The Medical News Report

June, 2019, #89

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

samlamonte@gmail.com

 

Important note:

   Because I start on these medical subjects several months before they are published, it is amazing how much information comes out in the medical literature as I finalize these subjects that require edits to my reports. This particular report is no exception, especially with the medical updates, since the information is so new. I doubt any other blog is as extensive and more up to date. Of course, it my pleasure to research hundreds of medical journal articles each month to provide you with the best and most pertinent information.

  If you want to have an app on your phone so that you can immediately access the medical reports, please email me and I will send the instructions as they are different for i-phones and androids.  Dr. Sam

 

Subjects:

1. The biggest Cartel in U. S. history—Big Pharma-price fixing; Trump requiring drug ads to state price per month—a must read!!! 

2. Medical Updates

   a) Religious freedom--Feds rule that doctors and nurses can opt out of performing abortions and sterilization procedures on the basis of personal or religious beliefs; Abortion laws

   b) Smoking cessation and weight gain—does it negate the benefits of not smoking? Update on use of e-cigarettes

   c) Suicides and overdoses on the rise!  

   d) How successful is colon cancer screening?  

   e) Vaginal mesh implants taken off the market by the FDA

   f) Recent Sunscreen concerns—mineral sunscreen alternatives

3. Common Running injuries

4. Cancer survivorship Series-#5Cancer survivorship Series-#5—Side effects of treatment-short and long term--eye and ear side effects, hair loss, infertility, skin cancers

5. Testicular disorders (non-cancer)

6. Diseases of the Muscles (Myopathies)—Hereditary and Acquired

 

 


 

June in Austria

 

              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. The biggest Cartel in U. S. history—Big Pharma-price fixing; Trump requiring TV drug ads to state price—a must read!!!   

  The U.S. Congress has protected the pharmaceutical companies since 1994 in trade deals (NAFTA). This is obviously being scrutized by the Trump Administration, and it will include the drug companies. 40% of finished drugs are now produced and imported into the U.S. This agreement allowed other countries to pay less for medicines at the expense of us. Some of the drug companies have moved their companies to other countries to evade taxes. Trump hopes that will stop.  

  Between 2007-2017, U.S. drug costs have risen from $236 billion to $333 billion even though 90% of drugs are generic. Of course, Americans by far take more medicine than any other country.

  Biologic drugs (Humira, Rituxin, Enbrel, Herceptin, interferons, insulins, immunologics for advanced cancer, etc.) for specific serious diseases accounts for 1% of the drugs but accounts for 30% of the expense of all drug costs, and under the current rules (Obama) are protected for 10 years and allowed essentially to charge whatever they can get away with “to recoup their investment”.

  Since President Trump signed the U.S./Mexico/Canada Trade Agreement, the drug companies have raised prices on 250 medications.

  It continues to be frustrating to report on the abusiveness conspiracy of Big Pharma. In our society (capitalism), there are limits to what can be done to curtail their maltreatment of the American public. The abuse also comes from our Congress, who accept Big Pharma donations and then refuse to bring up legislation to put these corporations in their place.

   An investigation of alleged price fixing in the generic drug sector involves 16 companies and over 1000 medications.

  It is now known that executives from various generic companies agreed to divide market shares in the U.S. to set maximum prices for various drugs. An example---doxycline (an antibiotic commonly prescribed) cost $20 for 500 pills in Oct. 2013, and is now $1800 as of April, 2014. Some companies have pleaded guilty and are cooperating with the Justice Department according to the Washington Post. But the fines are not enough! They need to go to jail.  Perhaps you saw this on 60 minutes this May 12.

  Generic drugs account for 90% of prescriptions, but account for only 23% of the total drug costs. And yet, these generics, which are supposed to be affordable, but that started changing with their collusion.

  Teva, Greenstone (Pfizer), and other generic companies have been caught colluding to raise generic prices as much as a 1000% and more. The State of Connecticut is currently suing these companies, having been caught red handed with documents, proving that these generic companies contacted each other and all agreed to shoot the price of these drugs exponentially higher. THIS IS ILLEGAL! Of course, these companies are denying all allegations. Let us hope that these criminals have to pay back the country for damaging our healthcare industry and making generic drugs too expensive for patients to afford. Think of the patients harmed by this collusion, not filling prescriptions because they are to costly with resulting aggravation of illness and disease. Why does it take a state to go after these crooks? Thank God the lawsuits are ongoing, but why has our Congress been led around by the pocketbook and not put pharmaceutical executives in prison??

Trump requires Big Pharma to provide the price of drugs advertised on TV  

  In another big move toward transparency in healthcare, President Trump announced in May that (direct to consumer) drug ads on TV will be required to include the price of the drug (per month). The New York Times, on May 8, announced that Alex Azar, U.S. Health and Human Resources Secretary, of the change. which of course will be challenged by Big Pharma, but drug prices must be announced on the TV ads sometime this summer.

  Only the most expensive cancer and autoimmune diseases drugs are advertised on TV, and they cost thousands. I have previously announced they spend more money on these ads than some of them do on research.

  As much as we all want our healthcare to be reformed, it will take attacking this monster one piece at a time, and will continue to be the number one presidential election issue. Expect both parties to introduce several healthcare bills in the near future.    

2. Medical Updates

  A. Religious freedom from abortions,etc. for doctors and nurses (and facilities); Abortion Laws challenged

  The Department of Health and Human Services has ruled that doctors and nurses can refuse to perform abortions and sterilization procedures on a personal or religious belief. I certainly would not want medical personnel performing procedures on me that they have a problem with, even if I was an advocate of these procedures.

  Regardless of which side you personally stand, I am thankful patients and groups can’t create legal havoc on those who choose to have religious or personal beliefs regarding these hot topics. Other health workers are protected as well. This ruling is backed up by 25 laws passed by Congress to protect “conscience rights”. It also includes protection for entities such as clinics and hospitals. Even if the government funds such procedures (Obamacare), these healthcare professionals and facilities are still protected.

  There is now an office of Conscience and Religious Freedom within the Office of Civil Rights, but the American Civil Liberties are all in with protests from a variety of groups, claiming many types of discrimination, hardship for those seeking these services, and it will not stop until there is a democratic congress and president. Clearly it will be a presidential race subject for sure.

  On the other hand, Alabama has essentially made abortion illegal, and if a doctor performs the procedure other than for saving the life of the mother, they can be sent to prison for 99 years (even attempting an abortion is a Class C felony—10 years prison). This means even rape and incest abortions are illegal. If approved, it will not go into effect for 6 months, but is clearly being challenged in the courts. This is pretty aggressive, and clearly these legislators are wanting to challenge Roe vs Wade. It also encourages illegal abortions by poorly trained people, delay in abortions by some, and can create emergency issues by some girls trying to abort themselves. As of this writing, Georgia and Missouri are considering joining Alabama. 

  When the government decides what a person can and cannot do with their bodies, this takes decisions out of the physician’s/patient’s hands and divides our country, which, as a physician, makes it difficult for me, in a non-religious sense.

  The fetal heartbeat bills by some states make more sense for many (Georgia, Kentucky, Mississippi, and Ohio—abortion permissible until a heartbeat is heard on ultrasound), but many girls do not even know they are pregnant until the end of the first trimester. As usual, there is argument on both sides, and I am not here to take sides, even though I have my personal opinion. I just wish it did not polarize Americans. Human life is at stake, so it is understandable.  

 

Medscape, May 3, 2019

B. Smoking cessation and weight gain—does it negate the benefits of stopping smoking? Update e-cigarettes

  1. Smoking cessation and weight gain 

  Smoking causes or contributes to many cancers and cardiovascular disease. We are seeing a shrinking number of smokers thankfully, but the damage is done for millions of Americans.

  There are many other benefits to stopping smoking, but there are other consequences that have created barriers to stopping, especially weight gain in women. With weight gain, there is a greater risk for developing type 2 Diabetes and cardiovascular disease. However, recent studies have shown continued decreased cardiovascular risk with smoking cessation especially after a few years of smoking cessation.

  The value of not smoking tobacco far outweighs the secondary weight gain many patients experience (average 10 pounds), but tell that to some women. After stopping smoking, the risk of lung cancer and other diseases decrease over time, however, the risk continues, and if a patient has smoked 1 pack of cigarettes for 30 years (or 3 packs a day for 10 years), there is considerable risk in developing lung cancer and these patients should be screened annually using low dose CT lung scans (talk to your doctor even if you have quit).

  It is critical for physicians to educate patients about seeking a dietician for advice on caloric restrictions to counter the drop in metabolism which occurs with smoking cessation. It is critical to start an exercise program to combat the weight gain that may occur. The weight gain usually levels off in a year or so. However, nicotine depresses appetite, so that needs to be understood before beginning this difficult task.

  Patients must overcome their fear of weight gain (especially women) as a barrier to smoking cessation as the benefits are so great even with some weight gain.

  2. Update on use of e-cigarettes

  Smoking cessation has been reported as successful with e-cigarettes (95% more effective than no other methods) as the use of other nicotine replacement methods including nicotine patches and gum (about 10-12% long term success), however, it is not approved by the FDA as a device for smoking cessation.

  Since 2007, when they were introduced and supported by big tobacco companies, and by 2014, 15% of adults had tried e-cigarettes. There is a perceived health benefit over smoking combustible cigarettes, not realizing there are still many carcinogens in e-cigarettes, but less than cigarettes. The long term effects of vaping are not known and won’t be for years to come. Fortunately, vaping is not allowed wherever cigarettes are not. The amount of smoke that is exhaled is much more than cigarettes, and the flavored e-cigarettes smell like the flavor.  

  Many adults have used e-cigarettes as a cessation device or at least to reduce the number of cigarettes smoked per day. A combination of varenicline (Chantix) and e-cigarettes is even more successful in promoting longer cessation rates and for adults according to a few studies.

  The devious tobacco industry introduced multiple flavored liquids (containing nicotine even higher than cigarettes) that is used in e-cigarettes and became extremely attractive to young people that had not started smoking and most of the youth don’t even realize there is nicotine in the fluid. The latest big success is the e-cigarette company Juul (75% of the market), which has a device that looks much like a computer USB plug, designed to camouflage what it really is (a gateway to cigarettes for youth), 40% owned by Philip Morris Tobacco Company.                    

JUUL

 

 

  As expected this was but another method the tobacco industry started using to addict teens and encourage them to start smoking cigarettes, since smoking rates have decreased over the past decade for adults. Addicting the next generation is crucial for the industry to continue as a billion dollar business. Another less well known issue is the higher nicotine concentration than cigarettes, potentially addicting people even faster than regular cigarettes.

  However, people can choose the concentration of nicotine in certain e-cigarettes, which can be used in decreasing doses to wean off nicotine for adults trying to quit cigarettes.

  The rapid increase in use of e-cigarettes has raised public health concerns. It is estimated that 1.3 million U.S. adolescents are vaping. 6.1% of 6th graders are vaping while 21% of 12th graders are, according to the NEJM, Jan, 2019.

  Of interest, the FDA just allowed Philip Morris Tobacco Co. to develop a new device that heats (not burns) tobacco so that the smoke inhaled will supposedly have less carcinogens in the inhalant. Stay tuned! Never trust the tobacco industry.

  I have discussed smoking cessation and methods to quit previously. Click on: www.themedicalnewsreport.com #25 and #73

NEJM, Sept., 2018

  C. Suicides and overdoses rising in the U.S

  Suicides in the U.S. are rising at an alarming rate. From 1999-2016, the rate has risen 25% according to the CDC and over half the states had over 30% rise accounting for 45,000 deaths in 2015 alone. North Dakota and Vermont had over 50% increase.

  A new study cited alarming information about increasing suicides in ages 10-14 with the highest increase. In past statistics, 80% were boys, but since since 2007, there has been a 13% increase in girls committing suicide narrowing the difference between sexes.

5 Firearms were used in over 50% of the cases, but all methods are on the increase. Deaths by suffocation and hanging have recently increased in girls. The emergence of social media is considered the possible reason for increases in girls. NEJM Journal Watch, May 20, 2019

  I have written about the factors that increase risk for suicide before in a previous report:

www.themedicalnewsreport.com #51

  

 

  54% did not have a known mental condition, and that is why friends and family need to be alert for the risk factors and act on them sooner than later (relationship trouble, life stressors, recent and impending crises, physical health problems, and substance abuse being the most common issues).

Risk Factors

   25% of those who commit suicide do not have suicide ideation, but those struggling with anxiety and depression are more prone to suicide. Those talking about being hopeless or helpless, those writing or talking about suicide, those in school whose grades suddenly take a downturn, those with guilt or shame, gays (especially transgender), and those with a traumatic brain injury or PTSD all are at risk.

  Cancer patients who are given the diagnosis of a very advanced cancer are at most risk of suicide during the first 6 months after the diagnosis (20% higher than general population). Oncologists should bring up the issue in these cases and initiate consultation if clearly the patient is obviously depressed or is non-compliant and misses treatments, etc.

  Men die 3.5x more often than women. White males account for 7 out of 10 suicides (2016) with the highest rate in the middle years of life. 

  Psychotherapy is necessary, and early recognition of risk factors is critical to overcome this terrible threat. Primary care physicians must ask patients about their psychological status when seen.

  There is no one answer to this problem, but recognition and media attention will help. 25 Americans attempt suicide every day (estimated 1.3 million per year). Suicide Hotlines must be posted often 1-800-SUICIDE (273-8255).

  Over 5000 military veterans commit suicide annually primarily from PTSD. I have discussed PTSD as well:

  www.themedicalnewsreport.com #36 , #37 and #38

  The best treatment today for PTSD is prolonged exposure therapy (a form of cognitive and behavioral therapy using retelling of the traumatic events and gradually exposing the patient to situations, places, and things that remind them of the traumas). Antidepressants (SSRIs—serotonin reuptake inhibitors) especially sertraline (Zoloft) are of help as well. Some studies show that combining these two therapies are no more effective than either separately. However, the dropout rate with exposure therapy is fairly high. NEJM, Dec. 2018   

Reference—Medpage, The American Federation for Suicide Prevention  www.afsp.org

Overdoses on the rise especially in women

  From 1999-2017, drug overdose and deaths have risen rapidly for women ages 30-64 from 6.7/100,000 to 24.7/100,000 population as reported by the CDC. This coincides with the opioid crisis, but includes other illicit and prescription drugs.

  The highest number of deaths from overdoses in 1999 was in ages 40-44, but in 2017, it is now older (50-54)!!

Overdose death percentage increases are as follows:

   Synthetic Opioids (fentanyl)-1643%, heroin- 915%, benzodiazepines (anxiety meds)-830%, prescription opioids (oxycodone, etc.), cocaine-280%, and antidepressants-176%.

  This change in age risk begs for more education of physicians and middle age women. Even in the face of governmental priorities to fight the opioid crisis and changes in prescribing, as long as illegal drugs are allowed to come over our borders, there will never be a decrease in the numbers. We must have immigration reform now!!

  Access to these drugs correlates with overdoses and deaths. Physicians have stopped writing as many prescriptions for chronic pain (and very limited numbers of pills), but when access to heroin and prescription drugs are as easy to obtain, no amount of rehab centers, laws, and rules will get this crisis under control.

CDC

  D. How successful is colon cancer screening?

  One of the most successful screening programs to date is colon cancer screening with either stool testing and or colonoscopy. Every 10 years, those 45 years and older should be tested if using colonoscopy, and every year for certain stool tests according to the American Cancer Society ( I was a member of that small ACS committee who changed the age to 45 from 50, because of increasing numbers of young people developing colon cancer).

  Screening improves recognition of precancerous polyps and or cancers in 30-40% more patients than those who are not screened. That said, there are still people who get screened and are diagnosed with colon cancer before the 10 year interval is up. Not enough people are not requesting stool tests. Doctors are not encouraging it enough.

 

 

 

  Annual stool testing, if carried out by a higher percentage of people could discover some of these cancers or polyps that are bleeding or are shedding enough DNA (Cologuard stool test) to prompt a colonoscopy before that 10 year interval. The downside is those with positive stool tests requiring colonoscopy that do not have cancer are being alarmed and unnecessarily tested with possible complications. This is the dilemma with all screening tests—false positives.

  There are 3 stool tests available: FOBT (fecal occult blood test--$22) and FIT (fecal immunochemical test--$219), and Cologuard—DNA test-$600. All are performed at home and the sample is sent in to the doctor or lab.

  The FIT and FOBT must be performed yearly, while Cologuard is every 3 years. 

  The FOBT and FIT tests for protein in red blood cells (from bleeding polyps or cancer).

  The FOBT can be affected by foods and medicine (FIT is not affected by foods). Foods that need to be avoided 2-3 days before the test (meat, cabbage, broccoli, cantaloupe, cauliflower, horseradish, mushrooms, turnips, and zucchini, large amounts of citrus, aspirin, and ibuprofen.

  The FIT test is more accurate than FOBT. Both FIT and FOBT require only a tiny sample to be sent in. Cologuard requires sending in the entire stool sample.

  Cologuard tests for DNA in polyps and cancer--$649, can be affected by food. It tests for the DNA in hemoglobin, which is the protein in blood cells. 

These tests should be covered by insurance.  

  

 

  Without being screened, the chance of being diagnosed with cancer is doubled. Remember, the goal of screening is discover polyps that may become cancerous, and can be removed before becoming malignant. Almost all cancers originate from certain types of colon polyps that take, on the average, about 10 years to develop into cancer….hence the 10 year interval for colonoscopy screening.

  A recent study noted that the time of day a patient sees her primary care doctor influences whether a patient gets screened, because they spend much less time as the day wears on screening rates at 8 am ordered colonoscopy 37% of the time compared to 23% by 5 pm. Doctors just cut that part of visit short. Too bad, but be aware and bring the subject up with your doctor.  JAMA Journal Watch, May 18, 2019

  Once a high risk polyp is removed, the interval for screening usally drops to every 5 years, as there may be more polyps growing in the future. This discussion pertains to the average risk person and not those who have risk factors such as family history, certain genetic syndromes, those with certain chronic inflammatory bowel disease (ulcerative colitis), etc.

Right sided colon cancers tougher to diagnose

  If one analyzes those who were screened and still were diagnosed with cancer before the 10 year interval was up, a majority of these were right sided colon cancers. Right sided (proximal) polyps are more likely to be flat and hard to see on colonoscopy and can be missed.

Preparation for a colonoscopy

  Some patients do not do a good job of cleaning their bowel out before colonoscopy (bowel prep), making examination more difficult. I am sure some small polyps are missed. Most cancers are easier to diagnose, but could be missed. If symptoms start, even after having a colonoscopy, go to the doctor and get a stool test.

   I recently lost a friend, who had a colonoscopy 2 years before he developed a right sided cancer and ignored abdominal symptoms and weight loss which led him to having an unresectable colon cancer and died a year later.

  The moral of the story is to be vigilant about any bowel changes, blood in the stool, or weight loss without an obvious cause even if a person has had colon cancer screening.  GET SCREENED STARTING AT AGE 45.   

  For an extensive discussion on colon cancer and screening, please go to my website: www.themedicalnewsreport.com #57 and #58

 

  F. Recent concerns about sunscreens-mineral alternatives

  No doubt everyone is aware of the publicity that sunscreen chemicals (benzenes are known to cause cancer) are absorbed into the blood stream. Because these products are sold over the counter, the FDA does not have control over the safety issues like it should. In spite of strongly recommending more research on the safety of these chemicals by the manufacturers, who have done little, forcing the FDA to perform some studies.

  The JAMA reported in a small study regarding the question of absorption, and their results confirmed these chemicals in the blood stream. Unfortunately, how much is safe has not been established, since these chemicals do have carcinogenic capabilities. JAMA, May 6, 2019

  With 3.3 million skin cancers occurring annually in the U.S., it is clear, all of us need to protect our skin.  Obviously covering the entire body with sunscreen all day every day is clearly more potentally hazardous than someone who covers their arms, face, and lower legs a few times a week for a few hours. It is still recommended to wear hats and clothing to protect our skin, and sunglasses to protect our eyes.

  Back in the day of zinc oxide (which does not absorb), there were few options, but now there are many more chemicals in modern sunscreens including several types of benzenes. Now many health food stores, etc., are selling alternative mineral sunscreens containing zinc oxide. Of course, UVA and UVB sun rays must be blocked to prevent sun damage, aging, and skin cancers.

 

  Look online for many options. The message is clearly to NOT stop using sunscreen, but to limit sun exposure and use clothing and wear sun glasses, using mineral alternatives, but using at least 30 SPF (sunprotective factors) on exposed surfaces is recommended. Using more than 30 does not add much more protection but does add more chemicals to the body.

    

  Place on the skin 30 minutes before exposure for the sunscreen to provide protection, and reapply every 2 hours. No sunscreen is waterproof, so reapply after getting in the water. Sprays should not be used on children or sprayed on the face, because of the inhalation of the aerosol.

  This article recommended to look for mineral sunscreens which contains zinc and titanium oxide generally considered safe.

  The FDA states that those with PABA (para-amino-benzoic acid) and trolamine salicylate including 12 other ingredients (benzenes, octocrylene, etc.) commonly used in sunscreens have not been sufficiently studied to be declared safe at low levels in the blood. Here are the three most common skin cancer a)left-squamous cell b) upper right-basal cell c) melanoma.

 

Getting skin cancers versus sun protection is clearly in favor of wearing the sunscreens. Just be smart! It is always about risk/benefit in anything we choose to do.

  This is a classic example of chemicals we put in our body that does not require full FDA jurisdiction, since it is “not a drug”. This true for the entire dietary supplement industry. If the manufacturers would have done studies in the first place, maybe we would already have some answers that we currently don’t have. Skin cancer surgery and facial reconstruction was a significant part of my practice.

  For a great discussion on skin cancers, click on:

www.themedicalnewsreport.com #5

  

G. FDA takes vaginal mesh implants off the market

  The FDA has ordered the manufacturers to stop making and selling vaginal mesh implants for urinary incontinence from pelvic organ prolapse.

  I hope you read the article I wrote recently on the subject of the mesh and the hundreds of complications that have occurred. It was under the heading of Bad Actors-Doctors, Lawyers, etc. www.themedicalnewsreport.com #83

  The original Swedish OB/Gyn surgeon did not perform adequate research on the implant regarding possible side effects over a 10 year period, and the world’s surgeons were duped into being told it was safe and jumped on the transvaginal placement of the mesh implant. The mesh implant was so much easier than the inpatient extensive surgical procedure that has been the standard of care. Training for the procedure was suspect too.

  The doctor sold the rights for millions to Johnson and Johnson Co. and the lawsuits have come fast and furious. The manufacturer is Boston Scientific and Coloplast. They are protesting the action to no avail.

  Extrusion of the implant, perforation of the bladder and bowel can occur, painful sex, etc. are all serious complications with what was thought to be an easy fix for a serious common complication from multiple births, obesity, prolapse of the uterus, etc. It was estimated that 1 in 15 women might need the implant removed over a 9 year period. Over 3 million women have had the procedure worldwide.

  For patients satisfied, the FDA does not recommend  removal, but should continue to be monitored by their surgeon. If persistent vaginal bleeding or discharge, pelvic or groin pain, or pain on sex occurs, their surgeons should be notified.

  The sad news is that thousands of women are going to be faced with continued symptoms from urinary incontinence or have to undergo the more traditional abdominal pelvic procedure.   Medpage, April, 2019

 

June in Austria

 

 

3. Common Running Injuries--Sports Medicine Series—Part 2

  Overuse is the most common reason (80%) for injuries from running. Tendon injuries are the most common and named tendopathy.

  Tendons of the knee cap(patella), Achilles, and hamstring are the most common areas involved, however, ankle injuries are common as are plantar (foot) injuries. Stress fractures do occur.

There is a difference between strains and sprains

  Sprains occur with tendon injuries and strains occur with muscles.

Incidence

  Overall injuries occur more common in males, however, knee and plantar fascia injuries are more common in females. 

  1% of the population runs on a regular basis. It has metabolic equivalents to swimming and cycling. Studies show about 27% of novice runners injure themselves withing a year, 32% in long runners, and 52% in marathon runners.

  a) Knee injuries

   Patellar (knee cap) tendon sprains causing tendonitis is the most common injury to the knee. Pain occurs below the knee cap and in the top of the tibial (shin) bone and is tender to the touch. Performing a squat will elicit pain. Ultrasound can define the injury. Treatment is conservative and when the pain subsides, exercises called concentric are used to strengthen these tendons by knee bends (flexion and extension on an decline table). Surgery is rarely required.

   b) Patellofemoral syndrome

  Pain is felt behind the patella in the anterior knee aggravated by going up or down stairs, running, or squatting. Treatment consists of 6 weeks leg strengthening with flexion exercises. NSAIDs (Aleve, Ibuprofen, etc.) help temporarily.

    c) Iliotibial band (ITB) syndrome

 

  Pain occurs in lateral aspect of the knee as the iliotibial band gets pinched by lateral aspect of the knee joint (lateral femoral condyle) and causes pain just below that area and can have a popping sound when the knee is flexed . This band arises from the iliac crest of the pelvis to the tibia just below the knee. It provides lateral stability to the thigh and knee. Pain can be felt at this point too (see drawing).

  Treatment is exercise therapy (plus NSAIDs) with strengthening of the hip abductors (moving the hip in a lateral direction with counter pressure. Improving flexibility of the hamstrings and stretching the ileotibial band (ITB) is also necessary. Massage therapy of the ITB is also valuable. Physical therapy consultation is always helpful.

   d) Foot and ankle injuries

      

  Ankle sprains are very common especially if running on uneven surfaces. “Turning the ankle” will create minor or even major tears (sprains) of lateral ligaments, however, fractures or avulsions of ligaments off ankle bones must be ruled out. Treatment may include rest, ice therapy, and elevation acutely, but taping, bracing, and the use of orthotics could be necessary for several months, as these sprains take considerable time to heal depending on the severity. Strengthening of the ankle with appropriate stretching will prevent future injuries. Of course, warming up before any sport is critical to prevent injury.

  Plantar fasciitis can also occur and has been discussed previously in the 74th report. To access, please click on:

www.themedicalnewsreport #74

  e) Achilles injury

    These are tendon injuries (strains) which account for 25% of foot and ankle injuries. Heel pain is present in most of these injuries and depending on the severity, swelling and tenderness of the tendon may be present. The injury occurs where the tendon inserts into the heel bone (calcaneus). Rupture of the Achilles tendon is a serious injury and may require months of therapy while healing.

  Shock wave therapy and acupuncture with e-stimulation may be of some value but studies are not convincing. Topical glyceryl trinitrate patches may also be of some value. Ultimately, physical therapy will be necessary to return this serious injury back to normal.

  Achilles tendons should not be injected with cortisone, as this predisposes to rupture. Platelet rich plasma injections are being used without scientific proof that they are valuable. Stem cell clinics are being used for all types of injuries without proven value in legitimate research.

   

 

  Rupture treatment can be non-surgical or surgical. Surgical repair leads to fewer re-ruptures over medical treatment, but there are more complications including deep venous thrombosis in the calf and nerve damage to the sural nerve (5%)-see right drawing above.

  The decision whether to operate or not should come from an experienced foot and ankle trained surgeon and the severity of the rupture, etc. BMJ, 2019

   f) Hamstring injuries

       The hamstring muscles are on the back of the upper leg. It consists of three muscles (biceps femoris, semitendinosis, and semimembranosis). Pulling the hamstring is uncommon in running, but could occur from hyperextension of the knee or not being warmed up before running.  

 

 

 

  Acute strains of this powerful muscle usually occur from sprints from any sport including baseball, football, tennis, and any sport when sudden movement of the hamstring occurs. Rest and ice treatments to allow hemorrhage in the muscle to subside and allow healing to occur may take weeks. This will be followed by intensive physical therapy to return range of motion and strength to the hamstring.

  Tendon injuries of the hamstring (hamstring tendopathy) can also occur where the hamstring inserts into the pelvis. Pain will be felt in the buttocks. Rest and NSAIDs are valuable in most cases. Selected cases will respond to cortisone injections.

   g) Medial tibial stress injuries (shin splints)

  Most runners have experienced shin splints from time to time. The anterior compartment syndrome occurs from irritation of the periosteum ove that compartment resulting in swelling of the anterior tibialis muscle. Since that compartment is so tightly enclosed, when that muscle swells it puts pressure on that periosteum (lining of the bone) which causes acute pain.

 

Prevention is stretching the anterior muscles of the leg.   Ankle flexing followed by placing the anterior surface of the foot on the ground and extending that anterior tibial compartment can potentially prevent this compartment syndrome. Extracorporeal shock therapy has been used with some value in 2 small trials.

 

  Tibial stress fractures are the most common stress fracture followed by stress fractures in the small bones of the ankle (navicular) and foot metatarsals. This is more common in women if they have reduced calcium in their bones (osteopenia-porosis). Time will heal these fractures with appropriate medical therapy.  

 J. American Medical Physician, 2018

  

     

4. Cancer Survivorship Issues Series--#5—updates; side effects of cancer treatment--eye and ear effects, hair loss, infertility, skin cancer

 

Defining the term cancer survivor! 

  Most cancer organizations and medical staff define cancer survivors as those who are first diagnosed until the end of life. I am a cancer survivor (since 1991). Many patients try hard to put cancer behind them once they are finished with treatment, but unless a survivor is in denial, this disease follows a survivor to the grave. Most organizations accept this term even imperfect as it is.  

More Side effects from cancer treatment

  This is the 5th part of this survivorship series. I have discussed many side effects of cancer including chemo brain, radiation damage to blood vessels and other tissues,  long term cognitive issues, chronic fatigue, nausea, chronic pain, disability, financial trouble, unproven and off-label treatments, skin reactions, liver failure, second cancers, and recurrence. This report concerns hair loss (temporary or permanent), eye and ear damage, premature cataracts, infertility, and skin cancers.

Hair Loss

  Hair cells grow rapidly, and because the rate at which a cell grows correlates with loss of these cells when chemotherapy is used, and hence hair loss is common with certain chemotherapeutic agents.

  Hair loss occurs all over the body, so eyebrows, eyelashes, pubic hair, etc. will be lost usually temporarily. The dose also plays a role and the frequency of administration.

  Hair loss usually begins 2-4 weeks once chemo is started. It usually continues through the treatment and will continue for a few weeks after treatment.

  Losing hair is a constant reminder that the survivor has cancer and is very distressing. Women frequently can be assisted with programs like the American Cancer Society from their wig boutique, an oncology partner. Many salons volunteer their time to provide expertise may provide a service as well. Special scarves can be donated as well.

    

When the hair returns it may have a different color or texture. It may, however, not be temporary.

  Preventive techniques of cooling caps are now often recommended. There, however, is slight risk of cancer appearing in the scalp, since the cooling prevents the chemo from having the same concentration in the scalp. It is also uncomfortably cold and causes temporary headaches.

  Minoxidil (Rogaine) used prior to and through treatment may have some influence on hair loss. Some studies report the hair returns faster with topical treatments.

  Before treatment, it may be wise to have the hair cut short, cease coloring, bleaching, and perming. Even during

  The hair should be treated gently with mild shampoos, minimal brushing, and massage are recommended.

  When the head loses hair, the survivor may feel unusually cold, and the skin is more vulnerable to sun damage, therefore, wearing some type of head cover is important and the use of sun screens is highly recommended.  

  Some survivors embrace their loss of hair and consider it a badge of courage. However, once the hair starts coming out in significant amounts, cutting the hair short might be a good suggestion.

  Radiation can also cause hair loss if cancers of the brain are being treated. It may also be permanent. Different types of radiation have varying effects, so speak to the oncologist about this issue. Special gentle hair care after treatment is critical.

  The most chemo agents that cause hair loss are Adriamycin, Cytoxin, Cerobine, etoposide, Taxotere, Taxol, Ellence, Hexalen, Vepesid, Idamycin, Ifex, Ixempra, Camptosar, Hycamptin, Navelbine, and Vincristine. However, any chemo can cause hair loss.  

Reference-American Cancer Society, Mayo Clinic, Verywellhealth  

 

Eye effects of cancer treatment

Cataract-cloudy lens

  Cancer treatments can have significant temporary or permanent side effects. Dry eyes, tearing, premature cataracts, light sensitivity, eye infections, altered vision, and even a change in eye color can occur from radiation, chemotherapy, corticosteroids, and immunotherapies.

  It is important for survivors to have an eye exam before treatment and report any changes as treatment ensues and annual exams after treatment to catch any problems that may be arising. Remember, pre-existing eye conditions can be especially affected with treatment.

Cloudy lens—premature cataracts

  Premature cataracts can occur with radiation and chemotherapy. People who are in the sun without blocking U-V rays will develop cataracts at an earlier age. Most patients do not need cataracts removed until late 70s. Half of all those in their 80s will have cataracts that need removal. It is still the number one cause of blindness in the world and the cause of 43% of blindness in the U.S. according to the famous Wilmer Eye Institute at Johns Hopkins.

  The institute cited an interference with a protein in the lens of the eye—alpha crystallins. Other symptoms of cataracts can be double vision, a sense that color is fading, halos around lights, sensitivity to bright light, or any distortion or fast changing eye sight. Clearly, being followed by an eye doctor is important.     

  I had radiation therapy to my head and neck when I was 50 years old, and in my 60s, developed cataracts needing surgery.

  Surgical removal has been reported in a previous Medical News Report: www.themedicalnewsreport.com/44

  Subscribe to Cure Today, a wonderful publication online (and hard copy) for cancer survivors and families. Free!

www.cure@curetoday.com

 

Side effects of cancer treatment on the ear—from radiation or tumors

  Cancers and cancer treatment can affect the hearing and balance.   

  Nasopharyngeal tumors (back of the nose and the throat above the soft palate) will block the Eustachian tube, the tube that connects the back of the nose to the middle ear. When radiation includes the head, the ears can be affected. That includes brain, and all head and neck cancers. When the Eustachian tube is blocked from swelling or even tumor, it will prevent equalization of pressure when a person swallows. Fullness in the ear and development of middle ear fluid will occur with hearing loss. This can be diagnosed by examination of eardrum. Fluid will be seen.

  When a person performs a Val Salva procedure (by holding the nose and blowing), air should fill the middle ear. If blocked, the technique will be unsuccessful. If this is present, an ENT examination must be performed. The middle fluid can be drained by placing a tube in the eardrum. Notice the bubbles in the middle ear in the photos on the right.

       

 

  Tumors in the temporal bone on the auditory nerve called an acoustic neuroma will cause hearing loss. These tumors are benign but can cause permanent hearing loss and  facial paralysis, and must be removed either through the mastoid portion of the bone, but more often through a posterior craniotomy. I assisted neurosurgeons to remove these tumors. Note the arrow pointing to the acoustic tumor pressing on the hearing nerve and the arrow pointing to the brain stem.

                           

  There are vascular tumors in the middle ear (glomus tumors grow into the middle ear and infiltrate the area. This requires an neurotological technique I performed as well. The right photo shows the tumor behind the eardrum.

      

  Radiation near the ear can cause the external ear canal to swell and block off. Also ear wax can be excessive from irritation and swelling.

Chemotherapy-caused ear side effects

  Most hearing problems caused by cancer treatments are from chemotherapy, and pre-treatment hearing tests need to be performed prior to using chemotherapy especially with  the platin group of agents. The loss will likely be permanent since the nerve is damaged and likely lasting.

  Ringing in the ears is a common symptom from these treatments and may be present before treatments which would enhance chances of hearing loss.

   If hearing loss starts, adjustments in treatment may be necessary.

  Hearing loss can be accompanied with dizziness. Balance issues can be caused by weakness from treatments, but also from chemo, since it is part of the inner ear. It also can be part of chemobrain.       

Reference--Cancer.net

Infertility

  This subject could and will be discussed in the next segment on testicular issues not caused by cancer, however, cancer treatment and surgical removal of the testicles boh can cause infertility. Both chemotherapy and radiation are toxic to the cells that produce testosterone responsible for creating sperm. But fertility for women can be just as affected, and preservation of eggs (ovum) is also important.

  Fertility requires a combination of good health, trace elements of such minerals as zinc, and aspartic acid, cooperation between the pituitary gland and the testicular cells and ovaries. Fertility requires adequate sperm production, good motility, and good passage of the sperm through the tubes to join with prostatic fluid. Pelvic cancer may well require removal of the reproductive organs, and chemo may well cause problems with fertility.

  Since cancer treatment of the testicle or any cancer treatment which includes chemotherapy and or radiation, can cause infertility, discussion for preservation of sperm before treatment should occur. Evaluation of the quality of the sperm will help assess the chances for conception after treatment.

  During puberty (13-14) sperm begins to form. Men older than age 40, the type and dose of chemo affect fertility more aggressively. Once chemo finishes, it may take 1-4 years for sperm production to return to normal. On the left are agents that have a high risk of causing infertility, while the agents on the right if used at lower to moderate doses may not create infertility. I am sure oncologists will have an updated list including new agents including immunotherapy agents.

   

  Hormone therapy after prostate cancer treatment is used to suppress testosterone, which in many cases stimulates prostate cancer and could assist in recurrence.

  Stem cell transplants require high doses of chemo and radiation which directly affects the testicles.  or the brain Brain cancers could interfere with hypothalamus and pituitary gland and thus production of female or male hormone.

  Avoiding sex or having protected sex is critical in certain cases especially radiation with seeds. Surgery for testicular and some bladder and colorectal cancers may create retrograde ejaculation (ejaculation into the bladder) due to interference with the ejaculation nerves. Sometimes the use of the decongestant Sudafed may reverse this phenomenon.

  Females must consult their gynecologists before cancer treatment. Pediatric patients may also have fertility problems in their future.

  Fertility experts should be consulted before treatment.  Reference –ACS

Skin Cancers

  Patients with melanoma have a significant risk of a second skin cancers, most likely another melanoma, but they also have the more common types as well (basal cell and squamous cell). All these cancers are related to sun or tanning booth exposure. I have discussed these skin cancers in previous reports with multiple photos; click on: www.themedicalnewsreport.com #5

  Genetic mutations occur in many cancers, and it is those who can mutate genes also in the skin, the body’s biggest organ especially patients with breast, prostate, colorectal, melanoma, and blood cancers. This goes both ways, in that those who have frequent skin cancers are more prone to these named cancers. In fact, all patients who have had one cancer are at higher risk for future cancers (especially chidren). Add environmental issues, such as smoking, drinking alcohol, frequent sun exposure, obesity, and family history all increases the risk of cancer in anyone, but even more so in those who have had a cancer in the past.

  Basal cell cancers (multiple) increase the risk of these systemic cancers according to a report from Stanford Department of Dermatology.

  People who have had organ transplants are especially prone to skin cancers and should wear protective clothing and avoid the sun.  

 

5. Testicular disorders—non-cancer

  Previously, I have reported on cancer of the testicle last month. There are, however, many other disorders that deserve reporting on.    


    

Anatomy

  Note the testicle, which is attached to the coiled tube (epididymis), which stores sperm. During ejaculation the sperm then travels through the tube (vas deferens) which mixes with prostatic fluid.

Testicular torsion

  Torsion of the testicle is a urologic emergency, and occurs when there is a twisting of the spermatic cord above the testicle causing strangulation of the vasculature to the testicle. It must be surgically reduced within 6 hours or there is a significant possibility that the testicle will be lost (42% were lost in one study).

  This usually occurs in teenagers 12-16. Patients present with acute pain in the lower abdomen and scrotum, nausea and vomiting with some relief when the scrotum is lifted up. Ultrasound may be helpful, but it is a clinical diagnosis. 

  Other issues that must be considered are orchiitis (inflammation of the testicle), epididymitis, strangulated hernia, trauma, tumor, or cellulitis of the scrotum. Arrow points to strangulated testicle (too late to salvage).

 

 

 

  Surgical manipulation of the tissues (to untwist the spermatic cord) is necessary if the testicle has been addressed within 6 hours, otherwise, an orchiectomy is necessary. An orchipexy is also necessary on both testicles to prevent future torsion if testicle is spared. This procedure elevates the testicle with a different attachment of the tissues.

  If a young man notes intermittent pain in the scrotum, the doctor should be alerted that torsion could happen (30-50% chance).

Hydrocele and Spermatocele

 

    

  The hydrocele is an excessive collection of fluid inside an anatomic tissue called the tunica vaginalis of the scrotum (see drawing above), which is a lining of of the scrotum. This tissue secretes this excessive fluid and is not absorbed fast enough and beomes a sac of fluid. This may be asymptomatic and only just feel like a non-painful fullness in the scrotum. 10% of testicular tumors present with an associated hydrocele. They can be aspirated, however, recurrence is not uncommon. Removal is more effective although there are the usual complications of any surgery (bleeding, hematoma, infection, and even chronic pain).

  The spermatocele is a cyst that develops from the epididymis. It is usually asymptomatic and the cause is uncertain. If it is found, check with a urologist. If it is painful, seek evaluation (ultrasound) and diagnosis.  

Varicocele

 

  This is essentially a cluster of varicose veins in the scrotum. Pain or a feeling of heaviness may occur. 15% of males have this diagnosis and account for 1/3 of male infertility. 90% occur on the left because of the way the testicular vein drains to the left renal vein. Treatment is not necessary unless infertility is an issue, because the heat of veins in the varicocele contribute to infertility.

Epididymitis (and orchitis)

 

  The epididymis is the coiled tube that stores sperm. It is usually casued by an STD (usually Chlamydia or gonorrhea)  or bacterial infection or even the mumps virus in young prepubertal boys). It is most common between the ages of 14-35. The scrotum is usually red and swollen. The testicle is usually infected as well. There is pain in the scrotum usually associated with painful or frequent urination. There may be a penile discharge and a low grade fever. Antibiotics may be necessary after being tested for STD and a bacterial infection. NSAIDs, elevation of the scrotum, and ice packs also will help.

Undescended Testicles (Crptorchidism)

 

 

This disorder occurs because the testicle does not travel from the abdomen into the scrotum in the last couple of months of pregnancy. Sometimes it is delayed and can take up to 6 months after birth before it is the correct position. After that, if it has not descended, surgical placement will be necessary.

  There are factors that predispose to this condition: premature birth, hereditary, Down’s syndrome, low birth weight, and exposure to certain pesticides by the parents, diabetes (or gestational) diabetes, obesity in the mother, or if she smokes or drinks alcohol during pregnancy.

  Undescended testes increase infertility, more likely to be injured if out of place, more likely to have cancer, and more likely to have torsion of the testicle.

WebMD

 

6. Diseases of the Muscles—Myopathies

  Muscle disease is an enormous subject. The National Neuroscience Institute divides muscle disorders into 2 major categories: Acquired disease and Hereditary

a) Acquired myopathies primarily involve adults. The Acquired types fall into 4 categories:

Endocrine

Inflammatory

Toxic

Secondary metabolic

 

b) Hereditary myopathies get most of the publicity because of the devastating effects on children, but they are less common.

  Myopathies encompass a wide spectrum of diseases. The drawing below demonstrates one type of muscle called skeletal muscle. Skeletal muscles support bones. The other type of muscle is smooth muscle. I will limit this report to the skeletal muscle diseases and disorders.

  The term “myopathy” means muscle disease that causes suffering. When a muscle malfunctions, this results in stiffness, muscle weakness, spasms, contractions.

 

A. Acquired (Non-genetic causes) Muscle Diseases

Causes—Inflammatory, Infectious, Secondary metabolic, and Endocrine

1) Inflammatory (autoimmune) myopathies

  There are 4 main types of muscle disease caused by some type of inflammatory disease, usually autoimmune: polymyositis, dermatomyositis, inclusion type, and necrotizing autoimmune myositis, and myasthenia gravis.

  I have reported on the entire group of autoimmune diseases that include these diseases that involve muscles:  www.themedicalnewsreport.com/ 

  a--Polymyositis affects skeletal muscles and affects those from 20-60 with muscle pain, and if not treated will lead to swallowing difficulties, speaking, walking, and standing up. They can also have arthritis, heart failure, arrhythmias, and respiratory difficulty.

  b—Dermatomyositis is the most common of these and symptoms include a red rash on the eyelids, face, knuckles, elbows, knees, and toes often worsened by the sun, which can be overlapped with lupus. There can be calcium deposits under the skin. Patients can have fevers, weight loss, with progressive muscle weakness. As opposed to polymyositis, these patients may experience cancers of the breast, ovary, lung, female genitalia, and colon. Occasionally, lupus, scleroderma, and rheumatoid arthritis can have overlap with this disease.

  c—Inclusion myositis occurs after age 50 and is another chronic progressive wating muscle disease. Weakness creates tripping and falling. Weakness in the hand muscles creates difficulty putting on clothes, buttoning, etc.

  d—Drug induced--Necrotizing autoimmune myositis can occur in association with cancer, after a viral illness, with other autoimmune diseases such as scleroderma, and now is occurring with the use of statins for cholesterol control called rhabdomyositis. Other medications include steroids, anti-virals, amiodarone, colchicines, Omeprazole, etc.

  e—Myasthenia Gravis

  This is a rare type of autoimmune muscle disease that affects muscle intermittently occurring in all races, genders, and at any age (20/10,000 people). Voluntary muscles are innervated through receptors in muscles that are stimulated by acetylcholine, which gets it orders from nerves. Myasthenia gravis patients do not have enough receptor sites per muscle because of an autoimmune response with the antibody that destroys about 80% of the receptor sites. These antibodies can be measured in the

blood of these patients. Muscle weakness occurs when the acetylcholine can’t stimulate the motor endplates.

www.myasthenia.org

  Symptoms usually start with generalized fatigue and weakness, drooping of the eyelids, facial weakness, double vision, trouble walking up stairs, and difficulty swallowing and chewing, and shortness of breath.

  In my practice, drooping of the eyelids was a dead give-away, and these patients were sent to neurologists for a workup and consultation with an ophthalmologist. Eye drops using neostigmine will reverse the drooping and double vision.

Examination

  Muscle reflexes are slow on exam and muscle tone is low. Of course, these symptom could come from many other diseases including vascular, etc. An Electromyogram can determine muscle function. 

Blood test and diagnostic testing

  Antibodies in the blood can be tested for, and there is a test called the Tensilon test, which consists of injecting IV the chemical edrophonuim, which will improve muscle movement including the droopy eyelids, which slows the breakdown of acetylcholine.

Imaging for tumors

  Chest scans can diagnose tumors in the chest called thymoma which must be ruled out. These come from the thymus gland, which is part of the immune system similar to lymph nodes. 15-20% of patients have this tumor interferes with the immune system. These tumors may be malignant and must be biopsied and removed if malignant or large causing respiratory symptoms.

Treatment

  Surgery

    A thymectomy (removal of thymoma) may cure the patient and restabilize the immune system.

  Medications

   Mestinon and pyridostigmine are anticholinesterase medications, which slows the breakdown of acetylcholine (mentioned above), the chemical necessary to make muscles function.

   Immunosuppressive medications such as prednisone, azothiaprine, rituximab, and others work by suppressing the immune reaction on muscles.

  Severe cases may be candidates for plasmapheresis, which removes harmful antibodies from the blood plasma.

 Results of therapy

 Most patients improve with treatment. The key is getting diagnosed. Being aware of the symptoms of myasthenia is critical for physicians to diagnose. Chronic fatigue and weakness opens the need for an extensive workup.

      

2) Infectious myopathies—can occur from overlying infections in the skin especially cellulitis

3) Secondary metabolic myopathiesOther metabolic diseases can cause myopathy such as diabetes, and other diseases that interfere with the metabolic function of muscles.

4) Endocrine (metabolic) myopathies

  Endocrine organs such as the thyroid and adrenal glands can cause muscle weakness especially from thyroid disease and adrenal gland disease causing high levels of cortisone.

B. Hereditary Muscle Disorders--Myopathies

     a)  Muscular Dystrophy

  We all have a place in our hearts for the Jerry Lewis Telethons for muscular dystrophy, but most of us have not experienced anyone with the diseases. There are over 30 types of muscular dystrophy and all are based on the muscles affected, the genes affected, the age of onset, and the progression of the disease.  This is a group of muscle diseases caused by a specific gene abnormality with progressive muscle wasting, weakness, and contractures. These gene mutations interfere with proteins (dystrophins) necessary to form healthy muscles. These are skeletal muscles (as opposed to smooth muscles which surround organs). Other issues include breathing difficulty from weakness of the chest muscles and heart trouble.

Major types of muscular dystrophy

  Although there are 30 types, Duchenne’s dystrophy, is by far the most common, however, there are many other forms of muscular dystrophy including Becker’s, Myotonic, Fascioscapularhumeral, Congenital, and Limb-Girdle, which are the more common types.

  --Duchenne’s Muscular Dystrophy

  Boys are affected usually at 3-5 years of age (girls may carry the gene) and it occurs in 1 in every 3000, and the symptoms begin with falling from weakness of the lower extremities, difficulty standing up, trouble with running or jumping, a waddling gait, walking on the toes, large calf muscles, muscle pain, and learning disabilities. In infants, there will be a delay in sitting up, standing, and walking.

 

 

These children usually are wheel chair bound and develop cardiac and respiratory complications which lead to premature death.

  --Becker’s dystrophy is a milder form of Duchenne’s and progresses slower beginning in the teens or early 20s.

Other types

  --Myotonic dystrophy is the most common adult onset muscular dystrophy is characterized by an inability to relax muscles at will following contractions. It is autosomal dominant, characterized by facial muscle wasting, droopy eyelids, hollow cheeks, and frontal balding. They have muscle wasting of the hands and feet.

These patients also have cardiomyopthy, hypogonadism(atrophy of the testicles), and diabetes. 

https://img.medscapestatic.com/pi/features/slideshow-slide/myopathies/fig12.jpg?resize=500:*

 

  --Fascioscapulohumeral dystrophy starts with facial and shoulder weakness, and winging of the shoulder blade (scapula)-it sticks out when a teenager (or later age) tries to raise their arm.

  --Congenital dystrophy occurs in boys and girls and is apparent at birth or in the first 2 years of life.

  --Limb-girdle dystrophy first affects the hips and shoulders, and they have difficulty lifting the foot. It usually begins in childhood or teen years.

  --Distal muscular dystrophy affects the arms, legs, hands, and feet and affect those in their 40s to 60s.

The family history may be positive for these diseases, a history of endocrine or autoimmune diseases, kidney disease, and or alcoholism. A history of medications that can cause muscle disease (cortisone, statins, HIV drugs, alcohol, or illicit drugs  --Oculopharyngeal dystrophy starts in their 40s and affects the eyelids, face, and neck followed by swallowing difficulty.

  --Emery-Dreiffus dystrophy affects mainly boys around the age of 10 and affects their heart as well along with muscle weakness.

Workup for suspected myopathies

1. History and Physical

  The family history is usually positive for the more common types of muscular dystrophy. Age of onset, and specific areas of muscle weakness, specific disabilities, etc. are all important questions to ask.

  Exposure to chemicals (herbicides, insecticides, and pesticides), a history of anesthetics for surgery, cortisone, statins, narcotics, and certain other less commonly known medications.

  An intensive neurological examination will illicit weakness, loss of reflexes, evidence of atrophy in certain muscle groups, tests for strength and weakness.   

 

2. Blood testswith destruction of muscles enzymes are elevated and genetic testing. Creatine kinase is elevated indicating muscle cell damage.

3. Electromyogram (EMG) test muscle function using electrical impulses

4. Muscle needle biopsy can tell which type of muscular dystrophy the child has.

5. Neuromuscular exam testing for reflexes and coordination.

6. Electrocardiogram will test for heart rhythm and heart muscle function.

7. Imaging including MRI and Ultrasound

Treatment

1. Physical, Occupational, Respiratory, and Speech therapy will be needed depending on the type of muscular dystrophy.

2. Medications

  a. Anti-gene therapy

Eliplirsen(Exondys51) is used in Duchenne’s to treat specific gene mutations which will increase the protein (dystrophin), which is being destroyed by the disease. Others include Emflaza and Translarna

  b. Anticonvulsants (gabapentins) are prescribed to reduce muscle spasms.

  c. Antihypertensives can improve heart problems.

  d. Immunosuppressants to slow muscle damage.

  e. Corticosteroids to slow down muscle damage and improve breathing

  f. Creatine can help supply energy to the muscles.

  Although not mentioned, one wold wonder if growh hormone and anaboliv steroids might be helpful.

Surgery

  A muscle biopsy is commonly performed to diagnose some of these myopathies. If breathing becomes too difficult, a tracheostomy may be necessary. Heat surgery may be required rarely.

Home treatments—physical and occupational therapy, home modifications

  Parents and caregivers are an integral part of the daily routine for these patients including all the therapies needed. A variety of aids will likely be necessary including wheelchairs, crutches, electric scooters, etc.

Clinical Trials are underway world wide to suppress or edit these genes that cause these diseases.

  The Muscular Dystrophy Association has many support groups and assistance with these patients and families. Donations through this agency have allowed for major research to be funded to find cures. Many advances have come from the generosity of our citizens, industry, and governmental support.

MDA, WebMD, Mayo Clinic

Contact Muscular Dystrophy Foundation for more information

   www.mda.org

Summation for musculoskeletal diseases-myopathy

  As usual, the underlying disease must be addressed.  Testing may include several of those under hereditary myopathies. A muscle biopsy is usually performed. Stopping the medications thought to be causal is very important.

  If autoimmune in cause, the biologic medications such as Embrel, methotrexate, chloroquine, azathioprine, high dose gamma globulin, and recently retuximab has been encouraging.

  Often avoidance of the sun is necessary especially with dermatomyositis. Physical therapy is necessary for strengthening and range of motion of joints.

WebMD, emedicine.net, Cleveland Clinic, www.rheumatology.org

  

This completes the June, 2019 report. Next month the July report will include:

1) TMJ-Temporomandibular Joint Syndrome

2) VTE-embolism from the lower leg veins

3) Essential tremors

4) Cholesterol Management update

5) High risk pregnancy

6) Breast cancer screening guidelines can be confusing

Stay Healthy and Well, my friends, Dr. Sam