The Medical New Report
July, 2017, #66
Samuel J. LaMonte, MD,FACS
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, instructions for care, 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 him or her. Always write down your questions before going for a visit.
Now, on with the information!! Thanks!! Dr. Sam
People who have cosmetic surgeries are everyday people and have chosen to have procedures is to improve their self-esteem. The other reason genital cosmetic surgery is gaining popularity is easy access to experienced specialists. There are surgical practices that primarily perform this type of surgery. Photos were taken from the website of Drs. Miklos and Moore (Atlanta).
Surgery to enhance the size of the penis with skin flaps or can be performed using various types of implants.
Below the shaft is enhanced in length and circumference using an implant.
The second successful penis transplant has been performed with return of sensation, urination capability, and partial erection capability. Many other transplants would be performed if it were not for the problems of taking anti-rejection drugs the rest of a patient’s life with the complications that can occur. Currently, there is intense research trying to come up with better anti-rejection treatments.
F. Final Comments:
I have discussed trans-gender reassignment surgery in a previous report if you are interested:
Successful sexual and urinary function after these procedures varies based on a variety of issues. Complications can occur, and it is imperative that a very experienced surgeon(s) (urological and gynecological) be sought to perform these procedures.
Careful consideration and perhaps psychological counseling might also be considered to rule body dysmorphia discussed in a previous report:
Physicians and patients often underestimate the harms and overestimate the benefit of tests and treatments, according to the JAMA, January, 9, 2017. This falls into the field of informed consent. However, physicians can “sell” these issues or put down testing very easily. Patients need to be more informed about health screens, because there are benefits and risks.Patients frequently have over-enthusiastic optimism. It is human to be this way and both the public and doctors are human with personal biases.
It is a monumental task for primary care doctors to keep up with all the evidenced-based information coming out in medical journals. That is why I write these reports, and some of this updated information may be new information your doctor may not be aware of. That is why I frequently suggest you bring this information to your doctor if pertinent. That is also why second opinions are important.
Waiting on test results
This can be nerve racking. When they are unfortunately falsely positive or negative, it creates unnecessary testing and sometimes surgery and complications. These facts must be pointed out by physicians.There is no innocent test or procedure. They are meant to find early disease and prevent death from advanced disease, but they can cause unnecessary testing, biopsies, and even surgeries.
False Positive Mammograms
Consider a false positive mammogram that appears to be positive for cancer. This may require re-testing, further breast exams, and even biopsies to prove there is no cancer present. What if the biopsy result is not conclusive? A re-biopsy or lumpectomy may be recommended.These are realities women need to consider.
That actually happened to me when I had an inconclusive needle biopsy of a neck node that was cancerous(having spread from a tiny cancer in my throat). The neck node had to be removed to prove there was cancer present. In my case, the surgery was necessary to make a diagnosis.
Wound infection from a biopsy can occur regardless of the final report results. The patient is harmed even though the biopsy result was good news. Pathologists just can’t always determine what they see on a pathology slide.
False positives have led to serious consequences, including hysterectomies, amputations, unnecessary pain and emotional trauma. These cases have led to law suits.
When a patient finds out there is no cancer present in a biopsy, there is a tendency to delay future (mammograms) screening tests, as reported by the internet journal Medscape. An average of 13 month delay occurred in these patients. Patients must be counseled regarding this issue and encouraged to continue routine testing.
National expenditures from false positive mammograms and over-diagnosis of breast cancer are estimated to be $4 billion a year according the publication Health Affairs in the April 2016 issue.
Mammograms are being over-interpreted as suspicious for cancer in 11% of the cases according to this article affecting 3.2 million patients per year. Of course, the fear of missing a cancer makes the doctor err on the side of suspicion for cancer (perhaps out of fear from a lawsuit).
I have to deal with this issue when helping the American Cancer Society revise the screening guidelines for cancers. This is the ugly truth (false positives and negatives) about screening normal populations, but these tests clearly save lives and yet can create harm as well.
Informed consent is necessary to make it clear about the risks and hazards of any test, procedure, or therapy.
Benefit versus risk issues have led some organizations to not recommend PSA testing for prostate cancer, as an example. Actor Ben Stiller, 48, stated that the PSA saved his life, and yet for others, unnecessary biopsies and possible infections can occur. That is why doctors recommend that the decision for any of these tests rests in the hands of the patient and their doctor. Guidelines from ACS or any other organization are just guidelines, not rules.
Tests such as colonoscopy may miss cancers because of a poor prep by the patient or certain polyps that are totally flat and easily missed (especially in the right side of the colon). In other words, patients have a responsibility to prepare for tests following instructions carefully.
Proper preparation for a test
An example is the PSA test. Doctors need to instruct patients to not ride a bike, have sex, or have a rectal exam for 48 hours before the test, as all of these circumstances can falsely raise the PSA results.
I hope this report has been valuable.
Reference—Medscape Business of Medicine, 2016
A. Joint replacements revisions; taking antibiotics before dental procedures
B.Chondroitin sulfate equally effective as NSAIDs in knee arthritis
1. Joint replacement revisions
1. Revision of joint replacement surgery
The indication for a joint replacement is pain and functional loss that is unacceptable to the patientthat is not controlled with more conservative non-surgical measures.
The risk for revision surgeryis quite high in younger men because of the aggressiveness of exercise after surgery, and frequently the size of the individual. With healthcare reform, recent studies apply cost effectiveness to the equation and are encouraging orthopedic surgeons to try and delay patients with their decision. The journals are full of articles pushing conservatism. What it means to you is insurance companies will pick up on this and refuse to pay until more rigorous indications for surgery are met.
Orthopedic surgeons already encourage patients to wait as long as they can before undergoing joint replacement. I had both my knees replaced 17 years ago, and with great results, I am still going strong (with certain restrictions) without pain. I was 58 at the time. I was told then I would have to have revisions in 10-15 years. Today, with improvement of implant materials, replacements are lasting longer.
UK researchers evaluated lifetime risk for revision surgery, based on patient age at the time of the initial procedure.
10 year survival of the implant was 96%,20 year survival was 85% for hips, and 96% and 90% for knees. For younger patients (50-59) the lifetime risk for revision was 20% for hips and 35% for knees.
Keep these statistics in mind when you contemplate joint replacement. However, if you are a person who is having major quality of life issues, don’t be afraid to express your strong feelings about needing surgical relief if medical treatments (including weight loss and physical therapy) are not working. It is up to you and your surgeon to consider surgery (at least for now).
Expertise of the surgeon
Ask your surgeon, what rate of revision he or she has experienced. Reference-The Journal Lancet, Feb. 2017
Rehabilitation facility for post-op care
Should patients go to a rehab facility immediately post-op to begin therapy or go straight home?
After 6 months, statistics show there is very little difference in results of physical and occupational therapy measuring pain, mobility, function, or quality of life. Home healthcare provides excellent in-home therapy. There are certain circumstances, however, that require consideration for rehab facilities at least for several days such as co-morbidities, access to home healthcare, bilateral knees, and toleration of exercises immediately after surgery. An 8 week regimen of postoperative rehabilitation is usually recommended.
Rehab hospitals increase the cost of a knee replacement an average of $10,000. If we are ever to contain healthcare costs, this kind of additional cost must be carefully considered.
2. Should joint replacement patients take antibiotics prior to routine dental procedures?
In the past, orthopedic surgeons uniformly recommended antibiotic coverage when having dental procedures for a person who had a previous joint replacement. Recent studies have not found it necessary after 1-2 years post-replacement. Of course, doctors are slow to change what they recommend, as are dentists. Why do they recommend it?
Research has proven that bacteria commonly get in the blood stream when dental procedures (even routine cleanings) are performed especially those with gum disease. There is a very small chance of bacteria getting into the joint replacement potentially causing an infection in the joint. Usually an antibiotic such as ampicillin is recommended (1-2 grams in one dose) on the day of the procedure. The American Dental Association and the American Academy of Orthopedic Surgeons in 2013 reversed their 2009 recommendation and do not recommend routine use of antibiotics in these patients.
Observational studies have shown that infection is extremely rare, and therefore, considering the potential for complications from antibiotics and antibiotic resistance issues, it would be wise to discuss this with your dentist, primary care physician, and orthopedic surgeon.
Entry of bacteria into the blood stream commonly occurs with any dental manipulation, and it is probably the most common reason bacterial infections invade heart valves (subacute bacterial endocarditis) and other implanted materials.
Dental health and hygiene is unquestionably vital to the health of our bodies.
It might be reasonable to cover a patient for 1-2 years after joint replacement, however, these medical associations recommend against patients automatically taking antibiotics every time they have a dental procedure for the rest of their life.
This must be discussed with a patient’s doctor and dentist!!
Reference- The Journal of American Academy of Orthopedic Surgeons, 2017
B. Chondroitin equally as effective as NSAIDs for knee arthritis
A recent study contradicted other studies regarding the value of chondroitin sulfate compared to prescription arthritis medications such as Celebrex, a common non-steroidal anti-inflammatory drug (NSAID). 600 people over 50 with documented knee arthritis were followed for 6 months. A “high quality “ chondroitin preparation (800mg) was taken by half the participants daily and the other half took 200mg of Celebrex.
At the end of the study, relief of pain and improvement in function was equal in each group.
There are several concerns taking NSAIDs for an extended period including increased risk of cardiovascular disease, stomach irritation (bleeding and ulcers), and kidney damage.
Chondroitin sulfate is an over the counter (OTC) medication often combined with glucosamine (but more expensive). There is also a litany of potential side effects of chondroitin as well, although usually well tolerated. Gastrointestinal upset can occur, heart complications, bleeding, and liver damage rarely. For patients with the diseases, it might prudent to discuss this with your doctor.
Go online and read the Mayo Clinic’s discussion:
There is conflicting information whether adding glucosamine to chondroitin is of value. It is made from shellfish shells, so be careful if you are allergic to shellfish. WebMD has a nice discussion on glucosamine and chondroitin.
The lesson….never take a routine daily medication (prescription or OTC) without clearing it with your doctor. Many people take both NSAIDs and Chondroitin and are potentially doubling their risk of side effects.
I have discussed joint replacement in previous reports for your information:www.themedicalnewsreport.com #10, #11, #12, #62
Heart block is an electrical conduction disorder of the heart, “blocking” the heart’s ability to send electrical impulses to the heart muscle to stimulate a normal regular heartbeat.
The heart has its own pacemaker, and when disease interferes with that conduction system, cardiac rhythm disturbance occurs. Heart block can be inherited but most are caused by underlying heart conditions such as atherosclerosis, heart failure, cardiomyopathy, etc.
This should be differentiated from heart blockage, which implies coronary artery blockage, which leads to a heart attack.
The heart’s pacemaker has two distinct locations in the heart muscle that create electrical impulses innervated by the vagus nerve (one of the 12 cranial nerves). They start in the atria of the heart and spread out to the ventricles.
B.How the heart beats—the electrical impulsestarts with the innervation from the vagus nerve (the tenth cranial nerve) to the sinoatrial node (SA), which spreads electrical impulses to the atrioventricular node (AV) and to the bundle of His (pronounced hisssss). This nerve splits into the right bundle branch and left bundle branch, which then sends out impulses to all portions of the ventricular muscle. This anatomy is demonstrated in the drawing below.
C. How the heart contracts
There is a 0.1 sec delay from the SA node to the AV node, which allows a pause between the atrium contracting and the ventricle contracting. This allows for blood to be pushed through the heart normally allowing the heart valves to open and close in a coordinated manner.
For an easy to understand video of the electrical system of the heart, click on
Pathway of the electrical circuit of the heart
D.Blockage of the electrical system is classified by where the blockage occurs in the electrical circuit (at the SA node, the AV node, or at or below the bundle of His in the right and left bundle branch). An EKG will determine the location of the heartblock.
E. Symptoms of heart block
Although heart block may not cause any symptoms, lightheadedness, palpitations, and fainting can be the first symptoms which could lead to the necessity for an artificial external pacemaker. The ultimate concern is complete heart block and ultimately stoppage of the heart.
In general, the further along the electrical circuit that the electrical abnormality occurs, the more potential for concern and ultimately complete heart block.
An EKG can demonstrate the degree and typeof heart block!! For those interested, read further!
1.There are 3 degrees of heart block:1st, 2nd, and 3rd (complete) degree heart block
This is determined by how long the interruption of nerve conduction occurs from the SA to the AV node as demonstrated on an EKG. First degree block implies a delay of 0.2 seconds.
a-First degree AV block—causes--itcan be caused by heart disease and or certain classes of blood pressure medication (beta blockers, calcium channel blockers, et.) and digitalis. Electrolyte abnormalities can also cause this. With first degree AV node heart block, there are rarely any clinical consequences in a patient without symptoms. (I have first degree AV block with no symptoms)
b-Second degree AV node heart block, may cause some mild symptoms, and it should be followed to monitor for progression to complete block. Because there is a more prolonged delay in nerve conduction, a heartbeat may not occur and an escape beat(s) will occur.
Bundle branch blocks (left and right)occur with 2nd degree heart blocks and are common. Above, in the anatomical drawings, the extension of the circuit nerves to the lower portion of the heart muscle from the Bundle of His is the right and left bundle branches.
In patients with bundle branch blocks, the underlying causes include aortic stenosis, cardiomyopathy, heart attacks (MIs), etc.
c-Complete heart block, the impulse from the SA to AV node is totally blocked. This typically activates a lower nerve (accessory pacemaker) in the circuit to stimulate a heartbeat (escape heartbeat). These patients usually experience a low heart rate (bradycardia), low blood pressure (hypotension), and can cause heart failure and other circulatory abnormalities. The most common cause of complete heart block is coronary artery disease with ischemia (lack of enough oxygen to the heart muscle causing angina). A heart attack can cause these conduction abnormalities.
2.There are 3 different types of heart block
a)SA node heart block
This rarely causes many symptoms. The rest of the electrical circuit can take over and keep the heart beating at least 40-60 beats a minute.
b)AV node heart block
AV block is the most common place for a blockage of the electrical circuit to occur and can progress to complete block.
c)Complete heart block
EKG demonstration of degrees of AV block:
For those interested, below is a normal electrical heart beat with the PR- QRS-T wave complex. This is what a heartbeat looks like on an EKG. The intervals between these electrical waves definedegrees of heart block.
G. Treatment of heart block
Usually 1st and 2nd degree heart block usually does not require treatment, however 3rd degree (complete) heart block commands treatment, medical and if not effective, a pacemaker is required. Advanced second degree block with bradycardia (low pulse) may require a pacemaker.
H. Treatment of underlying disease
Treating the underlying disease requires certain medication including beta blockers, anti-arrhythmia meds, calcium channel blockers, and digitalis (digoxin). However, any of these drugs may also cause the heart block and must be stopped.Patients with complete heart block frequently have atrial fibrillation and or coronary artery disease that must be addressed.
It is important to note that a sudden complete heart block is an emergency and 911 must be called.
Transcutaneous pacing of the heart is the treatment of choice. After stabilization with a temporary pacer, a permanent pacemaker is necessary.
Treating complete block should be based on symptoms and level of block (not the patient’s heart rate and blood pressure).
Pacemakers require monitoring to assure a normal sinus rhythm and adequate blood pressure. With internet apps, monitoring can be performed with an iphone now.
I have previously discussed the heart’s electrical system works, pacemakers and atrial fibrillation. Click on:www.themedicalnewsreport.com #9, #59
In summary, electrical abnormalities of the heart indicate some type of heart disease, a side effect of heart or blood pressure medication, or a metabolic abnormality (i.e. elevated potassium). Many of the early heart block abnormalities do not cause symptoms, and is a good reason to have a yearly EKG as one ages. Vague symptoms such as lethargy, feeling faint, dizziness, and weakness may be signs of some arrhythmia or heart block. When in doubt, if these symptoms occur suddenly, seek medical assistance. Identification, monitoring, and or treatment can be a life-saver.Pacemakers have saved millions of life.
Ref. Wikipedia, e-medicine.Medpage, American Heart Association
The American Cancer Society estimated that over 61,000 Americans will be diagnosed with primary kidney cancer. It is almost twice as common in men. Blacksand American Indians have slightly higher risk. Over 14,000 will die in 2017. The majority of cancers are adenocarcinoma. Most of these tumors are single, however, they can be multiple. Most are clear cell and papillary carcinomas.
Cigarette smoking, obesity, exposure to environmental substances (asbestos, cadmium, benzene, and herbacides), high blood pressure, chronic kidney diseases, and long term dialysis all are risk factors. People with a strong family history are also at higher risk. Taking diuretics (water pills) may increase the risk although it may be more likely linked to the hypertension being treated.
During the early 1940s, watches had radium dials placed on the numbers to allow the face to glow. This required workers to use a tiny fine paint brush to paint the radium on the dial, which was radioactive. They would lick the brush to create a fine point on the brush. An outbreak of bladder cancer occurred in these workers.
There are several genetic syndromes that run in families. This is true for genetic mutations that increase risk for breast, thyroid, and kidney cancer.
As other cancers, early symptoms are not usually present, but red blood cells in the urine might be picked up on a routine urinalysis. Flank pain or fullness, fatigue, weight loss, anemia, and swelling of the ankles all may occur as the tumor grows.
Children have a specific kidney cancer called Wilm’s tumor (nephroblastoma), a very aggressive tumor requiring surgical removal and chemotherapy.
D.Spread of cancer
Since these tumors can grow to quite a large size, they may grow into the adrenal gland (which sits on the top of the kidney) or into the regional lymph nodes. Metastases can occur anywhere in the body. I have diagnosed them in the tonsil and the skin of the forehead.
E.Staging of kidney cancer
The same staging holds true for this cancer as bladder and all major cancers. Treatment is determined by the extent of disease. MRI is used to determine extent of disease.
The usual treatment requires removal of the kidney (nephrectomy), and surrounding tissues (adrenal gland, lymph nodes, etc.). The staging may change once surgery is performed by a urologist. Other oncologists will be consulted depending on the stage of disease.
G.Recurrence, second cancers
Observation for recurrence will be planned for years after treatment and the stage of disease may require additional treatment. A separate second kidney cancer can occur.
Because of certain shared genetic overlaps, patients with kidney cancer are more prone to develop thyroid, bladder, prostate cancer, and melanoma.
H. Survival rates
If the cancer is confined to the kidney, the 5 year survival rate is 81-97%. If the cancer spreads to the lymph nodes, the rate is half (41%), and with distant spread, it can be as low as 8% 5 year survival rates.
For patients with metastatic disease, a trial of targeted therapy or immunotherapy may prolong the life span. MD Anderson Cancer Institute is combining immunotherapeutic agents (nivolumab-Opdivo) with targeted therapy (Avastin) and obtained a 53% response in a pilot study. The same drugs used in melanoma and lung cancer seem to provide the best response because of genetic mutation similarities. Clinical trials are the obvious choice for these patients. www.cancer.org
This completes the July report. I hope you have a great summer month and celebrate our country with a great 4th of July with friends and family.
Next month, the subjects for August will be:
1. Food allergies
2. Migraines and cardiovascular disease-a link; NSAIDs and cardiovascular risk
3. Genetic markers to guide the treatment of depression
4. Profile of today’s physicians-A must read!
5. Hematological System Series—Part 1--the basics about blood cells; the bone marrow
Stay healthy and well my friends!
Happy 4th of July