The Medical News Report

#103

August, 2020

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

samlamonte@gmail.com

 

Subjects for August, 2020:

1. Update on COVID-19; Flu and the pandemic this fall—double trouble?

 

2. Portable Medical Devices and Telemedicine

3. Facial Dermal Injections and Botox options for fine wrinkles and aging

 

4. Consumer report on sunscreens; Efudex cream to remove precancers of the skin

 

5. Chronic cough—the workup and management; new guidelines for lung cancer

 screening

 

 

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.

  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. Update on COVID-19; Influenza and the pandemic

 

Introduction

 There is once again a lot of important new information that will bring your knowledge up to date as of the end of July.

  There are a host of COVID-19 and Influenza subjects I will cover in this report, and it is important for the reader to stay up to date.

  The flu season will complicate the COVID-19 issue, and the other concern are the surges that have recently occurred because of younger people not following the science and rules. But there is good news about testing, which I will report below.

  Opening schools is a hotbed of controversy, and our children’s intellectual, mental, physical, and social welfare is at stake. We will cover this subject.

  There is no one fix for our country regarding this pandemic. Each state depending on their numbers will decide what can be done to get their state going.

  It is a presidential election year, as it has created a horrible political environment in which to function and at the same time fight a virus and save the economic welfare of our country. Unfortunately, we have a a segment of the country that has very different ideologies.

  Add the racial unrest, the anarchists, the destruction of our big cities, and we are facing such a huge challenge, I hope we can rise above all of it and get past this pandemic with a healthy and prosperous country.  

 

Predictions for the fall regarding which strains of influenza will need to be prevented with the flu vaccine

  Trying to predict what strains of flu will predominate each year has always been a “educated guess”, and that is based on the flu experience in the Southern Hemisphere, which occurs during our summer. Our flu shots consist of specific strains predicted to predominate our flu season based on their data. Some years, the prediction is better than others.

  Type A and B influenza virus predominates most years, and type B and H1N1 (a subtype of Influenza A) were the most common last year. In Florida and the South, type A was more common.  

  The season started early last year, prompting authorities to encourage everyone to get the flu vaccine earlier this year, especially with the pandemic still around. About 30-40% were protected last year. However, many had some benefit and had a much less severe case of the flu preventing pneumonia, hospitalization, and deaths. That is an important reason to get the flu shot!

  The swine flu (H1N1 or H1N3) are subtypes of influenza A and are predicted for this year, which is more severe for older people. This would be a worse case scenario with COVID-19 still a concern. Never before has it been so important to get the flu shot this year!!

 

Anti-viral medications potentially helpful in flu

  There are now four prescriptions that can potentially reduce the symptoms in a percentage of people.

  The 4 available anti-viral agent brand names are oral doses of Xofluza, Tamiflu, Relenza, and IV Rapivab (used in the hospital), according to Mayo Clinic. All must be given as quick as possible from the onset of symptoms (1-2 days).

  Viral resistance to these drugs is known, and may prevent the medication from being effective. There are rare but significant psychiatric side effects from these antivirals. Use of these drugs in a person with a psychiatric diagnosis is risky.

 

Use of Xofluza to prevent Influenza in close household contacts

  A recent report found a single oral dose of Xofluza were given as a preventative to half of 750 volunteers (the other half got a placebo) to attempt to prevent symptoms of flu. In this study, only 2% of that group developed the flu compared to 14% of the placebo group.

  This is statistically significant and may pave the pathway to use of anti-virals as a preventative against flu.

  Below is a chart showing the last statistics available from the CDC estimates of incidence and mortality for flu 2019-2020  

Flu/COVID-19 fall season—the potential for a perfect storm

  The young people are creating the current surge, and I wish the administration, the medical experts, and those in the media would crack down on those who are ignoring safety precautions and taking the virus home to their families and friends.

  Now, older adults are testing positive due to these inconsiderate younger generations that think they are immune and bullet proof.

  The country cannot withstand another shutdown, it is proven that most younger children cannot thrive in home school another year, and the side effects of the last shutdown have been well documented in my previous updates and in the media.

  The older people have been very good to protect themselves and, yes they have more skin in the game, but parents, teachers, peers, and friends of people less than 40 apparently need some guidance.

  Although the hospitals are filling up to some extent, the turnover is much faster with the average age of patient being 20 years younger in age than in previous months. It is because the treatment has improved greatly and recovery is significantly faster. Contrary to the media, most hospitals have plenty of capacity to handle sick patients, both COVID and non-COVID. PPEs are still a challenge in some areas.

  Deaths are down as well, but this is no time to be laxed in our safety measures. We can get this virus under control if we work together.

 

Rapid COVID test results now available; FDA just approved a combination Flu/COVID-19 test!!!

  The FDA just approved a 5 minute test for COVID-19 that has only 1 in 13 that are false negative. NIH has invested $1.5 billion for private companies to develop effective rapid testing. The original rapid tests were only correct in 60% of the cases.

   According to the White House, Adm. Brett Giroir, M.D., assistant Secretary of the Public Health in the Department of Health and Hunan Services, the new COVID-19 rapid test will include a test for both influenza A and B.

  This combination test will provide emergency and hospital facilities the capability to differentiate between coronavirus and the flu, or some cases both.

  It will not be available to all for some time, but will be prioritized for first responders, healthcare workers, and essential officials, long term care facilities, urgent care, and emergency facilities. It will prevent the delay of several days waiting for results.

  Millions of tests/day are needed but the labs are being overwhelmed currently, thus delaying for an average of 4.2 days according to HHS, not the reported 1-2 weeks.

  There is still a tradeoff for rapid testing in that there is still a higher false negative rate (1 in 13 in one study).

  They have also switched the responsibility from the CDC to HHS to collect data on number of cases and deaths, since there has been a lot of concern about the accuracy of the numbers coming from a variety of sources.

   The CDC still has the numbers of cases and deaths available on their website: www.cdc.org/coronavirus/2019

  As of July 27, 2020, there are 4.2 million cases and 147,000 deaths. Manatee and Sarasota counties have less than 2% of the cases in Florida. Those 3 counties continue report the highest number (42%). Rabun County, Georgia had 0.1% of the cases as opposed to Atlanta Metro which has over 1/3 of all the cases in Georgia.

  Recently, with the surge, the death rate has increased to 1.3%.

 

Home swabs reliable! Will be available in the near future

  Half the tests (at testing sites) are still taking too long (reported 4.2 days) because of the enormous volume. However, there is another innovation coming—home tests.

  A comparison of people provided with test kits collecting a midnasal swab at home (unsupervised) appears to be as valuable as swabs taken at a testing center, according to a study in the JAMA Network, July 22, 2020. Reliability was in the 80% range for both groups (*sensitivity and specificity).

   This is good news, and I suspect these home kits will be made available shortly from authorized centers (with a prescription), but BEWARE of unauthorized websites.

*Sensitivity is defined as being able to reliably discover the virus on a sample, whereas specificity is defined as the results being specific for COVID-19 and not other coronaviruses.

 

Three symptoms are the most common for COVID-19

  The three most common symptoms from various sites in 16 states according to the CDC are fever, cough, and shortness of breath (95%) with 43% having all 3 symptoms. CDC website, July 17, 2020

  Although the CDC has published 11 symptoms likely to be suspicious for a diagnosis of COVID-19, if a person has these symptoms, they need to be tested and have their doctor contacted. Recovery symptoms most commonly mentioned are cough, shortness of breath, and prolonged fatigue.

 

 Pathophysiology of the disease (summary report from JAMA, July 10, 2020)

 I remind the reader that the virus attacks the lung’s alveolar tiny blood vessels where there is exchange of carbon dioxide for oxygen. The lung’s bronchial tree end in these alveoli. This is a respiratory virus with damaging effects throughout the body.

When this happens the lining cells become inflamed with white blood cells that thicken the lining, blocking the exchange of carbon dioxide for oxygen creating pulmonary edema and respiratory distress, pneumonia, and other complications. This is complicated by abnormal blood clots leading to emboli causing heart attacks, strokes, and other cardiovascular events.

  25% of these patients have underlying medical diseases but account for 60-90% of hospitalizations. 17-35% of patients admitted are sick enough to be admitted to the ICU and a varying percentage require some type of respiratory assistance with oxygen (masks or ventilators). Multiple organ failure occurs when hypoxia occurs and can’t be reversed.

 

New information on treatment

  Besides respiratory support, antivirals, immune globulins, antibody plasma transfusions, immune modulators (monoclonal antibodies) that stimulate the immune system, anticoagulants, corticosteroids, and antibiotics are used in most cases. Now even anti-cancer drugs are being considered.

  Secondary bacterial infections occur and is the reason for antibiotics (not to treat a virus).

  Various trials of these and other medications have reported varying results. However, the death rate is dropping significantly with these treatments, and depending on the severity of the underlying diseases, patients are recovering quicker and more frequently.  

  These treatments are a must while we wait for a vaccine. Better treatments are making a big difference.

  Death rates increase with age, obesity, severity of disease, and underlying diseases. Long term outcomes are not known, but again would be expected to be prolonged based on the same above factors with weeks and months of recovery.

  Anticancer agents are being looked at as a treatment of COVID-19. Dexamethasone is already a well recognized cancer drug, and immunotherapeutic cancer drugs may be in the next wave of innovative drugs to treat severe viral patients. J. Oncology, Navigation, and Survival, July 20, 2020

 

Children and COVID-19; Opening schools

 

 Study shows children not likely to spread the virus

   Switzerland cited a small study of children less than 16 years of age who had symptoms of COVID-19. Of the 39 children in the study, 74% of the children were previously healthy, 18% were hospitalized, and none required admittance to the ICU.

  Average age of the child was 11 years of age. In 79% of the children, there was one household resident positive before the child was sick. If an adult, 85% were symptomatic, while 43% of the children had some mild symptoms.

  Symptoms in children were fever-67%, nasal discharge- 64%, and abdominal pain-28%.

  This small study demonstrates that children are not very likely to transmit the virus below 11 years of age, however, household adults can more easily infect their children. Those 11 years and older seem to transmit the virus similar to adults.

  NEJM, Adolescent and Pediatric Medicine, July 8, 2020

 

  2 international studies cited no effect on the virus spread with school closures. A study of county schools in the U.S. found that school closures did not affect viral spread. These studies influenced reopening schools in many countries around the world.

  44% of parents polled by CBS are fearful that virtual learning is inadequate. Lack of social interaction, asking questions, personal attention for those needing it, and discipline are some of the concerns.

  Education for parents, teachers, and children are a must to make informed decisions without prejudice from political sides.

  Safety is most important, but that must be balanced with the potential serious detriment to children and the devastating effect on the economy. However, we can have it both ways with cooperation and safe measures.

  I hope parents can put politics aside and make th decision based on science and cooperation from teachers and students.

CDC publication, early version of an October, 2020 release subject to change

  Children who are overweight and have health issues are in a vulnerable group just as are any age person, and must be much more careful when leaving home for any reason.

  In 2016, 18% of girls and 19% of boys were overweight. The South has over 20% overweight.

One final comment…mothers giving birth who were positive for the virus were very unlikely to transmit it to their baby, if they wore a mask and practiced proper hygiene (washing hands and breasts, etc.). Lancet Child and Adolescent Health Journal, July, 23, 2020

 

The new threat to Nursing homes-social isolation

  The backlash everyone expected from social isolation in nursing homes is now being reported in the medical literature. There is widespread depression, anxiety, worsening of dementia, withdrawal, failure to thrive, refusing to eat, and wanting to die.

  This has been one more major challenge to the staff of nursing homes, who are already under the gun to provide safety, increased sanitation, testing, and masks for staff.

  However, the Centers for Medicaid and Medicare have clarified their recommendations to include communal activities. Open air visitation in some states is now allowed with proper testing and protection for visitors to allow visitation still with distancing and masks.

  However, many nursing homes have been slow to allow visitation, communal activities, including eating together, etc. This has caused increased deaths due to the horrible side effects of isolation. And if they test positive, they are reported as a COVID death. Is the media covering this story?

  There is a chronic shortage of staff in these facilities and the pay is poor. The morale of these staff members is low and it can translate to the residents.

  The journal article cited that there has been a huge increase in prescribing antidepressants, anti-psychotics, and meds to combat anxiety in long term care.

  Of course, the lawsuits are everywhere!

JAMA, July 16, 2020

 

How the virus affects asymptomatic individuals-clinical features and immune response

Are symptomatic people infected with the virus showing any subclinical signs? How long does their immunity last?

  Asymptomatic individuals shed the virus longer than symptomatic ones, because these individuals do not stimulate much of an immune response (immunoglobulins and neutralizing antibodies).

  Viral shedding occurred in one publication for 19 days average whereas those who were symptomatic 14 days. However, viral shedding does not necessarily correlate with the person being infectious.

  IgG and neutralizing antibody levels were much lower in asymptomatic individuals. Asymptomatic transmission (silent spreaders) is one of the greatest concerns due to the lack of a strong immunological response. 20% of asymptomatic people will go on to develop symptoms within 3+ days and are called pre-symptomatic individuals who develop symptoms later in the disease.

  Of 37 matched individuals, 11 had abnormal lab studies (elevated cytokine, C-reactive protein, and alanine aminotransferase (this enzyme is used in testing), and had X-ray evidence of the classic “ground glass” appearance of one lung (as opposed to those who are sick and have respiratory symptoms who have both lungs involved).

  80% of these asymptomatic individuals tested positive for immunoglobulin antibodies (IgG) about 3-4 weeks after exposure. Symptomatic individuals had higher levels.

  About 8 weeks after exposure both groups (symptomatic and and asymptomatic) showed lowering of immunoglobulin and neutralizing antibody titers. This raises the question about future immunity from re-exposure and underlines the need for people who have been infected to continue to practice safe measures as if they were susceptible to the virus.

   It remains to be seen if these individuals will get reinfected. It stands to reason the lower lasting immunity will lessen the chances of being protected in the future. We will see!

 Medpage, a letter from the Editor, June 18, 2020

 

Recovery 

  It is now known that recovery will be prolonged by many days (weeks) for people, some of whom who only had milder symptoms. The CDC put out a report July 27, that 20% of previously healthy adults under 35 reported not being back to their previous state of health for up to 21 days. This was only a telephone survey. But, it points out to younger people that they should respect this virus!!

  Recovery usually includes fatigue, persistent cough, and  loss of smell and taste if initially affected (smell takes a long time to return).

  Those hospitalized, but not requiring ICU, usually takes 2-3 weeks to get back on their feet, but I predict it would take several weeks to have pre-virus health status, although underlying diseases dictate recovery.

  Those requiring ICU admission, especially if intubated and put on a ventilator, depending on underlying diseases, may 4-6 weeks or longer to recover.

  Complete recovery is extremely variable based on motivation to recover, getting back to work, responsibilities at home, adequacy of management of underlying disorders, and age.

  Just because there are still recovery symptoms does not mean they are still infectious! A study cited that very sick people take about an extra week to not be infectious (21 days), while the rest are free of infection in 14 days.

 

5 vaccines very promising!

  The University of Oxford, England, has announced expansion of their clinical trials because those receiving the vaccine created both an immunoglobulin (IgM and IgG) elevation but also a T-cell neutralizing antibody rise to fight the virus.

  This clinical trial will expand their volunteers to 30,000 volunteers this month, and feel they could have a vaccine ready by fall to be used more widely. It would still take months to implement such a vaccine.

  I already announced the 2 American vaccines which have 30,000 volunteers and starts 3rd stage clinical trials in this month. Safety and efficacy is of the utmost importance.

  Actually there are 5 vaccine candidates that are leading. All are mass producing their vaccine in the event they get FDA approval and will greatly shorten the downtime to get this vaccine to millions of Americans. 100 million doses are being produced. The feds are funding these projects.

 

Final Comment

  A new study cited 72 days was the average time for immunity in infected people begin to lower. This is not good news for lasting immunity and begs for a safe and effective vaccine.

  New information is being published by the week, and it appears an update will be valuable every 2-3 weeks. 

 

 

2. Portable diagnostic medical devices; telemedicine is here to stay

     

The GE V-scan ultrasound device for $3000 will allow doctors and even emergency personnel to use a hand held ultrasound in their offices. My orthopedist already has a relatively small ultrasound device in his office to direct steroid injections, etc. into joint spaces.

  The cardiologist can look at the heart valve function, the heart muscle function, check patency of the carotid arteries, and many other cardiac functions in the office without theoretically sending a patient for an echocardiogram (although that test is much more intensive providing many measurement of cardiac function).

  The urologist can test for bladder urine volume in the office and bedside, the presence of bladder stones or masses, perhaps a mass or large stone in the kidney, etc.

  OB-GYN doctors can look at the fetus during a routine office visit.

  I could go on, but you get the idea. With these portable devices, doctors and personnel can evaluate many aspects of the body right in the office or bedside.

  Such devices are making medicine more streamline and easier for a doctor to evaluate a patient easily right in the office. It does not necessarily lower the cost of medicine, but improves the quality of healthcare evaluation whether at the bedside, in the office, or in an emergency situation.  

  If the reader wants to see a you-tube presentation, just search for handheld ultrasound presentations, and see how simple the setup is. One of the better ones is the Phillips Lumify Ultrasound tutorial.

  The smart watches have opened a huge market for self evaluation of vital signs, EKG, exercise tolerance, emergency calls to monitors if a person falls, etc.

 

Telemedicine

  Direct to consumer advertising for medications and services has become big business, and popular with millennials, who do not rely on primary care doctors.

  By necessity, telemedicine has exploded as the COVID-19 pandemic took hold. Trying to prevent people going to a crowded waiting room was a timely step in the right direction. The healthcare professionals are being overwhelmed and even trying to get a doctor to return your call has been challenging.

  The chart below compares the number of office visits vs telemedical calls.

No doubt this form of healthcare streamlines convenience, but at what cost to the quality of care?

  Currently, most of the prescriptions center around contraceptives, erectile dysfunction pills, hair loss, and performance anxiety according to an article in the JAMA Sept. 10, 2019. However, that is expanding rapidly to include medical and psychological visits.

  After a patient initiates a visit through an app or website, a questionnaire is filled out before the intervention. A live virtual visit is initiated although in many cases there is no interaction with a healthcare provider. Companies either send the prescription to a pharmacy or mail the medication directly to the patient. Insurance may or may not reimburse depending on the reason for the visit.

  Some of the bigger sites promote free visits and make their revenue on the medicines they provide.

  The advantages are appealing and there is standardization of questionnaires, convenience, efficient, consistent, and comprehensive. Physicians can “see” hundreds on an e-visit compared to sitting in a waiting room, waiting to be seen, and being run in and out of a busy office. Of course, e-visits are meant to be used for complex issues, rather it is for straight forward issues.

  With the loss of physician workforce continuing and the shortage of primary care physicians, this will be an ever-increasing format for standard visits especially for those who do not have insurance, can’t get off work, and want the convenience.

  Psych visits are another much needed area for telemedicine and are beginning to be verysuccessful.

  Telemedicine fills a need for rural patients where doctors and other healthcare providers are scarce. It also prevents the embrassment of discussing “certain” issues face to face.

  Going the e-visit route presupposes that a patient is familiar with a specific medication they want, but these companies may not provide alternatives when there might be a better choice. Buyer beware!

  Off-label use of medication is another risk. An example is the use of a cardiac medication (propanolol) for “performance” anxiety.

  It is not well policed, and it will be some time before the risk/ benefits will be known. Often times, there is need for discussion of multiple complaints, monitoring of chronic health issues, etc.

  Do they discuss side effects, people who should not take a medication because of drug interactions, etc.

  In some minds, it is essentially choosing convenience over comprehensive medical care.

  Telemedicine is governed by state medical boards and rules and regulations vary from state to state.

  It is clear that with the cost of healthcare, lack of primary care, the added cost of going to urgent care and emergency departments, telemedicine will expand.  

 

3. Cosmetic Facial Dermal Injections and Botox-- options for fine wrinkles

Because everyone in medicine is trying to make a buck, primary care doctors and just about any doctor is legally able to open a “boutique” practice, hire some P.A.s or trained laymen to inject these fillers. Initially, only facial plastic and general plastic surgeons performed these office procedures. As a facial plastic surgeon, I spent 30 years providing these services as they came available. Now dermatology has included these services.

  Silicone was injected for years until it started migrating and causing deformities, especially industrial silicone. Do not get a silicone injection!!

  Silicone breast implants also were implicated erroneously for causing autoimmune diseases in women. It took years of research to prove there was no causal relationship and a lot of lawyers got rich from the lawsuits.

Today’s injectable fillers for fine wrinkles, smile lines, and volume loss of cheeks, chin, lips, and forehead

 

Hyaluronic acid fillers

  Hyaluronic acid is a natural occurring substance found in connective tissues. As we age the amount of this substance decreases in the skin layers and is one of the main reasons wrinkles occur when the elasticity of the skin begins to diminish.

  There are many fillers in this category including Restylane (4 different products), Juvederm (2 different products), Perlane, Prevelle Silk, Belotero Balance. They are typically used to add volume to the smile lines as they deepen, upper lip wrinkles, eye (squint) wrinkles, and under eye hollows. The results last about 4-6 months depending on the filler used.

  

 Collagen fillers

  Radiesse contains microspheres of collagen, the naturally occurring protein in skin that gives volume and elasticity to the skin, which restores the natural collagen and bulks up skin filling in wrinkles, grooves, and defects in the skin (acne scars). It also stimulates the body to produce more naturally occurring collagen. The smile lines are filled (below photo).

Bellafill is another type of injectable that contains microspheres of methylmethacrylate suspended in collagen.

Another collagen booster is Sculptra, which contains microparticles of biodegradable poly-L-lactic acid. As the microspheres degrade, they stimulate the skin to form more collagen.

Natural injectables—Fat injections    

  The patient’s own fat is an excellent filler in many places. It can fill the smile lines, increase volume in the cheeks, and plump up most areas that have lost volume. When I performed liposuction on facelift patients, I processed that fat and injected it into to the smile lines often filling that groove nicely. It can also plump up lips and cheeks.

  Laviv is a product that is created by removing skin cells from behind the ears. These skin cells are grown in the laboratory and then injected into the areas of need.

  The patient’s own blood (Vampire injections) can be used by removing the platelets and reinjecting the platelet rich plasma into the face, which then stimulates collagen formation.

Natural injectables—Fat injections    

  The patient’s own fat is an excellent filler in many places. It can fill the smile lines, increase volume in the cheeks, and plump up most areas that have lost volume. When I performed liposuction on facelift patients, I processed that fat and injected it into to the smile lines often filling that groove nicely. It can also plump up lips and cheeks.

  Laviv is a product that is created by removing skin cells from behind the ears. These skin cells are grown in the laboratory and then injected into the areas of need.

  The patient’s own blood (Vampire injections) can be used by removing the platelets and reinjecting the platelet rich plasma into the face, which then stimulates collagen formation.

Juve`derm injectable in tear troughs, smile lines, and lines outside the lips (Marionette lines)

 

            Dermal fillers to smile lines and cheeks

 

Cheek, chin, smile lines, and lips using Restylane

 

Lips using Restylane silk

 

Comment: When seeking treatment, be sure options are offered and price per syringe and the number of syringes. See a board certified plastic, facial plastic, or dermatologist to perform thes injections, although P.A.s are performing these procedures under the direction of these specialists.

  Individual physicians and their staff will have natural bias for specific fillers based on experience, ease of injections, less bruising, etc. Get a second opinion if not totally comfortable.

 

Botox injectables

  Botox is derived from a botulinum toxin Clostridium botulinum, a deadly cause of food poisoning. However, purified, it paralyzes nerves that innervate the skin muscles which are essentially frown lines to allow expression and close the eye when threatened when injected. Below are the nerves to be injected depending on the site desired to affect the muscle that create wrinkles.

  It can last for 3-4 months depending on the individual.

Botox affects acetylcholine, the neurotransmitter that allow a muscle action from the neuromuscular junction as seen in this drawing.

    

The technique to perform Botox injections must be very precise and performed by a trained specialist.

 

Common side effects of the injection

  Redness and some pain at the injection site is not uncommon. Icing the area before injection minimizes these effects. The redness may last 20-30 minutes, and the pain should dissipate. Bruising can occur and does not mean it was injected poorly. The bruising may last 7-14 days but are not very significant. Bleeding from the injection site is rare.

  Be sure and discuss any medications that should be stopped before injections that increase bleeding such as aspirin, ibuprofen, Aleve, vitamin E, fish oils (Omega 3 fatty acids), St. John’s Wort, gingko biloba, and gensing are common ones. Ice packs after injections are advisable.

 

Complications local and systemic-rare

  There are complications if injected accidentally into a blood vessel and can travel elsewhere causing weakness of other muscles including swallowing and breathing difficulties, trouble enunciating words, loss of bladder control, itchiness or rash. These are rare and in the best of hands should be extremely rare. If the injection material moves beyond the area locally, difficulty closing the eyelid, asymmetrical movement of the brows, or a droopy eyelid can occur and will not return until the Botox material wears off.

  Choose your provider carefully!! Obviously, if any of these complications occur, the person should contact the office ASAP.

 

Botox mistakes

  Overuse can create a “frozen face”. The goal of Botox is to lessen the deeper wrinkles without creating an artificial appearance. Facial expression is desirable and should be preserved to some extent. If it occurs, it will be present until the effects of the Botox dissipate in a few months.

  If an unscrupulous person waters down the Botox to make it go further, the results will not last as long. That is a good reason to seek care from a board certified dermatologist, facial or general plastic surgeon.

  Trying to raise the eyebrows with Botox injections into the brows can be effective, but also can cause too much temporary paralysis and make the brows appear too low. This is not true ptosis or paralysis of the upper eyelids. One brow can droop more than the other giving the appearance of asymmetry of the brows as mentioned in complications.

  It is best to inject just the forehead wrinkles that tend to be present in the midforehead. If the results are lopsided, reinjection of the areas is easy to perform and usually alleviates the problem.

 

Types of Botox

 

  Botox A, Dysport, and Xeomin

  These preparations are all botinum toxin, but Xeomin is more purified (fewer foreign proteins), however, none of these preparations are superior in results. Because Xeomin does not contain any preservatives, it does not need to be refrigerated. Botox and Xeomin are roughly $5.00 a unit and $4.00 for Dysport. Botox and Xeomin usually require 20 units for each session. Dysport requires about 40 units.

  Because Xeomin is free of additives, it may cause less chance of an allergic reaction. However, the additives in Dysport and Botox A are intentionally added to add weight to the liquid making it less likely to diffuse out into the tissues causing potentially fewer side effects.

  If however, there is a foreign body reaction in the skin to Botox A or Dysport, Xeomin may be used as a substitute. 

 

 Speed of action

   Xeomin has the longest “onset” of action usually requiring about 4 days, whereas Dysport’s onset of action is approximately 24 hours, and Botox about 72 hours.

 

 Training required

  Patients should inquire if their practitioner has had a formal training course. All three manufacturers recommend these training programs for all who are going to inject any form of Botox. 

 

Eye wrinkles can be helped with Botox

The forehead frown lines and squint eye lines are the most common areas for Botox.  It should not be injected around the lips.

Reference—International Association for Physicians in Aesthetic Medicine (provides training)

 

Botox mistakes

  Mistakes can happen with any procedure, but the good news is that the Botox will wear off in 3-4 months. Here is an example of the right forehead did not receive enough Botox and therefore asymmetry. Further injections should relieve the issue.

Other uses for Botox

  Any nerve problem can theoretically be helped with slowing that nerve down. Migraines are a great example. Injecting the nerves between eyebrows can relieve some migraines. Blepharospasm (spasms of the eyelids) is helped greatly. Neck and other muscle spasms and overactive bladder (spasms) respond to Botox. It can reduce sweating when injected into the armpits. It can be used for muscle spasms anywhere in the bottom, even for severe nerve pain caused by pinched nerves.  

WebMD   

 

 

4. Consumer Report on sunscreens and skin cancer; Using Efudex (5-FU) to treat precancers

There are two types of ultraviolet rays, UVA and UVB slightly different bands of light (there is a third band UVC).

  UVA is absorbed deeper in the skin and breaks down collagen and damages DNA in our skin cells which ages and wrinkles our skin by thinning the layers. It is a factor in skin cancer, but UVB is absorbed almost solely by the top layers of skin and is the main cause of skin cancer and sunburn. Clearly, any good sunscreen must cover both UVA and UVB.

  There is no tanning bed that is safe and has been linked to millions of skin cancers and increasingly a more common form of skin cancer, melanoma.  

2 types of sunscreens

  Titanium dioxide and zinc oxide sun screens are the common mineral sunscreens. The chemical sunscreens are more effective but contain oxybenzone, which washes off in water, and has been linked with damage to coral reefs. Oxybenzone containing sunscreens are banned in Key West and Hawaii.

 Oxybenzone containing sunscreens are not recommended by the American Academy of Pediatrics, because it has some mild hormonal effects on children.

  It is chemical vs mineral sunscreens, and the mineral sunscreens win for safety, but the chemical sunscreens are more protective.

  The choice for Consumer Reports are the chemical sunscreens  based on their uniform protective capability to protect from skin cancer and skin aging—they contain oxybenzone.

The mineral sunscreens do not protect as well, and are not uniform in containing UVA and UVB protection.

Bloodstream absorption from chemical sunscreens

  Recent studies have shown that these chemical sunscreens are absorbed into the bloodstream and can remain in the system for extended periods of time. This is being reviewed by the FDA and so far, there is no proof they are harmful to humans. The evidence about the coral reef damage is scant according to New York Chief of Dermatology, Michael Dannenburg.

  Enviornmentalists are against these chemical sunscreens.

 

The meaning of SPF (sun protective factor)

  Sunscreens need to contain both UVA and UVB SPF 30 for adequate sun protection, but must be reapplied every 2 hours. There is no sunscreen that is waterproof, and it is illegal to state that it is.

  The number 30 means how long it takes for the skin to redden. An SPF 50 would mean it takes 50 minutes to redden. An APF 30 allows 3% of UVB raysto hit the skin, whereas SPF 50 would allow 2%.

  Depending on the skin type, more SPF should be used. The minimum is SPF 30, and for most light skinned people SPF 50 is preferred by most dermatologists. Reapplying the sunscreen is mandatory.

  Hats, sunglasses, clothing, and umbrellas are all advisable to prevent excess sun exposure. Remember that sun rays will reflect off of water even with protection.

 

Medications and certain diseases that can sensitize the skin to the sun

  People with a history of multiple skin cancers, those on immunosuppressive medications, and those with who are on certain medications can sensitize the skin to the sun. Extreme care is necessary to prevent severe burns.

  An incomplete list includes (i.e. tetracycline, ciprofloxin, doxycline, some antidepressants (i.e. doxepin, and other tricyclics), antifungals, certain antihistamines (benadryl), Cordarone, a heart medication, Diuril, a water pill, NSAIDs (i.e.ibuprofen, naproxen), statins, those using Retin-A, and sulfa drugs. WebMD

 

Vitamin D is necessary; UV necessary for skin to make it!

  People need Vitamin D for good nutrition, and 20 minutes 3 times a day to significant parts of the skin is adequate for the skin to produce Vitamin D. However, the American Academy of Dermatology does not recommend sun exposure, rather food containing Vitamin D.

  Sunscreens block the skin’s ability to produce Vitamin D and UV light exposure is necessary for the skin to produce Vitamin D.

 

Precancerous skin (actinic keratoses)

  Skin cancers usually start as a precancerous, sensitive, redish, scaly spot on the skin, especially those that will progress to squamous cell carcinoma. Basal cell carcinomas usually develop without a precancerous state.

  Precancerous lesions can easily be removed with liquid nitrogen in a dermatologist’s or plastic surgeon’s office. However, if large areas of the skin are severely damaged from the sun with multiple precancerous lesions, it may be time to consider using Fluorouracil (Efudex) cream to remove all the sun damaged skin including precancers.

  Suspicious lesions need to biopsied, as Efudex is not adequate to treat actual skin cancers. Expertise in diagnosing these lesions is mandatory.

  I have personally used fluorouracil (Efudex) on several large areas on my face and limbs with great results. However, it is a painful, itchy, ugly experience, so be prepared for redness, ulceration, and scabbing of the precancerous skin areas. Efudex will not harm normal skin. It takes about a month for the skin to look good, lessen redness, and for women to smoothly apply makeup.

  I am sharing photos of my face, arms, and legs.

 

  The photo just below shows multiple precancerous lesions on the right side of my face.

       

2 weeks

1 month after Efudex

2 weeks with Efudex, right hand and lower arm

 

Below, the right arm healed previously treated with Efudex, and the left arm just finishing 2 weeks of Efudex. Note extreme redness and swelling of my left arm and hand. These arms were treated months apart.

Below is my left leg and how well it healed after a few weeks. Redness persists but it will disappear. Needless to say, the skin that replaces the damaged skin will be more easily damaged and must be protected from further damage by the sun.

      

 

It is imperative to revisit the doctor after treatment is completed and the skin is healed to make certain all lesions has disappeared.

  Laser peels can also be used to treat precancerous skin, but are expensive.

  Most people will stay with the program if they treat smaller surface areas at a time, because it makes the area quite sensitive, swells, and looks awful. Do not give up!!  Individual must think long term, and realize the treatment is preventing future multiple skin cancer surgeries. It is worth the inconvenience.

  I have treated the fronts of both my legs, my face, both  arms, and it has made a tremendous difference in the numbers of precancerous and cancerous lesions.  

  Having removed all the surface skin leaves an individual with new easily damaged skin from the sun, therefore, sunscreens (SPF 50) are mandatory, with limitation of sun, When in the sun, added protection with hats (with brims) sunglasses, and protective clothing is highly recommended.

  You must prepare yourself for some ugly red areas. It is applied nightly, when an individual hopefully will keep your paws off the area to prevent possibly getting the cream in the eye, which will be very irritating. Wash the hands frequently!

  No other creams are allowed on the treated areas until the 2 week treatment is completed. After treatment is completed, there will be need for major healing creams. I used Eucerin healing cream, but there are many creams available.

I am also a big proponent of using the actual clear gel- like interior of the leaves of the aloe plant to encourage faster healing. Buy a plant and split the leaves open, using a spoon to scrape the clear pulp out of the inside of the leaf and rub it on the healing areas. Aloe has been a treatment for burns for centuries. 

  I used this extensively on my facial plastic patients. If a person is willing to use it daily for 2 weeks, the results will be worth it. I spent 30 years removing major skin cancers of the face and scalp requiring major reconstructive techniques to repair the defects. My medical center had a Moh’s surgeon, and we worked together extensively.

  After the area is healed, keep in mind the area is brand new skin and very prone to skin damage from the sun, therefore, sunscreens and preferably clothing to protect these areas is important.

 

New treatment regimen

  Medscape reported that the addition of a psoriasis topical medicine, 0.005% calcipotriol, a vitamin D derivative, added to Efudex was more effective in clearing precancerous lesions on the skin than Efudex by itself. It was compared to Vaseline plus Efudex. The treatment lasted just 4 days. It not only cleared precancerous skin but reduced the number of squamous cell carcinoma for up to a year, but its advantage was gone by 2 years. Ask your dermatologist about this advance.

  In another study, after 4 years, those in the study group using calcipotriol and Efudex had only 7% cancers on the face and ear compared to the control group who had 28% of the participants with one or more cancers. (Efudex only). The study using calcipotriol on other parts of the body did not show an advantage.

  These studies were funded by the pharmaceutical company for research to be performed by the Sidney Kimmel Cancer Foundation and the National Institutes of Health. T-cell immunity was present in these tissues biopsied and is the supposed mechanism of action.   

  Oral Niacinamide 500mg twice a day, as a skin cancer preventative, has been recommended to me by my dermatologist. I am researching it and will start taking these pills soon. It must taken long term. There are no studies that give a timetable. There are side effects of this Vitamin B3, therefore, discuss with a dermatologist about the use. Never take any medicine (prescription or over the counter) without the consent of a doctor.

 

Skin cancers

  Basal cell and squamous cell carcinomas are the most common types of skin cancer, but the most deadly cancer is melanoma. I have reported on these cancers previously.

To read about melanoma, click on:

Reports\Medical Report 19.pdf

I will follow up on a deeper dive into skin cancer treatment and Moh’s surgery in a future report.

 

 

5. Chronic cough—the workup and management

Never trust the tobacco industry

 

 Coughing became a household word since the pandemic. But even though coughing was one of the hallmarks of COVID-19, most people have had episodes of coughing with colds, bronchitis, asthma, and the flu. However, there are a large number of people that suffer from a chronic cough either continuously or intermittently. They must go to their doctors to seek a diagnosis and help.

 

Chronic cough defined

   A chronic cough is defined as a continuous cough (even intermittently) for 8 weeks. A chronic cough can impair a person’s quality of life and lead to vomiting, muscle pain, rib fractures, urinary incontinence, tiredness, syncope (passing out), and even depression according to an article in the American Family Practice Journal, 2017.

  The type of cough is very important. Is it productive of phlegm, colored or clear. Is it associated with other symptoms such as heartburn, smoking, chest discomfort, post-nasal drip, hoarseness, seasonal allergies; does outside temperature affect it, is their snoring at night, does the cough occur when the person lies down at night, or with exercise?

  These are just some of the more common questions the patient should be asked, because there is a possible answer with every one of the yes answers.

  The workup could include a chest X-ray, a visit to an ENT doctor for a nose and throat exam. A pulmonologist can look down into the lungs (bronchoscopy) to evaluate the lower airway if warranted (bronchoscopy). A gastroenterologist can evaluate the esophagus and stomach for issues usually surrounding gastric reflux.

  

Many causes of a chronic cough that should be investigated:

 

 Smoker’s cough

  People who smoke essentially are chronically irritating their entire respiratory tract with every puff, and that goes for vapers as well. It is not uncommon for smokers to cough when they first get up in the morning to clear all the excess secretions out of their lungs that accumulated at night. They suffer from chronic bronchitis, leading to emphysema, and possibly cancer. If they have other common health issues such as gastric reflux, allergies, or asthma, they are just piling on with reasons for a chronic cough.

 

CT scan screening tests for smokers expanded

  Long time smokers (and those that quit) should be evaluated for lung cancer with a chest X-ray if symptomatic. For those asymptomatic, lung cancer screening is highly recommended using low dose spiral CT Scans to evaluate a silent cancer while it might be curable.

 

The new guidelines for asymptomatic individuals for annual lung cancer screening now include:

1. 20 year smokers with one pack a day or 10 years with 2 packs a day (previously was 30 pack years).

2. Those who have quit in the last 15 years with the above history, ages 50-80 (was age 55).

*These recommendations for people who have no symptoms and are otherwise healthy but were or are smokers.

  If a person quits after smoking the equivalent of 20 pack years, their risk stays with them for 15 years, and the only chance for a reasonable chance of cure is to find it on a CT scan. If they have quit for over 15 years or a medical condition precludes being a candidate for lung surgery, screening can be discontinued, according to the guidelines.

These guidelines are from the national advisory committee for the federal government—USPSTF 

https://uspreventativeservicestaskforce.org

 

Gastric reflux

  Gastric reflux is a very common cause of a chronic cough especially if it goes untreated. Many people do not have symptoms of heartburn but still reflux into their esophagus, and at night, they frequently reflux into their throats and aspirate acid into their lungs. Not only are their lungs at risk, but even their teeth can decay from acid eating at the enamel of their teeth.

  Patients with these symptoms should be prescribed antacid pills, either H2-inhibitors or PPIs, two types of medicine that can be prescribed or taken over the counter.

  Sleeping propped up at night, refraining from big meals at night, and stopping to drink any fluids at least 2-3 hours before bedtime will help. Taking a handful of medications at night can also aggravate this issue. Meds should be taken early in the evening.

  If medication does not relieve the chronic cough, they should consider seeing a gastroenterologist and have an endoscope used to evaluate the lower esophagus and stomach for a hiatal hernia, chronic esophagitis or even Barrett’s esophagus, a precancerous condition. A pulmonologist may also be a need.

 

Obstructive sleep apnea

  This condition is caused by the airway obstructing in the throat by a large tongue, large tonsils, a high arched palate, and chronic nasal obstruction from anatomical deformities in the nose, or allergic rhinitis. I have discussed this issue in several previous reports, and can be found in the Subject index on my website which will give a detailed discussion of this disorder. www.themedicalnewsreport.com

 

Medication can cause chronic cough

  Certain anti-hypertensive medication-lisinopril (Zestril) and enalapril (Vasotec), nasal sprays, statins, Carvediol, Actonel are some of the medications found on the internet.

 

Other causes

Postnasal drip, allergies, asthma, bronchitis, COPD, vocal cord damage, gastric reflux, inhalants (smog, chemicals, etc.), and of course viral and bacterial causes including COVID-19 and flu. These causes almost always are accompanied by other symptoms (fever, chills, sore throat, difficulty swallowing, hoarseness, etc.

  Cancer in throat, voice box (larynx), or lungs must be ruled out.

 

When is a cough an urgent issue?

  Coughing up blood (hemoptysis), chest pain, headaches, drowsiness, and confusion should alert a person to seek immediate medical attention. 

  If an individual has any blood in their phlegm, have trouble swallowing, choking episodes, hoarseness, or has persistent night sweats, seek help immediately.

  Coughing up discolored (yellow ot green) phlegm, a fever greater 100F, or starts wheezing, please call a doctor.

 

Treatment of a non-specific cough

  Obviously, any cough with a diagnosed cause must direct the treatment to the disorder. This may include an allergy workup by an allergist, allergy medication including antihistamines, decongestants, guiafenasin (Mucinex), cortisone medihalers (Vancenase, Flonase, Nasonex, etc.), cough medicine at night, salt water sniffs, warm salt water gargles, honey and ginger hot tea, hydration, special filters at home, compulsive cleaning at home, close windows, etc.

  There may be some obvious airway anatomical abnormalities (blocked nose from septal deviation, nasal turbinate enlargement, nasal polyps, etc.) which could easily be diagnosed by an ENT surgeon.

     

COPD patients have a great challenge with cough daily, and now that the latest medical literature is supporting a triple therapy patients are experiencing much fewer relapses of serious episodes. This, however, is reserved for those patients 

  The new recommendations are:

 budesonide+formoterol+glycopyrrolate—high dose therapy. Trelegy is the first triple therapy FDA approved and very expensive! Note that it contains umeclidinium instead of glycopyrrolate and vilanterol instead of formoterol, very similar medications.

  Triple therapy would be considered if dual therapy was not adequate in controlling symptoms and attacks.

  This therapy includes an inhaled corticosteroid, an anti-inflammatory agent, and 2 medications that relax smooth muscles in the walls of the bronchioles to combat spasm and enlarge the size of the openings--bronchodilators (wheezing , shortness of breath).

  Pneumonia and exacerbations was reduced in these more resistant cases in significant number.

American Journal of Respiratory Critical Care Medicine, June, 2020

  A note of caution….most of the newest inhalers contain medication powders that deliver higher concentrations of drug to the depths of the lung, however, hoarsenss and irritation of the throat can be a problem. There are liquid alternatives if these symptoms persist. Discuss with the doctor.

 

 

This completes the August, 2020 report:

 

The September, 2020 report will include:

 

1. More updates on COVID-19 as indicated

2.Classification of psychiatric disorders

3. e-cigarettes linked to smoking cigarettes in youth

4. Genetics and cancer

5. HPV virus vaccine—Gardisal-now only 1 shot

6. Do medication date of expiration mean anything?

7. Talcum powder and ovarian cancer-a myth

 

Stay healthy and well, my friends, Dr. Sam