The Medical News Report

June, 2021

#114

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for June, 2021:

1. The most recent updates on COVID-19 and vaccination issues

2. Drugs that cause arrhythmias (irregular heartbeats)—know your medication’s side effects

3. What is a liquid biopsy (blood and other tests) for diagnosing cancer?

4. Torn knee cartilage—surgery or physical therapy?

5. New surgical technique to cure obstructive sleep apnea

6. Probiotics—real value?

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.

  Thank you, Dr. Sam

  A NOTE ABOUT DRUGS COMING OVER THE BORDER FROM MEXICO

   SINCE THE BORDERS HAVE OPENED WIDELY, THE CARTELS ARE WORKING VIGOROUSLY WITH CHINESE COUNTERPARTS TO FLOOD OUR BORDER WITH FENTANYL, A DRUG 50X STRONGER THAN HEROIN AND 100X STRONGER THAN MORPHINE. AT ONE TIME, HEROIN WAS ACROSS THE COUNTER. ARE WE SLIPPING BACKWARDS?

90,000 DEATHS FROM OVERDOSES HAVE OCCURRED IN THIS COUNTRY THIS YEAR. MANY DRUGS NOW AVAILABLE ON THE INTERNET ARE BEING LACED WITH FENTANYL.

  THESE PILLS ARE FINDING THEIR WAY THROUGHOUT OUR COUNTRY. THESE DRUGS ARE CHEAP AND CAN KILL!

  THIS MASSIVE INCREASE IN DEATHS AND OVERDOSES HAVE BEEN GREATLY ACCELERATED BECAUSE THE MEXICAN CARTELS ARE GETTING INTO OUR COUNTRY QUITE EASILY THESE DAYS, SINCE OUR BORDER AGENTS ARE BABY SITTING THE THOUSANDS OF CHILDREN COMING INTO OUR COUNTRY. NOT ONLY DO THE CARTELS GET AN AVERAGE OF $9000 PER CHILD TO BRING THEM OVER THE BORDER TAKING ALL THE BORDER AGENTS’ TIME WHILE THEY ARE MAKING BILLIONS ON SMUGGLING DRUGS INTO THE U.S., AND FENTANYL IS THE MOST POPULAR DRUG SMUGGLED OVER THE BORDER AND BY FAR THE MOST DANGEROUS.

  THIS DRUG IS SOLEY PRODUCED IN CHINA, THEY ARE  LACING MANY KNOWN MEDICATIONS THAT CAN BE PURCHASED AS COUNTERFEIT DRUGS IN PAIN PILLS BUT ALSO DRUGS TREATING ADHD (ADDERALL FOR INSTANCE) AND OTHERS.

  PLEASE CONSIDER THE DEVASTATING EFFECT OF OUR BORDERS BEING OPENED SO WIDELY, AS IT MAY BE A WONDERFUL OPPORTUNITY FOR THESE YOUNG PEOPLE, BUT IT IS KILLING OUR ADULTS AND CHILDREN AT A SCARY RATE.                              THANK YOU, DR. SAM

1. COVID-19 Updates

A. Sick people are not getting tested

  A recent report from JAMA Network Open reported only 20% got tested, who become ill with COVID symptoms, even with fever greater 100.8 are getting tested. People just don’t want to know or face isolation, or they just have no concern for their fellow man. And now the testing sites are closing making it even more difficult to get tested.  

  Sadly people of color are only testing about 10% of the time if symptomatic.

   This tells me also the number of infected people in this country is probably 50% more than the CDC reports, just because of these statistics. Many countries are much tougher on people who are ill and don’t get tested.

  The Citizen Science Study reported no obvious reasons other than the expected….lack of testing facilities, poor knowledge about needing to be tested for contact tracing, etc. By now those excuses don’t hold water.

  Amazingly ¾ of the 3,800 participants in this study were women who did not get tested.

B. Nasal Vaccine Spray promising

  Already in clinical trials is a vaccine nasal spray against COVID-19, and this would be a tremendous advance and allow everyone to be protected. Recall there is a nasal spray against the flu for children. Since the entry of the virus in humans comes through the nose, this makes an excellent argument to stop it at it entry site. Medpage, May, 11, 2021

C. Masks not necessary for fully vaccinated individuals; Mixed messages from the CDC confuse businesses and the public

  By now everyone should know that if fully vaccinated, masks are not necessary for both indoor and outdoor activities, unless in a congested area (vague), traveling on public transportation, and hospitals. If not fully vaccinated, masks are recommended (note the word is very different than “must”) for indoor and outdoor events (there is no science for this recommendation outdoors). People still have a right to choose what they do, but so do businesses, therefore, if a business has yet to update their guidelines, please comply. Respect other’s decision to wear a mask or not.

  The mixed messaging from the CDC and the current administration has created more doubt and less confidence in getting vaccinated in returning our country to pre-pandemic prosperity. Politics have tarnished our country as always. Much of the decision making has not been backed up with good scientific findings, and certainly the timing of these messages is extremely in question.

  The public realizes there are politics in these decisions. Half the country believes we should be wearing masks and the other not. Wearing masks have defined people’s politics. Fear is another factor highly promoted.

  Of course, if not vaccinated, follow the CDC guidelines and wear masks when inside or around groups.

  The president and CDC failed to address those who have been infected (and by in large are as immune as those vaccinated), and still recommend masks in schools when these kids are the least likely to get infected or transmit it (that is the science!).

  This message has changed by the day, in fact, I have had to revise this report every few days. This is just not good communication, it won’t be well followed. Americans are just not going to keep up with the daily if not weekly change in guidelines.

  And speaking of CDC GUIDELINES, they are NOT LAWS or rules, just guidelines for people to decide on their own what is best for themselves and their families, but the media and certain spokesmen would lead you to believe it is law. Government seems to mix that up really well, and has made following their guidelines almost impossible, on top of differing guidance from states.

  Having different guidelines for the vaccinated and unvaccinated will just allow individuals to not tell the truth. Passports may make sense to some, but for most people, when there is an ID to vote, that will be a good time to consider a passport for vaccination. Just my opinion!

  Respect other people regarding mask wearing, please. Everyone will change behavior at their own pace.

  And finally, the CDC announced that the virus can be transmitted by droplets and aerosol, and to a less extent surfaces. This is old news, but put out just when they should be touting that this virus and its cases and deaths are at an all time low (1/3 less).

  This is a time to celebrate how well this virus is under control and that vaccinations are a great success, and everyone should get vaccinated. Rare side effects are not a good reason for hesitation, nor is that the vaccine was rushed.

  Until the school children issue stops being a stopgap for getting our country back to normal, these issues will divide us and create more controversy. In the meantime, it is the children who are suffering the most!! And they will for much longer than the pandemic lasted.

Agencies who recommend vaccines have dismal percentage of their employees getting vaccinated

  Dr. Anthony Fauci was asked by a congressional committee about the percentage of those vaccinated in his agency (Institute for Allergy and Infectious Disease) and the CDC. He announced about 60%!!! What kind of message is that, when the agencies who recommend the vaccine can only get 60% of their employees to get the vaccination? On the other hand, vaccine mandates are very controversial.

  Mixed messaging has their own people hesitating.

C. Pfizer now approved for those 12 and older

  The Pfizer vaccine is now approved (emergency use declaration) for those 12 and older. Moderna is only approved for those 18 and over. Research is ongoing covering those 2 years and older.

   This school issue has affected the workforce greatly without adequate childcare available, and mothers have not been able to get a job or go back to work!! Fear has ruled this country for 15 months with a very convenient virus that has taken us to our knees. It is teaching our country the wrong message. Fear will never win out!

D. Where did COVID-19 originate?

  There is still no ACTUAL proof where this virus started (Wuhan Viral Labs or an open food market) although more and more indirect evidence points to the possibility, and finally the administration is admitting the same.

  As an investigation was beginning, the Biden administration shut it down and leaned on the WHO (World Health Organization) to do the investigating. Then, with public pressure to get to the bottom of this issue, Biden has commissioned a 90 day investigation. Thank goodness, a U.S. investigation will begin, but it needs to be independent, and that means without anyone involved with previous collaboration or funding of this virus.

  To realize that the administration has now admitted that there is a possibility that this pandemic could originated from the Wuhan Virology Institute is a big step, since before they would not consider it a possibility. Now, too much information is out, and the pressure mounted requiring a reversal of decisions.

  This particular coronavirus is not easily transmittable to humans, according to many experts, and that it would have to be bioengineered to be easily transmittable. It has not been proven it was from bats. In fact, over this entire pandemic, there has been zero findings that it came from a bat and infected any human.

  This is the basis of research that many feel was occurring in the Wuhan labs…so called “gain of function” research. There are allegations that similar research was being carried out in labs in North Carolina back in 2014, but paused in 2017 only to be restarted by the NIH in 2017 for unknown reasons without the Trump administration being notified.

   News channels disclosed that grant money ($600,000) from the NIH (The Institute of Allergy and Infectious Disease—Director Dr. Fauci) via the Echo Foundation, a charitable organization, provided the grant to these Wuhan Chinese labs. This was denied by Dr. Anthony Fauci at a congressional hearing, but later stated that there were funds sent to the Wuhan Lab but not for gain of function  research (?).

  The devastating effects of engineering a coronavirus to attack human cells may have begun in those labs and got out of those labs innocently (safety of that lab and many others have been known). The fact that the Chinese Communist Party have not let our country in those labs to investigate is no surprise. The WHO was allowed in for a tour for 2 hours without seeing any documents, but that is it, and of course, found nothing suspicious.

  It is known that 3 of the researchers in that lab came down with COVID-19 like illness in November, 2019, long before this virus was known by the public.

  All Americans should want the answers regarding the virus, its origin, any cover up, and not stop until that happens. It should not be a political issue….this is a global insult taking over 3 million lives. 

  e Wwwwwe stillon folks…do the right thing.

E. The immune response of the COVID infection vs the vaccine; 3 phases of COVID-19 infections

  Which gives us better immunity….an infection or the vaccine? According to Dr. Marty Makary, Editor of Medpage, Professor at Johns Hopkins Medical Center in discussion with a virologist (Dr. Racaniello from Columbia University), it depends on the severity of the infection and the response a person’s immune system can mount.

  It is known that in a significant COVID-19 infection, the T- cell and antibody response is at least one year long according to documented research, whereas studies on vaccines have only been able to prove 6 months of good immunity due to the timeframe of current research. New research will be forth-coming about the longevity question and the re-infection issue.

Variants and the possibility of a fall booster

  A fall booster is already being studied, but nothing has been decided even if it will be needed. The advantage is it would include better immune response to variants. However, to date, the current U.S. approved vaccines are showing significant protection from the variants, and also the best way to prevent variants is considerable immunity in our country with either infection or vaccination, according to numerous scientists.

A person who contracts a mild infection (well over half the cases), the immune response is usually not as high as someone who has a significant infection, which should be a good reason to get vaccinated with better protection. These questions still unanswered gives some hesitancy to be vaccinated. Individuals should discuss this with their doctors if in doubt.

3 phases of clinical COVID-19 infection

 There are three clinical phases of COVID-19—1) the infection phase 2) pulmonary phase 3) inflammatory phase, and the doctors state treatment is different for each phase. We have come a long way in the understanding of how this virus works.

F. New antiviral better than remdesivir

  Drs. Makary and Racaneillo discussed a new antiviral, molnupiravir, which has shown great promise in its use against the disease in the early phase, now in clinical trial III.

  This experimental antiviral is proving more valuable than Remdesivir. This antiviral can clear the virus in 5 days. But just one drug is not enough. It can be given outpatient (remdesivir and molnupiravir). There are other RNA inhibitors being studied, with more weapons hopefully in the future.

Will we reach herd immunity?

  With 50% of adults having at least one vaccine and 50% of the population having been infected (estimates of asymptomatic or symptomatic), we should have herd immunity now. The numbers are dropping because the virus is having a harder time to find someone to infect…..that is the clear definition of Herd Immunity.

Is the CDC waiting for a magic number of low cases and deaths before declaring herd immunity is a factor?

  Above the diagram is the latest number of cases in the U.S. Add vaccinated and previously infected people, plus what is called exponential decay*, and we have herd immunity for the reason the numbers continue to drop.

*exponential decay is defined as the decrease of number of cases because fewer and fewer people are able to transmit the virus because of they are immune.

  The above discussion between Dr.Makary and Racaniello centered around the value of the vaccine to conquer the virus and its variants, and in their professional opinion it will. Now we just need more younger people to get vaccinated (85% over 60 have been vaccinated).

  We still have more than 40% of adults not vaccinated at all, mostly young people and children. 85% of seniors have been vaccinated.

  The conspiracy people are hurting our country more than ever. They are allowing people to die every day because of their fear, misinformation, and stubborn ideologies against vaccines.   

  With three vaccines approved in the U.S. and Pfizer near permanent FDA approval, there are plenty of vaccines available.

  The FDA has approved Pfizer under the emergency approval process for those 12 and above, and clinical trials are still in the works for children 6 months-11 years to receive either Pfizer and Moderna.  So far, they are being well tolerated with good immune response with a full adult dose, but not yet approved.

Fear in pregnant women totally uncalled for!

  Finally, pregnant women who get infected with COVID-19 are much more likely to have pregnancy complications and the infants were more likely to suffer pulmonary and brain issues than those non-infected. These ongoing studies once again make a convincing argument for vaccination in pre-pregnant and pregnant women without fear of major side effects. There is no evidence of interference with fertility, pregnancy outcomes, and effects on offspring.

   Pediatrics, April 22, 2021

G. Vaccination rate status; antivaxxers are dangerous for our country!

  A private school in Miami, Florida will not allow their teachers to be vaccinated because the head of the school says those who get vaccinated shed the spike proteins making women’ menstrual cycle irregular, cause miscarriages and sterility. Shame on her! There is no scientific proof the vaccine can shed proteins (in fact it is impossible), according to Zubin Damania, M.D. reported in Medpage Today, April 29, 2021

  The President of the U.S. tells us we don’t have to wear a mask outside if fully vaccinated, and then is photographed in isolated outdoor situations with a double mask. Finally , due to social pressures, he is now going without a mask on TV.

Drop the mask when outside, and obey the rules of stores and restaurants!  Most grocery stores are dropping the mandate, and by the time I send this report out, all will probably relax their restrictions.

  Vaccines are safe even if there are rare cases of blood clots, and other issues. There is no 100% guarantee for safety with any medicine. Everything has potential side effects for a few.

  I remind the reader that people who even get a mild symptomatic case of COVID-19 can have symptoms for months after recovery called “long haulers” (headache, cough, shortness of breath, etc.). Please get tested, if you have COVID symptoms, out of respect for those who have been in contact (contact tracing is critical).

H. Mental health deterioration

  The mental health od our country is deteriorating before our very eyes because of the some of the steps taken fighting the pandemic. Everyone talks about the mental health of children. I include the adult population. We know about the drug and homeless issue, but the diminished socialization of our adults will resonate for years to come.

  Less friendliness, isolation from those who do not agree with specific ideologies, ridicule of how parents are raising their children, and now with the Woke movement and radical re-education of our youth in schools regarding racism, our country is falling right into more division of our country, as we walk down the path to socialism.  

I.  Blood clotting issues with Johnson & Johnson and Astra Zenica

  J&J has been taken off pause and available with a warning about the very rare occurrence of blood clots 28 cases in 9 million doses. Astra Zenica has had over 200 cases and is not available in this country. There are some restrictions for younger women in some countries. These issues have not occurred with the Pfizer and Moderna vaccines, since they are made from the COVID viral spike protein while J&J and Astra Zenica are made from an adenovirus. J&J has been declared safe for most people over 16 in that the value is much greater than the harm. If this is the only option, talk to your doctor about choosing this specific vaccine.

  If interested, here is an explanation about these rare  blood clots shortly after receiving J&J and AstraZenica COVID vaccines, Astra Zenica vaccine usually 5-14 days after the dose.

  This and the J&J vaccine have had some rare cases with blood clots but in an unusual way (low platelets occur). Low platelets usually cause bleeding not blood clots, but since two of the COVID-19 vaccines created the problem, it has been better explained. If interested here is the explanation:

Similarity with autoimmune reaction to heparin

  Heparin (1-2% of cases), an anticoagulant (blood thinner), can cause an antibody response in certain patients that drops the platelet count but not before these small blood platelets can collect in vessels blocking them off. Rare but can be devastating, these clots can lodge in extremities or other organs. Most of the clots that occurred with post vaccination cases were cerebral venous thrombosis-CVT (pulmonary emboli, cerebral hemorrhages, and other types were less common). Ironically, this is exactly occurred to Hiliary Clinton with a  fall.

  This is in contrast with blood clots from lower leg and heart emboli not associated with low platelets. The cerebral venous drainage system is seen on the left below while on the right (see arrow), there is a blood clot in the post sagittal vein (the arrow on the left points to that anatomical site in the veins that drain the brain into the internal jugular vein.

Among the antibody abnormalities is anti-PF-4 antibodies (PF=platelet factor) which drops the platelet count, causing bleeding and secondary thrombosis caused by the specific vaccines.

  The platelets are destroyed by vaccine-induced antibodies in extremely rare cases (vaccine). The second process occurs by rapid consumption of the platelets, which stimulates more platelets that can aggregate forming a clot, most commonly in these cases in the veins that drain the brain. The vaccines apparently accelerate the destruction of platelets and create a low platelet count.  

Medpage Today, April 23, 2021

J. Cancer does not rest in a pandemic

  I have reported on the devastating unintended consequences of delaying routine and nonurgent health screenings being put off for over a year, elective surgeries being postponed for months, mental health issues delayed, creating mental deterioration of our young people because of being kept from face to face school.

  Scared people stayed home with heart attacks and strokes for fear of catching the virus in emergency departments. It was a perfect storm of putting our country on its knees physically, psychologically, financially, and spiritually.

  Cancer diagnoses have been delayed, cancers have gone undetected because of the lack of screening, and they have grown and sometimes spread.

  According to the publication HealthDay (5/5/2021), 10 million cancer screenings were missed during this pandemic in the U.S., published in JAMA Oncology.

  A recent report stated that 91% of breast screenings were not performed, 79% of colorectal screenings, and 63% of prostate screenings. The screenings returned to pre-pandemic levels by July 2020.

  The authors also reported that telehealth visits helped people get screenings scheduled. A Spanish study reported a 38% increase in lung cancer diagnoses once hospitals could accept patients for screening. JAMA Oncology, April 30, 2021 

2. Long list of drugs cause Arrhythmias (irregular heartbeats)—know your medication’s side effects

  The heart can be slowed (bradycardia) or made faster (tachycardia) with medications, it can cause ventricular and atrial arrhythmias*, it can prolong the electrical heart beat, and cause extra beats to the points it can cause cardiac arrest. This subject has been covered in previous reports.

  * The heart is made up of 4 chambers—right and left atria and right and left ventricles. All chambers have electrical wiring, and anywhere along the circuitry can be influenced by medications and disorders.

  Recently hydroxychloroquine has been widely used in patients with COVID-19, and if a person has a normal healthy heart, chances are extremely unlikely to cause heart rhythm problems.

  Clearly people who are older and have heart or lung trouble should be very careful to make sure their medications do not interfere with these organs.

  An EKG is the easiest way to determine how well the heart is beating, has no electrical abnormalities, and no irregular heart beats. These cardiac abnormalities may not cause any symptoms, and even in very healthy, athletic, younger people can have silent heart issues that could suddenly end their life in certain circumstances.

  It is important to be aware of episodes of palpitations, dizziness, lightheadedness, occasional visual abnormalities, etc. as these could indicate a heart rhythm trouble.

  Taking a medication that has the potential to aggravate a silent (or otherwise) heart problem is a risk when taking a multitude of medications. And when a person takes cardiac and or lung medications, they are set up for even greater risk with drug interactions.

  Many medications over the counter also can cause heart trouble including decongestants, antihistamines, gastrointestinal meds, etc. Always read the label and search for side effects of any medication (prescription or not). It could save an individual’s life.

  A recent article in the journal, Circulation, published a landmark article providing statements from the American Heart Association. It discussed heart arrhythmias and an extensive list of medications that can affect the heart rate and rhythm. This list is quite long and the names are generic, therefore, I will provide a list of drug categories (with examples) that potentially can cause arrhythmias.  These are general categories and does mean every drug in a category causes heart rhythm trouble.

  Talk to you doctor about the medications you are on, as doctor’s visits today don’t allow time enough to discuss side effects of drugs in many cases (unless you insist). Patients need to be proactive in asking questions about this issue and any other concerns before the doctor has left the room. Knowledge about health issues today is critical. The good ole days are gone!!

CATEGORIES OF MEDICATIONS THAT CAN POTENTIALLY AFFECT THE HEART:

1. Dementia meds (i.e. Aricept for Alzheimer’s disease, Antilirium)

2. Local anesthetics (i.e.bupivacane-topical or injection)

3. Antiarrhythmics (Drugs to lower blood pressure and stop certain ventricular arrhythmias, atrial fibrillation,  i.e. amiodarone)

4. Anti-cancer (thalidomide, 5-Fluorouracil, trastuzumab, etc.)

5. Antidepressants (Celexa, Prozac, etc.)

6. Antihypertensives (Catapres, Beta blockers including eye drops—Tenormin, Coreg, Inderal, etc.)

7. Digitalis drugs (Digoxin)

8. Drugs for multiple sclerosis—Gilenya

9. Vasodilator/antiplatelet—i.e. Persantine, Brilinta

10. Anti-inflammatory meds (NSAIDs such as Voltaren), (corticosteroids)

11. Antipsychotic—(i.e. Thorazine, Clozaril for schizophrenia)

12. Biphosphanates for osteoporosis—(i.e. Reclast, Fosamax)

13. Bronchodilators—(i.e. Albuterol, aminophylline, Atrovent)

14. Marijuana and synthetic cannabinoids

15. Catecholamines—(i.e., epinephrine, dopamine)

16. Alcohol, amphetamines, cocaine, ecstacy, MDMA-Molly, opiods

17. Immunotherapy—(i.e. interleukin 2)

18. Viagra

19. Caffeine

20. Uterine stimulants, migraine meds—(i.e.ergometrine)

21. Antibiotics (i.e. Azithromycin, Levofloxacin)

22. Antimalarials (hydroxycloroquine—also for COVID-19)

23. Antifungals—(i.e. fluconazole)

  For those interested in the categories of arrhythmias, here is a report on them.

    a. Bradyarrhythmias

  This category implies the pulse is slowed (<60 beats per minute), heart blocks, pauses, etc. Drugs that interfere with the sympathetic nerves that govern our heart rhythm can create this problem by affecting the electrical “nodes” in the heart muscle that create the heart beat.

   Treatment of these arrhythmias may include stopping the medication or adjusting the electrolytes in the body (especially potassium). Certain underlying diseases can predispose a person to these types of arrhythmias such as hypothyroidism, electrolytes abnormalities, and infection.

    b. Supraventricular tachycardias (ST)— there are 3 major types of ST—1) Atrioventricular nodal reentrant tachycardia-most common 2) Atrioventricular reciprocating tachycardia 3) Atrial tachycardia

  These episodes usually last 10-15 minutes and is of concern when happening frequently.

  Drugs that aggravate atrial fib. can do so in many ways based on the direct effect on the heart. These are treated with carotid massage, vagal maneuvers, beta blockers, and cardioconversion.

  Addressing the possibility of clots forming requiring anticoagulants must be considered even after stopping a drug that may have been the culprit. Alcohol will aggravate Afib as well. Evaluation of certain tests (D-dimer) to diagnose emboli should be considered among other tests.

  Transesophageal electrocardiography can help delineate the possibility of an atrial clot. If the rhythm does not convert to normal within a short period of time, electrocardioversion may be considered but after anticoagulation has been achieved.

    c. Atrial Tachycardia (AT)

   Stimulant type drugs can cause AT.

  There are also medications that can convert Afib as well (Tambocor, Rythmol SR, Sotalol, amidarone).

    d. Paroxysmal Atrial Tachycardia (PAT)

  It is not known how many cases are drug induced, but it is a common arrhythmia. Stimulants and certain psychiatric drugs, certain diuretics, and even corticosteroids can cause PAT.

    e. Drug induced ventricular arrhythmias

  Ventricular tachycardia(as opposed to atrial arrhythmias) are quite dangerous and can be associated with cardiovascular disease, cardiomyopathy, congenital heart disease, and sarcoidosis.

  Certain anti-arrhythmia medications are to be avoided when treating these cardiac abnormalities. Avoidance of known medications causing these heart problems is obvious, but if present after stopping a possible causal drug, cardioversion should be considered.

  Patients with known ventricular arrhythmias may need implantable cardioconverters (defibrillator) to shock the heart because of a sudden ventricular tachycardia which could lead to ventricular fibrillation, a lethal rhythm disturbance unless cardio-resuscitation with cardioversion is performed.

   f. Torsades De Pointes

  There are over 200 drugs on the market that can induce this syndrome. This has been reported as a side effect on hydroxychloroquine, a drug being used to treat COVID-19 (without evidence based value), but with significant reporting on its value. This cardiac abnormality causes a prolonged Q-T interval of the EKG’s QRS heart beat. Azithromycin in combination can both cause the abnormality. Other common antibiotics can cause the problem as well. Although rare, this abnormality can lead to ventricular fibrillation and death.

  Electrolyte abnormalities (potassium, magnesium, and calcium must be addressed to prevent this abnormality.

  Obviously, drugs with the potential to cause Torsades should not be given. Baseline EKGs should be performed when any drug that potentially can cause this abnormality.  Intravenous potassium or magnesium is necessary if these electrolytes are low.

  In summary, avoiding drugs that could possibly create cardiac arrhythmias would be wise in patients with pre-existing cardiac disease, electrolyte abnormalities, or those who are extremely ill with infection or other crises.

  Baseline EKGs are clearly needed in most cases when the drugs are clinically necessary and advice must be given to the patient to be on the lookout for any evidence of dizziness, lightheadedness, faint feeling, palpitation, or feeling an irregular pulse.

  It is often necessary to take medication with side effects because of the severity of the illness. Risk/benefits should always be discussed and alternative medications considered.  

The American Heart Association Scientific Statement published in Circulation, 2020

3.  What is a Liquid biopsy for cancer?

A liquid biopsy is a blood and other bodily fluid tests that can detect certain abnormalities from cancers that can appear in a blood sample. The drawing above shows some of the abnormalities that can be detected. The specificity of these abnormalities may not point directly to an organ, but can stimulate further testing to find a silent cancer including imaging and biopsies to confirm the presence of a tumor.

  We have had cancer screenings to detect asymptomatic tumors for decades. Exams (breast exam with mammogram, pelvic exam with Pap smear, prostate exam with PSA, colonoscopy with stool specimen for blood and DNA) can save lives, as much as 20%.

  There is early evidence that examination of certain genetic markers and chemical changes in the saliva, brain fluid, and mostly blood from tumors can provide evidence that there is an increased risk for certain cancers. There are already biologic markers well known in ovarian (CA- 125), prostate (PSA), colon (CEA blood test; Cologuard stool sample), and breast cancer (BRCA 1 and 2).

  Before these tests came about, DNA was found in bodily fluids from several diseases including cancers, inflammatory disorders, stroke, trauma, and sepsis.

  Dr. Nick Papadolpoulos, Johns Hopkins School of Medicine, was one of the first to imagine a blood test to diagnose cancer. There is intensive research seeking these biomarkers. Out of 100 different types of tumors, there are only screening tests for five cancers (cervical, breast, colon, prostate, and lung).

  “About 71% of deaths occur due to cancers that have no routinely recommended early detection testing”, according to Dr. Joshua Ofman, chief medical officer of a health care company developing liquid biopsies (quoted from CURE magazine Fall, 2020).

  The first FDA approved liquid biopsy was approved in 2016 for a certain type of lung cancer (EGFR-mutation). This makes these tumors susceptible to 2 targeted therapy medications—Tarceva and Tagrisso, which have given these patients more months of life compared to those without these markers.

  Later scientists discovered that changes in liquid biopsy results correlated with a positive response to chemotherapy. This has also been valuable in using immunotherapy as a cancer treatment.

  From there, it became evident that genetic markers could be detected even before the cancer had been diagnosed clinically in certain cases. Ovary (CA-125, CEA, CA19-9) and liver(Alpha fetoprotein--AFP) have reaped the highest results with known genetic markers.

  It also can detect molecular structural changes in cancers that can affect treatment during a course of therapy or following it (drug resistance). The NCI cited 77 different studies underway globally but are not yet for overall clinical use (still in clinical trials).   

  The FDA has approved a blood test (so called liquid biopsy) Guardant 360 CDx. It is the first comprehensive blood test performing genomic profiling across all solid tumors.

  This test can help determine what chemotherapy is chosen when a cancer is diagnosed. It is also helpful when certain treatments are not helping. The test results take 7 days.

  These results are much better for some cancers than others. This is not a test that normal healthy people should jump to, but might be appropriate with a strong family history, a history of previous cancers, and other factors that might suggest screening a family for certain cancers.

  The classic example is BRCA genetic mutation for breast and ovary cancer (80% and 50% chance respectively).

  Below is an example of the effectiveness pointing out that only 43% of cancers were caught early with this test. However, over time, as more genetic markers are discovered, the detection rate will climb. Blood, urine, and bodily fluids (cerebrospinal fluid, saliva) may be sources of DNA, RNA, proteins, cells and cellular particles from the cancer.

Cancer cells have DNA that can be detected in the blood and other bodily fluids of individuals theoretically before a cancer can be detected. It is hoped that some day, standardized tests may be offered just as a mammogram, etc. However, some of these markers do not point to a specific area of the body where the tumor can be detected. PET scans, etc. would be required to pinpoint abnormalities.  

  False positives do occur. This is early in the game, so enthusiasm must be tempered with the science. The National Cancer Institute (NCI) supports extensive research in this area.

  There are also liquid biopsies used to detect the status of a tumor or recurrence of cancers and can be extremely helpful even before there is any evidence of visible spread or shrinkage of a tumor.

  Targeted therapy is based on these biomarkers as well, and have advanced the proper treatments in many cancers.

  Only about 5% of cancers are hereditary. Most cancers lack well-established biomarkers, but DNA abnormalities are being detected in these research projects which will lead to clinical studies using patients. However, beware of internet sites citing tests that can detect cancer. Depend on your doctors to research these advances.

  Another test is coming to the U.S. but not FDA approved, the novel Galleri blood test (GRAIL, inc.). The company claims with one blood test, it can detect 50 different cancers. The first places this will be used is in Washington, Oregon, and California (Providence Health System). It will be use to complement other screening tests. Experts in this field at Fred Hutchinson Cancer Center in Seattle, stated that this test should be viewed as one which is under investigation and not ready for general use. There is a pilot study in the U.K., but when it gets to the U.S., expect a media blitz. What little information is available, the early cancers are found in only 18%.

Medscape Medical News, April 17, 2021

  This is an exciting area of medicine being able to use blood and other bodily fluids to determine the best treatments. It is similar to testing a bacteria and find out the best antibiotic to use.

NIH, College of American Pathologists

  By no means will these liquid biopsies replace the standard of care screening techniques for cancer. These tests will add to the battery of diagnostic tests to detect cancer earlier and save lives.

CURE MAGAZINE IS A FREE PUBLICATION TO PATIENTS AND FAMILIES OF CANCER SURVIVORS. LOG ON TO www.curetoday.com The publication is online and hard copy. It provides cancer updates, research news, and education for the layman and healthcare professionals. I highly recommend it.

4. Torn knee cartilage—physical therapy vs surgery  

Torn knee cartilage creates a problem in healing.  Cartilage does not have its own blood supply. It is nourished by the fluid in the joint, which comes from the lining of the joint called synovium.

  Because the cartilage rarely heals well, it has been managed by and large by surgical treatment. Decades ago, the entire cartilage was removed only to realize that was a mistake. I was one of those who had one removed.

  The New England Journal of Medicine released an article describing a study comparing physical therapy to surgical treatment. A 2003 study reported that physical therapy was equally valuable to surgery at 6 and 12 months, but 35% of those choosing physical therapy converted to surgery.

   Now the same group of patients have been continued to be followed. The new study appeared in the February 18, 2020 Journal Watch of the NEJM.  

  After 5 years of following these people with a torn cartilage and mild to moderate osteoarthritis, the results remain the same for the majority of the patients.

  Pain and function were the two main criteria for these results. After 24 months the amount of relief of pain and function of the knee plateaued in both groups. Of course, repeat injury and progression of arthritis had to be similar in both groups to keep those factors from interfering with the results. This was true with partial cartilage removal (menisectomy), but those who underwent a total menisectomy were more likely to undergo a total knee replacement (10%) vs 2% who were in the physical therapy group. I am also one of those who required a total knee replacement, although to be fair, both knees required replacing.

  Bone on bone occur from wear and tear even without an actual torn cartilage. Once that occurs, pain increases and requires management.

  Synvisc gel injections are effective on the short term, but ultimately a total or partial total knee replacement needs to be performed.     

  It would seem appropriate to consider physical therapy initially in uncomplicated torn cartilages at least for the first year.

  Once surgery has been performed, the likelihood of a knee replacement is more likely, based on this study.

  This information should be discussed with the orthopedic surgeon and a physical therapist. All surgeons utilize physical therapy at different rates. Some are quicker to recommend surgery. A second opinion may be in order, but the extent of torn cartilage will also determine the pathway to management.

  Removing cartilage puts the ends of the bones closer together and is more likely to initiate more arthritis, pain, loss of knee function leading to eventual bone on bone results and the necessity for replacement.

  Guidelines for a torn meniscus

1. A minor tear should heal significantly in 6-8 weeks. During that time, a knee brace may be recommended to support the knee. Rehabilitation should be supervised by a licensed physical therapist. Use of NSAIDs (Aleve, Ibuprofens, etc.), intermittent icing, and elevation will help swelling. There could be bleeding in the joint space, and it will take time for that bloody fluid to resolve. 

 Two types of meniscus tears

  Above are two drawings demonstrating a tear causing a flap of cartilage to lift up and displace. A bucket tear occurs with the tear forming a semicircle. There are actually 5 different types of tears.

  The knee has two cartilages--one for the femur and tibia. The menisci serve as a cushion between the tibia and femur, provides stabilization of the knee, helps with load bearing of the knee when lifting heavy objects, and separates the femur from the tibia. 

  Symptoms of a torn cartilage include a popping sensation, the knee locking out of place with difficulty straightening the knee, pain, swelling and stiffness, a feeling of instability when walking.

  Rotation of the knee especially with weight on the knee is usually the cause of a tear. When I tore my meniscus, I heard an audible pop and the knee locked on me while playing tennis.

  Tears can occur with or without ligamental injury and must be carefully evaluated in any injury..

Partial menisectomy

  Normally a partial meniscectomy is performed endoscopically, with the goal of retaining as much cartilage as possible. Stitiches may be used for a smaller tear or the torn piece may need to be removed.

  The endoscope requires a puncture type wound to access the knee. 3 endoscopic instruments are used to irrigate fluid, suction, and utilize tiny instruments to remove the torn cartilage, needle holders to suture the tears.

A total meniscectomy would involve removal of most of the cartilage, although, that is a last resort if the cartilage is chewed up from the injury. If removed, there are cartilage implants of artificial gel implants that can be placed.

   In less damaged cartilage, an alternative technique is available taking the patient’s own cartilage which can be harvested and grown in a laboratory. This is called autologous chondrocyte implantation and injected into the damaged cartilage. These implants take 9-12 months to heal.

  Cartilage transplants can also be used from from a cadaver. 

  Below is a gel implant on the left and injectible cartilage from cartilage cells grown in the laboratory.

The above left drawing shows donor plugs taken and implanted in the damaged area. The photo below shows a cartilage transplant, replacing a torn cartilage.

The result of trauma, recurrent or with injury creates a loss of the space between the femur and tibia, where eventually bone sits on bone causing considerable discomfort over time. Below is an example of a normal knee on the left and extreme narrowing of the joint space of the knee. 

Note the narrowing of the joint space especially on the inside of the right knee.

  There are orthopedists who specialize in these procedures, usually in large groups of these surgeons.

5. New additional surgical treatment for obstructive sleep apnea

       Mayo Clinic (above) drawing of normal and apnea airways

  Having spent many years perfecting the procedures for patients with resistant obstructive sleep apnea in my practice, it is always satisfying to see continued refinement on those procedures over the past 2 decades.

  I have reported on OSA in several reports over the years, and if you click on the SUBJECT INDEX on the homepage of my website www.themedicalnewsreport.com

Scroll down to the O section and you will find everything you could want to know about the diagnosis and treatment of OSA.

  In this report, I will discuss the results of a paper published in JAMA, September 4, 2020 regarding the procedures used to treat resistant OSA.

  There are a significant number of patients (50%) with OSA who do not respond to CPAP, BIPAP, dental appliances, weight loss programs, etc.

  A diagnosis of OSA is made in a certified sleep disorders center performing a polysomnogram, which I have described in detail previously.

  It is estimated that 10-17% of men and 3-9% of women have clinically significant OSA. Risk factors for OSA start with obesity, a short neck, dental and facial abnormalities, a large tongue and tonsils, and often there is little anatomic evidence of obvious issues.

  Anyone who snores at night should be suspect of having sleep apnea. Breath holding intermittently between snores is classic. Anyone who has this disorder is at higher risk for airway complications with surgical procedures, and should be pointed out to the anesthesiologist in preparation for general anesthesia or heavy IV sedation.  

  If oxygen levels drop substantially during apneic episodes (below 90% oxygen saturation), has at least 15 episodes of apnea that last more than a few seconds (usually 20 seconds or longer), then the disorder deserves treatment.

  This disorder causes daytime drowsiness and danger of accidents and effect on work and quality of life, nighttime heart irregularities (arrhythmias), hypertension, deoxygenation, pulmonary hypertension, and stress on every organ in the body including depression.

The classic procedure for OSA is the UVP—uvulopalatopharyngoplasty with or without tonsillectomy. This includes shortening the soft palate, removing the tonsil tissue, and removing redundant throat tissue.

  The only problem has been dealing with the tongue, which falls into the back of the throat, obstructing the airway. There is little that can be done in patients with short thick necks.

  Patients with OSA are usually overweight, and that must be addressed, however, the anatomical abnormalities in the throat and neck may not respond to that alone, but usually will help.

New procedure adds to success

  Reducing the size of the tongue has always been a challenge, and there have been procedures devised to move the mandible forward with jaw surgery (orthagnathic surgery), and even wedges of tongue have been removed, but these procedures are extremely invasive.

  A newer procedure using a radiofrequency wave to reduce the bulk of the base of the tongue is showing very promising results.

  Radiofrequency ablation, commonly used throughout the body, especially for pain management of pinched spinal nerves, used to reduce the size of metastatic cancers, etc.

  Radiofrequency generates heat from radio waves. It can help shrink areas around a pinched nerve, help migraines, and arthritis.

Procedure of Radiofrequency volume reduction of tongue

  7-9 passes of wand with a broad needle is inserted into the tissue of the back of the tongue allowing the radiofrequency waves to shrink that area. This wand is introduced under superficially just below the surface (submucosal to tongue muscle).

  The procedure takes only 5-10 minutes and usually requires repeating 5 times to attain the best results. It is performed under local anesthesia as an outpatient.

Illustration of the wands used in radiofrequency ablation procedures

  By using this procedure with little complication, over 6 months, the tongue will shrink to enable the patient to breathe more freely, reduce the number of apneic episodes to the mild or moderate categories, and will greatly reduce daytime drowsiness and quality of life issues. Unfortunately, in many cases, CPAP may still be necessary, but with milder episodes, the toleration of the mask CPAP is greatly enhanced.

Results

  The average number of apneic episodes in one study was 47 (apnea index), and with these surgeries, the number of episodes dropped to 20 (which is still mild OSA). Bed partners report less snoring which improved both of their night’s sleep. Oxygen saturation improved and more normal nighttime blood pressure was achieved. 

  Without addressing all anatomical abnormalities contributing to sleep apnea, there is little chance of complete cure, however, more than 50% improvement of the number of apneic episodes will improve daytime drowsiness. However, relieving cardiovascular complications (hypertension, arrthymias, heart failure, etc.) from OSA must be improved to reduce ultimate mortality rates.

  If weight loss does not occur (because obesity adds to the bulk of the neck), the results of the surgery will be less than desired. This requires cooperation from the patient with motivation to assist in the relief of OSA.

Maxillomandibular surgery and electrical stimulation of the tongue

  If there is a narrow dental arch, this forces the tongue into the throat while asleep, and jaw surgery may need to be addressed. A short jaw also projects the tongue into the back of the throat. I have reported on these procedures previously. Electrical stimulation of the tongue is also an option that creates more tongue rigidity preventing the tongues from totally obstructing the airway. This requires a pacemaker with electrodes implanted in the tongue permanently.

  There is no one-size-fits-all with OSA, and restarting CPAP may need to be used in certain cases as they are losing more weight.

  This is a very serious disorder, and with the obesity epidemic in the U.S., there appears to be increasing numbers of patients with clinically significant OSA.

  Patient selection is critical and surgical treatment should be reserved for those unable or unwilling to stay on CPAP every night. Surgery is difficult but rewarding in the right patients. My experience performing this surgery resulted in similar results. I always emphasized continued weight loss, long term follow up, and reporting of worsening of symptoms.

  Specialists in sleep medicine and ENT surgeons with extensive experience should be consulted.

JAMA, September 4, 2020

6. Probiotics

  A recent annual national conference by the American College of Gastroenterology (Ocober 26, 2020) presented findings on the use of probiotics and its value in gastrointestinal conditions.

  Probiotics are living microorganisms that are beneficial to the gastrointestinal tract. Certain foods contain these beneficial organisms—yogurt, some cheeses, kombucha, sauerkraut, miso, pickles, and raw unfiltered apple cider. Many foods have probiotics added to them.

  In preterm infants, the American Gastroenterological Association recommends specific probiotics to prevent necrotizing enterocolitis (a serious gastrointestinal disorder), but does not recommend  them for children with acute infectious gastroenteritis, or those with Crohn’s or ulcerative colitis, except in clinical trials.

  It is recommended to prevent antibiotic induced diarrhea in children and adults, and those with toxic liver disease. It is not recommended in acute pancreatitis.

  Probiotics can reduce cholesterol in some patients and may reduce the effects of childhood milk allergy. Some studies state there is evidence it may help depression using lactobacillus and the supplement methionine. Certain probiotics may reduce blood glucose in diabetics who take metformin.

  Immunocompromised patients and those with a short bowel syndrome may be harmed taking probiotics.

  Pouchitis* in both children and adults should be treated with a specific 8 strain probiotic regimen.

   *pouchitis is a pouch formed in the lining of the gut, when those with ulcerative colitis who require their colon removed.

  According to a specialist at Mayo clinic, the use of probiotics helped relieve functional symptoms of GI disorders improving diarrhea, bloating, abdominal pain, and constipation.

  Mayo Clinic used a 5 strain bacterial probiotic including Bifidobacterium strains, Lactobacillus sp., L. acidophylis, L paracasei, etc. alone or in multiple strains.

  It is well known that gastrointestinal diseases alter the gut bacteria (microbiome). These probiotics help balance the GI tract’s bacteria. In this study, each (188) participant received one capsule daily containing the probiotics. 85% of participants reached anticipated improvement of symptoms over 30 days. Only 8% reported side effects.

  Multiple studies have shown significant benefit. It deserves discussion with a physician if a gastrointestinal disorder exists.

  Taking antibiotics is the most common way the gut bacteria can be altered increasing the risk of harmful bacteria (C.diff.) and overgrowth of yeast causing infection in the mouth and rest of the GI tract including the vagina.

  I have previously reported the value of probiotics in reducing the risk of a severe gut infection such as C.diff. usually contracted in the hospital.

  Discuss the proper probiotics with your gastroenterologist or primary doctor to get the best chance of improvement of gastrointestinal symptoms whether from IBS, small bowel or large bowel disease.

Probiotics-Facts of Fiction, Medscape, March 3, 2021

 This completes the June report. Enjoy the summer, and stay well. If you have not been vaccinated, please do so.

 Next month, July, there will be shorter subjects will be:

1. Growing up in a foster home

2. Weight loss drug recalled

3. Some older Americans being left behind using telemedicine

4. Screening children for hypertension

5. Omega-3 fatty acids and cardiovascular disease

6. Statins reduce mortality by 25% in people over 75

Stay healthy and well, and get vaccinated!!

Dr. Sam