The Medical News Report

#102

 

July, 2020

Samuel J. LaMonte, M.D., FACS

 

www.themedicalnewsreport.com

samlamonte@gmail.com

 

Subjects for July, 2020:

1. New update on COVID-19—new treatments that will drop the death rate

2. Diagnosing lung diseases; differentiating restrictive from obstructive lung disorders- trying to understand spirometry lung testing

3. Suicide is on the rise! Resistant depression

4. Pancreatic cancer may be the second most common cause of death this year!

5.  When smokers who quit-- cardiovascular benefit and reduction in risk of lung cancer timeline? New information on lung cancer

6. It is “all in your head”—a guide to patients who hit a dead end with their doctors

 

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

  With COVID-19, no one can ignore their ongoing illnesses. They are critical in increasing your risk of getting infected and having a more severe case. Don’t ignore routine doctor’s visits and routine screenings for cancer.

  Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

Thanks!! Dr. Sam

 

 

 

 

 

 

 

 

1. COVID -19 PANDEMIC UPDATE  JULY, 2020

Current Nationwide Statistics

  As of June 23, there have been 2.2 million cases confirmed with close ot 120,000 deaths. Keep in mind, most healthy people do not get very sick, are asymptomatic, but can still spread the virus. Florida has 95,000 cases with 3,000 deaths. There is a surge of cases in several states including Florida, thanks to younger people not following the rules and taking this virus seriously. Georgia has 64,000 cases and 2,600 deaths. Cases are rising slightly in Florida, but mainly in younger healthy individuals who won’t practice good protective measures and are asymptomatic.

  There have 95,000 people who have tested positive and 32,000 who have died, therefore, 1/3 of these patients who are very vulnerable will die. That has to change. Rapid testing has proven to be less reliable (Abbott Labs), so tests still require the nasal and throat swabs all way back in the throat.

 

1. Answers are beginning to appear in medical journals

  We are now into the fifth month of this pandemic, although it was not named as such by the WHO until the middle of March, it was a serious breach of duty for the worldwide organization to alert everyone of even a possibility that human to human contact was possible.

  Our country has responded in lightning speed, even in the face of not being adequately prepared for a disaster the magnitude of which we have not seen in our lifetime. It also didn’t help for the original CDC tests to be contaminated. Thank God, this administration called on the private sector to make PPEs and develop testing.

  The country is opening up rather well, even in the face of crowds of protesters, and certain states penalizing their residents by dragging their feet to reopen with political overtones. You can only expect people to isolate for just so long, even when it is probably the correct thing to do. But the younger people are getting tested and are showing higer rates thanks to their lack of responsibility to follow the rules.

  We have faced a significant flu season, hurricanes, forest fires, floods, tornadoes, loss of a robust economy, destruction of trust between black Americans and police by a bad apple in Minnesota and another incident in Atlanta. 47 million Americans have been out of work, however, over 5 million jobs have been regained.

  Our nursing homes have been rocked by infection, and almost half of adults, who have underlying diseases are facing 6 times the risk of being hospitalized and 12 times greater risk of dying from COVID-19 according to the CDC.

  The U.S. has seen 1.76 million cases and 103,000 deaths in the U.S. as of June 16. There have been 1.3 million laboratory confirmed tests as of May 30. Age has been a big factor especially after age 60 with the highest numbers in 80 plus aged people. However, younger people under 60, usually with underlying risk factors, are still being hospitalized locally and elsewhere. No one is really safe unless they practice good preventative protection practices. 

 

2. Cases, deaths, high risk groups

  As of June 20, 2020, 2.2 million cases have been confirmed, and 120,000 deaths. Almost all states are seeing a drop in deaths and hospitalizations. Because of increased testing and younger people getting out, there is some rise in numbers, but expected. Of course, the media dramatizes the numbers, when 85% are either asymptomatic or have mild disease.

Age, cardiovascular disease (32%), diabetes (30%), and chronic lung disease (18%), obesity, smokers, and potentially immune-compromised people make up the majority of severe illness and death.

  14% of those infected were hospitalized, and 2% were admitted to the ICUs and 5% died. Fortunately studies on people immune-suppressed by disease or medications did not see an increase in hospitalizations because these people were very smart and isolated themselves and are performing maximal hygiene and use of personal protective devices. They are used to these risk factors.

  Only 11 counties out of the over 1300 counties in this country have seen increases in cases recently mostly due to more testing but also due to people getting out and not preventing transmission. Most of these counties have higher asymptomatic cases who have been tested.

  So far there has been no major outbreak in cities who have had riots and destruction with crowding of protesters. However, that should not make people forget about following CDC guidelines.

 

3. Knowing the difference between asymptomatic and presymptomatic people

  We now know that about 10% of asymptomatic people including children and young adults are actually presymptomatic, because they become symptomatic within an average of 4 days from being tested positively.

  As many as 50% of people infected are asymptomatic depending on which country’s statistics one follows.  The WHO and CDC state that 80% are either asymptomatic or have have mild disease.

  Sadly, a significant number of asymptomatic people do not develop much measurable antibodies, which probably equates to lack of immunity for future infections.

 

4. Surface contamination and aerosol transmission

  We now know surfaces are not as likely to transmit disease as reported by the CDC. We now know that the virus can aerosolize and be in the air for sometime especially in closed smaller spaces like bathrooms, elevators, and areas of poor ventilation. This is another potential source of transmission besides actual respiratory droplets of mucus from speaking, singing, coughing, or sneezing.

  This is a good reason to wear masks inside if 6 feet distance cannot be maintained.

 

5. Disparities in COVID-19

  There are certain races that are more at risk, especially blacks and American Indians, primarily because of higher rates of underlying health issues and being socioeconomically disadvantaged.

  Their fear of the “system”, having no insurance, and worry about getting sick if they go to the hospital are other factors, thus delaying their admission to the hospital. Delays in seeking care who are sick and also those who were reluctant to seek care because of a non-COVID health issue has increased health care challenges.

 

6. Unintended consequences are piling up

  I have discussed the unintended consequences on health issues at length. Here are just some of the issues that are going to be felt for years to come.

   1- Economic disaster

   2- Delays in management of chronic diseases—heart attacks, strokes, diabetes out of control, lung diseases worsened (39% of diagnostic tests for urgent disorders delayed)

   3- Home injuries, poisonings of children from cleaners

   4- Domestic violence, abuse, and pedophilia

   5- Mental distress from social isolation, loneliness, and

       fear, and those with COVID-19---PTSD, suicide,

       hotlines up 900%, depression-33%, insomnia-47%,

       memory difficulty-34%, concentration difficulty-38%

    6- Severe grief from being separated from sick family,

        hospitalized family, nursing home elderly,

        births, end of life, no funerals, no closure

    7- Substance, food, and alcohol abuse

    8- Delays in diagnosis of cancer estimated to 88,000

         Cases

    9- 1 million infections in children expected with delay in

         Vaccinations

   10. 28 million sugeries delayed globally

        

7. The CDC-9—symptoms of COVID-19

  The CDC has now named 9 symptoms that should require testing for COVID-19—70% present with cough , fever (>100.4F), and shortness of breath. 36% with muscle ache, and 34% headache. Other symptoms include chills, fatigue, loss of smell or taste, and sore throat. Not included in their 9 but can occur in less than 10% of the cases include gastrointestinal symptoms and loss of smell or taste.

 

8. When to seek immediate care

  It is important to know what symptoms should prompt a person or caregiver to seek immediate care: 1) shortness of breath increasing 2) chest pressure or pain in the chest 3) confusion or altered consciousness or 4) bluish lips or a dusky appearance (hypoxemia).

  People with underlying diseases should already be in contact with their doctor about maximal management of all medical concerns and be ready to go to the hospital when symptoms or conditions worsen regardless of whether they are COVID related.

 

9. How the virus attacks humans-A revision in thinking!

  For those who have been wondering why most chronic underlying diseases, if under control, can still increase the risk for a more severe case of the virus, there are several answers now known.

  The virus attacks human cells by invading the protein in the lining of human cells, especially the respiratory tract.  Specifically, the monoclonal neutralizing antibodies stimulated by this virus is a glycoprotein that does or does not allow viral entry into the human cell. The virus’ surface spikes attach to certain protein receptors on human cell surfaces. This allows access into the cell for replication and takeover of that cell. However, human neutralizing antibodies can block the virus’ attempt to enter the human cell. This type of antibody from human T-cells can defeat the virus, otherwise the patient may not have time to recover from this viral invasion. Remember, it is the virus that stimulates human T-cells to secrete cytokines. 

Below is a representation of that invasion.

 

This invasion is seen as a classic inflammatory antigen-antibody response, which incites a massive inflammatory invasion of human cells. This occurs from activation of B- and T-cell white blood lymphocytes. The B-cells secrete immunogobulins (IgM, IgG) and neutralizing antibodies from T-cell lymphocytes to fight the cytokines causing the disease especially the lungs. Cytokine stimulation is more pronounced than most other infections. Hence the term cytokine storm in COVID-19 infections.

The disease results in 3 major pathological conditions:

  1) An inflammatory multi-systems disease-- COVID-19 is an inflammatory disease that creates damage to the cell wall because of the pro-inflammatory markers such as cytokines ( there are others), not direct damage. It is our own immune system that does the damage similar to any autoimmune disease such as rheumatoid arthritis, lupus, MS, psoriasis, etc.

  2) Hyper-coagulopathy-- The other major influence by cytokines is increasing clotting factors (there are many clotting factors) that create clotting in major and minor blood vessels throughout the body. This results in strokes, heart attacks, and emboli in the lungs and other organs.

  3) Hypoxemia—A drop in oxygen transfer in the lungs occurs when the cell lining of the alveoli are thickened by deposits of fibrin and other breakdown products of blood cells, even iron (which is necessary for hemoglobin to carry oxygen).

  This physiologic crisis stresses the body to increase the release of cortisol from the adrenal glands, which raises the blood sugar (makes diabetes worse), and blood pressure (hypertensive people are in trouble), and ultimately if organs do not sufficiently oxygenate, they fail.

  The clotting issue is also a primary target of these cytokines increasing blood cltting factors causing emboli, heart attacks, strokes, and other vascular events.

  These physiologic events will either pass over several days or send the patient into shock and potentially death.

 

10. Autopsy results of COVID-19 patients and the hope for new treatments

  The patients who die from this virus show many of the features of the disease ARDS (diffuse lung damage with abnormal blood vessels around the tiny alveoli, which are the components of the lungs to exchange carbon dioxide for oxygen. However, there were distinct pathological differences….there intracellular virus and membrane disruption in the alveoli. Another difference was profound clotting of the tiny vessels surrounding the alveoli.

  This virus actually stimulated the growth of new vessels around the alveoli trying to repair the damage (it is called angiogenesis). NEJM, June, 2020

  The reason this angiogenesis issue and other pathological factors points to areas of research that might open up for the development of new therapies for COVID-19.

 

11. A revision in thinking about how COVID-19 damages the body, new treatment changes reducing deaths in patients in respiratory distress

Key changes: 1) The virus affects human cells differently, 2) Some proposed therapies do work and other don’t, 3) Ventilators not needed in many cases early cases, which can prevent ventilator damage

  As discussed in previous updates, currently, the only FDA approved treatment is Remdesivir, an antiviral agent, but many other medications are being used as an off-label even without proof of their value. However, other medications have been proven to be very valuable—corticosteroids and convalescent Plasma transfusions.

  Remdesivir reduces the length of hospitalization from an average of 15 days to 11 days. But there are other medications that are even more effective.

  When it became clear that this disease process was not  ARDS (acute respiratory distress syndrome), a pulmonary disease well known to the medical community, a different approach had to be chosen.

  At first, intravenous corticosteroids were not recommended to contend with the inflammatory condition of this disorder for fear it would reduce the body’s immune response to the virus. However when doctors were failing to save many patients on ventilators, some brave doctors had to re-think the use of steroids, a traditional anti-inflammatory medication.

  When relatively low doses of a corticosteroid (dexamethasone) were used, many of these patients improved. In one study, they were more effective the earlier they were started. 6 mg of dexamethasone (given intravenous) for 10 days was effective. This is now the standard of care in addition to other combinations of treatments. A new report found that 35% of deaths were averted in patients who were intubated and on ventilators, and 20% reduction in those on oxygen support with nasal cannulas or face masks. The University of Oxford

A change in how COVID-19 caused infection

  Doctors had to revise their thinking about how the virus was damaging the body. It became clearer that the virus was indirectly causing the infection by massively stimulating the human body’s own immune system which caused the damage. The body’s own immune system was sent out of control by the influence of the effects on human cells. Now that this is better understood, it became clear that the role of corticosteroids was needed to combat the over-reactive body’s immune system.

 

  With Remdesivir, corticosteroids, and convalescent plasma transfusions all showing promise separately and in combination, the doctors are finally getting ahead of this disease with better protocols.

  Convalescent plasma comes from recovered patients who have developed the above mentioned monoclonal antibodies. It is now a recognized possible treatment. It may also become a form of prevention. These antibodies are also going into clinical trials this summer may be used as a potential preventative vaccine. It is still not known which patient profiles will benefit the most from these plasma infusions. The answers will be forthcoming.

  Hydroxychloroquine was touted as a possible treatment and or prevention early on, however, studies has disproven their benefit and found to have too many cardiovascular side effects in these very sick individuals.

  The FDA has removed approval for the emergency use of this drug with or without azithromycin.

 

Ventilators no longer started as early

  The original standard of care included intubation and placing patients on a ventilator as soon as shortness of breath and or pneumonia was diagnosed. However, using high pressures on the ventilator caused as much damage as the disease raising the death rate. Doctors had to rethink the diagnosis of ARDS and change the regimen.

  Some very brave doctors decided to use masks and high pressure oxygen using nasal cannulas, and helmets with masks instead of ventilators. They found, to their surprise, that driving the oxygen levels to a lower level (>87%) was just as effective and still oxygenated the organs to prevent failure in many of these less sick patients. Previously, they felt the oxygen in the blood needed to be near normal (>95%). It didn’t work in all cases, so the more severe cases still had to be intubated and put on mechanical ventilators. This was reported June 4, 2020, in JAMA

  They also found that patients placed in the prone position (flat) were able to better oxygenate their lungs when not intubated. That position had been recommended for intubated patients as well.

  The death rate is now between 0.2-0.4% according to the CDC in the U.S., much lower than predicted by public health officials. 35% of patients are asymptomatic especially in younger people and women. 85% are either asymptomatic or have mild disease. If that is the case, why all the fuss? It is because these people can still infect those older and those with chronic diseases.

 

11.  Younger people are still susceptible to severe disease….MAKE NO MISTAKE! Surges in cases!

  With a surge in certain states primarily because younger people are not wearing masks and socially distancing, it is estimated that 29% of those infected are between ages of 20-44. In a group reported by Healthline.com of 500 people hospitalized, 21% were between ages 20-44, and 18% were between 45-54. 12% in ICU were below the age of 45, but most recovered and did not die. In France, 50% of the patients in ICU were under the age of 60. There is no data yet how many had underlying diseases and or were obese, but I am guessing they have risk factors.   

 

12. Violations against nursing homes

  Recent reports cited 95,000 nursing home patients in the U.S. have died from COVID-19, and 33,000 have died.

  5 states have been cited for violations for improper protection of their staff and patients in these nursing facilities. Many of these violations included rules requiring recovering infected patients discharged from the hospital being sent the nursing homes. But in the fine print, the facility was supposed to be capable of isolating these patients and many were not. Compliance by staff continues to be a challenge.

  We need our skilled nursing facilities, but some reforms in management are needed for this and for future infectious epidemics. These facilities have always been a hotbed of criticism and vulnerability because of the very type of residents that live there. Our most senior citizens must be better protected. Right now, they have gone through 3 months of not seeing their friends and relatives, because of the pandemic rules.

 

13. Testing

  Testing continues at record pace with over 15 million tests per month, and even though some of the rise in state cases are from testing increases, some are from the reopening our country especially by people ages 18-49.

  Keep in mind they are not more accurate than 90%, so if one has symptoms, but tests negative, talk to your doctor and consider retesting.

  Clearly, we will see breakouts in some areas, but interestingly enough, the protest rallies are not showing a great increase in cases per contact tracing. We must get our country back open, but in a safe and sane way.

  The U.S. positive cases are approximately 12% in hot spots, and that is a far cry from the 55-60% necessary to have herd immunity. We will need a vaccine to get to those numbers.

  It is a challenge for authorities to balance their decisions between science and economic disaster.

   I remind the reader that antibody tests are very reliable, but still not known if these antibodies will prevent future COVID-19 infections or how long that immunity will last.

  Asymptomatic people do not develop much of an antibody response, which could equate to vulnerability to another infection, although, they would probably become symptomatic. Most experts feel if a person who is infected once will probably have less severity if infected again.

  A side note! There have been discovered certain genome (2 chromosomal loci) changes in COVID-19 patients. One of the changes in ABO blood type category. Retrospective studies reported that people with Type A blood are at higher risk (45% greater) and for type O patients a 35% lower risk. And also people with type AB were actually better protected perhaps because of this genetic discovery. NEJM

 

14. Contact Tracing  

  Each infected person can infect 2-3 people according to Johns Hopkins Center for Health Security. This could lead to as many as 59,000 cases if left unchecked. Immediately contacting people who have been in contact with an infected person has been in contact with over the last week is necessary to request for 14 days.

  Close contact continues to be defined as contact with a person less than 6 feet for at least 15 minutes the previous 4 days before symptoms.

Testing only symptomatic people implies that up to 35% are being missed because they are asymptomatic.

 

15. What percent of people infected and recovered have enough immunity to prevent another infection?

  Positive antibody tests do not mean immunity. It is still unknown how long a person might be immune and prevent another attack of this virus. And it turns out that not all recovered patients have adequate antibody titers to fend off another infection.

  In review, there are 2 different types of immunity antibodies, immunoglobulins (IgM and IgG), and neutralizing antibodies.

  Routine antibody testing only test for IgM and IgG, and if they are elevated, it doesn’t automatically mean the patient is protected from future COVID-19 infections.

  Neutralizing antibodies bind to the receptor spike proteins which can prevent infection. This antibody is harder and more expensive to test for and, therefore, not practical to test large populations. It is necessary to come up with a practical test for neutralizing antibodies.

  However, researchers are able to test for these antibodies, and in one small study found that only 33% of the volunteers who were infected with a pseudo-COVID virus, developed adequate neutralizing antibodies. That is bad news!

  It has also been reported that those who are sicker (hospitalized individuals) develop higher neutralizing antibody titers than those who were not hospitalized.

  The country is desperate for blood and plasma donors for not only whole blood for injured patients and those who need elective surgical procedures, but convalescent plasma (those with high antibody titers) from recovered patients which can be used to treat hospitalized patients with COVID-19. Studies are ongoing to fnd how effective these plasma transfusions are.

  It I important to note that the CDC and others recommend no one with positive antibodies on testing should assume they are safe from future infections and exposure to sick patients. We need to know!!

 

16. Recovery

  The CDC defines someone who has recovered and be safe to be around people are those with no symptoms after 14 days and at least 3 days without any fever. For more elderly patients, they may shed the virus for up to 21 days, therefore need to be quarantined for 3 weeks as opposed to the recommended 14 days.

 

17. Prevention using masks

  Preventing transmission should be on everyone’s minds, and masks have been proven to decrease transmission by 60%. That and 6 feet distancing, along with compulsive hygiene are the best answers to prevent spread and resurgence of this virus. Some states are considering mandatory masks out in oublic.

  Protests have not proved to be hotspots of transmission so far. Rallies, going to church, and other group events should be limited to healthy people.

 

18. Flu vs COVID-19 in the Fall—important to understand the impact of both viruses

  There is little doubt that the fall will bring both influenza and some degree of COVID-19 as the weather begins to cool. In fact, COVID-19 may persist through the summer with current surges with reopening.

  Consider the cases and deaths from both viruses. However, those cases and deaths from flu span over half a year, and we already know about COVID-19. The concern will be adequacy of hospital beds if both viruses peak close to the same time. The current pandemic must report all cases whereas the flu is not required, so even the CDC deals with these 2 viruses quite differently and, therefore should not be compared.

  There is a geographic association with COVID-19 especially in the latitudes between 30 degrees North and 40 Degrees North. The map shows that includes the upper Northwest, Illinois, Michigan, and the Northeast U.S., South Korea, Europe, China, etc. These latitudes are where the virus has been most prevalent. It coincides with Brazil in the Southern Hemisphere (-30 to -40 degrees latitude).

19. Looking into the future

  It is important to note, as people develop respiratory symptoms (upper or lower respiratory), that patients and doctors must keep an open mind to diagnosis and management. Whether symptoms are a common cold, a non-COVID-19 virus, a bacterial infection, bronchitis, asthma, or even a flare-up of emphysema, can be determined with a history, physical examination, and lab tests. There will be a strong tendency for people to assume they have developed COVID-19 and may miss an opportunity to treat the other diseases including the flu.

 

20. Summary

  For now, if symptoms develop, get tested and call the doctor. Telemedicine will be here to stay and prevent the need for going to an ugent care or sitting in a doctor’s office.

  Talk to your doctor about the timing of this coming year’s flu vaccine, and hope for a vaccine by year’s end. We must encourage vaccination, and a massve campaign is needed since only 40-50% of people ge the flu vaccine annually and surveys are telling us that only about 50% will agree to a COvid-19 vaccine.

  Wear masks, socially distance, practice serious hygiene, manage any current underlying medical diseases, including recommended screenings for cancer, lose weight, exercise more, and improve the diet.

  Later in this report, I will discuss depression and suicide, issues that are fast rising in people and healthcare providers.

  We must get back our country but safely!!

 

 

2. Diagnosing lung diseases--differentiating obstructive (COPD) from restrictive lung disorders; understanding Spirometry

 

  I have reported on the spectrum of COPD—chronic obstructive pulmonary disease in a previous report; click on the website to review  www.themedicalnewsreport.com/77 

  Since COVID-19 put a spotlight on lung disorders, I felt it important to discuss how major lung diseases are worked up by pulmonary specialist. Getting a correct diagnosis has never been more important in an era when pre-existing lung disease sets a person up for a more serious case of COVID-19 and the flu.

  To clarify an issue that most people do not understand about airway problems-- there are 2 types of airway difficulty—restrictive and obstructive.

  Restrictive airways occur because of spasm in the smaller branches of the lungs—bronchi and bronchioles. The spasm narrows the airway causing decreased oxygen to the lungs with each breath. Breathing rates have to increase to compensate for the restriction in the airways.

  Obstruction occurs when there is something in the airway that blocks air from getting into the lungs normally. That is usually thickened secretions (sputum) which can be just inflamed mucus or a combination of pus and thickened secretions. People with COPD, chronic obstructive pulmonary disease (mostly emphysema) and asthma  would fit in this category.

  As in most cases of any disease, there is nothing simple. Obviously there is overlap in disease processes. Asthmatics with bronchospasm primarily can occasionally have very thick mucus and can be exposed to a virus or other type of infection with bronchitis, even infection, which complicates the disorder.

  By the same token, emphysema patients who have a great deal of excessive secretions, can occasionally have bronchospasm from excessive coughing and extreme efforts to clear secretions.

  A recent study cited a large number of patients are overdiagnosed as having COPD. The Journal Chest, 2015, reported that 55% were overdiagnosed because they had incomplete lung function studies according to the GOLD National standards for diagnosis based on spirometry tests. When diagnosed with COPD or any lung disease, it is critical that the disorder meet the criteria based on national standards.

 

Differentiating restrictive and obstructive lung disorders-the major diagnoses are presented in this following chart on the next page.

Spirometry (Pulmonary Function Testing)

  Using tests to validate clinical impressions is the art of medicine. Spirometry (breathing tests) provides physicians with results that validate some type of breathing disorder. It also can differentiate restrictive from obstructive lung disorders as well as following the effectiveness of treatment over time, and to validate the progression of a lung disorder, or even to evaluate the candidacy for a lung transplant.

  It is a test that measures the ability of the lungs to move air, oxygenate the blood, and also measures how well air can be inspired and can be forced out of the lungs, which is impaired in people with these lung diseases.

  One of the benefits of this breathing test is that abnormalities can be detected even when there are no symptoms. An example is a smoker will show decreased pulmonary function tests on spirometry long before obvious symptoms occur from chronic bronchitis. I suspect e-cigarette users will show abnormalities too. It is used to establish a diagnosis in such disorders as asthma, bronchitis, or emphysema. 

The office procedure is performed by a certified technician to evaluate how deep a person can breathe in and breath out in 1 second. The results are compared to normal individuals with no restrictive or obstructive abnormalities. A bronchodilator is used as well for a second set of breathing tests. If there is a great improvement, this assists the doctor in being able to prescribe these inhalers.

Here are the major tests performed for those who want to know!

PEFR=peak expiratory flow—maximum speed of expiration

FEV1=forced expiratory volume in 1 second—the amount of air that can be exhaled in 1 second

FVC=Forced vital capacity-represents the volume of air in the lungs that can be exhaled after a deep breath.

FEV1/FVC ratio=the ratio represents the percent of the lung air that can be exhaled in 1 second.

Example—FEV1 is 4 and the FVC is 5, the FEV1/FVC ratio would 4/5 (4 divided by 5)=80%

 

Results of testing and severity of disease is based on percentages of normal breathing on these tests

  If the FVC and FEV1 is equal to or greater than 80%, the test is normal. That means that a person can breathe out 80% of the air in 1 second. Mild disease=70-79%; Moderate disease=60-69%; Severe=less than 60%

  If the FEV1/FVC ratio is equal to or greater than 70% would be normal, therefore, anything below 70% would be abnormal. Mild disease=60-69%; Moderate=50-59%; Severe=less than 50%

  When a physician sees most patients, they will have a clinical diagnosis just from the history and and physical examination. The stethoscope allows a physician to hear various audible abnormalities—wheezes, rattling sound (rales), decreased sounds, etc.

Obstructive pulmonary patients

  In people with obstructive disease, it takes longer to expire the air out of the lung due to the abnormalities in the lung from narrowed bronchioles. When a bronchodilator is then breathed in, the bronchioles open up. Patients with asthma, and emphysema would improve with a bronchodilator.

  In a normal person, the ratio of the FEV1 to the FVC is 70-80%, and will be seen as <0.7 on the report and less than these percentages defines COPD in certain stages 1-4 correlated with symptoms of cough, production of sputum, and shortness of breath.

 

Differentiating restrictive vs obstructive lung disorders based on spirometry

For obstructive disease

  On testing, if a patient has a ratio of 70% (FEV1/FVC) with no bronchodilator and and after breathing a bronchodilator ratio of 80%, that indicates that the airflow obstruction is not fully reversible. This may require more extensive treatment regimens.

For restrictive disease

  Mild restrictive disease falls between ratios of 65-80% of predicted values, moderate between 50-65%, and severe if less than 50%.

  It is proper for the doctor to stge these diseases, and they are based on spirometry results.

For a close look at treatment of asthma, emphysema and bronchitis click on: www.themedicalnewsreport.com #77 and #96

 

3. Suicide is on the rise! Resistant Depression

  Suicide is on the rise, and not just from the opioid crisis, but now because of COVID-19, and the unrest in our country, which is skyrocketing. It has increased by 30% since 2000. The hotlines for suicide prevention are currently up by 900%. I enumerated the myriad of unintentional consequences of COVID-19 including numerous psychological effects. No age group is left out.

  There has been a 56% increase in young people age 10-24 in just 10 years and tripled in youth, ages 10-14, according to the CDC.

  142,000 Americans died from alcohol and drug overdoses and suicide in 2016, an 11% increase over 2015, according to a report from The Trust for America’s Health and Well Being. That compares to 142,000 over the previous entire decade. The increases are being seen in most races.

  It is difficult to know what percent of overdoses are true suicides. According to the CDC, 47,000 suicides were intentional in 2017.  

  Suicide computes to more than 1% of all deaths making it the 10th most common cause of death, but 2nd leading cause in ages 15-24. More males are successful (4X) but women are 3X more likely to attempt it. Those with substance abuse disorders are 6 more times likely to successfully die from suicide, but it is rarely just one factor that leads to suicide (alcohol, drugs, depression, stressful events, physical abuse, poverty, loneliness, loss, etc.).

  Attempted suicide should be thought as “a cry for help”.

  About 1% of people who attempt suicide and fail will try again. 10-15% of those who attempt it will eventually succeed. 1 out of 25 attempts will succeed. That increases to 1 in 4 for elderly people. 30-70% of those who attempt suicide have an underlying depression or bipolar disorder. Sadly, suicide accounted for 66% of violent deaths in 2013.

  A substantial number of people attempt suicide on an impulse, not taking more than 15 minutes to plan taking their own lives. In fact, those who have substance abuse tend to have impulsive personality disorders. Never discount a threat or someone talking about taking their life.

  Analysis of those who completed suicide the below chart shows the drugs and alcohol percentages in their blood stream at the time of death. Note alcohol, antideprssants, and benzodiazepines (anti-anxiety) drugs lead the list.

Some of the risk factors

  The greatest risk factor for suicide is a previous attempt. Alcohol and drugs play a major role in suicide. Since they tend to go hand and hand, it is critical to know about the history of both alcohol and drug abuse.

  A relatively new reason for suicide comes from patients who cannot get pain meds from their doctor anymore. This has occurred from the feds cracking down on physicians from being too liberal with pain meds for chronic pain.

Genetics plays a role in 38-55% of the time. People at higher risk are those who are in bad relationship, a war veteran, anyone with PTSD, those in financial distress, poor, homeless, those bullied or discriminated against for any reason, any mental disorder, history of a traumatic brain injury, and those that the household has firearms.

  Those who feel hopeless or helpless, do not have social support, a terminal illness, those who have lost the pleasure of life, poor coping skills, those agitated, feel they are trapped in a hopeless situation, depressed or anxious are all at higher risk. Those who are “neurotic” or introverted are at higher risk. Anyone without social or family support are more at risk.

  Social media has opened a huge opportunity for young people to become critical of each other, and bullying has gone viral. Staying up with popularity via the internet has created a serious hazard for ridicule, shaming, and jealousy. Young people even are prone to suicidal ideation when someone in their school or circle of friends. Some young people have begun to wear a mental disorder like a badge of courage.

  Some reports hae found that young people are refusing to work because they don’t feel mentally strong enough. What has happened to our youth? What has happened to parenting when the outside world is telling them to be weak and depend on others? What changes need to be made to turn this trend around?   

  The key to controlling this national tragedy is to prevent completion of those who have suicidal thoughts (ideation) and treat the underlying disorders that create the thought in the first place. There is some new evidence that some drugs may reduce suicidal ideation (ketamine and lithium) even better than cognitive psychotherapy.

  According to the Substance Abuse and Mental Health Services Administration, suicidal ideation, planning, and attempts have increased the most in the last 10 years among people ages 18-25 co-occuring with the increase in mental health conditions, especially major depressive episodes (#1 cause) and chronic substance abuse (#2 cause). This includes alcohol binging and abuse (drowning their sorrows” is not far from the truth. This may be a factor in up to 60% of the cases. Insomnia and frequent use of hypnotics (sleeping pills) increases the risk.

What are the signs someone is considering suicide?

Other signs include mood swings, cutting off friends and family, feeling trapped, and feeling like they are a burden. 8 of 10 have some sign of their intention (if people are aware of the signs). If a person talks about suicide, believe them and call a suicide helpline for assistance.

If you think someone is at risk:

Likelihood of choice of method of suicide is directly proportional to the availability of means--Firearms, ways of hanging (ropes, belts, etc.), pesticides, any kind of illicit drug or prescription medication, poisons, autos, etc. It is important to remove these methods from the household.

The percentage of suicides by firearms is the highest in the world in the U.S. because of easy access.

 

Treatment of suicidal ideation

  According to drugrehab.com, the number one component to recovery from addiction is “ a reason to live”.  Prevention of suicide means addressing underlying psychological and addictive factors.

  Artificial happiness through drugs and alcohol can’t replace the real thing when a person has no purpose, overcoming self doubt, feelings of worthlessness, failure, and isolation. The good news is addiction, suicidal ideation, and abuse are treatable.

  Recovery is a difficult process and in early recovery, since withdrawal is still going on, suicidal thoughts are a risk and should be addressed. Depression and mood disorders often accompany substance abuse. Recovery requires the brain to relearn to function without drugs and alcohol. Brain chemistry can readjust only with time.

Recovery attempts frequently occur after a stressful event such as a DUI, separation, divorce, or an accident.

  60% of people who attempt suicide do not seek professional help primarily because they don’t perceive a need for help or wanting to deal with the situation alone. Lack of social support and access to assistance are important factors. If anyone sees something that may indicate suicidal thoughts, fast action is necessary.

  Cognitive behavioral therapy combined with medication does improve the rates of those in the arena of suicide ideation, etc. especially in younger individuals. However, getting people to that stage of treatment is difficult and many cannot afford the treatment. Antidepressants may start to work in 1-2 weeks but take 6-8 weeks to be fully active. Reference--Mental Health America

 

What works?

  Rates of suicide were reduced statistically with lithium in patients with bipolar disorder, which is one of the primary therapeutic medications for that disorder. Bipolar patients are at higher risk for suicide. Other medications antidepressants are effective as well.

  Buprenorphine is a drug prescribed for opioid dependency, because, although it is an opioid drug, it does not produce the euphoric effect that the regular opioids do. Buprenorphine has been very successful in reducing opioid dependency, requiring a special certified doctor to prescribe. Now this study has reported a statistically significant reduction in suicide ideation.

Annals of Internal Medicine, September 3, 2019    

 For more information on PTSD, click on:

www.themedicalnewsreport.com/ 

 

Predicting recurrence of depression

  Major depression recurs in about 60% of patients, according to the Mayo Clinic. Major predictors are sudden stress from a variety of causes (including a pandemic) including certain genetic tendencies, social isolation from the current viral pandemic, those with poor self-esteem, dependent personalities, those pessimistic. Blood relatives with depression, bipolar disorder, alcoholism, the LBGTQ community, those with other psychological disorders such as eating disorder, anxiety, and PTSD. Any longstanding  serious chronic disease creates depression. Those who treat or experienced COVID-19 illness, especially those hospitalized are causing major depression. The financial stress brought on the current virus has caused major rises in depression and suicide.

Resistant depression is defined as severe depression that is not controlled with medications (at least 2) approved for depression. It does not include psychotherapy. Some psychiatrists feel that partial response does not mean resistant illness.

  Certain factors that contribute to inadequate treatment response include patients not taking medication as prescribed, inadequate dosage, early discontinuation of medication, misdiagnosis, and concurrent psychological disorders.

  It is estimated that 2/3 of patients will not respond to the first medication they are prescribed. Achieving long term remission is a challenge for healthcare professional treating patients with depression.

   5-13% of Americans suffer from significant depression during their lifetime. The mean age of onset is 30 years of age.

  Up to 1/3 of patients have resistant depression. This assumes changes in dosage have been attempted, there is compliance in medication consumption by the patient, and a trial of 2-3 prescription anti-depressants have been attempted.

  Blood tests to prove adequate blood levels may be necessary. Patients who have major feelings of helplessness and hopelessness are particularly prone to non-compliance in taking their medication as prescribed especially when their results are less than expected.

  Before being labeled resistant depression, confirmation that no other disorders (medical or psychological) are interfering with treatment response is a must.

  Cognitive behavioral therapy is strongly recommended in these patients as well, which reinforces the need to take the medication properly.

  Medical conditions that interfere with depression include certain cardiovascular conditions, especially those that create hypoxia (low oxygen levels), collagen vascular diseases (autoimmune) such as lupus and rheumatoid arthritis, and those who are abusing alcohol, or are withdrawing from amphetamines or cocaine.

  There are many medical illnesses that create depression including neurological diseases, low thyroid, diabetes, chronic pain, and cancer. These disorders must be looked for by the primary care physician.

  There are studies that cite no improvement adding psychotherapy to medications (i.e. Celexa and psychotherapy), however, it is a viable option that must be considered in resistant cases.

  Side effects are well known and are a significant reason for non-compliance (weight gain, sleep issues, loss of libido, apathy, etc.).

 

Trans-dermal patches for psychiatric disease treatment

  Recently a patch placed on the skin which can last days to weeks has been approved for schizophrenia (Secuado), but also will most assuredly be approved for all major psychiatric disorders in the future. Patient compliance has always been a serious issue including side effects and the fantasy that the person is doing well enough to stop the medication.

 

Combination of anti-depressants

  Adding additional antidepressants should be considered such as Celexa and Buprion or others plus Abilify.

 

 Electroconvulsive therapy (ECT)

  Ever since “One flew over the cuckoo nest”, ECT has had a bad name. But in resistant cases, those with psychotic depression, or those unable to tolerate medication, ECT can be quite helpful. Older patients may not respond as well and concern for prolonged cognitive issues is a concern. Short-term memory loss, learning, concentration, etc. are not uncommon with ECT. However, in resistant cases when the patient cannot function in life, those side effects can be tolerated. It can be lifesaving.

 

Vagal nerve stimulation

  Stimulation of the vagus nerve as it traverses the neck has shown some improvement, although some studies have not proven it better than a sham procedure.

 

Psychodelic drugs show significiant improvement

    A. Psilocybin

    B. Ketamine

 

A. Psilocybin (“magic mushrooms”)

 The FDA just recently approved this extract from certain mushrooms. The Usona Institute for Clinical and Translational Research (California) was granted permission to perform clinical trials (80 participants) on this drug for major depression disorder in patients 21-65. Half will be given the drug and half a placebo. It is estimated that the trial will be complete by 2021.

  It is still not available for clinical use outside the institute. Johns Hopkins School of Medicine, New York University School of Medicine, and Yale School of Medicine and other major medical centers have been involved with research using psilocybin.

  How this drug works in the brain to affect the neurotransmitters that are usually affected by anti-depressants, is being studied, but there are no details yet.

  With 17 million Americans with major depressive disorder and without a magic bullet to treat, it leaves physicans and patients frustrated. That is why the FDA is open to unorthodox treatments such as psychedelics.

 

B. Ketamine nasal spray (Esketamine)

  I have previously reported on ketamine, an anesthetic agent I used frequently to perform surgery under local anesthesia while in training and in animal research. The beauty of ketamine is excellent anesthesia without depressing respirations, therefore, patients do not require a ventilator during a procedure.

  It can create an hallucinogenic “trip” for a few hours after use. It make a person feel disconnected from their bodies. It was initially used during the Vietnam War for surgery in the field. It is very valuable in veterinarian surgery.

  Since it became available for special clinics to use, it unfortunately has become a party drug available on the black market called Special K.

  It is also available as a nasal spray (Esketamine) from certified physicians.

  It is being used in resistant depression, PTSD, and those with suicidal ideation. Clinical trials continue regarding value and drugs similar to ketamine are being developed.  The clinical trial administers the drug intravenously, 6 doses over 1-2 weeks with boosters every 3-5 weeks as needed. It is marketed as Narketan

Ketamine is not a quick fix, as it takes weeks to see  clinical improvement.

  Research on psychedelics including LSD will continue and their value will be realized, but at what dose and at what capacity, remains to be seen.

  Depression like many psychological disorders are in a sense a neurological disease with psychological manifestations. Until medicine has a better understanding of the brain and it’s neurochemistry, we will continue to have large gaps in treatment for these disorders.

Marijuana and Mental disorders

  A note about using cannabinoids---CBD and marijuana for mental health disorders. Don’t use it!! The Lancet Medical Journal reported on 40 randomized trials using various cannabis products especially for depression and anxiety (and others). There was no reported benefit, in fact, mixing it with alcohol and other substances increased depressive symptoms. Randomized clinical trials have shown no value in chronic pain, a problem commonly associated with depression. For those who feel they are being helped, the placebo effect must be taking place. As expected, using cannabis on a regular basis is of little value except in a small number of cases.  Reference- Lancet Psychiatry, Oct. 19, 2019

 Weight gain and taking antidepressants

One of the greatest challenges for physicians and their patients is that many of the antidepressant medications can cause weight gain. Some (not all) notice weight gain initially). It is now recommended that any patient prescribed the anti-depressants be placed on a weight reduction diet even if the person is not particularly overweight. Remember, some of the symptoms of depression cause weight gain alone.

  A discussion with the prescribing doctor should include weight management and selection of a medication less likely to cause weight gain.

  34 million Americans are currently on antidepressants. Staying on them is challenging for many reasons, but many women will not stay on their antidepressant if it is causing weight gain.

  A recent study (Journal of Obesity, September, 2019) found that obese patients on an antidepressant can lose as much weight as someone who is not taking psychiatric medication.

  Body fat mass is causally related to developing depression, according to a new study in Transactional Psychiatry, August, 2019. Obviously a huge number of obese patients need antidepressants, therefore, the issue of weight gain from these medications is important.

  In other reports, the utilization of weight loss medications and bariatric surgery for obesity should be included in this situation, but psychological counselors are not qualified to talk about this subject. Primary care doctors need to know who to refer these patients to for a thorough handling of the disorder.

 

Antidpressants that do not usually cause weight gain

  Bupropion (Wellbutrin), fluoxetine (Prozac), and Lexapro usually do not cause weight gain. Some of the older tricyclic (nortrptyline-Aventyl or Pamelor) antidepressants may not cause weight gain, but it varies with the patient, especially if an overlapping eating disorder is present.

  Zoloft and Paxil (all good antidepressants) are known to cause an average of 15-20 pounds and must be countered with caloric reduction, more plant based diets, more exercise (which helps depression), but regardless of the antidepressant chosen by the doctor, it must be successful in relieving depressive symptoms. The dose may need to be adjusted, and often different antidepressants will need to be tried to find the best medication for each individual’s needs.

  It also must be remembered that antidepressants take 4-6 weeks for these medications to be fully effective, and patients must begin reducing calories from the onset.

 

Withdrawal from stopping antidepressants

  After taking antidepressants for several months to years, it is critical, if a patient along with their treating physician, decides to stop the medication, that a careful plan be initiated. It may take 2-3 months to completely stop the medication, so lower doses need to be available to gradually reduce the medication dose.

Healthline.com; WebMD

 

4. Pancreatic cancer might be the second most common cause of death from cancer this year!

  Why is pancreatic cancer so bad? There is a simple answer….no symptoms early and when they occur, the tumor is advanced and possibly metastasized. A concise discussion by Dr. Richard C. Frank, oncologist at Sloan-Kettering Memorial Cancer Institute, NYC, in the cancer survivor magazine, Conquer*, updated our knowledge in this disease.

Conquer magazine and internet service is free to cancer survivors and caregivers www.conquermagazine.com

It is a great resource for those interested in keeping up with the latest in cancer.

  According to the National Cancer Institute, 56,770 Americans will be diagnosed with pancreatic cancer this year and 45,750 will die this year.

Alex Trebek, host of the TV game show, Jeopardy, just returned after undergoing several rounds of chemotherapy, stating that his chemo had shrunk the tumor enough for him to return to work. He has Stage IV cancer, which means it has advanced out of the pancreas. Although it is not known exactly what metastases he has, it grows into the surrounding tissues and lymph nodes in small intestine, the liver, lungs, and peritoneum (lining of the abdominal cavity). In 10%, the adrenal gland and bones are involved.

  Other celebrities that died with this disease are Patrick Swayze, Michael Landon, and Dizzy Gillespie. Steve Jobs died of a less type of pancreatic cancer. Supreme Court Justic Ruth Bader Ginsburg just announced that she was cancer free (that only means no cancer can be found in scans).

  The cure rate for Stage I (early disease) is 20-40%. For Stage IV, only 9% survive 5 years.

  The challenge of diagnosing this cancer is obvious, because the symptoms of vague fullness, abdominal discomfort, and fatigue would lead most physicians down a path of multiple intestinal diseases before be suspicious for pancreatic cancer. By the time weight loss, jaundice, and back pain occurs, it is usually metastatic.

  Ordering a CT scan on everyone with these vague symptoms would be considered over ordering tests. And yet, a scan will be diagnostic. No national organization has recommended routine screening for this cancer. However, if a person is a smoker, heavy drinker, obese, just developed a new case of diabetes, or has a family history of the disease, one might become suspicious earlier and order a scan.

  There is intensive research going on to discover a substance in the blood that indicates the possibility of pancreatic cancer. So far there is no blood test to use to screen patients. Dr. Frank is leading a clinical trial working on finding a blood test for screening.

 

Cancer Biomarkers

  There are other cancers that have markers—CA-125 for ovary, CEA-carcinoembryonic antigen) for colon and CA 19-9, ALK gene rearrangement in lung cancer, Alpha-fetoprotein for liver and germ cell tumors, B-cell immunoglobulin gene mutation for B-cell lymphoma, Beta-2-microglobulin for multiple myeloma, chronic lymphatic leukemia, Beta-human chorionic gonadotropin for choriocarcinoma and germ cell tumors in testicles and female cancers, bladder tumor antigen for bladder, kidney, and ureter cancer, BRCA1 and 2 gene mutations for breast and ovary cancer, the Philadelphia chromosome (BCR-ABL fusion gene) for certain leukemias and KRAS gene mutation for colorectal and lung cancer, PD-L1 for lung and stomach cancer. 

  Currently the treatment for pancreatic cancer for a potentially resectible tumor is the Whipple procedure, a very aggressive procedure that removes bowel and pancreas and surrounding tissues.

  Sometimes chemo may shrink a tumor and make it possible to remove the cancer. Radiation prior to surgery also may help. There are many patients who are opened up and the tumor is found to not be removable.

  Chemotherapy similar to colon cancer treatment is the standard therapy (FOLFIRINOX- 5-FU, oxaliplatin, and irinotecan) plus leucovorin. Other options include Gemzar and Abraxane. Most only live a year.

  As in most cancers, immunotherapy is in clinical trials especially used if certain tumor genetic markers are present (PD-L1) using Keytruda and Optivo.

  Progress continues and hope is always high for doctors like Dr. Frank to find a blood test that would help find earlt pancreatic cancers.

  For a more general discussion on this cancer, click on:  www.themedicalnewsreport.com #83

 

5. Length of time for a smoker who stops to reap cardiovascular benefits and reduce lung cancer risk? New information on lung cancer

 

Introduction

  According to the CDC, the smoking rate in the U.S. has dropped from 14% in 2017 to 13.7% in 2018, but the rate of e-cigarette smokers increased from 2.8% to 3.2% during the same years among adults.

  These statistics do not include 2.3% of middle schoolers that smoke cigarettes and 25.3% of high schoolers who are either smoking cigarettes or vaping (or both for flavoring).

   The current percent of cigarette smokers in the U.S. is at an all time low, but that is erased by vaping (e-cigarettes). However, people continue to quit daily with one cessation method or another (even vaping), and those people need to know the reward for quitting as they age.

  The JAMA network reported on the health benefits for smokers who quit.

 

Cardiovascular benefits

  Convincing someone to stop smoking is a futile effort, but knowing there is a reward for stopping is one way to encourage smokers to consider cessation.

  3 large groups were studied (total # was 8770 participants) with a mean age of 42.

-One third were smokers who did not quit

-One third were smokers who quit

-One third never smoked

  Smokers had at least 20 pack years each. All other factors were controlled so that other health issues did not complicate the data.

  Current smokers had a rate of 11.5 events compared to never smokers who had 6.5 events over that 26 years (about twice the # of events).

  The number of cardiovascular events were also compared 5 years later. There was a significant drop in cardiovascular events within 5 years after smoking cessation but nothing approaching never smokers.

  After 15 years of cessation, heavy smoking quitters and never smokers had about the same number of events. 

  These results are promising if smokers continue to abstain from tobacco, but it is clear the risk of cardiovascular diseases continues to be a concern for 15 years or longer especially those who are heavy smokers.

  Light smokers were defined as those smoking less than 20 pack years. If these smokers quit for 5 years, this study reported they are back to the same risk of cardiovascular disease as someone who never smoked.

  Smoking is responsible for 20% of deaths due to cardiovascular disease. Smoking cessation, however, reduces the risk over time. Cardiovascular outcomes included heart attack, heart failure, stroke, and cardiovascular death.  JAMA, August, 2019

  The other major concern is cancer, and lung cancer leads the list. However, smoking is linked to 15 different  cancers (oral, throat, laryngeal (voice box), esophagus, stomach, breast, pancreas, bladder, kidney, large bowel, bone marrow, liver, ovary, and cervix.

 

Lung cancer 

  Smoking is the number one cause of lung cancer.

 

Peter Fonda

 

230,000 cases were diagnosed in 2019 and 143,000 will die (lung cancer accounts for 23% of all cancer deaths). Only 16.4% are diagnosed with early stage disease. Peter Fonda (above), a long time smoker, died of lung cancer recently (son of Henry Fonda and brother of Jane Fonda, best known for his movie “Easy Rider”. Supreme Court Justice Ruth Bader Ginburg survived lung and pancreatic cancer.

   I diagnosed several incidental lung cancers in my 30 years of surgical practice, but the practice of performing screening chest X-rays before surgery is no longer recommended in asymptomatic people.      

  Secondhand smoke, radon, and other chemical exposures are all responsible for causing lung cancer (particularly non-small cell bronchogenic carcinoma).

  Lung cancer occurs in 2 main cell types—small cell (20%) and non-small cell (80%) carcinoma. Most smoking related cancers are non-small cell. Detecting early small cell carcinoma is very difficult even with the screening technique of spiral CT scan of the lung.

 

Liquid biopsies and spiral CT scan of the lungs

  There are several mutations and biomarkers that drive the occurrence of these cancers, also driven by smoking. These biologic drivers can determine longevity and predictability of treatment success. These genetic tests are called “liquid biopsies”.

  These “liquid biopsies” hopefully, in the future, will be used as a screening method in addition to the value of the spiral CT scan of the lungs, which can detect lung cancer in 24% of qualified people* and can save 15-20 % of these people from dying of cancer, because these cancers can  still be resectable and can be potentially cured.

*Qualified people for spiral CT scans include those who are smokers or have had 30 pack years of smoking and have quit, can have these screening scans annually and are usually covered by insurance. Unfortunately not enough people who qualify do not get tested (5-10%).

Reference--The National Cancer Institute

 

Good news for those who quit

  The good news is quitting smoking reduces the risk of developing lung cancer each year a smoker has quit. In one study reported by Very Well Health, 77% who are diagnosed with lung cancer have a history of smoking but only 11% were current smokers. (20% of lung cancer in women have never smoked). Most who develop lung cancer had quit 10 or more years, but after 5 years, the rate of cancers start to drop dramatically with a 50% drop in risk after 10-15 years. 

  The risk is still present throughout the rest of their lives especially for those who have 30 pack years* or more.

*30 pack years=could mean 1 pack a day for 30 years, or 3 packs a day for 10 years.

 

6. A guide for patients who are told “it’s all in your head”!

 

  I recently read an article in JAMA Neurology (Dr. Matthew Burke, Harvard Medical School  titled “Its all in your head”—Medicine’s Silent Epidemic by a neurologist who practices neuropsychiatry.

  There are many symptoms patients complain of from chronic fatigue to chronic muscle and joint pain, tremors, headaches, dizziness, etc. that can’t be explained with standard workups by physicians.

  Classic diagnoses without definitive clinical evidence include fibromyalgia, chronic fatigue syndrome, chronic Lyme disease, etc. Doctors have no specific treatment and many still do not believe the above entities exist.

  I recently explained the neurological abnormalities in these patients under the new specified name of Central Sensitivity Syndrome. This report is a must for an indepth explanation and validation of these disorders.  www.themedicalnewsreport.com/84

  Psychosomatic medicine is really the kind of medical issues I am referring to. It seems so simple to understand that the mind can make the body sick and vice versa.  But without a positive medical workup, doctors are left with little understanding of what they are seeing and how to treat it.

   Dr. Burke referred to a website for patients regarding these undiagnosable disorders for some help. 

www.neurosymptoms.org/

   Below is the part of the first page (on the next page). The link between emotional and physical disorders. The circuitry in the brain and the connections explain these disorders clearly, but the attitudes of physicians are still transitioning.

  Neurotransmitters, neurons, and synaptic connections continue to be better explained, and with the understanding of our brains at about 10%, can you imagine the future?

  Most of these patients have been called hypochondriacs and malingerers. These patients invariably get referred to psychiatrists. Often patients reach out to fringe medicine techniques, unnecessary procedures, and alternative practitioners. Naturally, these patients become frustrated, depressed, and desperate, all of which aggravates the underlying disorder.

  Disorders such as fibromyalgia, chronic fatigue, etc. are real and may have underlying autoimmune diseases that need treatment.

  In this day and time, when office visits continue to shorten, physicians are required to see more patients (most are employees of large medical centers), patients with difficult medical issues may be sent to the back of the line. Cost will continue to dictate healthcare regardless of the type.

  We must continue to seek out dedicated physicians that are willing to continue research in the mind/body/health area to find new avenues of understanding and eventual treatments. This area of medicine must reach out to a team of practitioners far beyond just MDs and ODs.

  Just as in the treatment of chronic pain, we must incorporate chiropractic, physical therapy, acupuncture, yoga, tai chi, and other forms of exercise, and yes even better understanding of other Eastern Medicine treatments (herbs, etc.), and diet manipulation (plant based diets, vegan, etc.) getting away from animal protein, which incites inflammation, the underlying cause of most diseases. Combining treatments of mind and body are necessary in many more disorders than these issues.

 

This completes the July, 2020 report.

 

The August, 2020 report will include:

1. Portable Medical Devices; Telemedicine takes hold!

2. Botox and facial fillers

3. Chronic cough

4. Cancer risk for children borne from women using fertility drugs

5. Screening guidelines for abdominal aortic aneurysms

6. Continued updates on COVID-19

 

Stay healthy and well, Dr. Sam