The Medical News Report

December, 2022

#131

Merry Christmas

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for December, 2022

1. The latest on COVID, RSV, and Flu

2. Cardiovascular and other diseases caused by triglycerides—the other fat; Statins update

3. Losing Weight—Diabetic meds vs Bariatric Surgery; drug shortage

4. OB/Gyn Series-Part 7—BRCA gene mutations—new information on multiple cancer risks

5. Spirituality and serious medical illness

6. Nursing and Physician Shortage; the future of our hospital care; Medicare Advantage may not be an advantage!

7. Comment on the midterm election

“A Child is Born”!!

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 treat

ment, 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 down before going for a visit.

1. Comment on COVID and the bivalent dose; RSV and Influenza:

  COVID bivalent vaccine and the previous standard vaccine, are the same in preventing milder infections (43%), but both types still decrease the severity of an infection, fewer hospitalizations and deaths, but the bivalent vaccine does a better job than the standard doses did. And now COVID is being greatly outpaced by RSV and influenza.

  The CDC continues to recommend the new booster, even if people have had the 3 (or maybe 4) standard doses. That goes for people who have not had a dose or infected for at least 3 months.

  People should be free of symptoms before receing a booster, and if in the 20% of those who have persistent (long COVID) symptoms, must discuss this with their physician. I would be concerned taking another dose if I still didn’t feel totally recovered. We still do not have good studies defining how long infected patients have reasonably good immunity. Experts differ in this area.

These are recommendations only, and some experts state that the new bivalent dose is for older Americans and those compromised in some way by underlying diseases that increase the risk of a more severe infection.

  For the rest of the population, it is a personal decision that guides the rest, and yet, the CDC recommends the vaccine for everyone over 12. And Biden in his recent foreign relations trip sided with several countries to require a COVID passport to fly!! China has locked down its country because of COVID, but many are questioning the real reason. Want to be like China?

  The bivalent booster covers the latest variants beyond BA.4, BA5; now BQ.1 and BQ1.1, the dominant variants in the U.S. The bivalent booster does not cover the latest BQ variants as well as the BA variants.

  The latest data is showing that those totally vaccinated are being hospitalized as often as the unvaccinated, therefore, it would helpful how the CDC defends their recommendations.  

  Because all 3 infections are in the mix now, masking recommendations may become stronger, but common sense is always very smart.

  Flu and RSV infections are filling the pediatric beds (14,000 children now), and with winter approaching, expect a rise in adult hospitalizations as well.  This is no surprise after isolation dropped our immunity for many viruses.

   When experts don’t agree, what are the rest of us to believe? Ask your doctor!!

For those who become symptomatic with a COVID infection!

  Those who become symptomatic are still encouraged to be tested for both COVID and flu, and if test positive for COVID, take an oral antiviral prescription (Paxlovid or Lageviro), especially in those over 60 and worried about a more severe infection (must be taken within the first few days of symptoms). Tamiflu is also recommended for early flu.

  For those more prone to a severe infection, monoclonal antbodies (bebtelovimab), a one time IV injection, are available at many clinics, ugent care, etc.

  RSV could be presumed in a young child or a senior patient, if negative for flu and COVID. There is no treatment for most patients, but should be admitted if sick. Diagnostic tools are available, but how available may be a question.

CDC Website

    It is a no brainer to receive all the COVID vaccines, and the recent flu shot if immunosuppressed, much older, or have underlying significant medical conditions regardless of age. Reinfections can still occur, but usually milder, even in the all vaccinated.

  Trust your doctors about an individual’s decision for multiple doses of the COVID vaccine.

  The flu and RSV season is early and filling the pediatric beds in some areas of the country including the southeast, with winter challenging us greatly.

  Get the flu shot as quick as you can, and make sure the kids get vaccinated. 14,000 beds have been filled. This is also stressing the shortage of healthcare workers.

RSV (respiratory syncytial virus) appears every year, but because of the pandemic, shutdown and masks in children, there has been what is called an “immunity debt”, which means kids and even adults have not been exposed to random viruses that can raise immune systems without any symptoms. 95% of infectious disease cases are from these 2 viruses (COVID isn’t in the running and we have mandates????). Most of the hospitalizations are in those with underlying conditions. RSV does not discriminate, and flu is worse in kids if they have respiratory issues chronically. Electron Microscopic photo of RSV.

RSV is the most common cause of bronchiolitis and pneumonia in young children, and the flu has always been more significant in kids than in COVID. Older seniors compromised in some way medically can be infected and develop pneumonia.

  Medical staff has been exhausted and overworked because of these hospitalizations (and pandemic), but in no way am I condoning any school closures and continue to be amazed that the schools are still insisting on masks (the ones they use don’t work), most of which are not the type that are efficient.

  Our children cannot be mistreated this way anymore with the mental and academic consequences of these questionable measures, much worse than COVID.

  The CDC and administration have been derelict in addressing these enormous consequences because of the mismanagement of the pandemic. And they won’t even deal with the origin of the coronovirus, thanks to the NIH’s funding this “gain of function” research in our country, Ukraine, and Wuhan, China.

  Washington D.C. is requiring proof of a negative COVID test for kids to return to school after the Christmas holiday!!!! (School boards and teacher’s unions).

  We need to make sure kids are not unnecessarily exposed to large groups of children without the hand cleansing and covering their mouth with cough or sneezing. Do not let your child attend school sick for any reason.    

  Children with any infection should be isolated from vulnerable seniors. Everyone must do their part in contending with this expected rise in these viruses.

  Unfortunately, the AMA and Academy of Pediatrics are trying to get the administration to create another emergency declaration on these viruses, and thankfully they have refused. These organizations are the socialist arm of medicine today, and a large number of physicians have resigned from them because of political actions, including me. The socialist movement is alive and well.

2. Cardiovascular and other diseases caused by elevated triglycerides—the other fat; Omega 3 fatty acids—important treatments and other uses

A. Opening remarks

  Triglycerides are the other bad fat, with cholesterol #1 (especially LDL). Elevations can occur in one or both of these fats (lipids). Checking the blood cholesterol will not usually include triglycerides unless the doctor adds a more extensive survey of blood fats--the Lipid profile.

  Fats are necessary for a normal functioning body, if in normal levels. Triglycerides play a good role in the cardiovascular, immune, pulmonary, and endocrine systems for normal function.

   Elevations of cholesterol and triglycerides will be present for decades before causing trouble, therefore, discovering elevations of the fats by age 40 should be performed, especially in families who are overweight, have diabetes, and heart disease. Overweight children should be checked too!

  Hypertriglyceridemia has been estimated to be present in as many as 35% of people and can increase the risk of cardiovascular disease by 30%. Diabetes, obesity, and sedentary habits, excess alcohol intake, and fatty diets are commonly present in these patients. These and other issues make up the Metabolic Syndrome, which raises risk considerably.

Triglycerides cause or contribute to disease

  Very few people know much about triglycerides, even though it is of great concern for people with cardiovascular disease, liver, pancreas, and kidney disease, and even those with a family history.

  Until the 1980s, triglycerides were not even thought to cause disease, but after decades of research, it became very clear, triglycerides, especially at high levels, can contribute to disease in several organs.

  Triglycerides are carried from the liver to the body using special lipoproteins, in a molecule called a chylomicron. When that protein is elevated in the blood, it picks up too much of the liver triglycerides and is seen elevated in the blood. This fat, just like cholesterol, can deposit in the lining of blood vessels, the liver and kidneys, and inflamed the pancreas.

  There are hereditary disorders of triglycerides, with elevation of beta lipoproteins, which can cause serious disease in these families—cardiovascular disease, non-alcoholic hepatitis with fatty liver, pancreatitis, and kidney damage. It has a higher incidence of type 2 diabetes.

    There are 5 types of hyperlipidemia in the Frederickson classification of hereditary hypertriglyceridemia, but are rare. Unfortunately, I have Type 3.

B. Lab tests and physical effects

  Those who have these diseases must have a complete lipid profile to not only evaluate the levels of triglycerides, but the various types of cholesterol (based on the density—HDL, LDL, etc.).

  A complete workup should include triglyceride levels (requires 10 hours of fasting), TSH (thyroid stimulating hormone), fasting blood sugar, liver function studies, ultrasound of the liver if a fatty liver is suspected, urinalysis, kidney function studies. Special tests to determine the hereditary types are necessary.

  Elevated triglycerides do not cause symptoms unless they are quite high (over 500-2000mg/dl), but when that high cause GI upset (from inflammation of the pancreas), difficulty breathing, fatty tumors in the skin (xanthomas—seen in below photos, and can cause a ring of fat around the iris of eye (arcus), shown above, and fatty tumors in the eyelids (xanthelasthma), also shown above.

Xanthoma

Xanthelasthma

Arcus senilis=triglyceride deposit around the edge of the iris

Refer to my website regarding fats with 3 different reports that can be found in the Subject Index on cholesterol at: www.themedicalnewsreport.com.

There are certain types of fatty acids that will lower triglycerides, primarily Omega-3 fatty acids. Omerga-6 fatty acids don’t help lower these fats, but may ply a role in normal metabolism.  

   1--Foods that contain omega 3 fatty acids

  The proper amount of triglycerides (carried in the blood as chylomicra) are a major source of energy, converted by the liver to glycerol for energy use by the cell.

  Omega 3 and other fatty acids are not made by the body and must be ingested, especially in some fish, seeds, and nuts, and 250-300mg need to be consumed per day. 2 servings of fatty fish a week (salmon, mackerel, cod liver oil 1 tbsp daily, tuna, herring, oysters, sardines, anchovies, caviar, flaxseed, soybeans and nuts, especially walnuts are valuable.

  Incidentally, the chemical GABA, gamma aminobutyric acid, found in many foods including beans, barley, peas, and rice, which can lower triglycerides and are natural relaxer of the brain, may be another source of help. It is an anti-inflammatory substance as well, and is available as a supplement.  

  Although less in amount, eggs, meat, and dairy products from grass fed animals, hemp seeds, spinach, and Brussels sprouts also provide some omega-3s. Krill oil and omega 3 supplements can provide these nutrients. However, the diet doesn’t contain as much of the 2 fatty acids needed to lower high triglycerides (EPA and DHA), therefore omega 3 fatty acid treatment is necessary.

  There are two specific types known to lower triglycerides--EPA-ecosapentenoic acid and DHA-docahexaenoic acid.

  Prescriptions of Omega 3s are superconcentrated, refined, and prevent burping the taste of fish. Recent research has found that EPA is more important than DHA, as EPA has a higher association with reduction of cardiovascular events and death, however, these 2 are currently the treatment of choice for hypertriglyceridemia. The are options for other medications which may help prevent cardiovascular and other diseases.

  2--Without treatment,

  Without treating lipid abnormalities, heart disease, diabetes, fatty liver syndrome (non-alcoholic hepatitis), pancreatitis, kidney damage, and hypothyroidism may deposit on the lining of blood vessels and infiltrate cells that damage.  

  In the 1980s, it was finally determined that triglycerides were harmful and should be lowered. Normal levels should be less than 200mg/dl, but many people with triglyceride trouble will have 500mg/dl or higher (often 1000-2000mg/dl) and must be treated to prevent the above medical risks. Minimal alcohol, a low fat diet, weight loss, and monitoring of the organs must be performed regularly as mentioned above.

  If the triglyceride levels are well above 500mg/dl,  triglyceride levels at 100mg/dl must be considered.

   3-- Diet and exercise

  No more than 20% of the diet should come from saturated fat, and less than 200mg per day of refined carbohydrates (minimal sugar and white bread and pasta) with high fiber are highly recommended in controlling triglycerides and cholesterol. No more than one alcoholic drink per day is recommended, and weight loss will reduce triglycerides.

  30-60 minutes of aerobic exercise most days of the week is highly recommended. Toning exercises (light weights, isometric exercises, yoga) are critical to complement the aerobic activity. Of course, this must be approved by the treating physician. Proper monitoring and management of any underlying diseases is also very important, and if may require consultation with heart, kidney, and liver specialists.

   4—Omega-3 fatty acids, statins, fibrates, aspirin, OTC fish oil; statin intolerance

Statins

  Statins, if cholesterol levels are elevated, may be recommended in addition to Omega-3 fatty acid therapy. There are several brands available, and to prevent side effects, the lowest (effective)dose should be tried.

  If intolerance occurs, another statin is recommended, before bailing on statins (GI upset and muscle pain, and rarely liver damage, elevation of the blood sugar, and mental fuzziness are possible side effects), according to the Mayo Clinic.

   There is about a 7% risk for women, obese patients, those with low thyroid, advanced age, those taking anti-arrhythmics, those with kidney or liver disease, and heavy drinkers. Do not stop this or any drug prescribed without discussing it with the prescribing doctor.

  Atorvastain is one of the most tolerable and effective statins, however simvastatin (Zocor) is less expensive.

  The erythromycins (like the Z-pack) may interact with this statin, so if an antibiotic is necessary, please discuss this interaction, as this drug will increase the level of the statin by affecting a liver enzyme. Also grapefruit juice, HIV drugs, fibrates, anti-fungals, and some immunosuppressant drugs interact.

  Co-enzyme Q (Quinol, etc.) may help when taking these medications, however, the literature is not strong, but heavily marketed. Taking a break from statins for a month to see if the symptoms are really from the statins is recommended. All these options, according to Mayo Clinic, should be discussed with the prescribing doctor.

Mayo Clinic.com

  Those with active liver disease also must be careful taking statins, especially rosuvastatin. Statins are very effective in lowering cardiovascular disease-- 20-60%, so don’t give up on them quickly.

Fibrates 

  Previously fibrates (finofibrate, pemafibrate, or gemfibrosil) were prescribed with statins for triglyceride lowering.

  New studies report that even if fibrates lower the triglycerides, they do not lower cardiovascular events, but will reduce fat in the liver, another key issue. If a person has a fatty liver, a history of pancreatitis, or other organs diseases, fibrates might be considered. It could be added to omega 3 fatty acids in those who need more lowering of the triglycerides (even though they may not lower cardiovascular disease), but then aspirin and omega-3 fatty acid drugs do.

 Niacin

  Niacin, vitamin B3, may be recommended (more than 1500mg daily), and is a great add-on of one can tolerate the flushing and burning sensation that some experience. Incidentally, it also reduces the risk of developing precancerous skin (ask your dermatologist).

Statins and Omega-3 fatty acids

  Statins (atorvastatin 20mg--Lipitor) plus purified prescription Omega-3 fatty acids (EPA and DHA) (4 gms per day—1 gm per capsule) is most commonly recommended.

  Each capsule contains 465 mg EPA and 376 mg of DHA. 

  The combination has shown a significant improvement in cardiovascular events (EPA better), but never depend on medication alone to lower heart disease events, because these studies usually include medication with the appropriate behavioral changes.

  There are 2 very expensive refined omega-3 fatty acid products (Vascepa and Lovaza), however, Vascepa does not contain DHA, which may be an advantage based on recent studies. These prescriptions are refined and very concentrated into 1000mg per capsule and don’t taste like fish, and doesn’t make one burp a fish taste. 4000mg a day is the recommended dose, that means only 2 capsules twice a day is all it takes.

  In 2014, the FDA approved a free fatty acid form of capsule (Epanova), and Vascazen, a medical food which contains 680mg of EPA and 110mg of DHA which can be tried with a low fat diet.

  Prescription Ezetimibe (Xetia) is a fat blocker that may be added to the regimen in resistant cases and is effective in lowering cholesterol and perhaps triglycerides. It is expensive, but does work well.  

Over the Counter meds

  Aspirin improves cardiovascular protection too

  A recent article on aspirin benefit, found that those with elevated lipoproteins can help prevent some cardiovascular disease and added to triglyceride treatment my be recommended.

   A baby aspirin=85mg daily may assist the body in prevention of cardiovascular events even in those without lipid issues, by thinning the blood (reduces platelets). Of course, discuss these issues with your doctor before taking any medication regularly, even OTC meds (over the counter).

Medscape, General Surgery, September 28,2022

   Fish oil OTC

  Taking over the counter unpurified omega 3 fatty acids will require a person to take 12-18 capsules a day to get the sufficient amount of EPA and DHA to treat high triglycerides. They are not refined and will taste like fish and will make you burp a fish taste, which is very unpleasant.

Value of weight lifting to aerobic activity

  A recent article regarding the addition of weight lifting to aerobic exercise, and found that the combination gave a 40% decrease in all-cause mortality. That is amazing, so hit the gym!!

Pregnant patients

  Special attention for these patients is in order, and adjustment of treatment may be required. Pancreatitis is significant concern, because of the intra-abdominal pressure preventing good drainage of the liver, gall bladder, and pancreas is critical. Also gestational diabetes may occur and pre-eclampsia with serious hypertension must be avoided. That means weight management is critical. Consultation with a high risk obstetrician may be wise. Patients who have the hereditary types of hypertriglyceridemia are especially at high risk.

D. Monitoring and surveillance

Monitoring of blood triglycerides (and cholesterol) and attendant diseases require close monitoring, with frequent testing of blood sugar, weight, and diet management. Adjustment of medications, diet, and exercise regimens may be needed.  This article is very extensive:

www.e-medicine.medscape.com/article/126568-overview#showall

3. Losing weight; Diabetic drugs vs. Bariatric surgery; Shortage of diabetic drugs

I have reported on semaglutide (Ozempic, Trulicity,Wegovy) a good anti-diabetic medication to control blood sugar by regulating insulin, and was found to create as much as a 15% of body weight loss of pounds (that is 34 pounds for an average person).

  These anti-diabetic drugs were incidentally found to create weight loss in a high percent of patients even in non-diabetics, and now we are experiencing a shortage because of the demand, including the Hollywood crowd. However, the price is terribly high—over $1000 per month. GoodRx with its coupon cost $932 at Walmart, CVS, and Walgreens.

  Off label prescribing is being driven by TV ads, and doctors want their patients to lose weight, so it is no surprise they are prescribing it frequently.

https://themedicalnewsreport.com/Medical Report 114.htm

  Another new diabetic drug, tirzepatide (Mounjaro) also FDA was approved recently, and was found to create as much as 22% of body weight using the highest weekly injectable dose. This medication cost over $1000 per month as well. The FDA has only approved it for type 2 diabetes. The higher dose costs $1600 a month.

  It is unclear if prediabetics can qualify under insurance.

  Sadly, Medicare will not pay for these drugs if not diabetic, while it was stated on TV, that Medicaid did. Fake news!  

  Semiglutide benefits the cardiovascular system and thus far Mounjaro has yet to show that benefit.

  If obese, it seems to me to be a no-brainer for insurance to cover it, to potentially prevent bariatric surgery, an dlower ultimate medical conditions. Unfortunately, these drugs will have to be taken the rest of the person’s life, and if stopped the weight will return.

  Hopefully, the price of these drugs can be addressed as has the price of insulin. Also there are several ways to get assistance from the pharmaceutical companies by contacting them and discussing the need for assistance based on price.

Need for more research for weight loss medications

  With obesity on the rise and type 2 diabetes as well, this country must address these two crises. The media and marketing companies clearly are trying to normalize being overweight, and physicians are not reimbursed for trying to spending time on developing and following a weight loss program (which is rarely successful long term), and physicians are prescribing these drugs off label and have created a serious shortage of these medications. Much research is necessary to develop weight loss cost meds, but Big Pharm won’t touch it. We need federal funding.

Diabetics skipping doses to save money

  1 in 6 diabetics are not taking a full dose trying to spread their bottle of insulin over more than a month. Trump and Biden have promised to get the drug companies to drop their prices, and neither have been successful. The White House does not own Big Pharma…..Big Pharma owns them.

  Biosimilar drugs are now being developed in place of insulin, since it is in short supply, while insulin could cost a patient as much as $1000 per month. Funding of biosimilar cheaper drugs has been hard to come by for obvious reasons as well, and this should be a high priority for any administration.

Bariatric Surgery still a very viable option

  Weight loss drugs seem so simple, and but the failure rate has always been high because patients don’t want to take a drug indefinitely (at a great expense), and any drug requires a serious addition of a low calorie diet, exercise, and depending just on medications is only delaying the inevitable…weight gain and worsening of diabetes, etc.

  Bariatric surgery may reverse diabetes, and is known to reduce heart events, lower cancer rates, etc. For those with more than a hundred pounds to lose need to be realistic about their options.

  Please discuss the surgical route as an alternative. It is very successful, but like any weight loss program can be reverse in time, if the patient doesn’t limit calories, and stretches the altered gut. CALORIES IN….CALORIES OUT!!

  Bariatric surgery should be considered in patients with heart disease, weight loss program failure, uncontrolled hypertension, non-alcoholic fatty liver, sleep apnea, and hard to control type 2 diabetes. Those with a BMI of 40 is considered extreme obesity, according to Mayo Clinic, and is one of the indications for bariatric surgery. The BMI has been criticized in defining obesity and is getting a lot press lately.

   Extensive testing and evaluation is necessary to be qualified as good candidate for surgery. Overweightness is just one factor. Motivation is critical (with counseling) and should be required with long term follow up, monitoring of the diet, life style behavioral motivation, and maintenance of co-existing medical conditions.

  Rerouting the stomach with the small intestine creates the best type of bariatric procedure, but it is a much more serious surgery. Gastric narrowing procedures are getting more popular. Stomach bands are not near as successful.

Types of Bariatric Surgery

  Bariatric techniques include Roux-en-Y (small stomach pouch sewn to a lower small intestine area), leaving the stomach the size of a walnut (3 pints can normally fill a stomach). This essentially bypasses food right into the small intestine (causing the dumping syndrome for soemtine). This procedure is the most common, is permanent, and gives the best results, but has more complications, hospitalizations, and nutritional deficiencies needing attention.    

Gastric sleeve

Sleeve gastrectomy involves cutting about 80% of stomach and creating a tube like stomach attached to the small intestine. The latest data reveals fewer revisions and hospitalizations than the Roux-en-Y procedure, but the ultimate issue is what works best. This procedure is far easier for the patient, but recurrence of weight is a bigger problem within months to years.

  The Mayo Clinic has a short video showing the procedures, which are excellent. Click on their website and look for them.  www.mayoclinic.org

Once on their website, type in bariatric surgery!

  Biliopancreatic diversion with duodenal switch involves creating a gastric sleeve and the duodenum is cut and bypasses the gall duct and pancreatic duct openings and sewning the end portion of the intestine to the duodenum near the stomach bypassing most of the intestine.

Maintenance of nutrition is the goal with supplements and vitamins which would not be absorbed in these procedures.

  The advantages of bariatric surgery are many including resolution of diabetes, heart disease progression, high blood pressure resolution, relief of obstructive sleep apnea, fatty live disease, reflux, and weight bearing diseases such as arthritis.

Mayo Clinic

  Complications of bariatric surgery may include dumping syndrome (need to have a bowel movement when food is eaten), diarrhea, bowel obstruction, gall stones, hernias, low blood sugar, malnutrition, ulcers, acid reflux, vomiting, and the need for revision surgeries. But usually the risks are far outweighed by the benefits, which may include saving your life.

  These procedures are performed endoscopically.

  There is no quick fix for people who have a serious weight problem, and requires a great support system. Talk to people who have had the surgery, and don’t be naïve about pills being the answer without accepting the full package of a program, support, and determination to reach goals. Family support, physician support, and extreme dedication to the process are a necessity. The rewards are MANY!

  Ultimately, it is the experience of the facility, the surgeon, and their staff that should determine options in weight loss surgery. With all the medications helping weight loss, certainly surgery should be for those who fail to lose enough weight, those who are good candidates for a major surgical procedure, and are motivated enough to be an integral part of the team.

Mayo Clinic, The University of Rochester 

4. OB/Gyn Series—Part 7—BRCA gene mutation—Other cancer risks for women

The importance of genetic testing for cancers and other diseases has never been more important with research advances.

  It is well known how important the BRCA 1 AND 2 gene mutation is for women with a high risk for breast and ovary cancer and more recently pancreatic cancer, and now prostate cancer in men.  

  Research using screening tools* points out that 2-7% of breast cancers and 10-15% of ovarian cancers are positive for either the BRCA 1 or 2 gene mutation. Women who carry one of the gene mutations have a lifetime risk of breast cancer of 45-90% with over half before the age of 50 and a 30 fold increase chance of ovarian cancer.

*Referral Screening tools can be found on this website: www.breastcancergenescreen.org 

  Another study has linked polycystic ovary syndrome (PCOS) and pancreatic cancer (twice as likely). It is thought that both diseases are inflammatory in causation, and since PCOS can occur in families, a genetic link is suspected, but not known.

  Obesity and diabetes are also commonly present in these patients. Obese women store more inflammatory markers in fat, and it is thought to be a factor in the link between these diseases.

  Here are the genetic finding following 63,800 with an average age of 61.

These are cumulative lifetime risks for each cancer:

BRCA 1—breast-72.5%; ovarian-65.6%; stomach-21.3%; pancreatic-16%; bile duct-11.2%

BRCA 2—breast-58.3%; prostate (male)-24.5%; stomach-19%; ovarian-19.8%; pancreatic 13.7%; esophageal-5.2%

  Another study added other cancers including cervical, colorectal, and endometrial.

  Those who have BRCA 1 tend to be diagnosed earlier than those with BRCA 2.

  Who should be tested for BRCA gene mutaations in families should rest on the expertise of a genetic counselor, mostly found in university settings and large medical centers.

  I have discussed this issue before regarding Anjolie Jolie’s experience https://themedicalnewsreport.com/Reports/Medical Report 17.pdf

 Decisions for prophylactic surgical removal of breasts and ovaries would require genetic consultation with the best experts in the region, including cancer centers.

JAMA Network, April 14, 2022

JAMA Oncology, June 14, 2022

Family History factors influencing decision to test for BRCA gene mutation:

1- Breast cancer diagnosed before the age of 50.

2- A family history of bilateral or multiple breast cancers are at higher risk.

3- Ovarian cancer at any age.

4- A known member of the family with a BRCA gene or a member in the family with triple negative breast cancer (no hormone markers).

5- Ashkenazi Jewish relative with breast or ovarian cancer.

6- Male family member with breast cancer (maybe prostate cancer too!)

Patients with a positive BRCA gene mutation have options: 

  --MRI of the breasts often at the discretion of the treating doctor, Tamoxifen*, bilateral mastectomy, bilateral ovary and tube removal, and testing for family members.

*Chemical prevention (Tamoxifen, Raloxifen)

  For more information on prophylactic breast and ovarian (and tube) surgical removal click on my website:

https://themedicalnewsreport.com/Reports/Medical Report 27.pdf

  Men in the families of those with BRCA gene must be monitored more closely for prostate cancer and start testing for the PSA earlier. Those should consider discussion as early as 40-45, since that is the age that is acceptable to start discussions with a doctor when there are other men in the family with prostate cancer. For black men, regular screenings should begin at age 45 and other men at 50, according to the American Cancer Society.

Chemoprophylaxis--Tamoxifen

   There are patients who choose preventative therapies to prevent breast cancer from occurring instead of having prophylactic surgery or just having annual imaging exams. It is called chemoprophylaxis. There are estrogen receptor modifiers (Tamoxifen and Raloxifen) and aromatase inhibitors. These are also recommended after breast cancer treatment if the cancer is estrogen positive, and can cut the risk of recurrence by 40%.

  Tamoxifen is the primary treatment, but raloxifene can be used in postmenopausal women (originally used to prevent osteoporosis in postmenopausal women). These oral medications block estrogen production by the adrenal glands.

  Another class of estrogen blockers are aromatase inhibitors that lower estrogen levels by blocking an enzyme, aromatase, from changing other hormones into estrogen. They are not yet approved in the U.S., but they are effective. (Arimidex, Aromasin, and Femara). These are used in postmenopausal women. Reference--American Cancer Society www.cancer.org

KEY POINTs about home genetic testing—limited value

  23 and me at home testing only tests for three Ashkenazi Jewish mutations in BRCA genes and does not test for 98% of BRCA gene mutations!!

Summary

  As technology improves, so will the diagnosis of early breast cancers. It is quite important for breast cancer to be diagnosed as early as possible (long before they are felt in the breast). That is the value of mammograms, as they save lives! Ultrasounds may also be recommended, especially in large breasted women.  

  I have discussed breast cancer at length previously. Consult the Subject index in the website for multiple reports:

www.themedicalnewsreport.com

The American Cancer Society

Mayo Clinic; JAMA

  5. Spirituality and serious medical illness and health

  Spirituality and health has always been an integral part of health. Very few physicians actually bring up the subject when medical illnesses become severe. Saying prayers for better outcomes and thanking a higher power for recovery is as common as taking medication. But how can medicine quantify its value to acknowledge its value and perhaps promote it?

  As a devout Christian, I have always appreciated how important prayer helps suffering. Praying for good doctors is a good thing too! Doctors need to know that God can enhance their effectiveness, not replace them.

  In past years, when I checked into a hospital for services, there was a question about what denomination of religion I preferred, and if I would like for a specific clergy to make an in-hospital visit. NO LONGER! SHAMEFUL! At least in non-denominational hospitals.

  For those who believe in God and other higher powers, having someone praying over them can be very calming and reassuring to someone facing great medical challenges. Even a note or email with a prayer in it can lift one’s spirits, lighten anxiety and depression, and hopelessness. Knowing people care is a very valuable and  meaningful emotion. Prayer groups are out there just for the asking.

  People isolated, living alone, with very little family and friends tend to do much poorer with serious medical issues. COVID-19 made that very apparent when so many people died alone without a funeral or loved ones able to be by their bedsides. It was one of the most devastating unintendened consequences of the pandemic.

  Spirituality is expressed through beliefs, values, traditions, and practices. Believing in a higher power has great significance if the person truly feels that prayer will help them, give them peace, and allay anxiety in a difficult medical situation for themselves, their family, and friends.

  Prayer chains in churches are very common, and social media has allowed communication to be accelerated in nervous scary times. I recently had a carotid procedure and had several prayer chains, personal friends, family  praying for a successful procedure…and it was, and it meant so much to me. It may not be important for some, and that is their right.

  There have been hundreds of documented cases of miraculous cures, with no medical treatments, and there have been totally unproven methods that have been pointed to that have been responsible for recoveries from serious illnesses without any scientific proof they helped.

  We know that the placebo effect is real, and if someone believes prayer or even worthless medicine will help, a rise in endorphin measurements and other neurobiological chemical stimulations may have had a positive effect on the DNA of a cancer, a heart muscle, a lung disease, or any number of unexplained benefits for innumerable conditions.

  That is why doctors call it,”practicing medicine”, as the body and the science that is known is far from complete and proven. Also the mind body phenomenon is for real.

  The will to live is another important reason why people get better, regardless of underlying reasons….motivation, religion, beliefs, and faith in a higher power to assist the doctors in improving a condition.

  “Giving up”, grief, depression, and a feeling of helplessness can drop corticosteroid, epinephrine, norepinephrine from the adrenal glands, and other neurochemical substances such as dopamine, serotonin, glucagon, insulin, and other metabolites involved in metabolism and neurostimulation.

  A literature review was undertaken and published in JAMA Network, July 12, 2022 (8946 articles) pertaining to spirituality and serious illness.

  Categories of evaluation were 1) the role of spirituality 2) spiritual needs 3) spiritual care 4) medical decision making 5) and interventions.

  Spirituality and assessment of all-cause mortality, physical health, health behaviors, mental health, and quality of life is certainly worth a look.  

  Results of interviews over time with these patients provided this information:

 1) spirituality is important to most people 2) spiritual needs are common 3) spiritual care was commonly desired 4) spiritual needs are rarely discussed by the medical team 5) spirituality could be included in medical decision making 6) spiritual care is rarely included in medical care 7) unaddressed spiritual needs are associated with poorer quality of life 8) providing spiritual care improves better end-of-life outcomes.

  The authors came up with 8 health outcomes regarding frequent attendance of religious services—1) frequent lower mortality rates 2)  less smoking and alcohol consumption 3) a better quality of life 4) better mental health outcomes 5) less risky behaviors (sexual) including drug and alcohol abuse in adolescents 6) fewer depressive episodes 7) fewer suicidal attempts.

  The top 3 outcomes with attendance of religious services were based on observational research: 1) improvement came from incorporating spiritual care into medical care in 92.5% of the cases 2) outcomes were improved with spiritual training of the medical team in 79.3% of the cases 3) practitioners of spiritual care (chaplains, etc.) in serious cases improved the outcomes in 69.2% of the cases.

  The recommendations were obvious from the authors:

1) incorporate and encourage patients to attend religious services, Sunday schools, Bible groups, television and online programs etc. to improve patient centered care and population health.

2) educate medical students and residents and public health professionals the benefit of spiritual incorporation in medical care. Healthcare professionals need to believe that discussing religious needs will help them take better care of their patients. Acceptance of spirituality is  important is critical in the medical community for success. If a doctor does not want to incorporate this personally to medical care, add a chaplain or spiritual consultant to assist.

3) recognize that spirituality is an important social factor asscociated in health and research, community assessments, and program implementations. Realize that patients desire this intervention.

4) It can help with medical decision making in serious illness (i.e. furthering treatments, clinical trials, improving patient compliance in treatment regimens, and cooperation with the physicians) .

5) not meeting these spirirual needs can have a detrimental effect on the outcome of medical care.

  It is implrtant to respect each religious belief, and if it is very different from the physician’s belief, they need to request assistance from the hospital administration. Diversity must respected and addressed.

  Life is a terminal disease!

  We are all going to die sooner or later, and we all hope it will be painless, but unfortunately for some, that will not be. When it is happening to a loved one, it is so painful to them as it is for the one on the death bed. But fear of dying should never be a problem if a patient knows God will be waiting. This little prayer from Pastor Rick Warren (that I read daily and recommend) is worth a look:

Medical Education and spirituality

  Spiritual education in medical training is and has been an elective in the student’s curriculum and should be mandated. Today, they mandate CRT training in some medical schools have included woke and CRT statements in their Hippocratic oath when graduating, which has created racial issues, as they are promoting equity instead of equality.

  Spirituality does not necessarily mean religious in cases when the subject may seem foreign or surprising that a physician or nurse would suggest incorporating such a concept. This study seemed to suggest, this would not occur as often as some healthcare providers would think. If a doctor isn’t comfortable with mentioning it, ask a nurse or assistant to take up the subject with selected patients.

  It is clear that religious consultants (chaplains) need to be reincorporated into this secularized country and hospitals that most are not religious-affiliated.

  There certainly needs to be an educational intervention with hospital boards as well, to encourage the addition of spirituality to improve patient outcomes, proven with reliable research. Additionally, national medical organizations need to be included in this environment of socialistic promotion, wokeism, and socialistic promotion.

JAMA Network, July 12, 2022 Harvard University and John F. Kennedy School of Government  

6. Nursing and physician shortages; the future of our hospital care; Medicare Advantage may not be an advantage

A recent article in Medscape Journal emphasized some serious factors leading to the worsening of the nursing shortage that could affect all of us especially when in the ED or hospital.

  Nursing care is more closely linked with healthcare quality than doctor care. Neither group are happy after suffering greatly during the pandemic with being overworked and facing death so often, frustrated often with inadequate and often wrong treatments. And with the added anger in the average American, their lives are being threatened.

  According to the U.S. Bureau of Labor Statistics, more than 200,000 registered nurse positions are projected to be vacant annually over the next decade, and that prediction was made before the pandemic, which created tremendous hardships on all hospital staff, and will worsen this prediction.

  There are currently 3.9 million nurses with an additional 1 million needed to fill vacancies and resupply those who retire, switch jobs, become travel nurses because of more pay, burnout, go back to school for higher degrees, creating a major shortage in nursing homes and nurses’ teachers, not to mention in the hospitals.  

  The Association of American Medical Colleges estimates by 2033, there will be a shortage of physicians between 59,100 to 139,000, spanning across both primary care and specialties, as millions walk across our open borders.

  Age is a big factor for both nurses and doctors. 50% of nuses are over the age of 55, and 52% of physicians is en- route to retirement.

  The need for more care per patient is another factor. The age of the U.S. is another factor with more seniors. Weight gain, hypertension, and diabetes are epidemic in numbers. Thankfully, cancer rates are slightly less, although there are some glaring exceptions (liver, pancreas, ovary, etc.).

  The shortage in rural hospitals is already on life support, and there are limits on the number of medical schools and nursing programs with cost for teachers and students escalating.  

  The pandemic brought fear to healthcare providers, mandates pushed many out of a job, many died or suffered serious COVID infections, and the dramatic increased need for clinical nurses drove a price war with the travel companies sending nurses to areas with extreme shortage.

  Inadequate staffing creates a negative environment for not only the nurses and doctors but patient care suffered as well. Pay discrepancy was created (and pay levels have been low for decades) and many hospitals did not have hazard pay for nurses, also requiring them to work longer hours and more shifts, burning out thousands of nurses ending in early retirement.

  There was lack of adequate mental health services for the staff. Loss of break time, sick leave, or a day off disappeared in many hospitals added to the increase in mental illness, drug abuse, and suicide.

  Inflation has hit these nursing professionals just like all of us. Hospital funding has been a factor in not keeping their nurses adequately paid.

  Although there are most nursing programs filled, the lack of teachers has created a bogged down system. Over 80,000 applicants for nursing school were turned away 20-19-2020 due to lack of faculty, clinical sites, classroom space, preceptors, and budget. Special advanced training programs need to be accelerated.

  Americans need to consider these internal medical crises when facing the possibility of socialized medicine, when it will lower quality of healthcare and affect all of us. Understanding that the leftists are pushing socialism with their woke agenda, climate change agenda, with an administration trying to run or lives, we all must reconsider what is the most important factors in our quality of life. Read my comments on the results of the midterm election next in this report.

Medicare Advantage is getting worse

  Federal regulations and insurance power have had a major influence on doctors but also patients. Narrowing of access to patients especially with Medicare Advantage and refusal for services by the physician and hospital continue to worsen, and by 2030, 60% of Medicare patients will be on this plan to save money, and a large number will not get what they thought they were going to get, according to a Senate Finance Committee.

  The costs of different Advantage plans may vary widely, therefore, be sure Medicare recipients talk to a specialist who provides a variety of plans (not just one), the coverage and non-coverages, the costs, the limitations in the plan, what physicians and hospitals are in their network and who is not, and how medications are covered.

   A review of their medications is crucial in deciding which plan to consider. Now is the time. If you are on Medicare of any kind, a review with an expert on health insurance should be performed yearly. It isn’t just about cost.

  The commercials for Medicare Advantage state that medication is part of the plan, however, a person must join a plan that has coverage whether HMO or PPO…it is not in all plans.

  Joe Namath and company have provided deceptive marketing statements according to the Senate, and are being called out by the government. The number of commercials on TV should tell you the story (only about Medicare Advantage), and those who are selling these plans are getting nice commissions. They are not selling standard Medicare Part A and B, with supplements to cover the 20% not covered, and Part D (medications). 

  About 10% of Medicare Advantage plans are selling most of the business, and those tend to be spending millions on TV ads.  

  How much do you think all those celebrities are getting paid to fill the airways with misinformation on Medicare Advantage?? You may get glasses, and tooth cleaning once a year, but you won’t get a critical study performed as rapidly as needed, delaying your healthcare, and your medications may not be covered even on a drug plan. The co-pay and deductible may be prohibitive.

  The price of all Medicare will continue to rise, and with savings in the Medicare Advantage plan for the government, a patient may save some money, but when it is time for referrals, special tests, complex treatments, and transfers to specialized centers etc., this is where it becomes difficult.

  Delays and often refusal for services for medically necessary services can be frustrating. Mayo Clinic, for example, does not accept most Medicare Advantage plans.

  It is my opinion that the feds are pushing Americans to a one payer healthcare system via Medicare Advantage, ending in socialized medicine. And just wait to see the quality of your care drop, with many exclusions in such a plan.

  For those who are healthy and do not suffer from chronic disease, Medicare Advantage should be attractive. But it is very frustrating for physicians and patients who want to have access to the latest diagnostic tests or certain specialists, and find out they are not covered.

  Look at Canada, and find out how many months it takes to get an MRI!! Once again, Medicare Advantage is one step closer to a socialized system, when access, acceptance of plans, and special procedures are desired. Surgery considered elective can be the first to go. Delay in diagnosis and treatment can be a concern, especially a socialized government run healthcare system. 

  As the country gets unhealthier with added pounds, increasing drug abuse and overdoses (fentanyl) and mental illness, diabetes and heart disease, we will need more extensive care, and it is just won’t be there, especially as millons of people are being added to our population, while fewer healthcare providers are available.

   The cost will always be a concern. This frustrates the patient, but it drives doctors crazy when insurance refuses to let them do their job. 

  If you visit your doctor and his head stays in a computer typing his visit with you, it upsets many patients, rightly so. Doctor’s employers require the notes for your visit to be typed and a copy sent to management, insurance, and perhaps to you, but patients deserve to feel their doctor is paying attention to them, their questions answered, and fills a patient’s expectations. Be nice, but request them to look at you!! Don’t forget to thank them. It matters!!

Medpage Today, November 4, 2022

What is changing about physician’s practices?

  Below is a list of reasons. As more and more physicians sell their practices to a large medical center or corporation, they have found that being an employee has its benefits, but they have lost one of the most important reason why they chose a medical career…be their own boss.

  Now they are told how many people to see, how many to admit to the hospital in some cases, and large medical corporations like HCA has been caught overadmitting patients to their hospitals, when case managers get involved with patient care. This has created some serious issues with doctors. These large centers have had to settle millions of dollars of lawsuits for their actions.

  Here are those statistics:

Primary care physicians have already had to give up hospital practice, but so are general internal medicine specialists, requiring individuals to increase the number of doctors seen for management of their health conditions.

  As much as I have told you to always compliment your doctors and nurses when appropriate, please understand the stress being put on them with these changes and worsened with the pandemic, open borders, mental illness skyrocketing, and the #1 reason for death in 18-45 year olds is fentanyl overdose. 2.4 million illegals over our borders this year.

  The AMA and most academic medical institutions have an answer…socialized medicine. And the employed doctors are giving in to the concept. They think it won’t influence, them, but most socialized medicine countries pay doctors much less than in our country. You think that won’t influence the experience you receive when seeing doctors???

  Each year doctors have to beg Congress not to reduce their Medicare pay by 3%, and this year I culd be even higher.

  46 bipartisan senators are trying to do away with that yearly decrease in doctor’s pay. Inflation hits healthcare professionals just as much as anyone, and Medicare reductions will be even higher, if we are so unfortunate to allow the government to run all of our healthcare.

  Hospitals need to enhance the working environment for their staff and spend much more time visibly appreciating their dedicated and hard working nurses.

  Closure of hospital beds has become an issue due to less staff. And the feds are fining hospitals (43% of 5713 hospitals for increased readmissions within 30 days of discharge).

  Thanks to Obamacare, those fines began reducing Medicare revenue by as much as 3+% annually, which is huge in that business. With the pandemic, readmissions increased greatly, and the feds didn’t take that into account, but paid them extra for death certificates from COVID, which padded the numbers, and now it is common knowledge that as many as 30% of COVID deaths were not directly caused by COVID, but underlying diseases. The feds used those numbers to push more fear into the country, and should be investigated. These pressures were greatly felt by doctors (and they didn’t get paid for treating COVID, with burnout of all staff reaching extremely high levels.

  There is a great need for residency programs for nursing graduates to transition into acute care facilities. With as many as 15 years of schooling for MDs, addressing the shortage is no easy task.

  Physicians cannot be as effective without adequate nursing care. We are totally dependent on nurses to implement healthcare protocols.

  Medscape, October 4, 2022

7. Comment on the Midterm Election

Many Republicans are wondering why they didn’t have a red wave, since Fox News and other conservative airways were touting it (too overconfident). Start with some Republican Congressmen “talking about abortion bans” (when most conservatives are not for a ban). Abortion was one of the most common reasons women voted Democrat, in the face of all the negative issues hitting every American. They have Biden as their president….they don’t care. They know he is not making any decisions, and embarrasses our country and the Dems daily. Uncle Joe must go, but he will run for another term, because he is controllable by the Obama people.

  They vote Democrat regardless, so wise up  conservatives!! The Dems will do anything to win!! Green energy is the other socialist promotion that is greatly supported by younger Americans, and the Dems are running this country for the future of them and not yours!!

  They don’t care about the consequences to our country, especially the GenZ people who get their news and opinions from biased social media while most TV news stations ignore the current problems our country, omit the crises and lie as much as the White House. Also there are millions of uninformed voters, who vote mostly on who they like….not for their policies.

  Blacks, younger people, LGBTQ+ community, white educated women, Hispanics (43% voted Democratic in 2022, but 56% in 2020, which is a great sign), and all who are being financially supported by the feds are beginning to outnumber the conservatives. The conservative voice must get louder WITH ACTION, not WORDS.   

  Do I have the answers?? I would say we must look at our ideologies and principles adjusting them to appeal to independents, younger people, and some moderate Dems. If we can’t….plan on losing, accepting higher taxes, green energy stomping out fossil fuel prematurely, a one political party country, totalitarianism, socialized medicine, open borders, crime, fentanyl, loss of freedom, shortages, and paying way more for food, products, gas, heating, and living, as the inflation rate is 7.7%, the highest in 40 years. And we may possibly be successfully defeated by our adversaries. If you don’t believe this, you have already been indoctrinated. Dems want everyone to suffer so that the country will fail, and the government can take over.  

  Socialism is driving much of the momentum the Dems support, because of the wokeism and socialist/Marxist ideologies they endorse. The Climate Change Act (formerly known by the Inflation Reduction Act) will succeed unless those who want to live in a democratic, free, constitutionally sound country, learn to adjust. I won’t.

    I have to congratulate the Democrats for outsmarting the Repubs! Can you believe they won votes by saying Repubs want to destroy our Democracy? Lying works apparently!! My God…. Dems are killing our democratic way of life on a daily basis. They also voted for Fetterman. But, Dems are team players and it shows! Wake up conservatives!!

  Speaking of woke and censorship, for those who follow me on Facebook…I have deleted it! I will miss my friends and family, but enough is enough!! I suggest everyone get off Facebook. And for God’s sake, delete TikTok (“media fentanyl”)…it is monitored by the Chinese Communists. George Soros just bought 18 Hispanic radio stations in large cities, starting with Miami. Media propaganda!! Remember Tokyo Rose??

  Mail-in ballots have destroyed our chances on close elections, and we need to get rid of the COVID rules instituted for voting.

  If the Republican House can do anything to deal with the election process, I hope they will..DAY 1. Repubs (the Republican Party leaders) need to reform the election process, to require ID, and be a citizen. They must do a better job of monitoring not only ballots but voting machines that suddenly stop working!! I can’t wait to see what goes wrong during or after the Herschel/Warnock runoff in Georgia. 

  Young people are Democrats (who are not being educated…they are being indoctrinated in schools) and voted this time (27% of Gen Z—18-29 voted). They will continue to be a bigger factor in future elections. Republicans must recruit more younger people, starting with retiring the older guard running the Republican Party.

  GenZ people are all for socialism, socialized medicine, and having tax payers pay for them and the rest of the non-tax paying country. Most of these people are still living off their parents. These younger people don’t look ahead, as they live in the present. Talk to your grandchildren if you question my statement.

  Medical schools are making graduating medical students recite woke and CRT statements in their Hippocratic Oath when they graduate. Add the University of Florida Medical School, who has lowered their admissions standards so that more Black people and other people of color can be admitted. We need the brightest students in medicine, regardless of their color, race, creed, or origin.

  We need new younger leaders to push more moderate ideologies and look to the future of our country, because, when every negative issue in this country was not enough to vote Republican, change has to happen, like it or not. 

  I must congratulate Nancy Pelosi, retiring after 35 years of service to the Democrats. She was a bad ass and did her job well. Repubs need one just like her.

  Inflation has hit doctors just as hard as anyone, and the feds want to reduce their Medicare/Medicaid revenue by 8%. Private doctors have split with the medical academics and national medical organinzations, because they have already moved into the socialist ring.

  Socialized medicine will not be what most Americans will tolerate and will have to buy extra insurance to cover many issues that will be cut out of socialized medicine. Ask Canadians and Brits. Young healthy people can’t relate, but when they do, it will be too late.

  As long as our future healthcare is at stake, I will continue to discuss the factors that could destroy it….socialism and Marxism. They are political, but as you have read, this report continues to provide the latest and best medical information with great subjects every month.

  I hope you had a wonderful Thanksgiving with your families, and I pray for all my readers to remain healthy and well. Get your vaccines and avoid high risk exposure if possible. Enjoy Christmas, Hanukkah, and a Happy New Year.  Dr. Sam

    This ends the December Medical News Report!

The January, 2023 report will include:

1. Proton vs Photon Radiotherapy for cancer-an update from throat to prostate

2. The mental health of children—PTSD, addiction, suicide, autism, learning, and maturation

3. Blood test for colon cancer may be as valuable as colonoscopy, but there is more information you need to know!!

4. OB/Gyn Series—part 8—premenstrual vaginitis; lesions of the ovary and fallopian tubes

5. The drug crisis from Marijuana to Fentanyl

6. The Polypill—new info

  Merry Christmas and Happy New Year. Happy Hannukah! Stay healthy and well, my friends, Dr. Sam