The Medical News Report

January, 2023

#132

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects including update on CPAP recalls:

1. Cancer of the Prostate—an update on options for treatment; side effects discussed

2. The Mental Health of Children—Part 1--autism, anxiety, and depression disorders, ADHD

3. OB/Gyn Series—Part 8—premenstrual vaginitis; lesions of the ovary and fallopian tubes

4. The drug crisis, from marijuana, alcohol, opioids, methamphetamine, and cocaine

5. The Polypill—new info

6. Comments on COVID, RSV, Influenza; vaccine safety

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. If you want this monthly report sent to your private email address, just email me samlamonte@gmail.com

  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

Update on Phillips Respironics CPAP machine recall (for obstructive sleep apnea)

 Phillips announcd more problems with their CPAP machines even after repairing them, and since changing the silicone seal in the machines to dampen the sound, it has created loss of pressure in some machines. If you have been waitng for repair on your CPAP machine, I advise you to seek another machine, as you can’t ignore the nightly obstructive sleep apnea effects on your body.

  Get back with a distributor and find a different machine, if you can find one, since 5 million machines were affected, and the company is now even more behind with distribution of new and repaired machines. Medpage, November 30, 2022

1. Prostate cancer—treatment options—an update; side effects of therapy discussed

A. General discussion

  The controversy between proton and photon radiation therapy continues today when prostate cancer is the issue. I have reported on this issue in 2021, and will discuss its use in prostate cancers below, but also report on all options for treating early prostate cancer. www.themedicalnewsreport.com/111

  Surgical and radiation therapy for early prostate cancer are good options and should be discussed at length. There are new techniques to consider.

  Because, I have 3 friends who are dealing with prostate cancer, I have updated my knowledge on the subject and share it with you.

  I will limit my reporting to early disease, since most men are diagnosed before it spreads out of the gland. Arrow points to the cancer.

Because cancer can run in families, it is now known that  even women who have the BRCA gene, which increases the risk of breast and ovary cancer (and several others) have their male famiy members experiencing a higher risk of prostate cancer and at an early age. This has led to recommendations for those male members in those families to have PSA testing earlier, perhaps at 40. This is another example of how important our family histories are, and find out if any members of the family (female) have had BRCA testing. If positive, men should get tested earlier. Of course, if prostate cancer runs in the family, early testing may be in order as well.

  This drawing shows the finger palpation of the prostate trans-rectally. This is not being performed on routine exams regularly. Lower rectal cancers can be picked up as well.

B. Diagnostic testing—PSA (prostatic specific antigen)

Black men should start discussing getting tested at 40, while white men and Hispanics can wait til possibly 50. I think discussion should begin earlierthan those ages to assess the risks and benefits of screening.

  If the PSA is rising, it is time to see a urologist and determine the need for need for biopsies of the gland. The current recommendation for biopsies include using MRI guided biopsies gives the surgeon the best chance of needle biosping the proper areas most suspicious.

  If biopsies are positive, the degree of severity of the malignant cells must be determined to calculate the Gleason score 1-10.

  The higher the score the more likely the cancer can spread, therefore, a treatment plan must be discussed talking not only with a urologic oncologic surgeon but a very experienced radiation therapist, who offers most of the types of RT now available.

  It is very important to know that, if over 70 and healthy with many years of longevity ahead of them, they should consider surveillance as an option rather than treatment.

   Older men with multiple health issues, should strongly consider watching rather than treating the cancer. If the Gleason score is on the lower side (less than 6 in some articles), and the extent of the cancer is small, and not close to the capsule lining, close observation can catch any progression, as these cancers grow slowly especially in older men. These are called clinically insignificant cancers.  

  Studies now confirm that if a cancer is under surveillance for months or even years, and the PSA begins to rise (with growth of the cancer), treatment is still very successful with the same survival data.

  The medical literature is full of articles about how much overdiagnosis is made, but these reports are about saving money, worrying about complications from biopsies, misdiagnosis, and overtreatment, and have little to do with the concerns, fear, and quality of life of each individual facing the possibility of cancer.

  Surveillance is a good opportunity in selected cases, and should be discussed with the oncologists.

C. Considerations for choice of therapy

  Age, general health, activity levels, and motivation for sex and acceptance of the inconvenience of treatment options with possible side effects are all factors in considering options for treatment.

  The American Cancer Society has an excellent section regarding “considerations for treatment options”. There are a lot of options. Recovery and side effects need intense discussion with the treating doctors. Also discuss using testosterone before or after, because these cancers grow with testosterone, and there will be some patients who should take testosterone blockers to prevent spread.  Taking testosterone unless the blood levels are low and causing symptoms is asking for the risk of stimulating an unknown prostate cancer.

  In my discussion with friends about their choice, I always point out, as I did as a head and neck cancer surgeon, that cure is #1, not convenience, ease of treatment, side effects, and follow up.

  The cure rate for early prostate cancer is 99% at 10 years, regardless of surgery or radiation, but there are many factors to consider when choosing the type of treatment based on the extent of the tumor, closeness of the tumor to the nerves that are necessary for erection, and the Gleason score. Bladder and rectal issues are also worth discussing.

  The proctitis, impotence, and urinary incontinence are the main concerns with any treatment. The age of the person certainly plays a role in the decision making, and the desire for continued sexual activity plays a big role in most men.  

  For men taking testosterone, it is important to understand that it can stimulate the cancer. Discussion should include should include: 1) stopping testosterone unless significantly low blood levels of testosterone exist. 2) taking an anti-testosterone medication if the Gleason score is high to prevent growth of the tumor and spread which can be started even before surgery or RT is start. There are studies that show better long term survival if taking this kind of hormonal medication.

  Testosterone is not only secreted by the prostate gland but the adrenal glands. Anti-testosterone medications will stop this hormone anywhere it is secreted. It may be recommended even in early cancers, but it may be recommended for very aggressive,more advanced, or recurrent cancers (these are often called castration resistant cancers).

  There are 6 FDA approved antiandrogen medications: Erleada, Casodex, Nubeqa, Xtandi, Eulexin, and Nilandron. Side effects should be discussed, because they cause tender swollen breast tissue in men, tireness, nausea, hot flashes, loss of sexual interest, and many constitutional symptoms, and if intolerant can be stopped. However, if recommended, at least consider it, if the cancer data points to the need of extra help to increase the chances of keeping the cancer under control.

D. Radiation therapy choices

  RT can be used for first treatment that still remains in the prostate gland and is low grade. Cure rates are about the same as a radical prostatectomy.

  It can be used, in addition to hormone therapy for cancers that have grown outside the gland into the nearby tissues (bladder, rectum).

  If the cancer is not removed completely (positive margins) or it recurs locally, RT can be used to slavage these cases with positive results.

  If the cancer is advanced, the cancer can be irradiated to keep it under control for as long as possible to prevent further spread and relieve symptoms of urinary obstruction, pain, etc.

  There is external beam therapy or internal RT!

  The American Cancer Society has a great discussion on all these options at www.cancer.org  I have taken the liberty of drawing from their discussion, but abbreviated for obvious reasons.

  There are 3 choices to consider based on the extent, grade, and stage of the prostate cance: 1) external beam 2) internal seeds 3) radiopharmaceuticals

   1--External beam Radiation

  (types-EBRT, 3-D CRT, IMRT, SBRT, Proton beam)

   a --EBRT—External (photon) beam radiation therapy is used to treat early cancers, or metastatic bone lesions causing pain.

  Treatments are performed 5 days a week for several weeks. Often it is wise to stay in a motel or hotel close to the facility, if traveling for more than an hour every day.

  Newer photon EBRT is focusing on higher doses with less damge to surrounding tissues.

   b--A special form of EBRT--3 dimensional conformal RT (3D-CRT) uses special computers that aim at the prostate from different directions to reduce RT to surrounding tissues.

   c--IMRT—intensity modulated RT is an advanced, and often used, form of 3-D CRT. The strength of the beam can be altered in certain areas that move around in different directions and angles for tissues that are more sensitive to the dose level, while delivering even higher doses to the cancer itself.

   d--MRI guided beams—IGRT can enhance the precision of the beam to make minor adjustments in dose providing more precise focus on the cancer itself.

   e--VMAT--volumetric modulated arc therapy uses a machine that delivers radiation quickly as it rotates once around the body. It is more convenient and faster to the patient, but yet to show better results than IMRT.

   f--SBRT--Stereotaxic body RT is becoming more popular because it takes only a few treatments using high doses of RT using an image guided technique. It is often known by the name of the machine such as Gamma Knife, X-knife, Cyberknife, and Clinac. Side effects are not better, with some studies reporting even higher rates than IMRT.

   g--Proton beam RT—unlike photon beam RT, proton energy is released both before and after the RT hits the prostate, causing less damage to surrounding tissues theoretically. It can release more radiation to the prostate. The proton beam can be aimed using the above techniques as IMRT and 3-D-CRT. Not all patients are good candidates.

  The theory is very useful in certain cancers, but not in the prostate, although those who receive this type of radiation become apostles of the technique, and are encouraged by the mega-million dollar ($50-150 million) centers that are required to house this type radiation, and to date the survival rates are the same and after a year or so have about the same side effects.

  The beam can be more precise and in children’s brain tumors, breast, esophageal, head and neck and throat cancers, and liver.

  Insurance considers prostate use as experimental and won’t pay for it, because the cost for proton is $32-45,000 compared to $18,570 for the other types of RT. It would need to be discussed and be sure Medicare and other insurance will pay for specific cases before considering a treatment that is no better than IMRT.

  Medscape stated that Medicare is currently paying a reduced amount for proton therapy, and by law, the center can’t make a patient pay the difference, but be sure you have written proof that your insurance will cover it, and you will not have to pay the difference.

Side Effects of all RT and surgery

  The desire for sexual potency preservation for younger people and those sexually active is a big issue when deciding treatment options, but none can guarantee “things” will be ok.

  Impotence tends to worsen with time after RT, whereas surgery may not, but swelling in the nerves created by surgery, even if left intact, may create some temporary impotence after the procedure. If erectile dysfunction was present before treatment, the patient must be realistic about the issue.

  Treatments for impotence should be discussed, and I just recently reported on the latest options for erectile dysfunction: www.themedicalnewsreport.com/130

  The younger a man is and his ability to have sex will correlate with a better chance for erectile function to return after surgical robotic treatment as long as the nerves are preserved. Radiation will also cause significant problems in most but may return in some. There is no guarantee with any type of treatment.

  The nerve supply to the prostate and penis is derived from two sources in the autonomic nervous system. Erections occur with stimulation of the parasympathetic nerves and ejaculation occurs from the sympathetic nerves, and they join together as the pelvic splanchnic plexus. These nerves come off the spinal nerves in the lumbar and sacral areas (hypogastric complex seen in the drawing below).

  Some of the branches pass through the prostate, but those to the penis pass just outside the gland , and if damaged or removed during surgery or radiation, impotence may occur.

Note the closeness of the nerves to the penis as it passes very close by prostatic tissue (arrow).

  Robotic surgery’s main appeal is to spare these nerves with the technique. However, since these nerves pass so close the capsule, the MRI must determine whether tumor invades (perineural invasion) them or is too close to leave the nerves.

  A radical prostatectomy removes these nerves, since the tissue immediately surrounding the prostate is removed.      

  There are varying studies to support brachytherapy as causing less erectile trouble, but others show no difference.

  Urinary incontinence will affect all men having any type of treatment (radical prostectomy, robotic surgery, and any type of RT). Treatment starts with Kegel exercises before treatment begins. Depends will be a necessity for some time. Hydration is important, but correlate to how many times urination is necessary.

  Proctitis (radiation burn of the rectum) can be lessened when the radiation therapist can place a protective hydrogel spacer (drawing below) between the prostate and rectum, to lessen the beam burn the area. Diarrhea is common. The gel is injected between the prostate and rectum, and is absorbable. Be sure your radiation therapist performs this.

Anal stricture and aggravation of hemorrhoids may be other concerns. A history of irritable bowel syndrome may also be aggravated, therefore discussing all of these potential issues may help a patient and doctor the best course of action. However, regardless of side effects, the primary concern getting rid of the cancer.

  Urethral stricture and other bladder issues may occur, especially if previous prostate surgery has been performed.  

  2--Internal seeds--Brachytherapy (also called seed implants or interstitial RT)

Options

  a) Brachytherapy uses small radioactive pellets or seeds alone, each about the size of a grain of rice, placed directly into the prostate by the radiation therapist.

  Seeds alone are used primarily for early stage cancer that is considered slow growing and low grade (Gleason less than 7).

   b) Brachytherapy can be combined with external radiation for cancers that are considered higher risk and has a higher Gleason score.

   c) Permanent (low dose rate—LDR) brachytherapy is another option which uses the insertion of needles with pellets or seeds (containing radioactive I-125 or palladium-103) into the cancer inserted through the skin in the area between the scrotum and the anus into the prostate. The needles are removed leaving the pellets in the prostate. About 100 seeds are used. External radiation can also be combined in certain cases with higher risk. 

  Patients who have had prostate surgery for obstruction (TURP) or have urinary obstructive problems (large gland) might have higher side effects and the placement of seeds might be harder. Trans-rectal ultrasound or CT scans can be used for better placement.

  d) Temporary (higher dose rate-HDR) brachytherapy is performed less often leaving high doses radiation in place for a short time. This technique uses catheters which are inserted inside the needles (60) with radioactive iridium-192 or cesium-137 for 10-15 minutes, and the radioactive material is removed each time. The catheters are left in place. 1-4 brief treatments are given over 2 days, and each time more radioactive material is inserted into the catheters. After the last treatment, the catheters are then removed with the radioactive material inside the catheter. It causes pain and swelling for about a week.

  Again, this type of radiation treatment may be a better choice for lower grade cancers which are not near the capsule.

Possible side effects for Brachytherapy

  With permanently placed seeds, they will be giving off low doses of radia for several weeks or months. Children and pregnant women should avoid these patients to prevent exposure. Traveling is not advised, but if it is a must, a doctor’s note may be necessary as the airport checkpoints may detect the radiation.

  The seeds may migrate, therefore, straining the urine for the first week or so.

  Just like external radiation, proctitis with burning, pain, diarrhea, and bleeding may occur temporarily. Frequent urination may occur and scarring in the urethra may occur causing obstruction necessitating urethral dilation. Erectile problems occur less often with seeds, although there are some studies that state they are the same. As in external beam therapy, the younger patients are the ones more likely to recover from erection difficulties.    

   3-- Radiopharmaceuticals    

  Radioactive drugs can be injected into the blood stream that travel to the prostatic cancer cells that have spread to other parts of the body. Cancer cells are metabolically more active and attract these drugs.

  The prostate cancer cells contain a protein in high concentrations called prostate specific membrane anigen (PSMA).

  A radiopharmaceutical, Lu-PSMA-617 or Pluvicto attaches to PSMA and the radiation goes directly to cancer cells. The patient can already have been treated with hormonal (antiandrogen) or chemotherapy for metastatic disease.

  There are also radiopharmaceuticals that target the bones, a common metastatic site for prostate cancer including Strontium-89, Samarium-153, and Radium-223.

Cryotherapy

  Cryosurgery is not a popular treatment for early cancer, but is around, and the subject may come up. It can be considered as an alternative to radiation therapy or surgery, however, it is not considered a first line of treatment by most oncologists.

  It requires a spinal or general anesthesia to allow the doctor to place needles in the prostate which allows a very cold gas to pass through them and destroy prostate tissue under transrectal ultrasound guidance.

  Warm water irrigates the bladder to prevent damage to the urethra, and a catheter is required to be worn for several weeks to allow emptying of the bladder. It is not a good option for men with a large prostate.

  Side effects are usually more significant than other treatments including a higher incidence of impotence from damage to the perineal nerves, however incontinence is less than other treatments.

E. Surgical treatment options

  The radical prostatectomy has been a time honored procedure to remove more locally advanced cases including the seminal vesicles and tissue surrounding the prostate leaving the rectum intact. Partial removal of the prostatic urethra and bladder neck may be required.

  The open radical procedure (retropubic or perineal) requires a long incision and is being less performed for early disease. The laparoscopic approach (with or without robotic technique) has taken over and requires several smaller incisions in the perineum and is just as successful as the open procedure. The older technique is performed through the abdominal wall. With the laparoscopic technique blood loss is less, and healing is faster, but impotence and urinary incontinence are about the same as the open procedure. Be sure a very experienced surgeon performs a laparoscopic procedure, probably a robotic experienced surgeon.

  Robotic prostate surgery is known as the nerve sparing procedure, but that depends on how close the cancer is to these nerves, which are just on the other side of the capsule, and damage to these nerves can occur even when trying to spare them.

  The American Cancer Society website states the side effects are similar to other procedures, so be sure you understand that. And of course be sure the surgeon is very experienced. DaVinci robotic procedure:

The surgeon sits next to the operating table and robotically manipulates the several endoscopic probes which are extensions of the surgeon’s hands.

Cancer left behind

  The pathology report may demonstrate that cancer cells were left behind from the surgery, and post-op radiation may be required or very close observation to watch the PSA rise or not, suggesting the advancement of that positive margin. When cancer is left behind, a second opinion is recommended, from a radiation therapist and your medical oncologist.

  Work on impotence after treatment

  After surgery and healing, it is advised to try and get an erection and if not, keep trying and consider Viagra, Cialis, etc. Injections, vacuum devices, and an implant are also available if erections are not successful after a year. If orgasm is feasible, there will be no ejaculate, but still pleasurable. When the seminal vesicles are removed, a dry orgasm will occur. Fertility will be no longer feasible since the tubes to the testes are removed.

American Cancer Society, Web-MD.  

  Second opinions are a must

   Second and even third opinions are a must and should include a surgeon and a radiation therapist. If the doctor is affiliated with a large center, it is important what options are available, and if there are not many options, see another doctor in another medical center.

  Travel is an issue, and if one must travel more than 30-45 minutes, staying in the area while being treated makes sense, since radiation therapy may involve treatments 5 days a week for several weeks.

  The American Cancer Society has for years teamed up with centers to provide wonderful facilities for patients to stay free of charge, called Hope Lodge, with over 30 locations across the country. Please check it out on their website.

  I was involved in helping promote these facilities while volunteering for ACS during my 40 years of service.

  The ACS also has drivers who can take patients to the treatment centers daily, and through a local cancer organization, as President of the Sid Weber Cancer organization in Sky Valley, Georgia, I created such a travel group of incredible volunteers with backup from ACS that has been going on for years and provided transportation to many patients in Rabun County to allow them to receive treatment out of town.

  Please donate to the American Cancer Society and Sid Weber Cancer Organization, as they have helped countless patients and families at no charge.   

Making decisions about treatment is critical!!

  Being extremely informed about the grade and score of the prostate cancer is understood. What is the size of the cancer, its position, the Gleason score, closeness to the capsule and nerves (which is not an intact capsule and has areas where muscle fibers easily penetrate the capsule and so can cancer?

  Underlying medical conditions, age, estimated longevity, etc. will influence the decision including observation over time.

  In conclusion, choosing the treatment of choice is primarily to cure the cancer, but side effects and convenience of treatment will play important roles, but should be secondary. Most treatments provide essentially the same cure rate and fortunately most prostate cancers grow slowly, so many patients may die of natural causes before a prostate cancer can get them.

2. The mental health of children—Part 1-- autism, anxiety and depression

Autism

  The diagnosis of autism has increased rapidly over the past few decades. 20 years ago, 1 in 100 children were diagnosed with some type of autism, and now 1 in 16 are diagnosed according to the CDC.

  There continues to be extensive research on risk factors including diet, diseases in the mother, vaccinations, water pollution, heredity, illicit drugs used by the mother, etc.

  The latest massive lawsuits are from the extensive use of acetaminophen (Tylenol) and medications that contain acetaminophen by the pregnant woman. This chemical has been used for over 100 years or much more often especially after aspirin was found to cause Reye’s Syndrome with kidney damage from aspirin use in children.

  The vaccine issue has been studied most extensively, and to date, vaccines do not increase the risk of having a child with autism. Now the lawsuits are rising rapidly when it was published that it caused an increased incidence of autism if children took the drug at age 12-18 months of age. Since this information came out, the use of ibuprofens has risen from 56% to 87% for fevers and after vaccinations.

  An Israeli study found an increased risk of autism and ADHD in children, if mothers took Tylenol type drugs extensively during pregnancy (28 or more days). Short term use is safe as reported by healthline.com. Doctors recommend that pregnant women avoid Tylenol for four consecutive weeks once they find out they are pregnant.

  17,098 autistic children, average age of 19 years (80% male) were compared to 4,145 siblings without an autistic diagnosis. They were found to have developmental delays of 7 to 19.7 months. Those with co-existing intellectual developmental abnormalities and other genetic neurodevelopmental issues were found to be diagnosed at a much earlier age (by the age of 5), and were present in 17-39% of these children and more common in females.

  Developmental milestones include: smiling, gross motor skills (sitting, crawling, and walking), self-help skills (feeding themselves), language skills, and toilet training.

  Language skills and toilet training were commonly delayed 1-2 years whereas those with pre-existing developmental delays showed as much as 7 year delays.

  If diagnosed by age 5, these children, mentioned above, had more co-existing intellectual developmental issues, however smiling, crawling, sitting upright, and walking were the same in the 5-9 and 10 years or older groups.

  This study points out the variability of milestone attainments in different age groups. Language skills and toilet training were the most delayed in each group.

  All of these developmental milestones must be monitored closely and addressed. More genetic research greatly needed.

JAMA Network, July 18, 2022; healthline.com; NIH studies-PubMed

Adult outcomes for autistic spectrum disorder

  Those who suffer from significant autism will have social integration issues, poor job prospects, and high rates of mental health issues as adults.

  Most with Asperger’s Syndrome fare pretty well, sometimes with special talents. The amount of mental health care and family support also can change outcomes greatly.

  Those who were diagnosed with autism as a child have an increased frequency for schizophrenia, bipolar disorder, neurotic and personality disorders, substance abuse, and anxiety disorders, according to studies in Finland. Psychological Medicine, Jan., 2019; PubMed Journal from the NIH

Anxiety, Depression Disorders

 The USPSTF* in their studies found that 7.8% of American children and adolescents age 8-18 years of age are currently dealing with an anxiety disorder, which correlates with future anxiety and depression issues.

  When discussing anxiety in children, parents need to have a face to face session with the doctor without the child in the room, and if there is an issue to address, bring it up with the child separately.

*USPSTF=U.S. Preventative Services Task Force

  The pandemic, school shootings, and social media are some of the primary reasons for these current disorders facing our children.

  The organization, for the first time, has recommended standard questionnaires to screen for anxiety starting at age 8-18 for the general population. Younger children do not have enough symptoms to screen the entire general population. This recommendation is based on the harms and benefits of screening, and the benefits far outweigh the harms.

  The USPSTF recognize 7 different types of anxiety disorders:

1. Generalized anxiety disorder, 2. Panic disorder, 3. Agoraphobia, 4. Specific phobias, 5. Separation anxiety, 6. Social anxiety, 7. Selective mutism*

*Selective mutism=inability to communicate or speak effectively in select social settings, such as school. 90% have phobias or social anxiety.

  Risk factors include genetic, personality, and environmental factors, such as attachment difficulties, interparental conflict, parental overprotection, early parental separation, and child maltreatment.

  Demographic factors include poverty, and low socioeconomic status, bad neighborhoods, large cities with high crime, etc.

  Some would say that the current parents are raising a bunch of “snow flakes”, and some of the measures handling stressful situations are having some unfortunate side effects with many children just not being able to cope with maturation and dealing with life. “Meltdowns” have become common. 

  It is always about a balance bewtween love, understanding, and discipline with GenZ, but even with cognitive behavioral therapy and medication, young people need to realize this may be the easiest time of their life, and when they grow up(?), and finally leave their parent’s home (48% in their 20s are living in their parent’s home), get a job, and make a living, their preparation must begin as a child. Otherwise, they will be looking for the government or someone to take of them the entire life, and that is happening right now with the socialist movement in this country.

Depression in children and adolescents

  Anxiety and depression can co-exist in certain cases. Growing up is stressful, but there are signs of depression to consider.

  Common symptoms of depression in the young include sadness, withdrawal, wanting to be alone, sleeping excessive hours, not enjoying fun times, changing eating habits, tiredness, feeling very sluggish, feeling worthless, useless, or guilty, inattentive, and with self destructive behavior (cutting, etc.). These symptoms can lead to suicidal ideation and attempts.

  It is difficult to get a child to talk about being depressed, and may more likely exhibit anger, appear unmotivated, or  become a trouble maker. Proper diagnosis of depression subtypes is critical to provide the best therapy.

Depression in teenagers

  Three types of presentation are common:

1) Anxious distress—may overlap with anxiety disorders

2) Melanotic distress—lack of response for issues that usually give enjoyment, usually associated with early morning awakening, worsened moods in the morning, major changes in appetite, feeling of agitation, guilt, and sluggishness.

3) Atypical features—the ability to temporarily cheer up with happy events only to appear depressed, increased appetite, excessive need for sleep, sensitivity to rejection, and a heavy feeling in extremities.

  There are several other disorders that have depression as a major symptom including bipolar disorder, cyclothymic disorder, disruptive mood dysregulation disorder, dysthymia (persistant depression), and premenstrual dysphoric disorder. (these different presentations are explained on the internet). 

Mayo Clinic

Treatment of anxiety and depression in children, adolescents, and teenagers

  Daily activities must be addressed—sleep, eating habits, school attendance, issue of social media, bullying, maltreatment by parents, violence, and postpartum depression.

  Underlying disorders must be diagnosed such as ADHD, bipolar disorder, psychosis, schizophrenia, etc. to properly care for these youngsters.

Cognitive Behavioral Therapy (CBT)

  CBT is commonly recommended at the school or by a private practitioner. Seeing a licensed psychologist certified in CBT is commonly used to determine the extent of the disorder and begin to help the child open up about the factors that are causing the anxiety and problem solve the issues with the youngster.

  The child must understand the relationships between beliefs, thoughts and feelings and the behavior that follows. They must believe that their perceptions directly influence how they react to certain situations. This is a short term type of therapy followed by a group of different type of therapies tailored for the patient’s needs.

  Common cognitive errors children can display:

1) Self reference—“people always focus attention on me, especially when I fail”.

2) Selective abstraction—“only my failures matter and I am measured by my failures”.

3) Over generalizing—“if something is true in one setting, it is true in every setting”.

4) Excessive responsibility—“I am responsible for every failure, and every bad thing that happens”.

5) Dichotomous thinking—“viewing the world in extremes…always black and white”.

  CBT goals (cognitive behavioral therapy)

  The patient is helped to unlearn negative reactions and learn new ones. The therapist helps break down overwhelming issues into smaller ones making them more manageable. They need to work on meeting short term goals, and thus allowing the patient to think, feel, and react in tough situations. Changing attitudes and perceptions can lead to better addressing specific issues in better ways.

  Techniques often used are 1) keeping a journal about feelings and reactions, 2) begin to challenge beliefs, 3) mindfulness—judging things in a non-judgmental way and approach, 4) relaxation exercises, 5) social, physical, and emotional exercises to better understand their emotional and behavioral patterns and adjust them.

  The average number of sessions is 16, and homework will likely be necessary to work on these exercises.

  CBT can help a variety of psychological disorders.

  When a psychiatrist is needed, it depends on many factors, including the decision to take medication, failure of cognitive therpy, etc.

  Medications of social anxiety disorder and depression

  NYU treats children with social anxiety disorders with drugs that increase the serotonin in the brain, a class of antidepressants, called SSRIs—selective serotonin reuptake inhibitors: paroxetine (Paxil), (sertraline (Zoloft), citralopram (Celexa).

  These medications must be monitored carefully as they can increase anxiety, insomnia, nausea, and vomiting.

  Suicidal ideation in a small percentage may occur. I will discuss suicide next month. If the child’s disorder is severe enough to prevent attending school or performing everyday duties, anti-anxiety medication may be prescribed: (alprazolam-(Xanax), or clonazepam(Klonopin). These medications can provide short term improvement, but are often abused, and can cause fatigue and sleepiness.  

  Responsibility, honesty, treating others well, avoiding jealousy, coping with peer pressure, minimizing exposure to social media, and respecting parents and others are all critical in developing self esteem and “fitting in”.

  Quality of life and being happy as an adult starts with parental guidance, encouraging a youngster to do the best they can do. Satisfaction for trying even if failure occurs, is just part of growing up.

  The LBGTQ Youth Mental Health National survey reported that 72% describe generalized anxiety disorders-- lesbians, gay, bisexual, transgender, and queer youth.  77% transgender and nonbinary youth have this disorder. Asking 5 year olds to digest thoughts about their gender is insane. BTW, 70% of kids who have gender identity difficulty are fine with their gender within a year, according to physicians in NY.

 Next month, I will report on LBGTQ community, because it is a group that needs special counseling and support without TV and schools trying to infiltrate their minds with mixed messages.

  Black children tend to have less anxiety than whites, probably because they have had to learn to toughen up earlier in their life. Non-Hispanic white children fare the worst. However, after the pandemic and increased crime in major cities, the black children are catching up.

  It is felt that racial discrimination may be a factor, and now that CRT is in the school, it could be that they have had to face more discrimination, not less.

  Less access to mental health services, substance and physical abuse in the home are factors as well, especially in American/Alaskan Native youth.

  If screening for anxiety and depression is to be successful in doctor’s offices, parent buy-in to answer survey questions honestly is critical.

  With this crazy radical world we live in, psychiatric issues are rising rapidly, and the shortage of professionals and funds to address these issues is alarming.

  Counselors recommend targeted school-based cognitive therapy to reduce anxiety and depression. With traumatic events (gun shootings, etc.), group therapy is recommended.

  Currently, only 46% of physicians seeing children screen kids for this disorder, but it should pick up now that there are federal recommendations. 75% of children see a pediatrician under age 5, but primary care doctors must accept this responsibility as well, since older children tend to prefer primary care from non-pediatricians. Unfortunately, only a third of older teens and young adults see any type of doctor regularly and prefer urgent care.

  1 in 5 who are 18 and younger have psychiatric disorders at some time in their lives, and the sooner the disorder is addressed, the better chance for eliminating many long term consequences.

  Parents must engage in school settings about bullying, and other traumatic situations that might precipitate this disorder. Monitoring the child’s social media is critical. Parents unwilling to engage in this circumstance leaves these children to be influenced by their peers and teachers, who may be biased in their ideologies.

  Any group (schools especially) with political influence trying to keep parents at arm’s length from their children need to be condemned, and yet, there is a movement in this country from the liberal left to make it law* that parents have no say in what their children are taught (including CRT and gender identity).

  Uninformed parents have no excuse if they want to be a good parent, otherwise, the traumas they experience during school hours will not be known, and they will be seeking outside the home answers. Issues include pregnancy, abortion, transgender issues, and other difficult problems needing parental input.

*There is a movement called the “Children Rights Act”, now being proposed, giving them individual rights without input from the parents and family.

JAMA, October 11, 2022; good therapy.org

Next month, Part 2 will include ADHD, suicide, PTSD, body dysmorphia, substance abuse, and  psychoses. Part 3 in March will be devoted to LBGTQ+ and their latest issues.

3. OB/Gyn Series—Part 8—premenstrual vaginitis; lesions of the ovary and fallopian tubes

Vaginitis

  Vaginitis affects most women at some time in their lives. The anatomy of the female pelvis with the close vicinity of the anal region creates issues of contamination from the bacteria which grows in the intestines.

  It can be caused by irritation from having sex, having vaginal deliveries, and exposure to a variety of infectious agents including bacteria, parasites, and fungus (candida in particular), sexually transmitted diseases, and can be altered even with medications that change the normal bacterial flora of the vagina.

  Symptoms of vaginitis include itching, irritation, and abnormal discharge, which may cause pain with intercourse. Some women are even allergic to their mate’s semen.

  70% of vaginitis is caused by vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis.

  The ph (acidity) of the vagina is important for normal functioning of the vagina, and is changed by all of the above infections. It prevents the vagina from cleaning itself, which is does normally.

  Microscopic examination of discharge secretions is necessary to identify the offending organisms, such as gonorrhea, yeast, trichomonas, and Chlamydia.

Vaginal Candidiasis (yeast infections)

  Yeast infections can be diagnosed with a wet prep in the doctor’s office (if set up in the office to perform this simple test by testing the ph of the vaginal discharge and looking at what bugs are seen on a slide under a simple microscope.

  A foul smelling cottage cheese discharge is a hint that it is fungal.

  If not available in the office, a polymerase chain reaction (PCR) test can be ordered. In recurrent cases, a culture might be recommended, but both tests require about 3 days for a diagnosis.

  Fungal infections can be more likely in diabetes, the use of antibiotics and corticosteroids. Killing the normal bacteria in the vagina, allow the balance between fungi and bacteria, allowing the yeast to grow and cause an discharge.

  If taking the above meds, eating yogurt (contains bacteria to normalize the flora), mild vinegar irrigation, using topical anti-fungal vaginal medications over the counter (can easily treat an infection), or a prescription of one dose of oral fluconazole (not approved during pregnancy) all are helpful. There are other antifungal prescription medications available such as terconazole, and clotrimazole and micronazole as topical antifungals.

  Treatment success is 80-90%. Aggressive douching is not recommended. No woman should douche daily. Careful cleaning of the perineal area is a must after elimination. Careful cleansing of the external genitalia and anus is critical. 70% of vaginitis is attributed to yeast infections.

Bacterial Vaginosis

  Overgrowth of normal bacteria can cause a “fishy” discharge and odor. If tested, the ph will be 5.0 or higher. Risk factors come from sexual intercourse, use of unclean vibrators, etc., lack of condom use, female partners, and frequent douching, which can change the bacterial flora necessary for a normal environment.

  If necessary, treatment may include oral metronidazole,  vaginal metronidazole or clindamycin with cure rates of 80%, and are safe during pregnancy.

  Condom use is highly recommended when a woman is experiencing any form of vaginitis.

Trichomonas vaginitis is an STD

  Trichomonas is a sexually transmitted infection! Vaginal irritation and a yellow-green discharge is common, but there may be no symptoms, which means if the woman has more than one partner, she will transmit it to another. Multiple sex partners and not using condoms are the most common causes.

  Treatment must include both patients and their partners. Oral metronidazole 500mg. twice daily for a week, however, a single dose may be effective, according to the JAMA article I used for this report.

  Sexual abstinence is recommended for a week after completing treatment (that means 2 weeks!). Retesting after 3 months is highly recommended even if the patient is asymptomatic, because women can still carry trichomonas.

  Patients who experience repeated infections should see a gynecologist. Also, since this is an STD, checking for others (gonorrhea, syphilis, HIV) is always recommended.

  It should be noted that as a woman passes through menopause, she will have thinning of the vulvovaginal lining, and estrogen creams may be very valuable allowing less painful and irritating sex, and create more normal mucus to be produced by the lining, which is helpful in maintaining normal cleansing.

JAMA, June 14, 2022

Lesions of the Ovary and Fallopian Tubes

  Lesions of the female organs are very common, and are found in 35% of premenopausal and 17% of postmenopausal women from benign to malignant.

  These lesions are called adnexal masses, because they are tissues that are on each side of the uterus. Ovaries and tubes are only a couple of inches in size when a woman is younger and reduce on size to an almond by menopause.

  When there is a mass present, it must be decided if it is an acute process needing urgent attention or a longer standing issue, determination of the potential for malignancy with appropriate management, and an approach that takes into consideration for the patient’s desire to have children and the hope to preserve hormonal secretion.

  Genetic testing is critical including the BRCA mutation, since if positive, carries a 50-60% chance of cancer of the ovary in women, not to mention 80% chance of breast cancer, and is now known that there 7 other cancers that are at risk for (melanoma, pancreas, colorectal, esophagus, liver, stomach, and cervix). A small chance of other cancer are mentioned in an article from the National Cancer Institute, including bone, laryngeal, throat, bile duct, and eye. In fact, those people who have genes for cancer have an increased risk for almost all cancers. And once a person develops a cancer, a second one is more likely than the general population.

  Even if a benign lesion exists, in the face of a positive BRCA gene, some women will choose prophylactic removal of the ovaries and tubes, because of the very high risk of breat or ovary cancer. Angelina Jolie is an example of a celebrity who had hers removed.

  Emergency surgery may be required based on transvaginal ultrasound, endoscopic inspection, and CT or MRI scans.

  Torsion (twisting) of the ovary and tube, ectopic pregnancy, cystic lesions from endometriosis or other causes including cancer must all be managed surgically.

  Pregnancy (HCG) testing is a must to rule out a tubal pregnancy.

  20% of tubal or ovarian cancers have a genetic basis, therefore the family history is critical.

   A pelvic exam cannot differentiate benign from malignant lesions, however, it does give important information about whether the lesion is fixed to the uterine wall, bladder, pelvic wall, or free, and the approximate size.

  As mentioned, transvaginal pelvic ultrasonography is the most important imaging tool to evaluate the extent of the lesion(s), and its potential to be malignant. There are classifications and factors that help the doctors to determine the chance of malignancy.

  CT scan is used to stage a known ovarian cancer.

  Lab tests should include CA-125 blood levels are elevated in 80% of ovarian or tubal cancers. However, women with metastatic ovarian cancers have normal levels early in the disease in premenopausal women and in certain types of ovarian cancer (mucinous cancers).

  CA-125 also can be elevated in pregnancy, endometriosis, inflammatory bowel disease, renal failure, and ascites (fluid in the abdomen) that is benign, and any inflammatory process of the lining of the abdomen (peritoneum). Levels do not confirm any specific diseases unless combined with other studies.

  There is another tumor marker, (human epididymis protein 4—HE4), that has been approved to evaluate the potential of malignancy. Another test used is the OVA1 index assay. These tests are very expensive, and should be ordered by the gynecologist.

Management of various lesions

  a) Simple cysts are usually benign, and studies have shown that 50-70% of these cysts resolve. If not, they need to be surgically removed, usually performed endoscopically. Cysts that are malignant tend to increase in complexity on ultrasound each month of observation. One study found that those with malignancy grow within 7 months since discovery.

  The American College of Gynecology considers 1 year follow up for stable cysts without solid components, and up to 2 years if the cyst is stable but has solid components.

   b) Complex cysts include hemorrhagic cysts, endometriosis lesions, and mature teratomas which are benign. Surgery should be considered for symptomatic patients using endoscopic approaches. Observation is still recommended for asymptomatic patients. Fertility is an important discussion, because surgical excision removes the chance of pregnancy, unless one sided.

   c) Indeterminate or malignant lesions deserve a gynecologic oncologist, although this study reported only 40-50% of these patients are referred beyond the standard gynecologist.

  Indications for surgery include post-menopausal woman with an elevated CA-125, ultrasound findings suggestive of cancer, ascites, a nodular or fixed mass, evidence of metastases, or other factors in assessment using formal risk assessment tests.

    d) Pregnant patients usually will be diagnosed with a benign dermoid cyst. CA-125 is elevated in pregnancy, so that does not help in assessing an ovarian mass. The ultrasound is critical and MRI (no radiation to child). If surgery is required, it should be performed in the second trimester to reduce the possibility of a spontaneous miscarriage.

NEJM, August 25, 2022

4. The drug crisis from marijuana, alcohol, opioids, methamphetamines, and cocaine; CDC guidelines for prescribing opioids—Part 1

The crisis and mental health shortages

  Our country is facing such a drug crisis. There are countries (China with the help of the Mexican Cartels) are trying to kill our younger people with fentanyl, now with the most common reason for death from age 18-45 being drugs, and the #2 cause of death in teenagers is suicide. 5000 suicides occurred in kids 5-19 in 2015-2016. This correlates with counties who are suffering from mental health professional shortages.

  With Biden having spent $10 trillion ($3 trillion on health) since taking office, the amount designated for mental health was pitiful, according to an article in JAMA Pediatrics, Nov.21, 2022. But hiring more mental health professionals is only a small part of the answer, as we are suffering from shortages of all healthcare professionals in the U.S. Even if billions of dollars were applied to improving mental health, it will take years to accomplish any major improvement.

 The opioid crisis

   With the disastrous attempt by the radical left to destroy our police force while totally ignoring our southern border, rebuilding our police forces is part of the solution. `     

  A few years ago, physicians were attacked by the feds for writing too many prescriptions for opioids (some actually were), and the number of prescriptions was greatly  reduced, but it created panic in the millions of patients in chronic pain.

  Refusing to continue to write prescriptions for those patients after the usual time period has created a stress on the doctor-patient relationship, and many doctors have now refused to treat patients in chronic pain, referring them to pain management physicians, surgeons, and physical therapists.

  For those in continuous need, this created a dilemma….where to find pain meds. Unfortunately, many turned to purchasing illegal street drugs.  Since the open borders have brought more fentanyl into our country, and unfortunately some of these people took fentanyl laced drugs, and accidentally overdosed.

  Why would these Cartels lace the usual drugs on the street from marijuana to all opioids? Because fentanyl is cheaper and enhances the effects of most drugs, factories on the other side of the border started mixing fentanyl with the usual street drugs, with no clue about the potency of the drugs they made.

  The results have devastated the deserving and, yes, the addicted. 110,000 overdoses occurred 2022, and about 70% of those who died had fentanyl in their blood. It is unknown how many were accidental, but I predict a high percent. This is happening to the GenZ crowd mostly, but every age group has been affected.

  Even though these illegal drugs are being confiscated by the tons, the U.S. admits they are just scatching the surface of the amount that gets by them, when over 100,000 got-a-aways came over the border in 2022 many trsnsporting drugs. The Cartels are using thousands of illegals to “mule” drugs across the border as part of the payment for them being brought to the border. It is estimated that 18,000 a month will come over our border as Title 42 is dropped (infectious diseases kept some of these illegals out). I can’t imagine the number of diseases they carrying over our border, filling our emergency centers.

  When asked about the southern border, the Secretary of Homeland Security (what a misnomer) Mayorkus, says “our borders are closed”. How can a human being lie to us for over 3 years, and still have a job? Obviously it is because the administration wants the border wide open (worst in the world) for future votes. The collateral damage does not concern them. The citizens of our country are of no concern to them. 2024 is a long time from now.

  The CDC states that in 2019, 66 million Americans binge drink and 21 million report illicit regular drug use. Every year, 16 million Americans abuse drugs, making up 6% of the population.

CDC guidelines on prescribing opioids; fentanyl  

  Opioids continue to be prescribed for chronic pain despite evidence that their short term benefits are small and long term benefits are even less valuable creating dependency and addiction in those incapable of stopping opioids.

  The CDC has yet to come up with consistent guidelines for the management of chronic pain, which created hesitancy in physicians to prescribe opioids and left them prescribing many non-opioids which were made even more difficult with federal laws and regulations.

  This has led to 2022 revisions by the CDC. Other than those with sickle cell crisis, cancer related pain, palliative care, and end of life care, they have expanded guidance for acute pain (<1 month’s duration), subacute pain (1-3 months duration) to help clinicians to weigh the risk/benefits for opioid prescribing.

  It has always been very clear to practitioners that every patient must be individually managed, and there is no “cookie cutter” algorithm that will work. This is in the face of this administration lowering Medicare and Medicaid payments to physicians by 2.5% (part of the $1.7 trillion omnibus bill just passed with no money allocated for the southern border.

  When prescribing opioids, the CDC recommends physicians use the lowest potency of drug (tramadol is least powerful) rather than jumping on oxycodone or stronger. It should be prescribed only for the days known to be necessary for a particular injury or surgery.

  Reassessing the patient’s pain levels is a much required step, providing guidance for further use of opioids and switching to non-opioids. A discussion about dependency is rarely performed, but should be, according to the CDC. Also the side effects of opioids must be managed (constipation, bladder difficulty, etc.).

  If a patient has been taking opioids for as long as a month, 10% tapering per month is recommended, not rapid withdrawal. Patient centered and individualized care is always recommended. Abandonment of patients is to be discouraged, and support should be sought.

  The CDC has taken so much criticism from the public and the healthcare industry after such haphazard recommendations and guidance that caused such horrible side effects during the pandemic, that it will be necessary for that agency to reform it’s organization and seek legal distancing from administrations who have abused the CDC politically and damaged their reputation for some time to come. Their recommendations are not being followed by most physicians.

NEJM, November 3, 2022

Fentanyl vaccine

  Typical of our government…instead of fighting the entry of fentanyl into our country and the drug crisis and overdose deaths, they are funding a fentanyl vaccine. Why? So people can take their illegal drugs more safely. OMG.

  Texas researchers have developed a vaccine to block the high in fentanyl in mice so far. It blocked several of the effects of fentanyl by blocking the drug from entering the brain. The hope is giving this vaccine will enhance sobriety and returning to normal life, according to a Houston University, published online in Pharmceutics journal on October, 2022.

  Sadly, it doesn’t block the effects of opioids. To date, the only antidote is naloxone (Narcan), which should be available OTC. Multiple doses of Narcan are necessary to reverse fentanyl.

  Funding by the U.S. Department of Defense!! In Medscape, November 8, 2022

Fentanyl test strips

  To date, the DEA (Drug Enforcement Agency) has made fentanyl test strips illegal and considers them drug paraphernalia. As always, the feds are out of step, as 30 states have legalized these strips, and should be passed out to every facility, drug store, etc. so that people who take medications or illegal drugs, for that matter, can make sure they are not going to die if they take the drugs.

  We must get over thinking we are enhancing the notion that people will increase the use of drugs by making them safer. Believe me….they will use them one way or the other. Why should we continue to see 110,000 overdoses and deaths mostly due to fentanyl.

  The U.S. must step out of the box and admit we have to provide safe needles (and clean the streets of used needles in downtowns of major cities where homeless live), provide Narcan for those who use, and start prescribing some of the alternative drugs in place of the more addicting drugs (buprenorphine, Naltrexone, methadone, etc.).

  It will always be controversial, but with the young people turning to illegal substances more and more, we have to accept the problem won’t stop. Where is the government in addressing mental health in our country, which includes drug addiction, overdoses, and the southern border invasion??

Part 2 on the drug crisis continues next month, with new information on marijuana, non-opioid treatment for pain and abuse, methamphetamine, cocaine,  and hallucinogens.

5. Another Look at the Polypill

  I recently reported about the use of the polypill to reduce cardiovascular events and mortality in older people, and it was believed to have a major effect. Most of the previous studies were published by foreign countries, and were given to younger people well under the age of 70, so the benefit in older people starting this pill if they have had a heart attack has not been studied..

  The NEJM published a study on people over 75 who had a previous heart attack in the past 6 months, and 2500 participants were randomized to receive the polypill or a placebo.

  The polypill contained atorvastatin (Lipitor—a statin) 20 or 40mg, aspirin 100mg, rampiril (Altace, an antihypertensive ACE inhibitor--2.5, 5.0, or 10mg based on European Society of Cardiology guidelines. Some countries  substituted the ACE inhibitor with a beta blocker (atenolol, metaprolol, etc.).

  Various outcomes were followed—another heart attack, stroke, cardiovascular death, or urgent revascularization (stent or bypass graft).

  After a 3 year observation, there was a significantly lower incidence of events in the group who took the polypill—9.5% in the polypill vs 12.7% in the placebo group.

  Whether this concept becomes a reality in America with some obvious barriers, (finding a commercial interest in it), it will require some congressional support and cooperation by the public.

  NEJM, August 26, 2022

6. Comments on COVID, RSV, Influenza; re-infection; vaccine safety, masks

  Re-infections have been studied in Iceland, and found that younger people (average age 34) were more likely to be infected, probably because they were much more likely to congregate whether they had a vaccine or not after having a COVID infection.

  About 10% of both groups got re-infected. Most of these people were infected with the earlier strains and when they got reinfected, it was from the Omicron strains. This tells us our immunity does not protect as well from the more recent strains, as expected. And immunity wanes after a year, no matter vaccines and infection.

  It tells us that if we had an infection early on with or without at least 2 doses of vaccine, the newer Omicron strains are more likely to infect. The re-infections are usually milder. Would the new bivalent Omicron booster prevent re-infection? No study has determined that yet, therefore, if you listen the CDC, get the booster. If you don’t, you are more likely to get re-infected. You must have faith that the bivalent booster is the best way to prevent reinfection or a bad case of the newer strains of COVID.

  Other factors must be considered….most of us have been exposed and didn’t get a symptomatic infection. For those without vulnerable underlying disease, that has been enough information to not get the most recent bivalent booster, but winter is still ongoing, and we may still get infected after the holiday get togethers. It is a calculation! Only 15% have received the new booster, and after 3 years of this pandemic, most are tired of being told what to do (COVID fatigue). It is with prayers that the winter is not going to surge too much.

 2022 was another year of questionable management of COVID using children as pawns for control by the administration and the teacher’s unions, and their school boards. And in the face of this, masks in Los Angeles are mandatory inside and out for all, when 90% of the masks worn are worthless.

  The media and CDC are pushing masks for everyone just in case the winter infections (regardless of what type) get severe and fill the hospitals. As usual, they are trying to scare us about the Tri-demic, and have decided to provide 4 free COVID tests per family through the winter, after having stopped this in last September. Of course, you have to request them from the government.

  As Title 42 is reversed, we are going to get 8000 illegals per day in our country coming over the southern border with any number of infectious diseases besides COVID. Title 42 is not just about COVID. It is a health issue, with no childhood vaccines, TB, a variety of respiratory diseases, and even non-infectious diseases our country’s doctors will face in the emergency departments.

COVID was a new Virus

  When the pandemic hit the U.S., we were blind-sided, and had to decide how to treat it, but this was a new virus, there was no known therapy, and doctors had to treat the symptoms rather than the disease (diseases that attacked the lungs severely (ARDS—acute respiratory distress syndrome using high pressure ventilators).

  They even tried a variety of antivirals including antiviral HIV drugs, and over the 3 years, most of the treatment has been disappointing. The most recent found to be of little value is the monoclonal antbodies.

  As always, we had to depend on Big Pharma to come to the rescue. Now Big Medicine, the feds, and Big Pharma are in bed together. But an untested vaccine was all we had, because we were not as prepared as we should have been, considering the previous viral illnesses.

  Since it was clear we needed a FDA approved vaccine to combat this virus, the time it normally takes to get a vaccine approved usually takes years, and we could not wait.

  President Trump used an executive order to create the Emergency Use Authorization act to speed up the process, and it was a tremendous success, even though it wasn’t near as preventative as hoped. Fortunately, it did reduce the severity of the disease and lowered death rates.

  Fortunately, although not near as effective as once thought, it had some serious side effects, but not in big numbers in humans.

  There are some articles now coming out in the medical journals that some animal studies were not as safe, therefore, there have been questions about longer term safety in the vaccine. We also had no idea long COVID syndrome would occur, and it is more likely to occur if not vaccinated. That should be a good reason to at least get the first doses of Pfizer or 2 doses of Moderna. Getting the bivalent 4^th dose has not been studied as to its effectiveness, but Big Medicine is convinced that it will be worth receiving, and most of those who have gotten the bivalent booster have been over 60 or immunocompromised in one or another.

Fine print of the Emergency Use Authorization Act

  What was never told the public or practicing doctors was that for this emergency-use ability to be authorized, there could be no known treatments available (when some would say there was).

  This created an opportunity for the experts to deny any treatments that might help treat or prevent the virus, as that would stop the emergency use authorization method.

  When drugs like hydroxychloroquine and ivermectin came along with zinc (now known to reduce the stay in the hospital by 4 days average), and Vitamin D, certain “Big Medicine” doctors denied their value and filled the medical journals with it.

   Then came the “fear tactics” from the administration and the CDC to scare everyone into being vaccinated,

which worked quite well for the first 3 doses of Pfizer and 2 doses of Moderna. But with time and experience, unnecessary lockdowns, mandates, and misinformation, and honestly outright lying, COVID fatigue has changed most people’s minds.

   Employed doctors were often told they were not allowed to prescribe these drugs, even if their personal experience was contrary, and if they did, they would be fired and their medical license pulled. Now, most are being reinstated!!

  This information came to light by several vocal doctors including Dr. Simone Gold, a California emergency room specialist, who realized no other therapy could be supported in competition with the vaccine, and as an employee in her emergency department could not prescribe these drugs. She finally resigned and, smartly, she has moved to Florida, and leads a large group of physicians called FRONTLINE PHYSICIANS, A TELEHEALTH COMPANY, WHO ARE NOT BEING CONTROLLED by Big Medicine or Big Pharma. No employee can tell her how to practice medicine.

   As a physician who sees the value of every treatment, I feel the vaccine is quite valuable for anyone with advanced age and underlying medical conditions. I also believe deciding on any treatment should come from a discussion with a patient’s physician. I am completely against COVID mandates. Government has got to get out of the way of physicians who are in the trenches, but with these medical academicians who are mostly socialists (I call them big Medicine), that has changed. You are seeing what socialized medicine will be like.

  Most of the drugs used in hospitalized patients have been found to be of little value but Big Medicine certainly supported using them. The learning curve has been humbling for physicians.

  What we have seen is the power and control of the current administration taking the authority of treatment away from the actively practicing physicians by convincing the socialist medical organizations and academic doctors to support them. This is a perfect example of a totalitarian government move now very active in our current administration and has made the CDC untrustworthy. The CDC doesn’t practice medicine….physicians and staff do!! The public has spoken because of this…..only 15% of the public have received the new bivalent booster, a great example of how far the CDC’s clout has slipped.

  This is the future of socialized medicine, and if that doesn’t scare you to death, you are not listening. The media, the internet giants (maybe not Twitter anymore), and most of the regular TV channels are ignoring all this country’s economic downfall and invasion of our southern border, and that is called CENSORSHIP (socialism’s middle name).

  People have decided that they can live with these infections regardless of how the media and this administration tries to scare them. That means some are going to suffer the consequences if they have not received at least the original vaccine plus one booster.

  A new study compared those who got infected and those who were totally vaccinated, and found that those with COVID infection have better natural immunity than those vaccinated, and more vaccinated people get reinfected than those with a previous COVID infection and no vaccine. Remember, the administration never admitted that natural immunity even existed…shame! And those people are mandated to get vaccinated in the military and other groups.

  Is the bivalent booster better than the previous monovalent booster…yes, but not much. Big Pharma touted this bivalent booster as much better than the  vaccine that didn’t cover the Omicron variants. Good data has yet to be published.

  It is true, after a year or so, immunity begins to wane, and vaccination is recommended.

  The CDC and many countries are supporting annual COVID boosters from now on.

  The FDA just approved the bivalent vaccine for kids 6 months and older. If a child has had a previous booster, they will not be qualified for one year to receive the bivalent (standard plus Omicron) vaccine.

Masks or not

  If a person is vulnerable to infections for any reason, masks, vaccines, and any other form of protection may make sense, however, the rest are not buying it.

  The CDC, the feds, the medical journals (Big Medicine), and all of public health is pushing the renewal of masks FOR ALL, and as we have seen over the last 3 years, their decisions don’t always make sense or are not supported by strong medical data.

  For the hundredth time, masks don’t keep people from breathing in disease. N-95 masks do a good job of preventing a person who is infected from spreading disease. How many N-95s have you seen when you go out??

  The consequences of masks are most egregious for children, and teacher’s unions, some school boards, etc. continue to ignore it. Those with any hearing loss are suffering just as much.

  I respect anyone who wears a mask, even those with their nose hanging out, who wear worthless masks, and wear the same one for a week. It is America, and we need to defend our rights and not be bullied by a totalitarian  administration, Big Pharma, and Big Medicine.

Flu vaccine effective this year

  The CDC reports that the vaccine this year is doing a good job of fighting the H3N2 influenza virus, the most common strain this year…..so get vaccinated!!

   COVID is a distant 3^rd, but still is killing (the U.S. just hit 1 million deaths depending on if you believe who is counting). Obviously not many people are fearing the new strains with just 15% getting the new bivalent vaccine, but winter has just hit, so we may have to adjust our thinking. We must remain vigilant and follow the guidelines (which are not laws) and change our minds if we need to. The holidays also will create a bump in cases as always, so stand by!!

Origin of COVID

  As a scientist, I understand the need for the Department of Defense to find biological weapons that may be needed to combat countries trying to invade our country. Our enemies are working on every kind of military weapon from improved supersonic missiles, including nuclear and biologic weapons. Why shouldn’t we?

  The discovery of this “gain of function” coronavirus was so dangerous the research, which was going on in the U.S. was recommended to be stopped by EcoHealth, (the non-profit company who was funded by the NIH to perform the same research that the Wuhan Virolgy Labs were performing), so the research and funding continued in Wuhan. The lies told about our involvement will continue.

  We have 7 million deaths worldwide (1 million in the U.s.) thanks to the lying and coverup by the Chinese Communist Lab, which was most assuredly leaked out of the lab, and China has not been put on trial for it with their lies and deceit. With our involvement, and a compromised president, it will take the Republican led House of Representatives to finally bring this up (Pelosi blocked any investigation by the Congress).

  Freedom of speech is no longer being practiced fully, with the socialists continuing to push us closer to socialism/Marxism, and when that happens, your rights as an American will be taken away from you including quality healthcare. Get off Facebook, and TickTok. I miss seeing family on Facebook, but I deleted it months ago…..you should too!!

  As 60 people who just died from the winter blizzards, your puppet president is vacationing in the Caribbean. OMG!! That speaks volumes about the leadership of our country.   

This ends the first report for 2023, WOW!!

We all must work on our New Year’s resolutions, get healthier, be kinder, and pray for peace, no wars, and prevent socialism!

February, 2023 subjects will be:

1. Kanye (Ye) West and Bipolar Disorder

2. Heart Failure management; Sudden Adult Death Syndrome (SADS)

3. More on COVID, RSV, and the Flu

4. Obstructive sleep apnea; CPAP recalls and shortages

5. Mental health in children and adolescents-Part 2   ADHD, Body Dysmorphia, Suicide, PTSD, Substance Abuse, and Psychoses

6. The Drug crisis—marijuana, alcohol,  non-opioids for pain and abuse, methamphetamines, and cocaine

  I hope you had a wonderful Christmas and New Year’s with family and friends. Pray for this beautiful America! Love it or leave it!!

                                                               Dr. Sam