The Medical New Report
If you are near Sky Valley over the 4th, be sure you read this calendar of events for July 2-Saturday, July 3-Sunday, and July 4- Monday. To attend the BBQ, you must purchase tickets before the event, as they will not be sold at the event. Donations go to the Sid Weber Memorial Cancer Fund to provide non-medical needs of cancer patients in Rabun County, Georgia.
The pancake breakfast is only $6.00, fireworks shot over the lake at 9pm are spectacular, and the kids love the duck races down the creek, fire engine rides, etc., with a parade and cookout, all starting at 10:30am on Monday.
Subjects for July, 2016:
Update on the Zika Virus-there has been a rapid rise in abortion requests because of the fear of Zika virus infection in Latin countries, where abortion is either illegal or highly restricted. There are some Olympians cancelling out of the Summer Games. Some governments are suggesting women put off pregnancy for the next 2 years without providing easy access to contraceptives or even counseling.
If you have been hospitalized recently, a doctor might have come to see you to examine you and manage your hospital care in association with your admitting doctor. Your admitting doctor focused on the reason for admission, and the “new doctor” (the hospitalist) took care of the rest of ongoing medical issues, such as diabetes, heart disease, etc., while in the hospital. Sounds good or is it just one more way that healthcare is increasing costs?
It is another layer of care in certain cases that is welcome, especially those with complicated problems…..but not all. In the past, a consult was requested by the admitting doctor for additional medical expertise. I think in the past physicians were more generalists, and if a patient needed additional care, it was provided by them.
Does a hospitalist makes rounds on a selected number of patients or everyone admitted to the hospital? Has the legal department decided this is a new way of protecting themselves, or are only patients with potential complications being followed?
An intensivist (sometimes the same person) coordinates acute care in intensive care units. Both types of specialized doctors are salaried and usually take 12 hour shifts 24/7 to optimize care while in the hospital.
Hospital-based physicians are the fastest growing specialty in healthcare. It is the coordination of care that these doctors are best at executing. Patients transitioning from the recovery room, to the ICU, and to a specialty care floor may lose continuity of care due to poor communication from one care unit to another. These doctors can be involved with these potentially comlicated times.
Chronic illness can complicate the simplest surgery or medical admission. In the past, a consult was requested for help in more complicated patients, but a consult is less effective than an in-hospital specialist trained to deal with immediate or emergency medical issues. These doctors fill that gap. Many sick patients need hourly visits from a doctor. Yes, it is more expensive care, but necessary in many cases and can save lives.
Having resident (in training) doctors in the hospital 24/7 has always been a strength of teaching hospitals. In private hospitals, where there is no training staff, there has always been the same need, and created the birth of the hospitalist and intensivist in the mid-90s. Now there are some 44,000 of these doctors in 60% of hospitals according to the Society of Hospital Medicine. Nurse practitioners and PAs are also filling this need in places that don’t have these super specialists.
Acceptance by the attending physician for the hospitalist is a must and not always an easy task. Most primary care doctors do not work in hospitals anymore, and that set the stage for the need of hospital-based specialists.
Agreement on care by various doctors can be challenging, and some physicians resent others meddling with their patients. Change is always hard and egos can get in the way. Growing pains inside the specialties still needs improvement.
Driven by Obamacare, healthcare reform, and the massive influx of immigrants, hospitalists were employed to be sure other issues were not being overlooked by the admitting doctor. As you know, abandoning fee-for-service payment for doctors and hospitals for risk-based coverage (quality of outcome), has made the healthcare system come up with models that will need to succeed in this new way to pay for healthcare, but this new layer of care has greatly increased healthcare costs. There is no way to reduce cost without quality suffering.
The Affordable Health Care Act (ACA) was never about being more affordable, even though we were fed that line from this amdinistration. This whole transition has been far from transparent, as it was promised. Our politicians have let us down, on both sides. I am unsure it will change.
Hospitalists are usually internal medicine or emergency medicine specialists who have additional training in acute care medicine. Specialty care units in the hospital may also hire in-hospital specialists, for example, neurologists to care for an acute stroke. Trauma doctors are usually general surgeons who are now employed full time to care for emergency coordination of the trauma that comes into the hospital. Hospitalists usually do not practice outside the hospital. They take shifts (usually 12 hours) and are replaced by other hospitalists when their shift ends.
Trying to improve the quality of care is admirable but costly. Bundling of payments for specific hospital cases (surgeries, strokes, heart attacks, kidney failure, pneumonia, etc.) has also made doctors and hospitals do a better job of caring for patients. Hiring hospitalists is a concrete way to address this issue, and in the end, potentially reduce cost by preventing serious medical complications.
In April, CMS (Centers for Medicare and Medicaid Services) ruled that hip and knee replacement surgeries with 90 days of postop care will be paid one lump sum in 67 metropolitan centers. My concern is it will prevent some higher risk patients from qualifying for elective procedures. This is one way our government is trying to curtail healthcare, in my opinion, and it will affect older Americans more than any other.
Another benefit of this dynamic change in healthcare is the addition of thousands of jobs not only for doctors but PAs and nurse practitioners, who will play a role in hospital-based care. One out of nine jobs today is in the healthcare industry.
The areas of expansion for hospitalists include perioperative care (care in preparing patients for procedures and postoperative care), palliative care, critical care, and post-discharge care as they transition back to their primary care professionals.Reference- MedicineNet.com is a good source for more information.
This disorder is characterized by unreasonable obsessive thoughts and fears (obsessions) that lead to anxiety and then to repetitive behaviors (compulsions) as seen in the above chart. The end result is potentially temporary relief. It is possible to have some obsessions and/or compulsions and still not have OCD. Trying to ignore these behaviors increases anxiety and distress especially if the person does not see these behaviors as out of the ordinary. OCD can create repetitive themes and behaviors which can complicate and cripple a person’s daily life.
A. Ritualistic behaviors occur, such as hand washing, making surroundings excessively orderly, with unwanted thoughts about harming themselves, checking locks and windows several times before leaving the house, etc.
B. One third of these patients have tics (sudden, brief, intermittent movement or making sounds).
C. Behind these obsessions are excessive concern for germs, doubts about self, images of blurting out obscenities, thoughts of aggression or acting out.
D. Compulsions include washing and cleaning, counting, demanding reassurances, excessive orderliness, or following a very strict routine.
E. To meet the criteria for OCD, these thoughts and actions need to be unwanted, recurrent, and persistent with interference of normal life.
F. Complications of OCD include failure at work, school, or social activities. OCD can create a poor quality of life, anxiety, depression, eating disorders, suicidal thoughts, and alcohol or substance abuse.
Certain professions tend to lend themselves to be perfectionistic, but being excessively OCD could easily interfere with relationships, work, and friendships.
A family history or very stressful lives can increase the risk of being OCD developing rituals, emotional distress, and intrusive thoughts.
It is the magnitude of these behaviors that can create a need for therapy. If these obsessions and or compulsions create quality of life issues, it is time to seek help.
Treatment options include psychotherapy and medications. As always, combining both modes of therapy will always create better control.
The type of psychotherapy needed is called exposure and response prevention (ERP). This involves exposing the patient to the particular unwanted situation or fear. Essentially it is learning to manage those obsessions and compulsions.
A. Antidepressants (Zoloft, Paxil, Anafranil, Luvox, and Prozac) tend to work the best. It often requires trial and error efforts to find the optimal medication and dose. Patients must not give up on these medications or stop them abruptly. SSRIs (selective serotonin release inhibitors) take a few weeks to work and the dose must be adjusted slowly whether increasing or decreasing the dose. Stopping an SSRI abruptly will create undesirable side effects such as sleep difficulty, anxiety, fatigue, and feeling very moody.
B. Research using electrical deep brain stimulation is showing some benefit in those who do not improve with medications and psychotherapy. This treatment is being investigated for numerous psychological disorders.
References-Mayo Clinic, The Michael Fox Foundation, The Parkinson’s disease Foundation; JAMA-Neurology, 2016
Continuing with the GI series, the small bowel (22-23 feet long by 1.5-2 inches wide) is a very busy part of the bowel. the major portion of digestion occurs in the small bowel by absorbing food minerals and nutrients (fat, protein, and carbohydrates).
The three parts of the small bowel are:
1) The duodenum, which connects to the stomach and accepts the bile and pancreatic ducts.
2) The jejunum, which mainly absorbs vitamin B12 and bile acids along with other nutrients.3) The ileum attaches to the colon.
The small intestine is attached by a thin membrane called the mesentery, which is rich in blood and lymph vessels supplying the blood to the small bowel. From the drawing, you can see the intricate anatomy of the mesentery.
In addition to digestion, the small bowel is involved with assisting the immune system using the gut bacterial flora, which is a source of immune capabilities plus the lymphoid tissue in the bowel lining. The lymph vessels return the byproducts to the blood.
The small bowel is rarely a source of a primary cancer, rather it is a common place for immune inflammatory bowel diseases, including Crohn’s and Celiac disease, lactose intolerance, and inflammatory bowel disease (IBD). I have discussed these 4 diseases at length
IBD, lactose intolerance, Celiac disease (gluten sensitivity) and Crohn’s disease
It was important to include in the GI series the small bowel. Next month, I will continue with the colon and rectum.
Quality of Life Issues and Side Effects of Cancer Treatment
Cancer is scary enough, but the side effects of treatment make it worse….nausea, hair loss, weight loss, pain, fatigue, cognitive difficulty, infertility, psychosocial issues (marital, sexual, depression, anxiety, etc.), disfigurement, disability, lymphedema, neurological deficit, cardiac and vascular obstruction, and second cancers to name a few.
Recognition of these side effects and surveillance for them what I have been working on for 5 years with the American Cancer Society through a CDC grant in cooperation with the George Washington University Cancer Institute. You can access all of our efforts now online on the American Cancer Society’s website. Here is just one of these offerings: http://www.cancer.org/treatment/survivorshipduringandaftertreatment/index
The Influence of Marital status and cancer survival
There is direct evidence that marital status influences the death, longevity and maintaining follow up for surveillance for side effects, recurrence, and second cancers. There is an overall increase in the risk of death for unmarried people. Psychological support from a spouse, significant other, and families is a critical factor.
Even insurance status and socioeconomic status affect outcomes of cancer survival.
Fatigue as a side effect of treatment
Fatigue is almost a universal problem as a result of cancer treatment. Surgery, chemotherapy, and radiation therapy create serious fatigue, and there is a scientific basis for it.
If a person is getting intermittent chemotherapy, the first few days after a treatment will usually be the worst, whereas radiation 5 days a week will be more consistently taxing. Surgery causes weakness, but fatigue is different from weakness following surgery.
Factors implicated in causing fatigue
Just as in chemobrain, there are similar factors that have been implicated but not proven:
Low sodium, dehydration, hypoglycemia, pro-inflammatory cytokine changes (these are immune system products), brain levels of serotonin (a neuroreceptor), weight loss, malnutrition, elevated white blood cell counts, and lack of exercise superimposed by weakness.
Oncologists need to address this issue as a specific medical phenomenon, and consider treatment.
Having had first-hand experience with cancer treatment induced fatigue, as a cancer survivor. It is a very real phenomenon and not well understood until recently. Subjective symptoms of feeling tired, weak, run down, feeling depressed, having no energy, not able to feel better with rest, even confused, hard to concentrate, and tiring out with the simplest task all can describe what fatigue is like when undergoing radiation and or chemotherapy.
Weakness tends to get better a little each day. With cancer treatment-induced fatigue, it can last for months, and even years in some. Rest does not alleviate it. I felt this type of fatigue for about 6 months before I felt like it was getting better. I had radiation twice a day for 7 weeks. Studies on breast cancer survivors noted fatigue for as long as 5 years after treatment.
Opioids will certainly contribute to the up and down feeling of fatigue, but it is also different.
Fatigue is a combination of physical, emotional, and mental sensations.
It can come and go, overwhelm a person one day, and seem less distressing the next. There is no doubt that depression plays a role, including other issues such as lack of nutrition and weight loss, anemia, pain, and the demands of trying to work or even doing the simplest chores.
Patients do not frequently report fatigue to their doctors. Caregivers and healthcare professionals need to address this with the patient (survivor) including whether they also feel they are depressed (have feelings of hopelessness and helplessness). They need to be encouraged that what they are feeling is normal and not to feel guilty about it.
Treatment of cancer related fatigue
There are many studies to prove exercise is the best answer to combat fatigue. Easily said….hard to do!! Regular small periods of exercise will combat and perhaps shorten the period of time for the fatigue syndrome. Caregivers and physicians must encourage this and “push” the survivor to do a little more every day. Incremental increases in physical exertion will show results.
Stimulants such as Ritalin have been used with some success in selected cases.
For further information on management of fatigue, please click here:
Motivation must be high to exercise when a survivor feels such overwhelming fatigue. Those who are in good physical condition prior to treatment usually fare better than those who are extremely sedentary. If there is overlapping depression, it must be addressed and treated with medications and even psychotherapy and or support groups.
Treatment of anemia, weight loss, electrolyte abnormalities (sodium and potassium), good nutrition with antioxidants, fruits and vegetables with several small meals is key to recovery.
Food supplements such as protein drinks (Ensure) should be considered to up the caloric consumption daily.
Smoking and alcohol cessation should be encouraged. Also careful monitoring of opioid intake (and potential abuse) is critical to keep the patient from self-induced lethargy and aggravation of fatigue and or depression.
Personal hygiene is also important including dental hygiene, prevention of opioid-induced constipation and urinary retention. All of these factors will assist in the treatment of fatigue.
As I was recovering, I hired a personal trainer at my gym that helped me tremendously. I lost 55 lbs. with my cancer experience, and was completely physically depleted when I began to rebuild my body, my self-esteem, and self-worth. These factors are at the heart of quality of life.
Fatigue, like any other challenge, can be conquered, but it takes a team of providers, family, and a strong survivor to withstand cancer treatment. However, the human spirit will prevail, and we can look forward to a life after cancer, because, cancer never wins!!
In the near future, I will discuss another side effect of cancer treatment- chronic pain.
35 million Americans are afflicted with rhinosinusitis annually, and there are 16 million office visits per year because of it.
Of all the various surgical procedures I performed over 30 years of private practice, endoscopic surgery for sinus disease was one of my favorites. Before the endoscope was introduced into sinus surgery, it was performed with loupes (magnified eye glasses) with very limited visibility through the nostril. The structures of the sinus are so close to the brain, making it risky in the hands of less experienced surgeons. The thickness of the sinus wall between the eye and brain can be as thin as an eggshell. Endoscopic surgery was a tremendous advance and made sinus surgery much more successful and safer.
A camera is attached to an endoscope, and I operated from a TV monitor. Techniques were carried out under general anesthesia. Below left, is a simplified drawing showing the endoscope in the nose with polyps, and the photo right demonstrates the typical set-up for endoscopic sinus surgery, with the surgeon operating off a TV monitor.
instrument (forceps and suction) is used to open the sinuses and remove the abnormal tissue.
The left above photo shows polypoid tissue in the nose blocking the airway and sinuses! The right photo shows the nasal cavity with normal turbinates. These turbinates warm and filter the air breathed, but also can enlarge from allergies and block the airway. They are frequently reduced in size. Below is a lateral view of how large turbinates can be. They can be cauterized, cut down in size, or in my practice, I used a laser, which greatly reduced bleeding.
Below, there is an abnormal CT scan, with blockage of the sinuses. The right lower panel shows an ethmoid sinus being endoscopically opened.The far right photo shows the ENT surgeon going over the CT scan with a patient, explaining the goal of sinus surgery.
Below is an endoscopic view of the ethmoid and sphenoid sinuses after surgical removal of tissue and thin bones that leave a honeycomb appearance of the ethmoid sinuses. A suction probe is present in the photo in the right lower portion of the photo.
The photo below demonstrates a surgically opened maxillary sinus!
Often, the partition between the nasal airways (the nasal septum) is crooked (seen in the above right drawing), obstructing the airway, and must be reconstructed (septoplasty). Nasal septal deviations are commonly caused by injury, but it is often a deformity a person is born with along with a variety of external deformities requiring cosmetic and or functional reconstruction (another favorite procedure of mine). Septal repair is necessary to easily access the sinuses and promote an open airway.
It is mandatory that the allergic issues of nasal and sinus disease be aggressively treated, otherwise the abnormal tissues may grow back defeating the purpose of the surgery!!
In my experience, these procedures were extremely successful in controlling the disease.
Office Balloon Sinus procedure
Recently, a new procedure, adapted from the traditional surgery was developed for selected cases, called a balloon sinuplasty. It can be performed under local anesthesia in the office. Keep in mind this is a much less aggressive technique designed to dilate the openings of the some of the sinuses to promote drainage. It may be valuable in a sinus infection that would not adequately clear. It entails introducing a tiny balloon through the opening of the sinus(s), to dilate the opening, and irrigating the sinus with fluid (saline, antibiotic, etc.).
It may need to be repeated, or of it is ineffective, traditional endoscopic surgery may be necessary.
Recovery is much faster, but much less is done in this office procedure. If it is offered to you, inquire about how many procedures the ENT surgeon has performed and the results expected, success in controlling the disease, complications, recurrences of disease, and the need for more formal sinus surgery.
The balloon sinuplasty procedure below in 4 steps:
Step 1 demonstrates the tiny balloon that has been endoscopically introduced through the maxillary sinus opening, and a catheter is introduced through the endoscope. Step 2 the balloon is inflated and in step 3 the catheter suctions and irrigates the maxillary sinus.
Step 4 shows the scope being removed.
Below is a photo of the instrument used to perform the sinuplasty, which has a suction attached to the instrument, and is flexible as well. The balloon is at the end of the instrument.
Again, it must be emphasized that medical and allergic management must be ongoing, including allergy consultation, testing, and allergy shots.
It is critical that any kind of surgical option offered should be only recommended after extensive attempts at medical management. I would strongly suggest you get a second opinion before proceeding with any of these procedures and have a very experienced ENT surgeon, who performs these procedures on a regular basis.
For a short video, click on: http://www.balloonsinuplasty.com/watch-bsp-tv/#category=procedure