The Medical News Report

October, 2020,

# 105

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

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Subjects for October:

1. Updates for COVID-19/Influenza

    --time for a flu shot!

2.  Prostate updates—

    A. Low grade Prostate cancer-watch or treat? New options

    B. New procedures for BPH (enlarged prostates) are better than TURP including the Urolift procedure

3. Sepsis (bugs in the blood)in COVID-19 and bacterial infections

4. More information on how pain works in the brain; how it differs in people

5. Primary Dysmenorrhea—Painful menstruation

6. Life expectation rises for the first time in 4 years

7. Are Generic drugs safe? Not necessarily!

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

Prayers for Supreme Court Justice Ruth Bader Ginsburg’s family, friends, and supporters. She was little in stature, but a giant in her influence over several decades regarding key issues that framed our country especially for women. Cancer tried to kill her several times, but with her fighting spirit (and great doctors), she overcame some of the toughest cancers around until the very end. She exemplifies what it means to be a fighter.

1. Updates on COVID-19/Influenza

  We are 10 months into this pandemic, and are still learning about this virus, its effect, our immune response to infection, the length of immunity, and treatments. In record time, the U.S. will have a vaccine realistically by the end of the year. It will take months to get everyone vaccinated for those willing, so we will have the entire flu season to contend with plus the pandemic. Time for get a flu shot!

  Hot spots are diminishing, people are trying to better contend with using protection, however, we have got a long way to go, and we must safely continue to reopen, as America’s family need their paychecks.

  For those at higher risk, extra precautions are necessary for the foreseeable future. Studies on prevention of respiratory infections using masks continues to be very sparce. Larger studies are needed to further prove their value.  Wearing a mask provides, in many cases, false security, according to an article in the Annals of Internal Medicine, June 24, 2020. However, if people feel more secure, It is their right.

  The CDC has sent out mixed messages several times which creates doubt on who is making the decisions about precautions, etc. Just a week ago, they stated that the virus can now spread by aerosol, and 6 feet may not be enough to protect. In just 3 days, they retracted the statement. We all must use common sense, and depending on who people listen to, they must be allowed to practice safety and respect each other, since obviously, we are not all following the same playbook. Sadly, the best we have is to wear a mask if we can’t socially distance, wash our hands frequently (20 seconds), and clean surfaces.

  For those who are still isolating, that is your decision. All of us have had to make personal decisions about how much risk we want to take. If an individual has respiratory symptoms, they must isolate until they are diagnosed. No exception!!

  Wear a mask around people and follow local rules as it is respectful and easy to follow. Some day hopefully soon we will have solid statistics on the actual value of masks.

  We have the greatest country in the world…..lets take care of it. Vote!   

   A. Time for a flu shot

  It is time for a flu shot. Do not procrastinate. Go to your pharmacy and get a shot, unless your doctor feels there is a medical reason not to.

  What is at stake is protecting an individual from influenza, or at least making the flu much less severe, depending on how well a person responds to the immune challenge of the vaccine. Older people do not create as strong an immune response as younger people, and that is why there is a stronger vaccine for people over 60.

  The symptoms of the shot could cause mild aching, fatigue, and even a low grade fever. THIS IS NOT THE FLU! THIS IS A REACTION TO THE INGREDIENTS IN THE SHOT. IF YOU ARE ALLERGIC TO EGGS, DISCUSS A SPECIAL TYPE OF NON-EGG VACCINE (THE VIRUS IS GROWN NORMALLY IN EGGS), CALLED RECOMBINANT FLU VACCINE (BRAND NAME FLUBLOCK).

Xofluza, an anti-viral has been reported to prevent the flu if taken in the first 1-2 days of symptoms. This compares to Tamiflu. A single dose was just as effective as 5 days of drug in this study. It further reduces transmission in flu cases. However, it is emphasized that flu shots are still very necessary to prevent flu. NEJM, July 23, 2020

   B. Statistics on COVID-19

  A new report has stated that less than 10% of the U.S. population has been infected, but with all the asymptomatic cases going undiagnosed, there is an estimated 10X that number. 6.7 million are confirmed with 200,000 deaths, the majority from nursing homes and those over 60 with underlying medical issues. Younger people with underlying diseases are at higher risk too. Over 50% of new cases are between 18-24. 

  The entire U.S. has had just under 50,000 new cases in the last month, quite a drop, and just under 1000 deaths. Lets hope the stats will continue to drop.

  According to Heritage Research Foundation, the spread of COVID-19 has been concentrated in a small number of counties in the U.S. and in just a few states. As of September 15, the 30 counties with the most COVID-19 deaths accounted for 26% of all the cases in the U.S. and 40% of all deaths, much greater than those couinties share of the population (18.4%). That is, just 1% of the counties in the U.S. representing over 18% of the population, are responsible for almost half of the deaths.

  Kings County and Queen’s County had over 14,500 deaths, the most in the country, followed by Los Angeles County, California (6400) and Cook County, Illinois (5100). The other top 50 counties with the most deaths were in Arizona, Florida, Texas, New Jersey, Connecticut, Massachusetts, and Pennsylvania.

  26.7% of U. S. counties have had 1 or fewer deaths in the U.S.   www.heritage.org

   C. Betadine swab in the nose kills COVID-19

  A study in JAMA-Otolaryngolgy Journal, September 17, 2020, reported that a 15 second swabbing of the nasal membranes with an experimental betadine solution (povidine-iodine) could inactivate COVID-19 as low as 0.5% in concentration. The authors caution store purchased betadine used on the skin may be toxic, and it will be sometime before this preventative treatment is FDA approved. Do not use betadine skin preparations in the nose. It should not be used in pregnant women, those with thyroid disease (the iodine), or those undergoing radioisotope cancer treatments for cancer.

  The study measured cell cultures of virus to determine their findings.

  Use in ENT surgery patients up to 7 weeks daily showed no toxic effects. This was a specially prepared bovine iodine solution.

  The article pointed out that the treatment could possibly diminish the severity of disease, limit spread to others, and diminish the amount of viral load to the lungs.

  This simple treatment would be a game changer when available. Saline nasal sprays also are still considered of some value in cleansing the nasal lining of viruses.

   D. More information on transmission of COVID-19

  South Korea analyzed 60,000 contacts that had pediatric age children. 6000 were confirmed cases during a 2 month period. The findings of this study found:

a) 12% of household contacts developed COVID-19.

b) 2% of non-household contacts developed the virus known to be in contact with these children.

c) 19% of household contacts 10-19 years of age developed COVID-19 compared to 5% younger than 10 years of age.

d) The detection rate was much lower among non-household contacts in all age groups.

  Clearly, COVID-19 continues to infect households more than any other venue. But, it does make a case for older children (10-19 years of age) transmitting the virus to family members since most of these older children and teenagers are asymptomatic. The study did not address how many adults infected their children. Younger children 9 years or younger are much less likely to bring home the virus from school or friends.

  This has been the case in other studies….older children can transmit the virus as often as young adults. NEJM Pediatrics, August 15, 2020

  In an Iceland study, 26% of quarantined households became infected, and outside the home, 5% became infected from these people.

  They stated that household members are 5X more likely to become infected from a member of that group even with quarantine. 0.9% of the country became infected (small country and everyone was tested) with 0.3% death rate (better than ours at 0.6%).

NEJM, September 1, 2020

  E. How many return the Emergency Department after initial visit?

  1 in 12 patients who were initially sent home from the ER returned within 72 hours. Of those patients, 5% were admitted. Most were over 60 years of age with underlying diseases and most had fever, evidence of pneumonia, and low blood oxygen levels. Academy of Emergency Room Medicine, August 27, 2020

  F. More on length of immunity

  Iceland and other countries have reported on the length of immunity, and about 4 months after discharge is the usual time for full immunity. We are still waitng to see how fast the antibodies in the blood drop, and how low it can go and still have immunity to reinfection, if any.

  G. Follow up on Saliva rapid testing for COVID-19

  I recently announced that saliva testing was found to be as valuable at nasopharyngeal swabs, and in a follow up it was found to be positive (81%) compared to the swabs (71%). This was tested 1-5 days after diagnosis. This means both have somewhat similar sensitivities for the test to be positive, however, not as many as 30% of these tests were negative when, in fact, the patients was diagnosed with COVID-19. 

  The authors of this study (from Yale Medical Center) in the New England Journal of Medicine note that even in the same patients, multiple tests may vary in being positive and negative. They also noted less variation in saliva tests than the nose swabs.

  Recent research has proven that saliva tests can be positive in asymptomatic individuals (later confirmed by nose swab testing).

  The clear advantage of the saliva test is self-administration and prevents contact with healthcare workers, no swabs, or protective gear.

  H. Stricter guidance on release of COVID-19 vaccine

  The FDA plans to recommend stricter guidance before the vaccine can be released with emergency authorization. They are recommending a 2 month waiting period from the time the trial administered the last dose of the 2 dose vaccine to see if there are any significant side effects that might occur.

  Johnson and Johnson has a phase 3 trial of a one dose vaccine, the only one with no booster.

 NEJM Journal Watch, September 23, 2020  

2. Prostate Updates

  A. New options-Low grade Prostate cancer—watch or treat?

  60% of men who are age 60 have cancer cells in their prostate, and 70% at age 70. Not all of these cancer cells become aggressive and require treatment. This is why the PSA is still being questioned as a screening test.

  I have discussed prostate cancer at length in previous reports, so click on my website and search under the SUBJECT INDEX on the home page.

  For those who are not aware of it, cancer can be very aggressive or actually slow growing (low grade). Pathologists grade prostate cancers using the Gleason score and PSA levels.  Many factors, however, must be considered when treating (or observing) prostate cancer.

  Most of the aggressive prostate cancers have a Gleason score of 6-8, while those with a score of 2-3 would be considered less aggressive, less likely to metastasize, and grow very slowly. Depending on a man’s age, over the past 10 years, it has become quite common for men and doctors to watch these cancers rather than proceed to surgery or radiation if the cancer is limited to the gland and not invading or very close to the capsule.

  Not every cancer doctor will agree when it comes to who should consider surveillance or have definitive treatment. Second and even third opinions are recommended before making a final decision.

  10 years ago 94% of men were opting for a radical prostatectomy with or without nerve sparing using robotic surgery or radiation (proton or photon) regardless of Gleason score, however, today, there is a growing number (30-50%) of patients with low grade cancer opting for surveillance. 90% of Swedish patients choose surveillance.

Surveillance findings (clinical observation)

  More than 40,000 Americans are diagnosed with low risk prostate cancer and choose surveillance (observation), while a similar number choose definitive treatment.

  Of those who play the waiting game, 1/3 opt out due to anxiety and worry about having an untreated cancer. Another 1/3 show progression of the cancer, requiring treatment, and the other 1/3 do not choose treatment, live out their lives, and die of some other disease preventing the consequences of surgery and or radiation (incontinence, impotence, scarring, etc.).

  One advantage of waiting to have treatment (if necessary) or continue surveillance, is the development of new techniques to treat low risk cancers.

New Techniques for treating localized prostate cancer

Multiple radiation options are increasing

  Because there are so many localized prostate cancers diagnosed with treatment options for radiation, there continues to be several options using external beam radiation and internal radiation. Lets face it, it is big business.

  There is no one best technique for localized cancers according to a host of cancer centers. Proton RT is 4-5 times more expensive and has no better survival rates than other options. There continues to be the debate about it causing fewer side effects.

  An even newer form of RT is stereotaxic body radiation (Cyberknife) which is less costly than all other choices and a large amount of radiation can be given over just a few days, so the recovery can begin earlier, but still has the usual side effects for some patients as the other techniques (urinary incontinence, rectal leakage, erectile dysfunction). These side effects can last for months or can be permanent depending on many factors.

  Clearly, more opinions should be sought before deciding, including surveillance for older patients. Surgery, RT, etc. all must be discussed based on age, sexual function, underlying medical issues, etc.

Provenge for surveillance patients

  Another technology being considered in surveillance patients is to utilize immunotherapy--sipuleucel-T (Provenge). This agent has been FDA approved for advanced prostate cancer.Provenge works by programming the immune system to seek out the cancer cells and destroy them. 30,000 men have received this therapy for advanced cancer, and now there is a ongoing study to use in 450 surveillance patients (Provent study) to find out if this biologic agent can kill these low risk cancers. Two previous studies have been very encouraging. Unfortunately, it costs $130,000 for 3 infusions.

  Provenge might be a good answer for those who have anxiety and extreme worry about having cancer, who might opt for surgical or radiation treatment. This could be an alternative.

  With new technologies always on the way, not only is this going to potentially prevent unnecessary treatment and the dreaded complications of these therapies.

  Treating these cancers with these new medications may be a real option in the near future and may also help keep these cancers under control, preventing aggressive standard treatment, allowing the natural aging process with deaths due to other causes.   

Reference: Medpage Today

  B. New procedures for BPH—benign prostate enlargement

The above drawing compares a normal prostate surrounding the prostatic urethra, whereas an enlarged prostate crowds the bladder and compresses the urethra.

  The prostate increases in size by 40% in a men in their 50s, and 80% in their 70s.

  25-50% of men do not stay on medications* because of side effects (erectile dysfunction, ejaculatory dysfunction, fatigue, weakness, and dizziness). While over 25% stop their medication by 1 year, only 3% choose some type of surgical intervention.

*medications include 3 classes of drugs for BPH—

  a--Alpha blockers (Flomax, Uroxatral, Cardura, Rapaflo and Hytrin). They relax certsin muscles making it easier to urinate. They do lower blood pressure, a side effect. Alpha blockers do not slow the growth of the prostate.

  b—5-alpha reductase inhibitors, which interfere with hormones that promote the growth of the prostate (Proscar, Avodart, Jalyn). Sexual side effects and retrograde ejaculation (ejaculate goes into the bladder during orgasm) are common.

  c—Phosphodiesterase-5 (PDE-5) is a erection dysfunction (ED) medication, Cialis, similar to Viagra. This is taken daily for ED but also helps BPH. Unfortunately, insurance does not cover it. It has the same side effects as Viagra, but does help the symptoms of BPH.

Surgical procedures for BPH—classic-TURP

  The classic TURP (transuretheral prostatectomy) is the standard of care for more significant prostatic obstruction, although it requires hospitalization, wearing a catheter for a few days, bleeding, and weeks of recovery.

The TURP (transurethral resection) is performed with a resectoscope with an electrode (essentially an electrical cutting knife) capable of taking slices of the obstructing prostatic tissue. These small pieces are flushed into the bladder and urinated out postop. This has been the preferred procedure for those with major obstruction. 5-7% resurgery rates are quoted.

  Recent improvements in relieving bladder obstruction from an enlarged prostate may be able to provide less aggressive and quicker healing procedures than the classic TURP-trans-urethral-resection of the prostate. Although minimally invasive, the postop course is not much better.

Minimally invasive procedures

  These procedure use lasers to burn, heat , or vaporize prostate tissue blocking the urethra. Even microwaves are used in one procedure. Another innovation is the Urolift procedure described below.

  Although these more minor procedures may be outpatient, getting well may take considerable time for the treated tissue to slough out and heal. They also are not as successful as TURP. Second opinions are recommended.

  Below is an actual photo of a laser enucleation of prostatic tissue.

Note the difference in the right drawing between the classic TURP and enucleation

  There is a new Protouch laser procedure (ProLEP) stated to be more effective than the holmium laser procedure. It is a more precise alternative to the TURP using a laser to enucleate the tissue. The PVP procedure uses a laser to perform photoselective vaporization of the obstructing prostate tissue.

  Another procedure is the TUMP (transurethral microwave therapy) which heats the tissue and kills specific amounts of tissue, which has to slough over time to accomplish the results.

  Analysis of 14,000 men (average age 68) compared the classic procedure to different types of laser procedures now commercially available. Some of the procedures enucleate the prostatic tissues around the urethra in pieces. The urologist breaks it up in pieces and shoves the prostatic tissue into the bladder and then is removed piecemeal. Other procedures involve vaporization or enucleation of prostate tissue using various laser technology. There are actually 8 different new procedures. 

  These procedures are touted to be much easier, outpatient, with fewer patients needing catheters, less bleeding, but the area still has to heal and that means several weeks for the area to function properly. All these procedures need to be compared based on a urologist’s experience.

  There is also greater improvement in peak urinary flow and prostatic symptoms after these newer procedures. Symptoms could include a paradoxical hyperactive bladder after relief of the obstruction, continued needing to get up at night, etc. Medications may still need to taken.

  The amount of the obstruction may be a factor in the urologist’s choice of procedures. Regardless, if symptoms are progressing, it is imperative that a man seek consultation….do not procrastinate men!!

  Seeing a urologist should include discussion regarding standard and newer outpatient procedures. Ask about  their expertise and experience in performing these newer prostatic removal procedures. Also the characteristics of a patient’s obstruction will determine the best procedure, so keep that in mind when discussing options and get a second opinion now that the options have expanded.

  The new laser enucleation techniques may be superior. Yet, these minimally invasive procedures require reoperation more frequently (as high as 30-40%) whereas the TURP has 5-7% reoperation.

  BMJ, Nov. 14, 2020

Prostatic Urethral Lift procedure—Urolift procedure

To visualize this procedure, one must appreciate that the prostate gland lateral lobes surrounds the urethra, and as the prostate enlarges with age, it obstructs the flow of urine. Using 4 clip implants pulls the lateral lobes of prostate tissue away from the urethra so that urine flows more easily.

  This is a newer procedure, therefore, a discussion with a urologist trained to perform this procedure is necessary, but also other options described above. I have reviewed a quality report from the Canadian Urological Journal, analyzing 5 year experience in 19 centers, many in the U.S.

  Analysis at 3 months postop (the only time more implants can be added), 88% reported greater improvement compared to a sham operation (note they are not comparing to TURP or other minimally invasive procedures) 2 weeks usually is required for urinary symptoms to resolve (burning, pain on urination, pelvic discomfort, and urgency).

  Only 20% required wearing a catheter for 24 hours, as this procedure does not cause the swelling the other procedures do. No new sexual dysfunction was reported.

  Surgical retreatment occurred in 14% with no sexual dysfunction over the 5 years.  

  The amount of obstruction will determine whether a minor procedure or a more traditional surgical removal of prostatic tissue is necessary.

  There is a 13.6% failure rate over 5 years. All procedures have a failure rate, because the prostate continues to enlarge with age. Even the TURP has some significant failure.

  If a person is satisfied with medication, clearly stay with the medications, because all these procedures have complications, and that should be part of any discussion when surgery is recommended.

  If the bladder dilates because of extended urinary obstruction, this will force surgery to prevent permanent damage.

  As high as 10-22% of operated patients restart medications.

  Getting up at night disturbs the sleep cycle and will interfere with daytime alertness, certainly would aggravate sleep apnea, and decrease quality of life. Men are much less likely to proceed with surgical intervention, but perhaps, the Urolift procedure may encourage men to at least seek consultation for BPH.

  I do have one concern…if cancer develops later, those implants would have to be removed if radiation was requested. That is a question for the urologist.

3. Sepsis and septicemia (infection in the blood)

The above drawing depicts bacteria circulating in the blood

  When infection gets into the blood, this is a very serious medical issue and potentially deadly. Most patients dying of COVID-19 had sepsis at the time of death. Bacteria (and other microbes) frequently travel through the blood from areas such as the gums (periodontitis), infections in the urinary and gastrointestinal tract, etc., but when the magnitude of the bugs becomes significant, the reaction of the body is extreme, usually bacteria.

  Sepsis is the reaction to septicemia, which is defined as infection in the blood stream. The reaction is an immunologic response that results in organ dysfunction and failure. This is what happens with COVID-19, an obvious viral causation.

  In numerous studies, the average age was 64, and they all had one underlying medical disease, and 90% had a community onset sepsis, defined as onset of the sepsis occurring within 3 days of hospitalization. The actual bacteria causing the sepsis was identified with blood cultures in over half of the cases. 40% died within 5 days of sepsis onset. Patients with a history of cirrhosis of the liver, immunocompromise, or vascular disease had an even higher death rate. JAMA Network, July 17,2020

  There is an actual assessment instrument for physicians to make the diagnosis at the bedside. (Sequential Organ Failure Assessment-qSOFA). A score is calculated based on certain metabolic activities including a respiratory rate of greater than 22/minute, a systolic blood pressure of less than 100mm/Hg., and altered consciousness. Severe sepsis can be defined as septicemia with organ failure.

  Septic shock occurs as the organs begin to fail and the blood pressure drops to dangerously low levels. Sepsis with organ failure is an end stage event, and must be reversed or death will occur. This occurs in COVID-19. Causes other than infection can cause shock and must be considered, such as salicylate poisoning (aspirin), amphetamine overdoses, or adrenal organ hemorrhage.

  Sepsis can occur from infectious and non-infectious sources. The most common infectious sources come from the gastrointestinal and urinary tracts. There can be an unrecognized source (i.e. pancreatitis, severe trauma) which causes respiratory failure (ARDS), thought to be the reason for the lung inflammation in COVID-19, however, it became obvious there was a difference in this viral infection, and changed the approach to COVID-19 patients in acute respiratory distress.

  The immunological response to sepsis comes from the T-cell lymphocytes which stimulate the release of proinflammatory markers such as cytokines, bradykinin, interleukins, etc. This is the same mechanism in COVID-19.

  Tests can be performed as follows: respiratory tract—low arterial oxygen levels (pAO2), blood—platelet count (low) and clotting studies (high), liver—serum bilirubin, kidney—serum creatinine (elevated) and low urine output, brain—consciousness score, and heart—low blood pressure requiring meds to raise the pressure. 

Causes and risk factors 

  Gastrointestinal causes include perforation of the bowel or pelvic organ. Meningitis, head and neck infection or abscess, kidney infection, pneumonia, cirrhosis, prostatitis, severe skin infection, bone infection (osteomyelitis), IV lines, bladder catheters, and other drains placed into the body (i.e postoperative surgical drains). Bed sores (decubitus ulcers) can also cause sepsis.

  Any person who is immunosupressed, pregnant, the very young and elderly, postoperative patients, diabetics, and any medical condition that worsens are at higher risk.

  Sepsis can be fatal in 25-40%. According to reports, as many as 40% of patients are re-hospitalized within 90 days, most commonly from recurrent infections.

Workup

  These patients are sick and need to be admitted to the hospital, most likely the ICU. Monitors of the heart rhythm respiratory rate, blood pressure, and temperature is vital, as these vital signs could change quickly.

  Laboratory tests include the CBC--complete blood count including platelet count, hemoglobin, hematocrit, white blood count and differential (types of white blood cells), chemistry tests to evaluate the vital organ functions, cultures of the blood, urine, and any obvious source of infection or abscess. There are certain biomarkers that may be abnormal in sepsis including procalcitonin* and presepsin, an immunologic biomarker used to diagnose early sepsis and prognosis.

*procalcitonin is a precursor protein for calcitonin, which made by the thyroid and is involved with regulation of calcium. It is elevated in infections, non-infectious inflammatory responses, sepsis, any major infection, and medullary thyroid carcinoma.

  Imaging tests can be critical to find the source of infection or other causes of suspected sepsis. Chest-X-ray, CTs of the chest and abdomen, ultrasounds of the bile duct, brain studies (MRI, spinal tap, etc.). EKG, cardiac enzymes, echocardiogram, and removal of any bodily fluid that might appear abnormally for study (i.e. fluid on the lung, ascites-fluid in the abdomen, and drainage of any abscess.

Abdominal wall abscess

The above scan shows an adominal wall abscess coming from a rupture in the intestine. The abscess is walled off and the actual connection can’t be seen.

Treatment 

  Historically, there are certain bacteria that are suspected of causing septicemia. Resistant Staphylococcal aureus (MRSA) and other gram* positive bacteria. Gram negative bacteria such as pseudomonas, E.coli, and others must be covered with braod spectrum antibiotics. Depending on the organ suspected will give the treating physician a clue of what bacteria must be covered with antibiotics.

  The cephalosporins and quinolones are common groups of antibiotics used.

  Surgical intervention is commonly necessary. In my practice, deep space abscesses froma dental cause or foreign body required opening of these spaces located in the deep spaces of the neck.

Complications from sepsis (post-intensive care syndrome)

  These patients get reinfected 40% of the time with re-infection and must be monitored carefully for months with close surveillance with tele-health and the like. Similar psychological, cognitive, and physical effects are prolonged in these patients similar to those with severe COVID-19.

  Many of these patients may require skilled nursing facilities, and with the pandemic, many families are reluctant to allow it out of fear of COVID-19 infection in these facilities (much safer today).

4. More information on how pain works in the brain; how it differs in people

We must learn from the past!

  Pain creates issues in not only our body but our minds. There is nothing that dominates our lives like when we are in pain. Trying to understand how pain is processed and perceived varies in people. This makes treatment extremely difficult and has lead to millions of abusers and addicts of opioids.

The pain cycle

  Pain rests in nerves called nociceptors. These nerves connect the entire body to the nerves just outside of the spinal cord. These nerves can sense painful stimuli and send signals to the spinal cord (ascending neural pathways) to the brain and neural cortex. The pain is perceived and stimulates neural impulses to the brain (hypothalamus) to secrete powerful opioid-like chemicals called endorphins and other natural opioids which inhibit these ascending pain pathways.

                  Pain pathway—nociceptive nerves

With blocking of these pain signals and the release of these chemicals allows relieve of the perception of pain, relieving inflammatory chemicals involved with pain perception. With these chemical releases comes a heightened state of sensibilities and a feeling of euphoria from no longer perceiving pain.

  The neurological mechanisms vary greatly in people and can be made more or less effective by repeated painful stimuli, and as pain is recurrent, the perception of pain can occur even when the stimuli are minimal.

  This concept lead to term central sensitization syndrome. I discussed this in some detail when discussing several syndromes that are affected by this mechanism, especially fibromyalgia, neuropathic pain and several forms of neuropathy caused by chemotherapy, diabetes, and other immune diseases, IBS (irritable bowel syndrome).

Click on www.themedicalnewsreport.com/84

This syndrome includes millions of people. 40% of those on chemotherapy experience some form of neuropathy. These chemicals change the sensitivity of the neurological pain pathways, and of are permanent.

Emotions and Pain

  The emotional states of people are greatly affected by pain and the perception of pain. What makes these issues so difficult is that there is no single pain center in the brain. Also with repeated pain stimuli, the links to cognition, memory of pain, and decision making become more indelible. It is well known that fear, anxiety, and sadness can make pain feel worse. Sadness can activate several brain regions, one of which is increasing perception of pain.

  There are people who do not perceive pain. They have 2 genetic mutations (FAAH) that reduce the breakdown of neurotransmitters called anadamides, which relieves pain. Interestingly, this lipid is involved in pathways for pain relief from cannabis.

  Another mutated gene was found in the children (mutation SCN9A) of a firewalker, who did not feel pain when walking through fires. The normal gene makes a protein (Navi7) that is instrumental in the transmission of pain messages from nociceptive neurons of the spinal cord. With the mutated gene SCN9A, this transmission is blocked preventing the sensation of pain in these people.

  There is an opposite story. There are people who have excess the Navi7 protein that increases transmission of pain and is found in rare syndromes that are inherited erythromylgia (man-on-fire) syndrome.

Key research on findng pain relievers that do not cause euphoria

  Research by pharmaceutical companies is ongoing to find a medication to help people with pain by blocking the Navi7 protein which would not have addictive symptoms and still relieve pain.

How opioids work

  Opioids work by binding to a protein on the surface of nerve cells called mu-opioid receptors that communicate with proteins inside the cell causing a feeling of pleasure and relieves pain.

  With abuse of opioids, the need for higher doses is necessary to accomplish the same effect on nerve cells to keep the euphoria going and thus addiction occurs. New non-addictive medications must bypass this process.

  Other research is ongoing with deep brain stimulation to relieve pain. Basic research has long understood that constant exposure to pain stimuli conditions the patient to over-respond to the least painful stimulus. Even anticipation of pain can create the same response.

  Deep brain stimulation is being used to allow patients to distinguish pain from non-painful stimuli, which can improve their quality of life.

  Even virtual reality is now being studied to increase a person’s pain threshold diverting attention to pleasurable experiences. Meditation and other techniques are valuable in the same way.

Information on this neurological pain research came from the January, 2020 edition of National Geographic on the future of medicine. I highly recommend the reader read it.

5. Primary Dysmenorrhea—painful menstruation

  Painful menstruation is a plague for women. Not only do they have to endure monthly periods, pain and other symptoms make it even more intolerable. No wonder they call it the scourge. But without monthly periods, there would be no cycle to create fertility.  

  Menstrual pain is the most common reason for a visit to the gynecologist, affecting 50-90% of women. This is called primary dysmenorrhea, whereas secondary dysmenorrhea is defined by painful bleeding due to an underlying pathological pelvic process including fibroids, endometriosis, adenomyosis, and congenital anatomic abnormalities.

  These abnormalities must be ruled out with a workup for dysmenorrhea.

From the National Institutes of Health

  Primary dysmenorrhea usually begins in adolescence after ovulatory cycles begin. The pain occurs from the release of the prostaglandins. Higher levels of this hormone can be found in the uterine menstrual sheddings during a period. Prostaglandins cause excessive contractions of the uterus resulting in associated symptoms of diarrhea and nausea, and fatigue. This usually occurs 6-24 months after periods begin.

  A few months ago I reported on the incidence of loss of productivity due to these monthly symptoms with it being the most common reason for absence from school or work (1 in 8 girls 14-20). So many women do not seek treatment because of the perception that it is a normal part of menstruation.

  The history should include age of menarche (periods beginning), intervals between periods, length of period, amount of bleeding, and a history of associated symptoms. The character of the pain duration is important, and when it stops also will give hints regarding the underlying cause.

  Pelvic pain that begins at the onset of a period and on one side the abdomen usually implies some form of congenital abnormality and requires immediate attention.

  The symptoms are the same each month in primary dysmenorrhea and does not progress. If the symptoms worsen, endometriosis should be suspected or other underlying causes.

  If missed periods occurs with pain, abnormal uterine bleeding, infertility, and a history of kidney abnormalities suggests a secondary cause.

  The pelvic exam should be performed during the period. Evidence of an enlarged uterus, deviation of the cervix, a palpable pelvic mass, nodules of the uterine ligaments, and infections with discharge should be looked for.

  Transvaginal ultrasound is the diagnostic procedure of choice (trans-abdominal ultrasound in non-sexual or very young individuals). Most anantomic abnormalities will be seen with this procedure although endometriosis may show no pathology. 

Treatment

  NSAIDs* should be tried and hormonal contraceptives, vaginal rings with hormones, transdermal patches, long acting contraceptives (estrogen rods). Heat, thiamine, magnesium, and Vitamin E are alternative meds.

  *non-steroidal anti-inflmmatory drugs (Aleve, Ibuprofen, etc.) One class of NSAIDs is the Cox-2 inhibitors and are especially helpful (Vioxx, Bextra, Celebrex).

  NSAIDs block prostaglandins by blocking the enzyme, cyclo-oxygenase, which mediates the production of this substance. They are effective in 70% of cases according to the NIH.

Treatment should be encouraged for 3-6 months and then re-evaluation is indicated. If initial treatment fails, the authors of this article stated that 70% of adolescents will be diagnosed with endometriosis.

JAMA-Women’s Health Dec. 19, 2019

6. Life expectancy rises for the first time in 4 years

  Life expectancy has been dropping in the last few years until 2017. The overall life expectancy in that year rose to 78.7 years (an increase of 0.1 years). For men-76.2 years and women-81.2 years. Women live 5 years longer than men and has remained the same dfference for years.

  The age adjusted death rate fell by 1.1%.

  As mentioned in the February, 2020 report, the main factors in the improved life expectancy in the U.S. are decrease in mortality in heart disease, cancer, chronic lung disease (COPD, asthma), and unintentional injuries.

  The age adjusted death rate from drug overdoses fell by 4.6% from opioids, while fentanyl deaths rose 10% (source comes from China).

  The infant mortality dropped by 2.3%.

  These statistics were reported by the CDC citing a little under 2.9 million deaths in 2018. Of course, COVID-19 has added over 200,000 deaths to the statistics.

  The 10 leading causes of death in the U.S. have remained the same (heart disease, cancer, unintentional injuries, chronic lung disease, stroke, Alzheimer’s, diabetes, influenza and pneumonia, kidney, and suicide). COVID-19 will be in the top 10 when it is added.

CDC’s National Center for Health Statistics for 2018

7. Are generic drugs safe? Not necessarily! 

  After watching a podcast on Medpage Today, an internet journal, I was more than a little bit concerned about the safety of our generic drugs. This podcast was run by the editor–in-chief of Medpage Today, Marty Makary, M.D., MPH, a well known and well respected physician. The guest was Katherine Eban, author of “Bottle of Lies-The Inside Story of the Generic Drug Boom”. I plan on reading her book, a New York Time Bestseller. She is a former NY Times journalist now working for Fortune magazine.

  Ms. Eban is an investigative journalist writing about the fraud, deceit by foreign country manufacturers, and the lack of adequate regulation by the FDA. It is extremely disturbing but not surprising.

  The FDA by law must make sure these generic drugs are safe and free of contaminants no matter where they are manufactured. They make scheduled site visits to these pharmaceutical plants mostly in third world countries. They schedule these visits in advance, so the company knows when they are coming and can clean up their facilities, and show off their best face.

  When they made site visits unannounced, in some cases, they were somewhat aghast at the condition of some facilities. The filth, lack of quality control was very telling in certain cases. The participants in this podcast stated that we were in an anti-regulatory era and the federal government needed to change their ways. The lack of repercussions is telling.  

  Rather than just accepting printouts of drug tests, some inspectors have gone into their computers and found metadata they excluded. An example are failed tests of their drug that were hidden from the inspector. In many cases, this data was destroyed. 

  An inspector in China who did inspections for 4 years found that 4/5 of the drugs had fraudulent data regarding the drug’s actual similarity to the brand drug. Where are the sanctions from the FDA?

  90% of drugs prescribed are generics, therefore, this industry must have even more vigilance in providing biologically the same drug in dose without contaminants, processed in a sterile environment. It is the responsibility of our government to assure the public, the U.S. pharmacies, and the doctors prescribing these generics that the product is processed with the same quality issues as they are in the U.S.

  The FDA does not do tests on drugs. They rely on manufacturers, and Big Pharma to submit quality and safety profile data. That is the problem!!! They rely on an honor system!!! With foreign countries???

  In many cases, the country of origin is not on the label of these drugs. Visits to evaluate these plants need to be without warning. We need more inspectors.

  Also these inspectors are treated like kings when they visit with all sorts of perks and incentives. That is wrong! These doctors on the podcast stated that our inspectors are not trained to inspect these plants. Why not?

  Lipitor, a statin for high cholesterol, was singled out as one of the drugs that was found to have substandard conditions in their plants.

  They witnessed fist fights from the different pharmaceutical reps who were trying to get their drugs approved first. It apparently was “first come first serve and first to file” regarding which company was approved first in submitting their application to the FDA. The first to file an application gets 6 month’s exclusivity in the marketplace with the sale of that generic.

  That exclusivity with Lipitor from a company in India was worth $600 million. The company, Ranbaxy, later was cited for several violations.

  It was stated that several congressmen who were getting big donations from Big Pharma, did not want to fund the FDA to carry out surprise inspections. OMG!

  As of this podcast, there has been no funds available to the inspectors to carry out surprise inspections.

  CBS’60 minutes had a piece about the generic drug companies colluding on their prices.

  The Cleveland Clinic has apparently created a black list of pharmaceutical generic companies they will not deal with. Why only them?

  There was an example of a drug for transplant patients (tacrolimus-an immunosuppressant) which was found to be inferior to the brand name at Loma Linda Medical Center in California.

  There are named whistleblowers who have come forward with accusations of fraud and misconduct, but not much has been done. It is death sentence for them in countries like India.

  It is pretty apparent why generic companies are making so much money outside the U.S. Their standards are inferior and we are consuming them! 

  Why aren’t generic drugs being manufactured in the U.S.? Simple….cost!! To keep the cost down, they must cut corners. But are the American people willing to consume generic drugs from other countries when the FDA is not performing  due diligence on these companies? This must be brought to the attention of our politicians….except they are the ones who are getting huge sums of money from Big Pharma. This is, in my mind, is a tragedy and must be investigated and solved. We deserve safe and effective generic drugs.

  Thre current administration is working on the cost of drugs currently, but it is not known if this issue has been included. It certainly screams for the need for generic drugs to be manufactured in our country.

  Keep in mind, this was a podcast presented through very reputable sources, but did not include any conversations with the FDA. Some investigative reporters must dig into this potential stye on the drug industry and our confidence in using generic drugs, which make up 90% of the medications prescribed today.  

This completes the October, 2020 report!

The November, 2020 subjects will be:

1. Updates on COVID-19/Flu

2.Medical marijuana; legalizing pot; cure for cancer??

3. Primary care medical practices

4. Anemia—iron deficiency, pernicious anemia

5. Advertising  and Medical Go-Fund-me accounts and

    Financing of snke oil treatments    

    Treatments,

6. 50% of Americans will be obese by 2030

STAY HEALTHY, SAFE, AND WELL, Dr. Sam