The Medical News Report

January 2021

#108

SamLaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for January, 2021:

1. The latest information about the COVID-19 vaccine, flu shots, and other updates

2. Screening guidelines for abdominal aortic aneurysms

3. Cancer risk for children borne from women with fertility treatment

4. Management of skin cancers—MOH’S SURGERY

5. New guidelines for testing the thyroid

6. Probiotics-guidelines for use, prebiotics

7. Missed medical diagnoses

Smoky Mountains

1. The latest information on the COVID-19 Vaccine

As the virus continues to spread for different reasons, the death rate continues to drop. Over 2 million vaccines have already been administered, and as many as 50 million will be vaccinated in the next month. There is light at the end of the tunnel! Stay vigilant with safety measures and get vaccinated.

Home tests

  Using the standard recommended PCR tests, which take a 2-3 days to get the results, require going to a facility to be tested, and while people wait for the results often do not isolate spreading the virus. To assist in safety measures, a home test with 15 minute results is a must.

  There are now 2 home tests available which are improving these needs. One requires a prescription from a doctor or online doctor service. The other FDA non-prescription approved test can be obtained by contacting www.pixel.labcorp.com

After a specimen is collected, it is mailed and then it takes 1-2 days for results once the specimen is received. This is a legitimate test using swabs in the nostrils by rotating the swab at least 5 times in each nostril. You must be 18 years or older to have this test. But it is still not an immediate results test.

  With many insurances, they will pay for the test with no upfront cost.

  The prescription test (Lucira COVID-19 all-in-one-test) can be obtained at pharmacies. The prescribing doctor must by law report the results, so the individual must call the doctor’s office and give them the results. I reported on this test last report. This 30 minute test can be performed at home with results from the apparatus.

  Image below of Lucira test kit:

These immediate tests will be a must at international airports and borders, hospitals, police and other facilities when people must be seen or assisted in close quarters. These immediate tests are antigen tests which require a much simpler and less expensive test.

  The vaccine will only accomplish part of the control the virus. Shutdowns, closing restaurants, and other facilities are not slowing the virus. When only 2% of spread have  proven to come from restaurants, why destroy this industry?

  As stated time and again, 70% of spread occurs in the home. Yet, masks, hygiene, and social distancing must continue as imperfect as they are. And again, vulnerable people, regardless of age, should not be going to public places unless absolutely necessary. We must get past the politics of this virus.

Post-discharge follow up issues of hospitalized patients—a real good reason to get vaccinated

  Annals of Internal Medicine reported on 1250 patients who were hospitalized for at least 5 days in 31 Michigan hospitals. Here were some of their findings after these patients were discharged after 60 days:

1) 20% did not follow up with their doctors.

2) 33% had persistent symptoms and 20% had new or worsening symptoms.

3) 40% had not returned to work. Of those returning to work had their hours cut back in 25% of the cases or their duties were modified.

4) 75% has mild to moderate emotional distress and 6% sought mental health care.

5) 62% were mildly or moderated financially distressed.

  With this kind of information, why would you not want to be vaccinated??

Helpful hints for post-COVID-19 cough

  Most doctors know the value of in-hospital intravenous corticosteroids and many are using it in medihalers in followup.

  An interview with 3 pulmonary specialists on a Medscape  interview, Dec 22, 2020, have recommended cortisone containing medihalers without albuterol (bronchodilators are usually recommended in asthmatics) in patients having continued cough after discharge. Steroids decrease inflammation and are helpful in the lingering cough from COVID-19.

  People with any type of pre-existng pulmonary problem  already have these medihalers. They recommend regular use of these medihalers at the first sign of COVID-19, according to Drs. Watto, Williams, and Brigham from hospitals in Philadelphia and San Antonio.

  Talk to your doctor about these recommendations.  

  Also, many doctors recommend various vitamins and medications that have had no evidence based research to prove their value beyond placebo, but that is between you and your doctor.

Answers regarding the COVID-19 vaccine

  The development of these vaccines is a miracle, and a testament to cooperation when a governmental administration can fund and demand prioritization over other priorities from a private industry. There may be plenty of room for criticism about the handling of this virus, but the speed and development of these vaccines is not one of them.

  It usually takes 10 plus years to develop a vaccine because of all the regulations and red tape created. With the emergency use law put into place by the current administration, it shows just how fast something can be done when leaders takes charge.

  This “warp speed” initiative in no way cut corners, diminished safety, or skipped steps in evaluation of effectiveness or side effects. Totally independent experts were responsible for the approval process, and the government did not have any influence on their decision.

  A couple of pauses occurred when an unusual side effects occurred, and the vaccine clinical trials were cleared by independent experts to restart. There is too much at risk to put out an unsafe and ineffective product in such a pandemic.

  If you don’t believe the science, that is your right. If you don’t believe these vaccines can be developed this quick, believe it!!

  Both political parties stated we must follow the science, and that is what has happened…mostly. Politics have no place when the health of our country is at stake (and yet it does).

  Regardless of vaccines, we all must continue safety measures even after receiving the vaccine until it has been proven otherwise and herd immunity is attained.

  This virus was unknown prior to November, 2019, with the illness not described until December (some question when China knew). A vaccine was ready for phase III in 6 months with 40,000 participants in just one study. In 9 months, we have a vaccine being administered. Amazing!

  Much was learned from the other coronavirus endemics (MERS and SARS virus), which has accelerated the process in the development of this vaccine.

Key point about the mRNA vaccines

  The mRNA (messenger ribonucleic acid) genetic material from COVID-19 provides the basis for the Pfizer vaccine development. The vaccine contains no live virus, so it cannot infect a person. The vaccines do not interact or affect the DNA in humans in anyway. The mRNA of the vaccine does not enter the human cell nucleus. The body breaks it down quickly.

  The vaccine requires 2 shots (21-28 days apart with Pfizer) to be highly effective.

  The only corners cut were bureaucracy, red tape, and some paperwork, typical of any governmental process. Independent experts cleared the vaccine for FDA approval, not any other group.

  The WHO declared this virus a pandemic on March 11, 2020, and now we have an active vaccine being administered.

  The only person that should not receive this vaccine are people with severe reactions to other vaccines. There should be a window of at least 2 weeks before receiving any other vaccine (including flu), According to the CDC.

  Reactions to the COVID-19 vaccine are similar to any other vaccine (headache, lethargy, muscle ache, fever, chills) and are less likely in older individuals according to the AMA, who has partnered with the FDA and the CDC.

Prioritization for Americans receiving the vaccine?

  Phase 1a

  Vaccination began with healthcare providers especially those on the frontline and nursing care facilities (patients and staff). Over 2 million doses have already been given.

  Phase 1b

  Just this week they have started to vaccinate those over 75* years of age and non-healthcare essential frontline workers to follow (includes police, firefighter, postal workers, food/agricultural workers, grocery store employees, public transit, childcare employees, teachers, and manufacture workers). Those 16 years and above are eligible. Children are not.

*Florida dropped the age to 65 (Govenor DeSantis)

   Phase 1c  Following these groups phase 1c will include all those age 65-74 and people 16-64 with a high risk condition (cancer, kidney disease, heart failure, obesity), followed by those essential workers excluded in phase 1b.

   Phase 2 will include everyone else not included above (all 16 and over). Reference— www.cdc.org

  Those on cancer treatment, those immunosuppressed, those with significant allergies, and those too ill to receive a vaccine should discuss the wisdom of receiving the vaccine. It is always about risk/benefit.

  It is recommended by the CDC that higher risk groups wait at least 15 minutes in the facility to be observed for any reactions, and if anaphylaxis previously occurred from allergens…30 minutes of observation. Any place providing these shots will have the ability to treat any significant acute reactions.

  When people with chronic health problems (40% of the population) are eligible, they will want to be vaccinated if approved by their doctors.

  The vaccine research did not include these high risk groups, so there is no proof they will be effective or that more serious side effects could occur. The answers will come with studies on these patients. These cases require a discussion with a doctor regarding risk/benefits.

  Those who have recovered from COVID-19 may be eligible for the vaccine, since re-infection is possible. MD Anderson’s website recommends waiting 90 days from COVID infection recovery, especially those who received monoclonal antibodies during their infection.

Vaccines can work in different ways, but the first two now approved (Pfizer and Moderna) both use an mRNA (ribonucleic acid) sequence that codes for the unique spike protein that is on the surface of the COVID-19 virus (SARS-CoV-2 is the official name). By binding that protein, replication (reproducing) is impossible and the virus dies.

  These spike proteins from the vaccine will be seen as foreign when a person is exposed to the virus. The individual will produce antibodies to combat the virus. All viruses are dependent on a host to live and reproduce.

  Two doses are required (21 days apart), and even though the first shot may give as much as 50% immunity, the second shot will increase it to 95% in the majority of people. These different vaccines are not interchangeable (stick with same vaccine), and no other vaccines for at least 2 weeks.

  There are three other types of vaccines being developed and submitted for approval in the next few months. One involves deactivated COVID virus, while another uses a different virus (adenovirus), that uses part of that virus’ DNA that encodes the COVID virus’ spike protein.

  Another uses a protein from the tip of the spike protein, which is injected to create immunity. All of these are showing success, but earlier in their clinical trials.

  Johnson and Johnson Co. hopes to have their vaccine ready by February.

  Children were not studied with these vaccines (commonly excluded), and therefore should not receive them under 16 years of age.

  A “bridging study” is planned to find out if they can have a safe and effective vaccine soon, according to an interview with Dr. Andrew Fauci. As few as 2000 participants are needed for a study on children when the vaccine is already known to be safe and effective. Once this study is complete, children will be able to receive the vaccine.

Does the over-65-age group flu shot give better immunity for seniors?

  A recent multicenter study compared the senior flu shot to the regular strength shot. There is 4 times more antigen in the senior shot, thought to be more likely to provide better protection for senior people who are thought to have less immune response than younger people.

  This study found no benefit for the stronger senior shot in protecting those with cardiovascular disease.

  Stronger senior shots (quadravalent) may be more likely to create the usual side effects of any vaccine-headache, muscle soreness, chills, and fever.

  That is good news in that seniors can request the standard strength shot, however, this decision should be discussed with an individual’s doctor before making this decision. Ref: NEJM, Sept. 15, 2020

What about other strains of COVID-19?

  Some different COVID strains have been reported in the UK, but have now been discovered in Australia, the Netherlands, Iceland, Denmark, and Italy. The EU has banned travel out of or into the UK. Chances are it is already present in the U.S., according to Dr. Fauci in a televised interview.

  This variant may be more transmissible but clinically does not cause greater illness or death in this interview.

  There are over 100 strains of coronavirus that have been discovered, so a strain from outside the country should be covered by the current vaccines, according to experts in the field.

  RNA viruses such as coronaviruses are well known to mutate, according to a Medscape interviewer, Dr. John Whyte in a discussion with Dr. Fauci. New clinical trials have already been started to answer that very question.

  However, it was clearly stated that researchers are quite prepared to address any mutation (variant) that might occur in the future and sequence a mutated virus and have another vaccine available in just 3 months according to the chief medical officer of M.D. Anderson Cancer institute, Dr. Welela Tereffe, M.D. It is stated that the current vaccines should cover these mutated cases, but is being studied currently.

What about pregnant and breast feeding mothers

  There is no data yet available for pregnant women taking this vaccine, however, RNA viruses are usually safe for breast feeding mothers. Since pregnant women are at an increased risk for severe viral disease and their babies are prone to being born preterm, vaccination can be considered. It is recommended that The OB/Gyn doctors discuss this with each individual regarding the pros and cons of accepting the vaccine.

Length of immunity from the vaccine

  Most coronaviruses are respiratory viruses and commonly provide immunity for about the same length of immunity as the flu virus, but no one knows yet. It is unlikely there will be immunity for years. Repeat boosters will likely be needed. Some of the infected cases showed a drop in antibodies within 3-4 months. Knowing what level of immunity will be needed to prevent infection remains to be known.

When will we have Herd Immunity?

  When those who are vaccinated and recovered patients from the virus combined account for 70-80% of the population, it is likely our country can attain herd immunity. Immediate testing must be used to screen anyone coming into this country. This means there are few enough people transmitting the virus to provide secondary protection to those who can’t take the vaccine.

  All the special prioritized groups should be vaccinated after March and allow anyone to be vaccinated by April at the earliest, according to Dr. Fauci.

Hesitancy to receive the vaccine

  There is still significant hesitancy in many Americans. The young are unlikely to take it, and certain ethnic groups are notoriously skeptical of the federal medical community. The media has an important responsibility to promote these vaccines and not spend the majority of time talking about isolated events of side effects of the vaccine. Will they??

  Celebrities, especially Hispanic and Black, need to speak loudly encouraging their groups to get vaccinated.

  We must trust the science just as it has been said from the beginning. Nothing is perfect, but unless we want to live with this virus and destroy our country, I suggest we get vaccinated and be a team player for the USA.

The Pfizer vaccine must be stored at -94F, and when thawed, the vial must be used within 6 hours. Dry ice containers are used for shipping and only special facilities can maintain that kind of temperature.

Moderna claims that its vaccine can be stored at 36-46F, meaning it can stored in a regular refrigerator. They also claim it can be stable, once thawed, for up to 30 days.

Vaccine information reference from M.D. Anderson Cancer Institute, December 15, 2020

2. Fertility Treatment—in vitro fertilization and Cancer; risk for children from women who underwent fertility treatment

  In vitro fertilization has been fairly successful (40% if under 35, 12% if over 40) allowing couples to bear children. However, it is expensive (average 12,500), with no guarantees, and requires procedures to fertilize and ovum with a sperm and introduce it into the woman’s body for pregnancy (introducing at least 3 embryos).

  There are risks not only to the woman but also to the children who are born.

   Two methods can be performed…frozen embryo transplantation or fresh embryos.

  A recent study found that frozen vs fresh embryo fertilization has no advantage over the other in rates of pregnancy (27% vs 29%) according to an IVF Center in Copenhagen, Denmark. I have a dear friend who used to perform these procedures in these Sacandavian centers.

  Freezing embryos is not considered necessary for women who have a reasonable number of follicles in their ovaries. (multicenter project in Denmark, Sweden, and Spain)

  Gonadotropin hormone releasing agonists are necessary in frozen IVF to stimulate the ovaries, and in a subgroup for fresh IVF (those who had more 18 follicles to prevent ovarian overstimulation syndrome).  

British Medical Journal, August, 2020

  The JAMA medical journal reported on a Danish study (1,085,175 children) that there is a small but substantial increased risk of children developing cancer if their mothers underwent fertility treatment using frozen embryo implantation. Leukemia and certain neurologic cancers were the most common.

  The risk of a child developing cancer from a fertile female is 17.5 per 100,000 versus 44 per 100,000 person-years. That equates to 2.4 times greater chance for children to develop cancer if their mothers underwent frozen embryo implantation.

  There was no increased risk for reproductive procedures such as artificial insemination (sperm donor intrauterine injections), or hormonal treatment(fertility drugs). The main concern came from frozen embryo transfer.

  What happens to frozen embryos in storing and preservation? It was found that infants born with this method had higher birth weights suggesting that the methods influence the intrauterine weight (observational study only). Excessive fetal growth has been linked to childhood cancer. This is in contrast to using fresh embryo transfers.

  The freezing and thawing techniques require certain cryoprotectants, which could be the reason for the increased cancer risk in the children. Also administration of estrogen and progesterone during the pregnancy is part of the protocol. However, in their analysis, these hormones were not at fault as a stand alone factor. The authors point to genetic changes in the fetus from the freezing process but not because of these hormones.

  Other fertility drugs such as clomiphene and gonadotropins are not implicated either. However, it is known when ovarian stimulation occurs, multiple births are not uncommon.

  Children born after medical fertility treatments have higher risks of perinatal outcomes including low birth weight, premature births, congenital malformations, and rare genetic imprinting disorders.   

  There is no one cancer that can be pointed to as the result of frozen embryo transfers. 

  Denmark utilizes fertilization techniques in greater numbers than most other countries. 9.8% of children born come from some type of fertility manipulation.

  It stands to reason, any time there is manipulation of a bodily process, it may create unintended consequences, and it is worth understanding the risk of any treatment or procedure before considering it.

  Patients must ask their doctors the downside of any treatment.  JAMA Network, Dec. 10, 2019

3. Screening guidelines for abdominal aortic aneurysms

  Vascular disease is often thought of as heart disease, but not only does it include strokes, but also peripheral vascular disease. As the heart sends blood out to the blood vessels, the main artery (aorta) provides blood to all the main arteries to the brain, extremities, but also the abdominal contents.

  The aorta can develop disease in its lining similar to other vessels. One of the concerns is a ballooning out of the vessel wall called aneursymal dilatation.

  The USPSTF* in the December 10, 2019 edition updated its 2014 recommendations for screening of the aorta. It now recommends that men who have ever smoked receive a one time screening (ultrasound) between the ages of 65-75. “Ever smoked” is usually defined as 100 cigarettes.

  This age and older have a highest incidence of developing an aneurysm that has the potential to rupture --7%. These recommendations do not include women who have smoked, even with a family history of aneurysm.

*USPSTF=U.S. Preventative Services Task Force, the major federal advisory committee.

  These recommendations come from 4 studies in 4 countries, who found that discovering an abdominal aortic aneurysm before rupture saves lives.

Treatment of aortic aneurysm

The improved technique of repair has led to part of the updates of screening. Aortic aneurysms that enlarge by 0.5cm (0.197 inches) in 6 months are considered high risk for rupture and should be considered for immediate repair. 

  Those people who have an aneurysm discovered should have a repeat ultrasound every 6 months. However large aneurysms should be repaired before they rupture.

  Physicians should be able to palpate large aneurysms unless the person is obese, but that is too late in many cases. Bruits (vascular sounds) can be heard from the blood swirling in the dilated area with a stethoscope.

  The incidence of abdominal aortic aneurysms between the ages of 50-84 is 1%, according to the screening company Lifeline.

  Symptoms are usually non-existent before rupture, and if that occurs, it is a serious emergency. Grafting inside the aneurysm is recommended leaving the aneurysm in place and a VA study found that most were still in working order after 15 years.

Reference—NEJM, Dec. 10, 2019

4. Management of difficult skin cancers—Moh’s Surgery

  Skin cancers are the most common cancer by far. The three common types of cancer are squamous cell carcinoma (20-50% of cases), basal cell carcinoma, and melanoma. There are other types of skin cancer that must be taken into consideration including metastatic cancers from other organs in the body, Merkel cell carcinoma, cutaneous lymphoma, Kaposi’s sarcoma (HIV-AIDS), and skin cancer originating from sweat and oil glands-- dermatofibrosarcoma protuberans.

  These rarer cancers tend to form quickly and spread early requiring immediate resection and chemotherapy (and radiation therapy).

Precancerous skin lesions are called actinic keratoses. These precancers can be destroyed with liquid nitrogen or  efudex cream (5-fluorouracil), and are covered in a different report coming in February, 2021.

  Many of the precancers may be felt before seen. They are simple scaly reddish spots on the skin that can be peeled off only to return. Left alone, they will may become squamous cell carcinomas. Examples of precancers:

New preventative vitamin may help

  A new chemopreventative agent (nicotinamide) is now recommended for people with considerable precancerous skin who continues to have new lesions. After taking this derivative of Vitamin B3-niacin, for 12 months at 500mg twice a day, there was a considerable reduction of pre-cancers in this group compared to a placebo group.

  The difference between the 3 most common cancers are usually apparent, but a biopsy is necessary to be sure. Also, if a melanoma is suspected, the depth is critical in staging. Also skip lesions in some these cancers can occur, requiring more extensive surgery than one would think.

  Recurrent skin cancers, cancers in critical areas where preservation of the surrounding geographic area is critical especially in the face, nose, ears, and eyes. I was privileged to perform hundreds of these types of skin cancer resections with sophisticated plastic reconstructions.

  These reconstructive procedures are worthy of an entire article, but perhaps beyond the scope of these reports. Skin cancer surgery was a significant part of my practice  and also reconstructing difficult facial defects after the skin cancer was removed by a specially trained Moh’s surgeon (dermatologist). What is Moh’s surgery?

Moh’s cancer surgery is the standard today, now that the training of some dermatologists extends to dermatopathology and plastic reconstruction. One of my partners in my clinic was a such a Moh’s surgeon, and we worked on hundreds of cases together. He would resect the cancers and require multiple resections in difficult facial areas. The patient was then sent to me for immediate or next day reconstruction. Before and after reconstruction.

  Moh’s technique was developed by a dermatologist, Dr. Fred Mohs. Today, it implies special evaluation of a skin cancer completely around the edges of the skin cancer, time consuming but more effective in being sure the cancer is adequately removed, especially in difficult facial areas where preserving tissue is critical.

This nasal reconstruction uses a bilobed flap to reconstruct the tip defect above. The photos below demonstrate a nasolabial flap to reconstruct the nasal defect.

Many Moh’s surgeons today have been trained to reconstruct their own skin defects, but the more complex ones can be referred to plastic surgeons.

  Squamous cell carcinoma is more serious because it can metastasize. It is not common, but the regional lymph nodes must be followed on larger and more aggressive forms of this kind of cancer.

  Basal cell carcinoma rarely spreads, but can recur and grow under the skin causing a challenging removal and reconstruction.

  Fair skinned people who get sunburned even as a child are more prone to these cancers. Sunburn seems to particularly be associated with later melanoma.

  People who have organ transplants are 65-250X more likely to develop squamous cell carcinoma. The immunosuppressive medications lowers the resistance to many types of infections and these cancers. People with transplants literally cannot be in the sun, and if they are they must wear protective clothing. These skin cancers will develop quickly and spread rapidly.

  It is 8X riskier for patients with chronic lymphocytic leukemia, and 2-4X more likely in patients with rheumatoid arthritis (and patients with other immune diseases) taking medications that suppress the immune system, which is needed in any autoimmune disease. 

Medscape CME and eduation course on skin cancer, August 10, 2020

  Size, depth of invasion, perineural (nerve) invasion, and differentiation of the tumor (how malignant the cells are) are the risk factors for a worse prognosis. Once the tumor passes through the skin to the subcutaneous tissue and fat, there is an 11X greater chance for that tumor to metastasize.

  MRI scans are the best way to define invasion, nerve spread, etc.

  Besides local resection, regional lymph node removal is the preferred method if there is a metastatic node.

  Chemotherapy (cemiplimab preferred) and or radiation may be considered if there is extensive regional spread.

  The cure rate--95% cure rate for local squamous cell cancers and 77% for recurrent ones if treated with Moh’s surgery.

  I want to make it very clear, not every skin cancer needs Moh’s surgery, and if one see a Moh’s surgeon in referral, the likelihood of Moh’s techniques will be recommended, therefore, question whether Moh’s surgery is essential.

   Primary resection with *frozen sections is just as valuable, however, as mentioned above, those facial lesions when trying to stay as close to the cancer and still remove it entirely does require consideration for Moh’s surgery.

*frozen sections are similar if performed by a pathologist or a dermatopathologist who is a Moh’s trained surgeon. The difference is the extent of looking around the borders in either selected places or following the tissue completely around the cancer. The difference in cure rates are about 92-95% for resection and frozen section vs Moh’s surgery 95-97%.

5. Time to test the function of the thyroid with different tests

  The thyroid is an endocrine organ which regulates metabolism, growth, and other functions. I discussed this gland and its disorders at length in a previous report, and to access it, click on www.themedicalnewsreport.com/32

New recommended thyroid test

  For decades, the test of choice has been the TSH levels in the blood. Recent studies confirm that the T4 levels have a stronger association with an  array of thyroid conditions rather than the TSH levels. In other words, the status of the thyroid is better assessed with the free throxine levels (T4) according to the lead Australian investigator, an expert researchist on thyroid disorders. 58 articles were reviewed regarding assessment of thyroid function in patients with atrial fibrillation, cancer, osteoporosis, dementia, pregnancy outcomes, etc.

  Based on these studies, Dr. Fitzgerald recommends doctors start testing the T4 levels rather than TSH levels as the best indicator of true thryroid function. TSH is a pituitary stimulating hormone, and to some degree, an indirect indicator of the function of the thyroid gland, while T4 is a direct indicator. The Journal Thyroid, April 29, 2020.

Physiology of the thyroid and the Endocrine System

The upper left diagram shows the sequence of activity from the brain to the pituitary, to the thyroid gland in th lower neck wrapped around the windpipe (trachea). The upper right drawing shows the feedback mechanism between these differen anatomical areas.

  The thyroid, like all endocrine glands, are governed by the hypothalamus in the brain (TRH), which then is controlled by the stimulating hormones in the pituitary gland (TSH) which sits at the base of the brain.

  These stimulating hormones keep the levels of the endocrine gland’s actual hormones at the necessary physiologic level to perform their tasks, whether it is the thyroid for metabolism, etc., insulin from the pancreas, estrogen from the ovaries, testosterone from the testes, cortisone from the adrenals, or calcium from the parathyroids.

  These stimulating hormones, in the case of the thyroid, is called TSH-throid stimulating hormone which stimulates the production of T4 (thyroxine). 

  T4 is converted to T3 (triiodothyronine) at the cellular level. For the thyroid to make T3, iodine is required, and must be provided by foods, especially iodinated salt (note that sea salt and kosher salt does not contain iodine).

  The feedback mechanism between the endocrine gland and the pituitary is important to understand. When  endocrine hormones produce adequate levels for the body, the hormone essentially tells the pituitary to quit making more stimulating hormone (feedback mechanism). This is important when a person is either hypothyroid (low) or hyperthyroid (high).

  Other experts caution that if a person is taking thyroid hormone replacement, it is still critical to evaluate the TSH levels for correlation.

  It is important that people who have thyroid disorders or diseases that may be influenced by thyroid hormones, consult with their doctor and ask them about the wisdom of testing T4 instead of TSH. Medscape, May 18, 2020

6. Recommendations for using probiotics from the American Gastroenterological Association; prebiotics differ!  

  To prevent gastrointestinal diseases, probiotics may be of some assistance in certain instances.

  The probiotic industry is totally unregulated and the public is at the marketed products to contain what it says it is, that the bacteria in the product are live cultures, the amount they say they are, and the best bacteria to consume. No one bacterial probiotic is worth much. Most good products should have several different types of bacteria.

The American Gastroenterological Association has published recommendations for certain diseases

  One of the most serious infections of the gut that can happen is Clostridium difficule (C.diff.)intestinal infection which can occur as a complication of antibiotics.

The current recommendation is:

 1) Saccharonmyces boulardii. Other options include Lactobacillus acidophilus or Lactobacillus bifidum plus Lactobacillus caseii. Bifidobacterium bifidum

2) Do not use probiotics when taking antibiotics except in a clinicial trial when treating C.diff.

3) Do not use probiotics if a person has inflammatory bowel disease (Crohn’s disease, ulcerative colitis) or irritable bowel syndrome unless in a clinical trial

4) If a person has some type of a surgical pouch from gastric bypass, cancer surgery, or loss of bowel from any type of surgery, an 8 strain of bacteria is recommended. Since this issue is slightly rare, the reader should discuss this with their surgeon and/or gastroenterologist.

5) Do not use probiotics in children for infectious diarrhea.

6) in preterm infants, a combination of Lactobacillus and Bifidobacterium is recommended to prevent necrotizing enterocolitis

Can probiotics lower the use of antibiotics in nursing home patients?

  Probiotics contain bacteria and are used widely in the healthcare industry and personally by people with the assumption that they will prevent yeast infections (orally and vaginally) when taking oral antibiotics. They have been used in nursing facilities to reduce the need for antibiotics, which is epidemic mainly due to urinary, respiratory and gastrointestinal infections.

  A study from the UK tried a combination of probiotics (lactobacillus and bifidobacterium) on 310 nursing home patients and followed for 8 months. Antibiotic use was not reduced in these facilities in both probiotic and control patients.

  Prophylactic use has little value in most patients unless there is a chronic infectious condition that is directed by a physician who recommends probiotics.

  Using probiotics simultaneously while taking antibiotics may have some minimal value but even though antibiotics are known to reduce the bacteria in the entire gastrointestinal and genital tract. However, for most healthy people probiotics are of little value. For patients who have chronic gastrointestinal tract disorders, the recommendations are above.

Prebiotics

  Prebiotics are different from probiotics and are found in many fiber-rich fruits and vegetables including garlic, artichokes, beans, onions, tomatoes, and all grains. These help promote floral growth naturally.

  Probiotic food substances include yogurt, kefir grain added to cow’s or goat’s milk, sauerkraut, tempeh fermented soy bean product, kimchi made with cabbage and a Korean dish, miso (fermented soy bean added to a fungus koji, kombucha is a fermented black or green tea, pickles, buttermilk, natto (another fermented soy product), a few cheeses (cheddar, mozzarella, and gouda).

Healthline.com  

7. Missed medical diagnoses

  Missing a medical diagnosis is everyone’s nightmare, patients and doctors. In the current environment of healthcare, with high costs, attempts to reform, lower revenue for doctors and hospitals, shorter doctor visits, nurse practitioners and physician’s assistants seeing more and more patients, telemedicine, delay in diagnostic and screening tests because of COVID-19, is it any wonder that diagnoses can be missed?

  Patients are told to return to the doctor if symptoms don’t resolve, and they don’t, underlying diseases can be missed.

  Because of shorter doctor visits, the reason for the actual visit is the only symptom that is usually addressed.

  Younger people often do not have routine annual visits, do not have a primary care doctor, often depend on urgent care, and don’t see the same doctor twice.

  Even tests are not full-proof, with a known percentage of false positives and negatives.

  These issues may be solid reasons to accept missed diagnoses, but not for patients, families, and the medical profession. It is a tragedy if one person has a missed diagnosis especially if it causes harm.

  For decades, 10-15% of diagnoses are missed according to several experts that follow quality control. A recent report in Medscape continuing Education, July 2, 2020 cited a study of 348 primary care visits and found 13% missed diagnoses in those visits.

  Estimates have been made that 100-200 million cases of misdiagnosis per year in the U.S. occur. Serious harm from these missed diagnoses occurs in 0.22% of hospitalized patients, and 0.81% of primary care outpatient visits. That translates into 80,000 missed diagnsoses per year.

  Vascular events, cancer, and infections account for the most missed diagnoses. This continuing education material stated that 1 in 10 people from vascular disease, cancer, or infection were misdiagnosed, diagnosed later, and more than half were permanently disabled or died from that misdiagnosis according to Dr. David E. Newman-Toker M.D., PhD, Director of the Armstrong Institute for Daignostic Excellence at Johns Hopkins School of Medicine in Baltimore, Md.

  Lung cancer was missed in 22% of cases while prostate was only missed in 2.4%. Routine chest X-rays are not performed routinely anymore, and some organizations do not feel that the PSA should be performed routinely. Mammograms are not infallible for several reasons, and colonoscopy can miss an early cancer especially in the right side of the colon.

  Vascular events such as a heart attack are rarely missed, because they are acute, however, endocarditis is missed 25% of the time, as is meningitis and spinal abscesses. Strokes are missed about 5-10 times more than heart attacks. Also brain hemorrhage and aortic aneurysms seem to rising in numbers.

  These researchers have seen little improvement over the last few decades.

  Factors include not following up on symptoms (patient responsibility most of the time). The lack of communication with patients in follow up (i.e. automated calls) does not guarantee the patient will show up. Patient reminders helps, but it is far from the answer. Better training for all healthcare workers, taking more responsibility by patients to understand and assist in their care is needed. (THAT IS ONE REASON I WRITE THE MEDICAL NEWS REPORT). With the predicted shortage of doctors now a problem, routine checkups are getting to be a thing of the past, especially for healthy people.

  The fact that patients see a different doctor for every disease is not helping. Primary care doctors, in this litiginous world, feel pressure to recommend more specialist consults for every disease. And yet, many electronic medical records do not see to it that the primary care doctor gets a report from the specialist, especially if the doctor is in another major medical network.

  Because it is known which diseases get misdiagnosed more often, some medical organizations recommend 15 targeted conditions be screened to reduce misdiagnoses. And yet, many of these diagnoses are not screened for, because of the low yield and the harm in testing (false positives) not to mention the cost.

  The 3 major categories that they recommend are vascular, cancer, and infections.  15 diagnoses they want to see focus on are:

1- Vascular—stroke, MI, venous and arterial thrombo- emboli, aortic aneurysms and dissections

2- Cancer—lung, breast, colon, prostate, and melanoma

3- Infections—sepsis, meningitis/encephalitis, spinal abscress, endocarditis, and pneumonia

  The pandemic has created major delay in diagnostic and screening tests, creating a tremendous number of medical events in the thousands (estimated number of delayed cancer diagnoses of 88,000). This virus has cost the U.S. as much as $7 trillion in many categories including healthcare outcomes).

  Trying to screen for the above 15 diseases would cost billions and obtaining support and financing this undertaking is questionable including non coverage by insurance companies.

  The “practice” of medicine will never be perfect, and with lawyers flooding the airwaves with ads for easy money from medical malpractice suits, is it any wonder physicians practice defensive medicine?

  Expecting compliance from patients to take their medicine, have recommended screenings, and have follow up by patients from any symptoms that get worse, persist, or do not abate is asking a great deal.

  There is no excuse for missing diagnoses, but there will always be symptoms patients ignore, do not divulge to their doctors (if they have one) and do not follow up. It is a two way street for patients and doctors to work together to attain the best healthcare quality and both need to do a better job.

  The current shape of the average American is appalling with 45% of adults in high risk categories for COVID-19, clearly pointing out our country needs to take responsibility to get healthier through exercise, proper diet, healthcare evaluations, taking their medications properly, and following up on any symptoms that do not improve or abate.

Medscape Continuing Education, July 2, 2020  

This completes January, 2021 report! Happy New Year 2021!

The February, 2021 report will include:

1. Stretch marks and cellulite

2. Link between obesity and hypertension in pregnant women—pre-eclampsia and eclampsia

3. What is new for lipids and cardiovascular disease; statins update

4. Genetics and cancer

5. Pregnancy issues-Part 1

     A. Link between obesity and hypertension in pregnant women

     B.  Pregnant women-marijuana

     C. NSAIDs and pregnancy—package warning strengthened

     D. Optimal management for miscarriages

     E. Folic acid supplement critical during pregnancy

I hope this year will be filled with happiness and joy for all! God bless America! Glad to see 2020 go! Happy New 2021!

Stay healthy and well, my friends, Dr.Sam