The Medical News Report

#121

February, 2022

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

  THE RED CROSS HAS ANOUNCED THAT THE BLOOD SUPPLY IN THE U.S. IS CRITICALLY LOW, BEING ABLE TO PROVIDE CERTAIN BLOOD TYPES FOR ONLY ONE DAY. ALL BLOOD TYPES ARE IN GREAT NEED. I DONATED 3 WEEKS AGO HAVING BEEN CONTACTED BY MY LOCAL BLOOD CENTER. PLEASE DONATE BLOOD NOW!

 THE PANDEMIC HAS CREATED FEAR IN CERTAIN PEOPLE ABOUT DONATING BLOOD. COVID IS CHECKED IN EVERY PINT OF BLOOD, PLATELET PACKS, ETC. THAT IS GIVEN TO PATIENTS. THERE IS NO DANGER IN GOING TO A BLOOD CENTER OR DONATING!!

February is Heart Month!

Get a heart check, cholesterol check, blood pressure measurement, and enquire with family members about heart disease in the family. 610,000 people die every year of cardiovascular disease (1 in 4 deaths are cardiovascular).

Subjects for February, 2022

1. COVID-19 updates; time for a different strategy?

2. Autoimmune diseases-Part 2—rheumatoid arthritis and multiple sclerosis

3. Degenerative shoulder rotator cuff tears—management options

4. Signs and prevention of prediabetes; nutritional myths

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

1. COVID-19 update

As of January 22,2022

63.7% fully vaccinated—proposed 80-85%

39.9% boostered

   1) The latest information

  We are at a time we should take stock regarding the strategies to fight COVID-19, especially since we may be peaking with the pandemic, and we don’t need more regulations that might have been of value this summer, but now the effort needs to adjust, according to many experts on both sides of the political spectrum

  Omicron has changed the equation, but it won’t last long, assuming another variant does not occur that is more worrisome.

  Previous attempts to impose federal power and control to fight this virus have run off track according to some politicians and experts, especially when a variant as mild as Omicron can block Delta and cause such mild disease except in those with underlying disease that complicates the illness. Those vulnerable must respect this variant.

  With so many people who have been vaccinated and have had the booster, ask why we need more mandates now? There are many opinions out there, as politics separates us, not science.

  The hardest hit areas of the U.S. in the Northeast have seen an overall 36% drop in infections. This is from a combination of more vaccinated and a milder variant cases, with reduction of Delta cases.

  The Prime Minister of UK, Boris Johnson, has announced no more mandates, masks are optional, and essentially told Britains to live with Omicron and deal with it. Their surge has passed. Of course, that is quite a controversial move for some Brits.

  Vaccines will be a critical part of continuing our fight against the pandemic or endemic, but thankfully Omicron has really reduced the severity of this virus even though the rate of positive tests is very high, because it is more infectious.

  The pandemic has created real havoc in keeping people out of work or school creating the worst shortages yet for products and workers. It will take some folks longer than others to realize we must learn to live with this virus and get our lives back. Older people, those in nursing homes, immunosuppressive patients, those obese, those with heart, lung, and kidney disease are will be at much higher risk for hospitalization. Unvaccinated are still at higher risk.

Can Omicron block herd immunity?

  Omicron may interfere with herd immunity according to some experts, because Omicron’s transmissibility is aided by evading immunity to infect people who were vaccinated, boosted, or had a prior infection, although CDC studies confirm 80% effectiveness from vaccines against Omicron (it was 96% against Delta).

  There is also evidence that the coronavirus will continue to find ways to break through or get around our immune defenses. Also milder infections tend to produce weaker immune responses, so mild Omicron cases are less likely to provide or boost immunity that is lasting and may be set up for breakthrough infections in the future.

  To reach herd immunity, individuals must generate lasting immunity by vaccines and infection, and both must block infections and onward transmission of the virus. Omicron apparently is preventing herd immunity in these ways, and future variants may be able to as well. Experts from Boston, Massachusetts General Hospital estimate that 20-50% of the population will test positive for Omicron. It will be interesting how high our immunity goes with Omicron infectio.

   I, for one, felt we should have already been at herd immunity, but with a variant that can resist immunity, we may never reach it, just like influenza, because there are different strains causing the infection(this year is H3N2 swine flu strain and the vaccine is not very effective). Those with health issues must also get the flu shot no matter what % of effectiveness there is to prevent hospitalization and death.

  That is not to say prior immunity offers no benefit according to the experts from the University of Washington in Seattle interviewed by Reuters state that vaccines combined with infections will help boost population immunity, which continues to make the disease less serious for those infected or reinfected, even if herd immunity is not reached.

  Really all this information means, is we are going to be living with coronavirus, and that is what many experts are stating. How individuals deal with it will vary.

  There has been some medical guessing going on at the federal level from the beginning, and unfortunately, it sometimes is the best experts can do, but should be admitted, according to experts cited below.

  It should be remembered that the strategy was to develop vaccines that would eradicate the virus, and that is not true. We have good vaccines to keep the virus from making as many people sick. That is what the flu shots does.

  In the beginning the only way to get researchers off their usually slow, overregulated pace was to create…emergency use authorization, and it has allowed a rapid manufacturing of vaccines faster than ever ( usually takes 8-10 years), and allowed us to benefit from successful vaccines, but in reality, these vaccines are experimental and far from perfect, and Omicron can resist their benefit.

  The manufacturers and promoters can’t be sued for an experimental project, so Big Pharma and all those who were part of it, including our federal officials are protected. Only full FDA approved medicines allow lawsuits for complications.

Omicron not only more contagious…they are more resistant!

  Omicron was touted as very transmissable and it is, but there are other reasons for their aggressive spread, according to Dr. Paul Offit, who serves on the FDA vaccine committee which is the official advisory committee to approve a drug or medical device.

  Dr. Offit states that the reason we are seeing Omicron spread so fast, replacing Delta, is Omicron is more immunologically resistant than Delta (and can even block Delta), vaccines, and some of the monoclonal antibody outpatient treatments including convalescent serum.

  The fact that the Omicron variant dwells in the nose and throat much more than the lungs is probably a good reason why it is easier to transmit, and a milder “cold-like illness”. Sounds like a good time to be doing routine gargles and salt water sniffs.

  Hospitals were full of unvaccinated people, which is still fairly true, a number of vaccinated are now filling some beds as well. Studies show these folks have underlying diseases (usually 4 different diseases according to the CDC) making them more vulnerable. Also half these admissions are mostly those admitted for underlying diseases, car accidents, routine surgery, etc. and not COVID even though they tested positive. You just can’t trust numbers of cases.

Omicron resists some of our treatments

  Some of our body’s immune response, the vaccine’s immune response for us, and certain treatments (monoclonal antibody drugs-Regeneron) are not as effective because Omicron has the ability to block them. We need more treatments. The FDA just jerked their approval for all monoclonals except sotrovimab as an outpatient therapy.

  The FDA just approved the use of a previously in-hospital approved medication, Remdesivir, to be used on some outpatients, with the new data on Omicron resistance to other treatments.

   If a person is sick enough, they should talk to their doctor about the oral treatment (Paxlovid) or these medications.

  Unvaccinated patients are still the most vulnerable, and they still need to be vaccinated. The fact that Omicron can infect everyone still does not give one a reason to not be.

  Boosters are very valuable to reduce infection, according to Dr. Offit, but the some of the boostered are getting sick too from Omicron (not near as much as those just vaccinated), therefore, no one is totally safe.

Medpage Today, January 12, 2022

Milder disease throughout the world, but still causing serious complications with the vulnerable and unvaccinated

  South Africa continues to see milder disease even in those with no vaccines. They are reporting a 25% reduction in severity compared to other variants for Omicron illness. Reuters, MDLinx, January 17, 2022 The UK notes a 1/3 drop in hospitalizations. However, the hospitals are stlll filling up in certain areas.

  Those at Massachusetts General Hospital with multiple predictions in a conference call with many other experts also feel that about 40% of Omicron cases will be asymptomatic and will never be tested unless for work or other reasons.

  They also state that contact tracing will become less useful in this environment, the major public health method of finding the source of the disease as they do in all infectious diseases. We must adjust public health techniques when necessary. Medicine must modify its methods of discovery, diagnosis, and treatment as the situation dictates.

  A study from Southern California cited a 53% reduction in hospitalizations with Omicron, a 74% lower rate of those needing intensive care, and a 91% reduction in death. MedRxiv, Jan.13, 2022, a preprint and not peer reviewed yet. Those still with high rates of hospitalization are mainly residual Delta variant cases.

  There are reports that Omicron is far from mild, but they are referencing those hospitalized because of other medical conditions, which may or may not be the cause for the admission, and hospitals don’t separate the two groups when reporting COVID cases.

   However, Omicron is 5X more likely to cause breakthrough infections than Delta, including those vaccinated and with boosters, according to Medpage Today, January 19, 2022

Masks

N-95 mask

3 ply surgical mask

How many times have you heard that even though most masks are of no value in preventing infection, “any mask is better than no mask”. It has become a political statement in some places, not a scientific one. Indoor events are still vulnerable places to get infected.

  Now that N-95 masks are available for the public, the CDC admits they are the choice with 3 ply surgical masks a far second. Single ply masks and cloth masks are of no value. The research has been known for a year. Tey must be changed daily.

  Emphasis on vaccines created a myopic attitude of our administration, not admitting the importance of natural immunity, quality masks, treatment options, testing, and relying on states to adjust their strategies based on hospitalizations and deaths.

  N-95 masks are the only single mask found to prevent droplet and aerosol transmission in at least 70% tested, if changed daily and worn tightly on the face. However, children are not able to wear these masks well, and are better suited for surgical masks, which the administration is going to supply schools shortly.

  For 2 years, people have been wearing masks inappropriately and or totally ineffective (cloth, paper, etc.). Unfortunately, the N-95 masks are very difficult to breathe through.

  The White House announced they are providing 400 million N-95 masks to pharmacies and health centers to be distributed for free to those who request them—3 per person in February. The supply is not that plentiful, and there are many online sites that sell fake Chinese mask, however, now the U.S. is manufacturing them and it will be these that will be distributed.

Mdlinx, Dec. 17, 2021

Alternative medications and personal hygiene

  Alternative medicines over the counter and some off label medicines are very popular to try and boost our immune system, and there is some data to support their use (zinc, Vitamins D and C, mouth and nasal washes), and even those medications who have been maligned such as those who claim value in hydroxychloroquine and ivermectin, there are still millions who are taking them (especially in other countries). Do you think Big Pharma was going to support cheap treatments when they are making $billions on their vaccines?

  According to Dr. Steve Hahn, former FDA Commisioner, all of these treatments may have some value but vaccines are still the most important weapon we have.

  There have been no long term studies on side effects of vaccines, and that is unfortunate, but when there is an emergency, time is of the essence.

   After 2 years we are discovering the vaccines are not near as valuable against the latest variant, Omicron, infecting those vaccinated and unvaccinated, and previously infected.  You can’t call this pandemic the “pandemic of the unvaccinated” anymore!

Hey…it is winter!

  Regardless of the progress we make or lose, it is winter time, and every respiratory disease (especially viruses such as RSV) is at its worst, and any 10-15% rise in hospitalizations will put a major burden on them, especially with reduced hospital staffing, healthcare worker burnouts from being overworked, and the length of this pandemic, as we are now going into our third year.

Placebo effect of vaccine side effects

  A recent study found that people are getting side effects as often with a placebo* shot than a COVID shot. Fatigue, headache, weakness, body ache was not greater for either the test group or the placebo group.

Long term side effects from the virus continue

  Even though there is a significant number of patients who have long term symptoms after they recover from COVID, they continue to have persistence of symptoms from respiratory, cardiovascular, kidney, and neuromuscular systems. Most last at least 6 months, but it all depends on how severe the disease affected that organ. Therefore, it would be no surprise that those with underlying system disease would continue to have difficulties. Age alone is a factor.

   I have discussed long term syndrome previously, and it was theorized that microclots continue to cause some of the symptoms stimulating cytokines, inflammatory markers that continue damage. Other studies conclude it is the secretion of interferons, other inflammatory markers, that are stimulated by the presence of the virus.

  One study found 30% who were unvaccinated developed some long term symptoms. This alone is good reason to get vaccinated.

  Now, Oxford University, has found that those with even mild Omicron disease, with or without symptoms, can have 6 months or more of memory and attention deficits that will disappear.

   If you are looking for a reason to stay on the couch and make excuses, I am not talking about you! I am talking about those who completely recover or never had any symptoms from COVID infection, but were test positive. Those can have these slight prolonged cognitive symptoms, and just need to understand that it will take a months to rid themselves of these annoying issues.   

  These long term syndrome patients need to be monitored to see what percent have permanent damage that will not improve. Even when the virus is gone, our immune system may not get any signals to stop producing these inflammatory proteins.

MDlinx, January 14, 2022 in the Australian Health News

2) Is it time for a “new normal” COVID Strategy?

  Several experts recommend a major change in COVID strategy—“A NEW NORMAL” (Dr. Ezekiel Emanuel, oncologist at U. Penn and former chief advisor to president Obama; Luciano Boro, chief scientist at the FDA, Michael Osteholm, U. Minn.; Rick Bright, Rockefeller Foundation) published in the JAMA Network These are former Biden medical advisers! It is time for disaster preparedness.

  With a 36-43%* approval rate of how the pandemic has been handled as well as the economy, it is past time to make major changes in the country’s approach to the pandemic. *different polls

  Some of these recommendations will require an enormous investment in public health. Some support federal power and control. But some are “no brainers”.

  There are many medical experts on both political sides that feel the strategic direction of the current administration has failed, and Dr. Emanuel and colleagues have published articles suggesting changes need to be made about the management of COVID-19 in the U.S.

JAMA Network published his recommendations.

  The administration is more concerned about the continuous and perpetual state of emergencies declared with each variant to increase vaccinations, which has created great controversy, divisiveness, and  more questions about vaccination. Not emphasizing proper masking (N-95 masks), ignoring natural immunity, shutdowns, and “a one size fits all” strategy has been largely unsuccessful, according to these experts.

  The Omicron variant has changed the equation. The authors suggest a national strategy of humility, admitting there are many factors previously sidelined that deserve attention (natural immunity, healthy individuals, less testing, no treatments for outpatientsm etc.).

  With the discovery of the mildness of the Omicron variant’s illnesses in most (even though very transmittable), COVID-19 should be considered a seasonal virus we will have to learn to live with, similar to the flu and colds.

  Geographic variations in our country have been present from the beginning and states are better suited to determine stratigies.

  Most vaccines were developed to eradicate the virus, which has not happened, even though that was boasted over the fall. The White House just needs to admit mistakes, but politics will not let that happen.

   Part of the humility, according to these experts, is admitting that there is a lot of educated guessing and not recommendations based on scientific certainty, according to the authors.

  A “new normal” is recommended with considerable adaptation for any national strategy. When Omicron started hitting those with vaccines and boosters, the strategy obviously needed to change, according to Dr. Emanuel. The words “eradication” and “elimination” of the virus, and shaming the unvaccinated should be stopped.

    Most of the other currently circulating viruses have not created emergency measures, and at this time, COVID should join them.

  The risk of death for influenza is close to the rate of COVID now (50-60,000 anually).

  There needs to be better efforts to address those with underlying diseases and health risk factors such as obesity is much more important than placing rules on general populations including different strategies for certain diverse populations.

  The authors emphasize rebuilding public health and public trust to respond to future pandemics, which will require real-time information systems, and a public health workforce that responds with flexible healthcare systems.

Key points emphasized:

1) A digital real-time integrated data system.

2) Instead of the CDC primarily spending a larger portion of their budget on data collection, primarily following disease after it has happened, there must be emergency workforces ready to address these crises from the outset. Expansion of local public health workers and school nurses is needed.

3) Telemedicine should be expanded with licensure to practice over state boundaries to address emergency needs in affected states.

4) Rebuild trust in the public health system including the CDC and the FDA. It is known that over $5 trillion has been spent on the pandemic and is probably over $10 trillion, depending on what is included.

5) Testing and reporting is a high priority.

JAMA Network, January 6, 2022; Medpage Today, Dr. Amesh Adlja, Johns Hopkins, Jan 7, 2022

  Not admitting the value of natural immunity has been a huge mistake and needs to be addressed and research for it, which was not addressed. Also, there must be honest and open dialog from experts that can gain the trust of all Americans, and between Dr. Fauci, the FDA, and CDC, that was not accomplished..

  Trying to vaccinate 80-85% is the highest goal thst should be attempted, and yet these epxerts are touting a 90% rate, which has never been attained anywhere. Canada has just placed a fine of over $100 for people who refuse to be vaccinated. That won’t work.

Othe recommendations:

  1-Variant specific vaccines will be necessary to maintain pre-pandemic levels. Dr. Emanuel recommends “universal* vaccines” (not currently available), which would prevent future variants, universal health cards, and school vaccination programs for mandates in school children. These are controversial recommendations.

*universal vaccines would include major variants, potential new variants, and other coronaviruses that cause upper respiratory illness mainly in children.

  2-Free home testing, home oral treatments, and outpatient treatment programs are all recommended.

  3-Research for more early treatments is especially needed now that Omicron is resistant to some the ones now used. 

 JAMA Network, January 6, 2022

Comment

  The “new normal” will cost $trillions (the U.S. has already spent $5 trillion on the pandemic), and the Congress must weigh-in on the final decisions with budgeting that we can afford, not executive orders.

  If some of these recommendations have a significant socialism tone with federal control, you are correct, but somewhere in the middle lies the real answers for a successful strategy for addressing future pandemics, so that cooperation will have to come from the majority of our country and those legislators with a brain.

  The federal government is notorious for throwing money at an issue with no real plan ready for action. We need a sustained bipartisan task force that is as independent as possible (being independent is one of the FDA and CDC’s greatest problems). A great example is the current legislature has voted to spend $102 million on healthcare worker burnout with no plan. Get the pandemic solved and the burnout will dissipate.

  There can never be a crisis in our country that we are not prepared for!! That is where we need to spend our tax dollars! When major polls tell us only 50% of the population trusts the CDC and under 40% trust the FDA, we must make some major changes. The approval of the strategy for managing the pandemic is 44% according to Pew Research.

2) Consequences of the pandemic

  The list is exhausting:

  Crime is escalating with less police confidence and no bail, anti-cop movements and attitude changes about our police departments, changes in misdemeanors punishment, obesity, undiagnosed health issues, lack of learning and social skills in school children with a rise in mental illness, untreated medical conditions, cramped nursing homes, malaise in people wanting to work when the federal government is paying them to stay home, while 10 million U.S. jobs are open, rising inflation (7%), shortage of a majority of supplies, fewer healthcare workers, a rise in mental illness and drug overdoses (40% increase in death rate ages 18-49 in 2021), closing of businesses, and worsening of the homelessness (63,000 in LA) are some of the major consequences of the pandemic.

  Nursing homes are so full in many places delaying discharge from hospitals already who are already strained by being understaffed, those with winter issues, multiple diseases, and overpopulation.

   In large metropolitan northern cities, there are still some hospitals delaying surgeries because of the surge in hospitalizations and lack of staff. U.S. hospitals lost $22 billion in revenue in 2020 because of the consequences of the pandemic. They can’t survive with another long delay in services, not to mention the increase in their diseases and deaths. Medscape Surgery, January 10, 2022

  According to morningconsult.com, 18% of healthcare workers have quit their jobs, while 12% have been laid off. 31% of those still working have considered leaving due to overwork, shortages, stress from the pandemic patients and concern for their own health.

  The healthcare costs have skyrocketed because of these factors. Conservatively, the U.S. has spent more than $5 trillion dollars on this pandemic ($64 trillion globally is a guess). $94 billion of pandemic money has been spent on the 2 million illegals in 2021.      

  There is always good news! In the first half of 2021, the vaccine saved 241,000 lives and prevented 1 million virus related hospitalizations. Virus-related does mean the patient may have been in the hospital for underlying diseases but might have been complicated by the virus. I will be interested in comparison figures the second half. JAMA Network, January 11, 2022 

   We all have to acknowledge the vaccine is not preventative but will keep the infection milder, and even if hospitalized, less severe. There is no reason to believe there will not be another variant, so be smart, do the best you can do, and stay safe.

  Below is the latest information from the CDC, FDA, the White House, and medical journals, like it or not. It is time for change!!   

3) Omicron Variant effects

  Omicron accounts for 95% of the new cases of COVID-19, mostly mild cases, but many are found to have a positive test when screened for other diseases orequired for work, and are asymptomatic.

  South Africa reports that Omicron has increased breakthrough infections and reinfections have risen 3-8 fold more than Delta, because they are able to spread more easily.

  Hospitalizations for other diseases with positive tests admitted accounts for 45% in some major hospitals. Still, in the UK, there are 1/3 fewer of Omicron hospitalizations than Delta. MDlinx, January 17, 2022

  The fact that Omicron stimulates neutralizing antibodies that kill the Delta variant is very good news, at least for those significantly vulnerable, regardless of age. Unfortunately it can also block a lot of the neutralizing antibodies put out by vaccines and natural infection. That is why it has traveled so fast across our country and the world. But there are other immune antibodies that still help.

  It is known that the Omicron variant lodges more in the upper airway (nose, throat, and bronchi) rather than the lungs. This is the reason the variant is not as severe, and is causing essentially a “cold”. MDlinx, Jan 3, 2022

  Children under 5 are getting the virus but rarely sick, as they are not yet eligible for the COVID vaccine. Why are vaccinations being recommended?

4) New research on how the virus invades cells, discovery of gene variant that protects against sever infection, Tuberculosis vaccine may extend the immune levels of vaccines

  The Karolinska Institute researchers have identified a gene variant (gene OAS1) that protects against severe disease caused by COVID-19., published in Nature Genetics. This variant is carried by certain European and African ancestry, and found in their DNA, and have a 20% lower risk of developing a severe case of COVID-19.

  This discovery opens the door for isolating and developing treatments that would include this gene variant. It also points clearly how important it is to include various ancestries around the world to study such diseases as COVID-19. Mdlinx, Jan. 13, 2022

  New research is discovering more about how COVID-19 travels from cell to cell, which hides from our immune systems, according to Ohio State’s Viral Research Department.

  The body’s neutralizing antibodies are less effective when the virus moves from cell to cell. Finding a new vaccine or treatment that hits the virus as it travels from cell to cell is a new key to fight these new variants, as they mutate to evade the body’s immune system.

Mechanism--The gateway to the inside of the cell for replication goes through a receptor with a protein spike (ACE-2), and that receptor is where the vaccine interferes with that protein. However, researchers found the virus can also fuse to cells that have low levels of the ACE-2 receptors on their surface and therefore can transmit quicker, such as the Omicron variant with 37 mutations.

  The WHO has strongly recommended a new drug to treat severe COVID. Baricitinib in combination with corticosteroids normally is used for rheumatoid arthritis, another autoimmune disease. BMJ, January 14, 2022

  Pfizer has had to add a third dose for children ages 2-4, because 2 doses are not enough in their clinical trials, still not recommended. These extremely young children just don’t mount the immune response older children can. Currently, vaccines are allowed for children 5 and older.

Tuberculosis vaccine may help the vaccines

  The BCG*vaccine used in endemic populations with tuberculosis is showing some cross reactivity with COVID and TB, as reported by the University of Houston. Both vaccines stimulate T cell lymphocyte and may assist in both diseases. MDlinx, January 17, 2022

5) Boosters combat Omicron…mostly! Another mandate?; some good news!

  Boosters are important to combat Omicron, even though some with boosters are still getting infected.

  A study (The Journal Cell, Dec.23, 2021) evaluating the immune (neutralizing antibodies) response from two doses of the vaccines found little ability to kill the Omicron variant (even after a recent dose), but the boosters had sufficient immunity in combating the variant especially preventing rising rates of hospitalizations and deaths.

  Since the booster immunity lasts only 3 months or more, a fourth booster has been discussed, but Israel reported using a 4^th shot does not raise the immune levels any higher in a clinical trial. They commented that the level of antibodies needed to prevent Omicron can not be reached with vaccines. MDlinx, Jan 17, 2022

   The unvaccinated healthy or not, who get infected and asymptomatic, are the highest spreaders of the virus because of the higher viral load in their respiratory tract, according to experts, and make them riskier for anyone in their homes, in public, and at work.

  The CDC now recommends a booster for young people 12-17 and older. It had been limited to people 18 and over (about 5 million young people). I have seen no science to back that recommendation.

  For children, RSV (respiratory synchial virus) and influenza can be serious illnesses and can occur simultaneously, as we are just now peaking in flu season and the winter months. New RSV research is encouraging.

  The length of each variant lasts 4-6 weeks according to South Africa, Israel, and the UK, therefore, it will still be spreading into February, and another variant may be coming (no evidence yet).

  Recent research has reported that the immune levels in the booster do not remain high after 3 months. This is going to create more doses in the future, unless this pandemic drops to a endemic, and even then, yearly boosters may occur unless a different kind of universal vaccine can be developed.

  Another “fly in the ointment” of the administration’s push for boosters even down to 2 year olds, when the immunological rise in immunity from the booster only lasts 3 months.

  Pfizer has developing an Omicron vaccine but will not be available in time to be of much value, even if ready in March.

Name change for fully vaccinated

  Originally, the CDC named those who were vaccinated with 2 doses of Pfizer and Moderna (1 dose of J&J) “fully vaccinated”. Now they changed that name to “up to date” on vaccinations, and to be fully vaccinated, you must receive the booster. I am so surprised. When will the booster be mandated?

Moderna booster ow available in 5 months after the last dose

  It was reported on January 7, that the Moderna vaccine booster should be given 5 months instead of 6, for those 18 and older. Their data has shown that people with boosters have a lower risk of getting a breakthrough infection and need the booster sooner. Why was the Pfizer vaccine not changed?

6) The U.S. Supreme Court rules on vaccine mandates

  The Supreme Court, on January 13, ruled against the mandates for businesses of 100 or more employees (80 million people), however, they allowed the mandate to remain for healthcare workers (20 million people).

  Any business can still require mandates, just not through the OSHA* route. Mandates will remain on the military and those that contract with them. Again, those with natural immunity are not counted in any way.

*Occupational Safety and Health Administration

  Mandates in the past, require the vaccine to protect the individual and the public, however, with the virus able to infect those even with boosters, that thesis does not fit.

7) 75,000 military refusing the vaccine

  40,000 Army military have refused the vaccine and are causing major concerns for our defense. 25,000 Air Force, Navy and Marine are added to the number. 10,000 in the Reserve and National Guard have refused. It is also creating a serious impact on recruitment. There is already discussion about mandating the booster.

  70% of those 17-24 are ineligible for the military, due to obesity, lack of a high school degree, past drug use, and criminal records. Mandates are helping.

  The Department of Defense estimated that 2% of the 20.6 million 17-21 year olds have the desire combination of strong academic credentials, adequate physical fitness, and an interest in serving.

  Add these together, and we have close to 75,000 military that could be lost out of 1.4 million total military.

  Initially, they were threatened with a dishonorable discharge but Congress blocked that stupidity. The main concern is veteran benefits and retirement funds.

  These men and women have devoted their lives to defending our country, and as a USAF retired flight surgeon, I am in total support of their devotion, patriotism, and sacrifices (including their lives) they have made. God bless them! They deserve VA benefits…all of them.

  The Supreme Court ruled only on the OSHA decisions for healthcare workers and big businesses, not the military.

8) Changes for days of quarantine and post-5 day testing; Dr. Walensky speaks

  The AMA’s President, Gerald E. Harmon, M.D., criticized the CDC for not recommending testing after 5 days of isolation. The CDC was already criticized for changing the quarantine period from 10 days to 5(31% that are infected are still infectious after 5 days).

  There are 2 reasons: the shortage of home rapid antigen tests, and the administration waiting too long (January) to purchase millions of tests when recommended in October. Now finding a test or standing in a long line is the result. The 4 tests per family being made available is just a start.

  Countries such as the UK have provided free home tests to all their residents months ago. This administration did not feel testing was important, and only pushed the vaccines, a noble effort, but certainly not the only strategy to combat the virus.

   Because the Omicron variant can infect those with vaccines and boosters, and the booster immune levels remain high for only 3 months, which has dropped enthusiasm to get vaccinated. This is partially the reason Israel is recommending a fourth vaccine for only those over 60, immunocompromised, nursing homes, and medical workers. They have become the global leader in vaccination information and guidance, according to Prime Minister Bennett. Mdlinx, Jan 3, 2022

  Since the CDC recommended a test optional after quarantining for 5 days, Dr. Harmon feels that is a mistake and is concerned and will overwhelm the medical facilities. There have been so many changes in recommendations from the CDC and the White House, it has created a lot of controversy and indecision.

  It was just announced that oral testing may be more effective than nasal testing, since Omicron may delay a nasal test being positive. Other countries are already using them. This is another issue that deserved major attention when testing was first started. Oral swabs would have been so much easier. But even today, the FDA and the CDC does not recommend oral/throat testing. The UK has recommended for some time either a nasal or oral swab. MDlinx, January 7, 2022

  Business and schools require negative testing to stay at work or in class. Flying requires a negative test 24 hrs. before the flight. All these issues clogged access.

www.ama.org

  Even the CDC stated that 31% of infected people are still infectious after 5 days.

Dr. Walensky, CDC Director, tried to clarify the change, by stating it was very important for those symptom-free after 5 days wear a mask and not go to restaurants and areas where people gather as they are still contagious. Certainly, if symptoms are still present, they should isolate for 10 days.

  She also stated kids 12-17 should receive their booster 5 months after the last dose of Moderna (6 for Pfizer). Only 35% of adults have received the booster. Only 16% of children currently have been fully vaccinated.

  Also asked at her press conference about Israel’s recommendation to consider a 4^th dose, she stated she is in communication with them, but the U.S. is way behind on the booster administration. 63% of Americans have been fully vaccinated, but with only 35% boostered, a 4^th dose is not a consideration at this time. Medpage Today, Jan. 7, 2022

  Dr. Walensky announced that 75% of hospitalizations have at least 4 underlying risk factors. Medpage Today, Jan. 7, 2022

  Information from South Africa, where the Omicron variant began, has found a tremendous drop in hospitalizations and deaths with Omicron compared to Delta. This is in a country with less than 20% vaccinated. It is 4-5X less severe than Delta, according to a publication in the International Journal of Infectious Diseases, Dec. 28, 2021

  Dr. Walensky also admitted miscommunication regarding CDC guidelines and vowed to do a better job, according to the WSJ* and hopefully she will be clearer in the future.

*Wall Street Journal, January 9, 2022

9) Home testing now available

  When the CDC was approached by companies who could manufacture millions of home tests, the administration said no, and continued the approach that the only way to get the pandemic under control was the vaccine. Home tests have been hard to find.

  Some unauthorized testing sites and home test kits can be purchased online that are unlicensed and the results can not be trusted, misleading the public, according to experts.

  As of January 18, there 4 free tests per family by logging on to: www.covidtests.org

  It was stated on Fox News that the tests sent out by the government are from China.

  4 tests per family is not enough for most people, if they are being required to test biweekly. Also, only 60-70% of tests are sensitive for several reasons, so as many as 30+% will be infected and have a false negative. Always retest in 2 days if symptoms persist.

  The FDA has also found that home rapid antgen tests are not as sensitive for Omicron. They still work, but there will more false negatives. Mdlinx, Dec. 29, 2021

  Again, if symptomatic, isolate, no matter if you have a positive or negative test. Rapid antigen retesting is a must with sick individuals within 2 days (or a PCR test can be performed, but these tests can be positive for 90 days).

  The CDC says it is only optional to get a test after 5 days if asymptomatic and free of fever for 48 hrs. Most hospitals are allowing their staff to return after 5 days as well, and will be welcome, as the staff shortage has created a lot of the problems for hospitals keeping all their beds open.

  The AMA does not agree with no testing after 5 days,  since 30% of people still test positive, according the CDC. This is what happens when supplies are not readily available.

  To purchase more tests, log on to Amazon.com for COVID home tests (20 tests for $229) which must be purchased but many insurance companies may reimburse if applied for. Check with the insurance to be sure.

10) Children—Vaccines and emphasis on keeping schools open; diabetes increased in infected kids (and adults); Hospitalized children 

  Some school districts didn’t get the memo from the White House to keep schools open. Many are teaching very controversial race-separating theories to our children.

  As Abraham Lincoln said, “one generation of education will determine the next generation of government”. Over 60% of those 30 and younger already support socialism and worse. GenX is marching to a different drummer.

  The Administration is trying to keep kids in school, and has announced some actions to come soon:

  1) 5 million no cost tests per month to schools, both rapid tests and PCR tests 

  2) Deploying federal surge testing sites for students, school staff, and families

  3) Developing COVID testing providers to set up school testing programs

  4) Offering new training, resources, and materials for implementing “ test to stay” in schools to increase education for school staff with fact sheets, etc.

  It is critical to keep schools open and any school that does not comply, and yet the Ivy League Schools have all gone virtual, and over 300 schools around the country with home classes that has reduced learning experiences. Medpage Today, January 12, 2022

3 doses of vaccine for children

  Pfizer, in their clinical trials, has had to switch to 3 doses for children 2-4 as their 2 doses were too weak ( trying to reduce side effects). This is admirable, but 3 doses is a lot to get children fully vaccinated. Vaccines are not approved yet for ages 2-4. They are also giving this dose to children 6 months of age as well. If immune response is sufficient, they will apply to the FDA for approval. A third dose is also being studied in kids 5 and older.

  In California, the government has encouraged schools to vaccinate the children without their parent’s permission. OMG!

Vaccines available for ages 5 and up; boosters 12 and up

  Vaccines are now approved for those 5 and older, and for those 12-17 now are eligible for boosters. Pfizer has developed a vaccine for children 6 months-4 but found their 2 doses were insufficient and now are working with 3 doses in their clinical trials.

  Only 25% of younger children are getting vaccinated because they are not likely to get sick, and parents want more information about the long term effects of the vaccine.

  Some parents see this maneuver as using children to protect adults, and many resent this, with no science proving a great value in keeping children out of the hospital (except those with underlying medical conditions), with no long term studies on side effects. Medpage Today, January 5, 2022

COVID and Diabetes

  Recent studies have shown that children who are infected with COVID-19 have an increased risk of developing diabetes, showing a 2 fold higher risk (166%). There are studies that also have seen higher rates in adults of developing diabetes after an infection. 

  The cytokine inflammatory markers stimulated by the virus create stress hyperglycemia, and change glucose metabolism. As many as half of these children develop a serious effect of hyperglycemia (ketacidosis), requiring insulin management and hospitalization.

  This is clearly a good reason for children to be vaccinated especially with a family history and or obesity.

Medpage Today, January 7, 2022

Children in the hospital—characteristics

  The American Academy of Pediatrics, January 21,2022 reported on 915 children from 6 hospitals during the summer of 2021. Here are some facts:

  a-38% were 12-17; 20% were 5-11; 17% were were 1-4; and 25% were less than 1.

  b-68% had underlying disease with 32% obese; 16% had co-existing viral infections, the most common was RSV (respiratory synchial virus most commonly in kids under 5)

  c-30% required ICU admission with 1/3 having underlying diseases—average length was only 2 days, and double that for those obese

  d-only 1 was vaccinated

  e-death rate 0.02%

11) Racial issues a factor in the pandemic?

  Some politicians are trying to make the pandemic a racial issue, stating that non-white people should get treatment preference, because they have higher hospitalization rates and, therefore, race should be a legitimate risk factor. Is it because the administration did not push treatment options earlier for these people of color, and what was done to increase their desire to get vaccinated and relieve their fear of the government? Not acknowledging natural immunity in these groups is a mistake, because people of colr have a high incidence of infection.  

  This may be a disperity issue for some politicians, but is  unconstitutional to make one group preferred over another, an attempt to separate the races and create more animosity, division in our country, and anger. (a classic factor in promoting socialism).

12) No changes in fertility for women after COVID vaccines; different for men with infections

  Amercian Journal of Epidemiology, January 20, 2022, reported that COVID vaccines for couples did not have a lower liklihood of getting pregnant, but previous infection with COVID-19 could affect male fertility. Couples who had a male partner infected with COVID-19, had an 18% lower liklihood of achieving pregnancy within 60 days of the vaccination.

  Vaccination does not cause infertility,but the infection can affect fertility in the short term.

  Other studies have reported similar results, so couples who want to get pregnant have no excuse not to be vaccinated. 

13)  No Rules for illegals, Crime and Fentanyl

  We have a health crisis on our southern border. COVID is spreading, and 2 million people are coming here needing money, healthcare, transportation, and housing, and they are getting it. Allowing these poor people across our border is not humanitarian, it is political!

  We have had major rules for certain groups (healthcare workers, first responders, larger businesses, school children, etc.) while ignoring any rules for the 2 million (low estimate many experts say) illegals that have  crossed our southern border in 2021, spending $billions to transport them all over our country, without testing, and  vaccines. $94 billion of pandemic stimulus money has been spent to manage this “cattle crossing”. It’s tax payer money!!

  Illegals can now fly on commercial airlines with no ID, only their warrants and future court appearance documents. Are you kidding me?

No emphasis on Crime and Fentanyl crisis

  The open border has allowed enough fentanyl to cross our southern border that potentially could kill the entire country (with 100,000 accidental or suicidal deaths in 2021 from this killer with lacing of many street drugs from marijuana to oxycodone, amphetamines, and cocaine). Street drugs are “cut” with carfentanyl with disastrous deadly results.

  The administration has ignored (stopped ICE) over 400,000 got-aways brought over the border by Mexican cartels (they are making over a $1 billion a month), with a shortage of border security aggravated by the pandemic.

  These criminals have skyrocketed human and sex trafficking, child abuse, and sexual mistreatment of thousands of women. Where is the “ME TOO” movement advocating for these abused women?

  Some of the mandates and shutdowns have not proven effective ultimately, but are still being pushed to raise the current 63% who are fully vaccinated (37% have had a booster). Omicron requires different strategies.

  Omicron has been a wakeup call that we may be coming closer to the end of the pandemic, but also realize constant genomic sequencing is mandatory to discover new variants that might not be so mild. We must hope scientists in contries globally will notify us rapidly (like South Africa and not China). The vulnerable must continue to do everything they can to stay safe. The pandemic will become endemic, but will still deserve serious respect and constant surveillance.

PANDEMIC FATIGUE IS PANDEMIC!

14) Myocarditis caused by COVID VACCINE

  Myocarditis has been one of the most feared side effect of the vaccines, but initially the pharmaceutical comoanies stated that the disease caused more heart issues than the vaccine. We finally have some high quality studies to settle this issue.

  Based on VAERS* data, the website that is used to report side effects of vaccines, states that there is an excess of cases from the vaccine over the number of cases from COVID.

*VAERS=Vaccine Adverse Event Reporting System  

  Myocarditis occurs within 7 days of the dose, more often the second dose, most common 16-17 (105.9 per millon doses), 12-15 (70.7 per million doses), and 56.3 per million doses for 18-24. Most were hospitalized with elevated blood troponins, abnormal EKG, and abnormal MRI. 87% were free of symptoms by discharge after receiving immunoglobulins and corticosteroids, as reported by the JAMA. They state that underreporting is likely.

  Therefore, myocarditis is associated with vaccines. Moderna reported higher numbers initially than Pfizer. But the FDA felt the side effects were low and the risk benfit ratio should be discussed with parents about their young male children.

  This data is only 3-6 months old, so there is no long term data on these young people.

  It is reported that myocarditis occurs in about 100 per million people from COVID-19. So there is a slight increase in cases from vaccines over the disease.

  Most present with chest pain, fullness, and shortness of breath. Their EKGs show various abnormalities that recede in time. Sinus tachycardia with various ST-T wave changes indicating damage to the heart muscle, and the MRI can demonstrate thickening of the heart muscle wall, as seen in these MRIs.

The good news is most of these youngsters completely recover. But it is an issue to consider.

2. Autoimmune diseases-Part 2

  Last month, I reported on a few of the more common diseases in this list of over 100. Lupus, dermatomyositis, scleroderma, and type 1 diabetes. This month, I will add to the list starting with rheumatoid arthritis and multiple sclerosis.

  8% of the U.S. population is affected by autoimmune diseases but 78% are women according to the CDC. There is circumstantial evidence that prior infections play a role in women. Female hormones seem to play a role in these considerable difference between sexes.

  Only heart disease and cancer is more common than this category of autoimmune diseases.

  I have reported on COVID-19 for 2 years, and understanding how the immune system can go wrong with this viral illness should be well understood if reading these monthly reports. It is the same immune system that goes wrong for unknown reasons and causes many diseases.

THIS IS A REVIEW FROM LAST MONTH DEFINING AUTOIMMUNE DISEASES:

  An auto-immune disease is defined as an abnormal stimulation of the body’s immune system turning it against some part or parts of our body where inflammation is detected. What causes that inflammation is not totally understood, but it is known there are genetic markers involved, and they run in families at times.

  The immune tissues contain lymphoid tissue, such as lymph nodes, tonsils, the spleen, bone marrow, and other tissues. See the drawing below, which was used last month as well.

  Normal healing depends on our immune system. It is a normal process to create a response when injury or disease occurs, by stimulate the right blood cells to flood an area that begins the process of healing. That does not work so well in these autoimmune diseases. Very specific areas in the body are seen as foreign, such as the lining of a bony joint, or the skin, etc.

  Environmental exposures combined with genetic factors are often the key to the disorder. The CDC points to past infections inciting the immune system predisposing an individual to these diseases.

  There is considerable overlap between these autoimmune diseases, as mentioned last month. Fibromyalgia is one of the most common overlapping illnesses.

  A recent publication of research from the University of Colorado with mice found that those with antibody- induced rheumatoid arthritis in their joints went on to develop spinal lesions very similar to spondylo-arthritis which then caused fusion of the vertebrae and curvature or bending of the backbone. They commented that this implies they are seeing a rising incidence in autoimmune diseases, with connections already known such as gum disease, which is known to cause serious inflammation affecting the entire body, and other eye diseases such as  macular degeneration. MDlinx, Jan. 5, 2022

  According to the NIH*, the following exposures influence some of these disease—*National Institutes of Health

a) Sun exposure with lupus b) Childhood poverty with rheumatoid arthritis c) Agricultural pesticides with rheumatoid arthritis in males d) Mercury exposure in food and drink influences the development of inflammatory bowel disease (Crohn’s and Celiac), lupus, and rheumatoid arthritis e) Genetic factors in Caucasian populations in Europe and the U.S. f) Smoking tobacco is linked with rheumatoid arthritis g) Vitamin D and nutrition may influence multiple sclerosis and lupus.

  The most common parts of the body affected are the joints, skin, and thyroid, although all organs are at risk.

  The top 10 diseases, according to the autoimmune registry are:

1-Rheumatoid arthritis, 2-Type 1 Diabetes, 3-Systemic Lupus Erythematosis, 4- Inflammatory bowel disease (Celiac disease, ulcerative colitis and Crohn’s disease) (not to be confused with IBS-irritable bowel syndrome most likely stress induced) 5-Skin symptoms and diseases-vitiligo-white spots, blisters, rashes 6-Rheumatic fever 7-Thyroid diseases-Hashimoto’s thyroiditis and Graves disease 8-Pernicious anemia 9-Alopecia areata10-Autoimmune thrombocytopenic purpura

  Women have 78% of autoimmune disease, therefore, female hormone must play a role. Those in the childbearing age, family history, enviornmental exposures, and certain ethnic groups (Black and Hispanic, although type 1 diabetes more common in whites) are also risk factors.

  The top 4 diseases women suffer from are:

1-Lupus 2-Multiple sclerosis 3-Thyroid diseases (Hashimoto’s thyroiditis and Graves disease) 4) Rheumatoid arthritis

This month, rheumatoid arthritis and multiple sclerosis will be covered.

1--Rheumatoid arthritis (RA)

  This type of arthritis can be a very disabling type, compared to osteoarthritis (wear and tear arthritis, gouty or psoriatic arthritis.

  As in all autoimmune diseases, RA attacks the collagen (protein) in the joints, mostly hands, feet, and knees, but any joint can be involved. It is the lining of the joints that is attacked and is inflamed. This causes fluid to form and deterioration of the joints often with deformity. It also causes chronic pain, and make the joint unsteady and not function as well. But since autoimmune diseases are collagen-vascular diseases, it can inflame other organs including blood vessels in the heart, lungs, and kidneys. RA can also affect the eye as well. Nodules in the skin may occur as seen below.

Deformity of the arthritis

Pain, stiffness, swollen joints, weight loss, fever, fatigue, and weakness accompany this disease at times.

Eye diseases in RA

1-dry eye syndrome

2-Sjogren’s syndrome with dry eyes from disease in lacrimal glands, dry mouth from disease in saliva glands including swelling of the glands.

3-episcleritis-inflammation of the sclera, the white part of the eye, mimicking “pink eye”.

4-uveitis-inflammation of the uvea, causing floaters and vision problems. The uvea is part of the middle layer of the eye, lying directly under the sclera, made up of the iris, ciliary body, and choroid. Check the Mayo Clinic website for details.

5-peripheral ulcerative keratitis (PUK), a serious inflammation of the blood vessels of the eye, ulcerations of the cornea, which can cause redness, pain, and light sensitivity.

6-retinal vaculitis, which is inflammation of the back side of the eye, which can cause vision difficulty.

7-glaucoma as a side effect of inflammation of the anterior chamber of the eye.

8-eye toxicity caused by eye medication such as plaquenil and chloroquine, which can damage the retina. Steroids can raise the eye pressure and create cataracts.

 Anti-inflammatory drugs and other medications are the mainstay of treatment. Ophthalmologists can diagnose and treat these diseases in those with RA or not.

Stages of RA:

RA may affect the spine as well, and most commonly affects the cervical spine. The symptoms are similar to osteoarthritis (pain, stiffness, loss of range of motion, headaches, warmth, pain radiating down the arm, etc.).

The above X-ray of the cervical spine shows lipping of the vertebral body, narrowing of the vertebral spaces, a displacement of the vertebrae (spondylolisthesis). The lower back can be involved and osteoarthritis can be present as well.

RA may not start until the 60s but can occur at any age. It is 2-3 times as common in women, as are most autoimmune diseases.

Advanced atherosclerosis and heart muscle disease (myocardits), heart failure, arrhythmias, stroke, and can cause as high as 40% of deaths in RA patients. The risk of heart attack increases by 60% after one yer with the diagnosis of RA.

  Vascular disease in other organs, such as the kidney, can cause disease.

  Genetics is involved and can run in families. The HLA gene (human leukocyte antigen) make the disease worse especially if accompanied by environmental factors such as smoking, and also in the obese. Women who have never given birth are more likely affected especially if their mothers were smokers. Also those in lower socioeconomic status tend to have a higher incidence. Breast feeding seems to be protective.

  Because of the severity of the disease, a rheumatologist should be consulted to assist a primary care or internal medicine doctor. In the early stages of the disease, RA can mimic other autoimmune diseases such as lupus, Sjogrens disease, Lyme disease, and osteoarthritis.

  Laboratory evaluation will demonstrate a positive RA test (>20u/dl), the ANA test (antinuclear antibodies) may be positive, an elevated anti-CCP (anti-cyclic citrullinated proteins) >20u/dl, abnormal findings in the CBC, and the   sedimentation rate may be elevated. All of these tests indicated inflammation.

  X-rays will eventually demonstrate deformity, joint swelling, however, not early.

  A workup involves keeping other collagen vascular diseases in mind. These diseases have similar symptoms at some time during the process. Skin diseases (nodules) associated with these joint and organ inflammatory responses may differentiate them. Here is a list of skin abnormalities that may be present, but can occur with other autoimmune diseases such as lupus, scleroderma, and dermatomyositis.

Treatment is similar to that described for these other autoimmune diseases including corticosteroids, NSAIDs-Celebrex, antimalarials and other disease modifying drugs such as hydroxychloroquine (Plaquenil), immunotherapy drugs (Arava, Azulfidine, and Xeljanz), and chemotherapy (i.e.Methotrexate). Injectible biologic agents such as Orencia, Humira, Cimzia, Enbrel, Remicade, and Kineret will be offered if the above drugs don’t control the pain and swelling.

  Before these medications are started, a tuberculosis skin test should be performed, as with a diminished immune system. Other infections are also more likely. A good antibody response from vaccines may not occur. There is research under way to determine the value of a third dose of COVID vaccine.

 Losing weight will help the stress on these joints.

Surgery for RA

  Surgery is a last resort, but when indicated, is a very effective. The neck is managed as any spine surgery would be, with relief of spinal nerve pinching, loss of vertebral stability, fixation, and removal of bone pressing on the spinal cord.

  Splints are used in most patients with disabling hand or foot disease. Prostheses replacing finger and knuckle abnormalities can provide return of function. Here is an example of a before and after of the right hand with good results on the left hand.

Left Side (Before) Right Side (After)

Prognosis

  Living with RA requires close monitoring of the patient with pain management consults, other internal medicine specialties depending on what organs may be involved, dermatology, ophthalmology, pulmonology, psychological and support services, and surgical consultations.

  Stiffness, pain, lack of mobility, and functions of joints require physical therapy, occupational therapy, and exercise (best to use aqua therapy), limiting further inflammation with the immune modifying agents, and major attempts to manage depression and anxiety, stop smoking, and pain medication abuse. Osteoporosis and other complications can occur, especially in those taking corticosteroids, and side effects of medications (anemia, infection, cancer-lymphoma,etc.).

  It is a challenge for patient, doctors, and families, but with coordination of services and care, a good quality of life can occur, expecting setbacks with more needed treatments, and accepting progression of disease in many of the patients.   

www.rheumatoidarthritis.org

2- Multiple Sclerosis

Incidence

  MS is the most common disabling disease of young people (usually diagnosed between age 20-40) with more than 400,000 cases in the U.S. (Multiple Sclerosis Foundation) with about 10,000 new cases each year. 2.8 million people globally are affected.

  3-5% are diagnosed before the age of 18. Twice as many women are diagnosed with MS as men, however, males frequently have a more serious type of MS. Caucasians are more likely to develop MS than other races.

Cause of the disease-new data

  New research confirms that Ebstein-Barr virus is the cause of MS, according to the authors from Harvard Medical School.

  Most of the patients are infected with the EB virus by age 18-20 years of age. The database came from the military. Of those with MS only one of the 801 had serologic evidence of the EB virus.

  It is not known why some with seropositive EBV get MS and some don’t. If it sounds familiar, it is the virus that caused infectious mononucleosis, however there is no vaccine for this virus.

  A vaccine could theoretically be developed to prevent the disease, and prevent MS and mono, just as the vaccine for HPV-(human papilloma virus) vaccine prevents genital, anal, and cervical cancers and probably oral and throat cancers.

J. Science, January 13, 2022

Mechanism of disease

  This neuro-immunologic disease affects the fatty lining (sheath) of nerves, creating loss of nourishment to the actual nerves causing defective neural signaling, which affects the nerves to the eye, brain and spinal cord.

  The body create an unknown autoimmune reaction against the myelin (a protein) in the sheath, the process  called demyelination. There is no known cause for this immune reaction anymore than why people develop rheumatoid arthritis. A specific nerve cell (oligodendrocyte) creates the myelin sheath, which is attacked. (drawing left).

The sheath is attacked by the immune response. The drawing (above right) shows the difference in a normal nerve and one affected by MS. The sheath is irregular with loss of the myelin in places with resultant scarring, neurological consequences (numbness, pain, weakness, etc.). 

  MS lesions correlate with progression of MS proven by special MRIs to detect early disease and more aggressive therapy.

Ref. The Journal Multiple Sclerosis, Dec., 2018 

Symptoms

  Symptoms are subtle, sometimes for years, leading to years of misdiagnosis. The average time it takes to verify a diagnosis of MS is 10 years. Numbness in different areas of the body, visual symptoms (double or blurred vision), balance and dizziness issues, muscle weakness (and or spasms) and fatigue that come and go (remissions and exacerbations) are some of the most common symptoms. Less common are speech and cognitive difficulty (40-70%), mood swings and depression, trouble walking, sexual dysfunction, bladder and bowel symptoms. Insomnia is very common in these patients.

Risk Factors/Genetics-new information

  One study found there was a significant number of female family members who demonstrated decreased vibratory sensation in the lower extremities even without demonstrable disease. Surveillance of family members is recommended. 15% of these patients have a family member with MS.

  There is no known genetic defect yet but it is estimated that if a family member has MS, their offspring has 2-5% risk of developing MS. Identical twins have a one in three chance of developing MS. If there is a family history, the patient is more likely to have an increased chance of severe brain damage on MRI scans.

  Smoking, infections, low levels of Vitamin D (often present in MS patients), and infections with EBV (Ebstein Barr Virus-infectious mono) are now known to be risk factors. The shingles virus is being studied. MS is not contagious! 

  Other risk factors (mild) include a diagnosis of other autoimmune diseases- thyroid disease (Hashimoto’s thyroiditis, inflammatory bowel disease, and type 1 diabetes mellitus.

  It is interesting that when women get pregnant, their symptoms frequently disappear but return a few months after giving birth, implying higher levels of estrogen during pregnancy may be protective and after delivery, the levels drop correlating with a relapse and more symptoms.   

  A common trigger for many autoimmune diseases is stress, mental or physical. Heat is particularly stressful on these patients, since many are not able to normally get rid of heat in their body due to dysregulation of the system. They are very prone to heat exhaustion and getting overheated can bring on a relapse. Getting overly tired and fatigue also can also bring on an episode.

  A new study demonstrated that food allergies could trigger an attack of MS. Control of these allergies would be recommended.

Clinically Isolated Syndrome (CIS)—the first symptom(s) of MS

  CIS is defined as the first episode of neurologic symptoms that lasts at least 24 hours and is caused by the first clinical evidence of inflammation or demyelination of the nerve(s). It can be a single neurologic symptom (monofocal) caused by one lesion or more than one neurologic symptoms (multifocal), such as isolated optic neuritis or associated with numbness, weakness, dizziness, etc.

  The development of CIS may or may not proceed to a clinical diagnosis of MS. Obviously, a neurologic workup is indicated in all cases suspected of MS including an MRI, which is diagnostic in most cases with lesions visible on the scan.

  An evaluation of the cerebrospinal fluid may show oligoclonal bands, which are special cells that are seen in the CSF fluid and is diagnostic for MS as well.

  If CIS occurs, and a diagnosis of MS is made, treatment would be started immediately. However, a significant number of patients will have no further symptoms for weeks or months, or never.

  There has been controversy on whether deciding to start treatment on patients who are highly suspected but not confirmed. Recent studies published in the journal Neurology followed these patients for years, and found that CIS patients found that early treatment with immune modifying medications had a better prognosis for the future with less progession. Neurology, Oct. 26, 2021

  This decision would come from a risk benefit discussion with the patient and family. The psychologic effect of being told a person has MS is extremely emotionally devastating. Living with any potentially disabling disease requires great support from family and friends and learning to cope. 

Types of MS

  There are different types of MS—5 (these are the revised types). These types are based on the frequency of episodes with or without periods of no symptoms or no progression.

1-Relapsing/Remitting is the most common (means symptoms go away or get better but come back which may be the same symptoms or new ones). 85% are initially diagnosed with this type. Relapses usually occur every 9-12 months.

2-Primary Progressive (slowly progressive with no relapses or recovery-about 10% of people).

3-Secondary Progressive (progressive with or without remissions; no recovery);. It is called secondary because most of the people with primary progressive eventually are diagnosed with this type.

4-Progressive/Relapsing (5%-the least common) characterized as worsening from the beginning with no recovery. There may be acute episodes with or without some recovery.

5-Non-progressive-There are people (such as my wife) who were diagnosed with relapsing/remitting type initially that do not progress as they age. A Swedish study reported there was a 22% chance of further progression if symptoms remain after age 40 and an additional 14% after 50.

  Therefore, if a woman or rarely a man lives into their 50s, there is over a third of those who will never progress!! Looking back at these patients, they had the mildest symptoms to start and had milder relapses.

  Another name for this group is NEDA (no evidence of disease activity) by neurologists. For the first time, the goal in treating many MS patients is to get them into this category with no evidence of activity rather than just controlling the disease.

  Thankfully, my wife fits in the non-progressive type with no symptoms for many years. Heat still can cause problems with her if she overdoes it. Years ago, she stopped taking any treatment and has no relapse at all. Ceasing treatment after several years of non-progression is again a serious discussion to have with the neurologist. Many are reluctant to stop treatment, but it is an option in very selective cases, considering the cost alone.

Diagnosis

  The diagnosis is made with an MRI scan, which shows classic holes in the brain (white areas in scan on the right scn), and depending on where these defects are present, it will determine the symptoms. These MS lesions are called plaques.

MS can affect primarily the spinal cord and cause severe weakness, difficulty walking, bladder and bowel symptoms, but lesions of the brain can occur in these patients as well. Below the scan of the spinal cord demonstrates a lesion (arrow) in the upper spinal cord.

Tracking the progress of MS

  The clinical history of progression is the most common way neurologists follow MS patients  (not tests). Standard MRIs may be offered depending on the clinical course, developing new symptoms, or patients just worried there might be more lesions without new symptoms.

  A new experimental monitoring method is following levels of iron in specific areas of the brain using special MRIs. Specifically, MS patients have higher levels of iron in the deep gray matter structures (basal ganglia) and lower levels in the thalamus.

  Brain atrophy is another method to monitor MS patients but it is independent of iron brain levels. In brain atrophy the brain actually shrinks in size.  

  Low iron levels in the thalamus are thought to be due to death of iron-rich oligodendrogliocytes (the cell involved in providing myelin enrichment to the lining of nerves). These findings correlate with disability in these patients.

  Time will tell if iron levels are a better way to follow MS patients, and are also being used to distinguish Parkinson’s disease from other types of diseases with tremors and are being used to predict progression of Alzheimer’s disease.   

Treatment

  a) Medications

  There has been great progress in treatment over the past decade. The mainstay in treatment still provides anti-immune and biologic therapies, but there are some excellent improvements. The focus of most of these medictions is to focus on the B cell lymphocyte which is thought to be the source of the immune dysfunction in causing MS.

 These treatments are extremely expensive. My wife’s used to take Avonex (an older treatment) and now costs an outrageous $7000 for weekly injections for a month, a medication that is over 20 years old. There are grants that can be applied for in helping with the cost and financial assistance from the drug companies.

Just recently the FDA approved ocrelizumab (monoclonal antibody)—IV infusion every 6 months, which is 95% more effective than Avonex and has dropped the relapse rate by 50% in remitting/relapsing MS. Ocrelizumab (Ocrevus) and ofatumumab (Kesimpta), cladribine (Mavenclad), siponimob (Mayzent), and other new immune modifiers are also FDA approved. The choice of medication depends on the experience and success in using particular drugs.

  The first FDA approved treatment for pediatric MS is fingolimod (Gilenya), which is superior to the interferon treatments, with 85% relapse-free periods of over 2 years according to a recent report in the NEJM-Journal Watch, October, 2018.

  With these treatments, they have changed the course of progression in a significant percentage preventing those with primary types from progressing to secondary types of MS from 50% progressing to about 1% per year. Even though many patients require canes and wheel chairs eventually, their disability has been lessened and their progression slowed with better quality of life.

  b) Vitamin D is still thought to play a role in MS and Vitamin D3 is recommended even without a deficiency by most neurologists (including my wife’s). Some studies suggest that MS patients may have less severe symptoms on a maintenance dose of vitamin D3 and may have a protective effect against MS. The connection may lie in D3’s positive effect on the immune system. There is also a connection between more cases of MS in northern colder climates with less sunshine (Vitamin D).

  The Institutes of Medicine normally recommend for ages 19-70, 600 IU daily of D3 and 800 IU for those 71 and older. If deficient, 50,000 IU orally weekly for 3 months are needed to return the vitamin D levels to normal. Some neurologists recommend maintain that dose, and must be discussed with the neurologist. There is no uniform recommendation from neurological organizations regarding the dose of Vitamin D3 in MS patients. High levels of Vitamin D can be toxic, and therefore, levels must be followed.   

   c) Treatment of symptoms and disability

  As one might expect, there is a tremendous amount of time and expense treating the neurological consequences of MS. Rehabilitation and physical therapy is critical in keeping quality of life optimal. Weakness and spasticity must be addressed. Occupational therapy is critical to keep patients as independent as possible.  

  Some of the most common complications of MS are muscle stiffness, fatigue, balance issues, weakness, and or paralysis of the lower legs, speech and swallowing difficulties, bladder (incontinence)/bowel dysfunctions(constipation), psychological issues (depressionvery common), and even seizures. All these issues affect daily life and must be constantly addressed and managed.

Research

  Stem cell research is now being used in clinical trials (not FDA approved) on a select number of patients who are not responding to the standard medications (remitting/relapsing and progressive types). Stem cells are removed from the patient’s own bone marrow.

   A collaborative study (5 countries) presented 55 patients who were treated with a stem cell transplant who were medication failures (and the control group of 55 patients who were treated with medications only). The results were quite amazing. After one year, the stem cell group had only one patient that relapsed and the control group (treated with medications only) had 39 out of 55 relapsed. These patients are currently being followed for 5 years. (Presentation from European Society of Bone Marrow Transplantation, 2018)

   Stem cell treatment can have serious side effects and those issues must be weighed when considering stem cell treatments.

  This is a technique used to replace the previous immune system in these patients, which created the disease in the first place. The results are encouraging but still not FDA approved as a standard treatment because of safety concerns.

  A blood test that identifies a protein that is released by damaged nerves is being studied. Hopefully in the future that will help with selection of patients for specific treatments. Diet, exercise, and stress management all seem to be helpful in controlling symptoms. The influence of the gut bacteria (microbiome) on MS is being studied as well, as these bacteria play a key role in our immune system.

  These patients are considered good candidates for medical marijuana especially for spasticity.   

Outcome

  About two thirds do not need a wheel chair and can lead very successful normal or near-normal lives. Canes and walkers may be needed.

  It is stated that on average, MS shortens the life span by about 7 years. But with the current success using newer therapies and exciting research, optimism is high in controlling MS relapses and increase the number of patients who do not progress.

 National Multiple Sclerosis Society, Healthline, NIH

Part 3 of Autoimmune diseases will include thyroiditis, inflammatory bowel disease, and primary skin involvement from immune related disease from the top 10 list.

3. Degenerative rotator cuff tears—shoulder pain--management options

  I have previously discussed total joint replacement of the shoulder joints and repair of the rotator cuff tears and strongly recommend you review those 2 articles:

www.themedicalnewsreport.com/39/40

  To understand the anatomy of these 4 key muscles (supraspinatus, infraspinatus, subscapularis, teres minor), please review the above articles.

  Chronic shoulder pain is a common problem, and requires orthopedic evaluation for the cause and proper management options need to be discussed. Lack of range of motion implies the beginning of a frozen shoulder usually from contracture of muscle tears in the rotator cuff, requiring management ASAP. The shoulder joint itself, of course, may contribute to this. Bone on bone causes not only pain, but it can create loss of range of motion.

  Seeing an orthopedist who specializes in upper arm surgery is recommended, as the shoulder is very complex. I have had both shoulder joints replaced.

  If a person is having pain at night interfering with sleep, that is one of the best indicators that seeking consultation is indicated. Athletes and  the rest of us too will have trouble using the upper body for golf, swimming, tennis, etc.

  Regardless of the cause, the shoulder must be strengthened to combat the pain and prevent loss of motion. Denying the issue will only allow the pathology to worsen, and release of the joint scarring may be required under general anesthesia.

  Of course, intensive supervised physical therapy is often successful and must be compulsively performed. I have had to continue shoulder exercises for years, as degenerative changes will occur with the rotator cuff creating more physical therapy to maintain strength and range of motion.

  Below is a drawing on the right shoulder from the backside. The supraspinatus muscle allow elevation of the arm away from the body, whereas the infraspinatus muscle allow the arm to be extended with the thumb up (like a hitchhiker).

  The drawing on the right shows the inside of the shoulder blade as if you were looking from the front of the body.

  These muscles  the most common tears, however, any or all of the 4 rotator muscles can be torn.

The rotator cuff consists of 4 muscles that provide the movement and rotation of the shoulder. Each muscle can be tested with the arm placed in different positions by the physician.

  If there are tears in these muscles it can destabilize not only the movement, but create severe pain and also change the position of the joint itself.

  There are acute rotator muscle tears, which if severe most likely will require surgery with intensive physical therapy for complete recovery. Partial tears may heal with time and physical therapy preventing surgery. The decision for surgery must come from the lack of improvement with conservative measures, and the patient’s need to be relieved of pain and have better function of the shoulder.

  As we age, degeneration from overuse of the rotator cuff occurs and causes serious pain with limitation of motion from pain and lack of rotational strengthening exercises.

  A recent publication Annals of Rheumatic Diseases, June, 2021 discussed aging causes of degenerative tears in the rotator cuff muscles. I am currently suffering from this very issue, but doing much better with physical therapy.

  Physical therapy was compared with surgical repair in both partial and complete tears of these muscles.

  Results--Those who had partial tears did as well with physical therapy alone compared to surgery, whereas the complete tears fared better with surgical repair.

  Seeing a certified physical therapist is crucial for them to teach the individual the precise exercises for the home exercises, using the proper bands, number of repetitions and how often. Depending on the surgeon, they expect the patient to have formal PT usually twice a week, plus a at-home exercise program. My surgeon is a big fan of using a swimming pool for the home program. Pool barbells are inexpensive and really help.

4. Prediabetes; nutritional myths

  While this report applies to prediabetics, it totally applies to anyone with a weight problem or other health problem who needs to develop a healthy life style.

  The word “diet” leaves a bad taste in my mouth….not to make a pun. There are so many angles to the successful weight loss programs, diets, and even medications to assist. It is one thing to lose weight, but keeping it off over a long period of time and positively influencing underlying diseases is another.

  The marketing companies of America are trying to normalize overweightness with plus size models, and Pintrest is banning weight loss ads starting this month advocating for body acceptance. The politically correct are at it again!! Accepting being overweight may be reality for some who have tried and failed with every diet imaginable, but it spells big trouble for the health of our country which is one of the fattest   

  The AMA reported that 1/3 of Americans are prediabetic (pre-type 2 diabetes) and overweight as well., while 10.5% have type 2 diabetes, while 13% of adults have diabetes. According to healthline.com 32.5% are overweight and 36.5 are obese in the U.S. Of course, not all who are overweight are pre-diabetic or diabetic, but 85% of diabetics are overweight. It is a huge risk factor either way and means we are facing continued increasing healthcare costs, because our country has been fattened up with fast food, good tasting fatty high caloric foods, and portion control is not an issue it seems.

  Prediabetes is defined as a blood sugar between 100-110mg/dl. While Type-1 Diabetes is an autoimmune disease starting in childhood, Type-2 Diabetes has a genetic component but is more affected by lifestyle choices.

  Prediabetes is a signal to individuals that those lifestyle choices are going in the wrong direction. Prediabetes is opportunity to assess your health and lifestyle and make changes before the body moves into the type 2 diabetic level (as the body starts being insensitive to insulin, the main pancreatic hormone that adjusts the blood sugar. Excessive blood sugar starts to damage the organs of the body.

   Unfortunately, according to experts 84% of prediabetics don’t know it. People don’t see a doctor for routine evaluations near as often as in the past, and don’t get their blood sugard tested.

Early signs of prediabetes--diabetic.news

  Although largely asymptomatic, there are some suttle signs to look for: 1) dark patches on the skin or darkening of the skin 2) low energy 3) weight loss 4) increased urination 5) thirst 6) weight gain is a primary risk factor for diabetes 7) increasing waist size 8) genetics-family history of diabetes 9) Race-Blacks, Hispanics, Asian-Americans, Pacific Islanders, and Alaskan natives 10) Polycystic ovaries-the cysts can secrete substances that influence the blood sugar 11) Obstructive sleep apnea often correlates with pre-diabetes. 12) Pregnancy-may cause gestational diabetes, a temporary condition, but again correlates with diabetes in the future. 13) Peripheral neuropathy-numbness and tingling usually in the lower extremities

  These signs will usually get worse when true diabetes worsens, but can start before a person is truly diabetic.

  The AMA put out several facts and some myths about diets that apply to almost anyone but certainly prediabetics:

1) Salt myths

  Americans acquire a taste for salt because so many products have salt added. The average person consumes 3400 mg/dl a day while the recommended amout is 2400 mg./dl (1 tsp).

SALT MYTHS--1) you should eliminate all salt from the diet 2) salt is in many products other than food including medications 3) sea salt contains less salt than iodinized salt 4) lower sodium foods have less taste-substitutes include spices, herbs, and citrus all enhance the flavor of foods. 5) not salting my foods means I don’t eat too much salt. 75% of salt is in processed foods. 6) I don’t eat salty foods—poultry, ham, cheese and bread are infused with salt, even butter. 7) My blood pressure is normal so I donlt need to watch my salt intake (The American Heart Association recommends even less salt than the AMA at 1500mg/dl.).

2) Foods that spike blood sugar—starchy foods like bread, pasta, potatoes…the white stuff. High glycemic foods should be avoided. Obviously, candies, donuts, cookies, etc. are a no-brainer. Cauliflower rice and beans are a good substitute for potatoes. A 10 inch small peperoni pizza has 580mg of salt and 3 grams of sugar.

  Basmati (sticky rice) ric has a high glycemic index, which raised the blood sugar. Eat brown rice instead, a high fiber product and a lower glycemic index.

  High fiber nutrients reduce the absorption of sugar from the digestive tract, such as beans, nuts, apples, and citrus fruits.

3) Diets—most diets are somewhat restrictive and to los eweight rapidly requires the body to metabolize foods differently. To lose 1-15 lbs can be easy, but those restrictions will not be healthy in the long run. Do your research before picking a specific diet, but most diets require caloric restriction between 1200-1500 calories but need to be balanced primarily with fish, some chicken, very lean met, vegetables, and fruits.

  If a diet promises rapid weight loss, be very careful!! 

  Restricting carbohydrates will allow loss of weight, but they are still required in the diet long term.

  Once most people reach their goal, the tendency is to gain the weight back. Consultation with a good nutrititionist will be well worth it.

  Avoid sugar sweetened drinks

4. Lifestyle behavioral changes—analysis of triggers for eating, anxiety and depression management, regular exercise (150 minutes a week of moderate intensity aerobic activity), times of the day of danger of binging, alcohol use, and reward days all should play a role. Also, when eating out, a plan of action needs to be in place.

  If psychological consultation seems reasonable, please proceed. Setting small, achievable goals within a timeframe is critical in success with weight loss. Keeping a food log can be helpful. Also planning a routine meal schedule is often helpful. Eating small meals every 3-4 hours will maintain a stable blood sugar and avoid sugarless drinks that may interfere with insulin resistance.

  Meeting recognized nutritional needs with a balanced diet is also valuable long term. Drink plenty of water and do not sit for long periods of time without moving every hour.  

Fatima Cody Stanford, MD, MPH, MPA, an obesity specialst in Boston, and an assistant professor at Harvard Medica School, has co-written a highly recommended book on Facing Overweight and Obesity, A complete guide for Adults and Children

5. Avoid diet labels

  It is more important to emphasize healthy eating with caloric restriction and all that goes into a well-rounded dietary behavior modification that allows slow persistent weigh loss without crash diets, severe restriction of certain types of nutrients, and a great realization that a successful weight loss program is more about behavior modification than dietary control.

6. Avoid sugary drinks and get used to drinking water

  As mentioned before, dietary with sugar substitute colas and soft drinks is known to increase insulin resistance which essentially menas that it take more insulin to lower the blood sugar making diabetes more difficult to control.

  An JAMA network study found that just one 12 ounce juice drink per day increases all cause mortality by 24%, with each additional 12 ounces juice drink increases the mortality by another 11%.

www.ama-assn.org/delivering care/public-health

7. Associated diseases

  Prediabetics are at high risk for 1) hypertension 2) high cholesterol 3) stroke 4) heart disease 5) kidney disease 5) nerve damage 6) vision damage 7) amputations

Mayo Clinic

  They make up a large part of those with the metabolic syndrome (hypertension, high blood sugar, excess body fat around the waist, and high cholesterol). The metabolic syndrome has been reported on by me several times and is high risk for heart attack and stroke.

Summation

  If a person is fortunate enough to catch diabetes at the pre-diabetic stage, take heed and turn it around while it is curable, because once diabetic, it is for life with all the complications of diabetes from blindness, to kidney failure, to heart attacks and strokes, to peripheral neuropathies, etc. I have reported on this disease often, so take the time to look in my subjects index and read about more indepth information on all these complications. 

  This completes the February, 2022 report and begins the 11^th year I have devoted a major part of my life revewing the latest information on a wide variety of health issues. It has been a ministry for me to share it with you, at no charge and with no commercials.  Happy Valentines Day, and remember it is Heart Month, so get a check up, please donate blood now!!

  Next Month, the March, 2022 report will include

1) COVID updates

2) Healthcare disparities

3) OB/Gyn Series—Part 1

4) Gummi bears and childhood poisoning

5) Less Chemotherapy for older patients

6) Cosmetic Skin Resurfacing procedures

Take care of yourself, and thank you for reading the Medical News Report, Dr. Sam