The Medical News Report for March, 2016, Celebrating Report # 50
Celebration for 50 Medical News Reports
Let me take this opportunity to say thank you for continuing to read these medical news reports. This is quite a milestone for me with the 50th report.
There is so much misinformation on the internet. I felt I could provide honest truthful information with no ulterior motive (no ads and nothing to sell). I now have over 500 subscribers that I send this report to. Staying up with the advances in medicine is a full time job, but it has been very gratifying and sharing it an even bigger thrill. Today being proactive about your health is a must, and I hope I have helped you do that. Thank you!
Subjects for March:
The incidence of HPV (human papilloma virus) that causes genital cancer and a high percentage of throat cancer has dramatically dropped since the initiation of the HPV vaccine (Gardasil) given to young children 10-11 years of age but can be given up to age 26 as long as it is before becoming sexually active (requires 3 doses). Once a person is infected, the vaccine is of no value. 20% of the population has been infected. The vaccine was begun in 2006 and has been improved with a newer more inclusive 9 valent vaccine more recently. There has been a drop in infections by 2/3rds in those who have been vaccinated. It is expected that the rate of cervical cancer and other genital cancers will drop precipitously when enough time has passed to study this. It takes many years for HPV throat cancer (oropharyngeal) to occur, however, genital cancers occur much faster from this virus.
Also continued careful monitoring with Pap smears and HPV tests during a pelvic exam will catch these cancers in a pre-cancerous phase and be easily treated and cancer prevented. The sad news is that the number of women getting routine Pap tests is diminishing. This is another public health failure.
The national election for our next leader will impact us more than any other election in our lifetime. Because of changing demographics, the country will soon have more Hispanics and other minority groups than any other groups. If you look at the cost of taking care of these groups, you will quickly realize that they are costing the taxpayer much more. The cost of healthcare is much greater because these groups do not practice preventative care, they tend to go to the doctor with more advanced disease requiring more expensive care, they over-utilize the emergency departments, and don’t fill prescriptions because of the cost in many cases. Many of this same group have Obamacare but can’t afford the deductibles and co-pays, so they don’t go to the doctor when they should. This is one of the biggest failures of Obamacare.
These groups need education about prevention, screening, and vaccinations, but in the meantime, the cost for these groups that are escalating. The young people are included in these groups because they think they are bullet-proof and haven’t hit the work force yet and don’t get insurance. So when you wonder why a socialist is giving Hillary a run for her money, it is very clear. These groups don’t want Obamacare or anything but free stuff including medical care with no deductibles, no co-pays, and no personal responsibility. These groups are largely leaning more and more liberal and soon a socialistic society will prevail and we will fail as a society. Add the refugees and illegals to that equation and we fail even faster. If you came from Syria or walk across our borders, would you not support a socialistic society that hands you free stuff? They don’t care who is paying for it. How long will the “rich” people be willing to work for less than 25% of the money they make?
There are two classes of Americans today….those who work for a living, and those who vote for a living!! It is sad but true!!
Federal programs are feeding more than 100 million Americans. Since 1983, the number of Americans depending on federal aid has increased from 66 to 153 million people. Total dependency on the government has skyrocketed from 66 to 109 million Americans during that same period of “relative” prosperity. We are moving from a federal aid to a federal dependency society. We are, therefore, on the way to socialism without even wanting it. Our young people are being taught by professors who were the protestors of the Vietnam War era. The academicians are penetrating the minds of our youth with socialistic ideology. It is no wonder that Senator Sanders is doing as well as he is. By the way, is Hillary not a socialist? She can’t explain the difference between a liberal and a socialist, when asked. Do you see where I am going this?
The federal government is preaching and recruiting Americans to use food stamps. Minimum wage workers are not able to make as much money as those on government dependency. It is no surprise the work force is shrinking. Where is the incentive to work? Increasing the minimum wage will create another layer of unemployment.
There is an interesting correlation brought to my attention from an article by James Bovard in the February issue of the Austrian. He said that the more people depend on the government, the less people will notice governmental abuse. That is what we are facing in our country with the current administration and future administrations with certain candidates.
Senator Sander’s free healthcare system will skyrocket to $12 trillion a year. I am in favor of helping people, and that is why I went into medicine. I may be old fashioned, but I like to know how we are going to pay for all this charity and maintain a democratic successful society.
I fear that the quality of healthcare will take a dive in the future, and we will in fact become a one payer system if the Republicans can’t come up with a better system. Articulation of these alternatives is hard to understand and articulate with sound bites.
Remember, if we don’t elect someone who is going to put a lid on the cost, regardless of party, we are doomed. Who do you trust to do that? It is the most important moment in our lifetimes to decide that. Our health is at stake!
I would be happy to hear from anyone who has a different view.
The World Health Organization has provided a travel alert for pregnant women (or possibly pregnant) to avoid the Caribbean, Central and South America (there have been outbreaks previously in Micronesia and French Polynesia). The virus was originally identified in the 1940s in Africa.
The chain of the events occurs when an infected person (man or woman) who returns to this country transmits the virus to the Aedes aegypti mosquito (this vector is known to inhabit the southern U.S.) by being bitten by that carrier mosquito. When that carrier mosquito bites that infected person, it can then bite another person and transmit the virus to them---this creates the chain of events.
The first trimester is the worst time for a woman to be exposed to the Zika virus that also causes yellow fever, chikungunya, and dengue fever (Aedes aegypti and albopictus). During the first 3 months, brain development is quite active and therefore more vulnerable to damage.
This mosquito is found in the southern border states in the U.S. especially Florida. It can also be transmitted through unprotected sexual intercourse as well. If a male has traveled to these countries, and his female partner is pregnant, he should use a condom or abstain from sex for at least a month.
Zika viral infections have been linked to over 4400 cases in Brazil. 6.5 million people from Central and South America to the U.S. in 2014. So far, the CDC has reported 90 cases of the Zika viral infections in the U.S.
Mosquito season in the South has yet to occur!
This virus has been linked (but not proven) to microcephaly, which is defined as a newborn with small head with considerable brain deformity, with an under developed and deformed brain.
The brain, as it grows, normally enlarges the skull. Since the brain does not grow, the skull doesn’t either. This creates neurodegenerative abnormalities.
It can occur as an isolated deformity or in combination with other congenital deformities. It is linked with seizures, hearing loss, serious delay in developmental milestones (sitting, standing, and walking), difficulty feeding (swallowing), balance issues, vision difficulty, and intellectual disability. There is also an increased incidence in Guillain-Barre syndrome (an immunological neurological disease that can cause severe paralysis).
Microcephaly has also been linked with rubella, cytomegalovirus, toxoplasmosis, malnutrition in mothers, alcohol abuse, certain drugs, and toxic chemicals. Depending on the severity of the microcephaly, the disability can be minimal to severe). About 15% are not severe. There could be other congenital deformities in addition to microcephaly.
There is also concern that there could be mental and neurologic side effects later in life even if microcephaly does not occur.
It is difficult to diagnose microcephaly in utero (ultrasound) before 20-22 weeks of pregnancy. Even if termination of pregnancy is being considered, it would require a late abortion.
For non-pregnant women or men who develop the virus, the symptoms are usually very mild (fever, rash, joint aches, and red eyes), and there is no known consequence of having had the virus to individual unless transmission occurs through sex or the mosquito bites an infected person creating the chain reaction of spread. 4 out 5 people will have no symptoms. For males, there is the possibility of transmitting the virus in semen to pregnant women.
3-4 million cases of infections in the Americas are expected in the next 12 months.
Testing of blood is only performed by the CDC. There is no vaccine and no treatment for these deformities. Women of child bearing age (who may be planning a pregnancy or are pregnant) who are outside especially in the mosquito belt of the U.S., should use DEET or other mosquito repellants when going outside. The mosquito tends to bite the extremities, so wear long pants and long sleeve shirts. Consider delaying travel outside the U.S. especially the Caribbean (including Puerto Rico), Central and South America.
If a person is thinking of going to Brazil for the Summer Olympics, birth control should be strongly considered long before going. Some U.S. Olympic female team members have reported reluctance to attend. There is even talk of postponing the Olympics. Brazil is also way behind in being prepared to have these games. The sanitary conditions are being questioned by the athletes.
Blood transfusions from infected individuals can transmit the disease, and therefore, the U.S. Red Cross is “asking” all those who have traveled to all these countries not give blood for at least 28 days after returning to the U.S. Canada has stated they will not allow their people to give blood for 21 days.
Officials in Brazil are genetically modifying these mosquitoes so that they will breed with the carrier mosquitoes which might prevent these mosquitoes from carrying the virus. Mass insecticide spraying is being used in Brazil, but that will only help to some degree.
Here are some tips everyone should know about preventing the increased likelihood of mosquito breeding including the use air conditioners, screens, and repellants (DEET, picaridin, oil of lemon eucalyptus, or IR3535 containing repellants :
It is known that mosquitoes tend to more commonly bite those with type O blood. The CDC has more than 30 countries on the travel alert status. Before travelling, check the CDC website.
References—CDC, Communicable Disease Center and the WHO, World Health Organization.
Blood tests are available but it estimated to be at least 18 months before a vaccine will be produced and ready for clinical trials. When it would become available to the public is not known.
Reference: WebMD, WHO, CDC
Hotline for Florida 1-855-6735
In October, 2015, the American Cancer Society changed its breast screening recommendations in 2 respects. 1) The age to start routine mammography screening for the average risk female, and 2) clinician breast exams.
As a member of this committee, I realize that when you recommend something to the public, it needs to be simple and crystal clear, however, the research does not make that possible. It is also made more difficult when recommendations are different for different age groups. However, the research dictates the recommendations.
The overriding emphasis is always that any decision about screening should be between a woman and her doctor. The key is for the doctor to point out the risks and benefits of screening.
Note the ACS recommends annual screening from 45-54, and biannual (every two years) from 55-74. After 75, it is up to the person and doctor to continue screening. The USPTF (the feds) still are recommending screening at 50 only biannually, but most of the rest of the societies (ACS included) recommend earlier screening. The ACS is currently meeting with these national groups to find common ground. However, don’t expect anyone to change their recommendations.
Be sure you and your doctor discuss this critical information and tailor your decision based on family history, genetic markers, and personal feelings and comfort for your decision.
We (the ACS) have already begun to research the literature for high risk groups and will hopefully have recommendations out in the next year.
Liver cancer is on the rise thanks to hepatitis B and C and alcoholism. There have been significant advances in the treatment of this cancer including liver transplantation; stereotaxic radiotherapy, and radiofrequency ablation. These are being used for inoperable liver cancers increasing their life spans. The liver is also one of the most common organs for metastases from other primary cancers, which can also be treated with these new modalities. The functions and vascularity of the liver make it a very attractive place to spread to.
We need to quickly review the functions of this amazing organ.
Here are the major functions:
The primary function of the liver is to detoxify chemicals, medications, alcohol, and bacteria our body takes in. It also produces bile acids that assist in digestion and absorption of certain vitamins (A, D, E, and K). It also stores vitamins, minerals, and sugar. It produces most of the clotting factors and proteins. The liver is also the biggest organ in the body other than skin.
The liver has great vascularity along with functions that it is attractive for cancer to spread to it. Cancers of the lung, pancreas, colon, breast, and melanoma are some of the cancers that spread to the liver. Cancers begin in the liver as well although much less common. Worldwide, primary liver cancer is the third most common cause of cancer death. If confined to the liver, there is a 28% 5 year survival rate. If the tumor is successfully removed, the survival climbs to 50%. With recent advances in biologic and targeted therapy for metastatic disease, survival is being prolonged even more.
There are chronic diseases that have an increased risk of being diagnosed with primary liver cancer (hepatoma):
1) Cirrhosis (alcoholic), 2) Hepatitis B, and C, 3) Aflatoxin-a by-product of mold that grows in spoiled food primarily occurring in Africa, Thailand, and the Philippines. It causes mutations in liver cells leading to cancer, 4) Fatty liver caused by obesity and type 2 diabetes (steatohepatitis)-it triples the risk over 10 years. The main reason liver cancer occurs is cirrhosis, whether alcoholic, through hepatitis (B or C), obesity, or diabetes. A high index of suspicion for liver cancer is necessary in those with any type of cirrhosis.
Early liver cancer is hard to diagnose since the symptoms are so vague (weight loss, loss of appetite, nausea, and fatigue). Later jaundice, abdominal pain, an enlarged abdomen from ascites or liver enlargement, and chalky stools may occur.
Although less common, the cancer can begin in the hepatic (bile) ducts as they drain the liver (cholangiocarcinoma).
The diagnosis of liver cancer is made with: 1) Blood test of the liver—alpha-fetoprotein—70% of patients with a liver cancer will have elevated levels. 2) Imaging—CT or MRI can diagnose liver cancer. Below are 2 examples of cancer in the liver. Note the arrows! The left is a large tumor (metastatic melanoma) and the right is a solitary nodule from a primary hepatoma.
Liver cancer can spread to the lymph nodes.
Cancers of the liver can be cured by a partial resection of the liver as a major portion of the liver can be removed. As long as the cancer is confined to the liver, the entire liver can be removed and a transplant can be performed.
I have a friend who had cirrhosis from Hepatitis C, who developed 2 small liver cancers, and had the liver removed and transplanted in the same operation. He was a very fortunate individual for his doctors to find a compatible liver before the cancer spread. He is free of disease and doing well.
If a liver transplant is not available, intra-catheter injections of chemotherapy (chemoembolization) directly into the tumor, radiofrequency ablation, investigative chemotherapy, and stereotaxic radiotherapy can slow down the growth (palliative treatment). Radiofrequency ablation is performed through a tiny incision with a probe placed in a tumor and electrical current is used to kill the tissue. Stereotaxic high-dose radiation is placed in pinpoint fashion to kill the tumors. A study at the University of Michigan uses both modalities and are reporting over 87% 1 year prevention of local progression of these tumors. So far they are equally effective. Journal of Clinical Oncology, 2015
Click on the American Cancer Society’s website for more information:
A recent study from JAMA (American Medical Association) reported equal efficiency for cessation in 3 different products after 26 weeks of not smoking (about 25% quit) with: 1) (Chantix) pill-varenicline 2) nicotine patches alone 3) nicotine patches plus 2 or 4 mg nicotine lozenges (2 or 4 mg.)
Using a combination of all these has not improved the success rate. Previously, it was thought a combination was superior. Adherence rates at 8 weeks was about 45% for all groups.
I would suggest you try one method, and if it doesn’t work, try another.
Below are the guidelines for physicians to help patients quit………….does your physician follow these key recommendations/
Although intended to encourage health care professionals to assist their patients in smoking cessation, they will be of considerable benefit to those seeking information quitting.
1. Nighttime eating is ok. Gaining weight is from taking in more calories than we spend. If you eat at night, there is no expenditure of calories. Also, if a person has GERD, it will be worse with food in the stomach. Many diet plans recommend not eating for 3-4 hours before bedtime.
2. Some sugars are worse than others. All sugars are absorbed and metabolized the same. Natural sugars from fruits give a person more benefit (vitamins, bulk), it is better to avoid the “white stuff” (carbs). Also sugar in soft drinks is a total waste. Most research has declared that carbohydrates are the most important food to limit, even more than fats. Also, remember some of the sugar substitutes cause insulin resistance. Skip the soft drinks!
3. Coffee is bad for a diet. Again, moderation is the key. Too much caffeine will make you withdraw and will give a person symptoms similar to feeling hypoglycemic. Coffee (caffeine or decaf) has valuable phytochemicals that are potent antioxidants. There is also research to show it may decrease your risk of some cancers, Parkinson’s disease, gallstones, and Type 2 diabetes. Stay away from syrup added coffee—mega calories! (Starbucks!!)
4. A low fat diet will make you lose more weight. Recently, dairy fats are said to be less harmful. The body requires all three food groups, and moderation of fats and carbs are best, but carbs are the worst by far. Good fats from avocados, nuts, fish, and seeds are of great value. Processed and fatty meats should be avoided.
5. Processed foods can increase the risk for all cancers. Recently, processed meats have been condemned by the World Health Organization because the process using nitrosamines are carcinogenic. The only cancer that is increased is colon cancer. Moderation of bacon, ham, salami, etc. is advised. The research has only stated that the meats processed have carcinogens in them, and there is no research that has quantified how much is going to cause cancer.
6. Sea salt is better for a diet. There is no evidence it is better. 75% of our daily salt intake comes from the foods we eat. Kosher and sea salt is a combination of potassium chloride and 40% sodium chloride but does not contain iodine. Table salt is sodium chloride, but contains iodine. Iodine is necessary for producing thyroxin, the main thyroid gland hormone.
7. Drinking lots of water will assist a diet. Hydration is very important for good health, but it is not going to make you lose weight. It is a good trick to drink a glass of water as a substitute for eating if you get the munchies and help prevent constipation.
8. Avoid processed grains if dieting. Whole grains are preferred but all of the processed grains are fortified with vitamins, phytochemicals, minerals, and are high in fiber. Excluding them in a diet is not wise and will constipate a person badly.
9. Too much sugar will give you diabetes. Not true. Type 1 diabetes is an autoimmune disease and Type 2 is caused by weight gain, inactivity, and heredity. We have already noted that lots of sugar is bad for a diet and your health, but by itself, does not cause diabetes. It certainly will make regulating a patient’s insulin levels very difficult. It is thought that sugar is the worst food group for dieting, health, and a balanced diet is preferred.
10. A person can spot diet with machines. Exercise alone will make you lose weight. Neither claims are true. Without limiting calories along with exercise will only give you increased muscle weight. Cutting corners does not work. Miracle diet plans and over the counter substances do not work.
11. Skipping breakfast is ok if dieting. NO! Many studies have proven that it is the best meal of the day and all the calories will be burned in that day. A person that has fasted all night needs calories. In fact, without breakfast, the body goes into a starvation mode lowering the metabolism rate. We want our machine to burn calories to the max! Exercise increases the metabolism all day! It has been known that people who skip breakfast have more obesity, higher lipids, higher blood pressure, and glucose intolerance. Now a large study has reported higher rates of heart disease and stroke. Don’t skip breakfast. Eat protein in the morning. Eat a small amount any time you feel hungry to keep the insulin levels from yo-yoing. YOU CAN DO IT!
Distribute your calories throughout the day, exercise daily, gets 8 hours of sleep, increase fruits and vegetables, eat less red meat, and drink a minimum of alcohol.
I refer you back to my multi-month discussion on obesity.
No one can go through life without anxious moments or episodes when anxiety is present. But when this disorder dominates a person’s life, it is very disabling. We all worry, but with a generalized anxiety disorder, but patients worry about everything all through the day.
Signs and symptoms include headaches, fatigue, muscle tension, trembling, twitching, sweating, difficulty swallowing, difficulty going to sleep, irritability, nausea, shortness of breath, lightheadedness, frequent urination, and even hot flashes.
3.1% (6.8 million) of Americans suffer from GAD. The average age of onset is 31 years of age. GAD is twice as common in women. It is diagnosed if these symptoms persist for 6 months or longer.
The criteria for diagnosis of GAD:
It is important to rule out any underlying diseases that may present with some of these symptoms.
The differential diagnosis includes hypochondriasis (now called health anxiety disorder)—these patients are preoccupied with illness. Obsessive compulsive disorder is characterized by irrational worry about irrational beliefs with compulsive and repetitive motions such as hand washing, checking the locks on doors over and over, etc. (this will be discussed in July).
Anxiety disorders are mediated by neurotransmitters such as serotonin, norepinephrine, gamma aminobutyric acid (GABA), and dopamine. Peripherally, the body’s sympathetic nervous system mediates the anxiety symptoms. Special tests of the brain have shown less receptor-binding by these neurotransmitters.
Treatment should include cognitive behavioral therapy, regular psychotherapy, and relaxation techniques. These treatments teach the patient to manage situations that create anxiety. Patients should avoid any form of stimulant including caffeine, illicit drugs, nicotine, etc. Patients very commonly use alcohol and other relaxing type of drugs to treat their symptoms leaving them very vulnerable to abuse.
Medications are of 2 varieties: anti-anxiety and anti-depressant medications. Anti-anxiety meds (tranquilizers) should be used for short periods of time, as they are easily abused.
The benzodiazepines are the main tranquilizers. They have psychoactive properties by enhancing the neurotransmitter GABA (gamma aminobutyric acid), which results in sedation, a hypnotic (sleep induction) effect, relief of anxiety, anticonvulsant effect, and muscle relaxation.
Benzodiazepines are classified into short, intermediate, and long acting. Short acting benzos are used for sleep, premedication before office or outpatient procedures while intermediate and long acting ones are used for anxiety. They are considered safe for short term use, however, there are some who will experience aggression or release of inhibitions, while a few will have paradoxical reactions. The concern with longer term use is a concern for dependence and withdrawal when stopped. The elderly are more sensitive to these medications. These medications can be taken orally, IV, IM, or even rectally.
The intermediate tranquilizers are usually recommended for only 2-4 weeks but can have longer term benefits. Some of the common benzos used for generalized anxiety disorders are Valium, Xanax, Klonopin, and Ativan. The treating physician will have to decide the best choice for you, based on many factors including the severity of symptoms. Patient education about these meds is very important. You can read on the web about each of these.
The most common long acting tranquilizes are the barbiturates. These can be abused easily and are not used as much.
Antidepressants are preferred for longer term anxiety disorders, but both benzodiazepines may be needed short term while the antidepressants start to work. They may be prescribed daily with the the benzos being used as needed.
SSRIs (selective serotonin reuptake inhibitors) are the most common antidepressants used today. This includes Cymbalta and Effexor I have described these meds in past reports:
In review, the second generation class of antidepressants keep the neurotransmitter, serotonin, in higher levels, which calms the brain and provides smoother reactions to both depressive and anxiety induced conditions. The most common SSRIs are Celexa, Lexapro, Prozac, Paxil, and Zoloft. These are better tolerated than the older forst generation antidepressant class such as the tricyclic anti-depressants (Tofranil) and MAO inhibitors (Nardil, Parnate). Side effects can occur, therefore, I would advise reading about any of these meds prescribed before accepting these meds.
These medications result in about 30-50% success rate. It may take trying more than one or two before finding a satisfactory medication.
Vilazodone (Viibryd) has just recently been approved but so far is no better than the other choices. Referral to a psychiatrist is indicated if these medications do not achieve success.
Anxiety is frequently associated with alcohol and/or drug abuse, depression, and associated physical health problems (psychosomatic). These issues must be addressed to successfully treat patients with chronic anxiety.
Classic psychosomatic illnesses include gastrointestinal diseases (vomiting, diarrhea, cramps, IBS-irritable bowel syndrome, tension headaches, migraines, back pain, insomnia, and asthma. Anxiety occurs in all of us, but when it persists for a prolonged period of time and interferes with a person’s functioning normally, it is time for an evaluation.
PANIC DISORDERS (panic attacks)
Panic disorders are defined as sudden episodes of fear, with a feeling of being out of control, with intense worry about the next attack. 6 million Americans (women twice as common) suffer from panic attacks. Not all patients will go on and have a lifelong panic disorder. These attacks may be associated with specific places that could key off an episode. Many types of physical symptoms can occur with these attacks (palpitations, sweating, hyperventilation, weakness, lightheadedness, stomach cramps, or chest pain). It tends to run in families.
Agoraphobia (fear of places) is a common type as is claustrophobia. Fear of dirt, heights, and certain situations all can be treated.
Benzodiazepines (tranquilizers) are very helpful especially for shorter term therapy, but may need to be prescribed for as long as 1 year. The APA (American Psychiatric Association) prefers treating anxiety disorders with anti-depressants, since they can be taken longer term and with more success, but take much longer to be effective, thus requiring the use of both classes of medications at least early on. Juggling these two categories of medications is best suited for experts in the field.
This completes the 50th report. Wow!! It has been my honor to provide you with the most up to date information on medical issues. Next month, I will discuss: 1) an update on blood pressure measurements, 2) updates on CPR techniques, 3) Suicide, 4) asymptomatic carotid artery obstruction—surgery vs. medical therapy; comparing result of carotid endarterectomy vs. stenting, 5) Pancreatic cancer, 6) Physician burnout, 7) an update on Florida allowing medical marijuana, and 8) Allergy Season is here.
Stay healthy and well, my friends!! Dr. Sam