The Medical News Report
Samuel J. LaMonte, M.D., FACS
February is Heart Month!
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Subjects for February,2023
This is the completion of my 11th year writing this report. It has kept me current in medicine and healthcare, and I have shared the latest medical information with you free without ads. The COVID information continues to be very important, and the controversy continues about the vaccines.
It has been a pleasure, as this has been my ministry in helping people understand their medical conditions.
We are facing tough times in healthcare, and we all must stay informed. These reports give you some of that opportunity.
Thank you for staying with me for 11 years, as it has been an honor and a privilege. Dr.Sam
a) Recall of baby Sleepers
After 115 deaths, 5.4 million Baby Sleepers have been recalled (Fischer-Price Rock ‘n Play and Kids 2 Rocking Sleepers) sold at Walmart, Target, and Amazon from 2009-2019. For refund-call 1-866-869-7054.
b. Good news, bad news for cancer
According the American Cancer Society, while there has been a 65% drop in cervical cancer rates, because of the HPV vaccine (Gardasil) in the last 10 years, And yet, only 32% of parents are getting their children vaccinated against the HPV virus, according to Dr. Knudsen, the new chief of ACS.
There has been a 3% increase in prostate cancer incidence, and most of these are advanced cases, especially in black men. And women are seeing a 4% increase in breast cancer annually according to a very recent report.
There has been great controversy about routine PSA blood tests for prostate cancer, and the federal advisory committee a few years ago, made an effort to change the need based on too much harm. I predict some men quit getting screened, and some cancers that could have been discovered earlier may have not been discovered until the men became symptomatic and their cancers were more advanced.
Black men are also notorious for not seeking routine cancer screenings. Trust in doctors continues to be an issue in some men, plus poorer neighborhoods don’t realize these screenings are free.
More outreach, education, and support will help bring them in, according to Dr.Knudsen, the new ACS Director.
There is also good news that the overall mortality from cancer has dropped 33% since 1991. The ACS attributes most of the drop because of advances in treatment for leukemia, melanoma, kidney, and even lung cancer. However, for women, breast, uterine, liver, and melanoma rates continue to rise, as mentioned above.. Routine doctor visits are still essential, and screenings are vital.
Prostate cancer screening routinely starts at 50, and 45 if Black, or have a first degree relative with prostate cancer, and 40 if there is more than one first degree family member who was diagnosed before the age of 65.
My doctor wants me screened at 80, because I am so healthy!? It is always the doctor’s decision.
For older men not in good health, should seriously consider stopping screening, but leave that up to the treating doctors.
Medscape Medical News, January 12, 2023
C. Marijuana is killing—high concentrations of THC
I am working on an extensive report on the drug crisis for this April, but I must mention right now that there are concentrations of THC, the chemical in marijuana, that have become so concentrated and potent, it is causing psychotic behavior, and is killing some, especially if tainted with fentanyl. Street drugs, regardless of type are being laced with fentanyl. The potency of any street drug is always a question.
Those taking CBD or THC must be getting their drops from a very reliable source. Street drugs and internet sites must be checked out carefully. If the recommended dose is on the label, don’t exceed it.
This is becoming another crisis, and many of those most affected are children and teenagers eating gummies or smoking very concentrated THC and have developed psychotic episodes. Anything approaching 10% concentration is very dangerous.
2. More on COVID; The divide in medicine; Is the bivalent booster worth it? More myocarditis from vaccine; RSV and Flu
According to the AMA News, the number of cases of COVID, RSV, and even Flu may have crested earlier this year, and there is now less concern that the hospitals will be overwhelmed by these infections. That is great news, but for the vulnerable, they must continue to get vaccinated, be careful with crowds, maintain maximum health maintenance on all underlying medical conditions, and hopefully this will get better by the end of March.
Always expect public health to take the most cautious concerning stand when dealing with any infectious disease, and it is true that when people fatigue out after a long bout of any disease, people will become very lackadaisical, even the vulnerable. However, a closer analysis of just who is being counted was not done.
A. Hospitalizations and deaths—with or from—numbers are being greatly overcounted!
One of the biggest flaws in the CDC’s has been trusting the surveillance number of hospitalizations that are caused by COVID, as well as the death rate. Dr. Leana Wen, medical consultant for CNN admitted there has been enormous overcounting of cases and deaths directly caused by COVID. All Johns Hopkins and the CDC can do is take the numbers they are given from hospitals throughout the country, and there is where the blame reallt exists.
The question she and many experts have raised is, are hospitalizations and deaths occurring directly because of COVID, or are they an additional diagnosis? Every person admitted to the hospital gets tested, and if they are positive, they are being counted as a case.
She was backed up by Dr. Robin Dretler, Emory Decatur Hospital, Atlanta, Georgia, and former President of Infectious Diseases Society of America, who stated recently that 90% of patients diagnosed with COVID are actually in the hospital for some other illness.
When the government pays the hospital 15% more when the person is admitted with COVID, these facilities are going to influence their doctors with the diagnoses placed on the records and death certificates. Hospitals in Massachusetts in recent months reported that COVID is accounting for less than 30% of hospitalizations.
The CDC and administration have done everything under their power to encourage, scare, and intimidate people to get vaccinated with the thumb of the White House right on them. And they wonder why their reputation has plummeted, now that data is disproving many of the issues they supported.
Dr. Tracy Hoeg, M.D, in Denmark pointed out that they have good evidence that greater than 40% of child COVID admissions were incidental and not directly caused by the virus.
Some of the main drugs used to treat COVID early in hospitalizations like molnupiravir (Lagevrio) have now found not to reduce the length of time in the hospital, another touting by the FDA, and it is just one more example of how the real world data answers the statements about how effective these treatments have been…not as good as we hoped. This is not the first medication found to not work well.
Lancet, Dec. 22, 2022
B. Who is speaking for COVID today?
There has been little medical information about COVID these days for 2 reasons---people are tired of listening to them, and they can’t scare the public anymore.
The other reason is the feds put a gag order on the FDA and CDC not to talk to the public. Instead, they put that task on Dr. Anthony Fauci. He has already retired, but he continues to be the main face on TV, saying very little worth hearing, and defending every word he has ever said.
The media, medical organizations, and the administration have “sainted” Dr. Fauci (mainly for his work in HIV), when it is known he has been lying to Congress and the country, and refusing to admit that he was aware of financial grants for “gain of function” research on the bat coronavirus by the NIH.
His recommendations for many pandemic actions by the White House was not founded on sound data and have changed many times. The feds are doing their best to increase their power and control, but now even the liberal media is getting nervous.
Doctors in power must admit when they are wrong, or at least tell the public what is known and what is hoped. We have had to depend on Israel for most of the important data on this disease.
The cover up of some of the side effects of the COVID drugs, medical devices, and vaccines by Big Pharma is being finally questioned, as time has passed and more data is available mostly from other countries. But in the meantime, Pfizer and Moderna have made $billions.
Think Big Pharma doesn’t “own” Congress and the White House to some degree? When Medicare and Medicaid told the hospitals, they would be paid more (15%) for every COVID case and death, who decided that, and what do you think happened?
The pandemic is under control, but certainly still a big concern.
C. COVID; Is the bivalent booster worth it?; Annual boosters?
The latest data from the CDC and Israeli studies have found that the latest bivalent Omicron variant/standard dose combo is no better than the previous standard COVID vaccine doses. That still makes the bivalent booster as good, just no better, than the standard vaccine, and the taxpayers paid $5 billion to Pfizer and Moderna to develop the bivalent booster.
The feds are no longer offering the standard dose, so we don’t have a choice, but at least it is still an effective booster. And the annual booster will be a bivalent vaccine booster from now on containing standard coronavirus and the latest variant(s).
One of the experts on the FDA Board (Dr.Paul Offit), stated that the booster will never be as effective when the next variant surfaces, and that will continue for years. It continues to be true that the newer variants are more infectious, but less serious!! The left leaning medical journals are filled with opinions now pointing fingers on anyone who disagrees with them, and Governor De Santis has become the latest “whipping person”, after quoting a Cleveland Clinic paper that stated the vaccines may actually increase the risk of developing an infection. I am waiting for more confirmation on that study.
He and other members of the FDA advisory committee recently admitted to CNN that Moderna left some important research data that the bivalent booster was no better and was published by CNN and reported by Medpage Today on January 11, 2023. The FDA still approved the booster. This is probably just one of many lies or omissions from these vaccine companies. Why are they not being punished? Just one more evidence of the coverup by our government having health impacts on our country, and the world, while Big Pharma has become richer with each check from them.
Immunity does not change that much with each variant, but an annual booster still makes sense for the vulnerable since immunity wanes after a year. The vaccine, bivalent or not, does reduce hospitalizations and death, according to the FDA.
The CDC just announced that people over 65 who have received the Pfizer bivalent booster have an increased number of strokes within 21 days of the injection. This has not been discovered in the Moderna vaccine. I doubt there is a large number or they would have stopped recommending the new booster. But it is one more concern especially for those with cardiovascular disease, and those patients are the ones who should benefit the most from the vaccine.
This side effect is just one more effect of the vaccine that makes people hesitant, and only 16% of the population have received the new bivalent booster (only 35% over 65). There has been no change in the CDC or FDA’s recommendation for the vaccines. Honesty is the best policy!!
People who are healthy and under 60 should consider waiting for better vaccines, according to some experts. However for the vulnerable groups getting an annual booster is still something to consider. And with all these recommendations, the administration has not stopped the mandate on the military.
Hospitalizations and deaths are continuing to drop for COVID while Influenza is now the main cause (20-30,000 deaths this year is expected, but could reach 60,000, according to the CDC). So get the flu vaccine!!
The FDA has decided to request their vaccine advisory group to weigh in on the value of an annual booster. Trying to decide what variants would be included in each year’s dose will be an educated guess, just like the flu vaccine. They are recommending it will be offered next fall. And possibly 2 for the vulnerable.
If you are over a year without an infection or vaccine dose, they still recommend a booster now, because imunity is waning. I have yet to know just how much waning is necessary to recommend it. Where are the studies with numbers?
AMA NEWS REPORT
D. The newest variant this month! FDA working on an annual schedule for COVID
Vaccine companies report continue to point out that the latest variants BQ.1 (a variant of BA.5) and XBB.1.5 (a variant of BA.2) are not as sensitive to the bivalent booster, but still effective enough against to receive it. Around 20% of infections are currently being caused by these new variants. You may have noticed this changes by the month.
The data continues to point out that active infection (natural immunity) from COVID creates stronger immunity than any vaccine, but still wanes after a year as well.
As the variants of Omicron change by the month, it is totally insane for Big Pharma to try and develop different boosters just to put more $billions in their pocket. They have stated that the new boosters are better, and now we know with peer reviewed data, that is untrue, however, it is as good as the standard booster.
It will be interesting how the public accepts their recommendations for an annual booster, but it certainly will simplify distribution and be available at the same time the flu shot will be.
Medpage Today, January 23, 2023
E. Concerns taking Paxlovid because of drug interactions; FDA removes medications for COVID treatment
Paxlovid is the most common effective oral treatment, although remdesivir (Veklury), an injection, normally used as an inpatient, is still available and somewhat effective. Convalescent serum is still available, now being used less frequently.
The feds recently announced that they would stop paying for Paxlovid soon, but when senior organizations jumped them, they were politically forced to pay another $2.5 billion to Pfizer to still pay for the drug.
Pfizer currently receives $530 per prescription for Paxlovid from the government, and one might think the government could negotiate a reduced price, but then who owns the Congress?? Big Pharma!! It is good that the public can still receive this prescription free for some more months.
It is very important that Paxlovid is very effective (44% less likely to be hospitalized) in preventing severe disease and the complications of it, so this report is not to deter anyone from taking oral Paxlovid, rather, it is important to know many medications can interfere with the drug, and may need to be temporaily stopped while taking Paxlovid.
An Israeli study found that if vaccinated, and over 65, hospitalizations were reduced by 73%, and deaths by 79%.
NEJM, September 1, 2023
Recent data has shown considerable concerns by doctors prescribing Paxlovid for those 65 and older for effects with the patient’s other meds. Also there is a significant list of meds (some below) that are contraindicated or of concern with Paxlovid. The first journal article I rea about concerns appeared in Medscape on January 19, 2023.
Be sure anyone wanting to take Paxlovid who is 65 or older discuss it with their primary care physician regardin the medications they currently take. If you don’t have one…..get one! Medications that create problems when taking Paxlovid are important, and people need to be discussing this with their doctor pre-COVID infection. Asking a pharmacist is second best, as they may know what drugs you take, but not how important they are regarding pausing them while taking Paxlovid.
One report stated out of 1500 physicians, they were asked if they were prescribing Paxlovid for patients over 65, and amazingly, only 37% were. Asked why, they stated that half of their patients were taking a drug(s) that was contraindicated or might negatively interact with Paxlovid, and the risk was too high to discontinue their meds temporarily. Another concern was a negative reaction with the kidneys. Only 22% were concerned about the rebound symptoms after stopping Paxlovid, which is not uncommon.
Only 14% of pharmacists prescribed the drug to those over 65, as Biden has given them the power to prescribe this one drug.
This may explain the lower number of prescriptions being written. And the feds paid Pfizer $2 billion for coverage of more Paxlovid.
Every age should review their medication list regarding the safely of Paxlovid and talk to their doctor.
Some of the drugs that interact with or are contraindicated taking Paxlovid.
7 common meds that interact with Paxlovid are statins, some heart and blood pressure meds, blood thinners, certain antidepressants such as Wellbutrin, trazodone, an antipsychotic such as Seroquel, Clozaril, Latuda, seizure meds such as Phenobarbital, Tegretol, Dilantin, Mysoline, migraine meds such as Relpax, Ubrelvy, Nurtec, and ergotamine meds, a birth control med with ethinyl estradiol, which is contained in vaginal rings, patches, etc., Viagra, Cialis, and Levitra, erythromycins, Flomax, Uroxitrol, Halcion, and many more are on the list.
Many of these medications can be stopped temporarily, but the treating doctor should make the decision!!
Good Rx has a good website to check with!! www.goodrx.com
Medscape Medical News, January 18, 2023
FDA removals and approvals
Bebtelovumab has been removed from FDA approval, which was also being recommended for more serious cases of COVID, as research has shown that it does not neutralize the latest Omicron variants of COVID (BQ.1 and BQ.1.1). Another one bites the dust.
The monoclonal antibody Evesheld is still FDA approved for some cases when the other drugs don’t work. Abcellera was just FDA approved, but its effectiveness has yet to proven long term. More data is disproving the values of these drugs such as monoclonal antibodies, antivirals, etc.
Our government has failed miserably in developing good treatments for COVID, as they invested all their money in the vaccine, and we still need a much more effective different generation vaccine.
One of the time tested medications, corticosteroids, continues to be very helpful as an inhaler, pills, or injections depending on the clinical circumstances. This drug was totally ignored when the pandemic began. It took some very brave doctors to start using this drug when those recommended were failing miserably, including high pressure ventilators. What a learning curve!! That is why medicine is called a PRACTICE.
As I read more conflicting results of testing of the medications to treat COVID, it appears Remdesivir is about the only medication that works fairly well for hospitalized patients, even with some side effects.
There is a good report that oral form of Remdesivir is as effective as the injectible form, and that Pfizer will request approval for its use from the FDA. The cost, however, would be much greater.
Paxlovid, while in short supply, is very effective to reduce severity for outpatients, especially in the vulnerable group, as mentioned. In fact, since it is in short supply, it should be reserved for the vulnerable populations.
Medscape Quiz, December 3, 2022
Medscape, Dec. 7, 2022
F. Long COVID syndrome better defined
I have reported that as high as 20% of patients hospitalized with COVID continue to have symptoms for months (they only have 2 years to draw from, so they don’t know how long it will continue). Most have fully recovered in a year, according to the CDC.
Symptoms of long COVID often include loss of smell and taste, cognitive impairment, weakness, palpitations, and breathing difficulty with a cough usually dissipating within a year, especially in younger people. Muscle and joint pain can also be a problem. Not surprisingly, older patients with underlying medical conditions can complicate the infection and make the recovery even longer with long COVID syndrome.
Effects on the diaphragm by COVID
Shortness of breath is a common symptom not only in acute infections but continues in the long syndrome.
Studies are pointing to the diaphragm, which may be weakened with an autoimmune inflammation from COVID of the 2 phrenic nerves, which are branches off the spinal cord (C-3-5) that innervate the left and right diaphragm, shown below, and are critical to assist in breathing.
When breathing, the diaphragm lowers with a breath, to allow maximum expansion of the lungs with air. If the muscles between the chest and abdomen are not able to function at 100%, shortness of breath will occur.
32% of those on a ventilator sustained long term diaphragmatic dysfunction on ultrasound at 15 months.
The CDC estimates that there are 23 million Americans with Long COVID who are covered by the American Disabilities Act.
Treating the symptoms of long COVID continues to be the hallmark of therapy, as there is still not specific treatment. Corticosteroids may be included to fight the inflammatory response created by not only the acute but the long term syndrome.
British Medical Journal, November, 2022
Medpage Today, January 6, 2023
Newer studies regarding heart and lung damage
A new study (HEAL-COVID from the UK) found that, in the following 6 months since hospitalization, 29% have had to be readmitted with heart and lung issues, and 12% died.
30% of them are given a new medical diagnosis, most commonly pulmonary, 5% with diabetes, and 5% with a new cardiac diagnosis. Is it the virus, or the treatment they received, or just coincidence? They don’t know. And there are journal articles now questioning the numbers who are really diagnosed with long COVID.
There is still a theory that microclots cause the Long COVID syndrome, created as an autoimmune reaction, and yet why don’t blood thinners stop it?
It has been reported that a blood thinner, apixaban (Eliquis) did not stop patients from dying later. The study compared a group who received the blood thinner vs. a group who did not and was treated with only supportive care. Both groups had 30% death rate.
Research continues to be unable to find the cause and adequate therapy for the long COVID syndrome.
It has been reported that the vaccine does lower the risk of developing the long COVID syndrome, which can affect any age…..pretty good reason for getting vaccinated. We are still concerned a newer variant learns how to evade the current vaccines.
MedscapeUK, Dec.2, 2022
G. When Japan has 91% of the population tripled vaccinated, why is the death rate so high?
One study may have the answer and you won’t like it!! A German study says the vaccine is damaging the heart, and those older and with underlying diseases especially heart disease, may be getting more damage to their hearts, and that is why there are higher death rates in older people in Japan.
The m-RNA vaccine makes the patient’s own immune cells attack the heart muscle in young males causing mypocarditis, which is known, but can occur at any age.
Think about it, the vaccine is designed to mobilize the person’s immune system, and when it does, those cells are possibly directly damaging their hearts, and when an infection comes around, the damage is worsened by the virus. What other organs are getting damaged?
The research studied 25 autopsies on people who died 28 days after they were vaccinated. Their hearts all had evidence of myocarditis. All appeared to have no previous heart disease. This publication was peer reviewed, the best kind of study.
Why aren’t we hearing about this study in the Journal of Clinical Research in Cardiology, the official journal for the German Cardiac Society. Epoch Times published this information. Why not the NYT, Washington Post, and on CNN, etc. Why not in the JAMA, NEJM, etc.?? Big Pharma has influence on these organizations.
Big Pharma has admitted that myocarditis is a side effect from these vaccines, the second dose even worse than the first. Think about all those people who had minimal symptoms from their myocarditis, and recovered with little data on these patients from the FDA, CDC, or Big Pharma.
This information really concerns me that we are not hearing about all the cases of myocarditis. Next month, I will be reporting on myocarditis and other inflammatory and immune disorders of the heart including pericardtitis, endocarditis, etc.
H. The divide in medicine—Big Medicine, Big Government, and Big Pharma
The reader must realize that the division in medicine is as strong as it has ever been. The academic medical institutions, most of the national medical organizations including the AMA, internal medicine organizations, the American Academy of Pediatrics, and others are supporting socialized medicine while many major medical centers are joining the totally woke, socialistic society being forced on us, are not condemning what is happening to our school children including CRT training and extreme racial equity, and now even in choice of medical school admissions.
The medical schools have changed the Hippocratic Oath for graduating doctors to include these concepts, and is trying to change the attitude of private doctors (and are), but current private doctors have rejected their ideology and thousands have dropped their memberships to these national organizations. But times are changing even for private doctors, because they are becoming employees.
With 70% of M.D.s now employees, they do not make all the medical decisions as they did when in private practice, and have had to accept what medical center employers and large medical organizations that employ them, tell them how to treat patients, when to admit, etc. Guidelines and recommendations have become rules (look at the CDC), and medicine today is trying to treat patients “cookie cutter style”, and anyone who has had years in medicine knows that each patient deserves individual treatment, and options ready to implement when one therapy is not working.
This issue plays role in any patient’s care, and underlines how important it is for patients to be knowledgable about their conditions, and if a patient doesn’t agree with their doctor, get a second opinion.
I am sad to see what is happening in this country, but even more so when every medical journal I read has liberal leaning, biased and woke opinion articles in them.
The healthcare crisis in the UK makes us look like we don’t have any problem. CNN News published an article on that UK crisis on January 23, 2023 that I will use in part to report the status of healthcare in the UK next month.
The chaos created in our country has a madness to the method, I am convinced…..it is called steps toward communism, based on the chaos theory from the Communist Manifesto. With overwhelming chaos in a country, the natural response is federal control. Is that what we are witnessing?
I want my readers to know that as Americans we must not be blinded by the tactics of those radical leftists who are hell bent to destroy capitalism, our constitutional rights, and carry us toward a communistic society, destroying the quality of our healthcare at the same time.
The young are all in for socialism with so little understanding about where it will take them. When they get older and start having medical issues, higher taxes, more responsibilities, etc., the quality of their healthcare and their lives will suffer, with healthcare deterioration first, they will wake up. Seniors will suffer more than any group.
This is not a Democratic/Republican issue…it is an American issue, and if we don’t get the infighting under control, retake the FBI, the CIA, the judicial parts of our government, and most of the media who love the chaos, we are doomed. There are really bad actors running those agencies and parts of government, and could care less about the health and welfare of our country. It is all about the power and control, and yes….money….your money to run it.
Doctors and nurses have been abused, overworked, often underpaid (the Congress just cut their Medicare and Medicaid pay by 2.2% with the $1.7 trillion Omnibus bill just passed), burned out, and ridiculed by patients because they won’t give them the prescriptions they want (and don’t need). Weight loss drugs are the latest issue.
With the CDC, the FDA, and the current administration making rules regarding the pandemic without sound medical data, which has become common place, we are facing difficult times in healthcare. With only one political party running our country, Censorship has become commonplace. It must end if this country is to survive.
Big Government strongly influenced by Big Pharma and Big Medicine has had 3 years to get a virus under control with vaccines and medicines that have been mediocre at best. Fear tactics pushed us towards a vaccine that was supposed to prevent COVID….a lie, and now the list grows!!
I. Viral diseases are mostly seasonal
We all have to deal with a variety of respiratory viruses each year, more in the colder months, and that will continue with or without COVID.
RSV has had a head start in 2022 and now we have a bad flu bug, with 15,000 children hospitalized for flu. How many were precautionary admissions vs real need? Good question!
Since the pandemic, patients have been admitted very quickly if they have any respiratory symptoms. COVID has increased our aggressiveness in evaluating and admitting patients especially if they have an underlying medical condition. It has increased the workload on the medical staff in hospitals. Patients have been quicker to go to the emergency room or their private doctor, since COVID heightened our fears, as more doctors and nurses are burning out, and choosing different positions, etc.
J. Real Effectiveness of vaccine in nursing home residents
A recent study found considerable effectiveness in keeping nursng home patients out of the hospital, by 70% with the current vaccines. That is proof positive that ALL nursing home patients need to be vaccinated including the boosters.
These vulnerable patients must try and protect themselves when in a group home with family assistance. Skilled nursing facilities are becoming understaffed, and we must play a more active role in seeing to it that they are being adequately cared for.
I will be reporting on the crisis in home health care and skilled nursing facilities (nursing homes) in the near future.
JAMA Network, Dec. 7, 2022
K. RSV—Respiratory Syncytial Virus
RSV is worse this year, because the public was isolated with the pandemic, even though only small children and older vulnerable people get sick.
COVID mandates continue for a disease less concerning than RSV and flu. These mandates must cease and people fired reinstated. Our military is still suffering from the mandate.
RSV hospitalizations are 10X more frequent than usual (usually in 1-2 year olds), but after this winter, it should level out back to prepandemic levels unless draconian methods by the administration or states reinitiate isolation.
The reason there is no RSV vaccine is because of a 1966 RSV vaccine created some disastrous side effects, and has most pharmaceutical companies shying away, however, with this year’s rise, research is ongoing for a new, safe vaccine by Pfizer. Who else? Who is making all the money?
Pfizer, in clinical trials only, is touting an 87% effectiveness against RSV, but not FDA approved…yet! Trusting in pharmaceutical reports continues, as data often later refutes their statements.
3. Management of Heart Failure; SADS—sudden adult (arrhythmic) death syndrome? Damar’s cardiac arrest; CPR
In 2017, I reported extensively on heart failure. It is time to update what I have previously discussed. Since I have been requested to report on SADS, I have added it to this report.
6 million Americans suffer from heart failure, and more common in females, which can be mild, moderate, or severe. It used to be called congestive heart failure, but it wasn’t covering all cases. The heart muscle can be thickened or thinned based on the disease process. Either way, the heart is unable to circulate blood properly, essentially failing.
In the 2017 report, I explained the functions of the heart muscle as a pump, the definition of heart failure, and the consequences that occur when the heart fails to function properly and its effects.
I explained the autonomic nervous system and how it innervates the heart muscle, the biggest smooth muscle in the body (as opposed to skeletal muscles). It is important to understand the difference and the nerves to them come from totally different systems.
All these issues are well covered in my 2017 report which is the basic science of heart failure and does not need to be repeated, when all you have to do is click on my website to that report at www.themedicalnewsreport.com #61
The anatomy of the heart
There are 4 chambers of the heart and a right side of the heart and a left side. Failure can occur on one or both sides of the heart, and they must be differentiated.
Follow with your eye from the right atrium that receives all the blood from the body’s veins to the right ventricle and then to the pulmonary artery, which fills the small vessels in the lungs to oxygenate the blood.
The blood comes out of the pulmonary vein to the left atrium, and then to left ventricle to the aorta to flow out to the body with oxygenated blood.
Blood flow through the heart
Chronic heat failure
Chronic heart failure treatment has made great strides, while acute heart failure still needs further fine-tuning. They continue to create new algorithms with new medications to treat this serious disorder.
When a person develops shortness of breath (most common symptom of heart failure) and goes to the emergency department, diagnostic testing for the cause, must determine the diagnosis and whether the patient is sufficiently ill enough to be admitted or treated as an outpatient. Regardless, the treatment likely will begin in the emergency department.
Many COVID patients filled the emergency departments with patients complaining of shortness of breath, so X-rays must be performed to check the size of the heart and what infiltrates (if any) are present to rule pneumonia, which usually would cause a fever and heart failure would not. However, COVID heart invasion can also cause heart failure.
When the heart fails to pump the blood fast enough the lungs will back up the fluid part of blood, and will be seen on X-ray (right sided heart failure), but if the left side of the heart fails, there is not enough pumping power to send the blood out to the body (the most common).
Regardless of any type of fluid buildup (heart failure fluid or pneumonia fluid), this will cause shortness of breath, because the body is not adequately being oxygenated, and can easily be seen with an oximeter placed on the finger.
With left sided heart failure the heart is either too weak to pump or the walls of the heart are too thick or too stiff to function.
Finding the underlying reason for the malfunction of the heart is critical in properly treating the patient, although the actual medications to treat the heart may overlap.
2 types of heart failure—diastolic and systolic
The heart can’t pump, or the heart can’t fill.
Most common causes of heart failure, mostly chronic (long standing)
1) arrhythmia (irregular heart beats)
2) cardiomyopathy—autoimmune diseases (lupus, rheumatoid arthritis, etc.), long term hypertension, heart attack, long term rapid heart rate, heart valve problem, COVID, and other types of infection of the heart muscle
3) congenital heart defects
5) heart attack
6) high blood pressure
7) blood clot in the lungs
9) lung diseases, i.e. COPD
Common causes of acute heart failure
1) allergic reaction
2) any illness that affects the whole body including alcohol and illicit drugs
3) blood clots that lodge in the lung vessels (emboli)
4) severe infections
5) medication side effects (diabetic drugs such as Avandia and Actos, etc), high doses of NSAIDs, blood pressure meds, cancer drugs, and any drug treating heart conditions, blood conditions, etc.
6) viruses that attack the heart muscle (myocarditis)
Risk factors for heart failure
It is important to know that there are factors that raise the liklihood heart failure can occur, so questions need to be asked by the staff: known heart condition, smoker, over 65, history of high cholesterol, inactive lifestyle, overweight, alcohol abuser, illicit drug use, sleep apnea, hypertension uncontrolled, diabetic, infection present from COVID, pneumonia, COPD, anemic, under cancer treatment, Black, or kidney disease present.
Other signs of heart failure
In addition to shortness of breath, coughing, fatigue, swelling of the lower extremities especially the feet and ankles, having to sleep propped up, loss of appetite, and enlargement of the neck veins, with frequent urination.
Complications of heart failure
1) Kidney failure from reduction of blood flow to the kidneys
2) Heart valve problems by overwhelming them with the heart muscle working overtime causing efficiency of the valve
3) Arrhythmias potentially causing death
4) Liver damage due to fluid backup from the heart
Testing begins with an EKG and an echocardiogram, but may include multiple cardiac imaging tests(Angiography, CT, MRI, chest X-ray) to determine the size, shape, and other anatomical findings that define the condition of the heart, and possible the coronary arteries.
Compare these two chest X-rays below. Note the fuzziness of the vessels (arrow), implying dilation with an enlarged heart, and fluid around the heart appearing as haziness.
The options for treatment have increased since I reported in 2017 with more options medically and mechanically. The treatment is multifactorial. There are still new algorithms trying to come up with new treatments, especially determining more quickly when to change or add treatment regimens to improve cardiac function and preserve the integrity of the heart muscle to prevent further deterioration.
Patients must be on board as an integral partner regarding their home therapies, rehab programs, exercise, diet, and other behavioral modifications to assist the cardiologist(s) to maintain and improve heart pumping capability.
If there are new or worsening symptoms, they must be in close contact with their doctors, so that if a patient needs further testing and face to face evaluation, that will occur as fast as possible.
2— Mechanical devices,
3— Surgical procedures,
4-- Reduction of sodium,
5— Other behavioral changes—quit smoking, drinking, not eating a fatty diet, manage stress, get an exercise program, and lose weight,
6-- Control other medical conditions that contribute to heart disease
a) ACE inhibitors (angiotensin converting enzymes)—relax the blood vessels to lower blood pressure, improve blood flow, and diminish the strain on the heart muscle enalapril (Vasotec), lisinopril (Prinivil, Zestril), or catapril.
b) Angiotensin II receptor blockers include losartan (Cozaar), valsartan (Diovan), candesartan (Atacand), which act similar to ACE inhibitors, but can be ordered if they are not tolerated.
Sacubitril/valsartan combined (Entresto)—sacubitril is a neprilsin inhibitor that is added to valsartan (Diovan), an angiotensin inhibitor, which has been found to be very effective in chronic heart failure.
Empaglifloxin (Jardiance), an antidiabetic drug and an alternative to Entresto, are the only 2 drugs FDA approved to treat heart failure with preserved ejection fraction.
These 2 drugs are very expensive, so consult GoodRX.
c) Beta blockers slow the heart rate and blood pressure, which can be used in addition to the top 2 categories. They improve heart muscle function making it more efficient as a pump. They include cavedilol (Coreg), metoprolol (Lopressor), and bisoprol.
d) Diuretics must be used to reduce the fluid buildup because of the failing heart from mild to severe. There are many choices but furosemide (Lasix) is still probably chosen the most. Electrolytes (potassium and magnesium) may be depleted with diuretics, therefore supplements may be necessary (must monitor blood levels).
e) Aldosterone antagonists are diuretics too, but do not deplete the electrolytes, however they can raise the level of potassium Spironolactone (Aldactone) or epleranone (Inspra).
f) Positive inoptropes are used as an IV medication for severe cases.
g) Digoxin (Lanoxin) is still a valuable drug to increase the strength of the heart muscle, and may be used especially in patients with atrial fibrillation, as it slows the heart rate.
h) Hydralazine and isosorbide (BiDil) combination may be added to the above regimens or replace ACE inhibitors and beta blockers if they are not working.
i) Vericiguat (Veriguvo) is a new drug added to the list for chronic heart failure and may lessen the number of hospitalizations. They stimulate guanylate cyclase, an enzyme that affects vasodilation.
j) Other medications are also often used in these patients to address added issues to lower high lipids, nitroglycerin for chest pain, etc.
2— Surgical procedures
When a pump is failing to do its job, either replace it (heart transplant) or take steps to make it more efficient. If there are coronoary arteries constricted, angioplasty may be necessary to dilate the areas of stenosis, or surgical replacement coronary bypass surgery using leg veins.
If the heart rhythm is inadequate to pump the blood, then a pacemaker may be necessary to get a better rate. Implanted under the skin.
If irregular heartbeats can’t be stopped with medication, then ablation of the nerve center in the heart may fix the issue, using electrical current. Pacemaker and defibrillator!
If there is a chance that the heart rhythm could go into ventricular fibrillation, an implantable defibribillator will shock the heart and hopefully return the heart rhythm to normal. Standard pacemakers can be implanted as well as a defibrillator implant simultaneously.
There are specialized pacemakers to address special issue with the lower ventricles. If they are out of sync, there is resyncronization biventricular pacemaker (CRT), that send signals to the ventricles so they can work simultaneously (for patients with an ejection fraction of 35% or less). Ejection fraction implies how much blood can be pumped through the heart per heartbeat.
If the cardiac ventricles are not pumping sufficiently, and a transplant is considered, an implantable ventricular assist device (VAD) can be placed usually in the left ventricle while waiting for a new heart or permanently if a patient is not a good candidate for a transplant.
Medscape General Surgery, Dec. 12, 2022
If a heart valve is faulty, it may be replaced with a TAVR* which allows repair or replacement of the aortic valve, the most common valve to faulter. It may be performed as an open heart procedure or the new valve may be paced transvenous.
*TAVR=transcatheter aortic valve replacement, using the arm vein to introduce the device inside the impaired aortic valve to provide better function and flow through that valve. A balloon dilates the damaged valve and then the new synthetic valve is placed, as shown below.
A team of doctors will be required to decide if a heart transplant is necessary, and if one is available in a timely fashion. Immunosuppressive therapy will necessary permanently.
If a patient is not able to continue treatment and is deteriorating, palliative therapy will be necessary. Coordination between the treating doctors, Hospice, and those in palliative care, which will treat the symptoms of the patient more strongly, even if it is not improving the condition. Vasodilators for shortness of breath, opioids for pain, nitroglycerine for angina, more diuretics to remove more fluid in the body created by the failing heart.
Advanced care directives and end of life care must be understood by the patient and family. Nurses, trained volunteers, and social workers are an integral part of any team facing end of life issues.
Mayo Clinic; NEJM, November 5, 2022; The American Heart Association
NEXT MONTH, I WILL REPORT ON INFLAMMATORY CONDITIONS OF THE HEART (MYOCARDITIS, ENDOCARDITIS, AND PERICARDITIS!
Since I have been asked about SADS, I will define it. And with the NFL player, Damar Hamlin, Buffalo Bills, who went into cardiac arrest from a blow to the chest, sudden death certainly is on the minds of many of us. He has recovered well, out of the hospital and recovering at home.
Whether he returns to football, remains to be seen. CPR saved him, but an immediate shock from an AED (automatic electrical device) would have been even better. Shocking the heart will return the heart to normal sinus rhythm in many cases, especially in cases such as Damar’s.
350,000 deaths per year occur from sudden cardiac arrest, most commonly from underlying coronary artery disease. Young people are more likely to have an underlying cardiomyopathy they are unaware of.
The term for cardiac arrest from blunt trauma to the chest, as in Damar’s case, is called commotio cordis, as the blunt object hits the chest in a vulnerable cycle of the heart, creating instability in the electrical system causing ventricular fibrillation.
Immediate CPR with AED asap is necessary for the heart to recover. The main lesson according to a cardiologist, Dr. Merrell Jessip, chief of the American Heart Association, is for people to learn CPR and use an AED (assisted electrical device).
The Red Cross has a tutorial on using an AED and performing CPR at: www.redcross.org
SIDS (suddent infant death syndrome)
The classic use of the term “sudden death syndrome” (SIDS) refers to infants who suddenly die in their crib usually from a positional standpoint suffocating with the face down, a sudden cardiac heart beat irregularity, and central apnea, etc.
There are defects in the infant brain that may predispose the event occurring. Many who die are low birth weight babies and have a respiratory infection. Babies should sleep on a solid surface face up, and should not sleep with a parent or animal that might compromise the infant’s airway. Overheating the baby’s room may predispose to trouble.
SADS(sudden adult death syndrome)
In younger adults, SADS should be defined as sudden arrhythmic death syndrome, and implies a sudden death in someone under 40.
We have heard of famous track stars who just fall over, usually from an acute change in the heart rhythm from a sudden unexpected electrical abnormality in the heart. The heart suddenly misfires and goes into ventricular fibrillation, which often is fatal, unless someone performs cardiac resuscitation immediately. Essentially, the NFL player had this syndrome, except it occurred with a blow to the chest, and help was immediately available.
There are certain EKG abnormalities that may likely cause no symptoms but can predispose to a sudden arrhythmia. The classic one is Wolf-Parkinson-White syndrome (WPW).
I lost a fellow surgical resident from an apparent sudden fatal arrhthymia at his desk while on call one night, who was known to have WPW syndrome. Fatigue certainly could be a factor in his case, since our residency was a marathon.
Other EKG abnormalities are a prolonged QT interval-Brugada syndrome, and any person with a known cardiac arrhythmia, previous heart attack or known coronary artery disease would be at risk for sudden death, but most will not occur before the age of 50.
With heart disease, still the number 1 cause of death, sudden cardiac death accounts for at least 50% of cardiovascular deaths at any age.
Many of the inherited cardiac EKG abnormalities could cause sudden death. The list is long and all can be picked up by an EKG, but are very uncommon to cause sudden death, if a person has one of these abnormalities.
Usually if these EKG abnormalities are found in a totally asymptomatic person, a cardiac workup might be in order including a stress test to see if the heart rhythm worsens.
Having a routine EKG is probably a good idea by age 40 unless there have been reasons to perform one earlier, although controversial. I feel regular checkups are worth the time and money.
80% of sudden deaths occur in the general population from associated coronary artery disease, which can be diagnosed with the above studies and even a coronary artery scan to measure the narrowness of the arteries. Having thickened coronary walls is only a risk factor, not necessarily going to cause trouble.
Those who get radiation therapy to their chests for cancers (including head and neck cancers and breast) will have thickened arteries, because the radiation will cause enough damage to create calcification and thickening.
A higher resting heart rate has been linked to sudden death risk. Obesity, diabetes, genetics, many medications, use of illicit drugs especially cocaine and amphetamines increases the risk of this syndrome.
Unknown congenital heart defects may be another cause. Many young people have undiagnosed cardiac issues and in school, and EKG before football and other sports might pick up some abnormality..
COVID and COVID vaccines are now another issue to add to the list. There is no data on people who develop myopericarditis from the shot or the disease.
If there is a history in the family, or any concerns about easy fatigue, being “our of shape”, etc. should raise the decision to get a heart checkup and an EKG. There is a lot of discussion currently about screening all athletes for cardiac disease, but it is still quite controversial, as it can create a lot of false positive and negative data.
Screening for obstructive sleep apnea (OSA)
Anyone who snores loudly, breathes loudly through the mouth, and has frequent periods of start and stop breathing, needs to investigate whether they have clinical obstructive apnea.
Anyone with daytime drowsiness, nods off during the day, doesn’t get restful sleep, is overweight, has trouble breathing through their nose associated with snoring, has chronic fatigue, difficult to treat hypertension, those with cardiovascular disease, has a short jaw, a short thick neck, and wants answers, obstructive sleep apnea may be the answer.
A certified sleep lab is required to diagnose if there is apnea, obstructive or otherwise, narcolepsy, restless leg syndrome, etc.
It is recommended all people asymptomatic 18 year olds and older be routinely screened with a questionnaire for obstructive sleep apnea. (that’s how common it is!)
The routine screening would not apply to those with obvious symptoms that might be caused by OSA---snoring, witnessed apnea, excessive daytime drowsiness, impaired cognition, mood changes, gasping or choking while asleep, or persons who have been referred for evaluation of OSA and must have a certified sleep study in an accredited lab.
All these people should be referred for medical evaluation of OSA, a sleep study, and follow up. This does not include a significant portion of the population, only those who fit in the asymptomatic category above.
Risk factors associated with OSA are males, older age (40-70), postmenopausal status, higher body mass index (BMI greater than 35 for females and 40 for males), those with craniofacial and upper airway abnormalities (enlarged tonsils, thick short necks, big tongue, narrow dental arch, short jaws, etc.), and those with hypertension.
Apneic episodes cause cardiac arrhythmias, coronary spasm, heart attacks, strokes, pulmonary hypertension, seizures, and with daytime results of fatigue, car accidents, poor work, lack of paying attention, personality changes, marital difficulties from separate bedrooms to divorce. These serious issues can be greatly helped with proper diagnosis and treatment.
Severely obese patients may even have to live with a permanent tracheostomy. That is much rarer, and treatment should always begin with CPAP machine therapy.
37% of men in the U.S. have some degree of obstructive sleep apnea, and 17% of women. Because of large tonsils many children has apnea, and many children and adults who are becoming overweight develop obstructive sleep apnea. That means millions of CPAP machines are in use. Millions more have snoring, and some milder forms of apnea which cause daytime drowsiness, feeling less than rested in the morning, and are doing nothing about it.
The mechanics of an apneic episode
Obstructive sleep apnea is caused by a myriad of anatomical issues in the nose and mouth. Note the tongue in the drawings below. See how close it is to the back of the throat, and as the drawing portrays, (on the next page), when a person falls asleep the tongue can easily block the nasal and oral airway by falling on the soft palate and back of the throat, which will obstruct the airway.
When the apneic episode occurs, and the oxygen levels in the blood start to drop, the brain senses this and the depth of sleep is changed with the body trying to relieve the blockage with the tongue muscle tone increasing, which lifts the tongue off the back of the throat.
Anatomical abnormalities that predispose to obstructive sleep apnea
Being overweight is one of the biggest reasons plain snoring can progress to obstructive sleep apnea. Dental arch narrowing, large tonsils, a long floppy soft palate, short neck, big tongue, redundant throat lining, and nasal obstruction all can play a role in this disorder.
A sleep lab study is critical, and technicians capable of fitting a proper CPAP machine on the patient, as a second night study is necessary to calibrate the machine (the right pressure necessary to blow enough air into the airway to relieve the airway obstruction.
Patient in sleep lab
More information about the Sleep Lab study
Candidates for any treatment begin with a certified sleep study, which monitors all night the brain waves (EEG), EKG, blood pressure measurement, heart monitor, oxygen saturation with and without an apneic episode, inspiration strap around the chest to determine when an apneic episode occurs and how long it occurs.
There are home units that can be rented, but they do not take the place of a certified sleep lab performing the study.
Once a diagnosis of obstructive sleep apnea is made (30 or more episodes per hour with oxygen desaturation, treatment options need to be discussed with a sleep specialist, usually a neurologist, pulmonary doctor, or ENT surgeon. Ultimately, a dentis specializing in dental splints to relieve apnea should be considered.
Options of treatment
A. CPAP machine
Most patients should be tested for the value of a CPAP machine, (continuous pulmonary airway pressure), and there are many varieties that can be tried, basd on the severity of the obstructions and the pressure necessary to relieve it.
B. Dental prostheses
These dental splint pull the mandible (lower jaw forward) which in turn pulls the base of the tongue off the back of the throat. It may or may or may not work, but is a consideration in those who do not want to use CPAP, can’t tolerate it, or have an obvious dental issue that would be perfect for these prostheses. See an expert, even if you have to travel to a large center, where the dentist has great experience.
C. The Inspire Procedure
One company is marketing their product heavily (Inspire), but their ads are don’t tell the story.
It requires surgical placement of a pacemaker type of unit placed in a pocket under the chest skin with electrodes which are tunneled under the skin, up the neck, and into the tongue close to the nerves (hypoglossal) that stimulates the tongue (drawings on next page).
During sleep, especially REM sleep, the tongue relaxs and can fall into the back of the throat, blocking the airway. When the tone of the tongue muscle during sleep is stimulated by these electrodes, the tongue will move forward in the mouth and off the back of the throat, hopefully relieving the obstruction and allowing the patient to take a breath.
In selected patients, this technique can be effective, but there are many factors that affect the airway and contributes to obstruction, including a short jaw, large tonsils, a long floppy soft palate, excessive and redundant mucosal lining in the throat, and even obstruction inside the nose which creates more mouth breathing, drying of the tongue and worsening of the obstruction.
Seeking a surgeon with experience will be difficult, because the procedure has only been around for a few years. University centers are likely to have such an ENT surgeon who performs the standard surgery for apnea, but also able to place these wires correctly.
D. Surgical correction of the nasal, oral and throat anatomy
Of course, surgical correction in many patients is an option (uvulopharyngopalatoplasty--UVP), which I performed quite often in my surgical practice with good results. Often surgical correction of a deviated septum and large nasal turbinates will improve the results.
I was co-director of the hospital’s sleep lab with a neurologist.
Large tonsils obstructing airway
Results of UVP
Nasal surgery to correct breathing issues including the UVP
The nasal airway is crucial for good airway flow to the lungs, and if the oral airway is blocked off with from obstruction, as it is in OSA, being able to breathe through the nose is critical.
The nasal septum is often crooked congenitally or trauma, and must be repaired with a septoplasty. Additionally, with allergic rhinitis, the nasal turbinates enlarge and block the airway.
Medical therapy is critical (antihistamines, decongestants, and nasal steroid sprays), but often unsuccessful. Having used a laser to reduce the size of these turbinates creates a much better airway. It is a great addition with or without the UVP.
The nasal septoplsty is performed inside the nose by reconstructing the crooked cartilage by removing it and using some of that cartilage to support the septum, so it does not change the outside of the nasal appearance.
The inferior (lower) turbinates can be partially removed with a scissors but I used a laser to prevent bleeding. The combination surgeries was quite successful in opening the airway not only during the day but at night when asleep.
Those in a VA study who underwent surgical correction (UVP) hada 30% lower mortality rate after 5 years. A Korean study found a reduction in heart attacks, hypertension, daytime drowsiness, heart failure, compared to a similar group without surgery. Weight loss must be addressed.
The country is gaining weight and the number who are past their ideal weight is over 50%. 20-30% are becoming overweight. This is creating not only an epidemic of obesity but one of obstructive sleep apnea, not to mention type 2 diabetes, hypertension, cardiac disease, strokes, kidney failure, and many social and work difficulties including not being qualified to be in the military.
I will be discussing the issue of being overweight and diabetes, the new treatments, and other issues next month.
Excessive weight is always a major factor that must be addressed for best results in addition to any treatment technique for apnea. Without weight loss, apnea will not resolve and make these treatments far less effective.
Considerable weight loss and bariatric surgery have also shown improvement in OSA.
Please refer to the subject index on my website under apnea. I have written about this subject many times. When you log on to the homepage, click on the subjects under (A) apnea and there are several reports I have discussed on all these apnea issues. www.themedicalnewsreport.com
JAMA Otolaryngology and Head and Neck Surgery, November 15, 2023
Who should consider getting evaluated?
1 in 15 Americans are being diagnosed with this disease. Don’t be in denial, and listen to your mate!! Get tested if a person snores, is overweight, has breath holding episodes seen by bed partner, someone who has daytime draowsiness, hard to treat hypertension, just to start with.
Recall of CPAP machines has created a shortage of machines
The shortage in CPAP machines has caused a crisis in the need for these machines from the millions of recalls from Phillips company, as obstructive sleep apnea numbers of Americans continue to rise rapidly.
It has become so serious that there has been federal intervention, as U.S. officials are considering legal action to speed the replacement of these machines.
Sound dampening foam in the pressurized in the brathing machines can break down, leading potentially to the patient breathing in black particles or toxic chemicals while they sleep.
Initially, Phillips, a Dutch company stated they could replace or repair the machines within a year, but after 5 million were recalled, they have had to prolong the length of time getting these machines bck to their clients.
This delay has created risky behavior in these patients, with many trying to tear out the foam, buying inferior machines online, or going without one.
The type of machine that is needed depends on the severity of the apnea, therefore, some may be able to use a machine that just covers the nose, but many require a mask that covers both the nose and mouth. This is determined in a second night study in a sleep lab, as CPAP machines must be calibrated.
Unfortunately, reducing cardiovascular events have not been proven by using CPAP machines but will definitely make a person feel better during the day. Failure of cardiovascular improvement is occurring , because so many being treated are not compliant, don’t lose weight, and still have some degree of significant apnea which continues hypertension, and other physiologic events in the heart and lung.
Even though persistent relief of clinical OSA (obstructive sleep apnea) can relieve daytime drowsiness, patients think they are free of apnea and stop losing weight and monitoring the effectiveness of CPAP. Weight loss methods may become more difficult to maintain.
Industry requires monitoring of the use of CPAP
Most industries require monitoring of the use of the CPAP machines for those operating hazardous equipment, driving trailer trucks filling our highways. That makes sure these workers are actually using the machines for at least 4 hours a night. Interestngly, that monitoring and drug testing has created a worker shortage in these workers, one more reason for delays in transportation of people, animals, and our food.
Physicians are quite frustrated trying to find adequate numbers of these refurbished machines, and these machines cost between $500-1000.
Why the recall?
The foam placed in the Phillips unit to reduce sound can cause allergic reactions, irritation of the respiratory tract aggravating underlying medical conditions, and inhaling cancer causing chemicals, according to the FDA.
The FDA has received over 70,000 complaints because of this foam, including pneumonia, headache, infection, and cancer, but no one can prove a causal relationship, and Phillips first reported a worst case scenario, but you know the lawyers were licking their chops.
Since the recall, Phillips has been replacing the foam that can degenerate into a powder containing silicone.
Phillips manufactures 1 million new machines per year, but the recall has created an extra burden.
The recall occurred after the FDA notified the company last November. Phillips states they have repaired 69% of the machines and hope to complete the repairs by year’s end. Half of the 5.5 mllion machines were sold to American customers.
Some clients have been told their machine type has been discontinued and could not be repaired. They have had to find a new machine from them or the few alternate companies available.
There are class action suits under way, and expect thousands of suits threatening the industry’s future. It is critical we have safe reliable CPAP machines, as the continued rise of obstructive sleep apnea requires more apnea relieving machines.
Medscape General Surgery, October 25, 2022
The federal work group (USPSTF) who advises the administration who should be screened for disease does not feel normal populations of Americans need to be screened for apnea yet, but any of the above symptoms puts male or female in a risk category that deserves screening.
Talk to your doctor, and discuss this, as more than half of Americans are in these categories, and with the rise of children and adults gaininig weight, this is a disturbing national health crisis that deserves much more attention. This issue must be addressed by Congress to support marketing of this serious medical, social, quality of life problem.
6. Mental Health in Youth, adolescents, and teenagers—Part 2—ADHD, PTSD, body dysmorphia, suicide, substance abuse, psychoses
When a 6 year old shoots his teacher, does that make enough of an impact on the government to address mental illness in our country?
We are spending $trillions on issues for the future, when we have an epidemic right now. Big Medicine needs to be all over this (Big Medicine=academic medical centers and their staff, medical organizations). They must convince the Congress this is becoming an epidemic.
U.S. Mental Health is broken. We are facing an enormous number of young people through our southern border, being killed by drugs coming across that border (110,000 in 2022) mostly from fentanyl which has laced many drugs well known to children and adults. Suicide is the second leading cause of death for teens.
The short supply of mental health workers has made it even worse. Just throwing money at it will not fix this crisis.
An article in JAMA-Pediatrics reported their were 10 important trends in teenagers, and these 6 highlight them:
1) They are in no hurry to progress from childhood to adolescence to teen years.
2) Cell phones have replaced social interaction face to face.
3) Insecurity in these teens is increasing and correlates with the sharp rise in mental health issues. The “snow flakes” are causing more trouble than it helps. Crying rooms, safe space, etc. has not created a better quality of life in these kids. The more screen time these kids use, the more unhappy they are (parents wake up).
4) The pandemic made this worse with no school, home school, isolation, and lack of activities to attend. Communities need to address this huge issue. Teachers and teacher’s union have devastated the school experience.
5) There is a huge gap in cultural diversity with few mental health professionals coming from these various races.
6) Poverty continues to strongly correlate with poor teen health outcomes.
As more and more people won’t even get a job, poverty is going in the wrong direction. 7% of the workforce quit their jobs in 2020. 13% changed their jobs. The administration spent $trillions handing out checks which weakened workers desire to even work at all. Even with checks stopping, there is still a huge impact on families. With a massive influx of young people coming across our border, high paying jobs are not looking good.
A. ADHD in children (and adults)
U.S. studies indicate that about 5% of children age 2-17 are diagnosed with ADHD, according to the American Psychiatric Association and about an estimated 10% of children probably have it.
Sadly, about 4.4% of adults have symptoms of this disorder or some type of psychiatric disorder with these symptoms, such as bipolar disorder. If a child is diagnosed with ADHD, as many as 80% may carry this diagnosis over to adulthood.
Boys are twice as likely to be diagnosed. In early 2000, this disorder was over diagnosed and many children were treated unnecessarily. Times have changed and today the diagnosis is more carefully used.
About half of these children have behavior or conduct problems and 1/3 have anxiety disorders, according to the CDC. It is estimated that ¾ receive some type of treatment.
This disorder is characterized as a child who might have excessive daydreaming, forget or lose things a lot, squirm and fidget often, talk too much, can’t sit still, pay attention, take impulsive risks, difficulty in resisting temptation, have trouble taking turns, and difficulty with getting along with others.
There are 3 types of ADHD:
1) Predominantly inattention—can’t organize, finish a task, pay attention to details, follow instructions, easily distracted, and forgets details of daily routines.
2) Predominantly hyperactive-impulsive—fidgets and talks a lot, hard to sit still at dinner table, etc., Often run, jump, and climb constantly, interrupts others, grabs things from others, speak at inappropriate times, can’t wait their turn, or listen to directions, often with accidents and injuries.
Causes include brain injury, sleep difficulty from sleep apnea, environmental exposures, alcohol and drug abuse by the mother during pregnancy, premature delivery, and low birth weight.
In my practice, I often was aware of a typical child all over my office, ignoring me when asked questions, and could not sit still, or allow examination.
These children often had large tonsils and fluid in their middle ears, and when I removed their tonsils, adenoids, and put tubes in their ears, their mothers would return for postop visits and remark that I had cured not only his ENT trouble, but his hyperactivity.
These tonsils and adenoids in the children were obstructing their airways at night, snored significantly, and were have undiagnosed sleep apnea. Those mothers thought I was a miracle worker, and in those days, we knew little about sleep apnea in children.
Treatment includes cognitive therapy and medications, and in my hands, if they had an obstructed airway, a T&A. Parent training and management in children under 6 is necessary up to age 12.
Medical therapy include using stimulants (they have a paradoxical reaction to them and slow them down).
Methyphenidate (Ritalin) has been a common treatment to curtail bad behavior especially in the classroom for ADHD. It does not help in learning and retaining academic material, but does help in improving academic work (37% more math work in one study) and fewer violations in class.
Loss of appetite and changes in libido may occur with ADHD medications (20% in the pediatric population).
Abuse of these drugs to lose weight or get high are common and Adderall is a common drug that is now a street drug. Although a prescription, theft of these drugs is common and commonly trafficked over the southern border.
There are several other side effects which could occur, and if a child (or an adult) is started on these medications, be aware from nervousness, headache, emotional lability, etc. Overstimulation is a possible with restlessness, tremors, and skin issues. As a parent any change in behavior (good or bad) must be observed and reported to the doctor, to adjust the dose.
Although not an issue for children who would not be taking monoamine oxidase inhibitors ( a rarely prescribed type of depression meds—Marplan, Nardil, Parnate, etc.)antidepressants such as , but they should not be taken if methyphenidate is to be prescribed, as it can cause a hypertensive crisis. As many as 80% will respond to Adderall, essentially amphetamines.
The FDA has approved 3 non-stimulants—atomoxetine (Strattera), guanfacine (Intuniv ER), and clonidine (Catapres and Kapvay), which is a blood pressure med and are meant for children who can’t tolerate the stimulants.
It is necessary to take these prescriptions regularly to allow an evening out of their behavior.
Mayo Clinic, FDA, CDC
The outcomes of this disorder are varied, but if symptoms persist, medication will have to be prescribed into adulthood, at least 70% of the patients. The effect on employment and socialization, etc. will need to be addressed. Even consideration for mild autism.
The military will not accept a person with this diagnosis or have a waiver based on certain criteria.
Children can suffer from any traumatic event to themselves and their family and friends. School shootings, murders in the neighborhood, trauma from accidents, etc. all take their toll.
Hiding traumas from children when their loved ones are suffering from them (drug abuse, divorce, mistreatment in the family, etc. child abuse) should not occur as they will be more aware than what they will admit to.
Symptoms may include night mares, sleep difficulty, bed wetting, self harm, anger, reliving the event, lack of positive emotions, ongoing fear and sadness, easily started, denial, or avoiding people or places involved with the event. Being very fidgety, restless, lack of attention, all similar to ADHD may be present.
It may require counseling letting the child know what they are feeling is normal, going to a safe place (home for battered women), support from friends, school, and family, and basic needs. Allowing the child to express his feelings with drawings, talk, play, or writing, is helpful.
Cognitive behavioral therapy is used to help children learn to change thoughts and feelings by first changing behavior in orfer to decrease symptoms. Family or group therapy, depending on the cause may be helpful.
Medications may be necessary to treat anxiety and depression.
It is critical those with any number of psychological problems may have suicidal ideation, and their closest people to the child or adolescent needs to monitor their social media, behavior, and actions including cutting, drug abuse, etc., and address the issue with notification to professionals for help.
Suicidal ideation is an umbrella term that describesd a spectrum of thoughts and behaviors associated with suicide, including thoughts, urges, plans, intent and attempts. There is a link from self harm to suicidal ideation in the youth. If your child or teen is cutting, or acting in dangerous ways, consider discussing the concern for progressing to suicide and try to get them counseling.
Suicide is commonly cited as the second most common cause of death among adolescents ages 15-19 and children 10-14. At least 7% of youth made one suicide attempt in the previous year and 13% made a plan. Girls are twice as likely to make a suicide attempt, but boys are 3X more likely to die from the attempt.
Medications, drugs and alcohol, firearms, car keys, etc. need to be locked up or removed from the home.
Warning signs include past behaviors, change in behaviors, cries for help to at least one person perhaps a friend which often happens, should notify the parents, social media postings. If there are overlapping stressors in the family, such as breakups, fights with parents, etc., these can layer with other stressors, and generate big emotions and put the child, adolescent, or teenager at an escalated risk.
The internet has become a media site that can glamorize self harm and even suicide. Japan has had a big problem with group suicide. Seven different reviews found an association between increased screen time and worse mental health in youth.
Cyberbullying has become a common link. This and other stressors require some type of support (group or solo), counseling, and treatment in certain cases based on the categories of psychological disorders.
Physicians must be more aware of these issues and screen their young patients. This issue affects girls and boys equally, according to several studies.
As much as the internet can be a negative, it is a site with a significant number of options for support, helplines, and people to talk to. We must make them readily available.
Starting the discussion with youth
a) be direct and open b) use appropriate language avoiding vague or confusing words c) mange your own emotions and be calm and responsive d) ask about intent and plans e) ask about coping resources and support.
Most youths are impulsive, especially teenagers, with about 69% of attempts escalating from ideation to an attempt in less than 30 minutes. Unless they have means to attempt action, the liklihood that the crisis will pass with out a fatal outcome is significantly decreased.
Over 90% of those who have previously attempted suicide will not go on to die by suicide. Mental health resources will reduce the risk even more. Suicidal ideation means the youth is in pain and may need treatment for suicidal ideation. Increasing coping skills and resilience by the youth from mental resources increases the liklihood they can overcome their ideation.
The National Suicide Prevention Hotline needs to be in your phone and the youths. 800-273-8255, and the crisis text line is 74174 via text message, both available 24/7 and have it ready. One can also dial 988 and the greeting on the line will route the caller to a local crisis center based on the caller’s area code. You can always dial 911.
CDC, Children’s Hospital of Colorado
D. Body Dysmorphia
Contrary to the media and certain political parties, body dysmorpia includes a lot of children who are very self conscious about the looks of their body, mostly those overweight, have congenital abnormalities, are short or even too tall for their age, and other issues, which, yes, does include those who are questioning their gender.
But for those who obsess over defects that no one can see, have a psychological condition and are not good candidates for surgery, as they will never be satisfied with the results. Anyone who performs cosmetic surgery must always weed these patients out or refer them for psychological evaluation before any consideration for surgical correction. Cosmetic surgery will make some of these patients worse, because the results will never give them satisfaction with this disorder. If I had a patient like this, I referred them for psychiatric consultation.
Next month, I will update information on gender identity, dysphoria, and gender affirming surgery, and I will add the psychiatric aspects of the subject.
Those who suffer from this body dysmorphia needs psychiatric help, not surgery or medication. Many of these teens and even adults see abnormalities in their body that others can’t see.
They also don’t see themselves as others do. Parents need to take these concerns seriously.
Surgery for the right youth makes a enormous difference in their psychological development when they increase their self-esteem, and confidence. I saw this in my cosmetic practice time and time again.
Otoplasty needs to be delayed until the ear cartilage has started to stiffen, usually around 6 or 7. These kids are most anxious to have their “Dumbo” ears fixed and it is a relatively simple procedure.
I preferred not considering nasal surgery on them until age 12-13, and it depended on how mature their facial features were for a rhinoplasty.
Chin and cheek implants could be performed at that time. If the jaw was too small or large, and oral surgery consult is recommended if the dental arch is a problem or the temporomandibular joints are causing pain.
Young women with small or large breasts see themselves as very different and want to be “normal”. There is no problem with most girls, but those who obsess and see themselves as far from the norm must be screened for this disorder, and referred for psychologic evaluation.
Those seeking liposuction procedures may have very little abnormality but see themselves as grotesquely fat or out of proportion. Again, the extent of the concern must be evaluated.
E. Substance abuse
I have been reporting on this subject with the enormous southern border crisis and fentanyl trafficking with over 110,000 drug overdoses in 2021.
Children are dying with fentanyl laced drugs as well, with rainbow pills that attract kids. Even normally prescribed drugs are being laced in factories in Mexico. At the end of this report is the latest information about these drugs, and different than this report centering on the youth.
Use and abuse includes tobacco and alcohol, which are so easily accessible that most kids start with these items. Marijuana is the next step. By the 12th grade, 2/3 of teens have tried alcohol. Half by the 9th grade have tried marijuana. 2 out of 10 have taken their parents opioids and other substances.
Unfortunately, substance use correlates with other risky behavior such as unprotected sex, dangerous driving, and other types of activities.
Pediatricians are now advised to screen for these behaviors including the prescence of anxiety, bullying, and depression.
Parents need to hide or lock up their pills….not my kids!!! Yea right!!!!
The CDC website
F. Psychoses in youth; pot psychosis
Psychotic behavior in children who smoked or ingested marijuana (THC), is being seen frequently in emergency departments, as confirmed by a friend and pediatric nurse in a pediatric hospital in Detroit. They have been using more potent THC products (10% and more).
The plants today are frequently full of 10% concentration in the leaves. And there are products now that concentrate THC over 50%, and they may be in gummies. This concentration is very dangerous and can lead to psychotic breaks while under the influence.
A Lancet Journal study cites the risk is 5X more likely for youth who smoke or consume potent THC products to develop psychotic behavior compared to those who don’t smoke or consume THC.
Cannabis use is present in 50% of youth with those who suffer from schizophrenia, and other forms of psychosis, with hallucinations, delusions, and disordered thinking. However, there are kids smoking or eating gummies with very high potency of THC (tetra hydrocannabinol), and have no idea about the strength of these products.
It is critical to understand that any of these substances (illegal or prescription) if consumed in potent doses and frequently, can cause psychotic behavior, whether these youth are predisposed by underlying psychologic disorders or not.
Schizophrenia and psychotic mood disorders are the most common psychotic issues in children and these spectrum disorders require both pharmacological and psychotherapeutic intervention.
Symptoms of schizophrenia include not being able to differentiate reality from TV show, dreams, stories, with an intense fear that someone or something is trying to harm them. Hearing whispered voices or seeing images is also common.
Children may have a prodrome, withdrawing from daily life, loss of interest in school and friends. They may have confused behavior intermittently with periods of sitting and staring. Acting like a much younger child can occur.
These disorders can run in families, and pregnant women who abuse drugs and alcohol, who are exposed to viruses, chemicals, etc., stress, and poor nutrition.
Treatment includes neuroleptics (anti-psychotics—Repose, Risperdal, Serenetal, Sparine, etc.) to reduce hallucinations and delusions. Hospitalization may be indicated to find the correct medication and dose as well as the initiation of psychotherapy. They reduce the dopamine levels in the brain tissue.
Next month, part 3 of the mental disorders of youth will be a report on gender dysphoria, and gender affirming treatment, and sadly this community suffers greatly from mental disorders and social dysfunction.
The March, 2023 Report will include:
1. Myocarditis and other inflammations of the heart; COVID vaccine side effects updated
2. Diabetic and weight loss treatments
3. Gender Identity, dysphoria, and gender affirming therapy—Mental Disorders series-part 3
4. Herpes Simplex—oral, ocular, and genital
5. Healthcare crisis in the UK—socialized medicine is dying!!
We have had some interesting weather this winter, and I hope you have had some great family time. Happy Valentine’ Day, and as always, stay safe, healthy, and well, Dr. Sam
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