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. 227 February 15, 2020 Milk is NOT Good For You?!

February 15, 2020

“Is nothing  sacred to
scientists?!”

 

 

Two Harvard scientists noting that the current U.S. recommendation is that adults consume three 8 oz. servings of milk products a day while we only consume an average of about half of that (1.6 servings per day), they decided that “the role of dairy consumption in human nutrition and disease prevention warrants careful assessment.” They just published their analysis of 121 peer-reviewed articles on “milk and health” and concluded that ” the health benefit of a high intake of milk products has not been established, and concerns exist about the risks of possible adverse health outcomes.” (1) That’s not what my mom said, but both these guys are nutritional experts . . . one of them is even a pediatrician! Wha-a-a-a?

The one clear benefit of milk is that milk “augments longitudinal growth and attained height”, i.e. infants and children with adequate nutrition who drink adequate milk are taller than those who don’t. There are lots of specific ingredients in milk that may have that growth-promoting effect, but there is no scientific consensus of which one it is, i.e. no one really knows. These two guys (Walter and David may be scientists but they put on their pants one leg at  time just like the rest of us) even tempered that positive comment by adding that “tall stature is associated with higher risks of many cancers, hip fractures, and pulmonary emboli”. Jeez louise !

Here are some of the surprising points of their analysis:

1. The current U.S. recommendation for daily consumption of milk products is based on only a short study (2-3 weeks) of just 155 adults.

2. Recommendations for daily calcium intake vary among countries by 100%. (U.S. 1000 mg; U.K. 700 mg.; WHO 500 mg.)

3. Countries with the highest intake of milk and calcium tend to have the highest rate of hip fractures.

4. There is no evidence that high intake of calcium as infants, children, or adolescents improve adult bone density or prevent later hip fractures. The concept of building up a “calcium bank” early in life for benefits in later life is not correct.

5. The consumption of either whole milk or low-fat milk or cheese has no association with weight change. However, yogurt consumption was associated with less weight gain. “Yogurt and other sources of probiotics in Western diets may protect against obesity through its effect on the gut microbiome or yogurt consumption may just be marker for a more healthy lifestyle”, i.e. nobody really knows.

6. In one study of three groups of young children those that consumed whole milk or 2% fat milk had lower BMIs or lower risk of obesity than those who drank low-fat or skim milk. This and other studies contradicts the U.S. Department of Agriculture (USDA) advice to choose reduced-fat dairy products.

7. Neither whole milk nor low-fat milk consumption has been clearly associated with the incidence of mortality from heart disease or stroke. Those rates appear to be dependent on the companion (or comparison) foods of dairy; ie. red meat, fish, or nuts.

8. Milk consumption is most consistently associated only with a higher risk of prostate cancer. Studies of the association of dairy consumption with colorectal, endometrial, and breast cancer show mixed and non-significant results.

9. The overall mortality based on other protein sources when compared to that of milk is higher for processed meat (+56%), eggs (+15%), and unprocessed meat (+a 5%), about the same for fish and poultry sources , and 10% lower for plant sources.

10. The environmental impact of dairy production is 5 to 10 times greater per unit of protein than the environmental effects of soy, legume, and grain production. “Limiting dairy production could make a major contribution toward reaching international greenhouse-gas targets.”

According to Walt and Dave the ideal “guidelines for adequate milk consumption should be 0 to 2 servings per day for adults, deemphasize reduced-fat milk as preferable to whole milk, and discourage consumption of sugar-sweetened dairy foods in populations with high rates of overweight and obesity.”

Of course, they added “pending additional research”.

According to MY mom, ice cream was non-fattening because its exact number of calories was burned in raising your stomach temperature back to normal after it had been chilled by the ice cream. . . . additional research is probably needed.

References:
1. NEJM 382:7, Feb 13, 2020, pg. 644-654
2. for the other side of the coin – “Benefits of Milk”, Dec. 2017,  https://www.medicalnewstoday.com/articles/273451


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.

 


Vol. 221 November 15, 2019 “Cassandra Speaking of Climate Change “

November 15, 2019

Cassandra: one who speaks a prophecy that no one heeds.

A friend of mine (actually his wife) was cleaning out his collection of many years of books, cowboy boots, framed certificates, and other cherished stuff when he found three 1996 pamphlets published by The Worldwatch Institute, an independent, nonprofit environmental research organization in Washington, DC. founded in 1974 and still going strong.  My friend thought I might be interested in them.  One of them, “Climate of Hope: New Strategies for Stabilizing the World’s Atmosphere” published in June 1996, prompted me to think about what were their predictions and did they come true? That is the subject of today’s blog.

Quotes directly from Worldwatch Paper #130 “Climate of Hope” June 1996:

  • “Climate change is likely to be erratic, disruptive, and unpredictable. . . The incidence of floods, droughts, fires and heat outbreaks is expected to increase in some regions.”
  • “Recent changes in global climate trends are almost certainly related to the rapid buildup of greenhouse gases.”
  • “Carbon dioxide is a greenhouse gas, letting in visible light from the sun but trapping heat near the earth’s surface.”
  • “Since carbon dioxide is a virtually inevitable product of fossil-fuel-based energy system, efforts to stabilize the climate will at some point have to require a fundamental revamping of that system. Exactly how to do this and at what cost have been subjects of considerable uncertainty and vehement debate.”

There are several greenhouse gases, including methane (hence the “target” on the backs of farting cows) and chlorofluorocarbons (CFCs, HFCs) which are manmade chemicals that have been largely phased out because of their depletion of the ozone layer. Sulfur gas, also from fossil fuel burning, is not a greenhouse gas but does produce acid rain. Stringent emission standards in the 90’s by most industrialized countries have significantly reduced the amount of sulfates in the atmosphere. Carbon dioxide is the largest greenhouse gas by volume in our atmosphere, and carbon dioxide level measurement have become a standard proxy for predicting world-wide temperature increases.

Prior to the industrial revolution in the 1800’s carbon dioxide levels in the atmosphere hovered just below 300 parts per million (ppm). In 1996 the level was 360 ppm. In order to slow global warming the carbon dioxide level will have to be below 500 ppm. Our world-wide carbon dioxide level is currently 420 ppm. “A 450 ppm target means cutting emissions by more than half by 2050. A level of 500 ppm, which would accelerate global warming, could be reached by 2050 if carbon dioxide emissions are not reduced.” (1996) Because carbon dioxide is a “long-lasting” gas in our atmosphere it’s effect on global temperature is cumulative over decades, so that if we (the world) wanted to return to 1996 levels we (the world) would have to go to zero carbon dioxide emissions, an impossible task.

More words from the 1996 Cassandra:
“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.”

Remember, these words are from 1996. As Yogi Berra said: “It’s like deja vu all over again.”

Meanwhile, as Stephen Colbert says occasionally,
Cause of the Vaping Lung Injury
In my last blog I reviewed a pathological study of lung tissue in 17 patients with the vaping related lung injury which showed no damages indicative of lipoid or oil-caused pathology. The researchers concluded that vitamin E oil was not the culprit, and that the lung injury was similar to that seen from inhalation of a toxic gas and not the inhalation of oil. They did not know what that “toxic gas” was.  The CDC has just released a study of 29 patients suggesting that the offending agent might actually be inhaled vitamin E acetate because they found that in the injured lungs. They also admitted that other unknown agents might be causing the injury.
Meanwhile, hospitals are reporting an increase (one a week in some places) of a hyperemesis syndrome, (persistent, prolonged vomiting), in heavy users of recreational marijuana. First identified in 2004 it can be difficult to diagnose as several other causes have to be ruled out with x-rays and lab tests, but it is increasing in states that have legalized recreational marijuana.

 

 


Vol. 220 November 1, 2019 Update on Vaping Lung Disease, Medical Marijuana, and CBD.

November 1, 2019

“We thought vaping was safe, and it wasn’t. . . it isn’t.”
-Charlie Baker, Massachusetts Governor, justifying his state-wide 3 month ban of vaping

 

What Causes Vaping Associated Lung Disease?
The plot thickens as to the cause of the nation-wide epidemic of vaping-associated lung injuries, including deaths. Our immediate “conventional wisdom” was that it was probably related to inhalation of the vitamin E oil  used to cut the black market THC. (You may have read it here first) Oil inhalation associated injury is now doubted after examination of lung biopsy tissue and/or autopsy specimens from 17 patients. Pathologists from the Mayo Clinic in Scottsdale, Arizona found no evidence of inhaled oil or the expected microscopic hallmarks of lipoid pneumonia in the lungs of patients with the lung injury after vaping. What they did find was evidence suggesting a chemical “burn” or reaction to a toxic gas. There was no sign of an immune response (like an allergic reaction) that would have suggested that only certain individuals could develop the lung injury disease. The researchers did not speculate as to what could have caused the injury, except they are clear that it doesn’t appear that vitamin E oil is the culprit. It puts us back to considering all possibilities: something added to black market vaping material (both THC and nicotine vapers have been injured or killed), noxious gas produced by the device itself, or a combination of the two. This lung injury epidemic began in August 2019 despite several previous years of vaping use, so “something has changed”.  Stay tuned, and don’t vape.

Are There Any Benefits of Medical Marijuana?
Despite the many claims of the benefits of medical marijuana for a variety of conditions, current scientific evidence supports benefits in only three situations: 1. reduce nausea and vomiting after receiving chemotherapy, 2. subjective decrease of spasticity symptoms in multiple sclerosis, and 3. improve chronic pain in adults. The benefit seen in a very rare form of childhood epilepsy is due to CBD alone, not THC. The old idea of benefit in glaucoma treatment was disproven a while back (remember folks? you may have first read it here). A current controlled study of the benefits of medical marijuana is underway at MGH and one of its researchers gave a interim report of their early findings at a conference I attended last week.

The researchers are attempting to do a randomized study of the benefits of medical marijuana in patients 18-55 yo.already holding a medical marijuana card (obtained from a marijuana-use certifying physician for $300 for a single visit). Neither of the researchers, and, in fact, not one of all the MGH physicians are marijuana-use certifying physicians. Since these patients view the marijuana as a treatment for their condition it is unethical to randomize some into a control group who would receive none. Since the clinic can not handle all comers at once they assigned about a third of the patients to a 3 month waiting list for their medical marijuana card. Tests and questions of both the waiting list patients (“control group”) and the patients receiving medical marijuana immediately (“treatment group”) should reveal reveal any benefits or harms from medical marijuana use. A previous study showed that obtaining a medical marijuana card caused holders to double the number of days per month that they used marijuana for their symptoms (from 7 1/2  to 15 days per month).

Since the researchers (along with everyone else) don’t really know what exactly is in the products purchased at a marijuana dispensary, they test for 11 different cannabis metabolites (including CBD) in the patient’s urine each visit. Preliminary data on 84 patients reveals 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 (a “marketing plus” since CBD is touted to reduce adverse effects of THC), one third of the patients had NO detectable CBD in their urine!

Spoiler alert: Today’s cannabis is not your father’s kind of cannabis. Joints at Woodstock had about 1-2% THC. Today the average joint has 6-12% THC. A new edible form of cannabis oil or syrup, called a “dab”, can be 60-90% THC. So “a little dab could really do you.”

What About CBD?
We know even less about the medical benefits of CBD despite the many advertising claims, wide spread ease of purchase, and Gronk’s testimonial endorsement. Cannabis contains over 200 cannabinoids. CBD is one and THC is another. Stay tuned. (Remember, you may have first read it here.)


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