Letter for January 6th, 2022

The first letter of the new year. 2 million Omicron cases per day? CDC guidelines are mercurial. Schools and hospitals struggling. Good news out there. Diabetes prevention. Covid, the new syphilis

Aware [commentary on key news]

So much has happened since the last letter I wrote. We’ve been extremely busy in the office with problems multiplying. The prediction of 1 million cases per day in the U.S. has proven accurate. Considering what I’ve seen with my patients, with cases going uncounted because of testing scarcity, and rapid antigen tests not being reported, I think we could easily be at 2 million cases per day right now. Omicron is proving to be more contagious than anything I’ve seen.

I spoke with a teacher tonight who shared that 30% of the teaching staff, and 25% of the kids in his district are out sick. Almost half of Philly schools have switched to virtual learning because of teachers being sick. Add 5 districts in Burlington County so far. Our child’s school is similarly affected. And this is happening in schools with decent mitigation strategies. I would have closed schools for a week after the holidays, given that so many people traveled and mixed, but alas. Long lines for testing, urgent care/emergency rooms beyond capacity, and limited treatment options are the new norm this month. Our hospital is on a surge footing, anticipating more staff shortages. A lot of my doctor friends have contracted Covid in the past 2 weeks. The number of people in our hospitals admitted for Covid is 4 times what it was a month ago.

The CDC has warped its isolation and quarantine guidelines to keep institutions from collapsing, to the detriment of the individual. I was up last night reading the newly revised guidelines, trying to follow the reasoning. It’s messy and confusing. The CDC points out that during the pandemic a paltry 25% of people with Covid have actually isolated for the full recommended duration. I’m going to quote a school leader’s email to us parents:

If your child has ANY COVID-like symptoms, even if they are vaccinated or test negative on a rapid test, DO NOT SEND YOUR CHILD TO SCHOOL.

Symptoms of Covid include the obvious cough, fever, shortness of breath, etc… but could simply be a mild sore throat, runny nose, or congestion. A negative test for Covid is reassuring but no proof. When we are sick we should stay home, period. Covid or not. That’s a common decency many have forgone, myself included before the pandemic, as the excessive demands of our lives and jobs made us think its OK to keep working despite being sick. Presenteeism is much more of an American problem that absenteeism. It leads to much more lost productivity and school closures in the current mess, and vulnerable people can wind up getting very sick.

It’s true that Omicron is on average less severe, affects the upper airways more than the lower lungs, is better fought off by the boosted, and requires all our best strategies to avoid. The risk of dying from Omicron is much less, especially if you are younger than 65 and vaccinated. Get vaccinated, boosted, wear a great mask, cool your jets for a while, take up knitting… whatever it takes. And if you are already sick please hang in there; many of us will be joining you shortly. And please share this encouraging graph of hospitalization rates in NYC based upon vaccination status:

Rapid antigen tests, if you can find them, are still working fairly well for detecting Omicron. They target the less-mutated nucleocapsid part of the virus. A positive rapid antigen test correlates with higher amounts of virus being present, and therefore higher infectious risk to others. This is one reason many have advocated for testing on day 5 of isolation before clearing people to return to work. Omicron is showing up in oral swabs better than nasal swabs, and this might be why many report the rapid antigen tests failing. The UK has recently advised a combined nose and throat swab for better sensitivity (video here).

If you like hard numbers to gauge risk, take these from Spectrum Health System in Michigan. They reported on December 28th:

• 386 patients are hospitalized with Covid-19. Of these, 323 are unvaccinated (84%) and 63 vaccinated.

• Of those 386 hospitalized, 107 are in ICU. Of these, 100 (93%) are unvaccinated and only 7 vaccinated.

• Of those 107 ICU patients, 68 were on ventilators. 64 (94%) unvaccinated and only 4 vaccinated.

I’ll end on some good news, as our weariness compounds this month.

• Without the vaccines, there would have been 1.1 million more deaths in the U.S. through just November, 2021, and 10 million more hospitalizations.

• Omicron is less severe on average.

• We have T-cells that are well trained by vaccination (and to a lesser degree prior infection), and these T-cells are also reducing severe disease and death from Omicron.

• Paxlovid, the pill from Pfizer, reduces the risk of severe disease and death by 90%, still works for Omicron, and will become more available soon despite being incredibly scarce right now - maybe enough to treat 300,000 of the most vulnerable Americans infected through the end of February, and more like 120 million available courses if needed by the time 2022 is over.

• Masks reduce transmission by up to 50%, and N95 masks by up to 95%, and are generally in stock.

• More antigen tests are coming, and must now be reimbursed by your health insurance thanks to the new federal government (Biden) rule.

• Kids under age 5 should be able to get the vaccine by summer (wish this were faster).

• Walter Reed Medical Center and others are working on (and having success with) pan-coronavirus vaccines that will be effective against all current and future variants.

• The James Webb Space Telescope did not explode yet!

• And finally, for Christmas, my wife got me an outdoor firepit thingy that works in the city… so if you want to come over for a beer and sit around the fire, please bring an IPA and I’ll spring for marshmallows.

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Alive [longevity and an ounce of prevention]

The joys of exercise, 1985.

A study published in 2002 looked at preventing the onset of diabetes in adults with prediabetes and obesity. There were 3 groups. The first was a “lifestyle intervention” group that was given a goal of losing 7% of body weight and exercising 2.5 hours per week, reinforced with 16 intensive educational sessions… and they did the best. Second prize for preventing diabetes onset went to the group that was prescribed metformin 850 mg twice daily and received standard prediabetes advice from a doctor. And finally, the group given placebo pills plus standard prediabetes advice did the worst in terms of progressing to diabetes over 3 years.

The groups were then enrolled in a long term follow up study over the next 21 years. The lifestyle group was given additional reinforcement sessions in terms of weight loss goals and exercise. The metformin group kept taking metformin. The placebo group kept doing their thing. Surprisingly, no differences were found in the long run:

Cardiovascular-related, cancer-related, and overall mortality did not differ between groups. And at 21 years, the prevalence of diabetes was 53%, 55%, and 60% in the lifestyle, metformin, and placebo groups, respectively.

I think this study casts some shade on the common practice of prescribing metformin to help prevent diabetes. It also shows the somewhat arbitrary distinction between prediabetes and diabetes, and that simply delaying the onset of diabetes is not as important as reversing insulin resistance as much as possible.

Insulin resistance affects a majority of adults, and up to 40% of young adults. It is a common thread in cancer risk, obesity, cardiovascular disease, and even erectile dysfunction.

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Well [ideas and studies that promote better health]

Have you heard of No-Shave November?

It’s “a month-long journey during which participants forgo shaving and grooming in order to evoke conversation and raise cancer awareness.”

I listened to an excellent podcast on this subject, hosted by Peter Panageas. He is a Senior VP at IBX, and presents a very compelling story of his father’s journey with prostate cancer, and weaves in an interview with Dr. Leonard Gomella, Chief of Urology at Jefferson. If you have questions about prostate cancer screening as a man, or want to understand more about this important subject for the men in your family, or even learn about the nuances of treatment options, then this podcast is highly recommended for you.

Artist James Henry Beard, sporting one.

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I will devote more time in upcoming letters to neglected themes I want to prioritize, like staying happy and human in spite of all this muck. I’m also going to plan a deep dive or two on alcohol, insulin resistance, and maybe a few good stories, assuming I have the time, and personal/family health.

The practice of medicine requires one to be a lifelong learner. The father of modern medicine, Sir William Osler, once stated: He who knows syphilis knows medicine. Syphilis can present in myriad ways, affecting most organ systems, and a mastery of this disease involves understanding most of the body. Covid-19 may well be this generation’s syphilis in terms of understanding the hundreds of effects it has on the body, and so I feel compelled to keep presenting the main points here.

I wish you well, and thanks for your interest!