The Medical Insider

Marc, age 22, developed a sore throat and dry cough. The next day, upon a friend’s suggestion, he did a drive-thru COVID-19 test at a local pharmacy. “Really easy,” he said.

He filled out a short online screening form, got an appointment within an hour. Before he left, he watched a video on do-it-yourself nose-swab. At the drive-thru, he was given a kit, swabbed himself and was done in minutes. The line was shorter than Popeye’s at dinner time.

Sponsored by the Family First Coronavirus Response Act, COVID-19 testing is free to Americans with or without insurance. Unlike hospitals and clinics, many drive-thru sites do not require a doctor’s referral.

In our medical teleconference, Gus, 46, said his glucose ran high. He was up several times at night to urinate. He needed insulin adjustment. Easy-peasy, we formulated a plan and were mighty pleased with ourselves.

Then he related an episode, by prefacing: “My wife said I must tell you this.” She, apparently, had been sitting quietly by the phone. Weeks ago, Gus experienced a sudden severe right arm pain that knocked him to the ground. The arm stayed numb for hours, and he’s been short of breath since.

I resisted an urge to shout, “Put your wife on the phone, Gus!” This could be anything from muscle spasm to heart attack. The first opportunity to do something had passed. Now we play catch up.

Call me SARS-CoV-2.

Short for severe acute respiratory syndrome coronavirus 2. I’m responsible for the current pandemic: COVID-19 (Corona Virus Disease 2019). I plan to stay.

My animal hosts are bats and/or pangolins; my country of origin, China. Please don’t call me batty or Chinese. It’s neither funny nor productive.

I have hundreds of relatives, mostly in animal reservoirs. I’m the 7th one to infect humans. But it’s likely you’ve been infected by any of my four pesky, but mild-mannered cousins, who are major causes of common colds (5% to 30%).

People, take a deep breath, please.

Yes, there are confirmed cases of COVID-19, the coronavirus, in Cuyahoga County.

First, the most important message about respiratory infections: If you’re sick, stay home. Call your doctor if needed.

Currently, we have no treatment or vaccines for it.

I want to bring you up to speed on three important preventative measures.

Hand wash or sanitizer?

Hand washing, done properly and regularly, removes germs and chemicals very well.

If soap and water aren’t available, hand sanitizer (at least 60% alcohol) works for most microbes, including corona and flu viruses. Because alcohol kills by contact, make sure your hands are not too dirty or oily.

Rex, Sam’s hairless cat – excuse me, Sphynx – has a thing for coffee. His motto: I came, I saw, I spilled it. He soaks keyboards, knocks over furniture – not thought possible given his weight.

I saw him leap from the kitchen counter, bounce off an unsuspecting guest’s shoulder and land atop the cabinets.

Worshipped, he’s the official family screen saver, dinner conversation – “You won’t believe what the cat did today…” – and snuggler.

All’s well in Catsville, except one minor inconvenience: Sam’s cat allergy.

At 18, I did a diet that worked splendidly. I’ll share, but you’ll roll your eyes.

Dieting is our culture. One in two teenage girls tries dieting, including one-third with normal weight. Boys: one in four.

Dieting is also a necessity. Experts predict one in five teens today will be obese by age 35. Obesity affects 40 percent of adults.

The good news is structured diet and exercise can mitigate most complications associated with obesity.

The first question most people ask: Which diet works best?

Walk in my shoes for a moment, please.

I’m a mother and a primary care physician. I aim to give my kids and my patients the best advice for living a long and healthy life.

When it comes to this job, I’m a winged unicorn of optimism. I believe an important fact: Experts estimate genetics contributes to 30% of our risk of early death.

That means longevity is a whopping 70%, you-can-make-it-happen modifiable. And the responsibility for making it happen falls on my right shoulder blade (yup, that’s where I feel the burn when things don’t work out).

In 2006, a miracle vaccine became a reality. Targeting human papillomavirus (HPV), this vaccine only not prevents infections but also prevents cancers.

HPV is ubiquitous, it lives on our skin. About 170 strains have been identified, 40 can make us sick.

The vaccine protects against the most malign strains, the culprits of most cervical cancer, genital warts, genital and throat cancers. HPV is the most common sexually transmitted disease.

In 1962, Calvin Stevens, a chemistry professor at Wayne State University, was looking for a sedative that could also relieve pain. He discovered ketamine.

It delivered.

First tested in the Vietnam War, ketamine, fast-acting and relatively safe, became the battlefield anesthetic of choice. Widely used in humans and animals, ketamine’s on the World Health Organization's Model List of Essential Medicines.

But in the 1970s, ketamine took a left turn and hit the club scene. Its “out of body” and “hearing angels” rep, and vile use as a rape drug, prompted the DEA to slap on a Schedule III controlled substance label.

In three years of writing this health column, I’ve made mistakes.

In my Oct. 15, 2019, column “Bacon and red meat: A hard 'no'?” I said, quoting from a 2018 JAMA article, that fish oil supplements were not helpful. But I failed to note a later study which showed that high-dose fish oil (4g daily) reduces cardiovascular events and death among a unique group of people – those with high triglycerides (a type of cholesterol) and at risk for heart diseases. The result of a similar study is about to come out. A correction is in order.

Recently I came across a study, the result so fantastic that my first reaction was – it’s too good to be true.

But curiosity got the better of me. I tracked down the article and read it. (It was either that or rake leaves.)

Published in the October issue of the European Heart Journal, the study has a pretty name: Hygia (the Greek goddess of health) Chronotherapy Trial. And a simple goal: Compare health outcomes between taking blood pressure (BP) medications at bedtime and in the morning. Drugs are once-daily.

The researchers followed tens of thousands of people for about six years. Astoundingly, when compared to morning-pill-poppers, bedtime-pill-poppers had half the rate of heart attacks, strokes and deaths.

On Oct. 1, the Annals of Internal Medicine published several studies on the health consequences of consuming red and processed meat. Their conclusion: Cutting down on red meat did nothing to smaller-ish nothing to improve our health.

The scientific and public health sectors are incensed.

The World Health Organization lists processed meat as a carcinogen, red meat as a potential carcinogen. The 2015-2020 U.S. Dietary Guidelines recommend limiting red meat to one, 3 ounce serving per week (steak the size of a deck of cards). The Harvard School of Public Health pitched a fit. Their 2012 study showed each extra daily serving of processed meat could increase the risk of death by 20 percent.

Sept. 26, 2019: The Centers for Disease Control and Prevention (CDC) just updated vaping-related lung injury to 805 cases, 12 confirmed deaths. When I started this article a few days ago, the count was 503, 7 confirmed deaths.

By the time you’re reading this article, I’m guessing it’ll be past a thousand.

On Sept. 20, a 59-year-old Beachwood man became the first confirmed case in Cuyahoga County.

What’s gone wrong? Vaping – the harmless steam smokers use to quit smoking – has been around for over a decade.

The FDA is hunting for culprits.

I'd like to share three simple steps which can significantly reduce your drug costs. No, they don’t work all the time (I don’t know what to do with drugs like Lantus, a long-acting insulin, either). But when they do work – oh, you’re gonna love me.

First, let’s debunk some myths.

1. Only one drug works.
2. Insurance offers the cheapest option.
3. Doctors know drug prices.

All false.

Why bother with shingles?

Because 1 in 3 people will get shingles. I did.

It’s caused by the chicken pox virus. The first time you’re infected, you get a diffuse rash – that’s chicken pox (varicella). The virus then sleeps in nerve endings (no, it never leaves). With age, weakening immunity or idiopathy (medical term for "worst-luck-ever"), the virus wakes up and causes a localized rash – that’s shingles (herpes zoster).

Thus its fancy-pants name – varicella-zoster virus (VZV).

We have an emerging liver problem. Better you hear from me first.

Fatty liver, or non-alcohol fatty liver disease (NAFLD), is the main reason I encounter mildly abnormal liver blood tests these days. Obesity is the most common risk factor.

Worldwide, 25% of people have fatty liver; in the overweight population, it's three in four. Another scary thing: It doesn’t spare children. In the general pediatric population, 3% to 10% of children have fatty liver; the incidence increases to 80% in overweight children.

What’s fatty liver?

Our liver filters blood – detoxifies bad stuff and synthesizes good stuff – and does everything under the sun to keep us out of trouble. Plus, it stores fat.

Piper, 54, plays piano, walks for exercise. Doesn’t own a TV!

You can’t tell by looking at her how knee osteoarthritis (the wear-and-tear kind) dictates even minor movements. In her 20s, Piper played wallyball (it’s volleyball on steroids), diving and bouncing off the walls. Today, rising from a chair, her knees hurt. After a long plane ride, they feel like they’d “explode.”

She takes sulindac (an NSAID, like ibuprofen) daily. This spring, she got a hyaluronic-acid knee injection. Like a miracle, she could walk up and down stairs pain-free. But in two to three weeks, the pain returned.

In a New York Times interview last year, Elon Musk, CEO of Tesla/SpaceX/whatever, said he works 120 hours a week and pulls all-nighters. As a very, very minor stockholder, I’m struck by his sacrifice, discipline, super-human productivity. But as a doctor, none of this is OK.

Why sleep?

Our body is a machine, programmed to shut down daily for maintenance. The younger you are, the more physical you are, the more sleep you need. Sleep is more than a La La Land where your dreams build a human colony on Mars. During sleep, your body and brain work tirelessly to connect, reconnect, grow, learn, repair, regenerate, remove toxins, ready to reboot for a new dawn. Sleep is your built-in fountain of youth.

BB, 47, is a long-term diabetic who needs pills and insulin injections. She’s been off insulin for a year – just can’t afford it. Her eyes are blurred; she feels irritable. I refill her meds, switch her insulin, add metformin (more about that later), and send her out with my fingers crossed.

Two weeks later I see her. ”How’s the glucose?”

Better. Her numbers make me smile.

But she’s not smiling. “I gained eight pounds in two weeks,” BB said. “I can’t fit into my size 4 pants.”

The irony of weight gain in diabetic management is not lost on me. Excess weight exacerbates insulin resistance – the last thing a diabetic needs.

But it doesn’t have to be that way.

Ever wonder if you needed a test or procedure?

“Should I start another pill for my diabetes?” “Do I need an MRI for my joint pain?”

You’d be right questioning the decision 20% of the time. Here’s why.

In a national survey, doctors estimated 20% of overall medical care was unnecessary, including one in five prescription drugs, one in four tests, one in 10 procedures. The two major reasons they give: fear of malpractice and patient pressure/request.

Years ago, Jim, age 50, had back surgery. Two lumbar vertebrae fused, screws placed. Two weeks ago, severe back pain shot down his left knee, knocked him to the floor, curled him into a fetal position.

He’s been to the ER five times. Doctors think it’s his hip, groin or back. He’s frustrated. Last night, for his pain, he bought a jar of CBD (cannabidiol) cream from his masseuse. “This stuff’s flying off the shelf,” she told him.

What’s CBD oil?

Marijuana plants contain hundreds of chemicals. The two big stars: CBD and THC (tetrahydrocannabinol). CBD does not produce a “high,” unlike THC.

My father was a 3-pack-a-day smoker. Started in the military. During the Chinese Civil War, he was conscripted to an island outpost, fighting the communists. Daily the two sides exchanged fire. Nightly, frogmen – nicknamed “water ghosts” – ambushed and killed patrols, cutting their ears off for tally. “Brothers killing brothers,” Father said. “You smoke or go insane.”

My mother tells a different story. The active war ended. In 1964, the U.S. Surgeon General first warned: "Smoking causes cancer." His words reverberated, reaching remote corners of the world, except, apparently, my dad’s ears. “Everybody quit but him.” She was not sympathetic.

At 62, he had a heart attack. After a five-vessel bypass, a grim-faced surgeon informed Mother that while the heart surgery was a success, he feared the worst. Dad’s lungs?

For the first time, we learned that he had advanced emphysema.

Last week I gave a short talk on dementia.

The church was set back from boisterous Detroit Road. In a sunlit, spacious room, home-made dishes packed two tables. The air was casual, familiar, coffee-warm. In the snow-capped meditation garden, I spotted half a dozen wild turkeys.

In my Sunday best, I was smart, gracious, gregarious and blissfully forgot an important message.

Here’s my talk, again, turkeys and punchline included.

Years ago, Deb, my neighbor, found a litter of kittens. The mother, a ropey black-and-white feral, was a neighborhood darling. “A working girl,” Deb said proudly, as she kept garden mice in check.

We called the Cleveland Animal Protective League for help. “The kittens need to be socialized, neutered and adopted; the mother, spayed and released,” we were told.

I’m cat-allergy exhibit A-Z: rash, runny nose, itchy eyes, coughing, sneezing, wheezing. After visiting cat homes, it takes me days to breathe normally. Deb handed me a kitten, the silky hair, wicked pupils, electrifying purring. In seconds, I was kitten-hooked.

Bertie, 47, went for a regular checkup. Her gynecologist, who’d known her for 18 years and delivered her two kids, walked her to the mammography suite after the visit.

“No appointments. Took me in right away. Such personal care,” she said cheerfully.

I had questions for my good friend. But first, does Bertie get a say in this?

To most of us, breast cancer has a face – friends, family, colleagues, ourselves. An estimated 41,400 people (40,920 women and 480 men) will die from breast cancer this year. Every pink ribbon renders a wrenching story.

The midwife consulted me on a genital ulcer. Popped up weeks ago, more irritating than painful.

I saw the ulcer, clean-scooped like a shallow half-teaspoon. I knew what it was. Hesitated. Because I couldn’t recall the last time I’d seen a case.

The next day, a simple blood test confirmed my suspicion. Among a dozen possibilities, it was indeed syphilis.

The old nemesis. For centuries, it was blamed for the brutality, paranoia, madness and dementia of the powerful and the famous: Henry VIII, Ivan the Terrible, Oscar Wilde, Friedrich Nietzsche, Al Capone.

My husband’s family is Scottish Canadian. Frugal, reserved, hard-working, tough as the granite they farmed in Eastern Ontario. Thrive on dry humor.  

One thing they do with abandon: Christmas dinner. Every year, we cross the Peace Bridge to his family home, to herb-studded roast beef, glazed ham, bricks of cranberry jelly and fruit cakes, strawberry trifle in brandy and sherry, egg nog, Yule Log. And my absolute favorite: Yorkshire pudding (egg batter baked in beef drippings).  

It’s a hard day’s night of eating – and heartburn.  

Heartburn presents differently in different people: burn, bile taste, hoarseness, lump in mid-throat, difficulty swallowing, coughing, worsening asthma or nothing.

My brain free-associates: my mom reminds me of Costco. Texting while driving: natural selection. Vladimir Putin: mutating Swine Flu.

But when people see me, their brains wander to exercise.

Colleen: “Want to come over for dinner? Five-ish? I should start swimming again.”

Liz: “Your dog is at my house again. No, I didn’t give her all the leftover chicken, just half. By the way, I did four miles on the treadmill today. On an incline.”

A stranger walking his dog: “That’s a pile of leaves you got there. I need to lift weights.”

I don’t know what it is about my face that drives people to exercise. But here I am, again, talking about the new exercise guidelines. Before you toss me to the same-old health-advice boneyard, let me tell you some wonderful news.

Pat, 60, is a home assistant. She can take pain. She had a root canal without anesthetics. A nerve conduction study using needles and electric shocks was a piece of cake, that is, compared to her fibromyalgia.

As a child, Pat had “sinus headaches”; as a teen, painful periods. One time she ended up in the ER for foot pain and swelling. The ER doctor said her “muscles are more sensitive than others.” This explanation stuck because she thought it made a lot of sense.

He wants to be referred to as a member of AA.

At 49, he sports a Paul Bunyan beard. He has blue eyes, is calm and kind. He tells a story how years ago, he drove out of his driveway and woke up a killer.

He first got drunk at 13, typical of most alcoholics he knows.

In high school, he drank on weekends. At 18, he enlisted in the Marine Corps. In Desert Storm, he worked two days on, two days off and every other weekend. The off-days were one big party.

For this article, I diligently researched incontinence jokes, but none put me in stitches. So I'll lay it out straight.

Women lose urine. And it’s not an “old-woman’s” thing. One-third of women between the ages of 30 and 50 report urinary incontinence.

If you can handle the occasional accidents and still find pee jokes funny, then do what you’ve always done. But if you sleep poorly, have tripped and fallen while rushing to restrooms, or find these accidents annoying, depressing, embarrassing and activity-limiting – know there’s help.

After Wednesday evening swim practice, I caught up with Sue leaving the locker room. She led our lane today. At a brutal pace.

“My grandson, one year old already,” Sue flashed a picture of a baby Buddha on her phone.

“Looks nothing like you,” I said honestly.

“Yeah,” Beaming still. “What you up to?”  

“Thinking about alcohol consumption,” I said, walking faster to keep up.

“Good idea.” In the parking lot, Sue waved her key fob like a wand. A white sedan blinked and blipped in response.

“The WHO reports alcohol causes one in 20 deaths worldwide,” I said, tailing her to the car.

“Who reported on what now?”

“Not who, Sue. W-H-O – the World Health Organization.”

Cruising Sanibel Island on a single-speed beach bike, my neighbor Sharon, then 52, did a “Flintstone front brake” (remember how Fred Flintstone stopped his stone car by dragging his heels? Yup, that one) and broke her right foot.

Her doctor frowned. “Something’s off,” he told her. A bone density study later, she was diagnosed with osteoporosis.

Two years ago, an infection caused a dental implant to fall off. Sharon became alarmed when two dentists refused to operate on her because she’d been on “antiresorptive medications” for osteoporosis for 12 years.

Sharon – and four out of 10 white females in the U.S. – will experience a spine, hip or wrist fracture sometime in their lifetimes; the rate is 13 percent for white male per the Centers for Disease Control and Prevention.

Our bones are a dynamic organ, like a house that’s constantly been remodeled.

Bone loss is natural aging. But when the demolition crew far outpaces the construction crew, bones thin critically, liable to fracture with minor injuries – it’s osteoporotic.   

Osteoporosis is diagnosed based on a bone density study (DXA). The U.S. Preventive Services Task Force recommends screening women once at age 65. Earlier if they have additional risk factors: parents with hip fractures, smoking, weight less than 127 pounds, excessive drinking, among others.

I want to talk about ways that can add 10 years – or more – to your life expectancy. Not just any years, active years – physically and mentally productive ones.

But before you light an extra candle for me, I have a confession to make.  

I like numbers.

Science is about hard, reproducible numbers. Yet in medicine, our numbers come from studies that are based on 5 million people – or 25. Some data, like the benefit of aspirin after heart attacks, measles and polio vaccines, and eating your greens, are Category-5-hurricane proof; others, less so.

It’s tough sending kids off to college.

Sure, my kids, like yours, never get in trouble. They exercise an hour a day, limit Fortnite/video games to two hours, put schoolwork before network, eat broccoli before brownies. Still, I believe they need certain facts straight. So when one of them says, “Hypothetically, if one …,” they can help each other, know what’s available, where to turn.

In launching my second child towards college, I keep these health issues in my peripheral vision.

Allen, 56, has a decision to make. Should he start prostate cancer screening? He knows two prostate cancer survivors.

His father was diagnosed with prostate cancer, young – in his 50s. Opting out of treatment on his doctor’s advice, he died at age 84, of Alzheimer’s complications.  

His friend Kevin, 73, was diagnosed at 53. He underwent prostatectomy, radiation and followed up diligently. Though he felt fine, last year a workup showed bone metastasis to his ribs, shoulder and hip.

Prostate cancer is very common.

Alex, 18, is home from college. He’s studying to be a respiratory therapist. For his summer job, he bikes 16 miles from Avon to North Olmsted and back, leaving at 5:10 a.m. every morning. He’s affable, athletic and “not unique.” Most remarkable, he’s been a diabetic since age 4 – and managed to keep nearly perfect glucose control.

Alex’s body makes no insulin. For every meal and activity, he calculates his carb and insulin needs. He thinks nothing of it. But in the past few years, a problem has crept up on him, and eight million other insulin-dependent diabetics in the U.S.

From 2002 to 2013, the price of insulin tripled (a vial of insulin went from $231 to $736). Who knows why. A survey shows almost half of diabetics skip needed medical care because they can’t afford it.

I buy organic products, but inconsistently. I buy organic milk, but not organic yogurt or butter. I track the Dirty Dozen, but balk at the cost of organic strawberries, and how fast they rot. It’s fair to ask how do organic foods, a palmy 46-billion-dollar industry, actually benefit us?

Good Earth policy?

Pouring less chemicals into the soil and water is a good thing. But massive imports of organic produce from overseas creates pollution. It makes equally good sense to buy local produce, and reduce food waste.

Better nutrition?

The American Academy of Pediatrics (AAP) states organic food doesn’t provide “any meaningful nutritional benefits or deficits” over conventionally grown foods. An apple is an apple is an apple. With or without the organic wink, potato chips will – always and above all – be a junk food.

Anne’s migraines started in her 20s. During an evaluation as a fledgling flight attendant, she developed a blinding headache during final descent and threw up all over her supervisor. That was the memory of her first migraine.

One in five women (most common between ages 18 and 44) suffers migraines – twice the frequency of men.  

Doctors tackle migraines using two lines of attack: mitigate and prevent. To mitigate acute pain, many drugs (or combinations) work. Two stand out: fast-acting NSAIDS (ibuprofen, naproxen sodium) and triptans.  

Most migraineurs have their own cocktails. The problem I see often is taking drugs too late.