James Marroquin

Over the past few weeks in my clinical practice I’ve had many conversations with patients about Covid boosters. Here’s some basic information to help make sense of it all.

What is Covid vaccine booster?

A Covid vaccine booster is simply an additional shot of the same vaccine. For example, if your first covid two shots were Pfizer, a booster is getting a third Pfizer shot. At this point, boosters are not a different strength or formulation of the vaccines.

Why are boosters being given?

For two reasons. 

First, some people with weakened immune systems might not have achieved a sufficient immune response to their first two Covid shots. Common examples of this situation are people on medicines to suppress their immune system to treat autoimmune diseases or to prevent rejection of an organ transplant. For such individuals, receiving a third shot will improve their immune system’s capacity to respond to Covid if they encounter it. 

The second reason for boosters is to restore immune protection from Covid that may wane over time. Thus far the biggest concern about waning protection is with the Pfizer vaccine. CDC data from September showed that beyond 120 days after the second dose of Pfizer, effectiveness of protection from hospitalization fell from 91 percent down to 77 percent. A study from Israel showed that among people 60 years or older who had been vaccinated 5 months earlier, those who had received a third shot of Pfizer were 19.5 times less likely to have severe Covid than those who had only received two shots.  

Protection from the Moderna vaccine seems to be waning less than Pfizer. The same CDC data that showed decreasing protection from Pfizer over time showed no such diminishment with Moderna. It found that Moderna vaccine continues be 92 percent effective against hospitalization even four months after the second shot.

Who should receive a booster?

There are two categories of people for whom the Centers for Disease Control (CDC) recommends a booster.

The first category are people with moderately or severely weakened immune systems. This includes people taking medicines that suppress their immune system to treat cancer or autoimmune conditions or to prevent rejection of a transplanted organ. It also includes people with conditions that impair the immune system such as certain cancers, immunodeficiencies, or advanced HIV. 

If you have a weakened immune system, you should receive a third shot of your Pfizer or Moderna vaccine at least 28 days after your second shot. The CDC did not make a recommendation about whether immunosuppressed people who received Johnson and Johnson should get an additional shot. But based on the recommendation of trustworthy experts, I recommend that immunosuppressed people who got the J&J get a booster with Pfizer, Moderna, or J&J.

The second category are certain individuals who received their second Pfizer shot over 6 months ago.

-If you are 65 years or older and received your second Pfizer shot over 6 months ago, you should get a Pfizer booster.

-If you are 18 years and older and have a health condition such as diabetes or heart disease, you are eligible to receive a third dose of Pfizer vaccine 6 months after your second one.

-If you are 18 years and older and live or work in a setting that puts you at risk of getting Covid, you are eligible to receive a third dose of Pfizer vaccine 6 months after your second one.  This category includes people who live in long-term care settings, along with teachers, grocery store workers, and health care workers. 

Should I get a booster if I received the Moderna vaccine? 

Only if your immune system is suppressed by a medicine or a health condition according to current CDC recommendations. But stay tuned because the FDA will be meeting on October 14 to discuss Moderna boosters and on October 15 to discuss J&J boosters.

Where should we get our Covid booster shot?

The simplest way is by making an appointment online with a pharmacy in your area. When you sign up for the booster, you can indicate you are in one of the categories that makes you eligible.

Can I get my flu shot and Covid booster at the same time?

Yes. The CDC states it is safe to do so.

Researchers in Hong Kong recently conducted a study of patients who received bariatric surgery, a procedure to lose weight. 5 years after the surgery, they compared patients who had undergone bariatric surgery to a control group of obese patients who had never undergone bariatric surgery. The study found that glucose and cholesterol levels, as well as blood pressure were significantly better in the group of people who had undergone bariatric surgery.

Reference

Wu T, Wong SKH, Law BTT, et al. Five‐year effectiveness of bariatric surgery on disease remission, weight loss, and changes of metabolic parameters in obese patients with type 2 diabetes: A population‐based propensity score‐matched cohort study [published ahead of print January 7, 2020]. Diabetes Metab Res Rev. doi:10.1002/dmrr.3236

In 1959, a cardiologist named Meyer Friedman began publishing an influential series of studies suggesting people with certain personality traits have a higher risk of developing heart disease. Individuals with what he called a Type A personality were especially preoccupied with time. Type A’s displayed a perpetual compulsion to quickly achieve as much as possible and became exasperated with obstacles to their goals.  In a 1959 study published in the Journal of the American Medical Association, Friedman found the prevalence of coronary artery disease was significantly higher in men with Type A personalities than in their otherwise similar peers.  Soon Type A became a popular term in everyday speech.

 

Physicians before Friedman also recognized the connection between the mind and heart. William Harvey, who is credited with discovering the circulatory system, wrote in 1628 that “every affection of the mind that is attended with pain or pleasure, hope or fear, is the cause of agitation whose influence extends to the heart.” And William Osler, who is considered the father of American medicine described the typical individual who develops coronary artery disease as a “keen and ambitious man, the indicator of whose engines are set a ‘full speed ahead.’ “

 

This month the medical journal The Lancet published research suggesting how emotional stress might cause cardiovascular disease. The study used brain imaging to measure activity in a part of the brain called the amygdala.  The amygdala is thought to be responsible for triggering the “fight or flight” response when we encounter danger.  Researchers found that higher activity in the amygdala was associated with increased activity in the bone marrow, inflammation in arteries, and bad cardiovascular outcomes such as heart attacks. The study’s authors hypothesize that stress activates the amygdala, which tells the bone marrow to produce cells that cause inflammation in arteries, which in turn raises the risk for heart attacks and strokes.

 

In a discussion of the study, its authors suggest that clinicians “could reasonably consider the possibility that alleviation of stress might result in benefits to the cardiovascular system” and that “eventually, chronic stress could be treated as an important risk factor for cardiovascular disease.”  Here are some common sense strategies for managing stress.

 

Get enough sleep: There is abundant evidence that sleep enables people to function at a higher level and better cope with stress. Overwhelming problems sometimes become manageable after a good night’s sleep.

Exercise: Exercise increases chemicals called endorphins that reduce pain and trigger positive feelings. It also improves sleep and lowers blood pressure.

Connect with people: Cultivating a strong network of family, friends, and colleagues will provide people to turn to when you need help. When problems happen, others can provide perspective, solutions, and encouragement.

Help other people: Caring for people in worse situations than yours can put your problems into perspective and promote gratitude for what you have. Knowing you’ve made a positive impact in somebody else’s life can also increase self-esteem.

Keep a gratitude journal: At the end of each day, write down what you are grateful for.

Avoid overcommitting: Having more obligations than you are capable of fulfilling predictably leads to feeling overwhelmed. Before committing to something, make sure you have the time, energy, and motivation to follow through. If you are already overcommitted, consider what commitments you might end.

Take breaks: Reflect upon what activities make you happy and recharged. Regularly make time to do them.

Meditate: According to the NIH’s National Center for Complementary and Integrative Health “some research suggests practicing meditation may lower blood pressure, symptoms of irritable bowel syndrome, anxiety, depression, and insomnia.” During meditation, you focus your attention and set aside the stream of jumbled thoughts that may be causing stress. One simple form of meditation is focusing on your breath as you inhale and exhale. As thoughts inevitably enter your consciousness, gently turn your attention back to your breath. Here is link to a website with instruction on how to meditate. http://www.mindful.org/mindfulness-how-to-do-it/

 

You can read the abstract to The Lancet study on stress and heart disease here. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31714-7/abstract

I just finished an inspiring book called Waking the Spirit. The author Andrew Schulman is a musician who nearly died in July, 2009. At age 57, a CT scan revealed what appeared to be pancreatic cancer. After undergoing an operation to remove the cancer,  the surgeon informed Schulman’s wife Wendy that the mass was found to be benign. But soon after receiving this good news, Schulman suddenly went into cardiac arrest. A blood transfusion had caused anaphylactic shock. On the 3rd day, Schulman was in the intensive care unit (ICU), Wendy began to wonder if her husband had lost his will to live. She told the ICU physician “if there’s one thing I know about my husband, it’s that he loves music more than anything else. It’s his passion. . . At this point music is the only thing that could get through to him.” With the physician’s permission, she inserted one earbud into her right ear and the other earbud into Schulman’s left ear. She then played his favorite piece, Johann Sebastian Bach’s St. Matthew Passion. Schulman writes that

Bach’s music began spinning into our ears. Ninety seconds after the flutes and oboes began playing that mesmerizing melody, slowly lifting ever upward, the voices entered, floating heavenward ‘Come, ye daughters, help me lament, Behold? Whom? The Bridegroom. Behold him! How? Like a lamb. Behold! What? Behold his patience. Behold!’ As the chorus sang, my bride was sitting with her face inches from her bridegroom, sharing the music that was bonding us together in the darkest moment of our lives. Bach’s masterpiece, some of the most glorious music ever written, tells a story centered on the most basic of human emotions: love, hate, betrayal, and redemption. . . . The music reached me.

Soon afterward Schulman’s vital signs began to improve. By the next day, the ICU physician felt that he was “out of the woods.” The nurses who cared for him later called it the St. Matthew Miracle.

After recovering, Schulman was inspired to use his musical talents to help other people likewise afflicted by illness. Six months after his own hospitalization, he returned to Beth Israel Medical Center to play the guitar for patients in the ICU. Soon he became a fixture there, integrating his own mode of healing with the rest of the care team.

The rest of Waking the Spirit consists of stories in which Schulman’s music played an important role in patients’ recoveries. Along the way, I learned more about the history of music in medicine and field of music therapy. In the end, Schulman’s service to others generated his own recovery. Due to the brain injury from his cardiac arrest, Schulman discovered that after his hospitalization, he could no longer memorize music. Then one day, he “awoke to a strange sensation in my head. It literally felt as if my brain was tingling.” He suddenly began to be able to play music by memory again. When Schulman presented his case to a neuroscientist, he was told his work in the ICU was the best possible type of rehabilitation for his injured brain. The researcher told him that

I think by committing yourself to playing in the ICU you forced your brain to rewire. The consistent and deliberate exercise every day of what you had to do to become what you call a medical musician, the constant auditory attention, the intense thinking as you watched the patients’ responses and the changes, or lack of changes, in the vital signs monitors over their beds, your constant awareness of all the sounds surrounding you so you could be attuned to other needs should an emergency arise, and, very importantly, making sure all your fine motor functions were at their best to guide you in making soothing and healing music for your patients–all these factors combined to force different parts of your brain to make new connections to each other. . . You did repair your own brain and gave yourself an upgrade at the same time.

Schulman writes that “I’d gone back to the ICU to avoid survivor’s guild and to give thanks for a great gift after having my life saved. I stayed because I found I loved this new experience of helping and healing others through music. I wound up healing myself as well.”

Here is a link to Waking the Spirit if you’d like to buy it or check it out at the library. https://www.kirkusreviews.com/book-reviews/andrew-schulman/waking-the-spirit/

 

 

It’s been a while since I’ve added anything to this blog. Teaching, medical practice, and family have left little time to write. But I’m finding that I miss doing so. So my modest goal is to regularly share interesting health stories with brief introductions.

Insomnia continues to be common problem that is challenging to treat. Medications like Ambien are often not very effective. Moreover, people who take them may become dependent upon them and develop side effects. An approach called cognitive behavioral therapy (CBT) is currently the recommended intervention for people suffering from insomnia. CBT trains people to use techniques that address mental factors that are associated with insomnia, such as a racing mind and worry about sleep. It also helps people establish habits, such as a regular night-time ritual, that are conducive to getting sound sleep.

The main limitation of CBT is that it takes time and money to see a therapist to provide it. And that is if you are able to find one of the limited number of therapists trained to apply CBT for people experiencing insomnia. That’s why it was good news that a recent study in the journal JAMA Psychiatry showed that an online program enabled people to resolve their insomnia through CBT without having to see a therapist.

300 participants were randomized for six weeks to either an online CBT program called SHUTi or to online patient education about improving sleep. After 1 year, 57% people who did the SHUTi CBT program no longer experienced insomnia. And more than seven out of 10 SHUTi participants showed improvement in their sleep.

The SHUTi program costs $135 to $156 according to the website here. http://www.myshuti.com

I plan to recommend the program to my patients experiencing insomnia and look forward to their feedback.  The JAMA Psychiatry article and a commentary on it in the same issue are linked below.

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2589161

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2589158

 

 

 

 

 

 

 

 

 

Almost everyday in the clinic patients ask for my take on recent studies raising concerns about Proton Pump Inhibitors (PPIs) such as Prilosec, Prevacid, and Nexium. I wrote a short article on the topic you can access through the link here

Heartburn article

 

Is it necessary to be fasting when you have labs drawn? The dogmatic answer has long been yes, creating an uncomfortable, inconvenient situation for patients.  They either have to return to the clinic a second time for labs or else uncomfortably fast until their doctor’s appointment. But a recent study published in JAMA Internal Medicine suggests that fasting likely isn’t necessary after all.

The study’s author looked at 3 meta-analyses (or collection of studies) and found the following:

-There wasn’t a significant difference in the cholesterol levels whether people fasted or not.

-Fasting and non-fasting lipid levels had the same predictive power for whether people would have an adverse cardiac event such as a heart attack.

For these reasons, clinical practice guidelines have changed to endorse non-fasting labs in most circumstances. The main situation when a person needs to do a fasting test is when the level of triglycerides (a type of bad cholesterol) is above 400. In this unusual circumstance, the lab should be repeated on a fasting basis.

This study’s conclusion, that people don’t need to usually fast for their labs, fits my practice. It’s news many patients will be glad to hear.

The study’s conclusions are linked here:

Article

 

In an interesting essay, Dr. Marvin Moser writes that “as late as the 1950s, elevated blood pressure was considered by many experts to be necessary for adequate perfusion of vital organs.”[1] The eminent American cardiologist Paul Dudley White suggested in 1937 that “hypertension may be an important compensatory mechanism that we should not tamper with even if we were certain we could control it.”

 

In 1937, 54 year old Franklin Roosevelt’s blood pressure was 162/98. But in accordance with medical opinion of the time, his personal physician did not prescribe medication to lower it. By 1941, a reading of 188/105 was recorded and finally a barbiturate and massages were prescribed. In 1944, a cardiologist examined Roosevelt and was appalled at what he found. Many of the now well-understood results of untreated high blood pressure were present. A chest x-ray showed fluid in his lungs and an enlarged heart from congestive heart failure. His urine showed protein due to kidney damage. The cardiologist recommended digitalis (a medication to treat heart failure) and a low salt diet. By the time Roosevelt attended the Yalta conference his blood pressure was recorded at 260/150. Seeing Roosevelt at the conference, Winston Churchill’s physician Lord Moran noted that “Roosevelt looked straight ahead with his mouth open as if he were not taking things in.” In 1945, while sitting for a portrait, Roosevelt complained of a headache and suddenly lost consciousness. His blood pressure was measured at over 300/190 and he was later found to have a cerebral hemorrhage.

 

In the late 1950s, thiazide diuretics were identified as the first well tolerated and effective medication for treating high blood pressure (hypertension). In the 1960s and 1970s, new blood pressure medications became available and a consensus on the importance of treating hypertension solidified.

 

It is now clear that treating hypertension early can prevent heart attacks and strokes, as well as heart and kidney failure. But until recently, there has been debate about how low we should aim to get the pressure. In November of this year, a landmark study called SPRINT (Systolic Pressure Intervention Trial) offered tremendous insight into this issue. The study took people 50 years and older with hypertension and randomized them to aim for a systolic blood pressure of either a) less than 140 or b) less than 120. The study was stopped earlier after 3.3 years when it became clear that the people with tighter blood pressure control were experiencing clear benefits. There were significantly less bad outcomes such as heart attacks, congestive heart failure, strokes, and death in the group with the lower blood pressure.

 

My takeaway from this study is to aim for a systolic blood pressure closer to 120 in patients I treat for hypertension. The trial provides firm evidence that doing so lowers the risk of having a heart attack, stroke, and congestive heart failure. Nonetheless, a person’s individual situation must be taken into account. As people age, the ability to compensate when standing up can be compromised, making them prone to fall if blood pressure is lowered too aggressively. In addition, decreasing blood pressure below a certain level in some people can cause fatigue and a poor quality of life. It takes more medications to achieve a lower blood pressure and these can sometimes have side effects. So patients and their doctors should work together to find a combination of medications and behaviors (such as exercise and diet) that fits their unique situations.

[1] Historical Perspectives on the Management of Hypertension

Although I’m not a neurologist, I’ve seen firsthand how devastating Parkinson’s Disease can be.  Parkinson’s does not just consist in tremors. It is a progressive neurological disorder than can ultimately take away essential capacities such as walking, writing, and swallowing.  Research into Parkinson’s has yielded impressive therapeutic interventions such as deep brain stimulation.  Nonetheless, the human brain is the most complicated structure in the known universe, so that our current understanding and treatment of Parkinson’s is limited.

I am moved by the courage people with Parkinson’s, as well as their loved ones, display in living with this disease.  CBS Sunday Morning recently had a segment that was particularly inspiring.  CBS correspond Leslie Stahl reports on how her husband and other people with Parkinson’s have found some hope and healing in an exercise program that uses boxing techniques.  In the segment, a researcher says a  study of the program showed it offers people with Parkinson’s genuine clinical benefit.  I highly recommend watching the segment  linked below (it starts with an advertisement that quickly passes).  Whatever challenges you face might seem less daunting after witnessing such bravery.

Here’s an article I wrote on a reproductive method that uses DNA from three different people to prevent mitochondrial diseases. The technique raises challenging ethical questions.

http://www.worldmag.com/2015/10/the_nuclear_option