The Medical News Report

November, 2021

#118

 

 

Samuel J. LaMonte, M.D., FACS

samlamonte@gmail.com

www.themedicalnewsreport.com

 

Subjects for November:

 

1. COVID-19—more information on safety, effectiveness, and boosters, and need for previously infected individuals to get vaccinated, more!  More FDA approvals

2. Veggie and fruit capsules—hype or help? Critical review!

3. FDA wants menthol removed from cigarettes; FDA approves first e-cigarette

4. Brain fog can come from many sources-new treatments

5. Shorter courses of antibiotics for most common bacterial infections

6. Growing up in foster homes

 

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.

  If you would like this report to come to your private email, just email me at samlamonte@gmail.com

 

  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.

  Thank you, Dr. Sam

 

1. COVID-19 more information import

 

COVID-19 has been here too long. Even though I report from the medical literature, the political contamination of our healthcare services has me very concerned, and as much as I want everyone to get vaccinated, behave, and follow the recommendations by the CDC and FDA, I think most of us realize that certain decisions do not follow sound science. When this happens, it makes people hesitate to follow guidelines. We all want this pandemic to be controlled, but no one factor will accomplish that. Lets get vaccinated but practice safe measures as well and separate medicine from politics.

 

  A) Statistics about COVID-19

  The Delta variant is on the down swing, and so are cases (50% of cases down and hospitalizations down by 43%, and deaths). 68.4% of adults are fully vaccinated. But since the effectiveness of the Pfizer vaccine dropped from 93% to 77% for the delta variant, according to the CDC, this means there will be more breakthrough infections, so we need to continue safety measures and for those select groups the booster. These improvements are not the result of mandates. A recent study in Israel noted 4% of hospitalizations who were admitted for COVID, had bee fully vaccinated.

  Baptist Hospital in Tampa had 900 in the hospital a month ago, and according to their administration, it is down to 100 in a month. That is a 90% drop before mandates. Why would we need them if the numbers are rapidly dropping?

   Herd immunity is playing a role, with more vaccinated, and boosters beginning. These mandates are going to create more unemployed people or employees being put on leave without pay who are refusing the vaccine and creating more nationwide (and global) shortages, lack of first responders and healthcare staff, delays, inflation, and more government dependency.

  When the delta variant gained hold of this country, children made up 13% of the hospitalizations (1 per 100, 000 daily), but has dropped considerably since September.

  There is another variant being watched, but not in the U.S. yet. It is called AY.4.2 currently slowly spreading in the UK. There is no evidence yet that it is more transmissible. Stay tuned.  

  There have been 1.5 million hospitalizations in 2021 according to USA Facts. 8 million have had a booster thus far and 175 million have been fully vaccinated in the U.S. out of the total of 332 million cited by the CDC. 53% are fully vaccinated in Florida and 45% in Georgia. Kids 5-11 make up another 28 million who might be vaccinated.

  With the drop in cases as seen on this chart below, it would be wise to delay these mandates if the cases don’t continue to drop. This started long before the mandates. The black line is unvaccinated and the blue line the vaccinated.  CDC chart shows the unvaccinated are 6x more likely to get COVID-19 and 11.3x more likely to die from it, but the death rate remains extremely low unless a person has life threatening underlying disease that prevent them from fighting the virus.

Allowing currently 1.7 million illegals in our country this year seems extremely counterproductive for our country to get this pandemic under the control since most are not even tested. Other countries can fly to the U.S. now, many countries being given a pass on being vaccinated. Are these groups more important than our very own tax paying citizens?

  The effectiveness of vaccines continues to show high percentages. A recent Israeli study has confirmed the same effectiveness (93%) of the Pfizer vaccine for adolescents.   NEJM, October 12, 2021

  28 million 5-11 year olds will be eligible for the vaccine at 1/3 the adult dose. 24% of parents polled, said would not allow, another 30+% said they need more data, and another 1/3 said they would have their children vaccinated.

   Masks, by the way (and other protective methods), reduce transmission in school 3x more likely according to Dr. Michelle Walensky, CDC chief. Will masks continue if vaccines are approved for these younger kids?

  FDA emergency authorization approval for the Pfizer vaccine should come within a few weeks. A 1/3 dose size results in a 90% effectiveness is recommended,  and no myocarditis cases reported! Safe and effective!

  Shockingly, 4.3 million Americans quit their job in August. 52% prefer to work from home. Millennials are the largest part of the workforce. Dissatisfaction in the workplace is rampant. 6 of 10 say it was the pandemic that changed their attitude.

 

  B) J&J Vaccine

  The FDA has decided that those having received the Johnson and Johnson single dose vaccine should receive a second dose. Will the booster be a third dose or the second dose? If the J&J vaccine was as good as the Pfizer or Moderna vaccines (as they said it was), now that the boosters of all three companies, why are they recommending the booster be given after 2 months of the initial single dose vaccine, while Pfizer and Moderna have to wait 6-8 months? Is it any wonder, why some just can’t trust what comes out of data from the vaccine companies?

  Mix and match boosters are acceptable for all 3 vaccines, although the J&J used an adenovirus to create the vaccine while the other 2 used a spike protein particle mRNA of COVID-19 to prepare their vaccine. No live virus is used in any of these vaccines.   

*vulnerable populations-65 and above, those with underlying medical issues regardless of age 18 and above,  those and those who are often being exposed to infected individuals, such as hospital personnel, first responders, and teachers.

 

  C) Don’t forget the other vaccines

There is still a need for the flu vaccine, so don’t get tunnel vision for the coronavirus. In fact a booster or regular dose of vaccine can be received at the same time, according to the CDC.

  Having such a low incidence of flu last year means people could have even lower immunity than usual for the flu strains which might increase the risk of contracting the flu, an opinion of some experts.

  Also shingles shots are critical for people over 55 as is the pneumonia shot, and children stay current with their childhood immunization schedule. I hope all these hundreds of thousands of illegals don’t interfere with our progress as they have none of these vaccines.

 

  D) Natural immunity

  There is new information about those with natural immunity may get better immunity with vaccines, however, not knowing what level of immunity really is needed for maximum protection is the problem. Where is the research? There are reports that natural immunity is even stronger than vaccine immunity. We need straight answers. It is known that even natural immunity wanes as do vaccinated people. They need boosters at least if not full vaccination.

  A Kentucky study by the CDC found those with proven natural immunity from a previous infection had a 2.3X greater chance of getting reinfected than those who had been vaccinated. Keep in mind, it was a small percentage since reinfections in vaccinated individuals occur in only 0.01%.

   The zeal in pushing the vaccine is admirable to a point, but leaving out recognition of immunity from getting the infection is a glaring error, and has created the main rub in this country. Those with natural immunity are mostly the ones refusing the vaccine. Why can’t there be an open debate about this issue, and resolve the issue?

  The administration makes decisions about protection based on higher immune levels equating to higher protection (from Israel), which is an observation, not solid randomized double blind studies and is weaker proof.

 

  E) Future vaccines

  Even though the vaccines cover the newer variants well, the pharma companies are already working on a second generation vaccine to better cover delta and future variants. Since all the coronaviruses enter the cell through the same mechanism (though the hACE2 receptor, which is on the spike of the surface of the virus), it will be likely that ultimately a third generation vaccine will be developed and can cover all of the coronoviruses, not just COVID-19—so called Dream Vaccine.

 

  F) People not returning to work; shortages; what is going on?

  What is behind the psychology of people not returning to work?? Here are some of the reason quoted:

 FEAR! HEALTH ISSUES SINCE COVID! LAZINESS! OUT OF THE HABIT! DIDN’T LIKE JOB ANYWAY! FEDERAL SUBSIDY! LEARNING TO LIVE WITH LESS IN THE FACE OF INFLATION! LOOKING FOR A BETTER JOB! NOW USED TO BEING WITH FAMILY AND CHILDREN! TAKE YOUR PICK, BECAUSE THEY ARE ALL FACTORS. ADD LOSING THEIR JOB FROM MANDATES. We still have the freedom of choice. That’s why our country must not go down the socialistic pathway.

  It only takes being home for a year or so to change the motivation for having a work ethic, according to studies.

  So far, only 1/3 of the 97 million who have refused the vaccine have broken down and got vaccinated. That still means 67 million more potentially could be out of work further crippling our country.

   The elections next year will determine the future of our country. This administration has a one track mind that vaccinations will rid us of this pandemic, when most experts see it as an endemic just like influenza.

 

  G) New delivery device for vaccines

  For your information, a 3-D printer that is producing a micro-needle vaccine patch, said to be more effective than an injection, may be available in the near future. Proceedings of the American Academy of Science from the University of North Carolina, October 6, 2021

 

 H) Herd Immunity

  The media and the feds are not talking about herd immunity, and we are there in most parts of the country. Even the hotspots are declining in cases thanks to people having been previously infected and vaccinated.

  Dr. Perry Wilson of Yale Medical Center states that herd immunity should be reached when 80% of the population has immunity. But others say different diseases require different percentages of her immunity. Early on experts stated 80%+ should be adequate, but that was before the  delta variant, and no one at the federal level wants to talk about it, because they would have to admit that infection immunity always plays a role in natural immnunity.

  Dr.Wilson points out some important facts about family herd immunity in households in a Swedish study published in JAMA Internal Medicine, October 11, 2021.

   One vaccinated family member (or one with natural immunity) drops the risk of other family members getting COVID without any immunity by 45% if a two member household. If 2 are immunized, there is a 75-86%  protection for the other members. So if we can protect our family members, the same should apply for the population.

Vaccinations drop transmission!

 

  I) Unintended consequences continue

  I remind the reader once again among the most devastating unintended consequences of the pandemic has been the psychological trauma to our country. The rate of infection and lack of mobility of our country are the two most important factors in creating anxiety and depression at monumental levels.

  Our country continues to lack the psychological support for millions of Americans. Add the 93,000 overdoses this past year, missed cancer screenings, delayed surgeries, worsening of chronic diseases, etc. and our government is not even coming close to addressing the issue. There are so many failures with managing this pandemic which will last for years. Younger individuals and women have shown the greatest impact on their lives.

The Lancet Journal estimated the impact globally at 53 million anxiety disorders and 76 million depressive disorders due to this pandemic. Lancet, Oct. 8, 2021

 

   Childhood Obesity Crisis

 Another article from the Coronavirus Resource Center involves obesity in children. The National Survey for Children’s Health reports that 1 in 6 (16.2%) youth age 10-17 have obesity and the pandemic made it accelerate. Hispanics have 21.3% and Blacks 23.7% are overweight or obese. Where is the crisis discussion from the media and administration?

  Kaiser Permanente Foundation reported a 45.7% increase for 5-11 year olds in the last year up from the horrible 36% before the pandemic. Medscape, October 15, 2021

 

   J) Eradication of this virus is not possible

   Trying to vaccinate every human comes with a high cost we do not need to pay. Vaccines are not meant to prevent infection, only keep people out of the hospital. Immunity would need to be kept too high, which vaccines are not designed to do.

   With our southern border open and travel restrictions opening, with immigration continuing, those factors are fighting the control of the virus in our country as these illegals are spreading all over the country sent by the federal government undermining exactly what they are trying to accomplish, often untested and unvaccinated. 1.7 million in 2021 alone.

  This virus will be an endemic virus just as the flu. It will not mimic smallpox or polio because it is not as deadly, but highly transmittable.

  Chaos in schools has contributed as well with no stability in the system. Children 5-11 will be eligible for vaccination in November at 1/3 the adult dose.

 

  K) Pregnancy and the vaccine

  As of mid September, 2021, there were only 25% of pregnant women that had been vaccinated. The CDC recommends all pregnant and breast feeding mothers be vaccinated. There many young women refusing vaccines even if they plan on getting pregnant in the next few years.

 

  Facing the virus

  Pregnant women are considered a high risk group for a more serious viral infection including complications of the fetus, and that risk should be weighed against the slight chance of a side effect from the vaccine. It is a safe vaccine! And they quaify for the booster as a high risk group.

  If a woman is scheduled for induced labor or a C-section, she must test negative, otherwise they will be quarantined before being allowed to come to the hospital.

  Breast feeding is much less likely to transmit the virus to the infant, whereas respiratory transmission is likely if the mother is infected. Separation from the child usually only occurs if the mother is quite ill. Vaccines make this issue go away.

 Concern for harm to the baby

 This group continues to fear the vaccine without any evidence of increased rates of spontaneous abortions (miscarriages) or birth defects. Serious discussion with an OB doctor is appropriate to discuss vaccination risks and benefits.

  Miscariages are related to age considerably. Various studies show rates as high as 53% above age 45, compared to 10% in women 25-29.

British Medical Journal 2019

  Many pregnant women who contracted the virus suffered greatly including premature labor, had low birth weight babies, spontaneous abortions, and birth defects in excess of a similar group who were vaccinated.

  Another study found the incidence was a risk of 14% in not only the general population but in those who were vaccinated with the COVID. No added risk!! These were women who received a dose around the time of becoming pregnant and before the 20th week of gestation. NEJM, October 12, 2012

  Keep in mind the vaccine does not change the mother’s or the baby’s DNA. There is no live virus in any COVID vaccine. Also if a woman is contemplating getting pregnant, the CDC recommends vaccination. As always the conversation regarding risks and benefits should occur before getting a vaccine if there is any concerns that need clarification.

 

 Here is the CDC website’s bullet points on the issue:

 

 

 

 

 

 

 

 

www.cdc.org  www.mayoclinic.org

 

  L) New oral antiviral seeking approval

   Merck Pharmaceuticals is requesting emergency approval for a new oral pill, molnupiravir, to fight COVID-19.

  Similar to the flu drug, Tamiflu ( not for COVID), it should be given as early as a person is diagnosed with a positive test. This antiviral was initially developed to treat flu, but was found to be effective against COVID-19.

  These antivirals actually influence the virus to create high levels of mutation, which are lethal to the virus when the virus tries to replicate. They do this by infiltrating the viral RNA.

  Clinical trials have shown a 50% reduction in hospitalizations and deaths with this oral antiviral. It is not as effective as the IV infusion of monoclonal antibodies, and it is not known if it can prevent the virus. It is potentially a new tool in the fight against COVID-19 and actually other coronavirus infections especially affecting children.

  This pill, if approved, is in no way a replacement for the vaccine or booster, but could be a tremendous tool especially in parts of the world unable to have adequate supplies of vaccines. Pfizer and Atea labs are also requesting approval of their similiar brand anti-viral pill. These pills taken twice a day for 5 days will cost $700, according to Merck, which would be a detriment unless covered by insurance.

  This will be the second anti-viral medication seeking approval as we already are using IV infusions of Regeneron (monoclonal antibody) in outpatient and hospitalized patients. Being used so widely, it is now in short supply.

  Remdesivir, another antiviral in hospitalized patients are losing their luster as a star player in more sick individuals, but it does reduce the number of days in the hospital (10 vs 15 days) according to the NIH.

  Keeping people at home and out of the hospital is a priority!!

  There is also research ongoing adding molnupiravir to an HIV drug, ritonavir, to see if the combo can prevent transmission of COVID to healthy individuals in households.

  Eventually the oral pill will compete with Regeneron, which is a several hour IV infusion for people exposed or recently diagnosed.  

Medicine.net, October 1, 2021; Medpage, October 7, 2021

  For review, here is a chart of the options for treatment in the hospital from the Health of Human Services Department. With the arsenal of treatment expanding, we are finally getting ahead of this virus.

M) Over the counter home COVID test kits-first smart phone test

  There are three types of tests available for diagnosing COVID-19—molecular (the gold standard PCR test) and antigen tests are available as home test kits.

  Antibody tests are run to prove the body has antibodies from an infection with COVID-19. These require a blood draw. These are still not recommended by the FDA or CDC to be used as a diagnosis of or adequate immunity to prevent future infections. They are used in research extensively to come to the conclusions of their studies. It is a shame, because if we knew the level of antibody to be attained to be safe, then those with prior infections, those who are concerned about needing the next dose, and those who are immunosuppressed, would know where they stand. Why hasn’t this happened?

  People previously infected have used them to try and prove they have natural immunity, but the feds won’t allow it, requiring vaccination just as if they had no antibodies. There is no question those with prior infection  will develop more antibodies with the vaccine, but are they necessary? This is a serious area of controversy. There is still not a valuable study to prove what level of antibodies is considered to be adequate for natural immunity or vaccine effectiveness. 

  BDX has developed the first smart phone home test for COVID-19. It is available through Amazon. You need a kit for swab testing of the nose, and then the smartphone can read the results on a test surface where the mucus is applied. 15 minute test. It can be shared with employees, airlines, family, etc.

   The top selling home test kit product group sold in CVS was for COVID-19. These home kits include  Abbott Binax Now COVID-19 rapid antigen test ($24) that provide results at home in 15 minutes. Ellume home rapid antigen test has been recalled because of questionable results.

  There is a PCR test (molecular test) available for home use-Pixel, ($124) but the swab must be sent to a lab for results. Another home PCR test is EmpowerDX ($99) PCR tests must be shipped to a testing center, but is more accurate than the antigen tests, which require a higher viral load in the nose to be positive.

  One study found a lower percentage of positive tests of the Abbott test compared to a PCR test. Another study found the Binax antigen test was 91% positive compared to positive PCR tests.  

  These tests were given emergency use authorization by the FDA by mid September. These test kits can also be purchased on Amazon, and other outlets, grocery stores, and pharmacies. To date there are 10 different tests availabl, but the effectiveness of one compared to another is not known.

  The speed of diagnosis is critical to prevent transmission and critical information for anyone having been in contact with the individual.

  Repeat home testing is recommended in the UK and gives its citizens kits of 7 test kits each.

  Anyone who has symptoms suggestive of COVID-19, influenza, or any upper respiratory infections, or someone who has been exposed should be tested.

  When best to test

  To get the best chance for a reliable test result, the symptoms should have been present for at least 3-5 days  or if been exposed after 3-5 days. While waiting for those days to pass, individuals should quarantine (although people rarely do) especially younger people. I am aware of people still going to events with symptoms….shameful.

  If a person receives a negative test and has symptoms, I suggest a visit to a doctor or testing center occur to be sure what the diagnosis is. Negative tests should be treated as presumptive and tested with the PCR test. The Delta variant should test equally well as other variants. If a test is positive, assume you have an active COVID infection.

   Comparing rapid antigen tests with PCR tests--accuracy

  These home rapid antigen tests are not as accurate as PCR tests obtained by testing centers, but sure are more convenient. Insurance papers would have to be filed for home tests with the cost up front. PCR tests at testing facilities are paid by the federal government.

  The rapid antigen tests (test for proteins from the surface of the virus) are not as accurate as the PCR test* (which detect genetic material from the virus).

  The antigen tests are even more likely to test negative in asymptomatic individuals. The other main disadvantage of a home test is the quality of the nasal swabbing, especially in children. Sticking that swab deep enough in the nose is critical.

  Trained staff will always get a higher percentage of good nasal swabs with the best chance of getting an accurate test.

  With either a positive rapid antigen test or PCR test, assume infection is present. Negative tests are presumptive and should be followed up with a PCR test.  Unfortunately PCR tests can remain positive after recovery with no symptoms, so early use is the best time to get reliable results that correlate with active infection.  

  Accuracy of PCR tests vary by facility but the average is 72% accuracy according to www.healthline.com

The average accuracy of a home antigen test is so varied, but the average is about 50%. Even though a low percentage, it is still very important to get diagnosed ASAP, and many people do not go get tested if only mildly sick and avoid going to a testing center, therefore, if they will use a home test, it is better than nothing.

*PCR test=polymerase chain reaction tests

  Asymptomatic infected individuals clear the virus even faster and the window of getting a positive test may be even smaller. As the viral load in the nose drops with several days, the test may not be accurate. That is why a nasal spray antiviral makes total sense. These are in clinical trials.

  There is a test that can detect not only COVID-19 but influenza A and B (Flu SC2 Multiplex Assay), but must get this test at a facility with this specific test.

  As more and more people use home tests the unintended consequence will be a drop in reported cases, as all PCR tests are required to report their findings to the CDC. It would be valuable to report a positive home test to a doctor or public health facility.

JAMA, October 12, 2021

 

    N) Safety issues for vaccines and preventing infections

Preventing infections

  I have reported on the standard safety measures to prevent contracting COVID-19 and influenza, including surgical masks, social distancing, avoiding crowds, washing hands and keeping nails clean and short, isolating when symptomatic, getting tested if exposed or symptomatic.

   Now we can add Hepa filters and UV light to prevent spread of the viral particles from the air with proven research. Medscape, October 08, 2021

  A very recent report on boosters found they are as safe as the second dose of the vaccine without more side effects. This comes from a CDC study of 22,000 individuals. 8 million have received the booster as of mid October.

  Regardless of these rare side effects, these vaccines are safe and very effective not only for the older variants but the delta and delta+.

  Myocarditis continues to be worrisome especially for young males, but only occur in 5/100,000 doses. There are some differences in vaccines with Moderna having a few more than Pfizer. There are other studies that differ. Moderna has emergency authrorization from the FDA including its booster. The Data analyzed by the FDA for the vaccine in 5-11 had no cases of myocarditis.

  The J&J vaccine has seen a small uptick in clotting issues. There are 2 different kinds of blood defects, bleeding and clotting. There are autoimmune platelet issues that can occur rarely with vaccines creating bleeding. The vaccine sees the platelet surface in a rare person a place to attach to and destroy the platelets, which cause bleeding.

  There are also J&J vaccine cases that create clots in the leg veins with emboli to the lungs. All these side effects certainly are much more common in the general population from injury, being immobile, birth control pills, and other chronic conditions.

  Other higher than expected side effects for these vaccines is enlarged lymph nodes*, acute appendicitis, and herpes zoster infections (shingles). Also included are pericarditis (lining of the heart, arrhythmias, heart attacks, and cerebral hemorrhage). All of these potential side effects are less than 5 cases/100,000 doses.  All these bleeding and clotting issues are much more likely to occur in those infected than those from the vaccine.

*Enlarged lymph nodes--women could have enlarged lymph nodes in the armpit of the arm injected and confuse this with cancer if a mammogram were performed.

  Anti-vaxxers continue to amaze me. They won’t accept a vaccine but jump at the chance of receiving IV infusions of monoclonal antibodies, an emergency use authorization drug, not actually FDA approved. I have relatives willing to lose their job rather get a vaccine.

  Booster side effects have not been reported in the medical literature. Even needing a booster is another reason for hesitancy in some people’s minds, but immunity rarely stays high with any vaccine.

  Medscape, October 4, 2021 

 

  O) Boosters, the delta variant, and need for vaccination in those previously infected, and the future of a “Dream vaccine”

  The initial push on needing the booster came from data that showed a decrease in the antibody levels around 8-10 months, while actual levels are still not known considered safe levels. Observational Israeli studies have shown that higher levels with boosters drops the reinfection rate in vaccinated individuals, although breakthrough rates are only 0.1%.

  The Lancet reported a 93% protection rates for fully vaccinated individuals, but it dropped to 47% at 5 months with Delta variants.  

  The booster group (969 participants) compared to the non-booster group (4633 participants).

  Another Israel study found that 12 days after a booster, there was a 11.3 fold decrease in confirmed infections in 60+ year old participants. It was even more impressive with a 19.5 fold decrease for severe infections.

  Research was performed at the Hebrew University in Jerusalem, Technion Israel of Technology, published in the NEJM, October, 7, 2021

  This information from the CDC and Israel confirmed their recommendations for those over 65 and those at high risk because of immunosuppression or chronic underlying illnesses. Dr. Walensky, FDA chief, went one step further (without proven science but common sense) and added those at high risk for exposure such as medical personnel, first responders, teachers, etc.

  The delta variant surge and cases (87% in the U.S.) was the reason to get the booster and was recommended by the CDC.

  The CDC announced that the booster as a third shot of Pfizer is safe and does not cause any more side effects than the second dose.

  I would hope that those with natural immunity come forward and get at least one dose of a vaccine. There is no reason to believe those previously infected will maintain a high level of immunity after a year. That makes more sense to some experts that I follow with great respect, such as Dr.Mark Makary of the Public Health Department of John Hopkins Medical Center.

 

Mix and Match boosters approved for all 3 vaccines

  Recent studies have found that mixing these vaccines may even create higher than usual immune responses compared to using the same vaccine. J&J and Moderna are now FDA approved as boosters under the emergency use authorization which will allow giving a Pfizer recipient with a Moderna or J&J booster, which is nothing more than the same formula as their original doses.

  Mixing these 3 vaccines is now approved as well but no recommendations are made for how to mix. I had reported in the past that mixing and matching in Europe had been being performed for the starter doses months ago. They also supported a second dose for J&J, as it appears the immunity drops off faster than the other 2. So much for them trying to market their product as a one dose vaccine.  And we wonder why thousands of people are refusing the vaccines when this kind of data comes out later.

  Here are the official recommendations for a booster from the CDC.

Polls from Kaiser Family Foundation found that 75% of those hesitant on getting the vaccine feel the need for a booster proves in their mind that the vaccine doesn’t work.

   Now 2200 healthcare employees at Kaiser are refusing the mandated vaccine and face firing by December 1. Is this really the way to man our hospitals adequately by firing the very people we need on the job? Hopefully, the majority will give in and accept vaccination, but thousands of employees in large businesses are walking out and accepting to be fired, especially when the feds are glad to send more money their way. Most of them also dropped the testing angle if they didn’t get the vaccine.

  If the booster becomes a part of the mandate, that will complicate the issue considerably. And if a yearly booster is required, will it become mandated?

  The federal government is testing the will of the people and as these people become unemployed, they just turn to unemployment benefits and child care subsidies to get by, which may be the plan as mandates are hurting our country tremendously compared to the value of lowering cases, when the case load is dropping quite fast anyway.

 

What is Hybrid immunity?

  Some may wonder if they have had the infection (natural immunity) and then had the vaccine, should they get a booster? Medpage, October, 2021 designates these people with hybrid immunity and do not need a booster. That was the medical journal’s recommendations, not the CDC’s.  They cited a study in the Journal Nature. These people have the highest immunity so far and there is little need for a booster. Of course, discuss this with your doctor.

  This country is the most vaccinated country in the world. I am sure many countries have mixed emotions about that when so many countries have low access to the vaccine at all.

 

 Dream vaccine

  Studies also have shown significantly elevated neutralizing antibodies against various coronaviruses from survivors of the 2003 SARS virus, and continue to have these levels 17 years later.

  However, those tested who had previously been infected with COVID-19, the level of those neutralizing antibodies from SARS were considerably lower against the current virus. However, patients currently vaccinated with COVID had high levels of neutralizing antibodies against both COVID-19 (proper name-SARS-Co-2) and SARS-Co-1 from 2003.

  With crossover with these vaccines, it is highly likely that in the future there may be a “dream vaccine” that could cover all coronaviruses even with mutations in the future.

  Boosters were also found to increase the neutralizing antibody levels.

NEJM, Oct. 7, 2021 (Duke University, Singapore School of Medicine)

 

  P) More on long term COVID Syndrome

  As previously reported, there are a certain number of infected patients, usually those who were hospitalized, who continue to have prolonged symptoms and in a variety of organs. Damage from COVID can be permanent, according to some articles, however, these issues occur in those who already had pre-existing issues.

  In review, the most common long term symptoms are a combination of PTSD from the ordeal of the illness, and autoimmune effects in ulnerable organs already with disease. Fatigue, shortness of breath, joint aches, muscle pain, headache, rapid heart beat, and intermittent fever. Children can have fatigue, shortness of breath, depression, and other symptoms. Insomnia and smell issues can affect both adults and children.

  Johns Hopkins Rehabilitation Center

  A recent study provided some insight into the origin of the cause. It has to do with tiny microclots found in the plasma of the blood and are resistant to being dissolved by the body’s defenses (fibrinolysis), and were found as molecules of inflammatory chemicals (amyloid and alpha-2 antiplasmin) that continue to cause autoimmune responses in organs.

  There is no actual treatment. Each patient will need different therapies depending on the complaints.

  The conclusions from this study was to continue anticoagulants in patients with this prolonged COVID-19 syndrome to prevent these microclots injuring multiple organs. Cardiovascular Diabetology, August 23, 2021

  14/1000 patients also develop kidney damage and 44 million have been infected in the U.S. from COVID-19, which is a significant number in addition to the significant burden of acute and chronic kidney disease in this country (1 in 7 older individuals in the U.S.).

  Regardless of the cause of long term syndrome, it certainly is one more reason to get fully vaccinated. Much more research is needed on the management of these patients, and data howlong it is lasting. Most are over these long term symptoms in less than 6 months.

Medpage Today, October 4, 2021

 

  R) Obesity in children and the pandemic; Changing Hispanic population in last 10 years and impact on COVID-19 and U.S. Healthcare

  COVID-19 has been associated with an increase in weight among not only adults, but children especially age 5-17. Before the pandemic, the percentage of children overweight or obese was 39%, and 11 months later increased to 39.4%, but kids 5-11 increased from 36.2% to 45.7%.

  This is expected but terrible news for these youths for the rest of their lives and fits the trends of increasing medical conditions caused by or accelerated by being overweight or obese. Parents must be aware and get more responsible, even if they are overweight themselves, which of course, is a typical association. JAMA, October 12, 2021

Hispanics and COVID

   The Hispanic population is increasing rapidly from both legal and illegal individuals. It is important to know a few facts about their health and how it affects their risks for COVID-19 and our healthcare system. Obesity is becoming epidemic at 25% including children.

 1. Hispanics are 50% more likely to die of diabetes and liver disease than whites. They have higher rates for kidney disease as well.

2. By 2035, 1 in 4 living in the U.S. will be Hispanics (1 in 6 now).

3. Hispanics death rate is 24% less than whites. They will be living longer. They suffer less from heart disease and cancer. There is 23% more obesity in Hispanics, now the greatest risk factor for severe COVID-19. Blacks and Hispanics are suffering from more severe COVID because of it.

4. These statistics worsen if the Hispanic is born in the U.S. (our wonderful diet rubs off on all populations-thank you fast food).

5. Puerto Ricans smoke more than any other population of Hispanics creating more lung disease which can complicate COVID.

6. 1 in 3 complete high school, 1 in 4 are below the poverty line, and 1 in 3 do not speak English. National Survey 2003-2013. These stats are clearly higher now in 2021.

7. 30% are less likely to have screening exams…cancer, etc.

8. Hispanics are 50% less likely to be vaccinated (COVID) than whites, and 70% more hesitant. Lack of education about COVID and vaccination is a major issue.  www.cdc.org

  How this country handles the million of illegal immigrants over the next few years, will have a major impact on our healthcare system in the U.S.

 

S) ? value of ivermectin and hydroxychloroquine

 

Ivermectin

  I finally found a good article on why some people still are pushing their doctors to be prescribed imervectin. Here is the science or the lack of it….

  Ivermectin does not attack the virus at the spike protein level, which is the way antivirals work for COVID-19. It is an authentic human drug for scabies, river blindness, and filariasis, and it also treats heartworm disease in animals. It has been use worldwide for 5 decades. It is cheap and an oral medication with very few side effects.

  Ivermectin binds to certain chloride channels and kills worms in their nervous system and affect the nerves and muscles of the worms killing it. But COVID has no muscles or nerves. Why should it help?

  A study showed ivermectin may have antiviral properties by affecting a protein called importin that virus can use in reproducing. Researchers infected a cell culture with COVID-19 added various concentrations of ivermectin, however, and the dose necessary was not achievable in humans (100x higher) to kill the virus.

  There have been several clinical trials proving value from  Egypt and Iran, most unpublished and ,therefore, not peer reviewed because the data have been in question, and that means it does not pass the smell test for quality research. Yet, these data are being used by certain advocacy groups to state why it works……if you trust good science, don’t use ivermectin. If you believe internet sites that are seriously in question, it is still a free country, so far, and take it. At least you will get the placebo benefit if you believe.   

Medscape, July, 14, 2021  Dr. Perry Wilson, Yale School of Medicine

 

Hydroxychloroquine

  The discussion on this drug, well known for treating malaria and diseases such as lupus, was touted early on by certain researchers that it can prevent and treat COVID-19 if taken early.

  President Trump was prescribed it and, and ever since that, the medical journals suddenly were filled with opinions from academics about its lack of effect and slammed the president night and day for takng it, when it was his personal physicians who prescribed the cocktail he took along wih other drugs including Remdesivir.

  Controversy makes for good political fodder. Those who believed it would help went to their doctors in droves and got prescriptions, since most physicians saw it as a somewhat innocent drug. The placebo effect made many advocates that went to the internet with their testimonials. To date research in the clinical setting is far from clear and most are poorly done according to many experts.

   The cocktail included often included zinc, vitamin D, and azithromycin (an erythromycin), with no clear help.

  Hydroxychloroquine can inhibit COVID-19 in the lab but data from some studies disagee. A recent study provided some information although the controversy will continue regardless. 821 people were in the study, half given a placebo and half hydroxychloroquine 4 days after the reported exposure before symptoms appeared. 107 were considered to have COVID-19 based on symptoms but only confirmed with the PCR test in 3% were positive. Symptoms occurred in both the positive test individuals and the placebo group. This makes research almost impossible.

  Side effects were more common in the hydroxchloroquine group (heart issues). What this flawed trial shows is how many people who were “exposed” never even got COVID but well might take the drug, and then think they were protected. Humans are always looking for a cheap quick fix to illness. No surprise. Until consistent research is published, it is probably a waste of time, especially now that we have proven treatments for early disease and even exposure.

  Most of the research to date has been with hospitalized patients which have shown no value consistently. It should have been done on those with early symptoms proven with positive PCR tests.

  The FDA revoked their authorization in June of 2020.

NEJM, August 20, 2020  

 

 

2. Veggie and Fruit capsules—hype or help

  The cable stations are filled with promises, testimonials, and hype about how wonderful these internet products can change your life. From the product, Relief Factor, that touts it can relieve any pain to the latest in vegetable and fruit supplements that turn your life around. For god’s sake, is the public naïve enough to think there is a quick fix to health?? YES!

  The sad news is people do not take in enough fruits and vegetables in their diet, and that is why these products flourish…right or wrong.  

  NEVER think a pill or potion will substitute for fresh foods. But for those who do not take in enough of these vital nutrients, they must rely sadly on supplements, a multibillion dollar industry.

  Does it hurt even though it may not help? Yes!! Because it makes people eat less proper foods and gives people rationale they can fill their diet with fried, fatty, and starchy fast foods with too much meat and not enough balance in their diet.

  We have seen through the years, without proper surveillance by the FDA, this industry has gone “hog wild” with dangerous substances included in their products from arsenic, mercury, ground up insects, etc. and with so many products using gummi bears as the vehicle, poisonings of children have risen significantly.

  There is no good research from the major medical journals that have analyzed these supplements, but there are significant watch dog organizations with well qualified nutritional experts, such as the source I used for this report. This site www.besthealthsupplementreviews.com

  This review used WebMD, healthline, Pubmed to provide us with truthful information. This site is for consumers, not a medical audience, but lets face it, the medical profession does not put these issues at the top of their list (prevention), when they are dealing most of the time with the other end of the spectrum…treating the results of disease and illness.

  Healthcare professionals can learn from this just as much as the non-medical public, including me (that is why I spend thousands of hours reporting on healthcare every year, to continue my education and share it with you).

Chemical nutrients are the essential ingredients maintaining health. These products can be easily consumed with a healthy diet consisting of protein, good fats, and good carbohydrates. This should come primarily from a variety of vegetables and fruits with much less from meats and fish.

  However, many American diets are reversed, and that is why the CDC in cooperation with Produce For Better Health Foundation have launched a national campaign “Fruits and Vegetables-More Matters”.

  This replaces the “5 a Day” campaign, now touting that adults need between 7-13 cups of produce/5 day to get the maximum benefits of fruits and vegetables. Here are the stats about average daily consumption:                                                                    

Recommended products highly rated:

  Although I am not citing medical journal articles, I am reporting what this website has stated, and each of you can take it from there. In no way am I endorsing these products.

  Here are the factors used to determine which of these nutritional supplement products are the best for consumption; key words like—“Doctor formulated”, “convenient capsule form”, “key nutrients in a single bottle”, and clear labeling. I think the price of the products should also be a factor.

  Their pick:

 #1 KaraMD—Pure Nature

This fits their criteria the best and the price is very reasonable ($40 for a 30 day supply). It contains no soy beans and is non-GMO and Vegan friendly. This outdistances all others, in their opinion. 2800 nutrients in 4 capsules per day.

 

#2 Balance of Nature

The website states this second place product has several deficiencies including not providing the actual amount of nutritious ingredients with a lot of filler from soybean and apple fiber.

  Soybean has some estrogenic capability and contains some ingredients that can cause allergic reaction.  Also taking 6 capsules a day is a lot, and more expensive than the #1 choice ( these capsules cost $100 for 30 days supply). Not validating the key ingredients in these capsules is a concern.

 

#3 Athletic Greens                                                    

 

 This is not doctor formulated, contains apple fiber filler, and is in an inconvenient powder form. It also costs $100 for a 30 day supply.

  There is no scientific proof that their ingredients are active, and contain the amount of nutrients it states. The source of the products, the contaminants and filler may be the reason to be somewhat suspicious of the 2nd and 3rd choice, but for people not able to or not willing to eat a significant amount of fruits and vegetables, this is a source, albeit expensive and questionable in improving health.

Be thankful everyday!

 

 

3. FDA wants to ban menthol from cigarettes; FDA initially approves the first e-cigarette

Menthol cigarette ban coming

The FDA, according to the new director, Dr. Janet Woodcock, is in the process of banning menthol from cigarettes. Mentholated cigarettes are a favorite of people of color, especially black people, low income communities, and LGBTQ+, and these groups smoke much more than other groups of individuals.

  The FDA estimates there 18 million people in the U.S. that smoke mentholated cigarettes. Also, there are flavored e-cigarettes, and cigars. They also stated that 85% of black people smoke mentholated cigarettes.

  Once the ban occurs, they estimate 900,000 people will quit. When Canada banned them, 22% of smokers quit, but 66% switched to regular cigarettes. The AMA, American Heart, and American Thoracic Associations are strongly in favor of it, and have tried to years to ban it. Add the American Cancer Society and American Lung Association to those groups dedicated to smoking cessation anyway that can be accomplished.  Physicians First Watch, May, 2021

  Discover magazine polled a large group and found that if menthol cigarettes are banned, 25% of those smoking menthol cigarettes would quit. However, black smoker are less likely to quit, and 85% of blacks smoke menthol cigarettes, and more than half of young smokers use mentholated cigarettes. 45,000 blacks die each year of cigarette caused cancers.

E-cigarettes

  The FDA has approved a premarket process for the first e-cigarette, citing reduced harm over traditional cigarettes. The product is VUSE SOLO.

The FDA only approved the tobacco flavored e-cigarettes and none of the candy flavored types were approved.

  Congress gave the FDA the ability to oversee the selling of e-cigarettes.

  The newly approved VUSE SOLO product has proven that users were exposed to fewer harmful and potentially harmful aerosols than cigarettes. Flavored products could lead to use of cigarettes especially in younger individuals.

  Even though the Reynold’s Tobacco Company has studies that confirm flavored tobacco also reduces smoking cigarettes, but the FDA did not agree because flavors are so seductive to the youth and e-cigarettes that taste like tobacco are less desirable. Reducing the amount of nicotine gradually is required to wean off the addicitive drug, nicotine.

  However, the AMA denounced the FDA’s decision, citing all e-cigarettes as dangerous and addictive.

  The FDA stated that while the product could be sold, it still cites that the product is not safe, is addictive, and leads to cigarette smoking.

Medpage, October 14, 2021

Nicotine patches can be obtained free at 1-866-NEW-LUNG when signing up to quit smoking.

 

4. Brain fog can come from many sources

Brain fog is a well known clinical entity from cancer treatments, head injuries, pregnancy, menopause, chronic fatigue syndrome and other central sensitivity syndromes, depression, brain disorders (MS, etc.), medications, even lupus, and more recently a significant longer term sequelae from COVID-19. The “long haulers” are experiencing fatigue, cough, headache, and brain fog for weeks and months.

  Brain fog is defined as an inability to concentrate, memory problems, sleep difficulty, confusion, difficulty focusing, and even expressing thoughts verbally.

  Brain fog may be temporary but needs managing.

  Management

--Addressing coping methods is important. They may include a) repetitive exercises to retrain the brain, b) tracking and understanding what influences memory problems, c) stress relief exercises including meditation, yoga, and other mindfulness techniques. The symptoms are similar to PTSD.

--Medications may help including 1) Ritalin 2) Aricept 3) Provigil 4) Namenda. The first is for ADHD and the other drugs for memory problems are prescribed for Alzhiemer’s Disease.

--Stay organized, control the surrounding environment with familiar settings including the work environment, keep a detailed calendar, and write things down necessary to remember, take frequent breaks, and physically and mentally exercise(walking, yoga, crossword puzzles, simple games, etc.

--support groups

Mayo Clinic Proceedings

 

 

 

 

 

 

 

5. Shorter courses of antibiotics for most common bacterial infections

  The American College of Physicians has issued a Best Practices Advice recommnedation suggesting that a shorter course of antibiotics for common bacterial infections. Overuse, resistance to the drugs, and long and unnecessary use has long been a major health issue. These best practices are published in the Annals of Internal Medicine, a major and important medical journal.

  Diseases analyzed included uncomplicated bronchitis, COPD, urinary tract infections, community acquired pneumonia, and cellulitis.

  10 days for most infections has been the standard for years, but now the organization states that in many cases 5 days is satisfactory in selected cases.

  The obvious method of action is for the physician to communicate with a patient at 5 days, and decide if further antibiotic therapy is really necessary. This doubles the work of the doctor, but will pay dividends. They could write a prescription for 5 days with a refill, but that doubles the effort for patients needing to get back to the pharmacy. Discuss this with your doctor.

  If patients are still symptomatic, most would think further antibiotics should be necessary, but it is not uncommon for symptoms to last longer while  the antibiotic is still working, so re-education of the public and physician offices would be necessary.

  So many patients push their doctors to write prescriptions for antibiotics unnecessarily, and many will cave to their request rather than spend the time explaining that the infection is viral, as an example, and antibiotics are not necessary, and actually harmful (creating resistant infections).

  It is estimated that 30% of antibiotics is unnecessarily prescribed or often wrongly prescribed just to please the patient and get to the next patient.

   It is always wise to culture the infected substance and run a sensitivity to various antibiotics even though most physicians would not wait on those studies before prescribing the usual and customary antibiotics. Stept tests and results are available in minutes.

  Antibiotic resistance has become a major health threat. Most are aware of MRSA*, a very resistant staph bacterial disease usually acquired in the hospital. But there are many other bacteria that are quite resistant to many antibiotics.

*MRSA=methacillin resistant Staphylococcal aureus infection

  It will be interesting to see if this recommendation is actually put into practice. 

 

6. Growing up in a foster care

In 2019, 672,000 children spent some time in foster care. And on any given day, there 424,000 children are in foster care. The average time spent is one and half years with 5% spending more than 5 or more years. The average age is 6½ years old. 20,000 age out of foster care (18 years of age) annually. The future of these children is not bright, with 50% of them at age 23 earning no income and the others averaging $7,500 annually. www.ifoster.org

  How many of these poor children coming across the border will wind up in foster care? Often, separation of children from parents is not in the best interests of the child, but court ordered for various reasons. The government has been woefully financing social services, healthcare services, and judicial systems supporting programs for dislocated children.

  Childhood development is critically tied to the home environment. This requires a relationship with an adult who is nurturing, protective, and fosters trust and safety, which is termed attachment. This can have a significant effect on the future of any relationship the person may seek.

  Separation between 6 months and 3 years can have significant developmental effects on the foster child resulting in emotional instability. Children older than 3-4, if separated, may be able to form attachment to a new family since some language skills will allow coping with loss and adjustment of change.

  Multiple placements are extremely difficult to overcome, and may require intensive help on many levels. American Academy of Pediatrics Publications, 2000, 2016 

 

 A. Here are some common sense items to help understand the issue of growing up in a foster home.

  1. Many of us could avoid foster care if parents were provided with the right help. More intensive services are necessary to prevent the state from becoming a parent, which is ill-equipped to provide a good substitute for real parents.

  2. Being in a facility until age 18 is no longer legal. In 2003, the average time in foster care was 13.5 months. The greatest need is for foster and adoptive parents to take in teenagers.

  3. Foster care is a scary place for children. It places them in a situation which they have no control over their lives, and the older the child or teenager, the more likely they will had several stints in the system. They’re not allowed, as teenagers to get a driver’s license or have sleepovers.

  Even if coming from a dysfunctional family, being uprooted and sent to foster care through no fault of their own, causes tremendous emotional trauma, and it is thought that PTSD is more likely in these youngsters than in combat veterans. Drug addiction, neglect, and abuse are common reason the parents lose custody and there are no close relatives to step in and accept the child.

  4. There aren’t enough good foster homes. Many wind up in group facilities and homes, and shelters, which are the worst scenario. Being able to match kids with foster parents with similar interests, needs, etc. and good chemistry is the best scenario. Unfortunately, they wind up any place there is an empty bed.

  5. Foster kids are good kids in a bad situation. They often develop challenging behavioral problems from anger and feelings of abandonment. Every child needs a cheering section, someone to be in their corner in good and bad times. They need someone to help them deal with the hurt and rejection. They need to feel like they belong!

  6. Adopting from foster care can include coverage of expenses including providing for another child in the home. The child’s healthcare and even college expenses may be covered.

  7. The government must provide more services and help in reuniting children with their parents or finding someone to adopt them. Children want to be adopted and develop stability in their lives.

  This information is taken from an article by Mary Lee, the National Coordinator for YVLife Set, a program for Youth Villages, and a former foster child herself. www.YVLifeSet.org

 

 

  B. Here are 4 things hard to understand unless you grew up in foster care—these come from foster kids:

  1) You are supposed to fail.

  ADHD is three times more likely. Developing brains can’t cope with the trauma of separation from parents and trying to adapt to often multiple sites where they grow up is extremely difficult with mental liability.

  Social workers burn out so fast when they contend with all the chaos of the system. Retaining good personnel is part of the problem.

  Families of some type are crucial for the greatest chance of a child growing up well balanced and able to function normally in society (but there are no guarantees, as we all know examples of those who choose the wrong path, often associated with drugs and prostitution). 

  2) Parents are impossible to replace

  Foster parents are usually not thought of as “real parents” unless they entered the system very early. If there are great memories of parents, even in a difficult or even troubled environment, still leaves kids with an imprint of them. That is not to say that foster children and foster parents cannot bond and have a very fruitful family experience.

  3) Lonliness is inevitable

  Even coming from a broken home, it is the only home they know. Everything else is foreign, and with it, comes extreme skepticism. Even when showered with a good environment, every gesture is viewed with suspicion. Believing in those who took a child away from their biological family even if absolutely necessary, creates an extreme incapability of trusting them especially if being tossed from house to house, which occurs most often. It is easy for them to withdraw and prevent themselves from accepting real and genune love and caring. Ultimately, many theorize they are the real cause for being sent to foster care, which creates lonliness and isolation.

 

  4) Love is so incredibly powerful

  Love is nourishment for the heart and soul. No matter how withdrawn, angry, and divisive a child may appear, they still want and need love. If they don’t get it from parents and siblings, they might find it in gangs, prostitution, and other pseudo-family settings.

  Self esteem is rapped up with love of self and that love must begin from parents. Emotional neglect might be the greatest form of abuse. However foster care can provide the needed ingredients to overcome if it goes well. “Clicking” with the right family may be difficult, but can be very rewarding when it happens. A foster family that can validate that love connection may be the only ingredient needed for success. Even if that situation did not ultimately work out, that feeling of love and self esteem can be carried forward.

This information came from a blog by Jasmine Doris

 

 

C. Types of behavioral and emotional issues

  The emotions can range from violent tantrums to sensory self stimulation in times of stress and excitement. Older children may have difficulty in understanding other people’s emotions.

  These children often may seem assertive, aggressive, or insensitive to the needs of others and have trouble understanding other people’s nonverbal social emotional cues. Foster children may be very controlling of their foster parents and siblings while very flexible with teachers, peers, and therapists and is very confusing to others.

  Special psychologists may be needed to address attachment related behaviors.

  Other children will suffer from classic PTSD reaching back to times of abandonment, or experiences at an orphanage settings.

  Pediatricians and primary care doctors must be aware of the implications of foster care in any form,including the consequences of abuse and neglect, challenges of attachment to caregivers, and the child’s response to stress when it occurs. Parenting classes for everyone is valuable but certainly for people willing to foster children, God bless them.

 

This completes the November, 2021 report.

 

Next month, the December report will include:

1. COVID-19 updates/Flu

2.Headaches

3. Alzheimer’s update; how the brain rids itself of metabolic products and how sleep plays a major role

4. Heel pain

5. Drug costs

 

Have a great Thanksgiving, and enjoy your friends and family. As always, stay healthy and well, my friends, Dr. Sam