The Medical News Report

December, 2021

#119

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

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Subjects for December, 2021:

1. COVID-19 update-natural immunity, more on long term COVID; comparing vaccines and boosters; origin of virus; now Omicron variant

2. Headache-diagnosis, workup, and treatment

3. Heel pain

4. Drug and healthcare costs in the U.S, Medicare prices rise--prices still going up

The Reason for the Season

Happy Hanakkah

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.

Thank you, Dr. Sam

  GOD BLESS OUR MILITARY AND VETERANS. As a veteran, I am humbled to have served in the USAF during the Vietnam War. We owe these heroes our love, respect, and always thank them for their service. As strong military is the best way to deter wars. Support veterans and our military

1. COVID-19 updates and political pressure; now Omicron

A. Omicron Variant

The pandemic is coming under control thanks to those who have been infected, those who have been very protective, and those who have been vaccinated. But just when most of us thought we could breathe easier, here comes another variant (with milder symptoms). We all must understand this will continue as long as we have COVID-19….(and it is not going away until everyone in the world is vaccinated, which will never happen. The thought of eradicating the virus is unsound, understanding viruses). CONTROL NOT ERADICATION!

  The new variant of concern (Omicron), first reported in South Africa, but already in several countries and probably already here, has shown some ability to replace the delta variant in unvaccinated individuals in South Africa.

  There is already a ban on travel from the Southern African countries as of 11-29,2021.  Other countries (EU, UK, and parts of Asia) have done the same unfortunately with financial disastrous consequences.

   The new governor of New York has cut elective surgery in NYC in response to the potential of this variant filling hospitals without a shred of evidence to back up such a questionable move. We already know the incredible damage that did the last time elective and non-emergent cases were delayed.  

  There is no information on how effective the vaccine will be against Omicron, but the chief of Moderna vaccine stated that it is likely will not be as effective, spurring grave concern with little scientific proof. However, Israel tested several people with the omicron variant with Pfizer and Moderna, and it was considered good protection. Of course, these vaccine companies will come up with a new vaccine to include Omicron, and keep the money rolling in. But don’t wait to get vaccinated or get a booster, waiting for some future vaccine or booster that is directed toward the omicron variant.

  We will be on standby til we find out its impact on those who have been fully vaccinated, those who have not, and those with natural immunity.

  There is some evidence that there have been fewer previously infected individuals with breakthrough infection than those vaccinated from the delta variant, but our country does not even recognize natural immunity recommending 2 doses of Pfizer and Moderna (and 1 for J&J).

  There are plenty of studies now to prove even better immunity for those with natural immunity. To be fair, there is evidence that if these individuals are vaccinated, they have increased antibodies, but no one knows what level of antibody is sufficient to protect us.

   Surveillance of potential Omicron cases will need to include all 3 groups (previously infected, vaccinated, and unvaccinated), but will the CDC do that? Of course, immunity wanes after 6 or more months in all cases, so we will need to know when these participants in studies were infected and vaccinated. 

  The doctors in South Africa state that Omicron cases have been very mild, with minimal cough, headache and muscle ache for about 48 hours.

  Of course those very vulnerable to infection will be more at risk for a more serious case, especially if transmission is high. We will know something about transmission, virulence, etc. by the time you receive this report.

  FACT NOT FEAR!!!

  It is recommended by the feds that everyone in close groups wear masks inside, a very unwelcome recommendation during the holidays. Those who are easily scared will be more fearful, and the rest will wait and see but all should be as cautious as possible. This is no time to let our guard completely down. The flu is around too.

  The Omicron has over 50 mutations, with 32 which affect the spike protein, the site where the virus enters the ACE-2 receptor, while the delta variant had 10 mutations affecting the spike protein. Does that mean it is stronger? Not necessarily!

  Scientists in labs will use human serum injected with vaccine to see if the new variant is killed, and we should know that information by the time you read this report. For now, we should be careful and be glad we have been vaccinated and boostered if indicated.

  Experts point out that as the same virus continues to mutate, notoriously it becomes less threatening. The number of mutations does not necessarily correlate with severity. Studies have proven that natural immunity as it wanes can be reinvigorated with just one dose of the vaccine, but that science is not mentioned by the CDC.

   No one’s immunity is going to stay high for over a year. We still don’t know the level of antibody necessary to be protective, and that is a shame. So all need a booster if in the categories specified. The FDA has now recommended boosters for all with no science to back up that decision, but with the Omicron variant, even a booster may not be as effective. We just don’t know yet.

  Currently, if you travel internationally, you must get a test 24 hours before going to the airport, regardless of vaccination status, and when the individual returns, get a test within 3 days and if not vaccinated must be quarantined for 5-7 days, if a returning American. Foreigners must be vaccinated and tested within 3 days.

  The first case has been tested positive in California from South Africa, had been vaccinated and had mild symptoms just like most vaccinated people do with a break through infection.

  We wait for how significant the variant really is.

  While all this concern is going on, the southern border continues to have thousands of unvaccinated and untested people being admitted into our country daily (2.1 million this year). Hypocrisy!

  As we wait for more information, more sequencing of people’s tests is necessary, so we will know where Omicron goes in the U.S. and provide that information to state officials. A PCR test does not give any information about variants. It requires a special test performed by scientists.

B. Single blood Test for immune levels; home tests still not the best

  There is a new study with the first single blood test with results not only for the neutralizing antibodies, but also the memory B cells. I hope that will be available very soon to the public.

  We still don’t have much of a reliable home test as most of them have a fairly high percentage of false negatives.

C. Good news about cases in U.S.  

  Here are the USA Facts with the stats since April, 2020 showing new cases per day. Note the influence of the Delta variant, late summer and early fall, but now a significant drop. Lets be thankful that we are seeing fewer cases with fewer hospitalizations and deaths.

The delta variant changed the complexion of this pandemic this past summer. Lets not “jump the gun” on the new variant. The vaccines have proven to be very effective for the delta variant, but transmission jumped up greatly especially in the 18-40 age group as they returned to work or play this summer and reduced their protective techniques. It was a good reason to get vaccinated, and if the younger population had agreed to have been vaccinated last spring, the delta variant would have been much less of a factor.

   However the Antivaxxers, the younger people still questioning safety (especially those wanting to become pregnant or pregnant), and those fearful from hearsay (especially persons of color) still represent over 20% who will not get vaccinated.

  Those who have previously tested positive should either get vaccinated or at least get a booster, as mentioned above. However, with the Omicron variant looming, more individuals will get the vacccine plus pharmacies are happy to give it to everyone ($$$), therefore, expect a high number seeking another shot.

D. Financial distress and employment effects

  Have we forgot the federal government has spent well over $1.7 trillion on COVID-19 including paying for vaccines, inpatient and now outpatient treatments for those infected?

  Insurance companies have been hit too, and you will see rises in premiums. Medicare premium Part A (from $148.50 to 170.10) is rising as well. Patients are now paying for services covered last year.

  In March 2020, Congress allocated $178 billion Provider Relief Fund to offset unreimbursed expenses for COVID treatment. As a condition for these funds, hospitals were prohibited from sending bills to patients for out-of-network care. The U.S. prepurchased vaccines before they were even available with no cost to patients. Hospitals had to state that every case who tested positive for at least 2 weeks once in the hospital died of COVID, even though in thousands of cases it was another disease that actually caused them to die.

  However, currently these temporary financial coverages have been reduced or expired. Insurance companies, by May 2021, began expecting copays from patients that run between $38,000 and $73,000. This has hit poorer Americans hard.

  Uninsured individuals are still being covered by the federal government, reimbursing $5.9 billion for testing, $3.6 billion for treatment, and $573 million in vaccines.

   As 2 million illegals have crossed our borders in 2021, they will get to enjoy our tax payor dollars as well. Medical bankruptcy is soaring. Those with long term COVID symptoms will be hit the hardest. 23% of hospitalized COVID patients have exhausted their savings after hospitalization.  JAMA, November 16, 2021

  Vaccines are still be covered since they were prepaid in early 2020.

  Add the stress to Social Security (55 million Americans currently receive SS and survivors insurance), by 2033, beneficiaries would receive only 76 cents for every dollar they should be receiving. Medicare Trust Funds will run out in 2026, but still be able to pay 91% of Part A and the other parts unaffected. AARP November Bulletin   

  OSHA* declared that those unvaccinated created an emergency health hazard and mandated the vaccine to all businesses with 100 employees or more, now blocked temporarily by the courts, as unconstitutional.

*OSHA=Occupational Safety and Health Administration

  Federal employees including the military were mandated early on and have until January 6 to be vaccinated, even without an alternative of weekly testing.  

  Thankfully mandates are blocked by the federal government, however, private businesses still have the power. Even healthcare staff mandates are being blocked, which is more controversial, but certain hospitals could demand it.

  Mandates would force thousands of people to be fired, quit their job, decide they don’t want to work for a variety of reasons, and continue to create a greater crisis in the shortage of products, lack of staff to keep businesses open, fewer healthcare staff, and deterioration of medical conditions for millions. Some groups want America to fail, and we must fight their attempts to push us toward socialism, which will destroy our current healthcare system.

  With 2.1 million illegals here this year (and 600,000 got aways), and legal immigration, we don’t have the medical manpower to withstand such a move. Burnout and retirement is at an all time high, so beware.

E. Drug crisis and the Pandemic 

  We now have 101,000 overdose deaths this year from fentanyl (thanks to China supplying the fentanyl to the cartels in Central America) who are walking back and forth our open southern border. Imagine the number of addicts who have been made worse with the pandemic, previous lockdowns and spiraling unemployment. The healthcare costs are huge, and yet our federal effort against mental illness continues to suffer.

F. Who is eligible for the booster dose of COVID-19; immune-compromised need extra dose

  Booster doses of Pfizer vaccine were approved originally for those with vulnerable medical conditions 18 and over, and the science supports this. However, without  consulting their expert panel advisors, the FDA and CDC decided to approve the booster for anyone 18 and over now for all 3 vaccines, if the individual is fully vaccinated.  Of course, the timing of Omicron was perfect to help the cause of boosters. They are still insisting on those with natural immunity from a prior infection be fully vaccinated. Science says one dose will do.

  There is no scientific proof healthy individuals under 65 to 18 will benefit from a booster dose. For Pfizer and Moderna, an individual can get the booster after 6 months since the last vaccine, and 2 months for J&J.

  Early information from Israel reports good protection for the vaccines from the Omicron variant, however, it is a small sample of people, but encouraging.

  The revenue gained based on these non-scientific decisions concerns me, and wonder if the lobbyists for Big Pharma are filling the pockets of our Congress. The non-scientific decisions fuel the hesitant to refuse the vaccine, but may be countered by the new variant if it is aggressive.

    It is sad that the FDA and CDC are NOT independent agencies, completely segregated from federal pressures, and always base every decision in sound peer reviewed, solid scientific research. Of course, emergencies are an exception as in any medical issue.

  Many of those immunocompromised patients were advised to receive a “third dose” as early as 1 month after their second dose (or first dose of J&J), since their immune response from the first two were sometimes insufficient to protect them as well as healthy individuals. Now they can still receive a fourth or booster dose 6 months later.

  Mixing and matching vaccines is now acceptable (they have been mixed for months in many parts of the world), however, I am aware of some physicians recommending only a half dose of the Moderna booster, since it has had more side effects than the other two U.S. approved vaccines. Scandanavian countries do not allow Moderna in individuals under 40, because of the higher risk of myocarditis, etc. Talk to your doctor about this issue. Also check with the facility where you plan on getting a booster, so you know what vaccine they are using.

  Many internet sites state that the booster is a different shot than a regular dose of the vaccine, but the only possible difference would be a revised dose for the more recent variants.

  Some experts are proponents of those previously infected (with natural immunity) being able to get a booster (after 6 months) and then considered fully vaccinated.

  No vaccine or infection is going to protect for more than a year, so boosters are certainly indicated for all those with any vulnerable condition or older age. This is based on waning antibody levels after 6 months, however, anyone can get it now with FDA approval. Such mixed messages have created confusion and more hesitancy than otherwise.

G. Natural immunity? Preliminary reports are now available; negates the mandate

  Absence of good data for the naturally infected has been very frustrating. Now, we are finally getting some valid science based reports that have been long overdue.

  The CDC estimates 1 in 4.2 cases have been reported. The University of Texas Southwestern estimates 71 million Americans have been infected. Add the number of vaccinated (60% have been vaccinated; 80% have had one dose), and we will continue to see a decrease in case numbers and deaths without a mandate.

  Over 5 million U.S. residents have been diagnosed and 475,000 have died since the beginning of the pandemic. It has been a long pandemic, but continued increase in  immunity from boosters should diminish the pandemic.

  Although in preprint form, MedRXiv medical journal endorsed by Yale and the British Medical Journal have just reported that previously infected individuals with natural immunity have equal immunity to those fully vaccinated.

  9 studies were reviewed and all revealed statistical equivalence between the vaccinated and those who had a previously proven infection with COVID-19. They reported those with healthy immune systems had reinfections 0-1 infections per 100 people. And Israel even reported greater protection than those vaccinated.

  Studies who vaccinated previously infected individuals showed only a modest increase in immune response since the protection from natural immunity was already quite good, especially in those with a healthy immunity.

  The Cleveland Clinic followed 52,000 patients and found equal protection in both groups, and the investigator did not feel vaccination afforded any benefit. They reported safe protection for at least a year after the infection.

  This study would not apply to immunosuppressed individuals. They still need vaccination including possibly 3 doses and a booster, which is discussed below.

  The latest JAMA published a study from Qatar following 99,226 individuals and found that those with a prior COVID-19 infection who had been vaccinated had a lower incidence of breakthrough infection (43) than those who had been vaccinated and had a breakthrough infection (368). This tells us 2 points of information—if previously infected, the antibody levels were higher than an uninfected person and when the vaccine was given them, and their breakthrough infections were fewer by far than those who had not been infected and had the vaccine.

  If healthy and younger than 65, it would be reasonable to feel that a bona-fide infection would protect individuals enough unless in a job that exposed them greatly.

  These studies negate the necessity of mandated vaccination for those healthy individuals previously infected. All vulnerable individuals regardless of age should be vaccinated. The other factor is transmission, and that is the real reason they support universal vaccination. Of course, the Omicron variant is an unknown factor for now.

  The catch is, many who had a mild infection were never tested, but a positive PCR test (and antigen home tests) are all that is needed to prove infection. However, there is one study that demonstrated lower immune levels in asymptomatic and very mild cases than those with moderate and severe infections. This makes the decision a little more difficult.

  The controversy will continue along political lines, and the report I cited above is in preprint submission to an internet journal. It has not been formally published or peer reviewed. It does agree with reports from Israel that cited data that those with natural immunity have equal or better immunity than those vaccinated.

  Of course, if these people get vaccinated, they will have even higher antibody levels but that is no proof that means there is better protection.

   A study in Belgium compared Moderna with Pfizer, and found that the Moderna vaccine provided better antibody levels in both unvaccinated and previously infected volunteers (also more side effects). The antibody levels were much higher in those previously infected with the virus. The healthcare participants averaged 45 years of age with 73% women.

  The Moderna vaccine has been noted to provide higher antibody levels more but both vaccines were in a very effective range and prevented symptomatic disease in high percentages for both.

  In this comparison study, those previously infected had 9x higher antibody levels than those never infected who had received both vaccines.

  Johns Hopkins has been performing their own research on previously infected individuals to answer these very pressing questions, and the results will be forth coming in the next few weeks according to Dr. Marty Makary, Public Health Department of John Hopkins, a leading facility since the beginning on all aspects of COVID-19.

   A Quebec study reported that older people over 50 who were infected previously had higher antibody levels than those under 50 who had been infected and were eventually vaccinated. This contradicts opinions by experts that older people can’t mount as an effective antibody level.

  Many European countries require certificates to travel or enter public places, but allow a proven history of COVID infection or vaccination to get a certificate. MedPage Today, Nov. 2, 2021

H. Children 5-11 now approved for vaccine

  Our children (and parents) have suffered greatly from at home schooling, and we still have states keeping kids at home. Will vaccines make a difference?

  Parents are waking up to negative teaching techniques installed in our schools and now are fighting the curriculum and school boards with strong voices that their opinions count at school and in the 2022 elections. They will also have strong feelings about the vaccine, the FDA has approved (Pfizer) for children 5-11 at a 1/3 dose level using the emergency use authorization route for 28 million children.

  Eligible kids will get 2 doses three weeks apart using 10mcg. dose and has been proven the vaccine keeps the children out of the hospital in 90% of the cases.

  According to a Kaiser Foundation survey, about 25% will have their children vaccinated right away. The other 75% are split between those wanting to see how children fair with the vaccine and those who will not allow their children to be vaccinated. MDlinx.com, November 1, 2021

  70% of children this age admitted to the hospital have a significant underlying medical condition, and it is these kids that certainly should receive the vaccine. Asthma is a key illness leading to hospitalization among other chronic conditions. Otherwise the risk of severe disease and death is less than 0.025%, the same as flu.

  However, the CDC insists all children should be vaccinated because of the delta and now the omicron variant, there will be pressure to comply.

  Many parents are concerned with a vaccine that has no long term data on safety. While, millions of doses are being sent out to some pharmacy chains (Walgreen’s), pediatricians, etc., the early evidence is clear that it is quite safe, and there is no evidence of fertility issues in babies born with mothers who have been vaccinated. But, this is early data for now.

  Also the concern for myocarditis continues even more so with Moderna, mostly 18-40 year olds. It is not approved for 5-11 year olds.

  Only 2000 children were studied by the CDC from 5-11 to determine the need for a vaccine. The study did show vaccines are better than no vaccine, but the number of infected cases in the non-vaccinated group was only 16 and the vaccinated group 3.

  This is too small of a sample to determine value, according to Johns Hopkins Medical Center, Department of Public Health. This leaves parents questioning whether they want to allow their young children to be vaccinated, when the risk of serious disease is so small and even transmission is lower. Disney won’t let any children on their cruise ships without being vaccinated, but was blocked by Florida Governor DeSantis.

  In fact, a Swedish study followed 1.8 million children and teachers who kept schools open even without masks or social distancing, and had no childhood deaths. The incidence of COVID infections in teachers was lower than most other professions.

  CDC stats on children and cases of COVID-19 are seen below:

The answer the FDA gives for recommending the vaccine is that even though children are extremely unlikely to have serious disease and almost never die, they can transmit the disease (less than adults). However those with  serious underlying disease (diabetes, obesity, lung disease, cancer, immunosuppressed, etc.) are not free from risk, according to the head of the Pediatric Academy,  Only 9% of the cases of COVID occur in children 5-11.

  Only 146 children died in the U.S. to date according to the CDC website.

  In another report 66% of parents polled are concerned about fertility issues in their children, say they want longer term studies before they decide.

  Missing school with any illness is a concern, but quarantine has become a reality even if a family member is diagnosed. And finally, it protects older people from exposure of an asymptomatic infected child which often happens. Do healthy kids need vaccinated? I am in support of it, but mandates have no place in this discussion.

I. Mandates for companies with 100 or more employees put on hold by courts

  A federal appeals court on November 11 called the mandate for companies “staggeringly overboard”, according to msn.com. The court ordered the mandate blocked and will likely go to the Supreme Court for the ultimate decision. These companies were required to get their employees vaccinated or tested weekly. They were told they could be fined $14,000 per incident under an emergency rule by OSHA (Occupational Safety and Health Administration) starting Jan. 1, 2022. This authorization was requested by the current administration as a health hazard, but vaccines have never been mandated through OSHA, and are currently blocked by the courts.

  The 3 judge panel at the federal level called the rule “fatally flawed” far exceeding OSHA’s authority. The threat of decimating the workforce is real concern. Thankfully mandates have been delayed until after Christmas.

  Currently the State of Oklahoma has blocked vaccine mandates on national guard members.

J. More information on the origin of COVID-19

  I have reported on the very likely origin of COVID-19 originating from the Virology Institute of Wuhan, China. I have provided details about the fraud in the original publication from the lab, changing the sequence of the RNA coronavirus. Still extremely controversial, is the origin from a virus from a bat or sequenced in the lab and accidentally leaked (which is not an uncommon occurrence in labs, I am sorry to say).

The NIH (the U.S. National Institutes of Health) acknowledged they have provided grants to the this Wuhan lab for research on coronaviruses, through a non-profit organization Eco-Health. Dr. Fauci, head of infectious disease at NIH denied under oath any NIH funding regarding “gain of function research”, when the organization contradicted him.

  Because the Chinese Communist Party’s Viral Lab refuses to provide any information, and has blocked the U.S. any access to their records, we likely will never have a clear answer. The WHO had a photo op visit of 2 hours with no results.

  For over a year, the Congress refused to investigate this issue. They finally created a small investigation group that found the evidence was more convincing that the lab created COVID-19 rather than originating in nature from bats. With the leak of the studied infected animals, which were sold by employees, they found their way to the seafood stores.  

  There is still no direct proof without Chinese cooperation. In fact, there has been an exhaustive amount of research looking for the current COVID-19 in any animals throughout the world, and this particular COVID-19 virus has not been found in one animal in nature.

  188 different animals have been tested with no COVID-19 virus found. Other coronaviruses have been found, but the viral sequencing is different, and it is known that the bat coronavirus is hard to transmit to other species. Why would they resequence the virus to make it more easily transmittable to humans??

  Keep in mind, it is not the Chinese people that should be blamed, only the Chinese Communist Party that runs the Wuhan lab, who will not cooperate with any country to analyze the records (but they probably do not even exist anymore).

  When will the next virus leak out of a lab and create another pandemic?

   One final note to raise the awareness of what China is doing to undermine the Western world. A Chinese professor at the University of Copenhagen, Denmark, conducted genetic research with the Chinese military without disclosing it to the University.

  Having told Reuters, this is the latest example of how the Chinese are pursuing military technology in other countries tapping into Western technology in a strategically sensitive area of biotechnology using monkeys to study different drugs to prevent brain damage with high altitude, a high priority for Chinese military who are operating at bases on their borders of other countries (Himalayans). Combining civilian and military research have created great concern in the U.S. Not a word regarding the origin continues from this administration.

Reuters, Nov. 19, 2021 in Medscape.  

K. Quick notes on important COVID issues

    1- Inhaled corticosteroids for early in the disease

  Corticosteroids were considered a possible help in reducing progression of COVID pulmonary symptoms. However, a Canadian study compared test positive symptomatic participants in the first 3-5 days with a similar group with placebo, and found no difference in respiratory symptoms or progression in COVID disease. British Medical Journal pre-published data reported in MDlinx, November 4, 2021

  It was reported that there is still promise in its value in older patients with pulmonary underlying disease who are not using inhaled corticosteroid products currently when infected. It’s always up to the doctors and the patients.

     2- Why get the flu vaccine?

  Last year the incidence of flu was very low (lowest since 1997), because the preventative steps for COVID were applicable to any virus. In fact, public health officials are concerned that many viruses may become more prevalent this winter because of the lack of exposure especially from children, the super-spreaders of flu but NOT COVID-19.

  Natural immunity from one year to the next has been ongoing, but with isolation, sterilization of surfaces, proper hand washing, social distancing, etc. that is not happening near the extent pre-pandemic.

  There is still little knowledge the interaction of these 2 viruses. There has been a lot of speculation, but no answers. However, the complications of both viruses overlap considerably, including neurological issues, and the symptoms overlap as well. It is not known if individuals are actually getting infected from both, however, the vaccines can be given at the same time, according to the CDC.

  The viruses affect adversely the same vulnerable groups. The CDC recommends all 6 months and older get the annual flu shot. However, if COVID infection is suspected, a flu shot should be delayed until there is full recovery or the symptoms pass from some other cold virus. Testing would obviously be indicated. All should be vaccinated now!   MDlinx.com, October 29, 2021

  Just because COVID-19 is dropping rapidly, the same precautions should be continued over the winter months to prevent all communicable diseases, and we should benefit with fewer sick individuals from these common viruses.

     3- Follow up on future vaccines

  Last month, I discussed the future “dream vaccine”, but further discussion is appropriate regarding just how these vaccines will improve protection for future variants.

  A study by the Australian Garvan Institute of Medical Research revealed a guide to developing future vaccines that prevent the coronavirus from infecting cells and are more resistant to future variants. They are working on vaccines that target different areas of the virus’ surface that are unlikely to mutate and develop features that could block the virus’ ability to infect cells (at the ACE2 binding site). These vaccines hopefully will not have to be updated and lead to better control of COVID-19, according to the institute. MDlinx.com, November, 2021

     4- Oral pill to stop COVID-19; Regeneron protection lasts at least 8 months

  Merck (molnupiravir) requested FDA approval, which is an oral pill to stop replication of the virus. Their research reports an 89% protection from hospitalization and severe illness. However, in 13-10 vote, the FDA narrowly approved the oral pill for adults with high risk. There assessment changed the protection down to 48% and are only preventing hospitalization without mention of helping to prevent or reduce symptoms for outpatients, which Regeneron does accomplish. There are other monoclonal antibodies seeking approval. Vaccination is the answer and not dependence on an oral pill or IV infusion for the unvaccinated.

  Some advisors suggest that a  pregnancy test should be ordered (and negative) before a prescription of this antiviral is written. Safety is also a concern needing more study (affecting DNA).

  There are other companies--Pfizer (paxlovid), coming forward seeking approval soon that may be more impressive.

  An antidepressant, fluvoxamine, has been found to reduce infection severity as well, but is not FDA approved for COVID. I just wanted the readers to know it may get around inner circles about its value. I know of no attempt to seek FDA approval as yet. NIH website

  Regeneron, the monoclonal antibody IV infusion given to prevent or protect individuals from hospitalization has now been proven to last at least 8 months after the infusion.

  Still, an oral pill is very attractive in the real world for its practicality.

Medical Express, November 8, 2021

Medpage Today, November 30, 2021

     5- How the Delta variant is tougher!

  We know that viruses mutate constantly, and it is their adaptability that keeps them viable. The Delta variant had a particular effective mutation from the original coronavirus. But it was not known why it created a higher transmission rate and a higher viral load when it attached to the nasal lining to travel down to the lungs. The answer is a particular glycoprotein in the spike of the virus’ surface. There is a particular N-terminal domain that enhances cell binding, and a receptor binding domain that engages with the ACE-2 receptor on human cells.

  Antibodies against COVID-19 latch onto to specific sites on that domain. The delta variant mutate that site and receptor binding domain to evade the antibodies trying to bind on that domain site. This occurs in the delta and kappa variants, according to an article in Science magazine, from the University of Washington School of Medicine. Of course, they will be analyzing the omicron variant as well.

  The neutralizing antibodies lost their ability to neutralize these two variants in a significant number. The J&J vaccine lost 50% of its ability to bind this domain thus allowing infection. Pfizer and Moderna were much more resistant to the Delta variant mutations.

  Why do we not have a delta variant vaccine? That is in clinical trials, when the vaccine is exactly the same with a sequenced addition of delta. This should have been FDA approved on an emergency basis, and it was not!!! I think people should think about that for a minute. We are still using vaccines from the original batch created in 2020.

  6. The FDA continues to discourage the use of antibody tests for knowledge about immunity protection

  Antibody tests commonly sought by the public to verify the level of protection from COVID-19 are very popular, and were approved initially as a test that could be marketed. On May 19, 2021, the FDA stated, “results from currently authorized SARS-CoV-2 antibody tests should not be used to evaluate a person’s level of immunity or pretection from COVID-19 at any time, and especially after the person received the COVID-19 vaccine”. It also should not be used to decide if a booster is necessary. It should be used as either a positive or negative test for antibodies, and that tells us nothing.

  These tests do test for all antibodies including some neutralizing antibodies, the most important killer of the virus, which makes the test a problem. Testing neutralizing antibodies is complex, stated in an article in the recent JAMA, Nov. 9, 2021

  Dr. Paul Offit, Director of the Vaccine Education Dept. at Children’s Hospital in Philadelphia argues blood testing for antibodies should not be used. The test does not measure memory B cells, which aren’t making antibodies unless challenged by the infection. However, research has proven memory T and B cells last about 6-8  months but are not included in these tests. It is this information that led to recommending boosters.

  He also stated that the levels of antibody continue to prevent more serious disease, but boosters will help prevent mild and asymptomatic disease. It will be months, before we find out if these boosters really drop the infection rates, but truly it is the hospitalizations we are trying to prevent.

  The public was led to believe we needed to eradicate this disease, and it is just not the correct way to approach….control not cure is the standard statement. We will have an endemic, just like the flu. JAMA, Nov.9, 2021

 7. COVID affecting smell and taste in more patients than thought

  A recent study estimate 1.6 million individuals are suffering from prolonged smell and taste disorders from the virus invading the olfactory cranial nerve above the mucous membranes of the nose. The symptoms are lasting 6 months or longer. This was cited in the JAMA-Otolargnogology and Head and Neck Surgery.

  While 95% recover by 6 months, 5% persist in this very significant quality of life issue. This means hundreds od usually younger individuals with mild disease are affected.

  This issue presses the need for advances in more research for a nasal spray to prevent viral replication, which is under way.

  This viral disorder adds to the large number of patients who had olfactory disorders prior to the pandemic (13.4 million in mostly individuals 40 and older.

  Smelling familiar foods daily actually has been found to reduce the disorder’s severity over time, according to the authors.

  Having worked up patients with smell and taste issues includes ruling out a tumor on the olfactory nerve, sinusitis, nasal polyps, head injury, other viral infections, early warning signs in neurodegenerative disoerds including Parkinson’s and Alzheimer’s disease, and aging.

  According to the NIH, 25% of the population above age of 40 have some form of smell and taste dysfunction.

  Apparently, initial statements from South African doctor have not seen the Omicron variant with smell and taste abnormalities.

  There is no direct treatment for this disorder, although I prescribed zinc, which seemed to help, but no scientific proof its help. Recovery does occur in a high percentage after ruling out treatable causes. NIH, 2013; Medpage Today, Nov. 18, 2021, Mayo Clinic

8. Counterfeit masks abound

  As stated before the only masks that are effective are surgical masks and N-95 masks. K-N-95 masks are sold everywhere and analysis of these masks continue to show a higher % of fake masks, not able to protect the mask wearer. Most of those purchased through Amazon are sent to fake mask vendors, according to the New York Times (11/30/21).  

2. Headaches—diagnosis, workup, and treatment

A. Classification

   Headaches affect us all at one time or another, but  chronic, recurrent headaches affect millions.

  The definition of a headache involves the neck secondarily or as a cause. The classification includes 13 groups of different types of pain in the head, eyes, and neck.

  The brain tissue and the skull bone have no pain fibers, so the pain comes from the surrounding structures covering the brain (meninges), the muscles, fascia and ligaments under the scalp, the sinuses and mucous membranes, the jaw joints, the ear structures, and the vessels throughout the head and neck.

  To be complete, the nerves that travel out of the brain, and cervical vertebrae must be included. When a specialist sees headache patients, the history and physical exam usually narrows the focus of concern rather quickly. Primary care, pediatricians, internists, neurologists, and otolaryngologists  (Ear, Nose, Throat, Head and Neck surgeons) all see these patients routinely. 30 years of my practice included hundreds of such patients, and requires a thorough exam, lab, and imaging studies. 

B. Categories of headache (2018 Update by the International Headache Classification of Disorders)

  There are 2 major groups of headaches—primary and secondary. The search for a source of headache begins with differentiating primary from secondary headaches.

  Primary headaches include-- migraine (12%), tension type (38%), trigeminal autonomic cephalgia including cluster headaches (1%), and others. These are not caused by an underlying medical condition.

  Secondary headaches occur because of some underlying medical condition, such as vascular, cancer, infectious, or an intracranial issue.

There are many structures in the head and neck that are pain sensitive including facial and neck tissue, cervical vertebrae, intrancranial arteries, venous sinuses that drain blood from the brain, the meninges (layers covering the brain), and select cranial nerves (V, VII, IX, and X). Head pain from any of these sources can be caused by pressure, traction, irritation, or inflammation from any of these structures.

  Headaches often release vasoactive and inflammatory chemicals including calcitonin gene related neuropeptides by nerves that are affected. These neuropeptides are the target for many medications to prevent and treat some of these headaches.

C. Diagnostic Approach--Workup

   Any workup begins with a thorough history and physical examination, as mentioned. Defining the character of the headache, location of the pain, onset, pre-headache symptoms, length of headache, associated symptoms, and symptoms after the headache all are critical in pointing to a diagnosis.

  The type of pain (dull, sharp, throbbing, etc.) is critical along with associated symptoms (photophobia-visual symptoms, nausea and vomiting, phonophobia—abnormal auditory sounds such as buzzing, ringing, loss of hearing, etc.), movement, underlying conditions, and for women during menstrual periods, and specific facial patterns of numbness and or pain. Tearing may occur with redness of the eye, drooping of the upper eyelid, constriction of the pupil, or nasal congestion may all point to a cluster headache.

  Transient neurologic symptoms can often accompany a migraine (aura), which will be described later under the migraine section.

  Persistent neurologic symptoms for several hours or days point to a cerebrovascular incident (stroke) or neoplastic cause (brain tumor). And those with an aura (symptoms prior to the event) prior to migraines have a higher incidence of stroke.

  Sudden headache at maximum level points to a possible Berry aneurysm, a subarachnoid hemorrhage from a vessel in the brain.

  Transient paralysis of one or more limbs may point to a transient ischemic attack (TIA).

  New headaches should be evaluated for secondary causes requiring an array of diagnostic tests.

  New onset headaches in individuals over 50 years of age may be due to a brain tumor or giant cell arteritis.

  Brain imaging may be necessary in patients with one-sided headache or those suggestive of cluster headache.

  EEG, spinal tap, brainstem audiogram, and blood tests may be ordered based on the history and physical exam.

  Laboratory evaluation for underlying diseases will be necessary and information about past medical conditions and family history must be questioned.  

  Now a look at the most common diagnoses made:

D. Types of headaches-Migraine Headache

  Migraines are a neurological disorder. It is typically characterized by severe, unilateral, throbbing headache lasting 4-72 hours that is aggravated by routine physical activity accompanied by photophobia (visual symptoms), and an aftermath of usually fatigue once the headache abates. 

  Migraines occur in 17% of women and 6% in men. Most have episodic migraines fewer than 15 days per month, although there are 3% who have chronic migraine.

  Estrogen levels in women play a role, more commonly starting when periods begin in youth, and estrogen containing contraceptives should be avoided especially in those who have associated auras. About 25% have auras. Women ages 20-44 have 2.5X greater risk of stroke.

  Pregnancy usually reduces the incidence of migraines, but treatment may still be required.  

   --Understanding migraines   

  The etiology of migraines has been back and forth from electrical stimulation starting in the brain to a peripheral nerve outside the brain. The latest thinking is migraines start with an electrical firing (cortical spreading depression) in a part of the brain, which communicates with the brain stem. From there, the brain stem communicates with a part of the brain (thalamus), which relays a signal to the sensory cortex of the brain. This causes a reflex stimulation of pain fibers that fire on the covering of the brain and vessels. These vessels constrict before they dilate. With the dilation, the pain fibers are stimulated causing the headache. This is the pathway in the brain.

The same inflammatory chemicals in migraine are the main culprit in COVID-19 (cytokines and chemokines) that incite neural stimulation.

   --Migraines-with and without aura—the old nomenclature defined those with an aura as classic and those without aura as common, no longer used.

  15% of the population have migraines. Recent research has proven that these headaches are caused by altered brain electrical activity as discussed above.

   These migraines are usually one-sided (but can be both), pulsating in character, lasting 4-72 hours, usually associated with nausea and vomiting, photophobia and phonophobia (increase intensity of lights and sound) with the headache being aggravated by activity.

  Patients frequently seek a quiet dark room when their headache is severe to diminish any outside stimuli.

  --There are 4 phases of a migraine:

  1. Prodrome---symptoms prior to headache, hours or days---altered behavior, mood, depression, bowel changes, changes in smell, or noise, cravings, stiffness of the neck, euphoria, or fatigue. This may occur hours or days prior to a headache.

  2. Aura---precedes immediately before the headache usually less than 60 minutes (in women migraines with aura increase the risk of strokes). Migraines may or may not have auras. There are 22 genes related to migraines mostly regarding the auras.

  1/3 of patients have auras and 2/3 do not.

   --These auras are characterized by:

    a) visual---intensity of light, lightning flashes (can be associated with no headache (called migraine equivalents), loss of vision, flickering light, or tunnel vision,

    b) sensory---needles and pins, loss of positional sense, or numbness

    c) speech and language abnormalities,

    d) dizziness,

    e) motor abnormalities—paralysis of parts of the body-hemiplegic migraine usually lasting more than one hour.

  3. Pain (rarely no pain)— 60% one sided (unilateral) usually, throbbing, moderately severe, comes on gradually, but 40% involve both sides with pain and tightness in the neck (tension-vascular), 90% with nausea and/or vomiting, a desire to be in a dark room, and can be associated with pallor, sweating, and frequent urination. Tenderness over the skin where the headache occurs is not infrequent with pulsation of the artery just above and in front of the ear in the temple (temporal artery).

  Migraines can frequently happen on the weekend when the stress of the week is less.

  4. Postdrome---this final phase can last for hours or days with tenderness where the headache occurred with fatigue, feeling of being “hung-over”, head pain, cognitive thinking difficulty, gut symptoms (diarrhea or constipation), weakness, or moody. Some feel very refreshed, euphoric, or tired.

 --Silent migraines (called migraine equivalents) most commonly are visual symptoms without headache. Flashing lights in the visual field may start centrally and widen until they recede and disappear with no other symptoms (ophthalmic migraines).

 --Triggers of migraines

   Stress, anxiety, depression, fatigue, hypoglycemia, or dehydration can predispose a person to having migraines, however, they can be hereditary.

   Headaches are one of the cardinal features of COVID-19 and have had major effects on those with pre-existing ones, especially migraines. Reports from many patients state that those with migraine have had a 60% increase in frequency. Patients with migraine are particularly susceptible to changes in regular routine, and the pandemic created a huge rise in headaches. Any stress, even changes in caffeine or alcohol consumption all can trigger an attack.

  Triggers for a migraine are mostly psychogenic. The headache tends to come on after the stress lets up as mentioned above (“weekend headaches”).

Foods can bring migraines on such as wine (tannins, sulfites), aged cheeses, MSG in oriental foods, pickles, pickled products, beans, dried fruits that contain sulfites, foods that contain tyramine (amino acid) such as alcohol,  plums, bananas and citrus, processed meats. Other food triggers can include yeast breads, choline (another amino acid) in dairy products, chocolate and coffee which contains caffeine, aspartamine and sulfites (a preservative) found in wine and other products (diet drinks, artificial sweeteners).

  It is very important to keep a diary of what an individual is eating and drinking when a migraine occurs. Weather change, strong scents, and even tight hair accessories can also key off a migraine. 

     --Rare types of migraines

          Chronic migraines

          Basilar migraine

           These migraines may be associated the source coming from the basilar artery at the base of the brain. These migraines have an aura of sudden vertigo followed by a headache).

           Hemiplegic migraine

           These are associated with (loss of motion of one side of the body).

           Menstrual migraine

           Abdominal migraine

             These rarer migraines are more common in youth with sudden abdominal pain lasting variable amounts of time. These would mimic any number of abdominal disorders.

    --Treatment of migraines

  It is important to accurately diagnose headaches properly because of the different medications needed to treat them. There many FDA approved medications for migraine, and there are others that are used off-label. Depend on the treating physician to select the best for each patient.

  This group of headache patients often overuse over- the-counter (OTC) medications before seeking help (60% of patients in one publication).

    1--BOTOX INJECTIONS

  Injection of botulinum toxin into the muscles between and above the eyes are very effective in treating migraines.

  This is the same injection used to paralyze muscles for frowning and eye wrinkles. These injections are a little more extensive, but the same botulinum toxin.

   When performing cosmetic forehead lifts in my practice, long before Botox was available, I was amazed when patients returned thanking me for a beautiful result but also their migraines disappeared.

   In forehead lifts the frown muscles are cut and scored to paralyze the frown muscles. Botox can do the same thing but must be repeated every 4-6 months. Since it is FDA approved, insurance should pay, but you will have to have your doctor send a letter stating that it is a treatment for migraines and not just for frowning.

The muscle you see in the below drawing shows the procerus muscle which is injected on each side to provide a reflex blockage of the neurological impulses coming from the brain in migraines.

  2--ELECTRICAL HEAD BAND (CEFALY)

  This apparatus is a battery powered electrical headband that delivers small electrical pulses (similar to a TENS unit) to those same muscles, and apparently works. It is FDA approved. Google it and see the information. It is not a joke! The stimulator will not help other types of headaches, so the diagnosis must be verified. The reviews are available, and should be looked at.

         3—CATEGORIES OF Medication

  There are over a hundred medicines being used to prevent and treat migraines. These medicines are not specifically FDA approved for migraines.

  There are a total of 4 different neuromodulation devices cleared by the FDA and are electrical current or magnetic stimulation devices, and some are handheld. Do not use these devices without discussion with a headache specialist.

  Treatments are divided into abortive, preventative, and relief therapies:

     A.  ABORTIVE MEDICATIONS

         --TRIPTANS—Axert, Relpax, Amerge, Maxalt, Imitrex, Zonig are brand names, available as a nasal spray and oral tablets, or injections. The sooner the treatment is started the better the results. The headache should subside within 2 hours in 20-30% of patients.

  Tryptans should not be taken with ergot medications and people with active heart disease because of the vasoconstrictive effects. These acute treatments are primarily from a group of TRIPTANS, which is a chemical to abort a migraine before it gets past the early prodrome phase.

  Tryptans bind serotonin, a neuroreceptor chemical that involves blood vessel dilation. Blocking the dilation allows vasoconstriction and relief of the pain coming from the dilated vessel nerve endings. Side effects include numbness and tingling of extremities, dizziness, dry mouth, and sleepiness.

-- DIHYDROERGOTAMINES (DHE) with and without barbiturates. One of the most common is ergotamine added to caffeine (Cafergot). Suppositories with phenergan and DHE are successful.  Nasal sprays of DHE have shown not only effectiveness in acute migraines but prevention of recurrence. It is also beneficial since most of these patients have nausea and oral meds may not stay down.

-- OTC MEDS include Motrin Migraine, Excedrin Migraine, which contain caffeine. Acetominaphen (Tylenol) may help.

-- NARCOTICS are frequently necessary. They should be monitored carefully to prevent abuse.

-- ANTINAUSEA MEDS treat the nausea and vomiting symptoms with migraine. REGLAN, COMPAZINE, PHENERGAN, and INAPSINE can be prescribed.

-- COMBINATIONS MEDICATIONS especially in suppositories, because many oral meds are not well tolerated in the acute phase because of nausea. Caffeine plus sumatriptan and ergotamine suppository is one example. 

  B. PREVENTATIVE MEDICATIONS

  These meds are taken daily to prevent these migraines especially for those with 6 headache days or more per month or even less with severe impairment.

  Beta-blockers---Inderal, Timolol, Metoprolol. These are anti-hypertensive medications that have the added benefit of helping migraine prevention.

  Calcium channel blockers—another antihypertensive—Verapamil

  Antidepressants—primarily the amitriptylines (Elavil)

  Anti-seizure meds—gabapentin (Neurontin), Topax, and Depakote

  Monoclonal antibody medications that may be prescribed that block the calcitonin gene related peptides. They are called CGRP inhibitors. Ajovy, Aimovig, Emgality, Nurtec ODT, Ubrelvy, and Vyepti, but due to the expense, they would be reserved for failures with less expensive medications.

  According to one report monoclonal antibody meds work very well in about 1/3 of the patients, and another 1/3 has some improvement, while the another 1/3 report no help.

  C. RELIEF OF ONGOING MIGRAINE HEADACHE

  Relief may come from narcotics, sedatives, anti-nausea meds, but only to cope with the pain and others symptoms. Once the migraine is full blown, relief meds are only partially successful.  Migraines can last up to 72 hours or more.

Reference www.WebMD.comwww.mayoclinic.org

www.wikipedia/migraine.orgwww.healthline.com

  D. BEHAVIORAL THERAPIES

  Psychotherapies are recommended by the Academy of of Neurology and the American Headache Society. Therapy would be used in addition to medical treatments in most cases. Setting up routine lifestyles with a plan to combat any stressor is advised, such as adding an additional hour of sleep per night.

  For individuals working from home and or require a significant amount of time on a computer screen should use special glasses with a FL-41 tint to combat the light. Medscape, May 12, 2021

  Anxiety is a clear issue with many of these patients and must be addressed to achieve adequate control.

   E. PERIPHERAL NERVE BLOCKS

  Injecting local nerves may be of help (occipital and trigeminal). I found these blocks with lidocaine and long acting steroid were more effective for tension-vascular headaches rather than migraines in my practice.

   F. MARIJUANA

  Cannabis may not FDA approved, but is often used with variable results. Discuss its use with the treating physician.

II. TENSION HEADACHE

  These headaches are well named, and by far are the most common type (40% of all headaches in the U.S.), most common in ages 30-39.

a) Description

  The pain begins with spasm in the muscles of the upper neck which creates pressure and tightness in the entire neck and shoulder group of muscles.  However, they may not be appreciated until the headache begins.

  Most people show tension somewhere in their body, and the neck and shoulders is by far the most common area. Half of the population have this type of headache sometime in their life. It is twice as common in females. Oddly, most patients don’t necessarily realize the tension is coming from the neck, because the pain is the predominant symptom which is usually felt as a tight band around the head (left slide below).

  In addition to major posterior (back of the neck) neck muscle tension, there are muscles in the forehead (frontalis) and temples (temporalis) that spasm and cause the pain by squeezing the sensory nerves of the lining of these muscles and in the scalp. Some describe it as pressure or a throbbing pain.

  It can be confused with a migraine, and some of these headaches have a vascular component, thus the name tension-vascular headache, but these headaches are not associated with auras, neurological abnormalities, visual changes, or nausea and vomiting (symptoms are typical migraine). They are not as incapacitating as migraines, but can be severe. They can come and go during the day, while migraines do not.

b) Causes

  The causes of tension headaches can occur from lack of or too little sleep, missing meals (hypoglycemia), anxiety, anger, eye strain, and a host of cervical abnormalities (arthritis, pinched disc, sitting in one position too long at a computer, even sleeping with the neck in an improper angle). See slide on the right above!

  The physician needs to rule out migraine, sinus headache, neurological causes, and other types of headaches, but the diagnosis is usually made with the history.

  CT and MRI scans are normal in most headache patients. The American Headache Society (via the American Board of Internal Medicine Foundation) is calling for fewer CT and MRI scans in stable headaches or ones that are clearly migraine, however, as pointed out in Medscape, that is controversial since a fourth of brain tumor patients can have isolated headaches. The other ¾ have associated seizures, cognitive abnormalities, and other neurological symptoms.

  Evaluation of the neck with X-rays can demonstrate many of the abnormalities (cervical arthritis, disc narrowing, etc.). If there are symptoms (numbness) radiating into the arm or hand with or without weakness, a more thorough evaluation by an orthopedic or neurological surgeon may be in order. Chiropractic physicians may be very helpful.

c) Treatment

  Tension headaches can be relieved with OTC meds including acetaminophen (Tylenol), NSAIDS (Aleve, Ibuprofen, etc.) and prescription muscle relaxers (Soma Compound, Flexeril, Valium, etc.) may be helpful. Most migraine medications are not effective for tension headaches.

  Biotherapies (biofeedback) or cognitive behavioral therapies are effective including antidepressants.

   Mirtazapine, an antidepressant, before bedtime has been recommended to stabilize the serotonin related effect in some headaches, even some migraine patients who are depressed.

  Physical therapy, acupuncture, heat alternating with ice is valuable. Chiropractic management is also commonly sought and can be quite helpful.

  Behavior changes help—more sleep, relaxation methods (yoga, meditation, massage), regular exercise, better nutrition, less caffeine and alcohol, better coping with stressful situations, and not internalizing anger.

  Tension headaches are a classic psychosomatic disorder and treatment must address both aspects of mind/body issues.

III. Trigeminal Autonomic Cephalgias*--CLUSTER HEADACHE

*The trigeminal nerve is one of the 12 major cranial nerves, that provides sensation to forehead and face.

a) Symptoms  

  These headaches occur on one side of the head and are severe. They often can be associated with pain behind or around the eye with tearing. The eye may be red and it can be associated with a runny nose on the side of the he It rarely can be associated with a droopy eyelid, a smaller pupil on that side, sweating on the same side of the face, and usually lasts from 15 minutes to as long as 3 hours. The pain can radiate into the jaw and neck, possibly confusing it with a tension headache.

These are one of the few headaches that are more common in males 4:1. These are much rarer headaches, but are somewhat classic in presentation when they occur.

  Even other symptoms of a migraine may occur, but movement does not make the headache worse and nausea and vomiting is rare, which is very common in migraines. These headaches occur in “clusters of time”, up to several separate times in one day, or every day for several days or weeks and then not appear for days or months.

b) neurological scans

  During a headache, an MRI may demonstrate dilation of the ophthalmic (eye) artery and a PET scan might demonstrate abnormalities in the cavernous sinus (venous blood cavity inside the skull).

  The cause is unknown, but clearly this is an atypical type of vascular headache.

  Trigeminal neuralgia may be confused with cluster headaches. The trigeminal nerve, a cranial nerve that sends sensation to the face in three branches) can create many of the signs of a cluster headache.

c) Triggers

  Some of the triggers can be alcohol, histamines released in seasonal allergies, stress, menstruation, nitroglycerin, and even smoking (nicotine).

  Other neurological abnormalities (brain tumor) including migraines need to be ruled out, and for that reason a neurological and an ophthalmology consult should be considered.

d) Treatment of cluster headaches

  During an acute attack, the pain can be helped with breathing oxygen with a mask and can relieve the headache in 70% of patients.

  Migraine meds can be valuable--injectable sumitryptan (Imitrex) or dihydroergotamine (Migranal).

  Corticosteroids, verapamil (Calan), lithium (Eskalith), valproic acid (Depakin), melatonin, and topiramate (Topamax) all have been effective.

  Treatment of headaches may be a hit and miss approach to see what will help the most.

  Heart patients can have complications from the sumitryptan and ergotamine, and there are many medications that have cross-reactivity especially with selective serotonin reuptake inhibitors (SSRIs-antidepressants).

References:

www.medicinenet.com/headache

www.mayoclinic.org/symptoms/headache

www.headaches.org  (American Headache Foundation)

3. Heel Pain

  Heel pain is a very common problem not only in those who plays sports, but in those much more sedentary. Here is a long list of possibilities. It is called a differential diagnosis:

  BELOW IS A LONG LIST OF POSSIBLE CAUSES

  Orthopedic surgeons or podiatrists are trained to deal with these issues.

When should an individual seek a doctor’s care?

  Severe pain or swelling, inability to bend the foot forward, walk on the toes (tiptoe), or walk normally with significant pain, or severe heel pain after an injury.

  Care for heel pain can be treated with ice alternated with heat, rest, use of NSAIDs (ibuprofen, Aleve, etc.), and the use of various orthotic appliances incuding gel pads,

socks with heel supports , wedge inserts, and stretch supports. The proper shoes are critical to allow proper orthotic arch and heel support.

  Although usually a local problem which occurs with injury, overuse, etc., there are cases related to gout, rheumatoid arthritis, etc.

  The most common causes include plantar fasciitis, heel spurs, injury that overstretches the heel anatomy including the Achilles tendon, plantar fascia ligamentous dettachment from the heel bone to the forward portion of the foot, a new or poorly fitting shoe, a boney spur abnormality of the calcaneus (heel bone), tendonitis of all these non-boney structures, a trapped nerve, or bursitis.

  Many occupations require individuals to be on their feet all day, lifting objects, etc. Being overweight is another risk factor.

  Any sport can create heel pain usually plantar fasciitis, from hyperextension of the tissues of the bottom of the foot, especially in tennis, pickle ball, running, etc.

  I reported with an indepth look at plantar fasciitis on a previous report.  Please click on: www.themedicalnewsreport.com #74

4. Drug and healthcare costs rising in the U.S. vs other countries; Medicare prices rise

Healthcare costs

  The Pandemic has diverted attention from another crisis….drug costs, which was a top concern. According to a 2019 Gallup Poll, 1/3 of American families delayed healthcare because of the cost of medication. These costs have grown by 344% since 1990.

  A February 2020 poll stated that 34% felt that rising healthcare costs posted the greatest threat to the economy. The pandemic has certainly created economic chaos with over 8 million jobs open and people depending on governmental handouts, shortages in all key jobs and professions, especially transportation, but healthcare, restaurants, and all services are suffering. The malaise of people working created by the lockdowns and isolations kept people home and got very used to not working. 60% now want to work from home even at less income.

  Over $1 trillion dollars as been spent on pandemic needs. Vaccines and medical treatments have been paid for by the federal government. So many resources and supplies were not produced in the U.S. and now inflation is hitting everyone.

  Healthcare utilization dropped out the bottom during the pandemic. Add over 1.7 million illegals coming over this year costing the tax payer billions, and one can see what we are facing, and make fertile ground for governmental healthcare (socialized medicine), which would cost trillions.

  No administration has been successful in curbing the rising cost of drugs. The Congress is not listening to the public.

Medpage Today, June 11, 2021

Medicare premiums rising!

  Expect a 15% rise in Medicare premiums for 2022. It will rise from $148.50 to $170.10, according to Modern Healthcare. CMS (Medicare Services) announced it the middle of November, as people are having to renew their plans.

  Medicare Advantage marketing has been overwhelming. It is much less expensive but essentially a Medicare HMO, so be sure you understand the various plans including the changing prices of drug costs which will likely rise.

  CMS blames the rise on the pandemic. Consider how many people were not working and not contributing funds to their paychecks for Social Security and Medicare. Inflation is a major issue, regardless of what is said.

  There will be some serious price increases in our daily life, and every U.S. person is going to suffer the rise. Consider it a tax on everyone. Inflation will continue through 2022.

Drug costs

  The U.S. spends 150% more on prescription drugs than 32 other countries, according to Rand Corporation analysis. Brand name drugs drive the costs. Generic drugs are actually cheaper in  the U.S. and begs the question why physicians prescribe more brand names.

  Brand names account for 11% of prescribed drugs in the U.S. and account for 84% of purchases, however generics only account for 12% of the money spent on drugs.

  Total drug expense is $795 billion annually. If you see an ad on TV for a medication, they are usually the most expensive, otherwise they wouldn’t advertise it.

Medpage Today, January 28, 2021  

  There have been a lot of promises from all politicians to reduce the price of drugs. We all know that is not going to happen with the Big Pharma lobbyists owning the Congress. There have been significant attempts to help the issue by reducing the size of the donut hole in Medicare Part D drug plan, sending discounts to patients instead of the middle men in pharmaceuticals (the distribution managers), helping reduce insulin costs, and other attempts, but overall the cost continues to rise.

  Not only does this reduce access to medicines, it even prevents patients from taking the meds prescribed, skip treatments, and worsen health outcomes.

  A recent study found that since 2010, insurance payments for drugs increased by 64% and out of pocket expenses increased by 53%. For specialty drugs, the out of pocket cost increased by 85% and 42% for non-specialty drugs. Insurer payments to the drug companies increased that same period by 116% for specialty drugs and 28% for non-specialty drugs.

  With doubling of healthcare costs since 2010, they outpace any increases in income or general inflation. Until the Congress can negotiate drug prices similar to other developed countries for Medicare patients, we are in trouble.

  With all the $trillions being spent on COVID-19 and the downfall of many state governments, it will be some time before any amount of tax will cover the enormous increase in healthcare medication costs.

  This is a very complicated issue and is extremely difficult to report on it, but I hope this brief report confirms we are facing serious trouble.  JAMA Network, December 9, 2021

This completes the last report for 2021, a year, most of us would like to forget. Here is hoping for a better 2022, and GOD BLESS ALL OUR MILITARY VETERANS. WE OWE THEM OUR FREEDOM.

January, 2022 subjects will include

1. COVID-19 updates

2. Autoimmune diseases-part 1

3. Hair loss in women

4. Blood clots, emboli, and bleeding disorders

5. New innovations in head and neck cancer

  Have a wonderful and blessed Christmas, Hanakkah, and Holiday with family and friends. Stay safe, and thank you for reading the Medical News Report for almost 10 years, Dr. Sam