The researchers admit they have no idea how napping provides that benefit, but speculate that it might be “stress relief”.
(Nadine Hauser, NBCNews, September 2019)

Vitamin D Supplement Does Not Strengthen Bones
Canadian researchers studied 311 healthy adults from the “land of lesser sun” (Calgary and Alaska) taking vitamin D supplements daily for three years and discovered that supplemental Vitamin D actually was associated with a decline in bone density: 1.2% decrease in those taking 400 units daily, 2.4% in those taking 4,000 units, and 3.5 % in the 10,000 units a day group. (The official Canadian recommendation for Vitamin D is 600 units a day)
(Burt, JAMA 2019 August 27;322)

Is Dark Chocolate Good For Your Heart?
The Mayo Clinic says that the beneficial ingredient in chocolate is flavanol which which acts as “an antioxidant that can reduce cell damage implicated in heart disease, helps lower blood pressure, and improve vascular function.” The problem, of course, is to get the flavanol benefit you would have to eat about seven average chocolate bars a day! The flavanol in cocoa is actually bitter and has to be masked with fats and sugar to make delicious-tasting  commercially available chocolate; consumption of which can lead to weight gain  and increased risk of associated diseases. Many of the “favorable studies” of the effect of chocolate have been industry-funded so “should be taken with a grain of salt, , , and not another square of chocolate.”
(Unsavory Truth: How Food Companies Skew the Science of What We Eat, Marion Nestle, NYU Professor of Nutrition and no relation to the candy maker, Bos Globe 10/27/19, A28)

Does Smartphone Screen Time Effect the Sense of Well Being?
Not really. A rigorous meta-analysis of 226 studies involving 275,000 people showed no significant link between depression and suicide and increased screen time. There was a tiny effect; about the same effect as wearing glasses. Many studies were based only on “time spent onscreen” with no data on “screen content”. It seems clear that heavy use of social media can be associated with harmful effects, but concern over average use of social media technology is overblown. One must remember that “association” does not prove “cause and effect”. Radio, video games, television, and even comics have caused consternation in the past about the harmful effects of technological innovation. in fact, Socrates bemoaned the new tradition of writing for fear it would diminish the power of memory. He was wrong about writing, but was prophetically correct about cell phones and our memory of phone numbers.
(Lydia Denworth, Scientific  American, November 2019, pg. 49)

Is Reading Printed Books with Children Better Than Reading Digital Books?
Yes. Reading printed books with children increased the mutual, reciprocal interactions between parental reader and the child when compared with reading digital, tablet-based books. Control and intrusive behavior on the part of both parent and child were decreased when reading printed books.

Is Red Meat Bad For You?
The Annals of Internal Medicine just “ corrected” (retracted) its publication of a 2019 study saying that most people could continue eating red and processed meat at their average consumption level without bad health effects. That report went against the prevailing scientific view that red or processed meat consumption is bad for you because of high amounts of saturated fat. The retraction was caused by the discovery that the principal author failed to disclose that he had received a sizable grant from Texas A&M AgriLife. It raised questions about conflict of interest and the researchers’ agenda “to make saturated fat look benign or beneficial”.

Benefits of Probiotics?

 

 

 

 

 

 

Enuff said.


Vol. 225 January 15, 2020 Hubslist’s 2019 Recap – Part II

January 13, 2020

Click on date to read the whole blog.

June 1: Juuling and Schooling  -All vaping solutions contain nicotine despite the label that says “contains no nicotine”, or even more cleverly “contains no nicotine tar”, which means of course “no tar”. Juul (jewel) is the most successful vaping company, so successful that it has become a verb, as in “Do you Juul?, Lets Juul.” Tobacco companies are investing in vaping because they know that the younger a person is when nicotine is introduced the more likely they will become a life-time tobacco user.

June 15: Hospital Readmission Reduction Program – At first blush it looked like this Medicare cost reduction program actually worked because “preventable” readmissions decreased for cardiac disease and pneumonia, but further analysis revealed five reasons why that wasn’t true.

July 1: Public Opinion About High Health Care Costs –Two-thirds of the U.S. public thinks that reducing health care costs is a top priority for both President Trump and Congress in 2019.  The expert opinion consensus is that the over $500 Billion (yes, that’s a “B”) cost of “unnecessary services”, “inefficient delivery” , and “excessive administrative cost” is a significant cause of the high cost of our health care, but only 23% of public poll respondents thought so.  The U.S. remains unique as the only developed nation lacking universal health care insurance for its people.

July 15: Tidbits for Summer Cookouts Fitbits- People walking only 4,400 steps a day (not the recommended 10,000 steps a day) had a lower “premature death rate”. Where did the 10,000 steps a day target come from?— a 1960 marketing campaign by a Japanese pedometer manufacturer that recognized that the Japanese character for 10,000 resembled a man walking! Screen Time – Research by Nielsen found that Americans aged 35 to 49 used social media 40 minutes more each week than millennials.  A researcher interviewing elementary school children uncovered a lot of complaints from the kids about prying their parents away from their screens. “Parents”, she sighed, “are the worst.”

August 1: Parenting “Unconventional Wisdom” – Breast feeding – The benefits of breast feeding infants are generally found in studies of mothers with a higher IQ and in a higher educational and economically class than non-breast feeding mothers. “So what is the real cause of breast-feeding benefits?” Sleep training – Many studies of sleep training show sizable improvements in maternal depression, family functioning, and no negative effects on infants. Working Moms – There is very little data about the pros and cons of mothers working outside the house except for the evidence supporting longer maternity leave which is beneficial to mother and infant in those first months.

September 1: Understanding Medical News About Famous People What is the prognosis for Andrews of the Patriots (pulmonary embolism) and Ginsburg of the Supreme Court (multiple cancers)? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistical outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows? Doctors may guess, but they really don’t know either.

September 15: Vaping and Fatal Pneumonia – There are so many additives in vaping solutions that it is not absolutely certain that vitamin E acetate oil causing lipoid pneumonia is the culprit, but some of the counterfeit vaping solutions used by recent respiratory-distress patients contained more than 50% vitamin E oil!  Who would guess that we would ever say, “It appears to be much safer to just smoke a joint!”

October 1: Vitamin supplements – Here’s more evidence-based skepticism about the benefits of both vitamin C and vitamin D supplements. I have cautioned against vitamin E . . .at least the inhaled form. Is there a vitamin F supplement to continue my alphabetic progression? Yes.  Vitamin F is an outdated term for omega-3 and omega-6 fatty acids,  but I think I’ll let that subject “sleep with the fishes” for the moment.

November 1: Vaping Disease, Medical Marijuana, and CBD –  Pathologists from the Mayo Clinic in Scottsdale, Arizona found no expected microscopic hallmarks of lipoid pneumonia in patients with vaping lung disease, but did find a chemical “burn” or reaction to a toxic gas. Medical marijuana resulted in minimal decrease of pain, little improvement in sleep, and virtually no effect on anxiety or depression. Despite the fact that patients were told by the sellers that there was CBD in the purchased product one third of the study patients had NO detectable CBD in their urine!

November 15: Climate Change Deja Vu from 1996 – “We are still a long way from stabilizing the global climate, a far more complex challenge than repairing the ozone layer. Even with quick action, some greenhouse gases will linger in the atmosphere for centuries. Still, close observers note that a climate of hope has crept into negotiations recently. Insurance companies, small island nations, and others with major interests in a stable climate have re-shaped the diplomatic playing field. Finally, the time for serious policymaking may be at hand.” (1996 Report)

December 1: Top 10 Dangerous Toys and Hazardous Vaping Pods – Though not lethal, yet, if ingested by toddlers the concentrated pods of marijuana for vaping devices can cause significant ICU stays for them. The even more concentrated forms of MJ in edible “dabs” (up to 90% THC) can really cause trouble. Ingesting the concentrated nicotine in vaping pods can actually be lethal to toddlers.

December 15: Changing My Medicare Health Insurance Plan Is Just like Placing a Bet  –  “Youse pays your money and youse takes your choice.” Or as one of my medical student buddies said when we were a lot younger, “Life insurance? You lose (die), you win ($). You win (live a long life), you lose ($).” Did I make the right choice in changing plans?  I’ll know in a year if I won the bet, or the house did.

 


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