Medical Bits – Vol. 3.4: Your Health and Medical News

Preventive Care.

We have discussed how the SARS-CoV2 Pandemic has altered so many aspects of life and Preventive Care in particular. Public health and immunization campaigns for other ailments have been disrupted and health budgets decimated worldwide. Many of you, have ignored your own problems and healthy routines (gaining on average 12-15 lbs), skipping check-ups and preventive care. Hence, I thought it appropriate to address Preventive Care and attempt to briefly “scratch” the surface of this broad subject and emphasize what works.

As you know, Preventive Care has multiple dimensions, from healthy exercise and dietary habits to proper and timely screening tests. We must prioritize the interventions with the highest benefits and the lowest risks. If your doctor orders a CT scan or imaging that is not warranted based on your individualized risk, it may find abnormalities that are not consequential and may lead to additional testing and the ill-defined “cost” of undue anxiety and loss of “happiness” that we all pursue, from sunrise to sunset and beyond. Thus, as we have repeated over the past 3 + years in our “Bits”, MORE is NOT BEST or BETTER!

Recommendations depend on age, sex, familial, occupational and personal histories. Sometimes, the best we can do or should do is to take a deep breath, observe our surroundings and be mindful of the good fortune to be awake, aware, alive and admiring our visible and invisible universes which always provides inner peace and joy!

You should remember that a (very small) portion of your taxes, funds preventive programs. Our CDC (Centers for Diseases Control and Prevention) dedicates 10% of its budget to Prevention and by some estimates, less than 2%. The US Preventive Services Task Force is funded through the Department of Health and Human Services (HHS). They publish evidence-based guidelines to help the public and physicians navigate the doubts and uncertainties posed by evolving technology, changing epidemiology and demographics. Thanks to cumulative preventive efforts longevity has doubled over the past century.

Life expectancy in 1900 was 47 years. It declined after the 1918 Flu Pandemic and has steadily risen since, to reach 82 years in 2016 (before likely receding again in the US, due to the Opiod Epidemic and COVID-19 Pandemic). By 2030, 20% of the world’s population will be over 60 years of age. How did Humanity gave itself an extra life? Through numerous, progressive scientific achievements and activism, as summarized by The Times.

How can we achieve adequate PREVENTION?

There lays the value of your “Periodic check-up”. Annual examinations and reviews may be beneficial for individuals older than 50 and every 3 years for those younger. But the most important part is the preventive counseling and dialogue that ensues at those encounters. They also offer an opportunity to discuss the inherent limitations of screening tests and the concepts of negative and positive predictive value. The probability of benefit from screening for disease may be overshadowed by the possibility of real harm from “overdiagnosis”. That is why a candid dialogue with your physician to set priorities and consider risks and benefits is so important.

Cardiovascular Disease Prevention:

Limiting or managing the modifiable cardiac risk factors:

• Diet (see Healthy Diet in Adults)
• Tobacco (see Tobacco Cessation)
• Hypertension (see Screening for HTN). Annually > 40 years and every 3-5 Earlier in those with risk factors.
• Limit salt intake to less than 2 grams daily. Almost impossible to accomplish if you eat commercially processed
• Dislipidemia – Cholesterol (see Cholesterol management). Screen all adults at Then, after 35 for men and after 45 for women.
• Obesity (see Weight management). Strive to maintain a normal weight and BMI below
• Physical Activity. The more, the merrier!
• Diabetes Mellitus. Keep your hemoglobin A1c below 7%.
• Aspirin for Primary Prevention. Only for those with significant CV
• Non-traditional measures: Coronary artery calcium testing, C-Reactive Protein, Carotid intima thickening, Assess individual risk and consider only in those with very high risk.

Cancer Prevention

Keep in mind that healthy habits and behavior do not lead to “immortality”. They may extend cancer-free survival by 8.5 years in women and 6.5 years in men.

The 2020 American Cancer Society guideline on diet and physical activity for cancer prevention recommends a healthy diet, defined as having a variety of vegetables (dark green, red and orange, fiber-rich legumes and others) fruits, and whole grains and limiting or not including processed meats, sugar-sweetened beverages, or highly processed foods and refined grain products. Fiber reduces colorectal cancer, heart disease and diabetes.

In summary: KEEP IT SIMPLE!

• Avoid tobacco, smoke and vapors of ANY kind! They cannot possibly be good for you, despite the claims of the Cannabis Industry and so many other loud “voices”.
• Remain physically active. It will boost your immunity and the “natural killer” cells in charge of cancer cell “surveillance and clean up”.
• Maintain a healthy weight. The incidence of colon, endometrial, pancreatic and postmenopausal breast cancer rises with weight and that risk can be ameliorated by weight loss.
• Eat your nuts, fruits, vegetables, legumes, whole grain bread and olive oil.
• Limit red meats.
• Eliminate trans-fats.
• Limit alcohol consumption (no more than 1-2 drinks/day).
• HPV vaccination (up to age 45).
• Hepatitis B vaccination
• Avoid excess sun-light.
• Do not take supplemental Omega 3 or 6 Free Fatty Acids.
• Enjoy your cup of coffee daily.
• Supplemental Vitamins and micronutrients have not been shown to be beneficial.
• Remember that 17-20% of cancers worldwide are caused by “infections” (Hepatitis B, Hepatitis C, HIV, HPV, Epstein-Barr, HTLV- 1, Helicobacter Pilori, Schistosomiasis, Liver Flukes, etc).

Breast Cancer

• Average risk, start digital mammography at 50 every 1-2 yrs.
• High risk – Family history, start mammography at age 40 and include genetic evaluation/counseling.
• Remember that mammography is inaccurate, associated with a significant risk of “overdiagnosis” and false positive results.
• Continue testing every 1-2 yrs until life expectancy is < 10 yrs.

Cervical Cancer

• Age 21-29: Pap smear every 3 yrs or every 5 yrs with HPV testing.
• Age 30-65: Pap smear and HPV testing every 5 yrs or pap test every 3 yrs.
• Age >65: No further testing required.
• VACCINATE with HPV series (3 shots) all males and females ages 11-26. Vaccines is approved through age 45, but likely beneficial (to reduce ano-genital and head-neck cancers) beyond although not well studied and not likely to be paid by insurance.

Ovarian Cancer

• Screening is only recommended for individuals with a family

Colorectal Cancer

• No risk factors: Start colonoscopy at age 45-50 and every 7-10 yrs if normal
• Family history: Frequency depends on individual risk and history
• Cologuard (DNA stool test) may help decrease frequency of colonoscopy.

Lung Cancer

• Reduce diesel exhaust and particulate matter exposure.
• Reduce chemical exposures.
• Reduce radon, asbestos and arsenic exposure.
• Annual low-dose CT in adults 5—80 with a 20 pack-year smoking history and smoke or quit within the past 15 yrs.

Prostate Cancer

• Medications to reduce the incidence of prostate cancer are not (Finasteride and Dutasteride reduce “low-grade” prostate cancer incidence, but increase more aggressive types.
• For men 55-69 yrs, periodic prostate-specific-antigen (PSA) based screening should be individualized.
• For men > 70 yrs, PSA-based screening is discouraged.

Melanoma

• Limit sun exposure
• Apply generous sunscreen SPF > 30, 15 minutes before going out and reapply every 2 hrs. Caution near water, snow, sand.

Hypothyroidism

• Screen periodically with high sensitivity TSH – Blood test.  Treat those with symptoms.

• Monitor those without symptoms with TSH and anti-thyroid peroxidase within 2-3 months.

Vitamin D Deficiency

• Daily intake of 1000 IU More in patients with low levels or malabsorption syndromes.

Sexually Transmitted Diseases

• Education on preventive strategies
• Barrier methods
• Vaccination for those vaccine-preventable STD’s
• Diagnosis, treatment, counseling and follow up of those infected.
• Pre-exposure prophylaxis for some conditions (HIV, Herpes).

Osteoporosis

• Promote achievement of high peak bone density in youth
• Weight-bearing exercises and adequate diet.  Limit carbonated beverages.
• Consider use of preventive strategies with your physician:

Vascular Disease

• Men aged 65-75 who ever smoked, should have an aortic ultrasound once.
• No indication for carotid artery disease screening unless additional risk factors present.

Immunizations

• One of the most important and time-sanctioned strategy since the days of Edward Jenner at the turn of the XVIII century and Louis Pasteur in the late XIX century.
• Special situations may require a discussion with your doctor.
• Most adults should follow the recommendations summarized in this table from the CDC and the Adult Committee in Immunization Practices (ACIP).

COVID-19 VACCINES

 At this time, there are twelve vaccines against COVID-19 approved in different nations and 31 vaccines making progress at the final Phase III clinical trials. In the US, three vaccines have received Emergency Use Authorization (EUA). Two mRNA vaccines were deployed in December 2020. The Pfizer – BioNTech and the Moderna – NIH-NIAID received preliminary approval and EUA and full approval in some nations. These vaccines had an impressive 95% efficacy and safety, as reported in their phase IIB-III clinical trials. Both require two injections, but early protection was noted as early as 12 days after the first injection. In the period between injections, the efficacy was almost 75% and the likelihood of severe disease declined even further. On February 27th, the Johnson & Johnson modified adenovirus vaccine received EUA. This past week, Novavax announced results of phase III clinical trial of its NVX-CoV2373 Vaccine which showed 90.4% overall efficacy and 93% efficacy against the five most prevalent SARS-CoV2 variants of concern. Approval is anticipated later this summer. The Gaithersburg company will supply up to 1.1 Billion doses to the international Vaccine Alliance – GAVI, supported by the WHO, the Bill and Melinda Gates Foundation, UNICEF and The Worldbank Group.

You have all read about the few complications induced by the adenovirus vector-based DNA vaccines (Ad26.CoV2 – J&J approved in the US and ChAdOx1nCov-19 – Oxford-AZ approved in the EU). The mechanism driving these rare complications has been elucidated. These vector-based vaccines appear to trigger IgG antibodies that recognize a receptor (Platelet Factor 4-PF4) in the surface of platelets (cells that aggregate to form clots and stop bleeding). The activation of platelets leads to the formation of innumerable clots within the circulation in unusual places.

Additional cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) have now been reported to both, European and US agencies, with 230 cases among 34 million recipients of the Oxford-AZ vaccine; 35 cases in 54 million recipients of Pfizer-BioNTech mRNA vaccine; 5 cases among 4 million vaccinated with the Moderna mRNA vaccine and 6 cases were described among over 7 million who received the J&J vaccine. It appears to be a wider phenomenon and not just related to the vector-based vaccines and as we scrutinize those immunized, the recognition of these phenomena is likely to rise. Fortunately, VITT are rare occurrences (approximately 1 case per ½ million doses) more common in young women, several on BCP or hormone replacement therapy (but a firm link has not been established) and we now know how to recognize them and effective treatment is available! These are very rare complications and pale in comparison to the benefits of preventing COVID-19 which has a mortality of 0.2-2% (depending on host) and potential long-term damage.

COVID-19 Variants and Mutants

There are several open-source databases tracking SARS-CoV-2 genomic sequences, but the largest and most popular is GISAID.

It was originally conceived in 2006 as a “bank” of genomic data from flu viruses, but the Pandemic has expanded its mission to promote the rapid sharing of data from all influenza and coronaviruses to help researchers understand how viruses evolve and spread during epidemics and pandemics. Scientists are able to upload the genomic sequence of the viral strain present in their communities. Their hard work has led to the sharing of more than 1.2 million coronavirus genome sequences from 172 nations, allowing researchers to track the development and movement of new variants across the planet.

Nextstrain, is another open-source consortium that follows numerous infectious diseases and updated several times weekly, tracking the global spread and flow of variants. You can read and explore more here.

How effective are vaccines against the variants reported? The vaccines remain EXTREMELY EFFECTIVE and all appear to make serious disease rare!

Out of more than 150 million fully vaccinated Americans (June 15th,2021), “breakthrough” infections occurred in less than 0.008%, hospitalizations in 0.0005% and deaths in 0.0001%! And even in Nursing Homes a recent report from the CDC indicates very low risk of disease after vaccination.

An article published in late April 2021, reported that in a cohort of 417 fully vaccinated individuals with the mRNA vaccines only 2 people developed disease with variants (E484K and B1.526 mutants). The study also confirmed that adequate titers of neutralizing antibodies persist for more than 6 months after immunization and likely much longer.

Also, data from the clinical trials indicates that infectivity in those vaccinated is decreased by at least 70%. Information from Israel suggests that in the few individuals that develop infection after vaccination, the viral load is much lower, making them less infectious.

Additional data now published demonstrated that the mRNA vaccines appear to be protective earlier than initially reported and achieve over 92% protection within 2 weeks of the 1st dose.

We have discussed in the past how SARS-CoV-2 relies on its Spike protein to attach to the epithelial cells of the respiratory system and become internalized into those cells to hi-jack the metabolic machinery to replicate and cause disease. Vaccine development has focused on this protein and all of them inoculate conformational variants of the Spike protein (mRNA particles encoding for them – proteins – attenuated viruses that expose the same antigen protein and inactivated viruses).

The P.1 and B.1.351 mutants, share a mutation that leads to a conformational change in the Spike protein and thus, appear to make the vaccines less effective, requiring higher neutralizing antibodies titers (NAb).

The variant B.1.617 (so called, Delta variant) initially detected in India in late 2020 that has new “dual” mutations –E484Q and L452R – likely fueling their epidemic, as they appear to increase transmission, increase severity of illness and to reduce the neutralization power achieved with vaccinations. Active surveillance (and your vigilance) continues.

We should emphasize that the immunogenic response and titers of antibodies induced by vaccination are effective. And the good news is that science is keeping up with these mutants. If these “bad guys” are able to cause breakthrough infections in vaccinated individuals, we may need a vaccine “update” or booster within a few months, but not certain at this point. For an excellent review of New Variants and Mutations.

A summary from the NEJM follows in this table.

The frequently updated Coronavirus Vaccine Tracker from the NYT is an excellent resource. Another excellent Covid-19 Research update from Nature.

The following graphic demonstrates how vaccinations are associated with economic growth and unlocking national economics’ potential. Of course, we should keep in mind that it represents relative % increase on a year earlier, and some economies (like my native Argentina) were devastated by the Pandemic with contractions in GDP close to 20%, from which “growth” is much easier.

National and International Vaccine Rollout information.

This NYT link has National and International Vaccine Rollout information.

WHY WOULD HUMANS DECLINE VACCINATION?

We must invite those hesitant about vaccination to share their fears, concerns and reasons to avoid vaccination. Here you can find an excellent review about vaccine hesitancy. Open ended questions such as “What do you think about the Covid vaccine?” may provide an opening to discuss and allay concerns. The best approach is to listen to their concerns without judgment, respect their concerns and emphasize your care about their welfare. Here is a wonderful interactive feature to help you and those slow to embrace the protective potential of vaccines.

Multiple surveys throughout our Nation have been completed and we now have maps that analyze the different reasons delaying vaccination. The most common:

1. 14% of the US population are “COVID Skeptics”.
2. 9% are “Cost-Conscious” and can’t afford to take time off or be out of work due to potential side-effects from the vaccine.
3. 8% are “Watchful” and waiting to see how safe and effective vaccines really are.
4. 4% are “Healthcare system Distrusters” and distrusters of the government in general. Fear of vaccine side-effects or complications is the most quoted.

WHAT TO DO?

1. COVID Skeptics” – Most common in AS, ND, NV. Avoid antagonizing or discrediting their beliefs. Best to acknowledge their thoughts and feelings and provide facts, underlining that vaccination not only may protect them, but will protect their families and friends.
2. “Cost-Conscious” – Most common in MS, WV, TN, AL and states with high poverty rates. In these places bringing the vaccine “to the people” and into churches, schools, grocery stores, etc. will increase vaccination rates.
3. “Watchful” – Most common in DL, HI, RI, OK, WV and WY. People are waiting to see how friends and acquaintances perform after vaccination. For them, best to keep the option of vaccination open and use gentle persuasion and data to nudge them in the “right” direction.
4. “Healthcare system Distrusters” – Most common in DC, MD, GA and particularly among African-American and Hispanic minorities. Here it is important for the public health authorities to partner with trusted members of the communities, provide equitable access to vaccination and to have transparent communication to enhance acceptance.

COVID-19 Vaccines: Q & A

1.    Pregnancy is a contraindication to Covid-19 vaccination.

No. In fact, a recent study confirmed no safety concerns with the mRNA vaccines and adequate protection.

The safest or most rational timing of vaccination during pregnancy has not been established, but as indicated in our prior “Bits”, best to inoculate in the second trimester, to ascertain protection to the mother in the third trimester (when infectious complications are more common) and to facilitate the placental transfer of antibodies and protection to the newborn.

2.    Do I need to continue to decontaminate surfaces?

No. As we learn more about transmission, we know that this is an airborne disease. It is highly unlikely that we can pick up an “infectious dose” on our fingertips.

3.    How long patients continue to shed live viruses?

The median time from symptom onset to viral clearance in culture was 7 days (+/- 5 days) but the median time to clearance of PCR was 34 days. The latest positive viral culture was 12 days after symptom onset. Thus, we may continue to shed the viral particles for a while, but they may be inactive and not likely to cause disease. This period may be longer in immunocompromised patients.

4.    Do I need to have oxygen available in case of need?

No. There is no evidence that more oxygen is better. In fact, multiple studies have shown that only patients with persistent oxygen saturation below 89% benefit from Oxygen. This applies to all humans, including patients with COPD, emphysema, heart failure and the rest. Most people discharged home on oxygen, do not need supplemental oxygen upon re-testing 2-3 weeks later. If you are “hoarding” an oxygen concentrator, have your physician return it and use those precious healthcare funds for other beneficial treatments.

5.    Are the vaccines safe?

YES. All the vaccines approved in the US are safe, trigger an excellent immunologic response across all age groups, are highly protective and cause minimal injection-site reactions and fatigue/malaise and occasional headaches (symptoms that are generally attributable to all vaccines and due to the immunogenic response triggered by the introduced antigens). The incidence of anaphylactic reactions (mostly in those with polyethylene glycol intolerance) is below 5/million inoculations and develops within 20 minutes of administration and Vaccine-associated clotting (VITT) complications reported above occur to about 1:200,000 people and we now know how to recognize them and treat effectively. Other abnormal immune responses such as persistent body aches, pericarditis, pleuritis, myocarditis and muscle aches have been reported.

6.    What is the duration of the protection elicited by vaccines?

The protection is anticipated to last at least 6-12 months and possibly a lot longer as the cellular immunity is stimulated as well and it is a long-lasting defense.

7.    Can vaccines possibly aggravate pre-existing conditions?

Yes. There are few reports of flares of autoimmune and inflammatory conditions such as inflammatory bowel disease, Crohn’s ulcerative colitis and polymyalgia rheumatica reported. But the benefits of vaccination outweigh the risks by thousands of folds.

8.    Could the messenger RNA vaccines get integrated into my DNA and cause mutations or long-lasting ill-effects?

No. This is biologically impossible. The small messenger RNA is quickly broken down and does not interact with humans’ DNA. Both vaccines have a tiny segment of mRNA encased in lipids.

9.    Asymptomatic individuals do not transmit COVID-19.

Yes. Multiple studies indicate that nearly ½ of transmissions are from people not feeling ill and about a third of all infected patients remain asymptomatic.

10.    Is the virus mutating such that the efficacy of vaccines is in peril? DO NOT WORRY!

Of course, the virus is mutating, just like any other virus multiplying in the trillions and infecting millions of hosts. As discussed, some of the mutations may lead to increased infectivity and severity of disease. SARS-CoV2 is a stable, non-segmented RNA virus. The infectivity of the virus increased early, as a result of a specific mutation carrying the spike protein D614G substitution, augmenting the virus infectivity and becoming the dominant strain causing disease in Northern Italy and the most prevalent variant throughout the world for most of 2020. New variants with heightened infectivity such as B.1.1.7 and now B.1.617 (so called, Delta variant) are displacing other less “efficient” strains. But vaccines are effective and if eventually booster vaccine “updates” are necessary, you will be “jab-ready”.

11.    Should people who recovered from COVID-19 infection be vaccinated?

Yes. It is not certain how long the immunity will last, and although long term humoral and cellular immunities are anticipated, the recommendation is to be vaccinated 90 days after the acute infection (mine: do it earlier!)

12.      Are people who cough or sneeze more infectious than others?

No. Transmission appears to be driven by the viral load of index cases. A higher viral load also increases the risk of developing symptomatic disease shortens the incubation period in a “dose-dependent” manner, as reported by The Lancet.

13.    When will vaccines become available for Children?

The clinical trials that led to the approval of the mRNA vaccines included adolescents ages 12-17. As of now, everyone older than 12 can be vaccinated. Children ages 6 months to11 years may have to wait till early fall as the results of the trials initiated in early March 2021 become available.

If you have 7 minutes daily, you can start to improve your fitness right now, and 11 more minutes will get you in shape!

Remember that the only certainty in life, is death and the only fountain of youth proven by science and experience are exercise, laughter, humor and a positive attitude!

Let me conclude with some words from the lush literary garden of Dr. Ignacio Chavez, Mexican Cardiologist which I came across as a medical student and to this day I cannot read without shedding a few emotional tears and getting some goose-bumps:

“Centuries ago, when Mount Olympus served as home to the Gods, Asklepios would come down to earth to cure the ills of men. One day, he turned to the sacred mountain and left his mission entrusted in the hands of a mortal. From that God of medicine, the only thing left was a temple, under pine trees and a blowing breeze at Epidaurus. And its cult. Men represented him with his head pensively beautiful, worthy of a God, with his long beard, which speaks of years and experience and with his rough cane, symbolizing the harsh difficulties of art.

Hippocrates picked up the legacy, and at the Asklepion of his island of Kos he developed the medicine of observation that we know today. Posterity called him “divine” because he humanized the medical art of his time, hitherto lacking in spirit. Also, because he complied with the Pythagorean precept: “To be like God, always tell the truth and always do good to others.”

We are his followers, Asclepiads of our times. Being faithful to his teaching and his example, we surely don’t aspire to be called “divine” as was him, but we do aspire as a reward to deserve to be called “Doctors”

OFFICE UPDATES:

Please, join me in congratulating and thanking Emily Ferguson for her invaluable work, wisdom and marvelous disposition! She is moving on to become a wonderful physician at Thomas Jefferson University in Philadelphia!

CONGRATULATIONS AND BEST OF LUCKS EMILY!

Welcome Simran Singh, who will take over her duties. Simran has been working with us for the past year. Originally from Upstate New York, she moved to the DMV area to complete her Master’s degree at Georgetown University and is working towards attending medical school next year. Simran looks forward to coming on board and being a part of your personalized care experience!

Simran Singh: simrans@chevychasepulmonary.com

Lastly, I will be on vacation from July 23rd through August 7th. My partners will cover my practice and as usual, they can be reached by calling the office at 301-656-7374.

Wishing you all a happy and healthy summer!

Carlos E. Picone, MD

5215 Loughboro Rd NW, Suite 400

Washington, DC 20016

301-656-7374

cpicone@chevychasepulmonary.com

References:

https://www.nejm.org/coronavirus

https://www.cdc.gov/coronavirus/2019-nCoV/index.html

https://www.who.int

https://clinicaltrials.gov/

https://www.nature.com/articles/d41586-020-00154-w]

https://science.sciencemag.org/content/early/2020/05/12/science.abc5312 https://www.nejm.org/doi/full/10.1056/NEJMp2005630?query=featured_co ronavirus

https://www.youtube.com/watch?v=-

Gn8oJY1VHY&feature=youtu.be https://www.cfr.org/backgrounder/what-world-doing-create-covid-19- vaccine

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805090/ https://www.nejm.org/doi/full/10.1056/NEJMcibr2009737?query=featured_ coronavirus

https://jamanetwork.com/journals/jama/fullarticle/2767840

https://www.nature.com/articles/d41586-020-00502-w

https://www.nap.edu/catalog/25914/discussion-draft-of-the-preliminary- framework-for-equitable-allocation-of-covid-19-vaccine

https://www.economist.com/briefing/2020/11/14/an-effective-covid-19- vaccine-is-a-turning-point-in-the-pandemic

https://www.economist.com/briefing/2021/02/13/vaccine-hesitancy-is- putting-progress-against-covid-19-at-risk

https://www.nature.com/articles/d41586-020-00502