Category Archives: Dr. C “Comments”

MEDICAL VIEWS: ‘MACULAR DEGENERATION RESEARCH’

Macular degeneration is a leading cause of visual impairment in people over 65 and can lead to blindness. One in three people will eventually suffer some degree of macular degeneration, which is caused by abnormal blood vessels under the retina, the light-sensitive part of the eye. We treat both the more common “dry” as well as the more dangerous “wet” forms of macular degeneration. While there is currently no cure for this disease, we offer the latest treatments to reduce the risk of vision loss and blindness. These include anti-VEGF drugs—which attack proteins that create the abnormal blood vessels that cause macular degeneration—and photodynamic therapy, in which patients ingest medication that is then activated with a laser.

To learn more about macular disease at Yale, visit: https://www.yalemedicine.org/departme…​.

COMMENTARY:

This high quality video shows several aspects of macular degeneration. It discusses treatments with stem cells that are in the research phase; in the future there may be replacements for the abnormal support cells, the vascular cells and pigmented epithelium, that are diseased in macular degeneration.

Current treatment centers on control of abnormal blood vessels either by photo active laser, laser coagulation, or anti-VEGF.
Macular degeneration has two forms, wet and dry. The wet macular degeneration has accumulations, or Drusen, under the epithelium. There are also machines to check the thickness of the macula, which is an aid in diagnosis.

The main symptom of macular degeneration or loss of vision especially in The center of the visual field, which is essential for reading.
As I mentioned in my podcast, I made a posting on macular degeneration that includes an amsler grid. Some early symptoms of macular degeneration include waviness of the lines of this grid. Certainly if you have any visual distortion or loss you should see an ophthalmologist.

If your medical plan permits it, I feel but a regular check buy an ophthalmologist approximately every 6 to 12 months, is very useful. My own ophthalmologist checks my  retinal thickness, optic nerve, pressure and peripheral Field ( to pick up glaucoma) as well as my vision on each visit.

Dr. C.

COVID-19: ‘REDUCING RISK NOW & PREPARING FOR THE NEXT PANDEMIC’ (PODCAST)

Virologist Angela Rasmussen talks about her battle against misinformation in the media, the virus, vaccines, disinfecting surfaces, home testing, and the next pandemic.

Eric J. Topol, MD: Hello, I’m Eric Topol for Medscape, and this is Medicine and the Machine. I’m so glad to have my colleague and partner in this podcast, Abraham Verghese, with me from Stanford. Today, we have the rarefied privilege to discuss the whole pandemic story, the virus and vaccines, with one of the country’s leading virologists, Dr Angela Rasmussen. Welcome, Angie.

Angela L. Rasmussen, MA, MPhil, PhD: Thank you so much for having me, Eric. It’s wonderful to be here.

COMMENTARY:

This podcast rectifies the blizzard of variously valid COVID information blaring on the media today, and adds to the discussion. Virologist Angela Rasmussen talks about several interesting aspects of the pandemic. BSL laboratories are discussed. BSL refers to Biological Safety Level. If a lab is dealing with a dangerous pathogen, like the hemorrhagic fever viruses, a level 4 lab is required.

“Moon suit”- like positive pressure encasements, special hoods and disposal devices are required to ensure containment of the organisms, and to prevent their escape into the environment.

She discussed the differences between live viruses, detected by PFUs (plaque-forming units) on a sheet of living cells, and what the available Covid tests pick up, namely RNA which may or not be infective. Saliva vs nasal swab samples, PCR vs antibody tests were compared. She explained what the “cycle number” in PCR tests refers to, and its significance She then discussed “fomite” transmission, and observed how hard it was to experimentally prove.

Aerosol transmission is thought more likely. Also discussed is how lucky we were that this Pandemic involved a Coronavirus, instead of another viral family that was less studied. Moderna, for instance, was in the process of developing a MERS ( a Coronavirus) Vaccine. She finished up with the observation that distancing and masks, although imperfect, are still useful.

–Dr. C.

POST COVID: “THE FUTURE OF ELDERLY CARE’ (VIDEO)

Across the rich world around half of covid-19 deaths have been in care homes. Countries need to radically rethink how they care for their elderly—and some innovative solutions are on offer.

COMMENTARY:

This video has a lot of information that would be of help to anyone who has a spouse or parent who is aging, especially if their frailty includes dementia. There were several good, general points.

As hard as it is to get old, it is even harder to be a caretaker of someone whose aging includes memory loss. Hired caretakers burn out at a high rate. The video highlighted Indonesia as a location that is compassionate, and gives quality care at about half the cost in developed countries.

The percentage of the elderly population needing care may well be 50% in 2050. I would not have guessed it, but the video asserts that 50% of individuals over 65 years of age need some help.

It is much better to stay at home, and medical sensor technology is making this increasingly possible. AI would be able to detect changes in a person’s routine that could be flagged.

Of course, it is much better to stay healthy longer. My posting “growing old” addresses this.

–Dr. C.

HEALTH & RETIREMENT: A LOOK AT MEDICARE, MEDIGAP AND PART D DRUG PLANS

If you’re enrolled only in original Medicare with a Medigap supplemental plan, and don’t use a drug plan, there’s no need to re-evaluate your coverage, experts say. But Part D drug plans should be reviewed annually. The same applies to Advantage plans, which often wrap in prescription coverage and can make changes to their rosters of in-network health care providers.

“The amount of information that consumers need to grasp is dizzying, and it turns them off from doing a search,” Mr. Riccardi said. “They feel paralyzed about making a choice, and some just don’t think there is a more affordable plan out there for them.”

November 13, 2020

When creation of the prescription drug benefit was being debated, progressive Medicare advocates fought to expand the existing program to include drug coverage, funded by a standard premium, similar to the structure of Part B. The standard Part B premium this year is $144.60; the only exceptions to that are high-income enrollees, who pay special income-related surcharges, and very low-income enrollees, who are eligible for special subsidies to help them meet Medicare costs.

“Given the enormous Medicare population that could be negotiated for, I think most drugs could be offered through a standard Medicare plan,” said Judith A. Stein, executive director of the Center for Medicare Advocacy.

“Instead, we have this very fragmented system that assumes very savvy, active consumers will somehow shop among dozens of plan options to see what drugs are available and at what cost with all the myriad co-pays and cost-sharing options,” she added.

Advocates like Ms. Stein also urged controlling program costs by allowing Medicare to negotiate drug prices with pharmaceutical companies — something the legislation that created Part D forbids.

Read full article in NY Times

COMMENTARY

Medicare is a blessing. It is a great help to retired and elderly people and generally does the job it was intended to do. There are a great variety of Medicare supplement plans and pharmaceutical purchase plans, And they jockey and change every year.

I get a headache just thinking about how to compare these plans from my individual needs and and whether their cost is worth it. The take-home message from the New York Times article is that you can get individual attention from an advisor who presumably knows the field well.

The key acronyms are SHIP and HICAP, which stands for state health insurance assist program and California health insurance counseling and advisor program respectively.

The California number is 1-800-434-0222. Be sure to write down the medications that you are taking and Your diagnosed illnesses, as well as your financial status in order to make best use of the service.

—Dr. C.

INFOGRAPHIC: ‘DIFFERENCES BETWEEN COVID-19, THE FLU AND ALLERGIES (2020)

COMMENTARY:

The infographic by the allergy and asthma foundation aims to distinguish between Covid, Influenza and allergy. I would like to discuss more than symptoms. Covid and Influenza are both caused by invading infectious viruses.

Allergy is an over-response by the sensitized body to harmless proteins from the environment Covid and Influenza viruses cause direct damage to the lining membranes of the respiratory tract provoking a protective response by the body which produces inflammation in the nose and lung. Rhinitis, bronchitis and pneumonia result, depending on the site of the inflammation.

The symptoms of Allergy are far different from both Influenza and covid. ITCHING of the nose, eyes and skin is the hallmark of allergic Rhinitis, allergic conjunctivitis and Hives, respectively. Influenza or Covid Infection of the nose, eyes and airways can produce sneezing, redness, coughing and difficulty breathing, but not usually itching.

Fever is characteristic of Influenza and Covid, but not of uncomplicated Allergy. Asthma can result from either infection or allergy, but is a separate beast, caused by release of different inflammatory cytokines.

The ASTHMATIC REACTION shows itself in the BLOCKAGE of breathing of air OUT of the lung, on EXHALATION. This blockage on exhalation in asthma is heard as wheezing, a musical sound. Just ask the wheezing person to take a deep breath IN, which should be easier, and then breathe out as fast as possible, which should be slower and more difficult. Fever is not a feature of uncomplicated Asthma. Influenza and Covid.

Both produce FEVER, fatigue, aching and usually coughing. Covid has the greater linkage with Coughing, which often progresses to Shortness of breath. Both Influenza and Covid can produce a sore throat and runny nose. LOSS OF SENSE OF SMELL is unique to Covid, although if your nose is stuffy, the sense of smell can be impaired. Influenza preys on the very young, which are generally spared from Covid.

If you are careful about social distancing and wear masks in public, and get sick, Covid is more likely, since COVID IS MORE CONTAGIOUS THAN INFLUENZA. Covid protections will probably result in fewer cases of Influenza this winter.

To summarize,both the “flu” and Covid 19 are infectious conditions, vastly different from allergy, which is a derailed body defense mechanism. Any of the three can result in an asthmatic reaction, though the fever of influenza often lessens the Asthmatic response to that condition.. Covid is much more contagious and severe than influenza and can cause more widespread organ damage. Be sure to practice MASK WEARING AND SOCIAL DISTANCING.

If you have asthma and it worsens, in my opinion, this favors covid. My asthmatic patients often got better with the fever of Influenza. If you have a CHILD that gets sick, it is more likely to be Influenza than Covid.

–Dr. C

CDC INFOGRAPHICS: ‘HEAT STROKE & HEAT EXHAUSTION’

COMMENTARY:

THERMOREGULATION, preservation of the normal body temperature, is well developed in humans, and monitoring the body temperature has been useful since the development of thermometers.

Indirect measurement by Infrared detectors is being widely used today to detect FEVER as a sign of Covid in gatherings such as schools. Reactive increase of body temperature in a cool environment is a body defense mechanism that I have discussed earlier. Contrary to general practice, Fever, in my opinion, should be left untreated unless excessive, such as above 103 degrees F., or even 104 degrees.

Excessive environmental temperature, such as in a closed car, Jacuzzi, or heat wave can defeat the body’s ability to defend the normal temperature. Children, with their high body surface to mass ratio, are particularly at risk, as periodic newspaper articles testify. HEAT STROKE is the most serious of heat-related illnesses, leading to high and increasing body temperature, mental symptoms, even convulsions, and is a MEDICAL EMERGENCY.

The treatment is to call 911, and to lower the body temperature by removing insulating clothing, and immersing in cold water. There are a variety of other conditions based on excessive exertion, water or salt loss.

These include HEAT EXHAUSTION. Older Workers are particularly susceptible, and medical clinic attention may be needed for fluid and electrolyte replacement. MUSCLE CRAMPS and even damage( Rhabdomyolysis), FAINTING (this has been discussed before) and Heat Rash can result from too hot an environment. Furry Animals Pant instinctively to get their highly vascular Tongue to “air condition” their bodies. Humans should dress and exercise appropriately when the environment requires it.

–Dr. C.

VIDEOS: DIAGNOSING AND TREATING COVID-19 (MAYO)

Dr. Stacey Rizza, an Mayo Clinic infectious diseases specialist, discusses the various ways COVID-19 is diagnosed and treated.

COVID-19 can be diagnosed several ways when looking for active infection.

“The most common way that testing is done is with a swab into the nose or into the nasal pharyngeal area,” says Dr. Stacey Rizza, a Mayo Clinic infectious diseases expert.

“This polymerase chain reaction (PCR) test is essentially a test looking for the genetic material of the virus.” If it’s positive, it means that person is infected with SARS-CoV-2, the coronavirus that causes COVID-19.

COMMENTARY:

Dr. Stacey Rizza from Mayo Clinic gave the standard Academic recommendations for Covid Testing and treatment. I will comment on how this differs from the testing recommendations of Dr. Michael Mina from the Chan school at Harvard and the actual treatment given to Donald Trump as we speak.

I agree with the latter recommendations, and route that I would opt for, were I to catch Covid 19. TESTING, if it is to be Epidemiologically effective should offer results that are rapidly available so as to reduce spreading of the virus and treatment delay. One trouble with PCR- based tests is that they are slow. Another trouble, according to Dr. Mina, is that if they run for 40 cycles for maximum sensitivity, they may pick up viral shedding that is too minor to be infective, and may cause unnecessary precautions, such as quarantining. If they run for 35 or even 30 cycles to show only infective, actionable cases, they take several days, and even then labs do not usually report the number of cycles run, but only yes or no, positive or negative.

The RAPID TESTS detect viral protein are available within hours. They are less sensitive, but in Dr. Mina’s view, this can be a virtue, since only definitely infected patients are identified. They are cheaper, and can even be done on site. Frequent testing more than makes up for decreased sensitivity. Most tests currently available use only specimens from nasal swabs, which are uncomfortable.

SALIVA is almost as sensitive, and has one additional virtue, when it comes to testing school children. If school children are organized into learning “pods”, They can all spit into a common collector, and the pod tested preemptively, at least twice weekly. If positive The entire pod is individually tested to find who is positive. Of course if a full 20 kids are in a pod, The sensitivity of the protein test may be insufficient for positive to survive a 20-fold dilution, but this can be empirically worked out. Twice weekly testing vs. every other week is much better for reducing the number of the pod members infected at time of discovery, as the NYT has illustrated.

TREATMENT given to Donald Trump has so far consisted of more than Remdesivir. He is also receiving Corticosteroids, plus an experimental double antibody mixture, derived from both Covid Convalescent serum, and monoclonal antibodies from a “humanized” murine source. The antibodies should theoretically be given early. The corticosteroids are generally not given until a bit later, but with the reported drop in O2 sats, he may be later in the disease than we are led to believe. To my knowledge, he is not receiving his tweeted Hydroxychloroquine- azithromycin combination.

If I were infected, at age 88, I would also like the antibody treatment, but most likely would not be allowed to get it.

–Dr. C.

NUTRITION INFOGRAPHIC: “GOOD AND BAD FATS”

Read more

COMMENTARY:

Water, the miracle molecule, proteins and fats are the very essence of life. Water does not dissolve fat, allowing for the cell membranes, and the compartmentalization of metabolic activity that allows life to happen.

FAT IS ESSENTIAL TO LIFE. Alas, all fats are not equally beneficial to nutrition, as the article stresses. Trans-fats, partially hydrogenated fatty acids produced mainly by industry, are the worst, acting to stimulate cholesterol synthesis, produce inflammation and damage the endoplasmic reticulum.

Their use has been banned in most countries. Saturated fat has been widely condemned, is not as good as the mono- and polyunsaturated fats, but not as bad as trans-fats. Some of life’s most delicious foods, such as cheeses, contain saturated fats, but it is best to keep down their consumption.

Remember that the first bite of something savory tastes the best; prevent habit from shoveling it down. Unsaturated fats are found in oily fish, which should be part of your diet.

Vegetables such as nuts, seeds, olives, and avocados are sources of “good fat” and should comprise 10-15% of your calories. Fats, compared to carbohydrates, contribute almost twice as many calories to your diet on a weight basis, and it’s easy to get carried away.

Total calories must be kept under control. STAY HEALTHY!

–Dr. C

STUDIES: “INSOMNIA / SHORT SLEEP DURATION” IS A TYPE 2 DIABETES “RISK FACTOR”

Diabetologia  (Sept 8, 2020) – Insomnia with objective short sleep duration has been associated with an increased risk of type 2 diabetes in observational studies [2728]. The present MR study found strong and suggestive evidence of a causal association of insomnia and short sleep duration, respectively, with increased risk of type 2 diabetes.

Conclusions/interpretation

The present study verified several previously reported risk factors and identified novel potential risk factors for type 2 diabetes. Prevention strategies for type 2 diabetes should be considered from multiple perspectives on obesity, mental health, sleep quality, education level, birthweight and smoking.

Read full study

COMMENTARY

This was a laborious and apparently objective study.

The discovery of insomnia as a unique risk factor is no surprise, and reinforces the restorative IMPORTANCE of SLEEP.

I was surprised to see docosohexanoic and Eicosapentanoic acids in the risk column and LDL in the good column. However they were studying type 2 diabetes, and not vascular health. I will continue to take my fish oil, and enjoy my HDL, which is in the good column.

—Dr. C.

STANFORD: RESEARCHERS FIND WAY TO “REGROW” NEW CARTILAGE IN JOINTS

The Stanford researchers figured out how to regrow articular cartilage by first causing slight injury to the joint tissue, then using chemical signals to steer the growth of skeletal stem cells as the injuries heal. The work was published Aug. 17 in the journal Nature Medicine.

“Cartilage has practically zero regenerative potential in adulthood, so once it’s injured or gone, what we can do for patients has been very limited,” said assistant professor of surgery Charles K.F. Chan, PhD. “It’s extremely gratifying to find a way to help the body regrow this important tissue.”

STANFORD MEDICINE (Aug 17, 2020): Researchers at the Stanford University School of Medicine have discovered a way to regenerate, in mice and human tissue, the cushion of cartilage found in joints.

Loss of this slippery and shock-absorbing tissue layer, called articular cartilage, is responsible for many cases of joint pain and arthritis, which afflicts more than 55 million Americans. Nearly 1 in 4 adult Americans suffer from arthritis, and far more are burdened by joint pain and inflammation generally.

Read full article

COMMENTARY

Stanford has come up with a Promising new approach to the surgical treatment of osteoarthritis. Unfortunately for the suffering public, this approach is still in the rodent experimental stage.

The pain of osteoarthritis is caused by the LOSS of the CARTILAGE which insulates the bone of the joints. The wonderful cartilage coating prevents the pain which would result from the rubbing of bone on bone. The best solution in osteoarthritis would be to replace the cartilage, and I have no doubt that this will be possible some day.

STEM CELLS is the theoretical method most commonly imagined when it comes to replacing lost tissue.. Brain cells, cardiac muscle cells, and pancreatic islet cells are some of the research areas. The development of stem cells from the cells of the Patient herself (iSCs) obviates the need for immunosuppression, which plagues allographs ( stem cells or organs from other humans).

Recently, in situ transformation of neighboring cells has been described, which sidesteps the need to introduce any cells. For instance the transformation of astrocytes (a type of brain cell) into neuronal stem cells of the dopamine lineage would be a great boon to Parkinson’s disease.

The Stanford method somewhat resembles this last-mentioned technique. An injury is created where the cartilage is desired. Like any injury, bleeding, clotting, and cell infiltration follows, destined to form a scar. However, the researchers added BMP-2, which in this milieu causes the pro-fibroblasts to head toward the bone (osteoblast) lineage. Since cartilage forms first in a tissue destined to be bone, they then added a VEGF antagonist, which interrupts the transformation in the desired cartilage stage. Both BMP-2 and anti-VEGF have already been approved for use, facilitating the development of this attractive therapy.

The researchers have even identified an excellent potential Patient Population: Osteoarthritis patients scheduled for surgical removal of the first metacarpal articulation with the wrist. They could do their procedure on this area, and if there is no benefit, They could just go ahead with the original plan of removal. The thumb happens to be one of my most painful arthritic areas.

I will most interestedly follow their research.

–Dr. C.