The Medical News Report

February, 2021

#109

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for February, 2020:

1. Update on COVID-19, vaccines, new data- 1 Year Anniversary!

2. What is new for lipids and cardiovascular disease; statins and other medications

3. Stretch Marks

4. Pregnancy issues-Part 1

     A. Link between obesity and hypertension in pregnant women

     B.  Pregnant women-marijuana

     C. NSAIDs and pregnancy—package warning strengthened

     D. Optimal management for miscarriages

     E. Folic acid supplement critical during pregnancy

     F. Higher rate of infertility in the sons of overweight mothers

5. Genetics and cancer

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.

  The COVID information I report on comes from the medical journals, and the CDC. I hope my updates have been helpful.

  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. Update on COVID-19—1 year and continuing!

As we approach one year dealing with this pandemic, with 24.5 million cases and 400,000 deaths, we have come a long way in knowledge, learning to cope with an unknown virus, and are suffering greatly from the physical, psychological, and financial consequences of this horrible pandemic. The first case was reported in the U.S. on January 20,2020.

  The good news is we are just about over the recent surge seeing a 20% drop in cases, according to the University of Washington’s Institute for health and Metrics. The peak occurred on January 16, 2021. That does not mean we are approaching herd immunity just yet;  just the end of another surge until a bunch of younger people get stupid again. The slowness of vaccination to the people could be another reason for a surge, new variants, and lax in people’s safety measures.

  Everyone is wondering why the distribution from the vaccine companies is so slow…..it is finally coming out that Pfizer overpromised the numbers and now are behind in production and the American people are standing in line. Moderna and Pfizer are now admitting there may be several weeks between the first and second dose?  Pfizer recommends a 3 week interval and Moderna, 4 weeks. However, they assure (?) us it will not affect the immunity, just delay it, and even if the second dose is given later than 6 weeks, individuals will not have to redo the first dose.

  Who said we could ever trust Big Pharma as they continue to raise drug prices?

  Also the CDC once again revised their stand on not mixing the vaccines. They now state that if the firsdt dose origin is unknown, it is ok to take whatever is available. That is going to create more doubt in taking the vaccine. Ref. CDC update, January 21, 2021

  Also another late breaking article from the JAMA-Internal Medicine, reported tthat saliva is as good as nasopharyngeal swabs are for diagnosing COVID-19. Where was this study months ago? If this is generally adopted, it will be a gamechanger making testing easy without needing a special trained individual swabbing the mouth and throat.

  With all this new information, especially the delay in providing vaccines, special emphasis on safety measures will need to continue for months, researchers announced this week. We just have to cooperate without applying draconian measures locking down businesses without scientific backup.

A) Negative COVID test is required now for all international flights as of Jan 10, 2021 to travel by air!

  The test must be performed 3 days prior to flying. Either a negative test or medical documentation of recovery from COVID-19. When they return, they need to be tested after 3-5 days and quarantine for 7 days. 

B) Children more likely to be infected in social groups than face to face schools.

  Because of this research, there is no reason schools should not be open according unless the area is a hotspot. In this case, neither children’s gatherings or in school programs should be open until the surge has slowed.

  President Biden has decreed the schools to be open, which the science has supported for months. And he announced there is nothing to change the trajectory of the virus (very different rhetoric when criticizing Trump). This mixed messaging is extremely harmful with the public wanting cooperation and better answers from our leaders.

C) Households continue to be the most likely place for transmission of the virus.

  The CDC continues to recommend isolation at home for exposure or illness, and that means this will continue to be greatest source of transmission. Being smart about safety measures when in public continues to be very important, as it is the only means of preventing spread we currently have, less than perfect as it is.

  59% of the cases come from asymptomatic people according to the CDC.

  Sustained exposure anywhere will also continue to be the major source for infection especially without masks, proper hand washing, and use of household items with infected individuals and especially when social distancing cannot be maintained.

 D) Lockdowns don’t work

  According to the CDC, 10% of the cases occur in individuals under 18 years of age. Places where shutdowns have occurred only encouraged private house parties, and special gatherings to get around isolation orders especially in young people (California). Even New York’s Governor Cuomo has admitted it wasn’t working. People are just not going to follow the rules for a long period of times (pandemic fatigue) especially those younger people that know they are less likely to get very ill.

  Transmission to children continues to be less likely than to adults (less than 10% of the cases), although transmission over 10 years of age began approaching adult rates in some studies. 69% of children have been exposed to positive tested people, and yet the infection rate is much lower than in adults. These kids have been exposed to other coronaviruses since birth which give them some protection.

  Spousal transmission was highest for family members as anticipated.  JAMA Network, Dec. 22, 2020

E) Severe COVID-19 infection--cytokine storm revisited; more treatments effective in hospitalized patients

  There has been much research trying to pin down how COVID-19 causes organ damage. Initially, it was reported the virus itself created pro-inflammatory markers (cytokines, etc.) that caused organ damage, and later it was found that the virus caused the individual’s own immune system to produce cytokines causing damage similar to people who have diseases called autoimmune disease (rheumatoid arthritis, MS, psoriasis, dermatomyositis, lupus, etc.) although much more severe.

  The medications that treat these diseases (immunosupressives) are reported to be effective against COVID-19. The newest reports include interleukin inhibitors (monoclonal antibody inhibitor)—IL6 (Actemra, Kevzara).

  The drug companies are studying all of these medications for their efficacy in hospitalized patients with COVID-19. These and others are now being used to treat outpatients and are seeing good results. The problem is availability. These antibody inhibitors plus Regeneron and corticosteroids have shown a drop in the need for hospitalization. These medications should be considered for those with underlying disease who are not yet sick enough for hospitalization.

  This is caused when viral cell death in organs occur, especially in the lungs, which releases inflammatory proteins. The release of these proteins causes a violent immunologic response causing the proinflammatory markers including cytokines to build in amount creating the “cytokine storm” previously described. There are other markers including a group called interleukins.

  Treatment with antibodies neutralizes the cytokines allowing recovery. The interleukin inhibitors have been added to the list as a recommended treatment in addition to steroids, monoclonal antibodies, Remdesivir, and others. But as often happens, there can be conflicting evidence in different studies (interleukin-6). We are winning the battle, but better treatment protocols are not enough. We must aggressively treat people to keep them out of the hospital. NEJM Journal Watch, Jan 10, 2021

F) COVID-19 is the third leading cause of death in the U.S., but death rate is declining! Herd Immunity on the way in a few months!

  This statistic does not take into consideration that many who die of heart events and cancer may test positive, but it still points to the severity and infectious nature of this virus, since those with any major disease are much more vulnerable to death from other factors. This is amplified by the new variants thought to be more infectious.

  While people over 45 are included in the third leading cause statistic, for those over 85, it is the second leading cause. The estimate is 50% less than actual, it is thought, as it is difficult to know if COVID is a primary or secondary cause of death.

  That is the bad news….now the good news…the death rate continues to decline. For hospitalized patients the rate over the past 6 months has dropped from 17% to 9%, and more recently dropped to 7% in the best performing hospitals. One main reason is having time to find out which medications, what level of oxygen at what pressure, position of the patient (prone), and creating a standard of care to determine what is working. There was no playbook!

  There was much confusion to start with, but the regimens are more clear and new treatments are coming on board. A new illness takes time to come up with the best treatment, no matter what the politicians say (and there is plenty of politics within the medical community as well).

  The hot spots get the media coverage, so don’t look for much coverage about the good news. Also vaccine issues continue to create doubt in people and are not getting vaccinated…even healthcare providers!! Time will change some minds with good safe results. All the research to date reports a very safe and effective vaccine.

Dr. Marty Makary (Editor-in-Chief of Medpage Internet Medical Journal and health policy expert from Johns Hopkins Medical Center) has just stated that herd immunity should start kicking in by April, since probably half of the country has already been exposed or infected and by then, hopefully 100 million Americans should have been vaccinated. (12.5 million so far in the U.S.) That is great news!  

  We still need more information about the length of immunity from the illness and the vaccine. It is reported to be as much as 8 months, but at what level can it drop and still prevent infection from a different strain or reinfection from the same one? NEJM, Oct. 23,2020

  Several tests have been compared testing the amount of antibody induced by the infection and the vaccine and the best test is the ELISA IgG3 assay to diagnose the illness  J. Infectious Diseases, Dec. 25, 2020

  Another bit of good news on convalescent plasma from people who have been infected and donate their plasma. Better mortality rates are being reported when used in hospitalized patients (22% vs 30%) who did not require mechanical ventilation. NEJM, January 13, 2021

G) Time for more emphasis on treatment to prevent hospitalization

  There is not enough media coverage and governmental emphasis on early treatment intervention to prevent hospitalization and ultimately reduce the hospital burden and deaths. There is proven value in using monoclonal antibody infusions (Regeneron), and Remdesivir to keep people out of the hospital. This is where the aggressive treatment must be highlighted, which can be performed outside the hospital. These medications are being underutilized in early cases. 

H) Rollout of vaccine slower than anticipated—poor state management; Vaccine effective against new strains

  Adding those 65-74 added a large burden to the rollout, when the initial recommendation from the CDC for 75 and older was dismissed in several states including Florida, we find ourselves waiting to be just scheduled for a vaccine. With Pfizer overpromising and underperforming, we are not receiving the number of doses. To date in Florida, only 1.1 million shots has been given (as of the January posting from the Florida officials have been administered).

  Non-residents are no longer eligible in Florida, however, any homeowner or those with proof of residency (2 pieces of document such as electrical, mortgage, or phone bill), those with a Florida driver’s license is able to schedule a vaccine 65 and over.

Besides local government distribution, Florida Governor DeSantis has 242 Publix pharmacies over 18 counties is providing 125 shots per day per pharmacy. Where is Walgreen’s and CVS? Distribution center shave too much power. 

  With the latest genetic variant, it has even heightened the anxiety, since it has been reported to be 50% more infectious, even though it does not cause a more severe case or increase mortality. These new variants are covered by the current vaccines, according to the CDC.

  Initially, 55% of the vaccine was initially being held back for the second dose, according to Dr. Marty Makary, Editor and Chief of Medscape. When this became known, the feds were pressured to release these much needed doses.

  The latest research from Pfizer reported that their vaccine neutralized the N501Y mutation in the B.1.1.7. strain, the new variant from the UK, as reported in NEJM Journal Watch, Jan. 10, 2021 from Pfizer release. This strain is reportedly expected to be the major strain in the U.S. by the end of March, according to the CDC.

  The third vaccine expected to be approved in the next few months is manufactured by J&J (Johnson and Johnson), who has a single dose vaccine expected to be approved. Too early to be sure, but one dose would simplfy things greatly. And it, like Moderna, does not require such low frozen temperatures (-94F) and can be stored in a refrigerator. There have been significant numbers of Pfizer vaccine wasted because of storage issues and the 6 hour window of useage.

I) CDC updates their contraindications for receiving the vaccine

  Any component of the vaccine including non-vaccine ingredients such as polysorbate or polyethylene glycol with a history of immediate reactions should not receive the vaccine. Any person who has an anaphylactic reaction to the first dose should not receive the vaccine.

  The websites of Moderna and Pfizer have all ingredients listed. Always consult with a personal physician regarding this issue, and if in question, consult an allergist for evaluation.

  The CDC defines any “immediate reaction” to include urticaria (hives), angioedema (swelling of body parts especially the airway, respiratory distress including wheezing, or actual anaphylaxis (drop in blood pressure and even cardiac arrest if not immediately treated).

  It has already been stated that anyone with reactions to previous vaccines, if they choose to be vaccinated, should wait at least 15 minutes in any facility in case there is a reaction where personnel are trained to deal with acute side effects.

  People who faint at the site of a needle, etc. (vasovagal syncope), which a psychological reaction to a stressful situation are not included in any immediate reaction category.

  Immediate reactions usually occur withing 15-30 minutes. Side effects do not usually occur for 1-3 days (swelling, redness, pain at the site, fatigue, muscle ache, chills, fever).

  Again, it was emphasized by the CDC that reactions to food, pet dander, latex gloves, medicinal topicals (iodine, etc.), etc. are not a contraindication to receiving the vaccine.

  Risk/benefit discussions should always occur between an individual and their trusted physician.

  Even though there are rare immediate reactions exploited by the media, they are rare, according to Dr. Tom Shimabukuro of the CDC.

  Side effects from the vaccine have been minimal, and as one article stated, the most common side effect of the vaccine is HOPE AND RELIEF!

J) Quarantine for 7 days appears adequate

  The CDC announced that a study in Vermont, which had recommended dropping the number of days of quarantine for 10 to 7, found that no one was able to transmit the virus if they had a negative PCR COVID-19 test at 7 days from exposure.

  The CDC still recommends 10 days, but hopefully studies such as the one in Vermont will allow them to revise their recommendations. The CDC has changed many of its guidelines over the course of the pandemic, so we will see if they change this one too.

  It should still be understood that 20-30% of those exposed do not isolate at all. CDC—Morbidity and Mortality Weekly Report, Jan 8, 2021

K) College towns showing huge rise in cases

  What a surprise!! Comparing the number of cases before classes began in the fall semester and 21 days later, there was an average of a 56% increase in numbers of positive cases (15 to 24 cases per thousand). Remote-only colleges found an average of 18% drop in the number of cases. 

  I have reported on the devastating effects of this virus from isolation, business closures, no face to face school, lack of cancer screenings, no immunizations given, etc. The government can only print just so much money.

L) New viral strain does not necessarily can create a false negative in testing.

  The FDA on Jan.12, 2021 announced that some of the new variants are not well covered by the standard PCR COVID test, and will create considerable numbers of false negatives. Correlation with symptoms is absolutely necessary, and if symptoms are present, it is recommended by the CDC that patients assume they are positive (infected) and seek their physician’s care.

  Research on improving these diagnostic tests are ongoing.

M) Reminders to read carefully!!

  1- This virus is not a living organism. It is protein molecule covered by a delicate membrane made of fat. When it attaches to a lining of the body, it converts to a more aggressive cell that multiplies. Since it is not a living organism, it can’t be killed. It has to decay on its own dependent on environmental influences (temperature, humidity, and type fo material where it lands).

  2- This virus is very fragile, only protected by the delicate membrane lining made of lipid (fat), which is easily ruptured with simple soap, alcohol (65%), using warm water (77 degrees or higher), diluted bleach, hydrogen peroxide, listerine (65% alcohol), dry, warm, and bright sunny (UV light) environments. Intact skin is protective, however rubbing eyes, touching nose and mouth could transmit the virus to membranes.

  3- Common surfaces have virus on them, even though they are less likely to be a source of transmission, they are still a source. Wash your hands 20 seconds or use hand sanitizer anytime touching common surfaces from phones, computers, door knobs, handles, etc.

  4- Moisturize hands often to prevent cracks in the skin where viruses can hide. Keep nails cut, and shave the beard!!

  5- Although there are no good studies to prove it, mouth wash with Listerine and salt water sniffs will reduce virus in the nose and mouth, so consider doing it, when out and about and return home. Antibacterial soap is no more valuable than regular soap. Also toothbrushes should be disinfected with 70% alcohol (Listerine) for one minute after use if people are living in a shared group setting.

  6- 6 feet of distance has proven to be the best form of prevention, although masks, if worn correctly, help as well. (Use new masks everyday or wash masks frequently). Wearing a mask out in the fresh air does nothing to prevent transmission (it is only a political statement). Dragging the virus into your house on your shoes is not an issue.

  7- Disinfecting all surfaces in a home without a positive tested person is unnecessary. If there is a sick person, they should wear a mask in the house, and isolate from other family members, including using a different bathroom, isolated dishes, utensils, bathroom products, hair brushes, toothbrushes, etc.

  8- Outdoor gas pumps, packaged cargo, ATMs, do not cause infection. Just wash your hands for sanitary purposes, not the virus. Food does not transmit the virus.

  9- Good ventilation prevents droplets from lingering in the air, but it take about 15 minutes of exposure with an infected person to get sick.

 10- Wearing a mask for long periods of time is unhealthy. Take some breaks from the mask if you must work in it all day. Wearing gloves is not recommended and can cause bacteria to grow on hands.

 Ref.--Johns Hopkins Research Hospital; Dr. Bonnie Henry, Health Officer for British Columbia

  11- The vaccine cannot give you the virus. You must get both shots of a 2-dose vaccine to attain 95% safety. You still must practice safety measures even after the second dose of the vaccine until there is proof it is safe.

  12- At 6 months, 75% of those hospitalized still had one persistent symptoms—most commonly muscle weakness and or fatigue (66%), sleeping difficulty (26%), and anxiety or depression (23%). Lancet, Jan 8, 2021

N) 5 reasons why we should continue to wear masks after receiving the vaccine?

1----No vaccine is 100% effective

    2----Vaccines don’t provide immediate protection

    3----Vaccines might not prevent you from spreading the virus

    4----Masks protect those who can’t take the vaccine and those immunocompromised

    5----Masks protect against any strain of coronavirus in spite of genetic mutations

  Remember, these arguments are based on hypothetical  science with little strong scientific evidence to back them up. Hopefully, in time, we will have clearer answers and better messaging. In the meantime, wear a mask when appropriate and leave the politics at home!

O) WHO finally able to investigate the origin of COVID-19 in Wuhan, China

  After more than a year since the coronavirus was discovered in Wuhan, China, and prevention of any investigating of their labs all this time, they are allowing the World Health Organization to come in to investigate…………. and after al the evidence is gone, find nothing to prove. What a scam and once again, we will know no more than we did a year ago, when China let the virus out of that province to spread all over the world without as much as an apology. I wonder what they are working on next as a new biological weapon.

  The U.S. is rejoining the WHO, and I hope our officials have learned their lesson dealing with this global program and are much more hands on.

 P) What recommended treatments do the FDA recommend for those in the earliest stage of COVID-19?

  There are no FDA approved medications specifically for this virus in the early stages of the disease, because the research has centered, appropriately, on the sickest individuals, and those with underlying diseases.

  All the evidence that is still weak comes from their use in other viral and upper respiratory infections, not COVID-19. This includes antivirals for flu, steroids for those who have asthma, COPD, etc., antibiotics which have immunomodulation capability, antimalarials (hydroxychloroquine), anti-parasitic (imectin), interferons, monoclonal antibodies, melatonin, and other immunological medications. That also includes high doses of zinc, Vitamin D, C, and a host of other antioxidants. None of these have well controlled studies to prove their value much past the effect of a placebo. Why?? I can’t answer this after publishing 13 updates on this disease.

  There has been much frustration dealing with this pandemic. The perfect storm of pandemic and election year turned the results upside down, and I wish the new administration the best in dealing with this crisis.

Q) Double masks???

  When Dr. Fauci suggests something, it would really be nice for him and others to state their recommendation is based on scientific proof (not common sense as Fauci said). I remind you that the only journal article comparing people with and without masks came from Denmark, and found no improvement in numbers of infections.

  And by the way, please say hi to people when they pass you in a store. We are getting very antisocial and it is going to create a permanent disconnect with human to human contact.

2. A new look at lipids and cardiovascular disease

Heart disease is still the number one killer in the U.S. and one of the proven determinants of the extent of disease centers around issues such as cholesterol, triglycerides, obesity, diabetes, heredity, smoking, and diet.

  It has been several years since I have done a deep dive into the lipid disorders. Certainly with the continued rise in obesity, there does not seem to be any reduction coming in the next few decades, and will increase.

  Atherosclerosis is the proper name for hardening of the arteries, and the hardening comes from lipid deposition in the lining of arteries, causing narrowing and eventual closing and clotting off of vessels causing heart attack, stroke, and a variety of ischemic episodes depending on where the vessel(s) are blocked.

Lipids and Lipoproteins in the development of cardiovascular disease

  Cholesterol and triglycerides are the major lipids (fats) in the body and a lipoprotein is composed of molecules of cholesterol, triglycerides, and a single apolipoprotein molecule.

  When fat is ingested, it is sent to the liver, and eventually released by the liver into the plasma. It binds with proteins called apolipoproteins, which delivers the molecule to cells for metabolic use.

  Cholesterol is a major fat but not a natural substance. Only 25% of cholesterol comes from foods, while 75% is produced by the liver. Cholesterol plays a major role in maintaining the body’s cell membranes and producing hormones.

  Triglycerides are rapidly removed from the lipoproteins  by enzymes (lipoprotein lipase), and the size of the molecule has names-- low density lipoprotein (LDL), high density (HDL), etc.. These particles can circulate out of the plasma and return via the lymphatic system or can be trapped in walls of arteries beginning the development of a plaque (atherosclerotic plaque).

  Below is a drawing showing how these plaques begin and eventually if untreated, can block a vessel.

The trapping of these apolipoproteins with lipids attached to the walls of vessels is the first step. When that occurs, cholesterol is released and macrophages (cells that pick up the garbage in the body) which get stuck on the walls and begin to form plaques. The plaque enlarges over time, eventually blocking the vessel’s blood flow. This drawing shows how the macrophage with the attach lipoproteins get caught in the vessel wall.

The actual number of apolipoprotein molecules in circulation is measured indirectly as low density- LDL-cholesterol and triglyceride levels.

Note lipids passing into the lining of the arteries

Laboratory measurement of the levels of serum lipids

  Cholesterol is measured in two lipoproteins-HDL (high density) and LDL (low density).  

  HDL is the good cholesterol and the higher the number the better, indicating a lower risk of cardiovascular disease.

  LDL is the bad cholesterol, and the higher the level, the higher risk of developing cardiovascular disease. LDL should be 100mg/ml or less.  If a person has CV disease, it is recommended the level be 70mg/ml or lower.

  The HDL levels should be higher than 40mg/ml and preferably over 60mg/ml, indicating protection against CV disease.

  All adults over 20 should have their cholesterol checked every 4-6 years.

Triglycerides

  Triglycerides are also measured in the blood, and should be less than 150mg/ml. There are hereditary disorders that may be associated with an elevated triglyceride and create a higher risk for CV disease, diabetes, and stroke.

  Risk factors for elevating triglycerides include alcohol, diabetes, smoking, obesity, and lack of exercise.

Total cholesterol

  Total cholesterol includes a test of LDL and HDL, VLDL (very low density cholesterol also bad). Levels above 200mg/ml are considered a risk factor for CV disease.

Cholesterol ratio

  Total cholesterol is divided by HDL and should be a ratio of 5:1. If the total cholesterol is 200 divided by the HDL of 40 (for instance), this would calculate to be a ratio of 5 to 1. It is recommended for the ratio to be 5:1 or lower with 3.5:1 being optimal.

Genetics and the Metabolic Syndrome

Cholesterol can be genetic and be elevated in families, thus creating a risk for CV disease. Obesity, cholesterol, triglycerides, type 2 diabetes, hypertension, elevated uric acid are all known as the metabolic syndrome and have high risk of CV disease.

Treatment—preventative medicine

   If there are fewer molecules of lipoprotein containing these lipids, then less can deposit on the lining of vessel, and prevent clinical disease.

Prevention techniques

  The best prevention for lipid elevations is a good diet such as Mediterranean, South Beach, Vegan, plant-based diet, Golo diet, etc. Reduction in sugar and fats with significant amount of fruits and vegetables will bring these lipids down, along with weight management, exercise, no smoking, less alcohol, and lower stress.  

  I have reviewed all these diets in previous reports found under DIETS in the SUBJECT INDEX found on the homepage:

www.themedicalnewsreport.com

Medications

  There are three medications that can lower the circulating LDL cholesterol particles—statins, ezetimibe (Xetia), and the more recent proprotein convertase inhibitors (PCSK9). The PCSK9 inhibitors regulate the amount of lipids that can be released from the liver. One or more of these medications may be prescribed to reduce the serum LDL-Cholesterol. Usually a statin is prescribed at the lowest level and can be adjusted upward depending on the response of the medication.

  If that does not lower the LDL-C to about 70mg/ml, ezetimbe may be added to a statin.

  The proprotein convertase inhibitor is very expensive and reserved for patient who do not respond to the other medications, from side effects or lack of tolerance.

JAMA Insights-Clinical Updates, July 22, 2020

  The FDA approved a new non-statin medication, bempedoic (Nexletol), a new class of drugs to lower LDL cholesterol. Studies reported that a 28% average reduction in this lipid can occur. The drug company is requesting FDA approval of this drug in combination with ezetimibe, which can lower the cholesterol 38-44%.

  An advantage is that this new drug does not cause muscle damage.

Statins

    Statins can reduce cardiovascular disease and even death in certain patients by 25-35% if added to a heart healthy diet, weight loss, management of other contributing diseases (co-morbidities), daily exercise, smoking cessation, and reduction of alcohol consumption.    

  Heredity can’t be removed from the equation, but with this regimen with statins, most patient’s lipid levels will decrease reducing risk of a heart attack or stroke.

  Statins can also reduce the recurrence of another heart attack or stroke by 40% according to WebMD.

  Statins block the enzyme in the liver that converts these lipids to cholesterol. They should be taken at night because the liver is most active metabolizing cholesterol while an individual is asleep.

  Side effects are uncommon. Some mild side effects such as headache, gastrointestinal symptoms may occur initially, but muscle ache is a concern that must be discussed, as it can rarely cause muscle damage from inflammation (myositis or in even rare cases rhabdomyolysis). Certain blood studies need to be ordered to evaluate this issue. Some cognitive issues may occur rarely, and blood sugars may rise. Diabetics must be on the watch for elevations that may require adjustment of their diabetic medication.

  These side effects are dose related, and the lowest dosage to be effective should be tried first. Zocor and Pravachol are said to have the fewest side effects.

  If a patient develops muscle ache, tenderness, or weakness, they should contact their physician immediately.

  There are numerous brands of statins, however, atorvastatin (Lipitor), Crestor, Zocor, Pravachol, are the most commonly prescribed. 17 million Americans take daily statins and it is estimated that 10-15 million more should.

Statins can reduce mortality even in the elderly

  Statins are the mainstay for reducing cholesterol, and have shown considerable benefit for those at most ages. With elderly people taking so many medications, it has been recommended that all those who are elderly discuss whether their medications with their primary care physicians. The benefit vs risks needed enumerated, but age does not necessarily increase risk of side effects.

  Side effects can include gait disturbance, diabetes, cataracts, liver toxicity, and muscle complications (rhabdomyolysis).

  When a person is within having a life span expectation of less than 10 years, statins have been questioned, because of the side effects.

   A recent study published in the JAMA, found that in 75 year olds, the overall mortality was 25% less in those who were taking statins. There was a 20% lower risk of dying from a cardiac death. This study spanned 7 years. These patients had been undertreated healthwise in a Veteran’s Hospital. This is a significant reason to strongly consider taking statins.

Omega 3 fatty acids fish oils to treat triglycerides

  The Veteran’s Administration has started a study prescribing Omega 3 fatty acids to follow their cholesterol levels, as these fatty acids are usually use to treat triglyceride elevation. This is being added to Simivastatin, the usual drug prescribed by the VA. The cholesterol is being lowered better with both drugs in older veterans. JAMA Cardiology, July 9, 2020

  4000 mg of Omega 3 fatty acids either by prescription or over the counter is the standard dose perday. It must contain specific types of omega 3 fatty acids: Each capsule of 1000 mg should contain these fre fatty acid esters:

EPA-Eicosapentaenoic acid- 400mg

DHA-Docosahexaenoic acid-300mg

  Dr. Tobias Mega 3 (contains the exact fatty acids as the prescriptions) on the internet is much less expensive.  Prescription fish oils include Vascepta, Lovasa, Epanova, and Omytryg. These prescriptions are very expensive. Be sure they are covered by your drug plan.

  An individual would have to eat a lot fish to consume 4000mg daily and 18 fish oil capsules to be equivalent to the 4000 mg required. That many capsules would cause a lot of gastrointestinal discontent and cause a fish taste from burping.

  Ask your doctor about adding omega 3 fatty acids to your regimen on controlling cholesterol.

Onhealth.com

3. Stretch Marks

  Our skin is a very elastic structure….but only up to a point. Collagen is the protein in our skin that allows elasticity. If stretched to far, it’s strands can break and the skin will be weak enough to show where the collagne gave way in the foor of stria…stretch marks.

  Consider the woman’s abdomen stretching to have a baby. Weight lifters can double the size of their muscles creating stria as can those who gain weight. Children grow quickly and the skin accommodates. These marks occur commonly on the abdomen, breast, hips, thighs, arm pits, and groin, but almost never on the face. That is because the facial blood supply is the best in the body and can with stand the collagen from breaking down.

  These stretch marks are permanent and no topical treatment can rid the body of them. Aggressive lubrication of the skin beginning early in the pregnancy may reduce the risk of stretch marks from having an expanding pregnant abdomen. Excessive weight gain during pregnancy will aggravate the problem.

  Over time, the vascularity of the stretch marks will fade to some extent becoming less apparent, but the actual marks will not narrow. 50-90% of adults have them.

Before and after—laser removal

Medications and certain medical diseases cause weight gain, swelling, bloating, changes in the skin including aging. Hormones and corticosteroids are common medications causing stretch marks. Cushing’s disease caused by adrenal gland excessive secretion of steroids is medical disease example. There are congenital disorders such as Ehrler’s Danlos Syndrome and Marfan’s disease that have defects in their collagen allowing heart disease and excessive joint movement.

  Laser treatments may help but will not completely remove the stria, since they are full thickness defects. Some improvement in certain selected individuals may occur. Multiple procedures may be necessary, and cost is a concern.

  The best way to prevent stretch marks (stria) is maintain the same weight not gaining large amounts of body weight. Children have growth spurts and may develop stretch marks.

  Staying hydrated helps, and WebMD suggests eating a diet rich in zinc (nuts, fish) and Vitamin A (citrus, milk, and sweet potatoes). Skin lotions to increase hydration and better moisturize the skin may be helpful if used daily.

  Retinol creams and laser treatments are touted as helping the appearance, but the science is weak. If one is considering these treatments, see a board certified dermatologist or plastic surgeon to discuss the pros and cons and expense of such treatments. Some tanning products may darken light colored stretch marks to make them appear less obvious. Scrubs, buffers, and microdermabrasion may smooth the skin but will not remove stretch marks.

The basis of plastic reconstructive surgery is possible because of the ability of the skin to stretch, something I did in my practice frequently.

  Spacer implants are used to stretch the scalp, breast, and other areas to allow the skin to be repaired or accommodate a larger implant as in breast reconstruction after cancer surgery, large skin defects after skin cancer surgery, etc. These areas must be stretched over time by slowly injecting saline into the spacer implants. This is an example of how important it is to have collagen in the skin to allow slow stretching of the skin. However, if the stretching is excessive, stretch marks will occur.

4. Pregnancy Issues-Part 1

  I will attempt to provide the reader some of the issues trending in the OB medical literature. As always, no one should act on the basis of these reports, but should be discussed with their OB doctor always.

  Having a healthy body prior to becoming pregnant is just as important as it is during the pregnancy. If a woman is contemplating becoming pregnant, discussion with their doctor is quite appropriate and cessation of poor behavior is a must to prevent trouble with a pregnancy. Also knowin family history of pregnancies may be valuable in consideration of pregnancy. Also women having pregnancy later in life comes with certain risks that need to be understood.

  This is part 1, and as the new medical literature provides new information, I will accumulate short reports regarding them.

A. Obesity and hypertension in pregnancy and pre-eclampsia; other risks for pregnant women  

  Obesity is an epidemic in America that is the underlying basis for a significant percentage of cardiovascular disease, cancer, liver and pancreas disease, and predisposes to orthopedic issues, accidents (falling asleep from fatigue secondary to obstructive sleep apnea), diabetes, and hypertension. America is just about the most unhealthy country in the modern world. Look what happened with COVID-19!

  Pregnancy is one of the most important times for a woman to be at the peak of her health to bring another human into this world. And yet, it is a huge factor in complicating pregnancy, and predisposing the infant to future diseases.

  A recent study (Ob-Gyn Journal, July, 2020) reported there are 8% of pregnancies affected by hypertensive disorders in pregnancy. It is the leading cause of morbidity and mortality in pregnancy.

  3 common hypertensive disorders in pregnancy include gestational hypertension, pre-eclampsia, and eclampsia. These disorders correlate with increasing BMI (waist size increases).

  Classes of obesity were 3. Class one (mild obesity) increased the risk by 1.13X in Class 1, 1.57X in Class 2 (moderate obesity), and 2.18X in class 3 (severe obesity). Those figures are double for late onset hypertension. 

  They also recommend early induction of labor to prevent late onset hypertension by 39 weeks and placing these women on low dose aspirin by 16 weeks.

  Another study followed new onset hypertension with pregnancy and subsequent high blood pressure following the pregnancy (6 weeks post-partum). 26% of black women and 23% of white women needed continuing blood pressure medicine for weeks if not months. This study requires surveillance for women with gestationl hypertension for several weeks after pregnancy.

  An interesting note—breast feeding lowers the risk of both postpartum diabetes and hypertension. JAMA Network, Dec. 1, 2020

 B. Marijuana and pregnant women

  A recent study published in Nature Medicine (August 10, 2020) stated their findings show a 1.5X greater risk of autism spectrum in their babies if marijuana was used regularly. The Canadian study included 500,000 pregnant women who had a 50% increase in the autism spectrum disorder. This study occurred before marijuana was legalized in Canada. That is disturbing.

 C. Optimal management for miscarriages

   Miscarriages occur in 20% of pregnancies. It is often diagnosed with ultrasound.

  Management options include expectant management, medical management, or surgical evacuation of the uterus.

  The psychological and physical harm include excessive vaginal bleeding, anxiety, depression, and PTSD.

  If the pregnancy is non-viable at less or equal to 14 weeks of gestation diagnosed with ultrasound, oral 200 mg. orally mifeprestone (Mifeprex) is administered to help the uterus evacuate the non-viable fetus. A study compared giving a second drug, misoprostol either at 48 hrs. after the first drug or later than 48 hours.

  The primary goal was to pass the gestational sac within 7 days. If significant gestational tissue was still present after that period of time, the second drug, misoprostol is administered or surgical evacuation can be performed.

  In the U.K., a research project compared group 1 (mifeprestone oral followed 48 hours later by misoprostol) and group 2 mifeprestone followed by misoprostol later than 48 hours). The timing of the misoprostol was  compared in these two groups.

 17% of group 1 failed to pass the gestational sac while group 2 did not pass the sac in 24% of cases.

  Overall 17% of group 1 required surgical evacuation vs group 2 had the procedure 25% of the time.

  This study showed that the combination of mifeprestone and misoprostol is superior to the use of mifeprestone alone.

  Mifeprestone’s use is supplied only to healthcare providers who are certified to prescribe this drug (regulated under the FDA’s Risk Evaluation and Mitigation Strategy, that has oversight on the safety and careful distribution of this drug to certified doctors).

  There are doctors that want this drug more widely available. This would put this drug in the hands of less qualified providers. The authors prefer misoprostol be placed in the cheek to be absorbed. Lancet, August 20, 2020

  Mifesprestone is a progesterone hormone blocker and is capable of ending a pregnancy if the pregnancy is less than 10 weeks of gestation (70 days from the last menstrual period). It also can control blood sugar in patients with Cushing’ disease who have type 2 diabetes. It primes the uterus before giving

  Misoprostol is a drug similar to prostaglandin, commonly used to induce uterine contractions to aid in the completion of expulsion of a miscarriage.

  These medications are not always successful, and 15-40% of women may have to take an additional dose of misoprostol. The success is stated to be 64-84% of cases, as stated in the Lancet Journal article.

  After taking mifeprestone, vaginal bleeding will occur usually in 1-2 days. This will be accompanied by nausea, cramps, weakness, dizziness, and diarrhea 2-24 hrs. after ingestion. Vaginal bleeding or spotting usally lasts 9-16 days but can last up to 30 days or longer.

  Alcohol and aspirin must be stopped as it can cause excessive bleeding. However ibuprofen and antinausea pills are recommended to counter the side effects.

  These pills are also used to induce a medical abortion, and Planned Parenthood provides the first pill (mifeprestone) at their clinics followed by the second pill (misoprostol)2-3 days later at home. They recommend the 4 pills supplied by Planned Parenthood for home use be placed on each side of the cheek lining (buccal mucosa) for absorption). 

  The combination pill strategy is controversial, and in the UK, it is recommended to use vaginal misoprostol alone.

  There are two types of miscarriage—missed (silent) and incomplete miscarriage. Missed miscarriages often go undetected. Incomplete  miscarriages can be partial (some of the fetus may be discharged).

  If there is retained fetus, infection can occur, and hospitalization and high dose antibiotic treatment. Fortunately, it is somewhat rare. Lancet, August 20,2020

 D. NSAIDs and pregnancy—package warning!

  The FDA warns against pregnant women taking NSAIDs (non-steroidal anti-inflammatory drugs). These include aspirin, naproxen (Aleve), ibuprofen, diclofenac (Voltaren, and other brand names), celecoxib (Celebrex), etc.

  After 20 weeks of gestation, there is a rare possibility that kidney damage can occur in infants. Fetal damage of the kidneys can drop the amount of amniotic fluid, cause fetal heart problems, and other side effects. Previously there was a package warning after 30 weeks for heart problems, but now the FDA has revised the warning after 20 weeks.

  Low dose aspirin (81mg) is an exception to these warnings as it is an important treatment for pregnant women.

  If a physician feels the need for NSAID therapy which outweighs the risks, it is recommended it be prescribed at the lowest possible effective dose. www.fda.org

  Low amniotic fluid levels can predispose to several health issues for the fetus. Amniotic fluid has vital nutrients  including hormones, immune cells, and the fetus’ urine. At 36 weeks, the amount of fluid is maximum (about a quart) and after that until term decreases. An ultrasound can estimate the amount of amniotic fluid.

  Leakage of amniotic fluid can occur as well. Low fluid can predispose to birth defects, miscarriage, pre-term babies, and stillbirth.

  Low levels of fluid during the third trimester can cause difficult delivery issues including collapse of the umbilical cord causing deoxygenation. It can increase the need for C-section, and slowed growth.

E. Folates prior to pregnancy may cut autism in half

  Folic acid, a dietary supplement, well known to be valuable in preventing neural tube deformities (spina bifida and anencephaly) in fetuses, has now shown to possibly prevent autism in children. Just one month of intake prior to pregnancy may cut the incidence in half, according to a study from Norway.

  During pregnancy, it is already recommended at 5 mg. daily in addition to prenatal vitamins.

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

  As described in the Feb, 2019 JAMA, these children whose mothers took folic acid for a month prior to getting pregnant were followed for 6 years. 0.1% of children developed autism in the treated group compared to the untreated group. That is a 39% lower incidence of autism in the treated group. 

  In this study, the majority of those studied were having their first child, and those who took folic acid tended to be better educated, thinner, and did not smoke. All these factors may play a role. There was some evidence that even if the woman took folic acid early in the pregnancy, it also may be protective.

  From this study, the chief investigator recommends all women consider taking folic acid if they anticipate becoming pregnant in the near future. Also, it is already recommended to take folic acid once a woman is pregnant throughout the pregnancy.

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

  1 in 88 pregnancies will produce an autistic child in the U.S. according to the CDC. Many foods including breads and pasta are fortified with folates.

  Even though other studies need to substantiate the value of folic acid, there is no reason not to recommend women contemplating pregnancy should consider taking daily folic acid and discuss this with the OB doctor.

F. Excess weight during pregnancy may affect son’s fertility

  This Danish study reported 9,232 participants (men and women ages 31-34), and 13% were overweight or obese mothers with a pre-pregnancy BMI above 25. There was 40% increase risk of their son’s being infertile, published in the American College of Obstetrics and Gynecology, a well controlled study (meaning factors like smoking, age, alcohol consumption, socioeconomic status, etc. had the same numbers in the overweight and normal weight pregnant women). It is felt to be caused by unknown hormonal factors yet to be proven.   

I will continue to provide information abou risk factors for pregnant women as they are published.

5. Genetics and cancer

  Cancer is a genetic disease, in that cancer is caused by certain changes to genes that control our cells function, especially how they grow and divide, according to the National Cancer Institute’s website. 5-10% of cancers have a hereditary connection.

  Genes carry the instructions that make proteins, that play an integral role in the function of a cell. Certain gene changes can cause cells to evade normal cellular growth and cause cells to become aggressive and cancerous.

  Certain cancers may come from genetic coding that is hereditary, while others can occur from environmental influences (carcinogens such as tobacco products, alcohol, dietary causes, chemicals, etc). When several of these factors combine, there is an increase risk of developing a cancer.

  Each person’s cancer has a number of more genetic changes than normal cells with a unique set of genetic alterations.

  As the knowledge of genetics and cancer continues to expand, more cancers are being found to have certain genetic mutations that play a role in diagnosing and selecting treatment options. Many of the immunotherapy agents have particular value in cancers that demonstrate certain genetic mutations making the cancer more susceptible to the treatment.

  For instance, colorectal cancer is now known to have 20-30% genetic markers that could impact treatment success. Lynch syndrome is the most common genetic colon cancer.

  These patient must have colonoscopy more frequently because they have significant numbers of polyps (>10 adenomas, >2 hamartomas, >5 serrated polyps) and if these precancers are present in an individual, they should be evaluated for genetic markers.

  Patients with colorectal or endometrial cancers with genetic markers with special genetic markers need close screening for all family members.

  There have been more than 50 hereditary cancer syndromes discovered. Genetic tests can detect genetic mutations that predispose people to developing certain cancers.

  Three of the more common genetic mutations are BRCA-1 and 2 (breast and ovary), PTEN mutations are associated with Cowden Syndrome (breast, thyroid, endometrial, and others). Hereditary syndromes such as the Lynch syndrome and TP53 in Li Fraumeni Syndrome (can cause certain cancers) have a high tendency to develop cancer in colon polyps.

  When a cancer seems to occur more often in a family, it is time to question a genetic link and discuss this with an oncologist or genetic counselor.

  Not only is it important to use genetic information to seek out family members and patients who have a higher risk for cancers, but to ask questions about the health of an individual’s family. Family history is important!!

  For patients who have cancer, oncologists will investigate the patient for genetic mutations. By performing a DNA sequencing test, the cancer cell DNA sequence of amino acids can be compared with normal cells from the patient’s saliva and blood, and possibly note genetic changes that may be driving the growth of a cancer cell. DNA tests can also determine if there is an inherited mutation.

  Internet sites can report some genetic information but are by no means complete. Genetic counselors are usually available in most major medical centers to advise testing and what it means.  

National Cancer Institute at the National Institutes of Health

This completes the February, 2021 report, and the also the completion of 8 full years providing my readers with the latest medical information from the medical journals.

  With COVID-19, it has required even more updates, but I hope it has given you more information about the virus that is evidenced based and not politicized. Stay safe, healthy, and well, my friends, Dr. Sam

Next month, the March, 2021 report will include:

1) Updates on COVID-19

2) Tardive dyskinesia

3) Coffee benefits

4) Bipolar disorder

5) Can estrogen lower breast cancer risk in menopausal women? Tamoxifen and breast cancer mortality

6) Allergy Shots

I wish you a Happy Valentine’s Day, and a healthy and happy month. Get vaccinated.

Thank you for reading The Medical News Report!! Dr.Sam