Letter for February 17, 2022

The untimely death of Bob Saget, and a word of caution with sedatives. BA.2 variant - will it get a name, and will it cause another surge? New conclusions about Vitamin D. Swearing is good for you.

Aware [commentary on key news]

I was saddened to hear of comedian Bob Saget’s death. He got much of his start in Philadelphia comedy clubs, and went on to become a famous and beloved celebrity. He could exude a wholesome Dad vibe on shows like Full House, or bring some crass humor to a comedy show. His autopsy showed massive head injuries, including a major fracture that led to intracranial bleeding.

Was there foul play? Investigators have found no evidence of assault. Instead it’s believed that he had a very serious fall, struck his head, became quickly disoriented, and was unable to call for help in time. The autopsy also found clonazepam and trazodone in his system. These are commonly prescribed medications for anxiety and insomnia. Side effects can include sedation, falls, and confusion, and are more risky to take as people get older.

As doctors we try to caution people about the risks of these medications even as we reluctantly prescribe them. Balancing the torments of extreme anxiety, panic attacks, acute stress, and intractable insomnia against the risks of medications which can calm the brain is not an easy proposition. If Bob Saget’s death was from passing out, falling, or otherwise striking his head, these medications might have contributed.

Saget also had Covid in January, and the virus was still detected upon autopsy through PCR. Covid can infect the central nervous system and cardiovascular system, and might have contributed directly by impairing balance or causing an arrhythmia. It could also indirectly increase the perceived need for medications like clonazepam. More evidence that Covid affects the brain came out this week. A major study confirmed that prior infection increases the risk of developing mental health problems for at least a year out.¹ New anxiety, depression, insomnia, and cognitive impairment rates were 30-80% higher in those who had been diagnosed with Covid. Even though this sounds bad, most people with Covid do recover without newly diagnosed mental illnesses.

It is certain that Saget will be missed. Regardless of the above speculation it is important to be judicious in the use of medications. We also need to be aware of the possible mental health aftereffects of Covid, so that we can try to understand and help those afflicted.

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The BA.2 variant continues to be an evolving problem. It is driving high infection rates in countries like Denmark and South Africa again. Current evidence suggests that evolution has made it even more contagious than Omicron, both from intrinsic advantages of the virus and from partial evasion of prior immunity from vaccination and infection. There is mixed evidence as to whether it can cause more severe disease, but it seems a little worse than Omicron. There is also mixed evidence as to whether monoclonal antibodies like sotrovimab will keep working.

BA.2 might soon have a Greek alphabet letter name, joining the pantheon of viral gods we all hate. Next in line in the alphabet is the letter “Pi.” I hope they skip that letter, because as you recall from math, pi=3.14159265359… with the decimal places going on into infinity. Pi would be bad for morale, as the concept of infinity kind of feels like how this pandemic is going. After Pi is Rho.

As politicians push past one another to get to the front of the line in ending mask mandates, it should be noted that the average number of American Covid cases just dipped below the peak of the nasty Delta wave. 3,000 Americans died of Covid just yesterday. 2 children in my daughter’s class tested positive today. The caution clock starts yet again, but with her being vaccinated and masked, hopefully the ripples will be contained. I want to believe the narrative that we can move on. So badly. And I think we can chill compared to a month ago. But if you want to Rho your boat safely until infection rates are better, keep wearing a good mask inside public buildings, consider free rapid antigen testing if you’re having an unmasked indoor get together (especially with older/vulnerable people), get boosted, and hope that Paxlovid pills will be more available soon. The weather is kind of nice, and the outdoors beckon. BA.2 is going to prolong the Omicron wave in a lot of places, but another tsunami is not expected.

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Alive [longevity and an ounce of prevention]

Vitamin D deficiency is important to treat, especially during the winter months in northern climates without much sun. Some studies have linked low vitamin D levels with higher risks of cardiovascular disease, cancers, osteoporosis, autoimmune diseases, and infections. The intuitive solution would be for everyone to take vitamin D supplements, and watch as the rates of these problems plummet. But yet another frustrating study has shown that Vitamin D supplementation does not improve mortality rates versus placebo over 5 years when given to randomly assigned people.²

One limitation of this study is that it did not stratify people who would most benefit from Vitamin D supplementation - namely people who started out deficient. They just gave it to everyone. In some ways this is helpful to answer the question “should everyone take Vitamin D to live longer?” The results suggest probably not.

Screening for vitamin D deficiency is most important in higher risk people - older homebound or institutionalized individuals, those with limited sun exposure, obesity, dark skin, osteoporosis, and malabsorption.

The medical reference most doctors consult (called UpToDate) suggests:

The approach to testing and replenishment is based upon an initial assessment of a patient's risk for having a low serum 25(OH)D level. For low-risk adults, we suggest not routinely screening individuals for vitamin D deficiency. Rather than screen, we suggest intake of 600 to 800 international units of vitamin D daily.

What about calcium? We should try to aim for a daily total calcium intake (diet plus supplementation) of 1000 mg for ages 19 to 70 years. A bit more like 1200 mg is recommended for women ages 51 through 70 years, and all adults 71 years and older.

Back to D. Not many foods naturally contain vitamin D. Fatty fish (like salmon, herring, and sardines) and eggs are the exceptions. The major sources of Vitamin D for most people is that made by our own skin, and foods fortified with vitamin D (like milk and some cereals). Humans evolved to get most of this vitamin/hormone by living in the sunlit world.

Mushrooms can contain Vitamin D2, which is not as effective as Vitamin D3. But most mushrooms are grown in the dark and do not produce much. Wild mushrooms and those grown in UV light do produce Vitamin D… but I wouldn’t trust myself, or even a great forager. It only takes one mistake with wild mushrooms. However, I would have trusted my grandfather, who was a country doctor, and had a secret, legendary spot in the Pennsylvania woods where he collected wild morels every Spring. Have your ever fried morels in butter and salt? Absolutely phenomenal.

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Happy [in the pursuit of contentment]

Swearing. It can be good for your health. People who swear have also been found to be slightly more genuine and honest in their overall behaviors:³

Studies have shown that swearing relieves stress, dulls the sensation of pain, fosters camaraderie among peers and is linked with traits like verbal fluency, openness and honesty… letting out a few choice words during a workout can actually make you stronger. In a study, participants who cursed aloud while gripping a hand vise were able to squeeze harder and longer.

In the office I am usually quite professional, but at home I have been known to drop a few curses when needed. It is a quite effective and economical way of dealing with the searing pain in my shin when I accidentally kick the bedframe while making the bed. But like any vice, swearing needs to be done in moderation, and so I have asked my daughter to fine me 25 cents each time I let out a gratuitous, non-therapeutic utterance. She has earned her first dollar this week.

If anyone reading this happens to be an accountant - can my daughter declare as legitimate income any money she makes from her language improvement venture? Can she then contribute those significant earnings to a Roth IRA?

I’ve also heard that GameStop might be a solid pick?

1. https://www.bmj.com/content/376/bmj-2021-068993

2. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00345-4/fulltext

3. https://www.discovermagazine.com/health/worried-about-your-foul-mouth-swearing-could-actually-be-good-for-you