The Medical News Report

September, 2023, # 140

Samuel J. LaMonte, M.D., FACS

samlamonte@gmail.com

www.themedicalnewsreport.com

Subjects for September

1. Late breaking Medical News-

  a) COVID-19 effects on reproduction; more on fall vaccine; side effects of vaccine and infection; Long COVID syndrome new updates and wasted research funds; The latest COVID variant-EG.5; genetic reason why some have no symptoms when test positive

  b) Foreign trained doctors may get to bypass training in U.S.  

  c) N95 masks cause cardiopulmonary stress;

  d) Doctors and nurses and workplace violence

  e) LeBron James’ son, Bronie and his cardiac arrest; causes of cardiac arrest

2. Breast Cancer Series-Part 3—complications of breast cancer treatment--recurrence and second breast cancer; therapy for lymphedema

3. Factors in cognitive decline (dementia)- health of a president and other politicians; New info on dementia; superagers

4. Celebrities with unusual diseases—3 autoimmune diseases

Nick Jonus-Type 1 Diabetes,

Ashton Kutcher-Autoimmune Vasculitis,

Elizabeth Hasselbach-Celiac Disease

5. The Coup we never knew 

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.

  If you are seeing just a PA and need to talk to the doctor, ask them to get the doctor if they are available or make another appointment specifically requesting the doctor.

Thank you, Dr. Sam

1. Late breaking Medical News

a) COVID issues-- effects on reproduction, fall vaccine and side effects continue to show up; Long COVID syndrome new updates; the latest COVID variant-EG.5; genetic reason why no symptoms when test positive

b) Foreign trained doctors may be able to skip U.S. training

c) N-95 masks cause cardiopulmonary stress

d) Doctor and nurses—workplace violence increasing

e) Cardiac arrest in basketball player--LeBron James’ 18 year old son, Bronie; update on NFL player

a) COVID issues update--Long COVID syndrome update; COVID effects on the reproductive system; fall vaccine booster and side effects continue to show up

 Long COVID syndrome new updates; wasted research funds

  More data from the CDC Morbidity and Mortality Weekly Report is being made available regarding symptoms that persist after having an infection (Long COVID Syndrome) regardless of severity. The survey (1741—2/3 of the patients were COVID test positive) included mostly females, which is no surprise since men are hard to get to participate as well as other minorities, which make diversity an issue.

  Some patients don’t develop long syndrome for weeks or months after total recovery . Thankfully, the incidence of this syndrome continues to drop, now down to 6% (20% a year ago).

  A JAMA study found that there were 4 categories of Long COVID symptoms most often present:

1. Loss of smell and taste.

2. Post-exertional malaise and fatigue.

3. Brain fog with post-exertional malaise and fatigue

4. Fatigue, post-exertional malaise, dizziness, brain fog, gastrointestinal issues, and palpitations.

  One in four survey participants had significant activity limitations.

  There are 37 separate symptoms described, but so many are vague, and I suspect depression is playing a strong role in many of these cases (especially in women), and underlying medical conditions are often the cause. Blaming all these symptoms on post-COVID is a stretch.

  Medicine loves to categorize illnesses, and when there are several underlying conditions present, which is usually the case, the scientific data becomes cloudy, opening up for many expert opinions, not true science. Also a significant number of these patients were COVID test negative.

  Dr. Eric Topol, editor-in-chief of the internet Medscape Journal and well respected writer regarding COVID, just announced that he is very disappointed with the $1.1 billion funds that were literally wasted by the NIH on Long COVID syndrome research since clinical trials were not used much, which gives us the best data. The administration threw so much unnecessary money at the pandemic, much of which hasn’t even been spent on COVID.

  Continued emphasis on long COVID is necessary since it is one of the best reasons for getting the original vaccine plus boosters, even though the syndrome continues to drop (6%).

  The vaccine has been disappointing for healthy individuals, but there is still a good many older people with significant medical issues that should be vaccinated to reduce the risk of hospitalization with an infection.

  These vaccines must not be taken for several weeks-months after complete recovery from an infection, even though the CDC recommends these vaccines begin when complete recovery occurs. If the patient has the Long COVID syndrome, one could consider them NOT RECOVERED, and a serious discussion with the treating doctor needs to occur. After all, the infection stimulates the same immune reaction as the vaccine, so it certainly makes sense to wait several week to months before getting the vaccine. The CDC still keeps putting out mixed messages. The vaccine can’t really raise the level of immunity much higher than the infection, and in fact, natural immunity is probably better than the vaccine, and the immunity lasts longer.

  Why people get the infection, all be it mild, more than once, continues to be in question…just one of many questions yet to be answered.

  Most of these long syndrome patients tend to be middle age, so older patients tend to be less likely to be in high risk areas, and are probably more careful with their social behavior.

Medpage Today, August 10, 2023 ; Medscape, August 9, 2023

  The pandemic has had many unintended consequences on our entire country, mostly bad, especially in children with a gap in development, academic initiative, and maturation without face to face schooling.

  The delay in diagnosing and treating multiple diseases has been terrible.

   We must be better prepared next time, because we know another pandemic will occur or at least some form of national health disaster. But will we?? And our administration is worried about climate change.

Fertility and COVID infection and vaccine

  There has been great interest on the effects of fertility from the COVID infection and vaccine. Take into consideration, depression, anxiety, suicide, and drug abuse has had a negative effect on sexual relations (perhaps number of pregnancies), so how does the COVID-19 virus affect fertility in males and females?

  The best study was published by the Library of Medicine in 2022, and found that the hormonal levels of women were affected short term, but not appreciably affected long term.

  The endometrium of the uterus, menstrual cycle, ovarian reserve, and embryos were affected due to an effect on hormonal levels, but returned to normal in just a few months.

  It should be noted that stress alone of any infection will interfere with menstrual cycles and all of reproductive physiology… but only temporarily.

  Studies have shown that younger cells tend to be more susceptible to viral infection, and all systems could suffer more.

  Embryo viability from the COVID-19 virus had significant temporary menstrual alterations, to some extent on ovarian reserve, and hormonal balance, but further research is necessary to find out the long term effects on reproduction and the live birth rate. We must keep in mind, we had no prior knowledge about the effects of the infection or the vaccine.

  In more severe COVID cases, there was a rise in the pituitary hormone, FSH (follicular stimulating hormone). This hormone stimulates the ovary to produce estrogen and keep the levels stable, but those levels return to normal in just a few months.

  Males, on the other hand, had impaired semen quality for an average of 3-6 months, even with mild infections. Males developed an average of a 20% drop in sperm count, motility, longevity, and other aspects of sperm, but it did not affect fertility rates in one large study. Further studies are greatly needed. (All illnesses that produce fever will affect semen value).

  Autopsy results (for those that died) in this group did demonstrate damage to the testicles related to the infection. (Elevated androgen levels are believed to be the mechanism by which the virus can enter cells more easily).

  The American Society of Reproductive Medicine and European Society of Reproduction and Embryology recommended ceasing human assisted reproductive technology during the pandemic (invitro fertilization). Once the spread of the virus was controlled, the societies recommended resuming treatments relieving the minds of those infertile couples. Does this equate to the timing of getting pregnant?

Library of Medicine, Jan. 16, 2022 published International Journal of Public Health; Medpage Today, June 30, 2023

Who needs the annual COVID vaccine booster?

  The experts continue to question just who needs an annual COVID booster. Most agree those vulnerable groups, regardless of age, should receive the booster, but expect many differences of opinion when talking to clinical physicians who are not employees, because their employer probably told them what to tell their patients.

  BTW, vaccinations are not free anymore, but will be covered by most insurance. The shots are over $100 per shot. However, a new administrative program called the “Bridge Access Program” will cover the COVID booster this fall free for those uninsured, according to the CDC, but will cease at the end of December, 2024.

  20-30 million people in this country ages 18-64, have not been vaccinated. JAMA, July 26, 2023, but healthy people rarely have much of an illness, in fact, even though there are more numbers of cases (hospitalizations), the CDC is still counting every positive test when a patient goes to the hospital FOR ANY REASON, meaning they are not differentiating those WITH a positive test and those being admitted to the hospital BECAUSE of COVID. Shameful!

  The administration continues to send mixed signals, and assumes the public is too stupid not to know the difference.

The New COVID variant—BA 2.86

  While the XBB.1.16 Omicron variant is still the prevalent variant of COVID-19 in the U.S., but on the decline, but the latest variant BA 2.86 is rising (about 25-30% according to the WHO) and will become a more dominant variant probably as the latest vaccine booster is available this fall.

  BA 2.86 has the same spike protein, but has a new mutation which has the capability to evade the current variant’s neutralizing antibodies. Each new variant has its own mutation, and that is what makes it different, but it is not a more serious variant, in fact, probably less, unless a patient is compromised.

  The U.S. is experiencing an increase number of hospitalizations and deaths (14%), but still drastically lower than last years’ rise, according to Dr. Carlos del Rio, Professor at Emory University, Dept. of Infectious Diseases. He said if a person is boosted, the liklihood of hospitalization is unlikely, and still the main reason for getting the booster.

  Dr. del Rio feels the coming September booster using the XBB.1.16 variant will cover this new variant.

  Most of us have had vaccines and boosters, and our immunity is over a year old. If you believe what we are told, the immunity drops significantly after a year or so. However, we still have recall antibodies that don’t go away. That is why the sick, immunocompromised, and those with clinical diseases should be boosted. Otherwise, most experts are not concerned, unless they are a public health official. Make your own decision or talk to your personal physician.

JAMA Network, August 17,2023

Genetic reason why some COVID infection patients don’t have symptoms

  Some people don’t have a clue they get COVID infection, and now it is felt it is because there is a genetic reason (HLA-B*15:01 allele) found in 1 in 10 people in European ancestry. There was some evidence in Black individuals as well, with less in Asians and Hispanics. A major portion of the country has European ancestry, so this genetic protection may have saved millions of people to be clinically infected and not have any symptoms.

  The sad news is, there was no study to prove or disprove that they can transmit the infection in others.

  Some would make the case for getting vaccinated, since they may be a transmitter, and others would rationalize not to, just because they have European ancestors. There is no commercial test available for this genetic allele.   

JAMA Network, August 2, 2023

b) Foreign trained doctors may be able to wave U.S. training for licensure

  I have been reporting on the shortage of doctors, their burnout, the added hours being placed on them, and at the same time our borders are being run over by millions of illegals, filling our emergency rooms, and filling doctor’s schedules, so that nurse practitioners and P.A.s are being allowed to treat patients (in some states even writing prescriptions without supervision (my PA writes mine since most prescriptions are electronic from the doctor’s office).

  The quality of care is suffering and with such severe shortages, Canada is now allowing U.S. doctors to come over the border and start practicing with a Canadian license immediately.

   Now, the American Medical Association is encouraging state medical boards to accept foreign medical school graduates and those who trained in specialty medicine outside the country to accept certification from the Educational Commission for Foreign Medical Graduates as verification of their credentials, rather than requiring documents directly from international medical schools. This will allow these doctors to skip applying for residency training in the U.S. which has always been required. This is not the quality of medicine I enjoyed in my 30 years.

  In Tennessee, the governor signed a new law giving temporary license to practice medicine without supervision. All they have to do is show that they had a 3 year residency in the doctor’s licensing country or have proof they have practiced in some country 3 out of the last 5 years. For them to start practice, they must apply with a physician who has a certified residency program accredited by the Accreditation Council for Graduate Medical Education. This doesn’t mean they will be practicing with supervision in every case.

  Some will wonder why that is a big deal. Many medical schools are far inferior to those in our country, and their specialty training in many countries has little standard training. This could potentially allow a doctor to go to an area needing doctors, and being able to practice without passing boards and or attending a certified residency training program.

  It is my serious recommendation that any new doctor who is seen should be asked about their training, where it occurred and how many years. I spent 5 years in post graduate training before being board qualified and accepted in a high quality multispecialty practice. After 2 years, I became board certified.

  These events that were made much worse from the pandemic have created a serious shortage of doctors and raise the question of competence. Every patient must become knowledgeable about their medical conditions.

Medscape General Surgery, June 26, 2023

c) N-95 masks cause cardiopulmonary stress

  As masks seem to be making a comeback (for little reason unless sick, immunocompromised, etc.), the best mask has some complications.

  N-95 facial masks properly worn has proven to prevent transmission of COVID-19, while most other masks available to the public have proven to be of little help. And all the time we were told to wear them or be ridiculed and asked to leave establishments. Research on humans was never carried out to prove or disprove their value (only on machines in labs). We have been lied to so many times by “the experts”, that their creditbility has rightly been questioned, and most people ignored protection. For those vulnerable groups of individuals, many became infected and thousands died.

    The Chinese have been wearing masks all along and most are wearing ineffective paper or cloth masks. It became a political instrument for some more radical groups, especially in the U.S.

  The medical professionals and first responders are at greatest risk, since they are more exposed to sick or injured people.

  Now there is new data to show that wearing the only really effective mask for hours can put stress on our cardiopulmonary systems. This study had subjects wear the mask for 14 hours and perform 30 minute light and very light intensity exercise. Blood analysis of oxygen saturation and other metabolites were evaluated.

  Within an hour, oxygen saturation decreased as measured by the finger pulse oximeter, with elevated heart rate and a drop in respiratory rate and increased respiratory resistance, noting a drop in blood oxygen levels and pH (acidity of the blood). This created an elevation of autonomic activation raising levels of epinephrine and norepinephrine secretion. This hormonal elevation accounted for a rise in respiratory resistance breathing through a mask that made it more difficult to breathe.

  It was noted that healthy individuals could compensate adequately, but those who are older, and have any cardiovascular or respiratory diseases, would be considered somewhat hazardous.

  This study was performed on 30 participants and is too small to totally accept the findings, however, it makes it clear, that there is some hazard wearing masks correctly using N-95 masks.

  For those who have tried to wear N-95 masks for over such a short time, appreciate the increased effort it is to breathe easily. I rarely see people wearing this mask, and the rest are worthless.

  JAMA Network, June 9, 2023

d) Doctors/nurses and workplace violence

  Sad but true!! The rising trend of violence, intimidation, threats, and attacks are increasing, not only in this country, but others. The mental health of people was greatly tested by the pandemic, and we all have had some adaptations, all not good.

  Tempers, impatience, substance abuse, selfishness, and less concern for our fellow man has become obvious.

  Medical offices, emergency departments, hospital staff, and those in nursing care facilities are all feeling the pressure to please their patients and their families.

  Ads on TV have increased demands by patients to have these medications prescribed, even when they are not indicated, or there are better, cheaper alternatives.

  There has been more violence, injuries, and deaths of these hard working medical personnel in the last few years than ever before.

Healthcare workers account for 73% of all nonfatal workplace injuries and illnesses in 2018. The industry’s number of total violent incidents has grown since 2011, so we can’t blame everything on the pandemic.

  About half of the violence comes from patients and customers, while the other half come from coworkers, and relatives of the workers.

  Stress is getting to everyone ,and the ability to cope with it properly, is slipping.

  This is just one more reason that has pushed healthcare professionals out of the most stressful places to work…emergency departments, in-hospital patient’s rooms, and even offices.

  Healthcare has 4X the rate of violence than other industries, according to the Cleveland Clinic.

  40% of healthcare workers have experienced workplace violence in the last 2 years, and the nursing staff has the highest rate, most commonly coming from men 35-65 years of age. Half were reported from incidents at the hands of combative patients.

  Verbal abuse continues to be the most common type, but most are reporting an increase in intensity. 62% were men.

  Whatever the root cause of workplace violence is, needs to improve. Patients need to respect their healthcare workers and treat them with kindness and gratitude for taking care of them. By the same token, doctors need to remember their bedside manner, and get their nose out of their computers.

e)  LeBron James’ 18 year old son, Bronie, who will play basketball for USC in the fall, suffered a cardiac arrest while practicing. Causes of cardiac arrest!!

Having played basketball in high school and college, I can vouch for what an aerobic sport it is, and there are many fit athletes who die of cardiac arrest, the most common being black college basketball players, according to the CDC.

  Many are found to have undiagnosed congenital hypertrophic cardiomyopathy, which implies a thicker heart muscle, which can affect the electrical system of the heart, causing rhythm abnormalities including ventricular fibrillation, which stops the heart. Without an AED electrical shock and or cardiac resuscitation, death will occur.

  There has been no official statement about the cause and circumstances about Bronie’s situation, but he was spotted near Mayo Clinic 2 weeks after the cardiac event. There is no official information that he had prior cardiac evaluation either or that he might have some pre-existing cardiac anatomical abnormalities.

  Sports programs don’t always do EKGs on every sports athlete, but an EKG can diagnose hypertrophic cardiomyopathy. The cost, however, would be quite  expensive for any high school or college to screen every athlete with an EKG, although I am sure larger facilities do. To date, there is no national requirements to screen athletes.

  Fortunately, most sports program staff have been trained how to use an AED (automatic electrical device) and perform hands on CPR. Routine practice drills are encouraged.

Note the position of the fingers for CPR. Compression should be strong and 100 per minute. Mouth to mouth is no longer recommended.

  Incidentally, last year, a USC player, had a cardiac arrest but recovered after CPR, and had a pulse generator* implanted to run his pacemaker, and is back playing basketball.

*pulse generators are the battery to provide the electrical input to the heart pacemaker, and it is implanted under the skin below the collarbone.

  Buffalo Bill defensive player Damar Hamlin, was hit in the chest by a helmet, creating “commutio cordis”, defined as an abrupt trauma to the anterior chest wall interfering just  at the exact time of an electrical heart beat causing cardiac arrest. He was resuscitated, had to be intubated and was on a ventilator for a few days before recovering. He is back with the Buffalo Bills for this season, already playing in preseason games.

Hamlin did not have congenital hypertrophic cardiomyopathy. This type of cardiomyopathy is not as dangerous as once was thought, and after a thorough stress cardiac evaluation, doctors are allowing some of these young people to return to their sport. Previously, cardiologists restricted anyone with this diagnosis from playing organized sports.

Note the thickness of the heart muscle on the right drawing below in this condition.

  There is still controversy regarding requiring an extensive cardiac evaluation to be eligible for varsity sports. There tends to be a high false positive rate, but each sports program and school must decide the criteria for eligibility.

Medpage Today, July 26, 2023

Causes of cardiac arrest

  Cardiac arrest usually results from ventricular fibrillation or sustained ventricular tachycardia.

Warning signs of a hidden cardiac problem

  1-unexplained fainting episodes with stress

  2-seizures without a clear pathologic EEG result

  3- unexplained accidents or car crashes

  4-heart failure of pacemaker dependency before age 50

  The underlying pathology centers around coronary artery disease as early as 35 years of age, and the cause may be hereditary.

  An EKG can diagnose any number of issues, such as abnormalities of the QRS complex, the actual electrical wave of the heart.

  If the reader has a 14 year old with any suspicious events related to exercise or sports, get them checked and have an EKG.

Medscape General Surgery, August 15, 2023

  I have reported on all types of heart muscle and valve abnormalities recently: Reports\Medical Report 15.pdf

2. Breast Cancer Series—Part 3—Complications of breast cancer treatment--recurrences and second breast cancers; other issues including therapy for lymphedema

Late complications of breast cancer treatment

  Long term and late complications of cardiovascular disease, can occur,especially in breast cancer and blood cancers. There is an increased incidence of pericarditis, cardiomyopathy, heart failure and hypertensive deaths.

  According to the CDC, cancer treatment ages the patients an average of 6½ years. Many of the chemotherapeutics drugs have some degree of cardiotoxicity, and radiation to the breast also radiates part of the lungs, and causes calcification of the coronary arteries.

  Thrombotic issues also occur in many cancer patients, including breast cancer patients. Lower leg thrombosis, thrombophlebitis, and embolism can occur while the patient is recovering, but there is still an increased risk as the years progress, especially if there is weight gain and they don’t get back to a regular exercise program.

  The study found the incidence of thrombosis to be 30.7% compared to a control group (24%).

   Infertility can be a problem and pre-treatment preservation of eggs should be considered. Premature menopause may occur.

  Concerns of fetal abnormality during or after treatment are a concern, and if still menstruating, may become pregnant. Birth control should be considered.

  With menopause, osteoporosis is a possible issue. Bone density studies should be performed and prevention using vitamin D and calcium containing products are a good idea.

  Rarely, leukemia can be caused by chemotherapy.

Mayo Clinic

  There will always be concern for recurrence and second cancers, and if depression persists, address it.

  Getting your general health back is often ignored, and patients must continue screening tests for cancer, management of all chronic diseases.

  Go to a gym and get active to bounce back, as it will take months to recover. Get vaccines, get dental checkups, avoid infections from crowds,  eat a lot of protein, vegetables, and fruits to maintain a nutritious diet. Consult a survivorship clinic to get the best information on dealing with, coping, and recovering cancer. Include your primary care doctor in your recovery and health maintenance.

Medpage Today, April 19, 2023 

Lymphedema

  Lymphedema of the arm can be a very serious issue functionally and cosmetically. Losing part or all of a brease is terrible enough, but at least it can be reconstructed or a bra insert can camouflage the difference in breast size. But some swelling of the arm and hand can’t be concealed, and compression garments may be necessary.

  Lymphedema occurs when the lymph vessels are blocked off by radiation and surgical removal of the lymph nodes and vessels that may or may not contain spread cancer cells. In severe cases, the chest wall can swell as can the neck. In severe cases, infection of the skin hardening and discoloration can occur. Difficulty using the fingers from restriction of motion in the hand, elbow, and shoulder. In the rarest of cases left untreated, it can create a type of sarcoma (cancer).

Note swelling of the right arm; garment compression of left arm

This condition can occur fairly soon or delay by months or even years as fibrosis increases.

  Lymph fluid carries the byproducts of cellular destruction, is part of the immune system, and contains cells that fight infection and cancer. It acts as a filter, and all vessels wind up draining into the jugular vein of the neck, the lymphatic duct just under the medial portion of the collarbone. Views of the lymphatic duct and lymph system.

  If there is special concern, ultrasounds or scans may be ordered. A dye study can track where the main blockage is occurring (lymphoscintigraphy).

Treatment  

  There are special physical therapists that should be consulted to manage this problem. Some big cancer centers may even have a special clinic for these women, as other parts of the body can have the same problem from other conditions.

  Exercise and manual manipulation of the arm to move the fluid out of the area. This has to be avoided if cellulitis, blood clots, or skin ulcers occur.

  Compression bandages and garments are often used and require a prescription for these special compression devices.

  Sequential pneumatic compression devices can move the fluid by intermittently compressing the arm and then releasing the compression to allow drainage.

  Surgical procedures can use lymph node transplants in early stage disease. Procedures to link some of the larger lymph vessels to blood vessels may be successful. Fibrotic tissue may be removed to improve drainage. Hardened fatty tissue may be treated with liposuction for better function, and excessive tissue may be removed in moderate to severe cases.

  Hygiene and special skin care are critical to prevent complications of the skin.

Mayo Clinic

General Comments regarding screening mammograms

  26% of breast cancers occur in postmenopausal women, and the rate is rising as it is in younger women under 50. As always, early diagnosis equals less treatment and faster recovery. Women should always be aware of their breasts and the changes that occur with age.

  Routine screening is absolutely necessary to diagnose these breast cancers early, long before they are felt by the woman. Early diagnosis can equate to greater than 90%+ 5 year survival rate, but it should be known that some breast cancers can recur as long as 20 years later.

  Once a breast cancer is treated with or without adjuvant therapy (tamoxifen, etc., chemo, immunotherapy), surveillance is critical to be on the lookout for recurrence and a chance of a second separate cancer.

  More conservative treatment may increase slightly the risk of recurrence, and without such hormonal treatments such as Tamoxifen, another breast cancer may be more likely to occur.

  There are cases where more conservative therapy is a real option, for instance, in older post-menopausal women, who can consider taking Tamoxifen instead of post-surgical radiation therapy.

  A study was performed in older women who had breast cancers measuring no more than 3 cm (1.18 inches) and had breast conserving surgery with and without radiation. After 10 years, the survival rate was 80% in both groups. However, the group without radiation had a 10% higher rate of recurrence, who obviously were still alive in 10 years, but might die later of that recurrence.

  46% of women discontinue Tamoxifen because of the side effects, whereas 24-36% are reported to have nonadherence of the medication in prevention trials. NEJM, Feb. 17, 2023

  In addition to lymphedema, radiation causes short term and long term side effects too. Pulmonary fibrosis, coronary artery calcification, skin color changes and hyperpigmentation all can occur. Breast size changes are not uncommon. Early on radiation can swell the breast and later cause shrinkage. Damage to an existing breast implant may require removal. Secondary cancers are rare (sarcoma) but lung cancer can occur, separate from metastatic lung spread.

Mayo Clinic

Recurrences of breast cancer

(Much of this was covered last month, but should be reviewed if interested in all the types of medical therapy used in recurrent and metastatic cancer.)

  Tumors can recur at the site of the first cancer, if a lumpectomy was performed, or when a mastectomy is perfomed, the recurrence can occur in skin of the chest wall. There may be changes in the skin of the breast,  inflammation or redness, or nipple discharge.

  Nodules on the chest wall under the skin should be checked immediately. A new area of thickening along or near the mastectomy scar can indicate a recurrence.

  A swelling in the armpit, near the collarbone, above or below, or in the neck should raise concern.

  Distant recurrence can occur in the bones, spine, liver, or lungs. Signs and symptoms include a persistent cough, persistent pain in the chest, back, or hip area, difficulty breathing, loss of appetite, weight loss, headaches, and seizures must be evaluated.

  That is why radiation and or chemo is recommended in certain higher risk patients. But even with these additional treatments, the cancer cells can still evade them, and it only takes a few to cause an eventual recurrence.

  Diet, exercise, and close monitoring as a cancer survivor is critical to optimize staying cancer free.

  The emotional trauma endured by the patient and family is very severe, and with time, support, and a positive attitude, patients can recover, not only physically but mentally, and spiritually. There are strong studies to prove that all these factors can improve survival. Support groups, breast cancer organizations (American Cancer Society, Breast Cancer Foundation, etc. are dedicated to support cancer patients. I spent 40 years doing that as a volunteer with ACS, had my own cancer to deal with, and had the fear all cancer patients have….recurrence.

Risk factors for recurrence include:

 --lymph node involvement, a larger tumor size, a positive or close margin after surgical excision.

- -margins of the tumor resection are checked carefully by the pathologist, and the result will have impact on the aggressiveness of treatment to follow more surgery, radiation, and or chemo and other forms of medical therapy.  

--those patients who decide not to follow up with radiation after a lumpectomy are at higher risk of recurrence.

--Younger patients particularly under the age of 35 at the time of diagnosis face a higher risk of recurrence.

--inflammatory breast cancer has a higher chance of redurrence.

 --those cancers that are hormone (estrogen and progesterone) receptor negative, HERS negative (Triple negative). These tumors don’t have as many markers in which to target therapy.

--HR+,HERS+ breast cancers account for 2/3 of breast cancers, and 1/3 of a subtype of these patients develop metastatic disease. Recent advances have found that the use of biological—trastuzumab deruxtecan improves survival.

--obesity is a risk factor

  These risk factors determine additional modes of therapy outlined last month including radiation, chemotherapy, hormone therpy, targeted therapy, bone building drugs to reduce the risk of recurrence in the bones, maintaining a healthy weight, exercising, eating a balanced protein rich healthy diet, avoiding tobacco, and excessive alcohol.

Treatment for recurrent cancer (see last month’s section on medical therapy of breast cancer)  

  A cancer patient must decide as quickly as possible whether they are tougher than the cancer. Meditation, prayer, and optimism, and any other emotion plus family and friend support is critical in overcoming the cancer.  

 Hormone receptor positive (HR)-positive, HERS protein negative have a sustained risk of recurrence up to 20 years from diagnosis!  

  Patients need to know the side effects of treatment and seek assistance from the doctors, friends, and family who will help you cope with frequent symptoms of pain, nausea, fatigue, hair loss, weakness, anxiety, depression, sleeping difficulty, and a feeling of helplessness.

Diagnosis of recurrence or a second breast cancer

  If the doctor suspects a recurrence or second breast cancer, a follow up mammogram or physical examination is necessary, plus imaging tests including MRI, CT, X-ray, bone scan, or PET scan.

  A biopsy of a suspicious area will be necessary to confirm recurrence. Tests for certain newer genetic markers in the cancer will assist the doctor in deciding if the tumor is recurrent or perhaps a different cancer.

Treatment for a local recurrence

  If the recurrence is confined to the breast, a complete mastectomy will be recommended (radical mastectomy) removing the entire breast, fatty tissue, and skin with the nipple. If there is not enough skin left to cover the chest wall, a flap of skin from the back may be used, or even a skin graft. If the armpit still has lymph nodes, they will remove them (axillary node dissection). 

  If no radiation was not previously used, RT will be recommended perhaps. It can’t be repeated for fear of excessive damage to the chest wall and lungs and heart. Chemotherapy will probably be recommended as well to prevent other recurrences from popping up.

  If the cancer is hormone positive, hormone therapy (Tamoxifen) may be recommended to block the estrogen and progesterone growth promotion just in case there are still viable cancer cells elsewhere.

  If testing shows the cancer cells produce excess HERS protein, medications will be prescribed to target that protein and slow the growth of any possible cancer elsewhere not yet visible.

  All the above treatments were extensively discussed last month.

Treatment for a regional recurrence

     More surgery will be necessary if there is a isolated regional recurrence. Radiation may also be recommended if the area had not been irradiated previously. If surgery isn’t possible RT may be used as the primary treatment.

  Chemotherapy, targeted therapy and or hormone therapy may be used additionally.

Treatment of a metastatic recurrence

  The goal of treating a metastatic breast cancer isn’t to cure the disease, but may allow the patient more time and relieve symptoms. There is always a balance between treating symptoms and causing more toxic effects of treatment. The advances in treatment of recurrent or metastatic disease has progressed nicely, and is keeping women alive for years with a a decent quality of life.

  Treatments may also include chemotherapy, hormone therapy, targeted therapy, and immunotherapy, all discussed last month. Adding immunotherapy will give the patient’s own immune system to fight the cancer, but there are always side effects which must be discussed. As mentioned above, the use of trastuzumab deruxtecan improves survival. Medscape, January 31, 2023

  Immunotherapy is a good option in triple negative breast cancer recurrences, because triple negative cancers mean there are no markers (hormone receptors or HERS protein) for other treatments. It will likely be combined with chemotherapy.

  Bone building drugs also may be prescribed to reduce the risk of the bones becoming involved.

  Spine metastases cause significant pain and respond fairly well to palliative RT.

  Quality of life issues; addressing complications of treatment; aging studies

  There are many long term repercussions from surviving cancer. First, you are a survivor, and that is great, but the rest of a survivor’s life, dealing with the fear of recurrence, side effects, or another cancer is of real concern. I know. I have had to deal with many consequences of radiation. But as a survivor, one must decide we are tougher than the cancer, and won’t let it dominiate us. We must not stay in denial either. We must do everything to make our lives better, and overcome these obstacles. Prayer, resolve, proactivity, etc., all are important. Exercise, stopping bad habits (smoking, drinking, bad nutrition, being overweight, etc.) all are important scientific-proven issues that will help recovery but also improve aging.

  A recent study on radiation dermatitis found that those who had more severe skin reactions from the radiation as it penetrates the skin. They found that these patients had Staphylococcus aureus bacteria in their nasal lining. They were carriers of this bug. It apparently can cause the redness, burning, and even scarring on the skin where the cancer is used to treat the breast and head neck cancers in this study. It was obvious the nose should be cultured before the treatment is started. There are special antibiotic ointments that can destroy those bacteria, and it would be a good idea to discuss this study with your surgeon/oncologist-medical or radiation.

JAMA Oncology, May 4,2023  

  Patients who endure breast cancer treatments biologically age faster according to Moffitt Cancer Center, Tampa, Florida. Cognitive issues also appear earlier. This was found particularly in those who had radiation.

  They have higher rates of cardiovascular disease (pericarditis, cardiomyopathies, heart failure, and hypertensive deaths) primarily when they lose the heart benefits of female hormones.

  The study included 4 million breast cancer survivors. More than 50,000 women had sisters that did not have breast cancer, and were the controls in this study, across the country (enrolled in a study from 2003-2009), who had 3 biological blood markers for aging. All the cancer patients remained free of cancer, but aged faster than their sisters, about 6+ years faster.

J National Cancer Institute, July 19, 2023   

  Thrombotic issues also occur in many cancer patients, including breast cancer patients. Lower leg thrombosis, thrombophlebitis, and embolism can occur while the patient is recovering, but there is still an increased risk as the years progress, especially if there is weight gain and they don’t get back to a regular exercise program.

  The study found the incidence to be 30.7% compared to a control group (24%).

Medpage Today, April 19, 2023

Clinical Trials

  A large clinical trial followed women who were put on Tamoxifen or Exemestane in several countries.

  These women were treated with Tamoxifen 20mg. once a day for 2.5-3.0 years to completely eradicate hormones from the body (breasts, adrenal glands, and body fat). After that treatment, they were switched to Exemestane 25mg. once a day for a total of 5 years.   

  The fact that, even though there were some recurrences as late as 20 years, the hormonal therapy (Tamoxifen) is the cornerstone of prevention with some women having additional chemotherapy after surgery (adjuvant therapy), which is decided based on the aggressiveness of the cancer.

  Based on these predictors, about 2/3 of the patients who were deemed low risk. 89% were alive while only 70% were living in the other 1/3 deemed high risk.

Medscape Breast Cancer Research, July 5, 2023

3. Factors and signs in Dementia (cognitive decline); Health of our officials

Age, dementia, and our country’s future

Factors in cognitive decline

  More than 6 million Americans are living with Alzheimer’s disease, the most common type of dementia, predicted to be 13 million by 2050.

  The most common types have been well described with vascular, Lewy Body dementia, Parkinson’s disease, frontotemporal dementia, and Mixed type, while rarer types are Huntington’s, Wernicke-Korsakoff, normal pressure hydrocephalus, Cruezfeldt-Jacob syndrome, etc.  www.dementia.org

  What are the 10 most common signs of early cognitive decline? 

1. difficulty with everyday tasks.

2. Repeating one self.

3. Communication problems

4. Getting lost.

5. Personality changes, anxous, easy to anger, fearful, suspicious, etc.’

6. Confusion about time and place.

7. Misplacing things.

8. Toubling behavior.

9. Loss of interest and apathy.

10. Forgetting memories. 

  7 national politicians and our president are 80 years old or older, and the likely Republican candidate is 76. Everyone has seen the misactions of Biden, Feinstein, and McConnell.

   We need some changes, and it starts with age limits, extreme independent, politically neutral cognitive and physical testing by physicians, who are independent as well, and if we would just have term limits, most of this nonsense would be taken care of it.

  I was 81 in August, and my cognitive functioning is still pretty solid with minimal issues (can’t remember names), but knowing what it is like to be 80, makes me realize our country needs younger politicians. Just running around the country and world representing the U.S., and not looking like a buffoon, with breaks in sleep constantly and probably living on Ambien, no president needs to be 80 with that schedule. And what about just worrying about our country would never let me sleep. Older people have sleep issues anyway. How Trump survives so well on 5 hours of sleep is beyond me and most experts.    

 These politicians don’t have independent doctors to insist they retire when they should for the sake of our country. Remember, politicians are paid by us and work for us, but not the ones in the White House today. Politicians need to be physically, cognitively, and psychologically fit, examined by independent physicians and psychologists who can give an unbiased, apolitical answer to the cognitive ability of the senator, congressman, or other federal employees.

  Term limits would take care of these aging issues, but as long as the very politicians that vote on that subject are those who would be affected, donlt hold your breath. Longevity and senority have taken over, and WE are not the primary reason for them running for multiple re-elections. How many millionaires are in congress with salaries of just $150,000 a year?

  Our president is slipping by the month. I don’t have to enumerate his limitations as he ages and clearly has some possible genetic reasons for his current diminished capacity.

  Sad that his wife hasn’t stepped in as a caring spouse to get him to retire and stop making a fool of himself daily. But how can she excuse his behavior? $50 million if you believe the Republicans. Power and control are powerful drugs!!

More discussion on risk factors and dementia

  Aging is a fact of life, and how we spend the previous decades may have a lot of to do with it. Some genetic markers clearly play a role, as do certain medical issues.

   Here are the most common factors:

   hypertension, obesity, sleep problems, social isolation including hearing and visual impairment. Lack of exercise, poor diet, smoking and excess alcohol and substance abuse, chronic depression and anxiety, increasing age (unless you are one of the lucky superagers, as they are called).

  High cholesterol, a form of a genetic lipid abnormality APOE e4, obstructive sleep apnea, and lack of mentally or socially challenging activities all play a role in Alzheimer research.

  The metabolic syndrome encompasses most of these factors (primarily obesity, hypertension, elevated cholesterol and triglycerides), type 2 diabetes, and low good cholesterol--HDL (less than 40mg/dl for men, and less 50mg/dl for women). Even prediabetes has its risks (100-120mg/dl).

  Certain inflammatory diseases, primarily autoimmune diseases can cause neuro-inflammation, well known in Parkinson’s disease, and Lewy body form of dementia, and they can increase neurodegeneration of the memory centers.

  Low income is a factor for a host of reasons including access to good medical care, poorer nutrition, increased stress and hazards.

  How much we can prevent this neurocognitive decline is up to each person, and after 60, it isn’t too late, so get to work! Being evaluated if there are early signs, is a good idea.

Mayo Clinic, National Institutes of Health

What about Superagers?

  Superagers are those elderly poople who have the memory of someone 20-30 years their junior.

  A new study has found the brains of superagers versus those who seem to age at the normal pace, have areas in the gray matter develop much slower than “normal” older adults. This study involved follow up on the participants’ memory for 6 years, and all were over 79.

  Scans showed less atrophy in the brain where memory is stored (frontotemporal regions) in the superagers compared to the controls.

  Superagers can be differentiated also with regard to mobility and fine motor skills. They determined that physical fitness was paramount for cognitive functioning, especially when these subjects were in their 40, 50, and 60s. Staying physically fit as we age is another important factor. These superagers also had less stress in their lives with less anxiety and depression disorders. Staying socially engaged is also critical. Isolation is a real negative. These subjects also had fewer neurodegenerative biomarkers, however, both subjects and controls had the same levels of APOE-e4 allele, prominent in Alzheimer’s disease, but not in superagers versus the controls.

  Using their algorithms, the researchers could only recognize 66% of the superagers, implying multiple factors yet to be recognized, probably genetic.

Medscape General Surgery, August 15, 2023

New treatments being targeted at amyloid and tau, and new causal factors; great progress coming

  It is becoming clearer that the proteins (amyloid, tau) deposited in greater amounts in the brains of Alzheimer’s correlate with causing this disease, and now with newer studies, showing the latest medications that lower the amount of these proteins in the brain on special imaging (PET scan), are showing improvement in symptoms, with the latest research on solanezumab, which targets these proteins. It has been years that the experts were unsure that these proteins caused the symptoms in these patients, but that is changing.

  There are other interesting factors that have come to life, including simple chronic constipation, as defined as having a bowel movement every 3 or more days. According to an Alzheimer’s Association International Conference in Amsterdam this month. There was a 73% higher risk in subjective cognitive decline.

  16% of the worldwide population is estimated to suffer from this problem. Those with chronic constipation have a different gut microbiome, which is thought to promote more inflammation in the body and brain. They also have fewer protective bacteria found in lower levels in Alzheimer’s.

  At least 25 grams of good food fiber is necessary to promote good gut bacteria, along with good hydration and exercise. Probiotics are helpful for some.

  The gut-brain connection continues to play a central role in promoting or preventing inflammation. As published by NBC Health/ AMA News, July 19,2023

Summary—There is Hope!!

  The pharmaceutical industry is rabid in trying to find the miracle drug (mostly monoclonal antibodies) to prevent or slow the progress of Alzheimer’s and other types of dementia. Two drugs in the past month have shown great promise, and the FDA just gave full approval for lecanemab (Leqembi), while studies on another monoclonal antibody are showing significant slowdown of symptoms-donanemab in a phase III trial. I already mentioned solanezumab. These drugs are targeting a modified form of amyloid, known as N3pG, studied by Lilly pharmaceuticals and presented at the Alzheimer’s Association International Conference just published in the JAMA. Another FDA approved monoclonal antibody, aducanumab (Aduhelm) will be marketed soon.   

  Donanemab, at 76 weeks, in the TRAILBLAZER ALZ 2 trial, compared to a placebo, showed significant slowing in those with moderate to severe mounts of amyloid in the brain (amyloid, a protein and tau tangles in the brain appear to be correlated with worsening of the dementia.

   However, there are some side effects creating microhemorrhaging and iron deposits in the brain (hemosiderin deposits in close to 20% of the tested group and 7.4% in the placebos with 3 deaths in that group) (1,736 participants), but because of these side effects a black box warning was required by the FDA to market Leqembi. There are other side effects which must be known as usual.

  Other somewhat effective drugs, such as memantine (Nemenda), which has impoved patient’s forgetfulness, feeling confused, or feeling anxious, which is being used in moderate to severe Alzheimer’s disease and vascular dementia, which can be taken for a year. There are many drug interactions that should be known.

  The cost of these drugs is $26,000 a year, as are most new drugs these days and may not yet be covered by insurance…pretty early, but encouraging. More hope is on the way!!

Medpage Today, July 17, 2023; Mayo Clinic

Regardless of political affiliation, we need proper physical, mental, and cognitive examinations for any candidate for our presidency. How can anyone rationalize who we have now??

4. Celebrities with unusual illnesses—3 autoimmune diseases--Nick Jonus-Type 1 Diabetes, Ashton Kucther-Autoimmune vasculitis, Elizabeth Hasselbach-Celiac disease

A. Nick Jonus—Type 1 Diabetes

   Nick Jonus, one of the Jonus Bros., and guest judge on “The Voice”, has been living with type 1 diabetes, previously known as juvenile or childhood diabetes. He was diagnosed as a teenager. He states the continuous glucose monitoring apparatus (Dexcom) changed his life in staying ahead of his blood sugar.

  Nick has learned the symptoms of high and low blood sugar, and sure doesn’t miss pricking his finger 10-12 times a day. He is now a father, rock star, advocate for type 1 diabetes, and advocating for a cure, which has some good news.

  When I was in medical school a long time ago, having diabetes as a child was close to a death sentence or at least a shortened life, due to the complications of the disease.

  Today, the proper careful management of childhood-type 1 diabetes has come a long way with great success. Using a continous monitoring apparatus (there are many of them) has changed the complexion of this previously deadly disease.

   Today, it is known to be an autoimmune disease, much like other autoimmune diseases, such as rheumatoid arthritis, lupus, or MS. The body’s immune system sees the pancreatic insulin-making cells (Islets of Langerhan) as foreign, and destroys them, creating a need for extrinsic insulin. All type 1 diabetics require insulin to manage the levels of blood glucose, as they fluctuate easily. Controlling a youngster’s blood sugar is a real challenge for parents and the youngster.

  There are 2 peaks of age when type 1 diabetes occur—4-7 and 10-14 years of age.

  Genetics and some viruses can cause type 1 diabetes as

well. This means it can occur in families, as most autoimmune diseases do. Although primary diabetes usually appears in adolescence, it can develop in adults. Differntiating type 1 and 2 is necessary to provide the best treatment.

  There is no cure, as with most autoimmune diseases. Trying to reverse the immune response has not been successful in any of these diseases.

  Insulin with continuous monitoring (CGM), diet, and lifestyle, can keep this disease under control, although, as is well known, young people don’t always manage their medical issues, and without knowledgeable, motivated parents, these young folks can easily get into trouble and face such issues as ketoacidosis, (described below).

  A recent symposium on diabetes announced that if the diabetes is well controlled from the early years, the usual diabetic complications can be prevented in many cases, and the presenters (Dr. David Nathan) stated that they are seeing mortality rates the same as the general population, a far cry from the statistics in the past century, when in 1970s, 1/3 had vision loss, 1 in 5 kidney failure and or heart attacks with stokes and amputation. Dr. Nathan also stated that it is never too late to initiate intensive glucose control and see great improvement in preventing complications.

  Weight issues continue to be challenging with 36% overweight and 40% obese, who are fighting diabetes. This correlates with fatty liver disease, and it could be a good reason for an increase in the number of type 1 and 2 diabetics during the pandemic.

Medscape, July 11, 2023

  Some studies saw an increase in childhood type 1 diabetes during COVID for reasons that should be obvious, after so many people could not or did not manage their underlying diseases, were isolated, could not access their medicine, could not access healthcare, ec.

  The symptoms of type 1 diabetes can be very similar to type 2—thirst, hunger, urinating excessively, and bedwetting is not uncommon in children, because of the excessive urination from excessive fluid intake. Losing weight without trying may be more common in type 1. Feeling tired, with mood swings also may occur. Blurry vision may occur as well.

  Insulin is necessary to provide a vehicle for glucose to enter the cells, lowering the blood sugar. Glucose is the main source of energy, and when it is elevated, life-threatening complications occur. Areas where insulin can be injected subcutaneously:

Complications of diabetes

(if you search in my subjects found by clicking on the icon on the home page, there are several reports on all the complications of diabetes, which are in much more detail) www.themedicalnewsreport.com/subjects

  The same organs are injured in type 1 and type 2 diabetes. It should be understood that all diabetics are much more prone to infections, and should be considered in the high risk group when discussing COVID or any other infection in the body. In fact, infections may bring the patient in for the first time when the diagnosis of diabetes is made.

Cardiovascular—heart attacks, strokes, and loss of blood supply to the lower extremities can be severe. Secondary lung disease can occur from heart failure, recurrent lung infections, etc.

Neurological—Neuropathy is very common with numbness, tingling, and even pain in the feet. Poor control of the blood sugar can lead to complete loss of sensation in lower extremities. Erectile dysfunction is not uncommon, as are digestive problems with nausea, vomiting, diarrhea, or constipation because of nerve loss of the gut motility (autonomic nervous system).

Kidneys—these organs are extremely vascular and the nerves and vessels can become inflamed causing kidney failure, the need for dialysis and the need for a transplant.

Eye disease—the blood vessels of the retina are damaged creating aneurysmal dilation and rupture with microbleeding in (diabetic retinopathy), which can cause blindness. Macular degeneration is more common, and cataracts occur earlier. Healthy retina below, and microaneurysms on the retina in diabetes, which rupture and bleed into the retina with loss of portions of the retina surface (white areas), creating blind spots. Laser therapy can stop bleeding from these new vessels.

Foot damage—nerve damage and blood vessel flow issues create numbness, higher risk of injury, fungal infections, and bacterial infections in the skin are common with unintentional injury because of the lack of feeling. Ulcers that won’t heal create serious comolications. Toenail hygiene is critical (get pedicures). Amputation is the result of infections, poor wound healing, and loss of blood supply from blood vessel obstruction in the lower leg and foot.

Skin and mouth—infections in teeth, gums (periodontal disease), and mouth are common, both bacterial and fungal. Gingivitis is a great concern and requires frequent dental cleanings, examinations, and treatment.

Pregnancy—diabetes increases miscarriages, stillbirths, and birth defects is of concern especially in poorly controlled diabetics. Pre-eclampsia (hypertension, etc.), eye problems, and ketoacidosis are more common.

Ketoacidosis is the most serious acute complication. Ketones develop in the blood when the blood sugar elevates, and there is not enough insulin to make the liver store all the sugar, which can’t store it all as glycogen, releasing ketones. The ketones are acidic, and cause severe dehydration, nausea, vomiting, confusion, a fruity breath, dry skin from dehydration, flushed face, fatigue, weakness, rapid breathing (trying to blow off the acidic nature of the blood-metabolic acidosis. Coma and death can occur.

  Unfortunately, some children are first diagnosed when they develop ketoacidosis. If the blood sugar rises close to 240 mg/dl, monitoring of the ketone levels in the urine are recommended.

  If the blood sugar gets over 300mg/dl and can’t be controlled, it is necessary to seek emergency help. The above symptoms should prompt a parent to take them to the emergency department, be admitted and have round the clock careful control of the blood sugar levels.

  Fluids IV with electrolytes (sodium, potassium, etc.) and short acting insulin is necessary to lower the blood sugar below 200-250mg/dl.

  The most common cause of diabetic ketoacidosis is not taking enough of or ignoring taking insulin, and infections which raise the blood sugar from stress of the disease. Often their insulin pump is plugged and parents must monitor them carefully.

Vulnerability to other autoimmune diseases and proness to infection

  Celiac disease and thyroiditis are 2 autoimmune diseases commonly seen in type 1 diabetes, however, any of the autoimmune diseases can occur from vasculitis to rheumatoid arthritis.  

  Children and younger people are more prone to ketoacidosis, in fact, 63% occur in those under 51 years of age. Type 1, as an autoimmune disease, pretty much destroys the pancreas’ ability to produce insulin.

  Diabetes in children can be type 2 because of obesity, or type 1 may become more serious with weight gain. As is known, 1/3 of the kids are overweight, and are facing type 2 diabetes in the future. All these children should be tested for prediabetes (100-120mg/dl), as the liklihood of developing clinical type 2 diabetes (70%).

  Differentiating type 1 from type 2 may be necessary, as type 1 comes of quickly and worsens as time goes on. Kids that become over weight will develop type 2 slowly as the blood sugar rises over time. With the weight issue worsening in youth, overlap can occur. The results of diabetes ultimately are the same regardless of type, just the age and how fast the progression occurs.

 Osteoporosis must be monitored for (Dexa scan), as diabetes may increase bone demineralization over time.

Blood sugar monitoring

  Testing blood sugars before each meal is necessary and a good reason to purchase a body monitor for continuous monitoring, which can be hooked up to an i-phone or smart watch. Also blood sugar monitors are highly recommended but expensive.

  There are closed loop monitoring systems that require some input from the patient, such as volume of carbohydrates consumed.

  Eating approximately the same number of calories at each meal is helpful to keep the insulin needed close to the same, but expecting that from most diabetics, especially young patients, is unrealistic. But good control of diabetes in most cases will directly correlate with the severity and occurrence of complications of the disease.

Insulin Pump

If an insulin pump is used, the monitor will determine the need for automatic injections of insulin by the pump. Eating a balanced nutritious quality diet with lots of vegetables and fruits, lean protein, and whole grains is critical, and for poor people and those with a broken home, this is not an easy task.

  Children are not easy eaters, many are picky, and being sure they are getting enough calories of good food is as a challenge.

  Exercise also is very necessary, but can change insulin needs, even the next morning after sports the night before.

  Vaccines are critical for these young people and children. That goes for all recommended vaccines, including the pneumonia vaccine and COVID, even though probably most healthy youngsters may or may not need these. These children are vulnerable.

  Growth spurts and puberty will also change insulain needs.

  Hypoglycemia is also an issue anytime a child misses a meal. Signs of hypoglycemia include pallor, weakness, irritability, hunger, sweating, dizziness, loss of consciousness ans seizures. Having an emergency injection of glucagon, orange juice, and other major sweet foods (hard candy, regular soda) should be close by at all times. Chocolate which usually has fats in it will not be absorbed as quickly.

  Retest blood sugar in 15 minutes to see if the blood sugar is adequate, and retest in another 15 minutes. Have the child eat a meal soon afer and retest.

  School teachers must be aware of the issue and be knowledgeable about the insulin needs, hypoglycemia, etc. That goes for grandparents and friends or anytime they are away. Mental health and substance abuse are critical to prevent serious complications.

Pancreatic transplants and stem cell transplants

  Stem cell transplants from cadaver pancreases are showing promising results for treating diabetes. Those not easily controlled with insulin are good candidates for the stem cell transplant. These stem cells are turning into insulin producing cells. 33% of cases in one study allowed the patients to give up insulin shots.

  A pancreatic transplant is another option but with 1.6 million with type 1, a cure for the majority is not possible. There are 35,000 transplants annually. They will have to take rejection medicine the rest fo their lives.   

Mayo Clinic, American Diabetes Association

B. Ashton Kutcher—Autoimmune Vasculitis

A couple of years ago, Kutcher’s vision and hearing began to fail. He had trouble walking. It is not known what other symptoms he had, but apparently he is getting better. It is not known just how many systems have been involved, but with time, several could.

  He was diagnosed with autoimmune vasculitis, which is characterized as inflammation and damage to blood vessels anywhere in the body. As many as 20 million people worldwide suffer from some form of vasculitis.

  Autoimmune diseases are known to come and go, without any warning, so treatment may or may not be the only factor when a person improves or deteriorates.

  Vasculitis involves inflammation of any blood vessels in the body, and different patients experience it in different ways, as vasculitis can be part of most autoimmune diseases (there are 97 different autoimmune diseases).

Since the blood vessels are inflamed, any organ can be involved. Most patients present with headache, fever, fatigue, weight loss, and general body aches and pains.

  There are many types of vasculitis, as seen above. They can be googled.

  The organs most involved are :

--digestive system with pain after eating, ulcers, and perforations.

--ears may cause hearing loss, ringing, and balance issues.

--eyes can cause itching, burning, and even double vision in giant cell arteritis, temporary or permanent blindness in one or both eyes, and can be the first sign of vasculitis.

--hands and feet may develop numbness or weakness of the extremities (neuropathy). There may be hardening of the soles or swelling.

Buerger’s disease

purpura    

dermatitis herpetiformis

--lungs may create shortness of breath or spitting up blood from broken blood vessels or swelling of the small sacs of air where blood transfers carbon dioxide to oxygen.

--skin may cause rash, sores, red spots, or hemorrhages (purpura).

Causes or triggers of vasculitis

  Infections (usually viral) including hepatitis B or C.

  Blood cancers

  Other immune diseases

  Reaction to certain drugs (i.e. hydralazine, minocycline, allopurinol, propylthiouracil, etc.)

Risk Factors

  The disease usually begins before age 50, and can run in families. Smoking tobacco or doing cocaine can increase the risk, especially in Buerger’s disease.  Infections are usually viral, including hepatitis B or C. Also those with other autimmune diseases often have vascultis, as mentioned above. Giant cell arteritis is more common in women while Buerger’s disease is more likely in men. Those with polymyalgia rheumatica are more prone to gaint cell arteritis involving the eye.

Complications  

  The hallmark of vasculitis are he complications, creating organ damage, blood clots, hemorrhage, vision loss. The treatments lower the immune system making these patients more prone to infections.

Diagnosis

  Since vasculitis can be part or all of the specific diseases, there are a host of diseases that are characterized by vasculitis. Behcet’s disease, Buerger’s disease, Wegener’s Granulomatosis, Cryoglobulemia, Giant cell arteritis, Kawasaki’s disease, and Takayasu’s arteritis are just some of the diseases with vasculitis.

  All of these are rare diseases, and if the reader is interested in any of these specific forms of vasculitis, please search them on the Mayo Clinic website.

  Blood tests usually ordered for all autoimmune diseases will reveal an elevation of the C-reactive protein, the antineutrophil antibody test (ANCA). The sed rate may be elevated, and the levels may vary with the severity of the disease as it progresses or resolves temporarily.  X-rays, scans, angiograms, and biopsies all give determine the diagnosis along with the clinical signs.

Treatment

  Corticosteroids are the standard anti-inflammatory medication. Side effects can be many after long use, and the lowest doseage is critical to attain to reverse the disease and not cause too much trouble including being immunosuppressed, causing diabetes, and weaken the bones.

  Medications that are biologics that target specific types of vasculitis, which include methotrexate, azothiaprine, mycophenolate, cyclophosphamide, tocilazuumab, and rituximab.

  Surgery may be required if an aneurysm enlarges causing risk of hemorrhage or ballooning out blocking passages of vessels.

  With vasculitis, blood vessels are narrowed because the inflammation thickens the walls of the blood vessels.

  Mayo Clinic lists these diseases that make up the group of vasculitis.

C. Elizabeth Hasselbach

You may remember her on the Fox and Friends morning show for a few years, and before that on The View, as the conservative voice when they had one, back in 2013.

  She is married to retired NFL quarterback Tim Hasselbach, who played 8 seasons with different teams. She was a great addition to the Fox show, but health issues with her intestines required her to retire.

   She, like many patients, were misdiagnosed as IBS (irritable bowel syndrome). It took her doctors 5 years to diagnose her disease, a gluten sensitivity syndrome—Celiac disease, one of 90 autoimmune diseases. She was very concerned she had cancer of the intestines, but fortunately proper bowel biopsies and food testing diagnosed the gluten hypersensitivity, and once she stopped eating gluten, her symptoms subsided.

Today, with so many people (200,000 per year in the U.S.) with Celiac disease, the grocery stores have gluten free products throughout.

  Gluten, a protein, is found in most breads (rye, wheat, barley), and beer made with barley.

  Gluten causes an immune response in the gut, eroding the villi of the intestinal wall, as seen in the drawing above, and over time the inflammatory reaction prevent proper digestion,causing bloating, gas, pain, diarrhea, fatigue, weight loss, and anemia (iron deficiency). There can be nausea, vomiting, and constipation as well.

  In children, Celiac disease can slow growth and development because of the malabsorption of vitamins, minerals, and nutrients with malnutrition.

  These children may have failure to thrive as an infant, have damage to their tooth enamel, weight loss, swollen bellies, anemia, constipation, gas, with pale foul smelling stools. Some may be short in stature, and have delayed puberty. They may have ADHD, learning disabilities, lack of coordination, and even seizures.

  As in so many patients with the autoimmune syndromes, systemic symptoms can include other immune diseases, with joint pain, mouth ulcers, skin rashes, headaches, nervous system symptoms of numbness and tingling of the hands and feet, balance issues, and cognitive impairment, and rarely reduced function of the spleen, which can increase the risk of infections.

  A specific type of blistering skin rash, dermatitis herpetiformis, may occur. With omission of gluten, the rash will improve. Biopsy of the skin will give the diagnosis.

Blood tests can diagnose antibodies against gluten, and genentic tests such as human leukocyte antigens.

  Endoscopy is critical to diagnose the disease. Capsule endoscopy can be used in some cases, and the swallowed tiny camera can visualize the abnormal lining of the small intestines.

  There is no cure but omitting gluten from the diet, over time, will promote healing of the lining of the small intestine.

  Celiac disease may run in families, as any of the autoimmune diseases, and surgery, pregnancy, childbirth, viral infections, and severe emotional distress may activate the disease.

  People with type 1 diabetes, Down’s or Turner’s syndrome, immune thyroiditis, and Addison’s disease have an increased risk of Celiac disease.

  Complications as an adult, include malnutrition, anemia, osteoporosis, infertility, miscarriages, lactose intolerance, and if patients don’t stop eating gluten increase the risk of gut lymphoma or cancer of small bowel can occur. Severe cases have more nervous system symptoms including seizures and peripheral neuropathy.

  There are patients who do not respond to omitting gluten, and develop colitis, pancreatic insufficiency, and lactose intolerance, requiring intensive treatment.

Foods with hidden gluten

  The following foods contain gluten besides wheat—barley, bulgur, durum, farina, Graham flour, malt, rye, semolina, spelt (a form of wheat), and, triticale. Be careful about mixes of foods, gravies, soups, and seasoned snacks such as potato chips and tortillas (unless corn).

  Gluten can be hidden in modified food starch, preservatives, and food stabilizers, vitamin and mineral supplements, lipstick products, toothpaste and mouth wash, communion wafers, envelope and stamp glue, and play dough. Look for products that specifically say, “gluten free”.

  Patients may need supplements of copper, zinc, folate, iron, B12, vitamin D, and K.

  Adults will take several years to heal, while children tend to be much better in 6-12 months.

  If inflammation is severe enough, corticosteroids, and medications to reduce the inflammatory reaction including Imuran or Entocort. Dapsone is recommended for dermatitis herpetifomis, just like those with vasculitis, discussed under Ashton Kutcher. As a reminder, all these autoimmune diseases overlap in some cases.

  Every patient will learn how compulsive or laxed they can be, but expect bloating and diarrhea if gluten containing foods are consumed in excess.

  Foods allowable are eggs, fresh meats, fruits, lentils, most dairy products (unless lactose intolerant), nuts, potatoes, vegetables, wine, and liquors. Corn and cornmeal, gluten free flour, quinoa, and rice are allowable.

  As you can read, these autoimmune diseases are distinct in some repects but overlap in many ways. Anyone who has them must not only be treated for the specific disease, but be tested over time for any number of other autoimmune diseases.

Mayo Clinic

5. The Coup we never Knew

   I don’t often run across an email that in just few words sums up how much trouble our country is in. Why report on this? How do these thing affect healthcare? 100%!! You may not agree with this man’s statements, but just read it and decide for yourselves.

This completes the September report.

  The October, 2023 report will continue with new subjects:

1. Late Breaking Medical news

2. Carotid artery blockage and strokes; new techniques to treat

3. Camp LeJuene and toxic water—health risks

4. Celebrities with unusual diseases—

Selena Gomez-kidney transplant from lupus,

Robin Roberts-myelodysplastic syndrome;

Kim Kardashian and Phil Mickelson-psoriasis and psoriatic arthritis

Thank you as always for reading my reports, and enjoy your Labor Day, at least for those willing to work. Our country must get its act together soon, or it will be too late. Does our country want to sit on their butts and let the government control your life?? That is what is at stake.

Stay healthy and well, my friends, Dr. Sam