Volume 6, Issue 9
September 2020
 
 
 
 
Frailty Considerations When Planning an IBD Treatment for Older Patients
 
 
 
 
When younger patients receive an IBD diagnosis, there's a good chance that it may be their only major health issue.  By contrast, older patients often have preexisting health conditions that may cause complicating issues if certain treatment programs for a new inflammatory bowel disease (IBD) diagnosis are used.  And even in some cases where there are no underlying health conditions, the age alone of the patient may impose a degree of frailty.  Older patients, especially older patients who have underlying conditions, may be less responsive to medications, they're at a greater risk of side effects from drugs, and they generally heal much more slowly than younger patients.  People are living longer, and since IBDs are not generally associated with an increased mortality risk, that means that the prevalence of IBDs, including microscopic colitis, among older adults is increasing.1

Allopathic medicine has a very worrisome characteristic.
Specialists especially, treat every organ in the body as if it operates independently of all other organs in the body.  And they treat the digestive system as if it operates independently of the nervous system, the cardiovascular system, and the respiratory system.

Most of us recognize that as a grossly invalid assumption.  We realize that the human body is a very complex, highly interdependent organism, where all systems share feedback and rely on each other.  If one organ malfunctions, or is the target of a medical procedure, many other organs in the body may be affected.  For most medical treatment procedures, the effect on other organs is usually slight, and we won't notice any adverse effects.

But occasionally, when doctors treat one issue, the treatment adversely affects other health issues, or other organs.  Sometimes the effect may be negligible, and sometimes it may be very significant.  In some situations, it can be adverse, even resulting in a life-threatening condition.  Considering the level of sophistication available with modern computer systems, perhaps it's time to reconsider the simplistic approach of allopathic medicine to at least take into consideration an evaluation of the relative frailty of older patients before an aggressive treatment plan for a major disease such as an IBD is selected.

Many IBD patients who require hospitalization tend to be frail.
A study that involved 47,402 patients who were hospitalized with IBD showed that approximately a third of them qualified as frail, based on a ranking system that rated their condition according to a number of issues that often lead to complications that result in adverse outcomes.2

References:
1. Bassett, M. (2020, August 26). Siddharth Singh, MD, on how frailty can affect outcomes in older adults with IBD. Retrived from https://www.medpagetoday.com/reading-room/aga/inflammatory-disease/88268?xid=nl_mpt_DHE_2020-08-27&eun=g443580d0r&utm_term=NL_Daily_DHE_dual-gmail-definition

2. Qian, A. S., Nguyen, N. H., Elia, J., Ohno-Machado, L., Sandborn, W. J., & Singh, S. (2020, August 26). Frailty is independently associated with mortality and readmission in hospitalized patients with inflammatory bowel diseases. Retrieved from https://www.medpagetoday.com/reading-room/aga/inflammatory-disease/88266


 
 
Seven Important Recent Discoveries About COVID-19
 
 
 
COVID-19 victims find themselves with a new social stigma.

Even after recovering from COVID-19, most victims of the disease discover that they are left with something new to face —the disease has transformed them into a persona non grata.  Even though they test negative for the disease, most other people prefer to give them a wide berth.  Even healthcare workers, although they are honored as Healthcare Heroes, often find themselves shunned, when out in public.  A survey found that about a third of the people who responded to the survey, avoid health care workers, and a quarter of them believe that the freedoms of healthcare workers should be restricted in order to protect others (Brooks, 2020, September 01).1  It's likely that this new behavior pattern will persist for years, even if coronaviruses were to be eliminated as a threat.

Many healthcare workers have had undiagnosed COVID-19.

According to a Medscape article, between April and June roughly 5 % of more than 3.000 frontline healthcare workers showed antibody evidence of prior COVID-19 infections (Reuters Staff, 2020, September 01).2  69 % of those cases were never diagnosed.  About a third of those with antibodies could not recall ever having any symptoms.  About two-thirds of them had never had a positive COVID-19 test result.  Infections were most common among those who did not always have proper personal protective equipment.

Underlying conditions and mortality risks with COVID-19.

Data collected from hundreds of hospitals in the U. S. has allowed a detailed assessment of the risks of more serious outcomes for COVID-19 patients who have certain underlying conditions (Fried, et al., 2020, August 28).3  In all, the records of 11,721 patients were analyzed.  About 60 % were 60 years of age, or older, and about 53 % were male.  47 % of the hospitalized patients had hypertension, 28 % had diabetes, and 19 % had cardiovascular disease.  16 % were obese, and 12 % had chronic kidney disease.  Almost 17 % of these patients required the use of ventilators.
​​​​​​​
Interestingly, despite the fact that hypertension was noted in 47 % of the hospitalized patients, as mentioned above, it was not independently associated with a more severe outcome or the use of a ventilator, nor were a history of pulmonary disease, or smoking (McNamara, 2020, September 01).4

The researchers also noted that patients who have liver disease, gastrointestinal diseases, and other autoimmune diseases (who often are treated with drugs that suppress their immune systems), had only a slightly increased risk of a more serious outcome.  It's likely that the increased risk in these cases is skewed toward the patients who are taking immune system suppressants, although this isn't actually stated in the article.

Most COVID-19-related deaths involve contributing conditions.
Only 6 % of death certificates in the U. S. list COVID-19 as the sole cause of death (Crist, 2020, September 01).5   So far, at least, 94 % of the death certificates for COVID-19-related fatalities also list other (preexisting) conditions that contributed to the fatal outcome.  The average number of contributing conditions listed was 2.6.  The bottom line is, healthy people (defined as people who have no preexisting health conditions) rarely die from COVID-19.


 
 
Concerns about the safety of COVID-19 vaccines are justified.

Many people, when asked, say that they probably will not take advantage of a vaccine then they first become available. While this may seem irrational to some, there are valid reasons for caution. Vaccine experts can cite a number of reasons why the vaccines that are being developed now may be risky for many people.  One of the problems arises because of the way that subjects are selected for the trials.  People over 65 years of age, and those under 18 are not included in the trials (Topol, & Offit, 2020, September 09).6  Neither are people who have preexisting conditions.  Minorities are very underrepresented. Obviously, the data from the trials will not be valid for anyone in these groups.  So why would they want to risk being vaccinated?

Another issue is the efficacy of the vaccines.
The article by Topol and Offit, (2020, September 09) also points out that efficacy may be a source of problems.  If a vaccine is about 75 % effective, then about 25 % of those vaccinated can still get sick (including severe symptoms).  And probably even a higher percentage could get a mild (or asymptomatic) infection, so that they might still be contagious to others, and continue to spread the disease.  These are valid concerns, especially since we know that if we all wear a mask, and stay at least six feet away from others, the risk of you or I developing COVID-19 is almost zero.

According to Dr Anthony Fauci, of the CDC, 40–45 % of Covid-19 cases are asymptomatic.
That suggests that asymptomatic carriers of the virus may be responsible for causing up to about 50 % of new cases (Frellick, 2020, September 11).7  This is such a high percentage that it significantly reduces the effectiveness of tracing contacts.  And it makes the wearing of masks by everyone who is out in public, very important, if this pandemic is to be controlled.

    Antihistamines show promise in preventing cytokine storms.
As many of us who have histamine issues associated with MC have found, taking antihistamines daily can significantly help to reduce and often prevent the symptoms caused by overactive mast cells.  Since cytokine storms are primarily caused by overactive mast cells due to histamine triggering, it's rather logical that they might be suppressed by antihistamine intervention.

The medical profession is finally beginning to recognize the value of this simple and economical treatment in the control of cytokine storms caused by COVID-19, and they're viewing this “discovery” as an “aha” moment. (Douglas, 2020, September 11).8


 
 
A study of exposure risks for COVID-19 has implicated restaurants, bars, and coffee shops.
 
 
 
According to the CDC, a case-control investigation of symptomatic patients at 11 U. S. health care facilities showed that going to places where eating and drinking were offered was associated with an increased risk of testing positive for COVID-19 (CDC COVID-19 Response Team, et al., (2020, September 11).9  In the study, those who tested positive were more than twice as likely to have dined at a restaurant in the previous two weeks, as those who tested negative.  Furthermore, those who tested positive were almost four times as likely to have gone to a bar or coffee shop, compared with those who tested negative.

 
 
 
Vitamin D, yet again

Another group of researchers proudly announces that they have shown that vitamin D strengthens the immune system.

Well duh!  Every time another group of researchers discovers that vitamin D increases disease resistance, they give the impression that they have just invented the wheel.  As if the importance of vitamin D for strengthening the immune system hasn't been known for almost a century.

Another group has shown that subjects in their study who had a vitamin D deficiency, had almost twice the risk of developing COVID-19 as those who were not deficient (Meltzer, et al., (2020, September 3).10  And they defined deficiency as having a serum level below 20 ng/mL, the level at which rickets can be prevented.  So not surprisingly, they hypothesized that vitamin D might be useful for lowering the risk of developing COVID-19.

But a far more important vitamin D study has been done in Italy.
The Italian study appears to prove that what we have been advocating ever since the pandemic began (keep your vitamin D level in the safe range), is right on target.  The study showed that low serum vitamin D levels is an independent risk factor for the development of more severe COVID-19 cases that require admission to intensive care, and a much higher risk of a fatal outcome (Busko, 2020, September 17).11  The study included 103 symptomatic patients who were admitted to a Milan hospital, 52 patients who tested positive, but had mild symptoms, and 206 healthy controls.

Compared with the others, hospitalized patients had the lowest vitamin D blood levels (a mean of 18.2 ng/mL.  Patients with mild symptoms had a vitamin D mean blood level of 30.3 ng/mL.  And subjects in the control group had a mean Vitamin D level of 25.4 ng/mL.

Compared with patients who had mild symptoms, Those who were hospitalized were slightly older, and were more likely to have at least one preexisting health issue.  79 % of those in the mild symptoms group were taking a vitamin D supplement, whereas only 30 % of those in the hospitalized cases were taking a vitamin D supplement.
​​​​​​​
54 of the hospitalized patients required ICU care, and 19 died.  Compared with the other hospitalized patients, those admitted to an ICU had a mean vitamin D level of 14.4 ng/mL, whereas those who did not require admission to an ICU had a mean vitamin D level of 22.4 ng/mL  Those who died, had a mean vitamin d level of 13.2 ng/mL, while those who survived the ICU treatment had a mean vitamin D level of 19.3 ng/mL.

References:

1. Brooks, M. (2020, September 01). New COVID-19 stigma: Widespread shunning of healthcare workers. Retrieved from https://www.medscape.com/viewarticle/936679

2. Reuters Staff. (2020, September 01). COVID-19 often undiagnosed in frontline hospital workers. Retrieved from https://www.medscape.com/viewarticle/936603

3. Fried, M. W., Crawford, J. M., Mospan, A. R., Watkins, S. E., Hernandez, B. M., Zink, R. C., Elliott, S., & Brown, Jr, R. S. (2020, August 28). Patient characteristics and outcomes of 11,721 patients with COVID19 hospitalized across the United States. Clinical Infectious Diseases, Retrieved from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1268/5898276

4. McNamara, D. (2020, September 01). High mortality rates reported in large COVID-19 study. Retrieved from https://www.medscape.com/viewarticle/936689

5. Crist, C. (2020, September 01). COVID-19 primary, not only, cause of 94% of deaths. Retrieved from https://www.medscape.com/viewarticle/936678

6. Topol, E.J., Offit, P. A. (2020, Septembr 09). Paul Offit's Biggest Concern About COVID Vaccines. Retrieved from https://www.medscape.com/viewarticle/936937?src=mkm_covid_update_200910_mscpedit_&uac=95382HN&impID=2558386&faf=1

7. Frellick, M. (2020, September 11).  Fauci: 'About 40%-45% of Infections Are Asymptomatic'. Retrieved from https://www.medscape.com/viewarticle/937297?src=mkm_covid_update_200914_mscpedit_&uac=95382HN&impID=2564790&faf=1

8. Douglas, D. (2020, September 11). Antihistamines May Help Calm COVID-19 Cytokine Storm. Retrieved from https://www.medscape.com/viewarticle/937178?src=mkm_covid_update_200914_mscpedit_&uac=95382HN&impID=2564790&faf=1

9. Fisher, K. A., Tenforde, M. W., Feldstein, L. R., Lindsell, C. J., Shapiro, N. I., Files, D. C., Gibbs, K. W. . . . CDC COVID-19 Response Team. (2020, September 11). Community and close contact exposures associated with COVID-19 among symptomatic adults ≥18 years in 11 outpatient health care facilities — United States, July 2020. Retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a5.htm#contribAff

10. Meltzer, D. O., Best, T. J., Zhang, H., Vokes, T., Arora, V. A., & Solway, J. (2020, September 3). Association of vitamin D status and other clinical characteristics with COVID-19 test results. Retrieved from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770157

11. Busko, M. (2020, September 17). Low vitamin D in COVID-19 predicts ICU admission, poor survival. Retrieved from https://www.medscape.com/viewarticle/937567?src=mkm_covid_update_200917_mscpedit_&uac=95382HN&impID=2570801&faf=1
 
 
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