REPORTS OF new drugs, new tests and new do’s and don’ts for combating Alzheimer’s disease (AD) via both prevention and treatment keep raising new hopes. Of more than five million Americans age 65 and older living with Alzheimer’s dementia in 2020, two-thirds are women.
The experimental drug aducanumab, which would be the first drug approved to slow deterioration in brain function, is currently under review by the FDA, with a final decision expected by March, although its advisory committee in early November advised against approval.
And about to be widely available is a blood test that assesses beta-amyloid plaques, considered early signs of AD pathology, in the brains of people experiencing new memory loss, according to the Alzheimer’s Drug Discovery Foundation. The early-detection test could help individuals begin exploring treatment options and provide a “reliable, accessible and affordable biomarker” for AD research.
The test’s developer, C2N Diagnostics, is also working on tests for other AD markers, such as tau proteins that form tangles in the brain—possibly the best predictor of future brain atrophy, according to PET (positron emission tomography) scans. PET scans, along with spinal fluid tests, are current gold standards for AD assessment—but are expensive, not covered by Medicare, and in the latter case, invasive.
Under do’s and don’ts for forestalling AD is “the Beers List” —drugs determined by Beers criteria (developed by Dr. M.H. Beers in 1991) to be risky for older adults—published by the American Geriatrics Society. In two large population studies, both benzodiazepines and anticholinergics, including medications for allergy, depression, high blood pressure and incontinence, raised the risk of dementia in people who used them for longer than a few months. While these drugs have side effects that include “confusion, clouded thinking and memory lapses,” studies have not yet proved that the drugs cause dementia, cautions the Harvard Health Letter. One reason: acetylcholine, the neurotransmitter in the brain that is both reduced by these drugs and involved in learning and the formation of new memories, declines naturally with age.
Nonetheless, researchers are eyeing the sage plant, known to affect amyloid buildup as well as cholinergic activity in the brain. In short-term studies with AD patients, sage supplements have provided some cognitive enhancement and brain protection. But researchers caution about the need for longer term studies as well as confirmation of safety and better information about which sage species and quality of extracts work best.
“Brain benefits” may also come from higher brain levels of omega-3 fatty acids, based on research by Costa Mesa California neuropsychiatrist Daniel Amen. Using SPECT (single photon emission computed tomography) scans—which can assess blood flow and activity in 128 specific regions of the brain—on a random group of 166 patients, researchers found greater blood flow in areas concerned with memory and cognition in those patients with higher blood levels of omega-3 fats.
Vascular disease in the heart and blood vessels is to date the best-documented target of omega-3s in the body, as well as appearing to be a key cause of cognitive decline. Also, cerebrovascular risk factors (hypertension, atherosclerosis, and diabetes) as well as aerobic exercise, Mediterranean diet, and cognitive and social engagement are keystones of the “Bredesen protocol,” named by California neurologist Dale Bredesen, which has been touted as the first approach to reverse declining brain function in AD patients.
Bredesen’s protocol, outlined in his two “End of Alzheimer’s” books, is available for patients— including assessments, tests and expert advice—for package fees starting around $1,000. However, an editorial earlier this year found “major flaws” and “second-rate science” in Bredesen’s research, writes cognitive neurologist Joanna Hellmuth of the UCSF Memory and Aging Center in Lancet Neurology. Hellmuth points out that these keystone lifestyle interventions are “largely cost-free” and considered standard of care in dementia clinics.
Inflammation, one focus of Bredesen’s protocol, is associated with “all known genetic and environmental risk factors for AD,” according to a review published in in Frontiers in Medicine. Among psychedelic drugs, both psilocybin and LSD have shown “potent anti-inflammation properties” that may be “overwhelmingly targeted to brain tissue.” In both “micro-doses” and large doses, the brain effects of these drugs, including induced plasticity and modification of connectivity between regions, suggest their benefits as a “strategy for neuroprotection and cognitive enhancement in [early] prodromal AD.”
But for many experts, aducanumab is the most significant recent development—in part because it would be the first new AD drug approved in 17 years and one of the few drugs approved in 40-plus years of AD research. Disagreement about whether the FDA should approve the drug focuses on the degree of improvement achieved—which is especially important considering the drug’s high cost.
Aducanumab targets one pathology of AD seen in patients not yet diagnosed with dementia but who have “mild cognitive impairment (MCI): changes in an individual’s cognitive abilities that, “while noticeable and often annoying, are not disabling,” writes neurologist Jason Karlawish at the University of Pennsylvania’s Penn Memory Center.
Approximately 40% of patients over age 65 diagnosed with MCI develop dementia within three years. In trials of aducanumab conducted by the drug’s developer, Biogen, 80% of participants with MCI also had PET scans showing elevated amounts of amyloid plaque in their brains.
While amyloid buildup is often seen in the brains of patients with AD, it is still not clearly the cause of AD dementia, which is linked most strongly to age and genetics. For this reason, Karlawish suggests that renaming might be in order—giving those with abnormal amyloid the option of saying they have amyloidosis. “A drug that targets a pathology targets stigma,” he writes, by offering “some explanation for what’s wrong, the hope of treatment, and a means to rethink and even rename a disease.”
For those who might be vulnerable to AD, a host of other don’ts include sugar and noise. According to one theory, fructose provokes many of the brain changes associated with AD. As for noise, a study on aging—with more than 5,000 participants age 65 and older, and almost 40% with MCI and 11% with AD—linked each 10-decibel (db) increase in community noise level with a 36% higher likelihood of MCI and a 29% increased risk for AD.
Possible causes for the negative effects of loud noise on the brain include increased heart rate, constriction of blood vessels and sleep loss—all associated with increased risk for dementia. Among hard-to-control community noises, the leaf blower ranks high. For anyone standing next to a leaf blower, its sound can measure over 100 decibels—compared to closer to 80 dbs at 50 feet, and compared to human speech at about 60 dbs.
The effects of noise are based on levels of both db loudness and perceived annoyance—with loud sounds made by paper, for example, more annoying than other sounds at the same db level. Thus, yoga teachers and others advise focusing on body and breath to resist being annoyed by sounds that cannot be controlled. Otherwise, the best advice: In the presence of loud noises, keep your distance.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
EXHAUSTIVE ATTEMPTS to make safe plans, especially for the holidays, revolve around testing—as do the most perplexing coronavirus conundrums: when, for what reasons and which tests to get. Whatever the drawbacks of any kind of test, almost any result can contribute to figuring out the best path forward.
The holiday recommendation from former Baltimore health commissioner Leana Wen: Quarantine for 14 days and then take a rapid-response test, ideally the day before gathering. Reducing infection risk requires a combination of quarantining, testing and precautions –- which includes handwashing, wearing masks and distancing.
The CDC last week issued new guidance defining “close” contact as 15 minutes of cumulative exposure within six feet in a 24-hour period — in contrast to the previous formula of 15 consecutive minutes.
But there is nothing magic about 15 minutes—or about six feet, writes Ryan Malosh, infectious disease epidemiologist at the University of Michigan School of Public Health. Malosh sees the recent guidance as indication that new evidence has emerged—but mostly as “important recognition of the ease with which this virus can spread.”
Among coronavirus tests, one category is diagnostic tests that assess active infection, using nasal or sputum samples—with two test types: P.C.R. (polymerase chain reaction) tests that detect genetic material, require laboratory processing and give results in anywhere from one day to two weeks; and rapid-response antigen tests that detect viral surface proteins responsible for provoking an immune response, can give results on the spot in 15 minutes and may become available for personal use, similar to pregnancy tests.
(In the other category are blood tests that detect antibodies, which the body produces several days after infection begins and which remain in the body for weeks or longer. Because the strength and duration of coronavirus antibodies are not well understood, a positive test result may not ensure protection—but can provide confirmation of infection late in the illness, in cases of suspected post-infectious syndromes and in epidemiological population studies.)
Debate about the value of the different tests used for diagnosis—P.C.R. tests and quick antigen tests—focuses on risks of false negative and false positive results.
The faster antigen tests, when given in random screening of students and staff members at the University of Arizona, detected only 32% of the positive cases identified by the P.C.R. test—creating a high rate of false negatives for the quick test that can encourage an unwarranted sense of security. And compared to the P.C.R. test, the antigen test also produced more false positives— which can be especially dangerous if people who in fact do not have COVID seek treatment or are put in quarantine alongside those with active infections.
Some experts argue, however, that rapid antigen tests are better at pinpointing specifically those individuals most likely to be contagious, and that the greater sensitivity of P.C.R. tests leads to positive results when there is too little virus in the body to spread it to other people. When the Arizona subjects included only those with symptoms, results were similar for both kinds of tests.
In addition, further testing of asymptomatic subjects with positive P.C.R. results found that some had no live virus at all, indicating that they were not contagious. But Jennifer Dien Bard, director of the clinical and microbiology and virology lab at the Los Angeles Children’s Hospital, warned about the inability to predict which sufferers would be carrying live virus: “There is no magic number cutoff for infectiousness.”
And about the low 32% detection rate of the antigen test, Dien Bard pointed out, “That’s worse than flipping a coin.” An additional risk if antigen tests become available for personal use: people who test positive will fail to let anyone know they have the virus.
Meanwhile, as wait times for P.C.R. test results are lengthening again as case numbers rise, the previously recommended strategy of getting tested before a trip or event has changed to testing four to five days beforehand and then maintaining quarantine until the results are in. Says former CDC director Thomas Frieden, “What good is testing if the results take four days to come back and infectious people aren’t isolated in the interim?”
Beyond testing, the next hope is a vaccine—with the candidate developed by Pfizer and BioNTech just announced in its final stage of trials; and the possibility of enough doses by the end of the year for high-risk groups: health care workers, older adults, those with risk factors like diabetes and people of color. To date this vaccine has shown 90% effectiveness, compared to around 50% for flu vaccines and 97% for the measles vaccine.
But not until application is made for “emergency use authorization,” expected by late November, will FDA scientists have a chance to examine raw data on safety and effectiveness. Remaining questions include how long the vaccine’s protection will last, and whether it can protect against severe cases or asymptomatic cases. One difficulty with this vaccine is that storage during transport must be kept at minus 94 degrees Fahrenheit.
Clinical trials for another dozen or so leading vaccine candidates are also in late stages—while China has proceeded to vaccinate hundreds of thousands of people around the world with its four candidates. Many criticize this strategy, but others respect Chinese science and believe the experience might yield good information about risk and effectiveness.
Similar to the workings of a vaccine, when someone wearing a mask does become infected, the reduced dose of virus is likely to produce asymptomatic infection—the case on cruise ships, at food processing plants and in jails—conferring immunity without severe infection.
Mask wearing accompanied by social distancing offered the greatest protection in a Harvard study of 104 workers in a Massachusetts supermarket. Although 91% of workers wore masks, only two-thirds said they could consistently practice social distancing—and those in contact with customers were five times more likely to be among the 21% who tested positive.
In the long run, lessons from the coronavirus about testing, vaccine development and protection may help deal with newly emerging infectious diseases (about 40 since the 1970s that have included SARS, MERS, Ebola and Zika) “at a rate that has not been seen before,” the WHO warns.
“People are traveling more frequently and far greater distances, living in more densely populated areas and coming into closer contact with wild animals,” according to a Baylor College of Medicine report. And in northern Denmark, farmed mink may be responsible for almost 400 recent coronavirus infections.
Other factors spurring the increase of emerging diseases include climate change, as warming temperatures allow mosquitoes to move into new regions; antimicrobial resistance; and a decline in vaccine coverage—the reason measles cases have been highest by far during the last decade.
Looking ahead to the cold weather, respiratory viruses thrive in dry, warm indoor conditions—with the statistical peak of most flu seasons coming just after Christmas and New Year’s, writes Joel Achenbach in the Washington Post. And recently experts have linked the national spike in coronavirus infections to household transmission, rather than to superspreader events.
Among the most important lessons from this coronavirus: Wear a mask and maintain social distancing. Also consider saying no to holiday invites this year. And when reason or opportunity presents itself, take a test—any test.
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19. To read more of her posts, click here.
“OBSESSIVE RUMINATION disorder” appeared as a possible diagnosis in a recent “Ask Amy” column — triggered by PTSD in a woman who couldn’t stop thinking about her husband’s affair that had occurred 20 years earlier when both were 19 years old.
Rumination—considered a “core” feature of OCD (obsessive-compulsive disorder, with obsessive thoughts and compulsive actions)—focuses on past events, viewing them with guilt, regret, anger and envy; and can cause feelings of sadness, hopelessness and anger. In contrast, worry concerns future anticipated events and creates anxiety.
“Obsessive thinking can be like a hamster wheel, as one hamster gets off, another takes its place and the wheel keeps spinning,” according to the Cognitive Health Group’s OCD website page.
“The thoughts and behaviors of a person with OCD are persistent and disruptive to daily functioning, according to verywellmind. And the OCD incidence of between 4 and 22% among those diagnosed with PTSD compares to around 1% for OCD in the general population.
Rumination disorder, along with other forms of OCD that occur with PTSD, can respond to mindfulness training “where you purposefully and consciously yank your mind back to the present,” writes Amy Dickinson.
Mindfulness exercises involving breath and body awareness focus on “being.” In contrast, rather than working with the body, cognitive behavior therapy (CBT) uses the mind to reframe obsessive thoughts with the goal of “doing,” or acting, differently.
Psychedelic drugs, in particular MDMA (also known as Ecstasy), have recently proved effective in countering OCD by reducing fear and defensiveness as well as by enhancing the therapeutic process. In Phase 2 trials, 107 participants diagnosed with chronic PTSD lasting an average of almost 18 years had three sessions of MDMA-assisted psychotherapy. At the 12-month follow-up, almost two thirds no longer fit the diagnosis.
Other psychedelic drugs—ketamine, LSD and psilocybin—have helped some patients but not all. While “psychedelic-assisted therapy” currently involves dozens of therapist-hours—making it costly, not yet covered by insurance—the effects of psychedelic drugs on interrupting or rearranging brain connectivity have provided new information on the brain circuits involved in PTSD-related OCD.
The neurological dysfunctions of OCD may begin with the insula, a small region near the front of the brain that seems to control salience—the selection among competing stimuli for which one commands the brain’s attention. The insula sorts emotional responses such as pain, love, craving, enjoyment of music and food —thereby determining the power of negative stimuli to evoke feelings of pain.
By sorting and weighing competing stimuli, the insula creates a “global emotional moment,” an image of ourselves at one point in time. The accumulation of such moments may form the basis of self-awareness, playing a role not just in cognition but in decision-making and motivation at any point in time.
In one study, fMRI (functional MRI) scans showing “resting-state brain connectivity” in veterans with PTSD found “aberrantly” greater positive connectivity between the insula and the amygdala—the brain’s center for emotions and emotional motivation—compared to connectivity between the amygdala and the hippocampus, the center for learning and memory. The conclusion: emotions like fear may have more direct and greater control over these individuals than learned experience.
The Mindfulness-Based Stress Reduction (MBSR) program, pioneered by Jon Kabat- Zinn more than 30 years ago at the University of Massachusetts, Amherst, involves intensive practice over eight weeks of classes, with daily guided meditations on a CD that offers various options—sitting, standing, laying down—and durations, from under four minutes to 45 minutes or longer.
Comparing treatments for PTSD, researchers in the 1990s concluded that, while CBT promotes cognitive awareness, the “being “ mode targeted by mindfulness training was the one that led to lasting emotional changes, according to London psychotherapist Sheri Jacobson, founder of London-based Harley Therapy.
“The greater and more consistent your awareness of the present moment, the more likely it is you will catch the negative thought spirals and choose to disengage from distressing moods or worries,” writes Jacobson.
Harley Therapy employs a combination of MBSR and CBT called MBCT: the CBT teaches recognizing and reframing negative thoughts, and mindfulness then helps you “be less caught up in mental loops in the first place,” Jacobson notes. Even after therapy, she warns, “the link in your brain between negative thoughts and negative moods still exists and is ready to be reactivated. So being able to monitor and contain reactivation, which mindfulness aids with, is invaluable.”
By the end of my MBSR course, I had gotten better at using 15-minute midday breaks to focus on breathing and relax my body, and then to let go of random thoughts swirling around my brain. But when the morning news sets off that rumination wheel, I appreciate the mental respites like Ask Amy.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
INVISIBLE DISABILITIES—notably pain and fatigue—can be difficult to measure objectively and are likely to be dismissed by friends, family and physicians. But with increasing numbers of Covid-19 “long-haulers” reporting such symptoms months after acute infection—on top of the extreme contagion and severity of this infection—new attention on such chronic disabilities might help counter what’s called “medical gaslighting.”
“My first symptom was that I couldn’t read a text message,” post-Covid patient Hannah Davis told Live Science. “Brain fog,” general cognitive dysfunction and trouble concentrating, were the prominent complaints from nearly 70% of 640 respondents in a patient-led group’s survey of long-haulers.
Notably with Covid-19, the different experiences of women vs. men— for both acute infection and lasting symptoms—has challenged the traditional approach of “bikini medicine,” which views female patients as interchangeable with male ones, “except for the organs covered by swimwear,” Tulane researcher Franck Mauvais-Jarvis told the Washington Post.
Following infection with Covid-19, women are more likely to suffer long-lasting symptoms—perhaps due to their more strenuous immune-system reactions to the initial infection. But the weaker immune responses of men may explain why their symptoms in the acute stage are more severe: by mid-October, 17,000 more men than women had died from this coronavirus.
(Another reason men might be more susceptible to severe Covid-19 is the much-higher levels of auto-antibodies to immune system proteins called interferon—in 12.5% of severely-ill men but only 2.6 percent of similarly ill women—that can help fight the infection.) Eventually, early screening could lead to different treatment for such patients.
Experts suspect that women’s stronger immune reaction to infection may result in lasting immune dysfunction or auto-immunity, causing symptoms similar to those following other infections—SARS, Ebola and Lyme Disease—in the same way women are more likely to suffer autoimmune diseases like lupus (nine times as many women as men) and multiple sclerosis (three times as many women).
Lyme Disease, for example, has led to persistent symptoms—excessive ongoing swelling of the joints and pain, nerve damage (neuropathy), severe fatigue, sleep disturbance and cognitive problems—in 10-20% of acute Lyme sufferers, lasting months or years following treatment but still doubted or dismissed by many physicians.
“Post-treatment Lyme Disease Syndrome is a real disorder,” says director of the Johns Hopkins Lyme Disease Clinical Research Center John Aucott, “that causes severe symptoms in the absence of clinically detectable infection.”
Following Covid-19 infection, the CDC found about one-third of younger patients with mild symptoms have ongoing problems, especially with periodic shortness of breath and exhaustion, for two to three weeks after infection—and some for six months or longer. Many of those who survive critical illness suffer post-intensive care syndrome (PICS), in particular following prolonged periods of time on a ventilator, heavy sedation and acute respiratory distress syndrome—fluid build-up in the lungs causing low blood oxygen levels.
“People are aging decades in the course of months, said Diana Berrent, who founded Survivor Corps—with membership currently over 100,000 to connect those who have been infected with Covid-19.
One beneficiary of intense post-Covid study is Edison Chiluisa, age 51, profiled in a recent Washington Post article, whose symptoms arose following severe infection in May and still plagued him by mid-October. Working at Yale-New Haven Medical Center, Chiluisa received care at one of the country’s proliferating post-Covid-19 Recovery programs.
An MRI of Chiluisa’s brain showed tiny lesions on the white matter that may be responsible for new stuttering as well as memory problems, insomnia, depression and other symptoms that resemble post-traumatic stress disorder. Such symptoms could be permanent, progressive or something the brain can work around by creating new pathways.
For his other symptoms—racing heart, and becoming easily winded and quickly exhausted —while tests have been mostly normal, Chiluisa has benefited from exams by clinic specialists, searching for causes that might include disruption in the autonomic nervous system—which controls functions such as heart and respiratory rates—or lasting damage due to immune and inflammatory responses in the acute stage.
While Operation Warp Speed continues aiming for a pre-election vaccine, the WHO warns younger people not to expect sufficient vaccine supplies before 2022. And as long as any group fails to receive vaccine protection, risks will continue for more vulnerable and older age groups: recently a 13-year old with no symptoms other than nasal congestion infected 11 family members, ages 9 to 72, in a shared vacation house.
With around 8.5 million Covid-19 sufferers in the U.S. to date, even if the percentage with long-term symptoms is small, those numbers could mount up. And many people with other post-infection syndromes, as well as those with hidden “nonmobility” symptoms from other causes, could benefit from the new attention, both financial and scientific.
After I spent several weeks with untreated, acute Lyme disease, doctors dismissed my newly interrupted sleep as a natural problem of aging, and my suddenly skyrocketing cholesterol as a result of diet, which had not changed. Only my complaint of peripheral neuropathy (dysfunction in peripheral nerves, usually in the legs and feet) received serious attention—because objective tests, notably a little plastic toothpick, could measure 50% loss of feeling in my feet
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19. To read more of her posts, click here.
WOMEN ARE more likely than men to experience motion sickness and also to have poorer visual-spatial skills, a combination that led “human factors” researchers at the University of Warwick to explore brain-training methods for decreasing motion sickness susceptibility as part of the push to develop driverless cars.
Discrepancies between motion sensed by the inner ear and visual stimuli processed by the brain may be the main cause of motion sickness. Faulty brain connections that are more common in women may also explain Mal de Debarquement syndrome (MDD), with sufferers having a sensation of motion inexplicably, when doing nothing, as well as for weeks and sometimes years after leaving a moving vehicle.
Symptoms of both motion sickness and MDD include not just nausea but sometimes debilitating fatigue along with dizziness, confusion and difficulty focusing—and can affect not only travelers but also users of virtual reality devices and the recently ubiquitous Zoom.
“Human factors research is all about how we can design products and services that are pleasurable,” said University of Warwick engineer Joseph Smyth. “Motion sickness has for a long time been a significant limitation to many people’s transport options.”
Motion sickness, also called kinetosis and travel sickness, occurs in susceptible people when motion is felt but not seen, as in a ship without windows or inattention to surroundings when moving on any vehicle; or from motion that is seen but not felt, as with jerky film images from a handheld camera or with video games.
Visuospatial performance is “dynamic,” changing with age and recent experiences, but also with fluctuations in levels of sex hormones. Performance for women is “most drastically reduced when menstruating” and improves with rising testosterone levels during hormone replacement therapy. Improvements that come after practice on video games and driving simulators gave researchers clues for relieving motion sickness.
Of 42 participants in the Warwick study, after assessments of their baseline visuospatial performance, half participated in on-road driving trials while the others used the driving simulation that is more likely to induce motion sickness. Over the next two weeks, for 15 minutes each day, participants practiced pen-and-paper visuospatial exercises: viewing a 3D shape and then correctly identifying which of several reoriented shapes matched the original—called “mental rotation tests”; paper-folding tasks; and analyses of spatial patterns.
By the end, both groups showed improvement in visuospatial performance that was statistically significant—and motion sickness declined by an average of 51% in simulated trials and 58% in on-road trials.
“Imagine if someone is waiting for a test drive in a new autonomous vehicle, they could sit in the showroom and do some ‘brain training puzzles’ on a tablet before going out in the car,” said Joseph Smyth. The exercises could reduce the risk of sickness for these drivers and might also help cruise passengers and users of virtual reality headsets.
Because visuospatial prowess can wax and wane, however, those who benefit from visuospatial exercises would need to do a little training before any activity that risks motion sickness.
Visuospatial exercises available online are generally costly, although the website HAPPYneuron offers free worksheet packets, including one exercise called “Turn Around and Around” that is similar to the mental rotation test—as is one familiar activity: moving a piece of furniture to a new location in the “mind’s eye.” Another is picturing the steps in a task before beginning to do it.
In contrast to those with motion sickness, MDD syndrome patients experience “a phantom perception of self-motion typically described as rocking, bobbing or swaying” that can occur in the absence of any prior movement, even when sleeping or standing still, according to NORD, the National Organization for Rare Disorders.
In these patients, the vestibule-ocular reflex (VOR) in the inner ear fails to maintain balance and stabilize the eyes during head movement, according to neurologist Bernard Cohen at Mt. Sinai School of Medicine, whose team tested a new treatment to readapt the VOR.
In the Mt. Sinai study of 24 participants, researchers moved visual surroundings at the same frequency as the subjects’ rocking or swaying movements, about one cycle per five seconds—with about three to five treatments a day for one week. Improvement lasted for an average of one year in 70% of subjects, while six had only transient improvement and one did not improve at all.
Vestibular rehabilitation—using exercises like those commonly prescribed to improve balance—as well as the newer brain stimulation methods can also help. And, although symptoms can worsen after traveling by train or car, and most often after a long boat trip, doing any of these can also provide short-term relief.
Boston retailer S.H., who has been diagnosed with MDD, experiences other anomalies that she thinks are related: a facility with writing backwards and reading upside down; and a consistent inability to give correct directions involving left and right turns, for which she always reverses the two.
Activities that can cause unpleasant reactions include sleeping on a waterbed and skiing, as well as Zoom meetings. But finding a solution may be the most urgent for Zoom sufferers during the ongoing pandemic when Zoom meetings seem to occur more frequently than in-person ones ever did.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
THE CHALLENGE in making a correct diagnosis belongs to doctors and other medical personnel, but crucial breakthroughs come sometimes from the way the patient tells her story and any evidence, such as photos or fluid samples, she can bring.
Recounting a recent medical misadventure in the Washington Post, retired neurologist Steven H. Horowitz described an “inept” diagnosis that could have resulted in him becoming quadriplegic. At an “elite medical center,” following a long bike ride, Horowitz reported numbness in his limbs, and his blood work showed active infection—key indicators that even medically unaware patients should recognize.
The spinal consultant, however, failed to check for the Babinski sign (reflex), a classic measure of spinal compression, and misidentified a mass on the MRI as a blood clot even while elevated blood proteins strongly suggested an abscess. When Horowitz finally was able to review his test results two days later, he needed immediate spinal surgery, followed by long-term intravenous antibiotics.
While the typical patient need not understand the details of blood markers, the presence of “elevated blood proteins” should encourage the search for causes of infection. The most worrisome protein indicators include ESR (erythrocyte sedimentation rate), indicating greater numbers of several proteins sticking to red blood cells, which makes them heavier; and CRP (C-reactive protein) assesses higher levels of that protein.
The unusual presence of blood can also be a vital clue, for example, visible blood in the urine called “gross hematuria” —which in a different medical mystery led to a belated diagnosis of kidney cancer in an atypically young patient. Hematuria can also be a sign of kidney disease, infection in either the kidney or the urinary tract, and a bladder or kidney stone.
In hindsight and maybe because she had worked in a medical clinic, the kidney-cancer patient suspected that bringing in either pictures or a sample of her bloody urine could have helped convince doctors that the cause was serious. “Somehow I think doctors believe patients when there is something visible or tangible, rather than just our words,” she said.
Sudden new symptoms that require urgent care are the most familiar, such as seeing bright flashes that may signal retinal detachment; or sleep disruption, irritability and headaches following a blow to the head that suggest concussion.
The acronym FAST, which should be familiar, refers to symptoms and response in the case of possible stroke: F for face drooping; A for arm weakness—raising both arms to compare; and S for speech difficulty when attempting an easy sentence. T for time indicates the need for very fast response: Call 911 and say, “I think stroke.”
But chronic symptoms like fatigue and pain can be trickier for physicians—tricky to measure, also tricky to diagnose because each has so many possible causes. Extreme fatigue can signal cancers of the pancreas, ovaries, brain and colon, as well as leukemia; and the addition of pain can indicate any cancer, but particularly bone cancer.
Fatigue can also suggest infection by a virus like SARS-CoV-2 or by the Lyme spirochete —although both infections are more commonly associated with other symptoms, like breathing difficulty or the red bull’s-eye rash as well as fever. Fatigue can also indicate complex chronic conditions like Chronic Fatigue Syndrome.
Even symptoms that sound vague can signal cancer or other serious illness diagnosis. Ovarian cancer patients often report a “feeling of fullness”—exactly the kind of complaint doctors have tended to dismiss; and bruising easily is a common a sign of leukemia—one symptom that might be more convincing with photos.
Clustered symptoms can also be a red flag. For carbon monoxide poisoning, victims often present with a “staggering variety of seemingly vague symptoms, including headache, vomiting and abdominal pain,” according to ABC News. “As a result, affected individuals can easily be misdiagnosed with a viral illness or food poisoning.”
One good way of learning about worrisome symptoms is reading patients’ stories, for example in “medical mysteries” columns or in collections like Every Patient Tells a Story by New York Times Magazine “Diagnosis” columnist Lisa Sanders.
Crucial non-medical information may also come from getting the whole story. In Horowitz’s piece, for example, anyone who takes long bike rides might benefit from learning that lower-than-usual handlebars—in Horowitz’s case two inches lower—can cause life-threatening spinal compression.
My education in symptom story-telling came after spending almost two weeks with severe muscle aches, along with fever and trouble sleeping, by the end labeling the pain a 10, with an unresponsive doctor—until I highlighted one symptom for which I had objective details.
“Every night I go to bed at midnight and sleep for half an hour,” I told the doctor. “At 12:30, I wake up and for the rest of the night am in such pain that sometimes I walk on the public beach in my nightgown.” Right away, I got the Lyme testing I’d requested from the beginning, along with a prescription for doxycycline—although the weeks of untreated Lyme may have caused lasting issues, in particular with sleep.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
IN THE 1970s, I went with my friend and co-worker Pat to a free dinner at the Cambridge, Massachusetts, Hare Krishna house, because she was interested in joining. (I was curious and also hoped to help discourage her.) After seemingly endless, very active dancing, loud music and chanting—getting us parched and hungry, and maybe keeping the dozens of homeless from returning too often—sweet desserts and very sugary punch were the only offerings.
Unhealthy diets along with sleep restrictions are features of many cults, including the New York-based Nxivm. Last week Seagram heiress Clare Bronfman was the first of those involved to receive a sentence: 81 months in jail plus fines and penalties close to a million dollars.
“The Vow,” now airing on HBO, tells the story of Nxivm (pronounced NEX-ee-um) with former cult members playing some of the roles. Sentencing for cult leader and convicted sex trafficker Keith Raniere—expected to be life in prison—will occur in October, and at a later date for actress Allison Mack, who pleaded guilty to racketeering and other charges.
The word “cult” is derogatory or, as explained by Mark Vicente, one of the many “appealing, complicated Nxivm refugees” who appear in the series: “We’re not [expletive] strange monsters that made bad choices our whole life. We didn’t join a cult. Nobody joins a cult! Nobody. They join a good thing— and then they realize they were [expletive],” according to a New York Times review.
Among formal definitions of cults is “an organized group or a solitary person whose purpose is to dominate cult members by using psychological manipulation and pressure strategies,” from a 2017 study of 31 former cult members by the French Interministerial Mission for the Fight against Drugs and Addictive Behaviors.
The “vulnerability factors” of cult members have a lot in common with those suffering addictive disorders, according to the study report, notably an “inability to change despite damage and risk.” And social impairment caused by spending so much time in service of the cult—study subjects remained in cults for an average of almost nine years—makes it difficult to leave.
Like addiction, cults have high “psychiatric comorbidity prevalence:” before joining, more than half of the subjects displayed an anxiety disorder and almost half had a mood disorder, in particular, depression —leading to the hypothesis that “commitment to and involvement with the group managed to relieve psychological suffering.” Before joining, most felt “attachment insecurity” —often associated with addictive disorders—and soon after joining experienced a “honeymoon” of psychological relief.
More than 12% had a prior addiction that they replaced with the cult commitment—called “addiction switch,” the researchers hypothesized. Behavioral addiction “consists of a compulsion to repeatedly engage in an action until it causes negative consequences to the person’s physical, mental, social and/or financial well-being,” according to a Spanish study in 2015 that documented increasing numbers of cults worldwide.
Indoctrination techniques, including excessive meditation or chanting—dubbed “mind-stilling”—can cause a dissociative mental state and a “high” similar to that of drugs, according to the study report. Exit counseling often involves using logic to appeal to the “thinking brain,” which practices of cult indoctrination and participation suppress.
Meditation of any kind is not for everyone, concluded Sharon Farber in Psychology Today, after attending the International Cultic Studies Association’s annual conference. Farber describes “soul murder,” coined by psychoanalyst Leonard Shengold to describe the intentional attempt to stamp out or compromise the separate identity of another person.”
Among “techniques of psychological manipulation,” explained in an Ohio Law Enforcement Primer on Cults, the explanation of “sleep deprivation and fatigue” is “disorientation and vulnerability created by prolonged mental and physical activity and withholding adequate rest and sleep.”
Also in the Primer, the description for “change of diet” is “disorientation and increased susceptibility to emotional arousal achieved by depriving the nervous system of necessary nutrients, through the use of low-protein, childlike food.”
One California cult espoused breathing as a substitute for eating, according to late Berkeley psychologist and cult expert Margaret Singer, who testified for the defense in the Patty Hearst trial. Singer estimated cults in the U.S. to number around 5,000 “small, abusive groups.”
Nxivm imposed a diet “near starvation” and limited sleep by requiring members to answer texts from the leader at all hours. What brought Nxivm under scrutiny were accusations from those who escaped that the cult involved a pyramid scheme and sex-trafficking. A secret group of women within the organization agreed to be called “slaves,” referred to Raniere as “master” and were branded with Raniere’s initials.
Since its founding in 1998, Nxivm attracted some 18,000 people to its workshops, costing thousands of dollars apiece and marketed as helping successful people overcome fear and find self-fulfillment. According to one lawsuit filed against the organization, however, Nxivm’s recruiters looked for “trust fund babies” and others who struggled with low self-esteem.
Clare Bronfman contributed more than $100 million of her inherited wealth to Nxivm, along with promising jobs and obtaining false visas to bring Mexican girls to cult headquarters near Albany. Loyal even today, Bronfman has said, “Nxivm and Keith greatly changed my life for the better.” Despite the pandemic, followers continue to organize dance parties outside the Brooklyn jail where Raniere is being held.
Hare Krishna appealed to my friend Pat, she explained, as a community that offered a sense of belonging to help her move away from her family’s strict South Boston Catholicism. After the evening though, with both of us dazed by the intense exercise and sugary repast, she thought joining Hari Krishna might be moving too far.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
“THE AMOUNT of acute injury and failure was unexpected and dramatic [in the kidneys, due to Covid-19 infection],” Yale University kidney specialist Alan Kliger told the Philadelphia Inquirer. The highest numbers of Covid-19 cases involving kidney damage come from the Northeast, where rates of infections spiked early compared to other parts of the country. These were affected later in the spring when physicians had more experience dealing with the virus.
The kidneys recover in most patients with Covid-related damage, but some require lifelong dialysis—using a machine to replace healthy kidney functions of filtering waste and rebalancing the body’s fluids. Even those who recover from acute kidney injury are at higher risk for developing chronic kidney disease later on.
Kidney damage—in patients with severe disease as well as for Covid “long haulers” whose symptoms persist —is just one of the warnings that this coronavirus could remain risky and worrisome until a vaccine becomes widely available. Several next-in-line candidates have two important advantages—requiring only one dose and not requiring extreme cold-chain (from manufacturer to pharmacy or clinic to patient) temperatures—compared with the earliest versions now in large-scale clinical trials. Maintaining temperatures of minus 80-95 degrees necessitates specially designed units for transport and storage and makes it difficult to vaccinate geographically distant populations.
In the effort to relax restrictions, gyms and health clubs may have reopened too early based on flawed research that included conflicts of interest—sponsorship by industry trade associations—as well as reliance on contact tracing. While improving, contact tracing requires the participation of individuals who receive a positive Covid-19 test to quickly inform every place they’ve been— grocery store, library, gym, etc.— which can be difficult.
With asymptomatic transmission accounting for up to 50% of new cases, one strategy that has proven effective for reopening is “cocooning,” based on research in Austin, Texas. Extending the strictest regulations only to “vulnerable populations” (those over 65 and those with pre-existing conditions) involves supporting work-at-home and paid leave to facilitate self-isolation.
For Covid-19 “long-haulers,” acute kidney injury (AKI) has affected one in every three people admitted to the hospital with the coronavirus infection. Even younger, healthier Covid-19 patients who never needed a ventilator or the ICU have left the hospital with kidney damage severe enough to require dialysis for the rest of their lives or until they receive a transplant.
Dialysis helps keep kidney patients alive but impairs their health and reduces life expectancy: a 30-year-old patient on dialysis looks more like a 55-year old, says Kliger. While healthy kidneys work round the clock, most patients undergo dialysis only for several hours three or more times a week at a center. Even those with home units used overnight spend hours without the filtering and rebalancing done by healthy kidneys.
Kidneys are at risk in critically ill patients because the organs need strong blood flow, which diminishes with dehydration and low blood pressure. And blood pressure is difficult to control in the presence of breathing problems. Also damaging to the kidneys in Covid-19 patients are blood clotting and the inflammation that accompanies an intense immune response.
When the kidneys stop working, toxins build up, which can cause confusion and even coma, explained University of Pittsburgh nephrologist Paul Palevsky. And fluids accumulate in the lungs, causing shortness of breath; while higher potassium levels can cause severe heart-rhythm problems.
For most people with chronic kidney disease, the main causes are type II diabetes and high blood pressure. Next is glomerulonephritis —diseases that damage the kidney’s filtering units, the glomeruli, a cluster of tiny vessels with thin walls that enable waste and water to pass through but block the larger blood cells and proteins. Because early kidney damage often has no symptoms, signs include urine samples containing blood, hemituria or protein.
Filtered fluid passes next into the tubules, which rebalance minerals, water, salts and glucose for reabsorption into the blood stream. Compared to the filtering process, this recalibration is more challenging for dialysis machines—which sometimes do it so abruptly that the body requires hours to recover, explains Seattle nephrologist Jonathan Himmelfarb. Dialysis costs almost $100,000 annually for the more than half a million Americans who rely on this treatment.
Referring to kidney damage and other symptoms in long-haulers, Covid-19 expert Anthony Fauci told the New York Times, “These are the kinds of things that tell us we must be humble and we do not completely understand the nature of this illness.”
—Mary Carpenter
Well-Being Editor Mary Carpenter is on a mission to keep us updated on Covid-19. To read more of her posts, click here.
ONE ART class assignment was to draw a scene upside down—another to draw only the negative spaces, for example, of kitchen utensils in a jar. The goal: better engaging the creative, right side of the brain. DC-area resident S.H. finds the assignments very difficult.
“It is a real trick to get rid of the part of your brain that just KNOWS how something looks and switch to seeing how things actually appear.” (S.H. uses the example of mistaken ideas most people have about the face: the eyes are not at the top where most people draw them but closer to the middle, and they are not simple almond shapes with circles in the center.)
People like S.H. believe they struggle with creative activities like art, writing, music and dance, because their left brain— which “just knows” and is thought to be more analytical and fact-based—dominates and suppresses creative input from the right side.
In recent years scientists have questioned generalizations about personalities based on differences in the two brain hemispheres. “For individual personality traits, such as creativity or a tendency toward the rational rather than the intuitive, there has been little or no evidence supporting a residence in one area of the brain,” according to Harvard rheumatologist Robert Shmerling.
Brain scans found no evidence of “sidedness” in a 2013 study at the University of Utah that included more than 1,000 people between the ages of 7 and 29 and divided areas of the brain into 7,000 regions. Writes Shmerling, “If you’ve always thought of yourself as a ‘numbers person’ or a creative sort, this research doesn’t change anything. But it’s probably inaccurate to link these traits to one side of your brain.”
“Many neuroscientists consider the concept of purely left-brain vs. right-brain characteristics a myth,” according to MedicineNet. And most research to date shows not only equal use of both sides of the brain but the need for abilities on both sides to work together on all tasks, including creative ones.
On the other hand, a recent brain-imaging study at Drexel University’s Creativity Research Lab assessing hemisphere dominance in creative endeavors found differences. Of 32 jazz guitarists asked to improvise, for those comparatively inexperienced at improvisation, “creativity is, in fact, driven primarily by the right hemisphere,” according to the National Science Foundation report.
On the other hand, those musicians who were experienced at improvisations relied primarily on their left hemispheres. “If creativity is defined in terms of the quality of a product, such as a song, invention, poem or painting, then the left hemisphere plays a key role,” said Drexel’s John Kounios.
According to another recent report, creativity relies on the ability to combine remote concepts…which would depend on associative processing in the right hemisphere, which is modulated by dopamine. Because higher dopamine levels constrain associations, lower levels in the right hemisphere allow for greater creativity on a range of tasks.
Finally, research on pigeons found one cause of “functional brain asymmetries” is timing: if both brain hemispheres are competing for control, the left is able to delay the activity or neurons in the right hemisphere—although the neurons in both hemispheres are also capable of synchronizing their activity.
And domination by one hemisphere can affect mental health. Hyperactivity in the right hemisphere, for example, plays a role in depression —when a less active left hemisphere is unable to restrain the processing of negative emotions, pessimistic thoughts and unconstructive thinking styles associated with the right.
Also, right-hemisphere lesions can be the cause of “delusional misidentification syndromes,” such as Capgras syndrome, in which sufferers view familiar people including family members as imposters.
Investigation into the different functions of each hemisphere began in the 1940s with surgery that severed the corpus callosum—the bundle of nerve fibers that connects the two sides of the brain—for patients with severe epilepsy. Since then, endless lists have divided tasks between the two hemispheres: for the left hemisphere, attention to details, analytical/logical thinking and mathematical ability; and for the right, understanding verbal ambiguity and emotional and implied meanings. In learning, left brainers are thought to be more visual and right brainers more auditory.
British psychiatrist and philosopher Iain McGilchrist— favorite author of Fawlty Towers actor John Cleese—questions what he calls the culture’s “left hemisphere chauvinism…that Left is the dominant, practical partner while the Right more or less sits around writing poetry.” In fact, McGilchrist believes, it is “Right that is responsible for surveying the whole scene and channeling incoming data, so it is more directly in touch with the world.”
Since the mid-1970s, books about both drawing and writing “on the right side of the brain” extend the notion that getting in touch with your right brain bolsters creativity. Gabriele Rico’s Writing the Natural Way suggests ways to “orchestrate hemispheric cooperation”—using “callosal inhibition,” blocking the flow of signals from left to right, or otherwise suppressing the left hemisphere.
Among famous examples cited are Einstein’s “thought experiments”—imagining what a light wave would look like if he were an observer riding along with it; or what it would feel like to be a man in a falling elevator, what would happen to his keys, etc. Einstein said that “only when these images became so clear they were voluntarily reproducible could he laboriously transform them into communicable language.”
Whatever is going on at the neurological level, many people attest to the success of such efforts. For writing, “clustering” exercises, also called “brain storming,” involve making charts that start with a single word surrounded by empty circles to be filled in with more single words, for example, “airplane” leads to “freedom” and “lonely”; “bend” leads to “dishonesty” and “old.”
Clustering may override left-hemisphere contributions such as syntax and at the same time create its own, “similar to watching clouds:” suddenly you see a horse or a duck, “it is a moment of pattern recognition,” accompanied by an emotional surge, the “aha!”
“People often lack any voice at all in their writing because they stop so often in the act of writing a sentence and worry and change their minds about which words to use…have none of the natural breath in writing that they have in speaking” —from writer Peter Elbow, included in Rico’s book.
Encouraging greater right-hemisphere contribution may be what some people consider listening to the subconscious —by efforts to put the conscious brain on hold. One suggestion is to write in your head while doing something automatic, like swimming or driving—even pretending to drive by holding an imaginary steering wheel, in Writing on Both Sides of the Brain, by Henriette Klauser.
The ultimate goal, Klauser points out, is “what EEGs show takes place in any highly creative thinking… ideas to crackle across those wires [between the two hemispheres] as idea and its implementation enhance and encourage each other.”
For drawing, S.H. wrote, “The upside-down exercise really works well. So does drawing negative space and looking at relationships.” But she compares these to her experiences with dance: “I don’t need to analyze the steps or count the beat—I can see what the teacher is doing and just copy it without any analysis – it’s very cool! I can’t necessarily duplicate it for someone else later without shifting back to left brain. In dance, I can really feel a right brain experience, but not yet with drawing— sadly!”
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
SARS-CoV-2 vaccines that are widely available for the general population could be a ways off, and both testing and contact tracing are still riddled with inefficiencies. As a result, improvements in the treatment of Covid is an important route forward —by reducing the severity of infection and the risk of dying—to make the threat of this coronavirus closer to that of seasonal flu and improve possibilities for reopening.
Seasonal flu, however, caused 61,000 deaths in the severe 2017-2018 season —less than one-third of deaths so far attributed to Covid in the U.S., but a high number. On the other hand, as winter approaches, worries mount that contracting both flu and Covid at the same time could make each a more serious illness.
Generally for treating Covid, emergency medicine and ICU doctors make decisions based on large, controlled studies —the current gold standard being Britain’s Recovery megatrial that early in the pandemic enrolled some 12,000 patients from National Health Service hospitals. In late June, Recovery released data from a controlled study of about 6,500 patients showing that treatment with the steroid dexamethasone reduces deaths by one-third for patients on a ventilator.
But beginning steroids at a crucial point in the progression of a Covid infection came first from the opposite end of the research spectrum — small-scale, individualized experiences of rheumatologists, who are experts in out-of-whack immune systems, notably in autoimmune diseases, explains Moises Velasquez-Manoff, whose recent New York Times magazine article explores rheumatologists’ role in revolutionizing Covid treatments.
Early on, rheumatologists focused on the immune overreaction known as a cytokine storm that was drowning the lungs of severely afflicted patients —which, their experience told them,, might be countered by immunosuppressants like steroids. Rheumatologists are also specialists in Covid symptoms afflicting “long-haulers” that are similar to those of Chronic Fatigue Syndrome (CFS), which includes prolonged relapses of exhaustion, cognitive dysfunction and other symptoms after a minimal amount of activity.
Rheumatology originated with the study of rheum —a word derived from phlegm, meaning “substances that flow,” one of the four bodily humors in an ancient system of medicine. Referred to as rheumatic diseases, systemic autoimmune conditions can affect the eyes skin, nervous system and internal organs—and include everything from chronic back pain and tendinitis to more than 100 forms of arthritis.
“The idea of manipulating the immune system as a way to fight Covid,” writes Velasquez-Manoff, first arose in China and soon after with Italian physicians desperate for a way to stop patients from dying. After a few successes, said Marco Gattorno, head of the Center for Autoinflammatory Diseases and Immunodeficiencies in Genoa, “We were able to convince [doctors] not to be too shy with glucocorticoids (steroids).”
In April, prior experience with rheumatoid arthritis (RA) provided a clue to Cornell Weill rheumatologist Iris Navarro-Millan, who had seen Covid patients declining rapidly, when she was treating a patient in his 60s who struggled to breathe even with nasal tubes and then a mask to dispense oxygen. Navarro-Millan tried the RA drug anakinra (with the patient’s consent). By the following morning, he no longer needed the mask, and a week later he went home.
Because autoimmune diseases are relatively rare, rheumatologists are more accustomed to relying on individual case experiences. “It’s hard to conduct large trials…to study a given drug in, for example, the sliver of lupus patients who develop cytokine storms,” writes Velasquez-Manoff. “The best evidence sometimes comes from case studies.”
In contrast, critical care doctors treating Covid have tended to rely on large studies of illnesses with symptoms closely related to those of Covid, like ARDS (acute respiratory distress syndrome) from the flu and sepsis, for which immunosuppressants did not work— and focused instead on bolstering the immune reaction fighting the virus.
Individualized treatment is especially important with Covid because of the crucial element of timing: using antivirals like remdesivir at early stages to suppress viral activity, but at a specific point when the virus is beyond control, turning to anti-inflammatories to counter immune system overreaction like the cytokine storm.
Clues to treating Covid come from people who test positive but are asymptomatic. “Their immune systems evidently handle the invasion with the perfect balance of aggression, restraint and repair—or tolerance—to stave off the disease,” explained Salk Institute infectious diseases specialist Janelle Ayres.
But until better tools exist to effectively eliminate the virus from our bodies, physicians have shifted their focus to tweaking the immune system, writes Manoff-Velazquez, “from eradicating the pathogen to helping the patient survive the pathogen.”
And while dexamethasone proved a major advance, it helped only those patients needing a ventilator (36%) or those on supplemental oxygen (18%) —but for less sick patients slightly increased the risk of death.
Among dozens of potential remedies focused on prodding the immune system now being studied, colchicine—used for thousands of years to treat gout, a type of arthritis—has few side effects and exists in pill form. Thus, it’s a simpler option than the more serious cancer drugs and high-tech “biologics,” antibodies manufactured in living cells, that are mostly given intravenously.
Large-scale studies on new treatments, however, may take a while to produce results impressive enough for general use. And even then, rheumatologic expertise may be what helps physicians do the necessary tailoring of treatments for individual patients, considering everything from their pre-existing conditions to crucial timing in the progression of their Covid infection.
For more immediate concerns, get a flu shot—though for sufficiently long-lasting protection, wait until the end of September. For those 65 and older, two vaccine options produce a stronger immune response than the standard dose—with the choice depending on your doctor’s advice: high-dose Fluzone, which contains four times the amount of antigen, and FLUAD which includes an adjuvant for extra boost. No research has yet compared these two.
And always: wear a mask.
—Mary Carpenter
Well-Being Editor Mary Carpenter is on a mission to keep us updated on Covid-19. To read more of her posts, click here.
“DON’T GO for the knee replacement until you are really suffering,” advised my orthopedist, “Otherwise you won’t be happy with the new knee.”
What I understood from his words was that, more than most medical decisions, this one is based on subjective criteria and mine alone to make. (The knee cartilage wore away years ago following arthroscopy and a meniscus repair, but mostly from arthritis and years of use.)
For problems with the body’s skeleton, including bones, joints, tendons and muscles, individual variations in body as well as mind—personal responses to pain and disability—make it difficult to generalize about which specialties and which treatments are most helpful, but the interventions are irreversible and not to be undertaken lightly.
For many people, one skeletal problem area that can be the root of much bigger ones along the way but is often ignored, overlooked or forgotten is the big toe. Its dysfunction is capable of throwing off and sometimes requiring replacement of the bigger joints, upwards from toe to head: ankles, knees, hips and even shoulders. “Unlike their parents, Baby Boomers do not accept foot pain as a natural part of aging,” according to Boston foot and ankle surgeon John Giurini. Even so, many boomers find themselves facing knee or hip replacement —or at least foot surgery—because of difficulties that began in the big toe years before.
Also, the same advances in medical technology that offer relief from big-toe problems—also used for hips and knees—can create unduly “high expectations, sometimes too high,” according to Cleveland foot and ankle surgeon Stephen Frania.
With each step forward, the big toe supports 50% of the body’s weight, making the MPJ or metatarsophalangeal joint the most likely target for osteoarthritis or posttraumatic arthritis and leading to hallux rigidus —loss of movement— or “stiff big toe.” (Hallux limitus is decreased movement.)
Hereditary or congenital defects in the foot or faulty foot mechanics can trigger arthritis, as can certain athletic activities—for example, “turf toe” in athletes who play games on artificial surfaces, which is caused by the sudden bending back of the big toe. Some studies suggest women are more likely to develop hallux rigidus.
Of the two most common traditional big toe interventions, cheilectomy involves removing damaged cartilage along with spurs or overgrowths and allows for immediate weight-bearing after the procedure. By contrast, surgical fusion or arthrodesis can require weeks or months off the foot to give the two joint bones that have been fixed in place time to heal together. Fusion also removes remaining motion from the MPJ.
The newest intervention involves synthetic implants, such as Cartiva, which is made of the same material used in contact lenses and designed to mimic natural cartilage found in the joint. Implants create space between the bones and allow for more movement than the other alternatives. Used in the U.S. since 2016, implants offer the possibility of weight-bearing on the joint as soon after surgery as tolerable, often the next day.
Cartiva has also proved helpful for knees. In a study of long-term benefits, 18 patients, average age 54, reported improvement five to eight years after surgery. On the other hand, there are so many options for failing knees, including constantly emerging new options for knee replacements like the “Chicago knee,” that deciding on an intervention becomes almost impossible.
Before big-toe surgery, Brigham and Women’s chief podiatrist James P. Loli, writing on a Harvard Health blog, recommends a first step of investing in properly fitted shoes —noting that foot length and width change with age, and many people fail to have their feet properly measured “for years.”
After shoes come orthotics, with three options: over-the-counter, “kiosk-generated” and professional custom orthotics. For a person “of average weight, height and foot type and with a generic problem such as heel pain,” OTC or kiosk can work fine —though they made need more frequent replacement, according to Loli.
Specific problems that may do better with prescription orthotics—more expensive and usually not covered by insurance—include severe flat feet as well as poor circulation and neuropathy (loss of feeling). Neuropathy—suffered most severely by those with diabetes — can be idiopathic, with no known cause, or follow traumatic injury, exposure to toxins, or infection—in my case, Lyme disease.
Visiting a podiatrist for a toe blister that worsened unnoticed because of neuropathy brought up questions for me similar to those seeking help for an aching big toe—and many other orthopedic issues —such as how bad is the discomfort, and it’s just a toe. At what point is it time for a medical intervention and how to choose the best one?
When I confided my worries that I had waited too long with the blister, the podiatrist told me, “The woman who came in yesterday, she’ll probably lose her leg!” But when I expressed sympathy for the woman, a diabetic, who made my neuropathy seem insignificant, the podiatrist assured me: “Neuropathy is neuropathy. But you won’t lose the toe.”
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
AMONG CAUTIONARY tales about the value of testing for the coronavirus comes the recent one of sailors on a fishing boat who received both virus and antibody testing before embarking — after which one sailor became so ill he required hospitalization, and 103 more became infected.
Headlines for the story touted the sparing of three sailors who had tested positive for coronavirus antibodies, indicating the good news that coronavirus antibodies can be protective. On the other hand, six sailors had originally received positive antibody results, but on retesting three were proven to be false positives.
Meanwhile, some countries, notably in Latin America, are paying serious attention to public health issues linked to the risk of serious illness caused by coronavirus infection—the so-called lifestyle-related diseases like obesity, diabetes and heart disease—by passing revolutionary anti-junk food laws.
Around the U.S., the “new velvet rope,” offered by medical concierge services at swank parties as well as by event and festival organizers, is private rapid testing; participants are admitted only after their tests come back negative. Rapid-result tests are available at locations around the country, but some involve waits of six hours or more in line or limited supplies that require arriving hours ahead of the dawn opening. Elsewhere people wait 7 to 14 days for test results.
As evident in the case of the sailors, though, it can take the coronavirus more than a week—and sometimes two—to show up in virus tests, making negative results far from definitive. “You can’t go to a house party the week before you see Grandma,” Demetre Daskalakis, New York City’s deputy commissioner of disease control told the New York Times— the reason the two-week quarantine is the preferred option.
Among the nearly half of U.S. states that require testing and/or quarantine for visitors from high-risk locations, New York imposes a two-week quarantine regardless of test results for visitors from high-risk states—those with a seven-day rolling average of positive cases exceeding 10 per 100,000 residents, or positive results in more than 10% of tests.
Maryland and Virginia have appeared on New York’s “restricted” list of more than 30 states for most of the summer, while D.C. has been on and off, and as of the end of last week was back on again.
For everyone, the mask remains essential protection, but must be removed immediately if wet. Because viruses thrive in wet, warm material, anyone removing a wet mask should touch only the ties or elastic bands—not the material or the face—and afterwards wash everything.
Recent reports on a North Carolina study suggested that some masks, notably gaiters, were ineffective or worse—while in fact the research had focused only on creating measurements for mask effectiveness and had assessed just one person wearing a gaiter—an inconclusive “N-of-one.”
What determines the success of any mask is fabric and fit, according to Virginia Tech professor Linsey Marr, who specializes in aerosols—and whose children wear gaiters. Masks with more than one layer of fabric —including inserts of material like Kleenex—do better than those with just one layer.
The WHO recommends cloth masks of three layers, of which the innermost layer should be wicking material such as soft cotton¯and the outermost layer, a fabric with some water resistance.
Every choice of mask requires compromise on one or more of the variables—fit, breathability, ease in taking on and off. While offering a list of good options, Wirecutter points out that “the best cloth face mask is the one you will wear (and not fuss with).”
Until a vaccine becomes available, the focus remains on antibodies and herd immunity. For this coronavirus, experts have begun to recalculate the percent of people with antibodies required to achieve herd immunity—meaning enough protected people to halt the virus’s spread among the population—down from 70% to 50% or lower.
Previously the target statistic was an R0—the reproductive number for the virus—of one, meaning that each infected person spreads it to only one additional individual. But that “doesn’t happen in real life,” Yale Global Health Institute Director Saad Omer told the New York Times—pointing to wide differences in density and demographics even among nearby locales.
Looking instead at locations, ranging from counties to neighborhoods, and comparing variables such as average age and income levels has turned up extreme differences in the numbers of people with antibodies—or example, 68% of those tested in Corona, Queens, compared with only 13% in more affluent Cobble Hill, Brooklyn.
Even among those who question the degree of protection created by antibodies, many agree that subpar levels of “herd immunity” might help residents in future waves of infection because “the same level of behavior change will have more effect on the disease now than it did four months ago,” according to Australian mathematician Joe Miller.
In Mexico, new anti-junk food laws that prohibit the sale of sugar-sweetened beverages and highly processed foods to those under 18 years old are “a huge win for public health,” according to Yale public health professor Rafael Perez-Escamilla. Another Mexican law taking effect in October requires black stop signs on packages of foods that are high in saturated fats, added sugar and sodium, and calories, which cannot be sold in schools.
“The pandemic has created an explosion of awareness about why Mexicans are so vulnerable to certain diseases,” writes Laura Reilley in the Washington Post—with 73% of Mexicans considered overweight and 34% “morbidly obese,” compared with the U.S. in 2017-2018: 42.4% obese and 9.2% “severely obese.”
The epidemic of lifestyle-related diseases and the coronavirus pandemic are “harmfully synergistic,” according to Dariush Mozaffarian, dean of the Friedman School of Nutrition Science and Policy at Tufts University. Ultra-processed foods —low in nutrients and high in calories, but also less expensive and more shelf-stable—have increased in variety and popularity during the pandemic.
One Mexican official described sugary drinks as “bottled poison.” Along with washing hands and wearing masks, says Mozaffarian, improving metabolic health “should be the third leg of the stool.”
—Mary Carpenter
Well-Being Editor Mary Carpenter is on a mission to keep us updated on Covid-19. To read more of her posts, click here.
“I HAVE antibodies, I had a positive antibody test,” said 20s-something budding actress R.P., who had never experienced symptoms of Covid-19. “I’m safe, and I don’t need a mask.”
But “immunity is a Rube Goldberg machine, a choreography of different proteins and cells that results in the body fending off a pathogen,” according to STAT —one reason to question, at least for now, the idea of an “immunity certificate” for anyone who has recovered from the virus or had a positive antibody test.
“The immunity that develops naturally during infection is suboptimal and short-lived in most people,” said Yale viral immunologist Akiko Iwasaki. While coronavirus antibodies may be effective for only two to three months in individuals who have been infected, their endurance may be even less in those who were asymptomatic.
As of late July, the date for expecting a safe and effective vaccine may be as soon as late December or early next year, according to NIH infectious diseases expert Anthony Fauci—with wide availability “several months” into 2021. But caveats remain about the possibilities that a vaccine will offer only short-lived protection and that adequate production, especially for a vaccine that requires two doses, could take up to two years.
Meanwhile, numbers are rising of Covid-19 “long-haulers”–those with lasting heart damage and post-viral symptoms similar to Chronic Fatigue Syndrome (CFS), which occur even in those who were asymptomatic. More than 80% of survivors of the earlier coronavirus SARS reported long-term symptoms.
Of 100 young Germans returning from ski vacations who had recovered from the virus, changes in the heart, such as inflammation, showed up on MRIs of about 75%, compared with those of controls.
Fauci compares a group of post-Covid-19 symptoms to CFS (also called myalgic encephalomyelitis, or ME/CFS), whose sufferers number about 2.5 million Americans—many of whom trace their illness to an acute episode of infectious disease, including mononucleosis and flu.
The cardinal symptom is “post-exertional malaise”—not fatigue alone but “a prolonged relapse of exhaustion, cognitive dysfunction and other symptoms after a minimal amount of activity,” according to STAT. While British physicians in the past advised CFS patients to resume regular activities as soon as possible, many now view the treatment as outdated and harmful.
Also outdated is concern about fomites, surfaces that spread the virus. “Surface transmission of Covid-19 is not justified at all by the science,” according to Rutgers microbiologist Emanuel Goldman, whose research just published in The Lancet showed erroneous conclusions came from studies using “unrealistically strong concentrations of the virus.”
“As many as 100 people would need to sneeze on the same area of a table to mimic [the] experimental conditions,” according to the Atlantic. In a famous March outbreak in a Seoul skyscraper, about half the members of a call center located on one side of the 11th floor got sick, but despite sharing elevators, less than 1% of 1,000 workers and residents throughout the rest of the building contracted the virus.
To counter both the “prevention fatigue” of people getting too much information and the false security conveyed by constantly spraying surfaces, Goldman advocates focusing on airborne transmission—notably in bars, indoor restaurants and gyms, “where patrons are huffing and puffing one another’s stale air.”
Finally, breathing practices now feature among the prescriptions given by some British physicians to improve respiratory health, both to help protect against the virus and to combat the disease in those who become infected, according to James Nestor, author of the forthcoming book Breath: The New Science of a Lost Art.
At Queen’s Hospital in London, the director of nursing recommends a breathing routine that involves taking an abdominal breath—breathing deeply enough that the lower abdomen expands—followed by a short breath-hold, repeating five times, and ending with a cough. The “perfect breath,” according to Nestor, involves taking about 5.5 breaths a minute—with each inhale and each exhale lasting about 5.5 seconds—which can help the diaphragm drop lower and rise higher, allowing more air to enter the lungs.
People today tend to over-breathe, taking 12 to 20 breaths a minute, which can stress the heart and nervous system. Nestor also recommends breathing through the nose, which produces nitric oxide (NO) that improves both the lungs’ ability to absorb oxygen and the transport of oxygen throughout the body—and can kill bacteria.
Researchers are studying inhaled NO treatment for Covid-19 patients—to dilate the arteries to increase blood flow, dilate the airways to increase oxygen delivery and directly inhibit the growth and spread of coronavirus in the lungs.
Wearing a mask is still the best protection against this coronavirus. Even masks that don’t protect perfectly can lower the viral dose, which means less severe illness. In the Czech Republic, for example, which required masks starting in mid-March, the death rate remained flat even when case numbers occasionally increased—meaning those who became infected didn’t get severely ill.
What might spur more vigilant mask wearing are the 14-day quarantines now required for people traveling from high-risk locations —a list on which D.C., Maryland and Virginia joined more than 30 other states in July. The definition of high risk is more than 10 new cases a day per 100,000 people in a rolling or moving average—updated every day—of the previous seven days.
In D.C., for example, with a current population of 705,749, more than 70 new daily cases on the rolling average means that District residents traveling to New York must quarantine after arriving—as must anyone traveling to D.C. from states like Delaware. By early August, D.C. decreased its case numbers far enough to be removed from the list, as did Delaware.
More than 25 cases per 100,000 people means a community should issue stay-at home orders, according to Harvard ethicist Danielle Allen, although many experts argue that “only a nationwide lockdown can contain the virus now.”
—Mary Carpenter
Well-Being Editor Mary Carpenter is on a mission to keep us updated on Covid-19. To read more of her posts, click here.
THE STANDARDkidney assessment adjusts for the dated racist assumption that black people have higher muscle mass and thus better kidney function. The test results—deeming the kidneys of many black patients in better shape than they are—can delay treatment or eligibility for transplant, often placing patients so low on wait lists that they die before having the chance to receive a new kidney.
Among racist medical practices recently receiving new attention, the dearth of images using dark skin in dermatology medical literature can impede the assessment of rashes on the toes and elsewhere linked to Covid-19—and lead to life-threatening incorrect diagnoses.
More difficult to address are the racist medical practices that stem from “implicit bias,” which includes a range of beliefs, especially affecting evaluation of pain. At least one life-threatening consequence of treating black patients differently is the three and a half times greater likelihood of healthy black children dying during surgery compared with white children.
While high rates of adult black patients’ deaths during surgery are often traced to overlapping health conditions or risks, black children with no underlying conditions still had a higher rate of death and complications after both elective and emergency procedures than their white peers.
Among outdated racist practices and beliefs from the past that persist today, commercial spirometers used to diagnose and monitor respiratory illness have a “race correction” built into the software to control for blacks’ “lack of lung capacity,” as described by Thomas Jefferson.
The spirometer’s designer, Louisiana physician Samuel Cartwright, estimated blacks’ lung deficiency at 20% and suggested treatment using forced labor to “vitalize” the blood. (Cartwright also described a disease of the mind called drapetomania that caused enslaved people to run away from their enslavers.)
While the proportion of images using dark skin in dermatology textbooks ranges from 4 to 18%, the one exception is sexually transmitted diseases—with images using black skin appearing twice as often for infections that are sexually transmitted, compared to 28% of images using black skin for infectious diseases in general.
The dermatology bias creates a painful reminder of the Tuskegee researchers who withheld diagnosis and failed for decades to treat black men with syphilis. Black skin was also the object of racist experimentation in the 1900s by Georgia physician Thomas Hamilton, who created blisters and then cut into the skin of one slave while attempting to prove that black skin was thicker than white skin.
While areas of medical bias, such as textbook images, may take longer to correct, objective measurements involving the spirometer and kidney tests could be easy to change. The kidney function test that measures “estimated glomerular filtration rate” (eGFR)—the ability of the kidneys to filter waste from the blood—includes a variable of race (along with age, gender and levels of the waste product creatinine) that allows for only two groups, black and not black, with points added to raise the scores for those in the black group.
Individual medical institutes have started adjusting for muscle mass instead of race, but some physicians argue that any role of muscle mass is medically unfounded and call for eliminating this variable entirely. To date the National Kidney Foundation has “declined to comment on eGFR testing,” according to STAT; the foundation has convened a task force but is not expected to change the test.
Looking at implicit bias in medical practice, studies of medical students repeatedly find widespread beliefs that “black people’s nerve endings are less sensitive than white people’s… their skin is thicker.. their blood coagulates more quickly,” writes University of Washington health researcher Janice Sabin.
Implicit bias has the most impact in medically ambiguous situations. For pain that has no clear cause, such as traumatic injury, providers rely more heavily on their personal judgment. In addition, the media often exposes medical providers to stereotypes and images, that, for example, associate black people with substance abuse and drug-seeking behavior.
A meta-analysis of research over 20 years that included many sources of pain found that black patients were 22% less likely than white patients to receive any pain medication—with the greatest disparities for conditions like backache, migraine and abdominal pain.
Many people find it easier to recognize pain in faces like their own—making it easier for white medical providers to assess pain in white faces. “We are in the midst of an Implicit Revolution,” writes Sabin, “bringing new insights into how our minds work…we operate at the unconscious level much more than we ever imagined.”
Exercises like taking the “Implicit Association Test” can help medical providers recognize and acknowledge their biases. And learning about disparities in pain management can help clinicians improve their practices. But some experts put their greatest hope in finding more objective measures—for pain, a blood test using biomarkers could measure intensity.
In White Fragility, Robin DiAngelo explores the evolution of racism in American medicine. Early in U.S. history, “tension between the noble ideology of equality and the cruel reality of…enslavement…had to be reconciled. Jefferson and others turned to science…Race science…legitimized racism and privileged the status of those defined as white.”
She explains, “The idea of race as a biological construct makes it easy to believe that many of the divisions we see in society are natural. But race, like gender, is socially constructed. Under the skin, there is no biological race.”
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
BY NOW, many people know the story of the two Missouri hair stylists who saw 139 clients while they were developing symptoms of Covid-19 until they each tested positive for the virus. Yet not one of the 104 clients who agreed to be interviewed became infected. Both stylists and every client had worn some face covering.
Said CDC Director Robert Redfield , “If we could get everybody to wear a mask right now, I really think in the next four, six, eight weeks, we could bring this epidemic under control.”
Last week, along with viral transmission via infected persons and contaminated surfaces, the World Health Organization added airborne particles that “defy gravity—able to hang in the air for many hours or even days, and travel the length of a room,” according to Kobe University fluid dynamics expert Makoto Tsubokura.
The best defense against aerosolized virus particles: diffusing and diluting them by opening windows and doors, ensuring HVAC systems circulate fresh air, even using small desk fans—and always wearing a mask. Since February, the Japanese have kept Covid-19 numbers down by countering airborne particles and avoiding “the three Cs”: cramped spaces, crowded areas and close conversation.
For anyone needing extra motivation to take strict precautions, however, the more time that passes before becoming infected means better chances of recovery as treatments continue to improve.
Although statistics on deaths have many confounding variables—ages of patients, numbers getting tested—in one Milan hospital, among patients about the same average age, from March to May, the percent of Covid-19 patients who died dropped from 20% to 2%.
For treating Covid-19, the greatest challenge is the drastically different remedies that work at each stage of infection— but could prove deadly if mis-timed —from antivirals early on to steroids and other medications to counter later-stage immune system overreaction.
Early-stage virus treatments all await more research. As the virus enters alveolar cells in the lungs that transport oxygen to the blood, it turns the cells into viral copy machines and blocks normal cell operations.
The antiviral drug remdesivir interferes with the enzyme that allows the virus to reproduce—both reducing amount of virus in the body and improving the lung disease caused by the virus. Remdesivir in one study to date reduced the hospital stay for 1,000 Covid-19 patients to 11 days compared to 15 for those taking a placebo—but was less effective in sicker patients, including those on a ventilator.
In the later stages of Covid-19, cytokines signal the body’s immune system to send “repairing blood” to the infected cells. With overactive cytokines, however, the lung cells drown—even those not yet infected—blocking transportation of oxygen into the body. The result, ARDS (acute respiratory distress system), is the cause of death in most Covid-19 patients.
In addition, overactive cytokines make blood vessels more permeable to facilitate passage of immune cells from the blood to attack the virus. But too much permeability stimulates the clotting system to produce a proliferation of little blood clots throughout the body, with results that include stroke as well as heart or kidney failure.
Among other remedies, convalescent plasma and monoclonal antibodies each have the potential to combat the virus at various stages of the infection—as well as for prevention in healthy people—but production in sufficient quantities is tricky.
Convalescent plasma from recovered patients—used for more than 100 years to treat everything from measles to SARS —can block the virus from infecting cells. Currently limited to intravenous administration, plasma has proven safe in almost 30,000 hospitalized patients in the U.S.
But its effectiveness remains uncertain in the absence of research that includes a control population. In addition, plasma collection has many requirements: donors must have received a positive test result for the virus, have had no symptoms for 14 days, currently test negative, have high enough antibody levels in their plasma—and have a blood type compatible with the patient receiving the donation.
Monoclonal antibodies—biotechnology drugs that can block the virus—are increasingly the focus of attention for Solidarity, WHO’s program to coordinate coronavirus research in different European countries, as well as for Operation Warp Speed in the U.S. Again, the challenge might be producing sufficiently large quantities.
Finally, the best treatment for late stage Covid-19 may be steroids—in particular, dexamethasone. But the timing of steroids is a balancing act—not so early that they suppress the immune system while it is still needed to fight the virus, but not so late that over-reactivity has become a death sentence.
Dexamethasone reduced deaths by one-third in patients on a ventilator in the massive U.K. Recovery Program that has enrolled 12,000 patients in hundreds of participating hospitals.
Meanwhile, a word-of-mouth treatment that has proved helpful is “proning,” also called “tummy time,” which involves flipping Covid-19 patients onto their stomachs to give the lungs more room to fill with air—compared with the supine position where the position of organs against the lungs can make it harder to breathe.
For many patients, a combination of several therapies given at different times during treatment has helped with recovery—as has greater awareness of “silent hypoxia,” when the lung cells are becoming dysfunctional in the absence of other symptoms.
As wait times for test results increase with recent surges of Covid-19 cases in the U.S.—making it harder to know an individual’s current infection status—the need to observe strict social distancing becomes more important. In an effort to create more useful messaging, Marm Kilpatrick, infectious diseases researcher at the University of California Santa Cruz suggests: “Wear a mask. Meet Outside. Give Space.”
—Mary Carpenter
Well-Being Editor Mary Carpenter is on a mission to keep us updated on Covid-19. To read more of her posts, click here.
Everything (Almost) You Should Know About Sunscreen
INTO THE selection process for best sunscreens (those offering the most protection with the least risk of harm) enters a new variable: blue light from device screens, which may increase pigmentation and effects of aging on the skin.
At a 2019 sunscreen symposium, “there was unanimous consensus among chemists and FDA personnel there that we do need to start to include blue-light protection into sunscreens going forward,” according to Miami dermatologist Loretta Ciraldo.
That iron oxide is the only sunscreen ingredient offering protection against high-energy visible (HEV) light from device screens adds to the advantages of “mineral”—versus “chemical” — sunscreens, said dermatologist Shari Marchbein at New York University School of Medicine.
While chemical ingredients “don’t do anything” to protect against HEV light, according to Marchbein, other mineral ingredients like zinc oxide provide some protection because of their light-scattering components. Although dermatologists predict a proliferation of blue-light-specific products, for now only a few contain iron oxide, including Elizabeth Arden’s PREVAGE city Smart Broad Spectrum and Murad City Skin Age Defense.
Meanwhile, in interim reports for an updated FDA “Guide to Sunscreens” —promised for January of 2020 and now expected in November—the only two ingredients to receive a GRASE (generally recognized as safe) rating are titanium dioxide and zinc oxide, both found in mineral sunscreens.
While unlikely, come November, the FDA could make all chemical sunscreen ingredients illegal. Another warning in the 2019 FDA “proposed” requirements: to protect sunscreens from excessive heat and direct sun, wrap them in towels or keep them in coolers or in the shade.
Additional sunscreen warnings from about one-third of dermatologists extend to all spray formulations. These include the greater difficulty assessing if and where adequate amounts have been applied as well as the risk of inhalation, especially if sprayed near the mouth.
Chemical sunscreens, however, including ingredients like oxybenzone, receive higher marks for protection from Consumer Reports. Another advantage: many offer “very water-resistant” protection for 80 minutes—compared to the limit of 40 minutes for most mineral options.
Oxybenzone tops the list of sunscreen-ingredient warnings from the Environmental Working Group. Among several sunscreen ingredients that can enter the bloodstream and remain in the body for extended periods of time, oxybenzone can disrupt hormones and has been linked to increased risk of endometriosis.
But the EWG reserves its biggest warning for the failure of most sunscreens to protect against UVA rays, which penetrate the skin more deeply and are more difficult to block. UVA rays suppress the immune system, may contribute to skin aging and are associated with higher risk of melanoma. Zinc oxide does the best job among sunscreen ingredients of protecting against UVA, followed by the chemical avobenzone.
In addition, the EWG warns against high-SPF products, arguing that increased SPF diminishes UVA protection. For this reason, people who rely on high-SPF sunscreens “may expose themselves to more harmful ultraviolet radiation…people trust these high SPF products too much,” according to the EWG’s Guide to Sunscreens.
Because of FDA restrictions on ingredients and concentrations, U.S. sunscreens offer far less protection against UVA than UVB rays, and this is worse for products with the highest SPF values,” according to the EWG. For this reason, Europe permits the sale of fewer than half of American products with SPF over 50.
Of UVA-protective ingredients permitted in European sunscreens but not in the U.S., the FDA has allowed Laroche-Posay to use ecamsule (Mexoryl) in one product, “Anthelios SX,” a moisturizer with an SPF of 15 but clearly marked “Mexoryl SX.” For wider FDA approval, the parent company L’Oreal would need to fund further research, but ecamsule is one of the chemicals absorbed by the body and thus opposed by the EWG.
The EWG also questions the “broad spectrum” claim for many products due to lax standards for using the label. “One study found that participants who used a poor-quality broad-spectrum sunscreen for two days on a tropical beach got the same UVA exposure as those visiting a tanning salon once.”
Another worry about UVA rays is that they penetrate glass, according to the American Cancer Society, making it important for anyone sitting indoors near sunny windows to reapply sunscreen every two hours—the same as anyone spending time outside.
Blue light—potentially contributing to effects similar to those of UVA rays—may be another reason to wear sunscreen indoors. While sun is the main source of HEV light, we get a “significant dose” from screens and indoor lighting, according to Marchbein. Blue light may also contribute to cataracts, glaucoma and other eye diseases.
The limited research to date showed blue light caused hyperpigmentation but only in people with darker skin tones. Other evidence suggests that blue light contributes to photoaging, leading to wrinkles and skin laxity. And, anecdotally, dermatologists report seeing new patterns of hyperpigmentation that may be related to holding cell phones against the cheek.
Waiting for “the majority of sunscreens [to eventually] protect against blue light,” Ciraldo suggests lowering brightness levels on screens to 50% or go to the darker “night shift” setting to help prevent skin damage.
In the end, Marchbein cautions that blue light also provides many benefits — “plays a critical role in maintaining good health… regulates our body’s circadian rhythm…elevates mood and helps memory and cognitive function.”
With no sunscreen excelling in the selection process on best protection with least harm — and all potentially creating the same false security as those with high SPF — the best protection against damaging rays may come from elsewhere: stay indoors as much as possible during peak sun hours from 10am to 4pm and otherwise wear long sleeves and a large hat.
Off-hours, though, enjoy warm, bright sunlight whenever possible. Allow device screens lights to stay sufficiently bright to enable reading without strain. And do whatever else it takes to keep from worrying about one more thing.
—Mary Carpenter
Every Tuesday, well-being editor Mary Carpenter delivers health news you can use.
A DC–REGION childcare worker in her mid-20s, M.R. returned to work on a recent Monday with a skeleton staff to prepare for reopening before the kids arrived. On Tuesday night, she learned a colleague had just received a positive Covid-19 test result; the center had suspended reopening—after alerting everyone involved; and she needed to get tested.
For a pandemic that has been underway for more than six months, the surprisingly complicated decisions M.R.—or anyone without symptoms seeking reassurance after possible exposure–must make include how long to wait for the best chance that a test could detect the virus; where to be tested —at no cost and conveniently close to her D.C. apartment, or elsewhere; and which kind of test (among polymerase chain reaction tests for the virus, not the serological antibody test) to get.
Information at Penn Medicine—linked from a D.C. testing information site—is current but shows how murky the situation continues to be: “Since COVID-19 tests are new, knowing the accuracy is challenging. The accuracy and predictive values of SARS-CoV-2 testing have not been evaluated and the accuracy of testing depends on which test is used, the type of specimen tested, how it was collected and the duration of illness.”
Testing on the day of exposure will fail to detect active virus 100% of the time. For those who develop symptoms, a test given three days after the symptoms start will still produce negative results 20% of the time, according to Harvard Health Publishing. (Because the common swab test works by detecting genetic material from the coronavirus, positive tests are almost 100% accurate.)
Testing four days following exposure will still fail to detect active virus 40% of the time—because of the low number of viral particles in the nose or saliva by then, according to Harvard Health Publishing. And the biggest risk of false negatives is the false confidence they offer—enabling those tested, along with everyone around them, to believe they are out of the woods, not contagious and do not need to take precautions.
On contact tracing, Frieden adds, “What good is testing if contact tracing doesn’t identify and warn exposed people quickly?” The latest research suggests that “people may actually be most likely to spread the virus to others during the 48 hours before they start to experience symptoms,” according to Harvard Health.
Looking for a local test site can also be tricky, with choices varying among states and even among regions within states. For example, of four Yale-affiliated hospitals in Connecticut, three offer tests with results in seven hours while a fourth in New London takes “much longer,” according to a local health clinic.
“It may take a lab about 24 hours to run your test,” according to WebMD. But you might not get your results for several days. Future tests might be faster.” Official D.C. testing sites must mail test results rather than communicating them online or by phone.
While the CDC lists “point-of-care” swab tests that produce results on-site within an hour, there is still no evidence to support use of these tests in clinical settings, according to the Center for Evidence-based Medicine.
In D.C.,information on testing sites is in flux. Anyone with health insurance might do best to make an appointment at a medical facility rather than opting for the free fire-station test conveniently located around the corner, because most free test sites offer limited hours, the likelihood of long wait times —relevant for M.R. and others—and have strict residency requirements.
Specific CVS pharmacies offer testing but require filling out a strict questionnaire to qualify, which eliminates most people who have no symptoms or do not work in healthcare.
Alternatives to the common swab test are still in the research stage. For those that use saliva, early reports suggest fewer false negatives. In the U.S. these appear to be available only under emergency-use authorization and often with high price tags—but this situation is also in flux. Trials involving thousands of volunteers on an at-home saliva test are underway in the U.K.
In recent news, “an instant coronavirus breathalyzer,” developed by an Israeli team at Ben-Gurion University, can detect the virus in exhaled breath; produces results within a minute; and has a “success rate of 90%” in trials to date. In the handheld device, which looks like a small kazoo, a chip with densely packed sensors capture tiny particles, including viruses, in the breath.
Each device can process about 4,000 individuals a day, which allows for easy testing of travelers at airports and train stations—and reassurance seekers everywhere. The device could receive fast-track FDA approval by September.
“Strip tests” could also help with testing larger numbers of people, although positive results from these require followup from a swab or saliva test. Strip tests currently in development involve spitting into a tube and then inserting a paper strip containing proteins or another substance that detect the presence of the virus. The main advantage is cost—as low as $1 to $5 a day for regular, repeated testing—compared to $50 to $150 for each standard swab test.
For now, the U.S. is considering pooled testing—cheaper, easy to repeat regularly and most useful for schools, offices and factories. Labs take individual samples, set aside part of each sample, and combine the rest into batches of 5 or 10 samples each: if a pool yields a positive result, the lab retests the remaining part of the sample from each individual in that group.
For years, the method has worked well for screening pooled samples of donated blood, and it can increase testing capacity by at least 70%, according to a Nebraska state lab director. But pooled testing is less useful when the percent of those infected rises above 10 per 100 people, because too many samples must be retested, with an added delay of several days for each person to learn their result.
In M.R.’s case, because her exposure may have begun on the Monday morning when she started work, waiting until Friday for testing should have given her about a 60% chance of an accurate result. She also needed to begin an immediate self-quarantine—for 14 days, because the virus’s incubation period can last that long—during which, in an ideal world, to reassure herself and others, she should be able to get a new test every few days.
—Mary Carpenter
Well-Being Editor Mary Carpenter continues to update us on Covid-19. To read more of her posts, click here.
IN OUR 20s, my best childhood friend, Lizzie, told me she’d recently almost died from fatty liver disease, which neither of us had heard of and she could not explain. Today, the aggressive form of fatty liver disease may soon become the number one reason for liver transplants.
The benign condition, non-alcoholic fatty liver disease (NAFLD), affects about one-third of Americans — more than 80 million, compared with 35 million for both types of diabetes combined, although the conditions are related. NAFLD occurs in 40 to 80 percent of people who have type 2 diabetes, as well as in 30 to 90 percent of people who are obese.
(Newly diagnosed cases of diabetes linked to severe Covid-19 may have arisen in conjunction with NAFLD: in these patients, levels in the blood of both sugar and ketones are extremely high. Fatty deposits in the liver produce ketones to prevent starvation when insulin levels fall too low to metabolize sugar.)
Benign fatty liver disease can cause fatigue and abdominal pain but most often has no symptoms, and diagnosis usually arises only in the course of treating other conditions. Experts compare NAFLD to “pre-diabetes,” requiring attention only to prevent an advance to the more aggressive form of the disease.
Aggressive liver disease, called NASH (for nonalcoholic steatohepatitis), causes scarring, which leads to cirrhosis in about 5 to 10% of patients. Besides fatigue, symptoms of NASH include severe abdominal pain and swelling, weight loss and sometimes reddish palms and yellowing of the skin and eyes. Risk of developing NASH increases for patients who are obese and have poorly controlled diabetes.
Of about 30 million Americans with NASH, 90% are either overweight or obese—although about 7% with the disease are “lean.” Genes play a role, with the genetic variant linked to fatty liver disease, PNPLA3, present in about 18% of African Americans, 25% of European Caucasians, and 49% of Hispanics, who are “disproportionately affected by fatty liver disease,” according to Jay Horton, nutrition director at UT Southwestern Medical Center. For people with this gene, obesity is like “a switch that turns the [fatty liver] disease on.”
The most common cause of death in NASH sufferers is cardiovascular disease, as it is with uncontrolled diabetes. High levels of glucose in the blood can damage blood vessels and the nerves that control both the blood vessels and the heart. People with diabetes tend to develop heart disease at a younger age and are nearly twice as likely to die from heart disease or stroke than those without diabetes.
“The connection between fatty liver and early signs of plaque in the coronary arteries is increasingly compelling,” says hepatologist Tracey Simon at Massachusetts General Hospital. And excess fat around the liver and other organs in the abdomen—known as abdominal obesity —seems to accelerate the progression of fatty liver to the more serious disease.
Early detection of fatty liver disease is currently not a priority because there are no drug treatments—although many pharmaceutical companies are working on drugs to reduce fat in the liver. Finding a cure for fatty liver disease is the “next big frontier” in medical advancements, according to Rohit Loomba, chairman of the American Liver Foundation’s National Medical Advisory Committee — because the number of deaths from chronic liver disease and cirrhosis has risen every year since 2007.
On the other hand, diet and exercise can reverse most damage: The liver is capable of regenerating to become healthy and whole even with as little as 25% intact. Located in the upper abdomen just below the diaphragm on the right side extending toward the left, the liver is the largest and heaviest internal organ—in women averaging 3.25 pounds, compared to 2.71 pounds for the brain.
The liver metabolizes food to create energy by storing glucose, converting fat and breaking down proteins. The liver also clears the body of toxic substances including poisons, drugs, alcohol and waste products —which can accumulate in the body as the liver becomes impaired and in dire cases requires emergency treatment.
The best-known emergency condition is “acute fatty liver of pregnancy,” a rare complication that occurs most often in mothers with low body weight when the fetus is male. My friend Lizzie said her doctors had never seen an urgent case before in someone who wasn’t pregnant. Also, she was not overweight and drank no more than the rest of us, in our 20s in the 1970s.
After her near-death bout, Lizzie learned that she could “never drink again,” which sounded dire at that point in our lives. For most, though, fatty liver is not a disease —but, like pre-diabetes, just another reason to be vigilant about diet and exercise.
INTO THE selection process for best sunscreens (those offering the most protection with the least risk of harm) enters a new variable: 
