The Medical News Report

March, 2021

#110

Samuel J LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects:

1. Update on COVID vaccines and other important developments

2. Tardive dyskinesia-side effect of mental health medications

3. Coffee benefits

4. Bipolar disorders

5. Can estrogen lower the risk of breast cancer in menopausal women? Tamoxifen and breast cancer mortality

6. Allergy shots, etc.

IMPORTANT REMINDER!!!! PLEASE READ!!!

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

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

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

  Thank you, Dr. Sam

Yoga classes for everyone on great website

Dear Readers,

  I normally do not put advertisements on my website, but Denise Paska has been my yoga teacher for 4 years and has created a wonderful website for those who do not have access to classes or want to have their classes in the privacy of their home.

  I have been doing yoga classes for many years and highly recommend it for anyone. Denise’s unlimited number of classes is $30 per month when you sign up and can cancel at any time.

  Contact Denise at dpaska@icloud.com for more information. The website is www.trifitglobal.com if you want to see what the website has to offer.

  She has strength, aerobic, stretching, and yoga classes for all ages and physical conditions. Of course, before entering into any exercise program, be sure and clear it with your doctor.

  I highly recommend Denise with her excellent technique and easy to follow classes online.  Thank you,  Dr. Sam

1. Update on COVID-19 vaccines and other important developments

1—Immune response continues after mild infection

  More recent studies continue to report that the immune response is good even in mild cases of COVID-19 lasting at least 3 months. If exposed to the virus again, the immune response was adequate to prevent reinfection. Great news!

2—CDC mask mandates continue, double masks??

  The CDC has a new director (Dr. Michelle Walensky, MD, MPH), and with it comes new a federal public health mandate to wear masks on all public transportation, which includes before boarding and disembarking these means. Refusing to wear a mask in these areas is a federal violation enforced by the Transportation Security Administration. These previous recommendations are coming out now as law from the new administration, so get used to it.

Dr.John T. Brooks, medical officer for the CDC wants people to wear two masks. If you wear one correctly (I said correctly), there is only a 40% safety factor, so in the wisdom of the CDC, they have recommended 2 masks. It will be interesting to see if people comply. Wearing two masks incorrectly is just as stupid!

  I am glad to finally see a 40% possible protection finally quoted for mask wearing. As you recall, the only study to date that I reported on previously, actually compared maskers against non-maskers over 3 months, and found no difference in the number of cases. This Danish study in Lancet has been attacked by some ivory tower experts, but it appears to be a legitimate study. If you listen to the news channels, you would think there are multiple valid studies proving their value, and that is only in the lab, not in the real world. Regardless, it is a simple thing to do and should be used.

  I am following the guidelines as many people are, but without the additional safety measures, masks are not much protection. It is all we have, and the experts continue to be concerned with these more easily transmissible variants. Some are covered and some are not by the vaccines.

3—Vaccine updates

Johnson and Johnson receives approval from the FDA

  J&J announced they have an effective one dose vaccine and have been given emergency use approval by the FDA for its one* shot vaccine.

  This vaccine is not as effective as the others approved but still very effective. In the U.S., it is 72% effective, however, where there are new variants in South Africa (variant B1.351) that may be resistant and have dropped the efficacy to 57%. This is still quite effective since the flu vaccines are usually in the 40-60% range. This lack of complete protection is why we must continue to wear masks and practice other safety measures for now. The other major variant in the U.S. is B1.117.

*One shot dose vaccines at 70% or greater efficacy has been considered very good coverage in the U.S., according to Dr. Robert Atmar, professor of infectious disease at Baylor College of Medicine in Houston.

  J&J vaccine is viable for 3 months in a standard refrigerator.

  This vaccine uses another virus (adenovirus--a very common respiratory virus) that causes a major number of URIs (colds). It can stimulate the same antibodies the other COVID vaccines do. They announced that they could manufacture 30 million doses by April.

  The other vaccines use messenger RNA from COVID-19.

  These mutant variants have complicated the recovery from this virus as it is thought that this new variant may be somewhat resistant to the other vaccines (Pfizer, Moderna, Novavax). New variants are expected.

  It is critical that as many people get vaccinated to help prevent these new variants from getting a stronghold in the U.S. and throughout the world, according to other experts. It may be necessary to upgrade these vaccines if these variants dominate.

  Astra Zenica vaccine (65% efficacy) and Novavax (90%) were initially authorized in Great Britain. However, because of the South African variant, these two vaccines were stopped for a month because they were not adequately protecting those vaccinated. With changes in the vaccines, they were cleared for use, but no question the efficacy issue is going to put AstraZenica at the back of the line unless the only one available. These vaccines are not FDA approved.

AMA Morning Rounds, February 1, 2021

Effectiveness of the Pfizer vaccine in the real world

  The latest information on the Pfizer vaccine

  Evaluating 600,000 vaccine recipients, 7 days after the second dose, there was 90% effectiveness in preventing symptomatic illness, 87% effective in preventing hospitalization, and 90% effective against asymptomatic illness. With these numbers, we are looking for a seriously effective vaccine.

4—New CDC Director has new rules

  There is a new CDC Director, Dr. Rochelle Walensky, M.D., M.P.H., an infectious disease specialist at Harvard Medical School and Massachusetts General Hospital in Boston.

  On her first day, she shut down any residential evictions for health reasons. She is rethinking the priorities for vaccination, looking to the military and other groups to administer vaccines to bolster those giving the shots, expanding the sites to stadiums, gymnasiums, mobile units, pharmacies, etc. She also expects to ask for a major infusion into the financial support of public health, notoriously under-funded. She also wants to improve the communication with the staff at the CDC and have their voices heard more often.

  Considering the significant revisions of guidelines from the CDC over these past months, confusion has occurred with the the public, Dr. Walensky wants to have better communication with the public as well. She needs to address why states do not follow science in their decision making for their residents.

  The communication with the previous administration was good, but many studies had not been completed, so those experts could only report their recommendations from published reports at that time. There is more information now, and the recommendations changed based on those newer studies.

www.ama-assoc.org

5—Dr. Marty Makary speaks out about second dose of vaccine

   The discussion about the slowness of vaccine administration continues but is improving as more and more sites are being authorized to give the shots.

  Dr. Marty Makary* is one of my favorite expert physicians who I listen to because of his straight talk without political overtones, stated that hospitals and some states have been holding back the second shot, when we are facing new variants that are even more infectious than the ones the original virus was meant to cover.

  Fortunately, some of these variants are covered by Pfizer and Moderna, but others are still in question, and there are discussions in the medical journals that with just the first shot, there is as much as 90% safety for at least a few weeks.

  With that in mind, some articles in the journals have reported that one shot might hold us over until most of those vulnerable could be vaccinated. Then the second shot could be administered. We are waiting for an answer to that. Dr. Walensky still can’t speak about the wisdom of one dose, because there are no studies to support such a recommendation.

*Dr. Marty Makary is Editor-in-Chief of Medpage and Professor of Surgery and consultant at Johns Hopkins Medical School.

  Dr. Makary stated that only 62% of the vaccines available have been given as of the publication (Feb. 3, 2021). A report on Feb 24, stated that about 20% of the public had been vaccinated.

  The NEJM (Dr. Sadoff )has stated that immunity (neutralizing antibodies) will give a better result in the second month after the vaccine. One of the researchers (Dr. Andrew Pollard) for Oxford University’s vaccine group states that a second dose (AstraZenica/Oxford) given later than recommended may provide a better response (2-3 months vs. 4 weeks). Moderna has made some of the same statements. These issues must be peer reviewed before the CDC would sddress these issues.

  The UK has already given guidance to wait 12 weeks before the second shot.

  It is time for the FDA to become more transparent with their decisions, according to Dr.Makary. Dr. Walensky, CDC Director, continues to stand pat on the current 1-2 dose waitng period (3 and 4 weeks for Pfizer and Moderna).

  There are still many people stepping in and getting the vaccine ahead of so many who are more needy. Politics continue to enter the prioritization issue.

  Publix, Walmart, CVS, Walgreens, health departments, hospitals, high schools, etc. are being mobilized to render greater numbers of injections, if the pharmaceutical companies can deliver the vaccines. Weather and delay in production have been major culprits in some of those businesses being able to provide the vaccine.

  The numbers continue to rise for people willing to be vaccinated (66% over 64, 46% for essential workers, and now only 32% are refusing the vaccine). Even Black people are starting o believe (53% will likely get the shot). There is a new effort to reach out to underserved populations, those homebound, without computers, etc.

  Medpage, Feb.3, 2021 

What about those previously infected and then get the vaccine?

  Those who have had a positive test for COVID-19 and then have the vaccine later are developing much higher antibody responses to just one dose of the vaccine, as reported in Physician’s First Watch, Feb. 1, 2021.

  It was suggested that those who have had the infection and tested positive could just have one dose of the vaccine and prevent unnecessary side effects from a second dose.

  The Russian vaccine (Sputnik V) was found to have 92% efficacy in the final clinical trial, as reported by Lancet.

6- Length of immunity after the vaccine

  The length of immunity continues to be of concern for those who are infected by the virus and or for those who get the vaccine.

  What is known is that there will be at least 3 months of solid immunity, however, because the T and B lymphocytes that create the antibodies continue to circulate, when a new infection challenges the body, it is hoped that these same lymphocytes can be called upon to produce more IgG, IgM, and neutralizing antibodies (and other cytokines) to ward off future infections.

  It is known that by 6 months, neutralizing antibodies levels drop by 80%. However, scientists found that there are viral remnants in the body driving the adaptive immune response that keep these cells potentially capable of fighting a new infection.   

  It is too soon to know in the real world. Only time will give us these answers. This pandemic is an ever-evolving virus.  There are so many factors that play a role in each person’s immune capabilities. It only stands to reason that healthier people will be better off, but there is no science yet to prove that point for COVID-19.

Nature, Jan.18, 2021

7- Guidance for post-vaccine people exposed to the virus

  When a person has had both vaccines and is 3 weeks past the last shot, and within a window of 3 months since having the last injection, if they are exposed, the CDC now says they do not need to quarantine. This also includes that the person develops no symptoms. All others should quarantine. www.cdc.gov  Of course, safety measures are still recommended.

8- Viral variants (mutations)

The current dominant variant, B.1.1.7, is covered by the current vaccines (Pfizer better than Moderna), but just as one variant is discovered, another appears. The South African variant appears to have some resistance to Novavax and AstraZenica (now approved outside the U.S.). Even Moderna does not hold up well against the South African variant. The vaccines seems to prevent more serious disease but are less effective in preventing milder disease.

  The other successful treatment commonly being used are monoclonal antibodies, which are developed from tightly targeted sites on the virus surface. There is concern with mutations, and these antibodies will need to adapt and companies like Eli Lilly are already working on this.

  It is clear with all that is happening, we really can’t depend on vaccines alone to be protected, and safety measures need to continue regardless, and herd immunity  must occur.

  All viruses mutate, but the COVID-19 virus has mutated slowly over the past year. The flu, by contrast, mutates rapidly, requiring annual injections.

  It is too soon to know how often these vaccines will be need to be repeated. What level of antibody in the blood will be protective, and how long the vaccine’s response will last is still unknown. It will vary in people based on their own body’s ability to respond to the vaccine.

  It will take a few months to develop revised vaccines for all the newer variants, and will continue to be produced very rapidly.

  Additionally, COVID-19 testing products are having to adapt to these variants to pick them up when patients need to be tested.

9--Still good news

  There was an article in the NY Times and Forbes (Kaiser Foundation) that announced there has been an 80% drop in numbers of cases in nursing homes in the U.S. and a 66% drop in deaths since the vaccine has rolled out. The way the article was written it appeared to be propaganda for the vaccine, not to take away from the tremendous value of it. I realize any good news about the vaccine will encourage acceptance of the vaccine.

  It was stated by the current administration that 50 million people in the U.S. have been vaccinated. Bloomberg announced that hospitalizations have dropped by 72% in a month according to the CDC.

  Pfizer and Moderna are already working on vaccine that cover all current variants and may require a third booster in 6-12 months after the first dose.

  In the face of it all, the number of cases and deaths continue to drop. And China is limiting travel during their Lunar Year Celebration, which as you will recall, was the avenue of rapid spread of the virus worldwide from Wuhan last year.

  Anyone heard about the “big” investigation by the WHO about the source of the virus in Wuhan, now that it has been a year since they lied about the transmissibility of COVID-19? They spent 3 hours with 3 scientists walking through their facility……. I feel so much better!

  Finally, rapid testing has had a big impact on transmission, since people can know quickly if they are positive or negative. That and safety measures, plus the vaccine is defeating this virus. Get vaccinated and be careful.

10—72% of cases come from ages 20-49

  The latest information from the journal Science reported that 72% of cases are occurring in those age 20-49, and highest from 35-49. It is recommended by these researchers that this age group get vaccinated ASAP. However, the science still prioritizes older people and those with underlying medical issues that increase the risk of more severe illness.

  They also reported that the number of cases occurring from school reopening has been minimal.

  As the number of seniors are vaccinated, there should be a rapid decline in deaths since most are old and usually have underlying medical issues.

11—New drugs; Value of supplements

New drugs

  Researchers continue to bring forward new immunologic medications to stimulate the body’s own ability to fight the COVID-19—tocilizumab (Acetimra) from a RECOVERY clinical trial in the UK.

  Tocilizumab is an inhibitor of one of the major cytokines—interleukin 6, which is released by the human body in major amounts stimulated by the virus.

  Currently this drug is used commonly to treat rheumatoid arthritis and other autoimmune diseases (lupus, Sjogren’s syndrome, etc.). It has yet to be approved by the FDA for COVID-19, but is in a category of medications that are being currently used and in clinical trials.

  Tocilizumab is used in combination with corticosteroids (dexamethasone) to reduce the inflammatory response in the body, primarily in the lungs.

  The mortality was improved from 47% to 54% in the most critically ill patients, in ICU, needing ventilation with oxygen. This may not seem like a large value, but when people are in severe condition, any help is appreciated. We will continue to follow these medications and their possible approval.

Medpage, Feb. 11, 2021

Remdesivir

Remdesivir has been approved and found to be quite effective in those hospitalized to reduce the number of hospital days by 5-7, saving lives and reducing complications. However, for those on ventilators, it starts losing its effect, and should not be started as early as possible, according to new guidance from the American College of Physicians. It  is theorized that the disease has transformed from a viral disease to an inflammatory one.

  When patients are hospitalized Remdesivir should be given for 5 days and if they require a ventilator, it should be extended for an additional 5 days. This is in distinction for someone who is admitted requiring a ventilator immediately. Of course, physicians will make the decisions on such matters.

Interferons for outpatients

  Another type of treatment that is in a special group of immunotherapeutic agents often used in treating autoimmune diseases such as multiple sclerosis, chronic hepatitis, leukemia, lymphoma, and malignant melanoma.

  There is alpha, beta, gamma, and now lambda.

Peginterferon lambda, in a recent Canadian study, found it can reduce the viral shedding and diminished the severity of respiratory symptoms compared to placebo. By day 7, 80% of patients were negative for COVID-19 RNA, compared to 63% in the placebo group receiving the other medications.

  This drug could become another option for early cases. There are only two other drugs proven to be effective in randomized clinical trials (Remdesivir and dexamethasone) in early outpatient settings with mild to moderate symptoms. Studies need to be performed using peginterferon with these other medications. Lancet, Feb. 5, 2021

Nutritional Supplements do not help the course of COVID-19

  For those banking on high doses of zinc and vitamin C to lessen the chances of severity of COVID-19, forget it, according to a study issued by the Cleveland Clinic. This included number of days of illness, liklihood of hospitalization, deaths, recovery, etc.

  A lot of people are taking these supplements, but if you believe science, you are wasting your money, according to the Cleveland Clinic. COVID A to Z Study, JAMA Network Open, Feb. 12, 2021

  What this study did not challenge is do these supplements prevent illness. It would be very difficult to study that issue, but it is highly unlikely that dietary supplements alone can prevent a person from contracting the virus. Depend of safety measures and getting the vaccine.

12—Steroid inhalers of value for early cases

  Asthmatics do not make up much of the case load of patients needing hospitalization. Could it be that the inhalers most of them use regularly are preventing them from needing hospitalization? This one example of budenoside, a corticosteroid often used in many inhalers with and without bronchodilator medications (albuterol, formoterol, etc.).

It is the conclusion in this University of Oxford study that consideration for early use of corticosteroid inhalers be prescribed in mild COVID-19 cases, especially if they have any respiratory symptoms. It is worthwhile discussing these inhalers immediately with your doctor if you develop symptoms suspicious of COVID-19, get tested, and don’t wait around for more severe symptoms. This would give a person a jumpstart on this virus using the steroid inhaler to combat the inflammatory response to virus.

  Since the latest recommendations are for asthmatics to use these inhalers only when symptoms arise, if a person is asthmatic and develops symptoms, they should consider using their prescribed medihalers with corticosteroid with or without bronchodilator, of course with the approval of their doctor. The length of use would be up to the doctor, however, this study found the average patient using these medihalers was 7 days. 

Medpage, February 9, 2021

13--When will we get herd immunity?

  The estimates continue to be prolonged as we deal with variants, horrible winter weather, etc., but here is the latest estimate from the CDC. Experts usually agree that 70% of the population needs to have been infected or vaccinated for herd immunity to be effective in reducing the number of cases. That includes still using well known safety measures. Will this disease circle back as variants establish themselves? No one knows yet! Below is a graph showing that late November, 2021, will be the time we hit 70%. I predict this will continue to drift into 2022.

14. Why are the teachers blocking children from returning to school face to face?

  Ignoring the science that clearly states schools can reopen without teachers all getting vaccinated. And yet the the powerful teacher’s union is refusing to return to the classrooms for that and other reasons in some cities (Philadelphia is the latest). Follow the science….is all we heard, and yet politics is blocking a medically and psychiatrically necessary to reopen schools. This is a sad day as politics corrupt our attempt to overcome the disastrous effects of the pandemic and help our children.

2. Tardive dyskinesia-common side effect of mental health medications

  With TV ads every day about this disorder, someone must be making big bucks on the treatment. According to the literature, the U.S. has only 200,000 people who suffer from this disorder.

Definition

  Dyskinesia is defined as involuntary motor movements of the body. These movements come from disorders or certain medications that deplete dopamine, a brain chemical called a neurotransmitter. Coordinated movements occur when the transmission of nerve impulses are fluid. That requires dopamine among other neurotransmitters.

  Diets high in sugar and saturated fats can deplete dopamine.

Orofacial dyskinesia

  Symptoms come from involuntary facial movements include smacking of the lips, tongue jutting, grimacing of the face, puffing the cheeks, chewing action, frowning, pursing of the lips, and lip smacking. This looks similar to Tourette’s syndrome. Repetition of speech during the movements can occur.

Dyskinesia of the limbs

  Involuntary movements of the arms and legs include wiggling of the fingers, tapping the foot, flapping of the arms, thrusting out of the pelvis, or swaying of the hips from side to side. These movements can be fast or slow.

Causes

  One of the common causes comes from taking antipsychotic medications such as schizophrenia and bipolar disorder (Thorazine, Prolixin, Halodol, Risperdal, and Zyprexa). Antidepressants also may cause this disorder (trazadone, Zoloft, Prozac, etc.). Anti-seizure medications include phenobarbital and Dilantin.

  Other anti-nausea meds include Phenergan, Compazine and Reglan. This can occur months or years after being put on these medications. Some studies suggest that 30-50% of patients taking these medications may have some symptoms of this disorder.

  There are other diseases that may cause dyskinesia that must be considered as well including Parkinson’s disease, Huntington’s Palsy, Tourette’s syndrome, cerebral palsy, and stroke. Certain blood tests and brain scans may be necessary to differentiate these causes.

Risk Factors

  A higher risk occurs in postmenopausal women, individuals age over 55, and black or Asian.

Treatment

  Changing medications may help, however, if these movements occur, a patient should never discontinue the current medication without the direction of the treating physician. Lowering the dose may help.

  All the TV ads center around recently FDA approved medications Austedo and Ingrezza. These medications work by regulating dopamine in the brain.

  Dietary supplements (not proven) are mentioned to perhaps help the movement by WebMD—melatonin, Gingko Biloba, Vitamin B6 and Vitamin E.

WebMD

3. Coffee benefits for real

Caffeine and Blood pressure

Coffee has been maligned because of the cardiovascular effect of caffeine on blood pressure (elevation) and cardiovascular health. A new report (British Medical Journal) has just reversed this overall trend for most people who do not have serious hypertension or cardiovascular disease.

  Guidance from an individual’s doctor is always required, since once a person hears there are benefits of any natural product, they could overdo it.

  Coffee contains 1000 bioactive compounds, many of which are antioxidants.

*Antioxidants are compounds that inhibit oxidation. Oxidation is a chemical process in the body that produces free radicals that can create a chain of reactions that can damage cells in the body. Foods and supplements that have antioxidant capability counter these destructive reactions.

  The British Medical Journal (BMJ) cited the following benefits (and risks) for consumption of either caffeinated or decaf coffee (at least 3-4 cups per day):

1- There is a 17% lower risk for all-cause mortality and 19% reduction in cardiovascular deaths for coffee (caffeine and non-caffeine) drinkers compared to non-coffee drinkers.

2- Coffee also lowers the risk of certain cancers (melanoma, prostate, and liver), and some liver conditions.

3- Both caffeinated and decaf coffee lowers the risk for type 2 diabetes.

4- In pregnancy, high consumption of coffee has certain detrimental effects: higher pregnancy loss, lower birth weight, and pre-term births. There is also a higher risk of fractures in females (not males).

5- Adding cream and or sugar to coffee may negate the benefits of coffee and sabotage a diet.

  If a person drinks 2-3 cups of coffee per day, here is what the calorie count is, and here are the facts:

1- a cup of coffee contains 5 calories 2- 1 tsp of sugar contains 16 calories 3- Half anf Half cream contains 37 calories for 2 tbsp. 4- Whipping cream contains 101 calories in 2 tbsp. 5- Fat free milk contains 10 calories in 2 tbsp. 

6-This article stated that coffee should not be recommended as a health benefit based on these findings, rather coffee is safe to consume for most people. 

BMJ, November, 2017

Caffeine and menopause

   Caffeine and menopausal symptoms have been studies extensively, and some studies conflict, but a recent study reported by the Mayo Clinic Bulletin found that caffeinated coffee and other beverages increase hot flashes and other vasomotor caused symptoms. Cutting back on these caffeinated beverages decreases symptoms. www.mayoclinic.org/diseases

Coffee and cancer incidence

Dr. Sanji Chopra, liver expert at Harvard medical school, has been a great proponent of black only coffee for a multitude of health benefits. When you consider these percentages, there really is not many nutrients that are any better to lower disease risk and all-cause mortality than coffee.

  In an interview with Dr. Chopra, he stated that observations over years has shown that coffee drinkers (2 cups or more) have lower liver enzyme levels, less evidence of liver scarring (cirrhosis) from disease on autopsy, and 50% less chance of hospitalization for cirrhosis, 40% less liver cancer, but also less metastatic prostate cancer, less skin cancer (including melanoma), and endometrial cancer.

  One must drink 4-6 cups of coffee to reduce the risk of developing type 2 diabetes, and if a person is type 2 diabetic, and drinks 2 cups a day, they can reduce cardiovascular mortality risk by 40%.

  Although these are observational studies, coffee drinkers have a lower incidence of Parkinson’s disease, lower cognitive decline with age.

  Coffee drinkers have lower levels of CRP (C-reactive protein, TNF-alpha), which are inflammatory markers responsible for so many diseases.

  Also people who drink coffee regularly have longer telomeres, which is linked to slower cellular aging. People who are on the Mediterranean diet, and those who exercise regularly also have longer telomeres.

  Cream and sugar destroys some of the benefit of coffee, but just how much is not quantifiable. However, Dr. Chopra is definitely against artificial sweeteners, because it causes glucose intolerance, and reduces the microbiome of the gut, so important to the immunity of the body.

4. Bipolar disorders

This disorder used to be called manic-depressive disorder. It is described as an individual with highs and lows, but it is much, much more complicated.

   Bipolar disorder is characterized as severe mood swings that result in psychological impairment and significant behavioral impairment. If the reader has ever had the experience of knowing an individual with this disorder, you have had quite a ride.

  There is often an underlying affective disorder as well. Affective disorder is a spectrum disease from unipolar depression to bipolar disorders, Type 1 and 2.

  The main characteristic separating bipolar disorder from other affective disorders is the presence of manic or hypomanic episodes that may alternate with depressive episodes. But there are always atypical individuals that don’t quite fit, and thus need to be classified as “other or bipolar related disorders”.

  Defining manic and hypomanic symptoms as well as Bipolar I and II is necessary for the reader to understand the difference. It basically a spectrum disease from mild to severe.

  The term unipolar disorder implies usually depressive episodes. 

  Bipolar I disorder is defined as overt manic episodes with a range of manifestations including overconfidence, grandiosity, talkativeness, lacking inhibitions, daredevil-like, irritability, decreased need for sleep, and elevated mood. Psychotic symptoms such as delusions, paranoia, and hallucinations occur in 75% during manic episodes. Episodes can be severe and prevent normal psychosocial functioning and require hospitalization.

  Bipolar II disorder is defined as primarily depressive episodes alternating with hypomanic phases.

  Manic episodes are defined as severe episodes of symptoms lasting a week or more and may require hospitalization, since it interferes with daily life. These manic episodes may alternate with depressive episodes, but not always.

  Hypomanic episodes are just less severe, lasting a for just a few days, without being out of control. Individuals may progress to manic episodes. Hypomanic episodes can also alternate with depressive episodes. To be labeled hypomanic, an individual needs to have unusually prolonged high moods and high energy, jittery, and all of the symptoms of mania, but less severe. And there are no psychotic symptoms.

  Depressive episodes usally last longer than the manic episodes in I and II. 1/3 of patients are not diagnosed for at least 10 years. 1.5-2.4% of the population has been diagnosed with one of these disorders.

  Family history may play a role. 6-7% of these patients will commit suicide, which makes it 20-30X more likely. 

  People also hear of psychlo-thymic disorder which is defined as manic behavior alternating with depressive episodes for at least 2 years. Co-existing psychological disorders are common and confuse the diagnosis. Anxiety (72%), personality disorders (36%), substance abuse (56%), and ADHD (20%) are common. Therefore, anyone with these diagnoses are at increased risk for bipolar disorder.

  These patients also have higher than normal numbers of other physical health issues such as *metabolic syndrome (37%), migraine (35%), obesity (21%), type 2 diabetes.

*metabolic syndrome includes several medical issues that raise the risk of cardiovascular disease—obesity, hypertension, diabetes, and high cholesterol. Because of these underlying issues and the risk of the disorder itself doubles the risk of death. 

  Bipolar disorders usually begins around the age of 20.

  Diagnosing patients correctly is necessary to prescribe the correct types of therapy. It is also critical for patients and families to understand the dynamics of this disorder and patients must be willing to stay on their meds and follow up when scheduled. That is a real problem.

  There are many other disorders to be ruled out in evaluating patients suspected of bipolar disorder. They include schizoaffective disorder, neurosyphilis, dementia, hypothyroidism, fatigue from anemia, and even congestive heart syndrome.

Management

  Most of these individuals seek the help of a primary care doctor first, and it is imperative those health care professionals be on the alert. They are not going to come in with classic symptoms, rather, they will complain of anxiety or depression or both, substance abuse, or even psychotic symptoms.

  Psychiatric consultation is indicated to assess underlying signs of suicide, substance abuse, and evidence of psychotic symptoms leading to harm of the patient or others.

  Because there are different phases of this disorder, treatment must match the manic or the depressive phase.

  Drugs approved to treat bipolar disorder-manic phase are lithium, carbamazepine (Tegretol), and valproate(Depakote). These medications may have to be adjusted in dose or switched if the symptoms do not improve in 1-2 weeks. Halodol, paliperidone (Invega) may also be helpful.

  Depressive symptoms require mood stabilizers and antidepressants. Adding them to manic medications may be necessary, as the patient may not be willing to come forward and admit to a switch in phases.

  There are a number of off label medications that are being tried including NSAIDs (non-steroidal anti-inflammatory drugs), ketamine, Mirapex, etc. Even ECT (shock therapy)may be effective in resistant cases.

  A variety of psychotherapy techniques have been tried.

  The NEJM review article that I obtained much of this information from stated that either lithium plus Depakote or lithium provided the best results.

  In talking to psychiatry friends, the main concern is keeping these patients on their meds. Long acting injections have recently been successful in providing stabilizing blood levels in those patients who are not compliant.

  Monoring for side effects including liver and kidney function studies. Dizziness, drowsiness, tremors, dry mouth, thirst, stomach effects, and blurred vision create poor compliance in staying on lithium. NEJM, July 2, 2020

5. Can estrogen lower the risk of menopausal women? Tamoxifen and breast cancer mortality

Hormone therapy for menopausal women

  Over 20 years ago, the Women’s Health Initiative created quite a controversy when they came out with potential harms of menopausal hormonal therapy. Prior to this initiative, estrogen was used commonly for menopausal symptoms, however, in the 1960s, it was found that it increased uterine cancer.

  The researchers discovered that adding progesterone to the estrogen lowered the incidence of uterine cancer.

  In the early 1990s, it was discovered that the combination hormone therapy increased the risk of breast cancer, increased cardiovascular disease, thromboembolic disease, but decreased colon cancer and hip fractures. The medical profession then condemned the combination therapy, and only estrogen was continued cautiously if symptoms dictated the need. Women were told to use vaginal estrogen for atrophic vaginal lining and dryness.

Screening mammography in Australia

  In JAMA, July, 2020, a large study of 10,000+ women who took estrogen alone had a 30% lower risk of breast cancer and mortality. The other arm of the study had women taking estrogen and progesterone and found that they had an increased rate of breast cancer (36%) but no increase in mortality if breast cancer occurred.

  It is also interesting that these results were more significant for women who never had a benign breast biopsy or a family history of breast cancer.

  With these results in mind, is estrogen alone a chemopreventative for breast cancer?? It is known that tamoxifen for 5 years is used as a chemopreventative after a woman was diagnosed with a estrogen positive breast cancer. It is less often used in selective women to prevent the first breast cancer.

  It was stated in the editorial section of JAMA, that even though the lower incidence of breast cancer and mortality was significant, it was less valuable for high risk women (family history, dense breasts, etc.).

  This study does not clarify in simple terms whether to use estrogen after menopause, but will make the physician question in what selected women estrogen might be of help in women who have severe postmenopausal symptoms, have heart disease, osteoporosis, etc.

  For women who have had a hysterectomy, it is a little bit clearer that estrogen alone may be helpful considering all the risk factors for and against developing not only breast cancer, but other serious health issues.

  It was stated that these results from this major study will not allow the doctor to conclude that estrogen should be used as a chemopreventative for breat cancer.

  This new study will undoubtedly increase the length of conversation between physician and patient regarding the use of estrogen alone for menopausal women.

JAMA, July 28, 2020

Tamoxifen reduces breast cancer mortality

  Mammography can reduce cancer deaths by diagnosing more breast cancers at a early stage. However, a study in Australia gives the credit to the use of tamoxifen, an anti-estrogen medication used as an adjuvant therapy for 5 years after a diagnosis of an estrogen positive breast cancer in the early stages. In this study published in JAMA Network, June, 2020, over 3 decades, 76,000 women were followed ages 50-69. 72% of premenopausal and 29% of postmenopausal women received tamoxifen. Breast cancer mortality fell from 32/100,000 in 1982 to 24/100,000 in 2013.

  However, because the incidence of advanced cancer has increased in the face of screening mammography, for that reason Australia has discontinued screening mammography. That is a huge step that must be considered but not abandoned in the screening cancer programs in the U.S. without significant research using the U.S. population. The number of variables to control in these studies complicates the issue.

  Obesity and other factors that are increasing in the U.S. and has had an influence on the rise of breast cancer, not to mention changes in our demographics.

  For now, the doctors will be encouraging adjuvant therapy with tamoxifen as a chemopreventative after treatment for an early (Stage I and II) breast cancer.

American Cancer Society recommendations for screening mammography

  Screening mammography will be recommended for the general population starting at age 45 until cancer organizations change their minds about this. The American Cancer Society recommends a woman begin discussions about screening mammography at ages 40-44 with women ages 45-55 having the test every year, and 55 and older every other year. The American Cancer Society’s website: www.cancer.org

  For women with risk factors (BRCA gene mutation, dense breasts, family history, chest radiation before age 30 for cancer treatment, and certain hereditary syndromes), more frequent testing may be recommended. . For more information, consult the ACS website 

  Women should discuss this with their doctors, but feel good that careful monitoring of breast health is an important part of healthcare.  3D mammography has been an important advance and should be discussed.

6. Allergy Shots

Allergies to our environment is constant with little times of the year when some type of allergen is not causing health issues especially in warmer climates.

  Allergy immunotherapy is the proper name for having an allergy specialist administer allergy shots, by providing the smallest amount of the actual allergen in the form of an injection to stimulate the body’s own defenses by forming antibodies to combat the environment’s challenges.

  It is important to note that prevention is always an important method to use and must not be disregarded. Compulsive housekeeping, closing windows when the wind is blowing, getting rid of cotton drapes, etc. which collect allergens will help. Rugs are also a common problem with danders, house mites and insect parts to collect and must be removed. Animal allergies may be an issue that may require keeping animals out of the bedroom and even having to get someone to adopt them.

  Consulting an allergist is the first step. Skin testing and blood workup is necessary to diagnose which allergens are the main culprits. Shots begin with very low doses of serum to begin challenging the immune system. The goal of allergy shots is to provide the greatest dose without causing an undue reaction to the shot and creating prevention of symptoms.

  Anaphylaxis is a concern, and can be very severe, dropping the blood pressure causing shock and death. That is why, at least for the first few months, the allergy shots must be administered in a doctor’s office. If a patient lives out of town, a primary care doctor can accept the responsibility of monitoring the patient in the office for 30 minutes or more and be prepared to treat an overly bad reaction with a shot of adrenalin (Epipen). These adrenalin injectables should also be stored at home in the event of a delayed reaction.

  It usually requires weekly shots for 6 months or so to reach a “maintenance dose” for an extended period of time, usually 3-5 years.

  It also requires at least 6 months for relief of symptoms to begin, therefore, patience and understanding is important. The whole family must be on board in preventing allergies in the home.

  If allergies cannot be controlled by medication, consultation with an allergist is a wise decision.

  Moving to other parts of the country rarely relieves the problem, as environmental allergies are everywhere.

Consult one of the websites for allergists in your locale.  www.aaoallergy.org/patient-resources/

JAMA-Otolaryngology, August 6, 2020

 New oral therapy for peanut allergies

Palforzia, an oral medication has been FDA approved for children to build tolerance to peanuts. It is a powder manufactured from peanuts, and can be mixed into foods like yogurt, apple sauce, etc. It can be started as early as 4 years of age up to age 17 as a maintenance therapy. It can mitigate anaphylaxis from accidental ingestion of peanuts.

  Discuss with personal physicians.

This completes #111, the March 2021 report. Please look over the April’s report subjects:

1. COVID-19 uodate

2. Americans depend on medications rather than healthy behaviors

3. The rise of robotic surgery

4. Genetic ancestry testing

5. Proton vs photon radiation therapy for locally advanced prostate cancer

6. Dupuytren’s contracture-injections vs surgery

  It is my privilege to continue to report on the latest in medical information from the medical literature. Stay healthy and well, my friends, Dr. Sam