Category Archives: Dr. C “Comments”

TREATING DEPRESSION: DEEP BRAIN STIMULATION (UCSF)

UCSF Health physicians have successfully treated a patient with severe depression by tapping into the specific brain circuit involved in depressive brain patterns and resetting them using the equivalent of a pacemaker for the brain.

COMMENTARY:

UCSF is my medical alma mater, and I am proud to comment on their info graphic about need-driven deep brain stimulation (DBS). This is not only a good idea, it should spearhead a personalized wave of the future.

Your body’s metabolism is a great balancing act, and needs to be kept on an even keel, to maintain the stability of your internal environment. What is “good” at one time may be deleterious at another.

Good illustrations of this are insulin and thyroid hormone. Both too little and too much is deleterious.

Likewise, the need for DBS varies.. This was recognized by the designers of feedback-driven DBS. The amygdala is overactive when the depressive wave is greatest, triggering the deep brain stimulation. As the depressive wave lightens, the stimulation diminishes or stops.

Engineers are quite attentive to this idea.  A similar feedback mechanism is used by implanted heart stimulators, or “ defibrillators“. if the heart slows down excessively, there is stimulation of the atrium to restore the proper rate. If the ventricle is ineffective, and fibrillates, it is given a shock which acts like rebooting your computer.

Chronotherapy, the administration of medication depending upon the time of day, is a kindred idea, illustrated by asthma. Wheezing attacks peak at night, when adrenaline and cortisol ebb, and so should the blood levels of the anti-asthmatic medication, theophylline.

Another illustration is the medication omeprazole, a proton pump inhibitor that reduces stomach acid. Reflux of this acid into the esophagus increases when you are recumbent and sleeping.. The need for the antacid is therefore greatest at night.

It is estimated that the effects of at least 50% of all medications would  benefit by attending to the diurnal cycles. If your symptoms cycle with the sun, ask your doctor about your medications.

—Dr. C.

Covid-19: Patients Dying In Name Of Vaccine Freedom

In the video above, Alexander Stockton, a producer on the Opinion Video team, explores two of the main reasons the number of Covid cases is soaring once again in the United States: vaccine hesitancy and refusal.

“It’s hard to watch the pandemic drag on as Americans refuse the vaccine in the name of freedom,” he says. Seeking understanding, Mr. Stockton travels to Mountain Home, Ark., in the Ozarks, a region with galloping contagion and — not unrelated — abysmal vaccination rates. He finds that a range of feelings and beliefs underpins the low rates — including fear, skepticism and a libertarian strain of defiance.

This doubt even extends to the staff at a regional hospital, where about half of the medical personnel are not vaccinated — even while the intensive care unit is crowded with unvaccinated Covid patients fighting for their lives. Mountain Home — like the United States as a whole — is caught in a tug of war between private liberty and public health. But Mr. Stockton suggests that unless government upholds its duty to protect Americans, keeping the common good in mind, this may be a battle with no end.

COMMENTARY:

I am a Doctor Who has studied the miracle of MRNA Covid vaccine, and who knows that it cannot get into the nucleus of any of my cells or long remain in my body.

I have studied the transmission and pathogenesis of Covid, and know how it works. The knowledge that it could affect my thinking, memory, my very essence, and the fact that it could last indefinitely after the initial illness has certainly made me a believer.

There is an element of truth in the concerns of anti-vaxers and anti-maskers. Unfortunately the problem is not black and white. No vaccine is 100% safe, although the mRNA vaccines come close. There is some worry about clotting problems with a few people, particularly the young. This risk is measured in terms of problems per million people getting the vaccine, and is vanishingly small compared to the alternative of exposing yourself to the ravages of Covid.

An intelligent friend of mine who is a nurse has auto immune disease, and vaccines tend to hit her hard. Unfortunately the fact that she is a nurse and is exposed a lot to the public make her more likely to get Covid, and her auto immunity would render her much more likely to have complications, should she get it. She has received her first injection of Covid vaccine, and had a lot of fatigue, headaches and symptoms that were relatively self-limited.

Masks are mainly useful in protecting other people from the mask-wearer and only slightly helpful in protecting the mask wearer from other people. Also, I have read a long article about some subtle disadvantages of forcing children to wear masks although I think it’s still a good idea, particularly when Covid is common in the community.

The main problem is that Americans have freedom of choice without the knowledge to weigh the benefits and hazards of receiving the vaccine, versus the hazards of getting the disease.

There are times when we should unload the making of such statistical decisions on people who know more about the vagaries of disease.
In my opinion, the states which allow hospitals to require their healthcare workers to receive vaccination, and allow schools to require their students and teachers to receive vaccination are in the right. Currently, there are less problems in those states.

Covid is certainly a nasty disease, and even doubly vaccinated people can be spreaders. As an elderly vaccinated person, I still treat everybody as if they are infected, and require masks when visitors come. When inside, I sit by an open door, with a fan behind me blowing air in the other direction.

At the age of 89, I cannot afford to get Covid-19.

—Dr. C.

HARVARD STUDY: VITAMIN D LOWERS THE RISK OF YOUNG-ONSET COLORECTAL CANCER

COMMENTARY:

Vitamin D has many beneficial effects, but my comments will be restricted to the effect of vitamin D on cancer.

Interest in this association was started by the observation that certain cancers are less common near the equator, where there is more sunlight exposure, and therefore more natural vitamin D generation in your skin.
The most information on cancer in humans Is available on colorectal, breast, prostate, and pancreatic cancer. Colorectal cancer, highlighted DWW our posting, is the only cancer that apparently is affected by vitamin D.

Several studies have suggested that vitamin D can decrease cancer cell growth, stimulate cell death, and reduce cancer blood vessel formation. Increasing cell death, or apoptosis, is what interests me the most, since this is one of the factors which increases inflammation in aging.

The infographics stated that only 300 international units of vitamin D is necessary to produce a 50 Percent reduction in cancer, and that a healthy diet generally supplies this.

I personally take 5000 international units vitamin D. This produces a blood level of about 60 ng/mL, and what the NFL recommends to keep their players healthy, and well within the maximum recommended level of 120 ng/milliliter.

Excessive vitamin D can produce an elevated calcium blood level, and mine is within normal limits. I take the higher dose because of vitamin D’s other effects, such is benefiting the immune system in a time of Conid-19.

I suggest that you get a vitamin D blood level, and also a calcium blood level if you elect to take more of this useful vitamin.

–Dr. C

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SCIENCE: CLEANING INDOOR AIR WILL IMPROVE HUMAN HEALTH AND COGNITION

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COMMENTARY:

Joseph Allen, the “air investigator”, was apparently on board early in the COVID-19 epidemic, stressing the importance of suspended  air particulates, less than 2 microns in size, causing transmission of the disease.

His article in Science: “clean indoor air will improve human health and cognition” is well worth reading, or at least inspecting the info graphic. As a practicing allergist, I was aware that inside dust mite particles and mold spores made allergies worse. We had a service where we would go into homes and sample the air. An excess of certain Indoor mold spores, compared with those outside, would indicate a “problem home”. We would then try to find the water leakage source that produced the molds.

I also had a patient who could not tolerate a new house, with its carpets and other artificial materials. The only place where she felt better was in an old seaside house 100 miles south of San Francisco. I thought there were some psychological factors, but who knows? Volatile organic compounds, VOCs, probably affect some people more severely.

Beginning shortly after the energy crisis in the 80s, the “sick building syndrome”, characterized by headache and fatigue in certain buildings, was on the news. The eventual solution was to create better ventilation, with a reduction of CO2 and VOCs in those buildings. In addition, federal agencies began banning certain artificial  fabrics that out-gassed VOCs.

There was eventually less talk about sick building syndrome, except for the occasional air system which was contaminated with Legionella bacteria.

The present article stresses accumulation of CO2 and VOCs In the stale air in the individual home or office as a cause of diminished attention and productivity.

CO2 monitors still cost about $200, and so I think I am going to just try to increase the ventilation in my office, where I get sleepy in the afternoon, by opening the windows and sliding doors. I wonder about  the indoor CO2 in Scandinavian winters, where depression is increased.

—Dr. C.

VIEWS: IS U.S. HEALTHCARE SYSTEM BROKEN? (HARVARD)

Here’s a question that’s been on my mind and perhaps yours: Is the US healthcare system expensive, complicated, dysfunctional, or broken? The simple answer is yes to all.

Below are 10 of the most convincing arguments I’ve heard that our system needs a major overhaul. And that’s just the tip of the iceberg. Remember, an entire industry has evolved in the US just to help people navigate the maddeningly complex task of choosing a health insurance plan.

The cost is enormous

  • High cost, not highest quality. Despite spending far more on healthcare than other high-income nations, the US scores poorly on many key health measures, including life expectancy, preventable hospital admissions, suicide, and maternal mortality. And for all that expense, satisfaction with the current healthcare system is relatively low in the US.
  • Financial burden. High costs combined with high numbers of underinsured or uninsured means many people risk bankruptcy if they develop a serious illness. Prices vary widely, and it’s nearly impossible to compare the quality or cost of your healthcare options — or even to know how big a bill to expect. And even when you ask lots of questions ahead of time and stick with recommended doctors in your health insurance network, you may still wind up getting a surprise bill. My neighbor did after knee surgery: even though the hospital and his surgeon were in his insurance network, the anesthesiologist was not.

Access is uneven

  • Health insurance tied to employment. During World War II, healthcare was offered as a way to attract workers since employers had few other options. Few people had private insurance then, but now a layoff can jeopardize your access to healthcare.
  • Healthcare disparities. The current US healthcare system has a cruel tendency to delay or deny high-quality care to those who are most in need of it but can least afford its high cost. This contributes to avoidable healthcare disparities for people of color and other disadvantaged groups.
  • Health insurers may discourage care to hold down costs. Many health insurance companies restrict expensive medications, tests, and other services by declining coverage until forms are filled out to justify the service to the insurer. True, this can prevent unnecessary expense to the healthcare system — and to the insurance company. Yet it also discourages care deemed appropriate by your physician.

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Dr. C Commentary:

Please refer to the DWWR Posting on “concierge doctors” for my rant on the current healthcare system, which I will not repeat.

The truth is more nuanced. All countries are having trouble of one sort or another with their healthcare systems. This is due to the inherent expense of today’s top flight medicine. The very best care requires costly high technology and drugs that are intrinsically hard to produce. And you have to know where to look. I am very thankful for my medical degree, and that I have kept up with current advances.

You would probably need a Government entirely of physicians to develop the willpower to do something for health, which always starts with PREVENTATIVE MEDICINE, A hard sell, given that you must spend money and effort to block something which will probably, but may not always, occur.

There is low hanging fruit. Why are sugary drinks not heavily taxed, since they produce obesity which causes a lot of costly medical disorders, such as diabetes, inflammatory diseases, and cancer, but not everybody all the time?

Why is efficiency of telehealth not more widely embraced, but stymied by moneymaking lobbiests and lawyer powered difficulties, in addition to Patient’s and doctor’s old habits?

And then there are the jealously guarded  American freedoms to do stupid things, such as avoid vaccines and masks, even in a prodigiously expensive and dangerous Covid  epidemic.

Given human nature, a complete solution would seem to be impossible, and we should content ourselves with minor victories wherever they can be attained.

Embrace sleep, diet, and exercise, and KEEP HEALTHY.

–Dr. C

TeleHealth: Weill Cornell ‘Center For Virtual Care’ Expands Training Courses

The new eCornell course, which features a curriculum in-line with the Association of American Medical College’s Telehealth Competencies, offers instruction on how to harness the digital health medium to effectively create a therapeutic patient-provider encounter. Students learn essentials including verbal and nonverbal communication strategies to convey empathy and compassion, how to overcome technical challenges, and how to conduct remote patient exams.

Digital health and the tools for patients to virtually reach their health care providers have quickly become a mainstay of medical care during the COVID-19 pandemic. Weill Cornell Medicine’s Center for Virtual Care is positioned at the leading edge of this health care delivery transformation. Leveraging their years of experience with video visits, the center’s experts train providers how to best use it to give their patients comprehensive, compassionate care.

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DR. C Comments

Telehealth offers significant advantages to both patient and doctor. It should be a welcome and valuable addition to the medical profession in its desire to deliver comprehensive care to patients. However, Telemedicine faces a number of barriers both from the medical side and the patient side, not to mention insurance, lawyers, and government.

A good video was posted from Cornell, which aims to get doctors to develop a set of behavioral skills which will make telemedicine more personal. Of course, training should be extended to peripheral sensing devices that will enhance the ability of doctors to gain information at a distance, as well as familiarization with a user-friendly electronic system to navigate.

Patients also need a special course in how to become more Competent in the technical aspects of telemedicine,  sensors and other challenges. Since  Telemedicine visits occur at widely spaced intervals, even an intensive training course might find the patient unfamiliar with the system at the time of need.

Recently, I signed up for a zoom consultation At UCLA medical Center. It was very helpful to have a knowledgeable person on the phone directing me through the maze that got me signed up to “my chart”, The electronic system that UCLA uses. Even though I took Notes, when it is actually time to get into the system and  go to the virtual waiting room of my chart, I may well have difficulty.

And that’s just one system. It seems as though doctors offices, different medical systems, and different health plans all have their own unique electronic systems which are enough different to be confusing to the patient.

I can only hope that the newer generations, having grown up using these electronic devices, will have enough facility to easily interface with their doctor electronically. Until the older generation passes on, however,  there will be ongoing challenges.

AMERICAN DIET: THE COVID SURGE IN SNACKING (VIDEO)

With Americans stuck at home, snack food has become a valuable commodity for the pandemic stressed consumer. North American sales of savory snacks like chips, popcorn, and pretzels climbed to $56.9 billion in 2020. In stressful times, people turn to snacking for comfort and Covid-19 has transformed kitchens across the U.S. into giant vending machines. So, has Covid-19 put an end to the shift to healthier snacks?

DR. C’S COMMENTS:

Snacking with its  concomitant weight gain has increased with Covid. Of course Snacking didn’t originate with Covid, and it has long been common in Overweight people.  Snacks are engineered to taste terrific, which means containing a lot of fat, sugar, and salt, easily be over done. Good nutrition  is an afterthought to snack companies.

The Small volume of snacks, eaten frequently, Does not cause the satiation that comes with regular meals.

In my opinion, one of the major mechanisms by which TIME RESTRICTED EATING causes weight loss is by its prohibition of snacks. In the narrow window of time that you’re allowed to eat, you are hungry and eat regular food which tends to be of higher quality. Your stomach is full. You feel full and are not tempted to snack. Sugary drinks and snacks are bad for health.

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.