NEW THOUGHTS ON THE SURGICAL MASK

Previous essays I have published take the WHO ( World Health Organization) viewpoint that regular masks are not effective and do not need to be worn by the general public.  A surgeon friend of mine brought up a point that I had not considered.  He has a broader vision that all people ought to wear the regular surgical mask because it would be a social equalizer.  Now, if you see people in the street with a mask on, you have this gut reaction, they must be infectious, and you ought to distance yourself from them.  If everyone wore a mask, regardless of what type, we would all be equal and would be reminded that distance is essential, along with coughing and sneezing.

As pointed out by many previously, the N95 mask is the only mask that protects the wearer as it filters out particles the size of the virus.  These masks are not all that easy to wear.  Firstly, they must be fitted for each individual. They are tight, uncomfortable, and can actually bruise the delicate skin on the face.  Because they filter out very small particles, it is hard to draw air through them, and it makes breathing a real chore.  The common surgical type mask, on the other hand, is easy to wear and easy to breathe through and does prevent larger droplets from contaminating the environment even though it does not filter out incoming air well, especially aerosolized particles. The standard surgical mask, therefore, may protect the environment from broadcasting the larger droplet spray, but to a lesser extent, the wearer of the mask. It is the large droplets that are presumed to be the primary mode of transmission.

The history of that mask goes back to Paul Berger, a French surgeon, who in 1899 published a paper where he said, “For several years I have been worried as to  the part that drops of liquid project from the mouth of the operator, and may cause infections (in the patient on whom the operation is performed)…”.  He started to wear the cloth mask and insisted that his assistants would do likewise.  The response from his fellow surgeons was one of ridicule, just like they ridiculed Ignaz Semmelweis, who suggested we ought to wash our hands after performing an autopsy.  Ignaz postulated that “little plants” from the dead body could get on the hands, and whatever killed that person would then be transmitted to the hands and then to a new victim.  Berger suffered the same kind of insults regarding his new idea of wearing a facemask. Semmelweis, in the interim, became so convinced that handwashing was actually saving lives that he started attacking his surgeon colleagues in the local newspaper, calling them murderers.  They responded by incarcerating him in an insane asylum where he died, knowing he was right. 

Berger seemed headed for the same fate, had it not been for the famous surgeon, Jan Mikulicz. Jan also chimed in with an article that mirrored Berger’s ideas about spraying droplets while talking, coughing, and sneezing.  Jan was the protégé of another famous surgeon, Theodor Billroth. With those names as character references,  the mask became the standard for all surgeons in short order.

Just recently, an interesting experiment proved that talking/singing can spread disease.  A minister in Mount Vernon, Washington, who refused to follow the social distancing order, held choir practice, and 60 members of his choir showed up.  None of them were ill, none of them coughed or sneezed.  They just sang for two hours.  Within a few weeks, 45 of them were sick with COVID-19, and several had died, proving that just talking (or in this case singing) was sufficient to spread the virus. It is thought that the majority of transmission is by larger droplets rather than finer particle spread.  Had these singers all worn masks, it is likely that none, or at least fewer, would have been infected. Of course, that experiment has not yet been done, but it would be interesting if it were.  I would suggest the next minister who wants to break the law, that the choir participants should all wear masks, and perhaps he would kill fewer of them.

I do understand the science behind the difference between the regular face mask and the N-95 mask. Still, I will have to change my opinion and go against the recommendation of the WHO (World Health Organization) and start wearing my homemade double layer mask my wife sewed from old (washed x 3) underwear (I am serious!).

HOW TO DEFEAT COVID-19, LESSONS WE HAVE LEARNED FROM HISTORY

This is a novel experience for the whole world, no pun intended. The last time we saw anything like this was over 100 years ago. “We” may be an exaggeration, as I still had 25 years to go to exist. From historical accounts, we are handling it far better than the country did then, with the possible exception of St. Louis, which in 1918 shut down the entire city, including schools, bars, most businesses except coffin makers and embalmers.  Theater owners and musicians were the most vocal opponents, claiming their livelihood was being destroyed. When all was said and done, and the quarantine lifted several months later, St. Louis had only 31,500 of its inhabitants that contracted the flu, and only 1,703 deaths in a city of 800,000.  The rest of the country did not fare as well, 675,000 Americans died. Many towns had so many deaths they had to stack the bodies on the sidewalks outside the mortuaries.

We are currently, 3/24/2020, in the exponential growth phase, with a doubling of cases every three days in our community, and no obvious blunting of the curve.  I still see a lot of traffic on the road, plus people standing in line very close to the person in front of them, and the young who, out of school, are heading for the beach.  It seems we are not taking this very seriously yet!  Although I am an optimist, we are not following the mandate very strictly. We need to tighten up the transmission rate.  I suppose it will take some law enforcement methods to get people to comply.  The R0 is still above 1. 

The concept of R0 (pronounced R naught) is the number of people a single person with the disease will infect.  If R0= 1, then the disease will stay at its current level.  If it is less than 1, it will eventually burn itself out.  But if it is any number greater than 1, it will grow, the speed of growth dependent on that number.

Author of chart: Kiera Campell

The R0 of COVID-19 is probably around 2 now.  When you are #2 you need to try harder as the saying goes.

The current public health measures include: 

  • Frequent hand washing (for 20 seconds), and clothing especially cover clothing.
  • Keep two yards distance between individuals
  • No more than ten people in one group (that includes going to Houses of Worship)
  • Stay home and work from home
  • Cover coughs and sneezes
  • Disinfect surfaces touched by people (countertops, door nobs, etc.) The virus stays infectious for at least 4 hours on copper, but maybe for three days on stainless or plastic surfaces. A recent report from one of the Princess Cruise Ships had viral particles that were still infectious 17 days after the ship had been evacuated!
  • Don’t touch your face (where the virus gains entrance to your body)
  • Avoid contact with sick people

Notice, masks are not on the recommendation list as the regular surgical masks are not sufficient to filter out the virus when inhaling. However, a sick person who wears such a mask will limit the particulate spray if they cough or sneeze.  It takes a better mask (the N-95) to actually filter out the virus, which is currently recommended for health care workers only.  The general public is discouraged from using them as they are in short supply, thus taking away masks from those that really need it.

These are not all the measures that could be taken.  More confining measures may become necessary.  The shutting down of services could be much more severe. Food sources could be centralized and restricted to one member of a family.    An entire city or region could be shut down with armed military control of egress and ingress—the less contact of people with other people, the less chance to transmit the disease. Testing of the population, as South Korea has done, would identify the people who are at the greatest danger of spreading the virus and emphasizing the isolation of those people. One problem would be identifying those people because individuals start shedding the virus before they develop symptoms, and some remain asymptomatic, which would require largescale testing of everyone. That would require massive testing centers, and special hospitals to relocate large segments of the population and contain them.  The more stringent the measures, the more adverse the effect on our Country’s economy would result.

At this point, opening the economy back up, as suggested by some, would cost lives. What good does “Social Distancing” do? That question was answered 102 years ago. If we compare the 1918 St. Louis death rate of 31 deaths per 100,000 population per week, with strict social distancing, to Philadelphia at 257 deaths per 100,000 population per week, during no public health measures, gives us an over eight times greater mortality. Are we willing to trade loss of lives for fully stocked shelves of toilet paper? Besides, there would still be significant panic, and it would be nowhere near normal.  We have no drugs that will attack the virus, nor do we have vaccines that will prevent infection at this time.  Currently, several medications will be tested, however, to determine if there is any efficacy for them to use either as a treatment or prophylactically to prevent infections. 

Chloroquine and hydroxychloroquine are both drugs that have been around for several decades.  Their original use was for malaria treatment and prevention, as well as rheumatoid arthritis.  The Chinese experience, as well as the French experience, suggests that these drugs reduce the viral load.  This, however, has not been confirmed by rigorous scientific studies, and may just be another toilet paper fairy tale at this point.

Ritonavir/lopinavir, a combination drug for HIV, has been in use since 2000.  It impedes the replication of the virus and has shown efficacy with the MERS virus in animal studies, but when tried in China was not useful.  This drug combination is also being tested in combination with interferon-beta.  No clear results are available from that study yet.

Immunologic treatments with serum from recovered Covid-19 patients has also given hopeful results.   Ultimately making our own antibodies, stimulated by a vaccine, will be the answer.  Several vaccine trials are in Phase 1 trials.

HOW EPIDEMICS HAVE AFFECTED US

Here it is 2020, and we are still battling pandemics.  History records the first recognized pandemic in 165 AD, the Antonine Plague.  Marcus Aurelius Antonius was emperor and gets the credit as it occurred on his watch. It was a virus, probably measles or smallpox, nevertheless devastating. It killed one-third of the empire! 

We have had pandemics at regular intervals that decimated the population, but each time it seems that a smaller percentage of the people had to die. The plague of Justinian took 30 million. It was likely Pasteurella (now renamed Yersinia) Pestis, a gram-negative bacteria that was carried by fleas that infested rats. It occurred during Justinian’s reign, 541-540 AD, and is said to have thwarted Justinian’s efforts to reunite the Eastern and Western Roman Empire. From 1347 to 1351, the “Black Death” as the Plague was called, swept in from Central Asia on the backs of black rats that carried infected fleas.  It came in on the Silk Road, then transferring to merchant ships going to Genoa, Italy.  The world population had been 475 million but shrank down to 350 million.  1631 saw it for a return engagement in Italy, but later in 1665  in London, and yet again in 1885 in China and India with at least 12 million deaths. This was probably the most lethal of the pandemics so far. Europe lost half its population. It had three forms, bubonic, pneumonic, and septicemic.  The bubonic form was named for the enlarged lymph nodes that occurred in the axilla and groin called “Bubos.”  In the pneumonic form, the bacteria directly attack the lungs causing death sooner; therefore, the most lethal. The septicemic plague occurs in the bloodstream and is usually not infectious.

As a child growing up in Austria, I was always fascinated by the “Pest” (the German word for plague) columns. Most  European cities have a memorial erected to commemorate the plague depicting grotesquely posed dying humans often intermixed with devil and angel-like sculptings. Antibiotics were still far off then. Most of the first generation antibiotics, even Sulfa drugs, would have been effective against the “Black Death,” had they been available.

FJ6AKF Austria, Vienna, Graben, Pestsaule, Plague Column, 1693, detail.

In the late 1800s, the Yellow Fever virus decimated 150,000 French and Americans. This was related to the efforts to connect the Atlantic and Pacific Oceans by way of digging the Panama Canal. Yellow Fever is a viral disease transmitted, most often, by the female mosquito, Aedes aegypti. In 1793 there was an outbreak in Philadelphia, the then capital of the US. Nine percent of the population died, and the inhabitants of the city fled, including the President of the United States, George Washington.

Walter Reed, an army doctor, was the most instrumental in finally beating the disease, by control measures of the mosquito’s breeding in bodies of stagnant water and implementing extensive vaccinations. As an aside, it was Dr. Walter Reed, who gave us the procedure consent form.  When he was doing his experiments with yellow fever vaccinations in Cuba, he had the troops sign a paper that indicated there could be ill effects from what he was doing to them.

From 1889 to 1890, it was the Russian Flu that took 1 million people—followed by the Spanish Flu from 1918-1919, courtesy of the H1N1 swine flu, with 50 to 100 million deaths, the second worst pandemic. Later the 1957 H2N2 virus with 1.1 million people.  And then the Hong Kong Flu in 1968-1970 H3N2 virus took another 1,000,000. 

HIV Aids started in Africa, probably another zoonosis, a disease derived from animals. This one was transmitted from chimpanzees and began in 1981.  I remember listening to a lecture that mentioned this strange new disease that affected Haitians, Homosexuals, and Hemophiliacs.  It was something I thought would never have much to do with my career.  How wrong I was! It changed my entire approach to the surgical patient.  It has killed nearly 35 million people, including a physician acquaintance. I had an injury caring for a dying HIV  patient.  The ID doctor that cared for me, suggested I immediately cut off the finger where the injury occurred.  I didn’t follow his advice but did spend the next few anxious months checking my blood tests frequently. The newer antiviral drugs have finally made a dent in this disease, but HIV remains a formidable enemy. 

The more recent epidemics are far less lethal.  The 2009-2010 Swine Flu, another H1N1 virus, was only 200,000 deaths, SARS a mere 770, and MERS 850.  Ebola was more challenging to control and killed 11,000 people. It was named after a river, the Ebola River, which means “Black River,” sufficiently ominous-sounding, for a virus that looks like a worm under an electron microscope and has no known cure, with a mortality rate of 50 to 90%.

Our latest, now declared a pandemic, bat derived, Covid-19 has killed 11,921 as of 3/21/2020   8:43 AM EST. We have brought back an old response to epidemics, the quarantine. The process of isolating sick people was mentioned in Leviticus, and used in the Middle Ages to contain Leprosy.  In 1448 the Venetian bureaucracy imposed a 40 day waiting period before allowing ships to dock, to be sure no one on board had the plague.  The word “Quarantena” means “40 days” in the 15th-century Venetian language. 

There is good news, though.  Several drugs have shown some activity against the virus, including an old anti-malarial medicine, chloroquine. Several antiviral drugs are beneficial, and also serum from recovered Covid-19 patients contains antibodies that seem to help in very sick victims.  Based on that news, the market gained just 300 points, and then quickly plummeted by 900 points; so Wallstreet is not yet all that convinced.   

THE ONLY THING WE HAVE TO FEAR…

I confess I am a relentless optimist.  The joke of the two boys, one an optimist and the other a pessimist, portrays the difference quite well.  The pessimist got a pony for his birthday.  He sat looking at his new pony with large tears running down his cheeks. “Why so sad?” he was asked.  “All ponies eventually die!” he blurted out between the tears.  The optimist was given a room full of manure.  He was happily throwing the manure up into the air, giddy with joy.  “Why so happy?” he was asked.  “With all this horse poop around, there has to be a pony somewhere!” 

Despite all the pessimism we are steeped in, I am optimistic. One of our biggest fears is fear itself, as said so well by one of the icons of our nation, Franklin Delano Roosevelt, who uttered those words during another crisis our country faced, different but yet similar in terms of even greater risk to life, lifestyle, the economy, and need for regulation of its citizens.  A lot of damage has been done by the panic of the coronavirus, which I feel has been whipped up by the media and a lot of craziness in the social media. The rumors that the virus was created by the Chinese, the Russians, the Martians, the Jews, or the US military, with one of their weaponizing projects gone rogue, is just insane. First of all, we are not that sophisticated to create viruses (yet), although the Martians might be if they existed.  And this would be a totally new way of terrorism that has never been accomplished by humans before.  The global stock markets have shed 6 trillion dollars, while the US markets own 2/3 of that loss i.e., 4 trillion.  This seems like another over-reaction in my view. Coronavirus (COVID-19) is nowhere near the aggressiveness of other pandemics we have had.  The mortality is going to settle out at less than 1%, and the older population, especially the ones with comorbidities, are at greatest risk.  The 1918 Spanish flu, which was the H1N1 swine flu killed 100,000,000. Both MERS and SARS were more aggressive, but peaked out before widespread epidemics. China has peaked out and is on the other side of the curve both in terms of the disease and in terms of its economy. Even their domestic air travel is showing signs of recovery.   South Korea is close behind in beating the epidemic. The warm weather is coming.  All previous viral epidemics showed an amelioration when the temperature went up, and this will likely do the same with this epidemic (something good that can be said about global warming).

I do have concerns about the wisdom of shutting down the whole country with its obvious detrimental consequences to the economy, when isolating the likely susceptible at risk are the only ones that really need to be. The rest of the healthy younger population could be getting herd immunity. But all the smarter people than me with a lot of data from other countries that have gone through this seem to think that the social distancing, the school closures, limiting the number of people gathering at no more than ten, and working from home, etc. are what is necessary.  In the meantime, there are at least ten vaccine candidates out there with Moderna, Inc (Nasdaq: MRNA) in Phase 1 trials that have started today. Several anti-viral drugs that are already available have proven some efficacy against the coronavirus, as does serum from recovered coronavirus patients. Our President and Chief of Optimism thinks by July this will be contained. I do believe that everything that can be done is being done, and a lot of very smart people are involved. There are reasons to be optimistic. There really are no other choices. 

CORONAVIRUS FOR DUMMIES

My last two essays were, you guessed it, on COVID-19. That is all you hear on the radio or TV these days. In keeping with the trend, I am continuing to stir the pot. It has gone viral.  Coronavirus, true to its name, is a virus that has gone viral! 

Viruses grow exponentially (J-shaped growth curve), the fastest growth rate there is, the larger the growing population, the faster the growth, as long as the food holds out.  When the food runs out, the curve then changes to a logistic curve (S-shaped growth curve).  This curve shows a slowing down of growth. So what makes the curve slow down?  There are only two things that make the curve slow down: #1 fewer in the susceptible herd are available (either through the susceptible making themselves less available or the process makes the susceptibles less available ).  #2 the rate of growth slows down.  This happens when it takes longer to infect the next person.  This could be when people wash their hands more often, don’t go out to spread the virus, or at least sneeze into a napkin. Ultimately when the food supply runs out, both mechanisms are at work, reducing the susceptible and the rate of spread.

The number of new cases will slow down, guaranteed! But will we still be alive to talk about it? I think we will.  There are several reasons I believe this.  We are worried about it, in fact too worried! As evidenced by the stock market!  The virus is not as dangerous as the news media tells us.  The mortality rate is likely not 9% as SARS was, it is closer to 0.1% as the last flu outbreak was. The measures we are taking to reduce the number of people exposed, and the rate of spread will reduce the number of new cases.  It is common sense not to go out and buy cruise trip tickets.  It is common sense to limit your unnecessary exposure to large crowds.  It is common sense to wash your hands often.  It is common sense not to bring the virus close to the places the virus gains entry to your lungs, like your eyes, your nose, and mouth. The virus stays active for a couple of days on any surface, such as a door nob, so washing hands is not only hygienic but important.

I have been in the doctor business over two-thirds of my lifetime, and have washed my hands to the point that I have scrubbed off my fingerprints. 

They always have trouble when I need to give a fingerprint for a passport or other ID, because I obliterated them off over the years. I first learned to scrub for surgery in my third year of medical school at UCLA from one of the icons of surgery. He put soot on our hands, then blindfolded us, gave us a brush and soap, and made us scrub our hands. You would be surprised how much soot stayed on our hands and the places that were most likely to remain black, the back of our hands, the webspace between the fingers, and the space between the wrist and the palm.   For medical students, it was a minimum of ten minutes (first scrub of the day) to get our hands clean. But for our purposes, washing for 20 seconds is generally enough.  I learned a nice little trick from my grandchildren’s primary school teacher, singing the “Happy Birthday” song twice (at regular speed) is precisely 20 seconds. 

You get the virus from another person, either through direct contact or through a surface, the infected person has left some body fluids.  Avoiding other people is one way to decrease contact.  I believe that shaking hands was an ancient, rather strange custom.  It goes back to the Middle Ages when you met someone in the forest. You extended your right hand, as did the other person, to show that they did not have a dagger in it.  It was somewhat awkward standing there with both your and his hands extended, so grabbing and shaking seemed like the right thing to do. As we don’t carry daggers any more, this Middle Age custom has outlived its usefulness and needs to stop.  I vote for the Mr. Spock handshake: right hand raised at your side with the index and middle finger spread form the ring and pinky finger in a V configuration.  This is necessary because if you don’t spread your fingers, it looks like a “Heil Hitler.” And if you leave just your middle finger up, it changes the entire meaning.

Viruses, like white men, can’t jump. Therefore a yard distance between people should be enough although the CDC in an abundance of caution has now revised it to two yards unless they are coughing or sneezing. If they are, you need to get out of that room, because the sneeze generates particles that are as small as 5 microns in diameter that travel over 100 miles per hour, and can stay in the air indefinitely like any pollen sized or smaller particle.

Masks are not very helpful, except for the ill person who coughs and sneezes.  It keeps the particles that are spewed out more confined.  Regular masks, actually, are not very effective in preventing inhalation.  For one thing, the sides allow fine airborne mist to enter the space behind the mask, which is inhaled. To be effective, it has to be a special mask fitted to the individual that allows only air that goes through the mask to get to the person using it.  Those masks do not let fine mist or small particles to go through.  These are called N95 masks.    

Hugging is another one of those human customs that should go away.  I won’t even discuss kissing.  Hugging and kissing ought to go the way of arranged marriages and should be relegated to the XO on the written word.

Good Luck!! Gus Iwasiuk XOXO

LIES, DAMNED LIES, AND STATISTICS

Mark Twain by A.F.Bradley ©       Benjamin Disraeli  Photos.com/Jupiterimages ©

“There are three kinds of lies: Lies, Damned Lies, and Statistics.” The phrase is often claimed to be one of Mark Twain’s quotes, who, in fact, attributed it to Benjamin Disraeli, who served Queen Victoria as Prime Minister of the United Kingdom.  This quote is not found anywhere in Disraeli’s writings, although he may have said those words. Regardless of who said it, the sentence argues that statistics are often the worst kind of misinformation because they have the authority of numbers; the sources are hard to pinpoint and dispute and therefore are believed.

I fell into this trap recently and exposed my ignorance by quoting the Coronavirus mortality statistics, as given in large part, by the Chinese government.  The clue to me should have been “Chinese government.” The number of deaths I saw in the news was 3,132 deaths of a total of 92,303 (the newest numbers 3,886 deaths and 111,650 total cases). Nevertheless, mortality rates remain close to 3.4%.  The number of people that died is probably accurate.  It is hard to fake death, and counting the dead is likely to be reasonably precise. If they don’t move, they are probably dead.  The denominator has grown to 111,650 people that have the disease and are almost certain to be undercounted.  Mild cases are frequently not diagnosed or reported.  A runny nose is a runny nose, not COVID 19, in most people’s judgement, but then again, it could be.  The denominator is likely a much larger number judging from statistical analysis of previous epidemics. This would significantly revise mortality downward.

That, however, is not the essential source of misleading information. To accurately estimate disease mortality, raw numbers give the wrong impression.  In the seasonal flu mortality, we see every year, and the numbers are more accurately reported remaining under 1% because:

  • We are in the USA
  • Our health reporting is mandated by governmental agencies (not necessarily a strong point)
  • We try to be scientifically as honest as we can with checks and balances that report dishonesty or ulterior motives for inflating or deflating numbers
  • The people in charge of reporting don’t have quite the hidden motives or pressures as an autocracy generates, who initially punished reporting physicians
  • Our system has multiple sources of input that act as an automatic control mechanism
  • Our math adds the mild cases and estimates of asymptomatic people to the calculations (although this has to be retrospective)

Almost all comorbidities affect mortality rates: heart disease, chronic lung disease, renal failure, liver failure, obesity, neurologic disease, diabetes, cancer, immune deficiency, pregnancy, age, etc.

Without knowing the demographics of the population under discussion, raw data mortality rates are almost meaningless.  In the 2017-2018 flu season, which was one of the most severe epidemics in the last decade, if you were a healthy person, not pregnant, under 65 years of age, your risk of death was under 1%, but if you had a heart problem and were over 65 your mortality was over 10%.

How can we interpolate all this to the Coronavirus?  The 3.4% mortality rate is a raw number for many (but not all affected people); the mild ones didn’t even get counted.  I hate to use the term “fake news” because of its political overtones, but I think it is justified here.  The news media has “hyped up” this issue with inflated numbers for reasons that are suspicious to me.  To sell more newspapers? To be ahead in reporting doom and gloom? (which seems to be a habit of the news media culture). Or is it to affect elections? To create panic? To develop financial uncertainty? To…?  A recently published editorial in the most prestigious medical journal in the world, The New England Journal of Medicine written by Anthony S. Fauci (the nation’s leading expert on infectious diseases), H. Clifford Lane, and Robert R. Redfield, https://www.nejm.org/doi/full/10.1056/NEJMe2002387 has stated, and I quote, “the case fatality rate (of Covid 19) may be considerably less than 1% (the bold letters are mine). This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%).”  So take everything with a grain of salt!

 

 

 

 

 

 

 

COVID 19

In 2017-2018 45,000,000 people had seasonal influenza in the US and 61,000 people died of it.

“Coronavirus,” the cause of COVID 19 (Corona Virus Disease 2019) at this point has infected 92,303 cases worldwide with 3,132 deaths, which is a 3.4 % risk of dying.  Taking all comers, healthy people have a 0.9% chance of dying, while people with heart disease have a 10.5% chance of dying. The virus has an affinity for lung tissue because the viral surface has little projections that fit precisely into mirror image receptacles on the lung cell surface. If it gets into the lungs, it takes over the lung cell’s DNA by inserting itself into our DNA and starts reproducing, as viruses lack the ability to reproduce without using cells of other organisms like us.  It’s all about reproduction! That process kills the lung cell, and we are left with fewer and fewer lung cells to exchange COfor O2.  When there are not enough lung cells to exchange the gases, we become hypoxic (not enough O2 for the brain) and we die.  97% of us can beat the virus by making antibodies, and we recover. Depending on what kind of other diseases we harbor anywhere from 3% to 10.5% of us can’t.  Coronavirus is more virulent than regular flu, but not as virulent as some.  There are plenty of other viruses that are worse.  Ebola, for example, kills 50% of its victims, and smallpox had a 20% mortality in unvaccinated individuals.  But the 1918 pandemic (Spanish flu)  killed 100,000,000 people, the worst pandemic in human history.

So far, COVID 19 has not been all that impressive in the US, 121 cases with 9 deaths.  Of course, that is not what could happen.  If we don’t take the correct infection control measures, we will be in a world of hurt, so to speak!  The steps that have been made so far exceed anything that has been done in the past. I believe that if we take the common-sense steps we are told to do, we will remain relatively safe. Ultimately a vaccine is the answer. 

We owe vaccination to Edward Jenner, a physician, who noticed that milkmaids who contracted a benign disease called cowpox from the infected udders of cows did not contract deadly smallpox. During Jenner’s time 1/5th of the English population secumbed to smallpox.  In 1796 Jenner took some of the pus from a milkmaid’s hand that had the cowpox variola and scratched the skin of his first patient, the son of his gardener, placing a small amount of the pus on it.  It produced a local infection but never spread to the whole person. It worked, and no one that underwent vaccination got smallpox.  Jenner is credited with saving more lives than any other human being in all of history. The Latin word for cow is vaca.  Hence he called his procedure vaccination. In the early 1970s smallpox vaccination was stopped, and by 1979 WHO (the World Health Organization) declared smallpox eradicated from the face of this earth. The virus is no longer present in our world except in one laboratory that keeps the culture under close guard primarily for the study of this once deadly killer that potentially could be weaponized. Anyone older than age 50 still bears the telltale scars of the vaccination that left two pockmarks, usually on the right upper arm.   Smallpox vaccination is the first vaccine and the only disease that has been eradicated.

Coronavirus, too, will take its place in the history books of vanquished viruses, and it will not be because of avoiding Corona Beer as 30% of the population has done.   Multiple laboratories around the world are furiously working on an effective vaccine.  Apparently, Israel is ahead of most, claiming a vaccine will be available in weeks to months. After that, we should be able to go back to our routine lives.

ENTROPY

Ludwig Boltzmann was probably the most important scientist of the 19th century.  He was an Austrian physicist who introduced the concept of atoms.  He was ridiculed and harassed to the extent that he eventually committed suicide in a desperate depression of what he saw as a rejection of him and his life’s work.  The most prominent scientists of the time stood up during his lectures to declare that atoms are just an imaginary construct to explain mathematical formulations, not reality.  Scientific journals did not even allow him to use the term, “atom,” as it was just not scientific. Besides who has ever seen an atom? He traveled to the attend the World’s Fair in St. Louis in 1904, also to Berkeley and Stanford, where he lectured and discussed his atomic theories with colleagues, but failed to realize that proof of his concepts and theories was just around the corner, and he would be vindicated. But it was not to be. In 1906, while vacationing in Italy he hanged himself while his family was out swimming in the Adriatic.

The picture above is his gravesite in the Zentralfriehof (Central cemetery) of Vienna. The inscription above his bust, S=k.log W is a formula that sums up his interpretation of the second law of thermodynamics.  S is entropy (the level of disorganization), k is the Boltzmann constant, and W is all the possible molecular states.  In 1906 there were four known states of matter: solid, liquid, gas, and plasma. 

But there is a fifth possible molecular state, the Bose-Einstein condensate (BEC) that both men had theorized but was not created until 1995, long after Bose and Einstein had joined the immortals. Satyendra Nath Bose, born in Calcutta India, became a theoretical physicist. While studying a particular molecular relationship of gases under various thermal environments, called the Maxwell-Boltzmann distribution, he theorized that under very cold conditions, the molecules would not behave as the Maxwell-Boltzmann statistics predicted. He presented his thoughts to Albert Einstein who agreed and helped Bose publish his theory. During extremely low temperatures, he showed that atoms lose their individual structure and fuse together into one super-atom at the balmy warm temperature of one billionth of a degree above absolute 0. Matter does not behave the same in this state.  Electrons can sneak through the maze of now motionless fused together atoms, without any loss of heat, it now has become a superconductor. That super cool matter can even explode like a supernova, fondly called “a bosenova.” I never got past college freshman physics, so my level of physics competency would not be able to tell you if Bose-Einstein condensates would also act differently than Boltzmann’s formula on entropy would predict.

The first law of thermodynamics states that energy is constant in the universe.  It can neither be created nor destroyed, although it can transform from one state to another.  For example, fire can heat water which will produce steam which will drive a piston up and down to turn a wheel.  Heat is transformed into mechanical energy. 

The second law was the focus of Boltzmann’s attention.  Entropy, the level of disorganization, increases with time.  He realized that the disorder in the universe must always get more disorganized.  Even if you think you are organizing your house, sweeping, washing, making the beds, straightening the table cloth etc. etc., you are breathing, moving muscles, moving the broom.  In aggregate, you are using up energy, disbursing heat, excreting CO2, using up O2, burning up sugar and degrading the body’s tissues.  You are increasing entropy.   Just as burning a log in the fireplace making a pile of ashes from an organized piece of wood, with bark, fibers, and nutrients that used to course through its tubules.  Entropy is increasing, as it must.  Just as the energy of heat must flow from a higher level of heat to a lower level (colder) and can never be in the opposite direction, things are constantly getting worse.  But as it does so, it peels off energy. Without this energy nothing would work, nothing could grow, nothing could exist. It is this energy we use to live and thrive. In driving a car it burns a very organized, symmetrical, aromatic six carbon organic chemical, that derives from ancient life through complex processes.  As it combusts, it winds up as CO2 and H2O. But it generates the energy to get us from point A to point B. Without this inevitable process called entropy, we would not be able to survive.  Eventually, entropy will reach a level of equilibrium where no further disorganization can happen, where entropy will cease to increase.  This will happen when no more energy is readily available, and the universe will be a dark, empty, and cold place. But don’t worry, this will take billions upon trillions of years. We can still celebrate a few more birthdays.

The third law of thermodynamics deals with when entropy reaches that equilibrium.  Entropy will reach a steady-state, when it is so cold it will be the theoretically lowest temperature that it can get, 0 Kelvin.  If heat is molecular motion, there will be absolutely no motion. In Centigrade that would be – 273.5 ̊C which happens to be absolute zero, calculated correctly by William Thomson, which earned him the title of Lord Kelvin.

At that temperature, the state of matter would all transform into the Bose-Einstein condensate, one super-atom of the universe.   And if S=k.logW does not apply to this form of matter, it would set up for the release of all the nuclear forces,  another “Big Bang” or in this case a “Bosenova” as so eloquently stated by Yogi Berra, “It’s déjà vu all over again!” 

COLON CANCER FOR DUMMIES

I do not intend to be condescending, but I do believe that most people are ignorant of the dangers of this killer.  I have spent a half-century grappling with most of the variations of this disease and have some idea how underhanded, furtive, and devastating it can be. 

Unfortunately, even fellow physicians have ignored patients presenting with symptoms that demand investigation, such as blood in the stool. But because the patient was too young, too old, just worked up a year ago and not found to have a problem, etc. it was ignored. As astonishing as it sounds, there are 26-year-old people that get colon cancer too.  Familial adenomatous polyposis, a hereditary condition, patients can develop cancer quite early and need to start screening as young as age 10.  Almost 100% of patients that have presented with colon cancer to me self-diagnose as bleeding from hemorrhoids.  The patients, or sometimes their primary physician, has treated the hemorrhoids for months for this benign disease while ignoring the tell-tale signs of the monster waiting to be discovered just beyond the finger. Furthermore having hemorrhoids does not preclude also having cancer.

The colon is one organ that does not inspire glamour. Politically the colon does not garner the publicity, the fundraising capability, or the interest as, for example, breast cancer.  It is after all the transporter of the end of digestion back to nature.  Its contents are often used as a four-letter word to curse or denounce a person, thing, or event, a word that is recognized in all languages as one of extreme displeasure. Even our closest cousins, the chimpanzee, share in this.  When they want to show their extreme unhappiness, they throw “it” at you.

There is a story of how the actual word originated.  I don’t know if it is true or not.  It is said that during our Civil War, wood and coal became a commodity that was increasingly difficult to obtain because the war consumed all possible sources of energy. Cattle feedlots produced large amounts of cow dung that, when dry, burned quite well.  It was packed and shipped to parts of the country that needed it most.  Some lethal accidents occurred when the cow dung got wet in a closed area, such as the hold of a ship. Methane gas was released.  When someone with a lit lantern went down below deck an explosion ensued.  From that experience, cow dung had to be shipped above deck.  The shipping containers were inscribed with warning signs, “SHIP HIGH IN TRANSIT” abbreviating it into its acronym created SHIT.   

1 in 20 Americans will be afflicted with colon cancer during their lifetime.  This year 53,200 people will die from it, the second leading cause of cancer deaths of both men and women combined. The lung is still number one. Happily, we are making an impact as the death rate (deaths per 100,000) in colon cancer is dropping, except in the population under 55, where it has increased 2% per year since 2007.  This has prompted the American Cancer Society to revise its screening guidelines to age 45 for people at average risk, that includes those people that do not have a family or personal history of colon cancer or polyps, hereditary colon cancer syndromes, or a personal history of inflammatory bowel disease.

Most colon cancer starts as a polyp.  There is a condition called Hereditary Non-Polyposis Colorectal Cancer (HNPCC) that skips the polyp phase and goes straight to cancer but is not very common (1 in 400 people have it).  But nevertheless, nearly all cancers start as a polyp.  There are different types of polyps, some more dangerous than others. In order of increasing risk inflammatory polyps are the lowest risk, then hyperplastic polyps, of which the serrated kind are more dangerous, and then the adenomatous polyp, and finally the highest risk are the villous polyps.  Size also plays a role, the larger the more serious. The question often comes up,  “When should I have my next colonoscopy?” It is a statistical answer that depends on age, family history, how many, what kind, and how big the polyps found were (about a third of the people I have examined I have found have had one or more polyps)  I would often enlist the patient’s input before I would give a semi-definitive answer.  Even the low-risk hyperplastic polyps, that are supposedly benign and offer no increased risk, but if there are lots of them, especially on the left side of the colon or have elements of being a serrated polyp on microscopic exam worry me, and I would see these people back in 1 to 3 years.

Additionally, many pathologists are not yet attuned to the serrated polyp designation that makes them a notch more dangerous. I always reviewed the pathology slides myself with the pathologist and recall seeing a polyp that was half hyperplastic and half villous which is just a step away from cancer, and raised my threshold of concern for the supposedly harmless hyperplastic polyp. Recently the ACS guidelines state you do not need a colonoscopy after age 85. But if you are healthy and likely will live another 10 years, why not?  Death from untreated colon cancer is quite unpleasant with colostomies and painful swollen bellies at the end. 

There are several screening exams that have their own risks, accuracy, costs, difficulty, and inconvenience.  The simple test for blood in the stool has no risk, although a little unpleasant. It is hower not all that accurate.  Only one-third of cancers will show a positive test, not a very good track record.  A more accurate test is the Cologuard stool test, although it is not a certainty that if positive you have cancer and if negative that you don’t.  13% of the time it is positive and the patient does not have cancer (false positive) and 8% of the time the test is negative when indeed the patient has cancer (false negative).  It has no real risks and is easy to do. Just collect a stool sample in the privacy of your home and send it off to the lab in the provided container.  It screens for DNA that is related to cancer or pre-cancer, such as a polyp. Many insurances pay part or all of the cost of $649.

Colonoscopy is the gold standard, but also the most expensive, unpleasant, and risky.  The radiologists have expanded on the old fashioned barium enema, or more sophisticated double contrast study, both of which are screening exams for colon cancer, but they too can miss cancer.  The newer version is the CT colonography.  By offering this exam the patient avoids the unpleasantness of a colonoscopy, but not the prep for it.  The patient must still have a pristine colon. Otherwise small bits of stool will be interpreted as a polyp, which will then prompt a colonoscopic exam.  The CT colonography often raises more questions than it answers and has not been the answer to how to avoid the formal colonoscopy.

Colonoscopy is a direct visual inspection of the entire colon and therefore is the most accurate.  But it too is not 100%.  The colon has many twists, turns, and folds where small cancers or polyps can hide, but if done correctly it is extremely unlikely that anything will be missed. It will surprise you that doing a colonoscopy too fast is actually a measure of poor quality.  At some centers, nurses actually time your withdrawal time and if you come out in less than 6 minutes you are “timed out” so to speak. 

The big risk is a perforation, followed by bleeding, a partial burn injury from polyp removal, infection, adverse anesthetic problems, complications from the prep especially in older individuals getting fluid overload, or sometimes dehydration, and cardiovascular problems. Still, perforation remains the most feared of the complications. The literature quotes a rate of 0.016% to 0.2% risk.  But therapeutic colonoscopies and large polypectomies have a perforation rate as high as 5%.  My own perforation rate in 40 years was 2 in about 15,000 colonoscopies (.013%), but I do remember both vividly, and both survived.

A word about the prep.  Having had several colonoscopies myself in my now 77 years of life, I must say that for science to have landed us on the moon, being able to transplant hearts, livers, lungs, we are woefully lacking sophistication in cleaning out the colon.  To say it was unpleasant is an understatement, and the most often prescribed prep, Go-LYTELY, is a misnomer in my book. Newer preps are available that make it a bit easier but at rather exorbitant prices. The old 1.5 oz. of Fleets Phosphosoda taken two times was still the easiest, quickest, and least unpleasant.  Unfortunately, it killed a few people and was removed from the market.

A PRIMER IN HOW TO RECOGNIZE NEANDERTHAL GENES IN OURSELVES AND OTHERS

Now that the human genome has been sequenced, and Neanderthal genes have been found in up to 4% of our DNA, we can no longer deny our ancestral roots.  Some of us have more of it and others less.  Asians and the native people of Oceana have more Denisovan genes than the Neanderthal genes, up to 5% in some of them. Denisovans were not a known hominid species until recently when a discovery in Siberia of hominid skeletal and dental remains was uncovered.  The DNA was neither Homo sapiens or Homo neanderthalensis but a heretofore unknown hominid.

Neanderthal (also written as Neandertal) appeared in the Pleistocene Epoch  (2.6 million years to 11,800 years ago) first found in the Neander Valley (Tal) in Germany.  When first discovered in 1856, they were thought to be deformed H. sapiens, but when they were found all over Europe and the Middle East, the deformed theory was discarded and they got their own species name, even though some paleontologists thought that a bit premature. Strangely, 25,000 years ago Neanderthals disappeared. Charles Darwin published The Origin of Species in 1859. Various theories of their extinction have been postulated.  This was in the midst of the last ice age.  Could that have been their death nail? Did we out-hunt them, competing for every bit of protein in the cold barren land that was overwhelmed with ice?  Did we absorb them as suggested by our own DNA? Or did we kill them?  There is evidence of cannibalism that could have contributed.

Getting back on how to recognize them within and amongst us.  They actually had a larger brain housed in a lower profile cranium. The brows were more prominent, and the nose and eye sockets had bigger openings. The front teeth were larger, spaced farther apart, and the occipital ridges were more prominent, suggesting stronger posterior neck muscles.

The chin was what we would classify as weak. Their hyoid bone in front of where the voice box would be, suggested they had similar linguistic skills to us. Also, they could not have had the stone tool technology and social customs, such as the burial of the dead, decorative arts, and even flute-like musical instruments without language.  They had pale skin and possibly red hair, making them more sensitive to UV light and prone to skin cancers.  Other genetic studies suggest they were prone to depression and eating disorders. 

They did not have the ability to domesticate animals and lacked dogs that could have helped them in hunting larger game.  This lack of skills with taming animals may have contributed to their demise.

Putting it all together.  If you see a red-haired very muscular person, especially the back of the neck, about 5 foot 5 inches tall, a barrel chest with large hands and size 13 shoes, a weak chin, prominent brows and premature aging from sun damage, with possibly a skin lesion or two, who is kind of mean, hates dogs, and is grouchy, you may be meeting one of them.