The Medical News Report
April, 2019, #87
Samuel J LaMonte, M.D., FACS
1. Medical Updates—
a) Why don’t patients take their meds as prescribed?
b) Treating mild hypertension with medication may be unnecessary!
c) Too much sugar in most yogurts!
d) Preferences by millennials (18-34) for healthcare—changing the face of medicine
e) President Trump signs historic Maternity Mortality Prevention Bill; New recommendations for perinatal depression screening for mothers
2. Syncope—Part 2--Orthostatic Hypotension (drop in blood pressure with standing)
3. Explanation of the Cannabis plants—marijuana and industrial hemp plants, their products and medical value
4. Compulsive social media devices—medical consequences
5. New success with a new therapy for glioblastomas of the brain—electrical field therapy in combination with chemotherapy; immunotherapy prior to surgery
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
a) Medication adherence by patients
One of the biggest concerns physicians have is that patients are not taking their medications as prescribed, stopping medications, and taking over the counter medications that may interfere with current medications, and using alternative medical treatments without their patients telling them.
2038 patients were interviewed with poorly controlled diabetes, hyperlipidemia, and poorly controlled hypertension. Patients were able to improve their medication adherence with mailed and text reminders, and medication reminder electronic pillboxes. They increased adherence for anti-hypertensive meds from 36 to 42%, but were unable to increase adherence to anti-diabetes medications.
This study found two major behavioral barriers to adherence were forgetfulness and misperception about benefits and adverse effects of treatment. JAMA, August, 2018
b) Treating mild hypertension with medication may not be necessary
A study from UK researchers found that those with mild hypertension not treated had no difference in all-cause mortality with than those who were treated with medication to further lower their blood pressure. This study followed 19,143 patients.
All these patients had low risk for cardiovascular disease based on an absence of any prior or current heart history, diabetes, chronic kidney disease, or family history of early cardiovascular disease.
They defined mild hypertension as those with a blood pressure reading of 140-159/90-99 based on a large database in the UK.
Over treating high blood pressure seems to have become popular with studies reporting less mortality in patients with blood pressure over 120-80. However, most of these studies included those with high medical risk factors.
It should be very clear, patients with mild hypertension should lose weight, eat healthier, and exercise before accepting life-long antihypertensives.
This study will be controversial, but does point out that jumping to anti-hypertensive meds before initiating behavior modification behavior approaches first, should be discussed with a person’s doctor. Obviously, a patient’s motivation to lower blood pressure with non-medicine means is critical. JAMA Internal Medicine, October 29, 2018
There are complications especially in older people trying to keep their blood pressure too low including syncope (fainting--orthostatic hypotension) which can accompany injury which will be discussed below.
Home monitoring of blood pressure is a must to monitor variations in blood pressure during the day and night.
c) Too much sugar in most yogurts
Most grocery store yogurts are packed with sugar. This included children’s yogurt, daily alternatives, desserts, and flavored or fruit containing yogurts. Low sugar yogurt is defined in the study from the British Medical Journal was no more than 5 gms per 100 cc of yogurt. Only natural/Greek yogurt contained that amount, and all the others exceeded 10gms/100cc, and one contained 16gms./100cc.
Since yogurt is perceived as healthy, this is a worrisome finding. The USDA recommends that 2000 calories per day should not exceed 50gms. Stick with natural/Greek yogurt without fruit. BMJ-2018
d) Millennials’ preference for healthcare—changing the face of medicine
Millennials are making their mark on society more than ever and are being vigorously trained to be proactive not only politicially but in every way. They are in line to change the way that healthcare will be utilized now and in the future. This group makes up the largest work force in the country.
Millennials defined as ages 18-34 prefer seeing doctors in urgent care facilities, drug store doctors, etc., and 40% do not even see or have a primary care doctor. They will not spend time away from work to see a doctor during working hours, which means they are going to seek care after regular hours. They are happy to see nurse practitioners and P.A.s rather than physicians, because the majority of them have less serious disease concerns.
Because of this, are you surprised that CVS, Walmart, and Walgreen’s are opening walk-in clinics in their stores?
Millennials have been raised in an era of instant information on the internet. Convenience is number 1. They are also the most cost-conscious group and will price-shop. They seek out the most discounted service when it comes to healthcare and medicine.
Half of millennials do not seek preventative services or routine checkups. Telehealth (doctor visit on face to face internet interviews) is preferred by 74% of this group. These young people will google information about any symptom before seeking care.
Doctors are encouraged to have their website up to date and provide easy to access to medical information. They want to make appointments online, and will not sit on the phone waiting for office personnel to finally speak to them.
Physicians must realize they are firmly entrenched in the digital era, and they better adapt. This will change the face of medicine for the future, and may be all for the better. It is time medicine becomes much more price transparent, and insurance companies and healthcare facilities need to join in so that patients are not shocked by medical bills. The old way of doing business is about to change….hopefully.
However, what will their health outcomes be 20-30 years from now, and what kind of quality of care are they sacrificing if any?
e) President Trump signs historic Maternity Mortality Prevention Bill; New recommendations for screening expectant mothers for depression
President Trump signed into law an historic maternity mortality bill aimed at reducing the high U.S. maternal mortality rate, the highest in all developed nations (about 700 deaths a year), which has risen 250% since 1987, according to the CDC. They estimate 60% of the deaths are preventable.
The bill provides $50 million in grants over 5 years so that all states can form committees to investigate every pregnancy related death and target ways to prevent others.
Obesity, diabetes, and heart disease along with little or no prenatal care are the primary factors leading to these deaths. The opioid crisis also is playing a role. The mortality rate is 3X higher in African American women. Medscape, Dec., 2018
Perinatal screening for depression now recommended
Interventions to prevent perinatal depression are now being recommended by the USPSTF* for clinicians. 1 in 7 women have depression during pregnancy or post-partum. This has implications for the mother and the child. Counseling is highly recommended including cognitive behavioral therapy and interpersonal therapy. Screening these expectant mothers for socioeconomic factors (low income, single parenthood, etc.), pre-existing depression, gestational diabetes, abuse, and unplanned pregnancy have shown to be valuable. Initiation by clinicians is highly recommended, however, insurance coverage could be an issue for some.
Symptoms include loss of interest and energy, depressed mood, feelings of worthlessness, sleep difficulty, changes in eating habits, cognitive changes in thinking and concentration, and suicidal thoughts.
Symptoms should be present for a minimum of 2 weeks before referral for counseling is recommended.
These symptoms interfere with maternal efficiency and child care. It increases pre-term birth, lower birth weight, early cessation of breast feeding, and they are less likely to have their child vaccinated or have well-baby checkups. It can also affect the child’s cognitive and emotional development and lead to more behavioral problems. *USPSTF=U.S. Preventative Services Task ForceJAMA, Feb. 12, 2019
This report follows last month’s discussion on causes of syncope including diagnosis and treatment. Postural orthostatic hypotension is usually mild but can be serious and an indication an underlying disease or disorder. When this occurs, there is a wide range of causes to consider. I suffered from this disorder, and although it disappeared, it was pretty scary for about 4 weeks.
Symptoms of postural orthostatic hypotension
Most people have experienced lightheadedness when standing up rapidly, but there are many who are seriously affected when they standup from either a lying or sitting position causing fainting and in some cases a seizure from acute loss of blood flow to the brain. Patients who feel this must sit or lie down immediately, or they will pass out, fall, and possible seriously injure themselves.
In contrast, when a patient experiences the symptoms of postural hypotension, patients do not experience classic dizziness as in other situations such as benign positional vertigo, which may feel similar but must be differentiated by a physician. Vertigo is usually an inner ear issue. The term dizziness and lightheadedness is often confused. For a discussion on vertigo, please click on this previous report:
Defining orthostatic hyptension
Orthostatic hypotension is defined as a 20mm drop in pressure from lying down to standing up. In many, an elevated pulse occurs (usually 120 beats per minute). This combination is called POTS—postural orthostatic tachycardia syndrome. Some will experience symptoms immediately and in others, there may be a delay of 1-3 minutes.
A tilt test can diagnose this, by measuring the blood pressure in the flat, sitting, and standing position.
Patients may be experiencing headache, double or blurred vision, palpitations (tachycardia may occur to compensate for lower blood pressure), irregular heartbeat, pale skin, redness of lower extremities, and many other signs and symptoms depending on the cause, if there is one.
Physiological compensations—basic science
There are physiologic mechanisms that automatically occur when standing up to prevent blood pressure from dropping suddenly.
To understand how the body performs its magic, you need to know the basics of the autonomic nervous system.
The Autonomic Nervous System
A) The heart and blood vessels are a complex system that is governed by nerves from the brain. The autonomic nervous system is in command of the heart and blood vessels in cooperation with certain hormone systems secreted by the adrenal glands and kidneys. This system is responsible for regulating the body’s unconscious actions.
B) The two major parts of the autonomic system are the sympathetic and parasympathetic system.
The parasympathetic nervous system is innervated by the 10th cranial nerve (Vagus nerve) and is the main source of innervation of the electrical system of the heart and relaxation of smooth muscles in blood vessels and organs. (It also innervates the gut involved with digestion and sphincter control. It is the “rest and digest” system.)
The sympathetic system is the “fight and flight” system. In stimulating the secretion of epinephrine and norepinephrine, this raises the heart rate and constricts blood vessels to raise the blood pressure. These two systems allow the body to respond to the external environment and recover from its responses. Below is a drawing that depicts all of the organs affected by the autonomic nervous system and their functions.
Risk Factors and Causes
1. Heart conditions such as valvular conditions, heart attacks, and heart rhythm disturbance
3. Heat exposure
4. Excess alcohol
5. Medications--high blood pressure medicine, diuretics, and nitrates (i.e. nitroglycerine), medicines that treat Parkinson’s disease, erectile dysfunction meds (Viagra), certain medications for psychiatric disease, and meds for prostate enlargement (Flomax).
5. Large meals will shunt blod to the stomach away from the general circulation and aggravate hypotension.
6. The elderly can have trouble if they are not mobile and active. There are receptors in blood vessels called baroreceptors that do not function as well after the age of 65 that can be a factor.
7. Endocrine diseases including diabetes, adrenal insufficiency (Addison’s disease), and thyroid conditions.
9. Autoimmune diseases are often linked to this condition. Many patients with orthostatic hypotension have a disorder called dysautonomia, which is defined as a dysfunction of the autonomic nervous system, however, there are many patients who have this dysfunction that do not have orthostatic hypotension. Dysautonomia is an umbrella term and includes many diseases, as shown in the drawing below. Certain suspected diseases must be included in a *differential diagnosis based on symptoms, signs on examination, lab and imaging studies.
*Differential diagnosis is a term doctors use to rule in or out diseases, when faced with a patient with certain signs and symptoms.
What causes the autonomic nervous system to malfunction is not known, but there are many serious diseases that may be associated with this syndrome and are considered autoimmune diseases including diabetes, lupus, rheumatoid arthritis, bowel disease (Crohn’s and Ulcerative colitis), multiple sclerosis, chronic fatigue syndrome, multiple systems atrophy including Parkinson’s disease, amyloidosis, cystic fibrosis, and ALS (amyotrophic lateral sclerosis). The workup would include tests to diagnose these disorders.
A cardiac workup including an EKG and Holter monitor (24-48 hrs.) is necessary to rule out arrhythmias and heart damage. Echocardiogram may be recommended.
Further testing will be determined by possible other diseases that are suspected. This could include a test for autoimmune disorders, protein abnormalities in the blood, etc.
A neurologist should be consulted and an ophthalmologist if any visual symptoms occur. If there are gastrointestinal symptoms present, a gastroenterologist should be considered to determine a dysfunction of stomach and intestines.
Treatment of orthostatic hypotension
The recommended treatment is to counter low blood pressure with medications to raise the blood pressure (vasopressors), such as Midodrine, 2.5mg three times a day. These medications act on the tone of blood vessels.
Neurogenic orthostatic hypotension
The most common neurological diseases with orthostatic hypotension are Parkinson’s disease, multiple system atrophy, and pure autonomic failure. A drug used in Parkinson’s may help--droxidopa (Northera) and might have value in these patients.
Treatment of orthostatic postural hypotension
Fludrocortisone is prescribed to expand the fluid volume in the body and is also used in some cases in combination with Midodrine, a vasopressor medication to increase vascular tone which raises the blood pressure mentioned above.
If abdominal pooling of blood is excessive after eating meals—so called gastric shunt, a medication that will limit blood into the gut called Octreotide subcutaneous injection, may be beneficial.
Other medications include pseudoephedrine (Sudafed) with or without Midodrine, and pridostigmine.
For those who are elderly and at bedrest, these medications are not indicated. Mobility is key to overcome pooling of blood in the body from being in bed or inactive including pressure stockings.
Other recommendations to prevent orthostatic hypotension
a) Increase sodium in the diet to 3000 to 10,000mg
b) Increased hydration to 2-3 liters of fluid per day (even water boluses)
c) Lower carbohydrate diet; healthy diet, avoid gluten, and energy drinks
d) Eat small meals more often
e) Exercise in the recumbent position
f) Avoid extreme heat due to the lack of sweating
g) Avoid excess alcohol
h) Avoid donating blood
i) Compression stocking to knee or waist; binding of the abdomen in patients who have serious symptoms after a meal from dilation of the stomach (gastroparesis) may be necessary.
j) Manage stress--anxiety and depression must be treated, and underlying cardiovascular, neurological, and autoimmune diseases must be diagnosed and treated. Stress can activate autoimmune diseases.
Orthostatic hypotension may be an isolated disorder without an obvious underlying disease but may likely resurface with time. The disorder and prognosis is determined by the underlying disease.
My hypotensive syndrome just went away suddenly after 4 weeks. In my case, the cause was unknown, and there was no obvious reason it went away, but I could not drive, and was house bound until this syndrome went away. There is always the chance it will return.
Orthostatic hypotension can be treated to prevent a drop in pressure, however, it is imperative to rule out an underlying disease process. Support from primary care, cardiology, neurology, and rheumatology may be necessary.
Medpage, Cleveland Clinic, NIH (National Institutes of Health), Medicinenet.com
Cannabis is the proper name (genus) of the plants, and the two most common are two different species-- marijuana and hemp. The marijuana plant contains the psychoactive chemical, THC (tetrahydrocannabinol). The hemp plant is an industrial plant that is used for clothing, paper, biofuels, and plastics and has almost no psychoactive ingredients.
All Cannabis plants and its products had been placed in the Schedule 1 group of controlled substances by the federal government since 1970.
The U.S. Congress passed the 2018 Farm Bill for farmers to grow industrial hemp. This is projected to be a $20 billion business by 2022. The products of hemp have no psychoactive ingredients and include CBD products (cannabidiol), which is the most common (recently) legal component of marijuana being used.
The non-psychoactive chemical that is commonly used is CBD (cannabidiol) that has professed to have many medical uses. CBD oil is now legal in many states and can be easily purchased online or in special pharmacies and “head shops”. It is the main product that is recommended as medical marijuana.
The FDA has approved three cannabinoids. Epidiolex (cannabidiol-CBD oil) has been approved for two rare seizure disorders. Dronabidiol and nabilone is also approved for nausea and vomiting associated with cancer chemotherapy. Dronabidiol is also approved to stimulate the appetite and weight loss for AIDS patients. These two substances do contain THC. The FDA has not approved either THC or CBD as a dietary supplement. It is also illegal to add these products to food. However, there are many foods planning on adding CBD to their products. We will see how that works out.
Some of the medical diseases that are considered under the medical marijuana laws include multiple sclerosis for neuropathy, fibromyalgia, cigarette addiction, intestinal disorders, PTSD, and insomnia to name a few. There are claims that it has antidepressive, anti-inflammatory, anti-eplieptic, antioxidant, muscle relaxant, and sedative properties. Much research is necessary to provide solid evidence. There are cannibinoid receptors in the brain, organs, and immune system, but how they influence disorders still remains vague.
There are 10 states that have legalized recreational marijuana—Alaska, Washington, Oregon, California, Nevada, Colorado, Michigan, Vermont, Maine, and Washington D.C. Utah, Oklahoma and Missouri voted to legalize it, but may not be available yet in stores. 33 states have voted to use medical marijuana. The federal government still has not legalized it, and it is still a federal offense, but authorities are not enforcing the laws. Selective enforcement of laws seems to be the wave of the future and is a dangerous precedent to set. As the liberal Americans increase in numbers, relaxation of laws will abound.
The federal government is coming around, but they have had to wait on authentic reproducible research. Medical marijuana is being prescribed much slower than hoped, which just makes people go through other street sources.
As many as 25% of cancer survivors are using some form of cannabinoids, legal or not, according to an article on the website Oncology Pharmacist. Most do not tell their doctor they are using these products which happens with most alternative therapies. The oncologists need to be aware.
The dangers of psychoactive drugs
As with any psychoactive substance, there is always abuse with consequences.
In the State of Washington, where pot has been legal for awhile, the deaths from auto accidents linked to pot use has doubled in the last 2 years.
Cognitive effects of using pot regularly
In a recent study, there were 88 young people (18-25) recruited who used pot regularly to test their verbal memory. Half continued to smoke pot for one month and half abstained (tested with urine THC tests).
Using standardized testing for verbal memory and learning, researchers found that there was substantial improvement in memory over a month of abstinence.
More studies need to analyze academic grades in school and the effect of smoking marijuana, but I suspect the results will be predictable.
There are studies using MRI scans on pot smokers showing reduced activity in the medial and lateral temporal lobes, parietal and frontal lobes of the brain. In heavy users, even a month after abstinence, they still demonstrated reduced activity in areas of the brain involved in cognition. For heavy pot smokers over a long period of time, they will continue to experience cognitive difficulty even if they stop.
If a parent’s teenager does poorly in school, I would recommend they bring up the question of smoking marijuana and educating them about the effects on memory and learning. Parents must not be naïve. These issues must be continued to be studied.
Journal of Clinical Psychiatry, 2018, National Institutes of Health
The new generation and their preoccupation with cell phones, games, and constant communication
There is an epidemic of health issues occurring because of electronic media especially with the youth.
JAMA cited a link with ADHD and excessive use of electronic media. The current incidence is 7% from 1981-2014. This has been rising in the recent decade thought in part to rapid exchange social media, rapid fire games, etc. in mid-adolescence. Being young is a time when there is a high period of neural maturation during which neural circuitry and underlying attention and behavior control mature rapidly. Rapid fire electronic media exposure may disrupt neurodevelopment leading to ADHD, according to researchers.
In the past, ADHD was thought to be a child onset disorder but is now known to occur in adolescence and adulthood.
2800 students were studied for over 2 years without symptoms of ADHD, and found a rising incidence of ADHD to the level of 10%, especially in males. Violent and fast pace games were particularly pointed to as a risk, but video chatting, online shopping, commonly checking social media sites, and even streaming movies are suspect as well.
ADHD is associated with an increased risk of substance abuse, higher crime rate, lower educational attainment, depressive symptoms, and delinquent behavior. JAMA, Jul, 2018.
Loneliness and social isolation linked to use of social media
One might think that being on Facebook, Snapchat, Twitter, etc. would combat loneliness, but studies say the reverse is true. It also creates social isolation by resorting to the social media instead of face-to-face communication which promotes well-being much more than electronic media.
Studies in those 19-32 years of age show that those who are on social media for 2 hours or more have these problems. American Journal of Preventative Medicine
Loneliness and social isolation feed each other, and both drive social media use. Replacing one’s real world with the internet is definitely detrimental to people’s well being. “Likes” on a post is no substitution for human to human personal contact.
The use of social media and social isolation may become necessary in the elderly when friends and family move away or die. It may be a poor substitute but still connecting online can be beneficial.
Loneliness is a potent negative health effect. It elevates stress hormones and inflammation which are known factors creating an increase risk for cardiovascular disease, immune diseases such as rheumatoid arthritis, type 2 diabetes, dementia, Alzheimer’s, and even suicide especially as one ages.
However, consider the number of people who meet online and create a real relationship, whether illicit or legitimate. So there can be benefits as well.
The American Academy of Pediatrics characterizes a syndrome called social media depression, a problem for many young people.
They cite 8 cues that might point to social media depression: 1) productivity is dampened in favor of social media time 2) increasing distraction from real life situations 3) creation of social phobias that prevent real conversations and interactions away from social media 4) creation of feelings of inadequacy when constantly comparing oneself to those on social media 5) fear of missing out on news about everything 6) creates inactivity, obesity, isolation, and social inadequacy 7) promotes fear of being alone 8) promotes or exacerbates unhappiness, sadness, potential for being bullied, etc. social isolation and withdrawal.
Social media bullying and sexting since the internet has come into our lives, and the world will never be the same. I have reported on bullying including cyber bullying; click on:
For sexting and its consequences, click on www.themedicalnewsreport.com #82
The National Safety Council reported that 26% of car accidents are linked to cell phones—texting (only 5%), 95% from talking on the phone, hand-held or hands-free. Only 12 states have made it illegal to talk on a hand-held device, but distraction, even eating while driving, is a cause.
More education for young people must start with parents but public education is necessary as well.
In memory of Win Boileau, who was a dear friend from the time we were in the Air Force together until his untimely death a few years ago from this very tumor, here with Ginny!
A recent article in JAMA-Journal Watch reported a significant development in the treatment of a common and very malignant brain and spinal cord tumor which frequently is extremely lethal—glioblastoma multiforme. These tumors are rarely cured. Survival rarely surpasses 20 months, and when they recur survival is usually less than 12 months. Subtotal removal with radiation and chemotherapy is usually the standard of care. One of the oral chemotherapeutic agents frequently used is temozolomide (Temodar,Temodal, or Temcad).
For a review of brain tumors, click on my website:
Electrical Field therapy—a new innovation
A new study combined the use of the above mentioned chemotherapeutic agent with alternating electrical field treatments (TTFields).
Alternating electric field therapy is a type of electromagnetic therapy using low intensity electrical fields, which can interfere with cancer cell’s ability to grow and spread. The electrical treatments affect cancer cells more than normal brain cells. Half of 695 patients from multiple cancer centers were treated with Temodar and the other half combined the electrical field treatments with this chemo agent.The treatment was administered over an average amount of time of 8.2 months and followed for 40 months. Patients with the combined treatment survived an average of 6.7 months compared to 4.0 months for temozolomide alone with the average overall survival of 20.9 months compared to 16.0 months. This equates to an increased survival of 18% using the combined therapy. It can be used instead of chemotherapy, but is no more successful, although it has side effects that chemo has. The device can, however, cause skin irritation, mood swings, headaches and rarely seizures.
Optune electrical field therapy machine (shown above)
The electromagnetic field treatment was administered by shaving the head and placing a cap over the scalp with 4 electrodes to send electrical impulses into the brain 20-22 hours a day.
The device is named Optune manufactured by Novocure—cost is $21,000 per month (no Medicare coverage).
The cost of cancer care today is disgusting whether insurance covers part of it or not. It is causing a significant percentage of bankruptcies today.
This electrical field therapy is known to interfere with the mitosis (cell division) of cancer cells. Because cancer cells divide and multiply so much faster than normal cells, these cells are more sensitive to these treatments. This is the basis of most cancer treatments that affect the cancer cell as it grows.
Quack treatments-photo from the Museum of Quackery
In the field of medical quackery, electrical head devices have been used as far back as the 1800s. Those charlatans had the idea that electromagnetic waves might help disease with no research to prove its benefit. Quackery is alive and well throughout the world. When people are desperate, they will go to the ends of the earth to find a “miracle cure”.
Although this therapeutic advance is new, many more studies are forthcoming using electrical field stimulation. It is also showing significant benefit adding it to radiation and or surgery for these brain tumors. It should not be thought of a solo treatment for any cancer. More to come in the future!! JAMA-Journal Watch, Dec. 2017; American Cancer Society
Other innovative treatments for brain tumors
1- Recombinant polio virus vaccine
While there is promise for treating these tumors, it is important that when these tumors recur, doctors have something to offer these survivors. While new biologic agents are being studied, targeted therapies, vaccines, and other therapies are being studied, and most are experimental at this point.
Brain tumors are different than most tumors in that they have less mutations, lack T-cell infiltration, and do not have immune checkpoints to block immune response that other tumors elsewhere in the body have. This makes treating brain tumors more difficult in addition to their location to vital functions of the brain.
A live attenuated poliovirus type 1 (Saban) vaccine which can use its ribosome entry sites in cancer cells replacing their genetic material with that of human rhinovirus type 2. This causes death of the cancer cell.
A study was reported in the NEJM treating 61 patients with recurrent glioblastoma and had their tumors injected with this vaccine. The control group came from other medical centers. Results at 24 and 36 months showed a higher survival in the treated group (21% in treated group compared to 14% in the controls). Although the success was somewhat minimal, it is how research begins to finds answers. NEJM, Jul 12, 2018.
Currently the only vaccine approved by the FDA to clinically treat cancer is Sepuleucel-T (Provenge) for advanced prostate cancer. As in all vaccines, they stimulate the patient’s own immune system to fight the cancer.
2- Immunotherapy before surgery doubles survival time
Another innovation is the use of immunotherapy prior to surgical removal of glioblastomas, called neoadjuvant therapy. Reported by M.D. Anderson Cancer Institute, patients were given one of the checkpoint inhibitors pembrolizumab, which blocks the programmed cell death protein known as PD-1, and was given to patients prior to attempts to surgically remove glioblastomas. The survival rate was compared to a group of patients who received the immunotherapeutic drug after surgery. The survival time was doubled in those who received the immunotherapy prior to surgery.
This type of immunotherapy is also showing promising results with melanoma, metastatic breast cancer, and resectable lung cancer. www.mdanderson.org
This completes the April, 2019 report.
Next month, the May, 2019 report will include:
1. Medical Updates
3. Hyperhidrosis—excessive sweating
4. Contact lens—an update
5. Lyme disease
6. Testicular diseases—part 1--cancer
I hope you have a wonderful spring. Stay healthy and well, my friends, Dr. Sam