The Medical News Report, November, 2014
Sam La Monte, M.D., FACS
Advances in Medicine and Healthcare
For a free monthly subscription
1. Can artificial sweeteners make you
2. Clinician’s fatigue by giving into
patient’s request for unnecessary
3. Prostate Cancer-Part 4--Staging
options for treatment.
4. Loss of the sense of smell and the
risk of cardiovascular disease death.
5. Is a blood test coming to detect
6. When is it time to switch doctors?...
common complaints of patients.
7. Life Expectancy continues to climb.
8. What is the optimum systolic blood
pressure to maintain?
Can Artificial Sweeteners make you gain
Yes, says some of the latest research on such sweeteners such as
saccharin and aspartamine. They can interfere with
gut bacteria that actually allow the other sugars you consume (and they are
hidden everywhere) to be better
absorbed, thus cancelling out any
benefit of drinking or eating low
calorie artificial sweetener products,
especially soft drinks. With better
intestinal absorption of sugar, this
raises the blood sugar and predispose to
pre-diabetes. The doctors (Samadi and
Siegel) on the Fox News show “Housecalls”,
sweeteners also continue to keep you addicted to the taste of
since these products are sweeter tasting
than regular glucose, fructose, etc.
Natural sugars are still not good for
Agave is the only one that is natural and does not raise the blood
sugar. I have previously discussed the
harms of sugars extensively.
Medical News Report #4
Now it appears, we are fooling ourselves by drinking artificially
sweetened products. In fact, the doctors
on Housecall, state that the
pediatricians at the NYCLangone Medical
DIET DRINKS FOR CHILDREN, AND IF a CHILD
IS GOING TO DRINK AN OCCASIONAL SODA,
JUST DRINK THE REGULAR SOFT DRINKS. If a person is drinking a large amount of “diet” drinks, it
should be minimized while trying to lose
weight.This information is
controversial, but certainly, if you are
pre-diabetic or diabetic, discuss this
with your doctor.
Also, artificial sweetener lovers, these substances are made from
(genetically engineered organisms).
This issue has become a world-wide
concern and is banned in most countries,
but not ours!!!! It is quite
controversial, although the National
Institutes of Health state, that GMOs
are safe. Read what they say. You
There is evidence in children that these products may be boosting
the epidemic of type 2 diabetes.
Further information about artificial sweeteners:
I would also suggest you tune into the
Doctor shows on Sirius/XM channel 81
radio, which also originates from the
NYC Langone Medical Center. These
experts have call in shows, which are
quite informative. Most medical subjects
are covered from A-Z.
HAPPY HANUKKAH Dec. 16-24, 2014
Unnecessary antibiotic prescriptions for
viral respiratory infection by fatigued
I have discussed the diagnosis and treatment ofcolds, viral upper
respiratory infections, and sinusitis in
A new study has shed some light on how clinicians fall into the
trap of letting well-meaning parents or
patients that insist antibiotics be
prescribed for what appears to be a
viral or allergic sore throat, cough, or
stopped up sinuses. Doctors have to
defend the reasons why an antibiotic is
not indicated if a viral infection is
diagnosed. We do have rapid strep tests
in the office (there is a only a 5%
chance there is a false negative
result). I have also discussed when a
cold becomes a bacterial sinusitis in
A recent study measured how many antibiotic prescriptions were
written in the first hour of a doctor’s
schedule and the fourth hour. 25% more
prescriptions were written in the
fourth. Analysis of the time spent with
each patient was shorter at the end of
the schedule. Doctors admitted fatigue
was a factor, and were more likely to
recommend an antibiotic inappropriately
to prevent a lengthy explanation that
antibiotics were not indicated.
As an ENT surgeon, I told patients to return if they worsened
with a viral infection. Some of those
patients, in a small number, did need a
resistance continues to be an
increasingly serious problem, and doctors are facing bacteria that are resistant to all
antibiotics except very toxic ones.
A new factor has popped up in doctors giving in to patient’s
satisfaction questionnaires. As doctors are becoming employees, their salary is partially
based on these surveys. Physician groups
arecurrently requesting that patients
take more responsibility for their care
along with the doctors (patient-centered
Why should a patient downgrade a doctor
on a survey because the doctor refused
to give the patient an inappropriate
antibiotic? Many physician groups are
concerned about this. This is just one
example of why doctors get worn down and
Where is the legal reform??.... another omission that is unfair
and needs to be included. Insurance
premiums are going up as much as 20% in
2015. The “Affordable Care Act” is
Ref. NEJM (New England Journal of Medicine), 2014, MedPage.
Prostate Cancer-Part 4—Staging and
considerations for Type(s) of Treatment
Staging determines the choice of treatment, the extent of the
cancer, and the probable 5 year survival
rate. Most prostate cancers do not kill
the patient. Other causes frequently are
the cause of death. It is for that
reason, one of the choices, especially
for more senior patients may be to NOT
TREAT THE CANCER. It is a real option
after 75 years of age.
I have previously discussed general information, the PSA test,
and the Gleason Score in the past 3
It is not easy for patients to decide on a treatment plan for
this cancer. There are many options when
considering therapeutic regimens.
The oncologist has many factors to consider:
1. Patient status, co-morbidities (other
2. Age (healthy enough to tolerate
therapy or have a
Expected life expectancy of less than 10
Older patients might consider not
treating a slow
3. Stage of the tumor (I,II,III, and IV)
number (LESS THAN 10 or over 10)
5. Gleason score (6 or less vs. greater
6. Results of imaging studies (CT,MRI,
7. Side effects frequently play a major
role in a
patient deciding on a choice of
treatment. These must
8. Patient’s willingness to drive or be
atreatment facility daily for radiation.
9. Patients may need to continue a part
or full time job
during the treatment.
10. Patient’s ability to make co-pays.
of all tumors is critical to determine
the proper treatment(s) and is used to
communicate with other doctors (other
oncologists and referring doctors). A
patient should consider consulting at
least a surgeon and radiation oncologist
todiscuss the option(s) for treatment
(urological/surgical, radiation, and
medical). I would also recommend talking
to a medical oncologist just in case any
chemo is contemplated.
The prostate cancer staging system uses
the T,N,M rating.
T=tumor N=nodes M=metastases
T=tumor (the size, position in or out of the prostate)
T uses a 1-4 rating
based on the extent of the tumor, T1-found incidentally during a
prostatectomy for BPH (enlarged
prostate), T2-found on one side of the
prostate,T3-both sides, T4- to the outer
capsule or through it involving the
the immediate surrounding tissue such as
the bladder, rectum, andurethral
The seminal vesicles (and Cowper’s glands) provide the liquid for
sperm during orgasm as seen in the
The PSA number and the Gleason scores are taken into consideration in
staging. The cutoff for the PSA is less than 6, 6-10, 10-19, 20 and
greater. The Gleason score is separated
from 6 or less, 7, 8 or greater. The
higher the scores, the more malignant
the tumor, the survival rates is
Knowing the tumor is
male hormone sensitive or not
is important in determining medical
N=nodes (indicates the lymph node spread, either one or more).
The N uses X,0, and 1 (this is easier to follow, since the X
means the nodes were not assessed, 0
means no nodes, and 1 means one or more
M=metastasis (spread to other parts of the body, including the
lymph nodes, bone, lungs, liver, or
M uses 0,1a,1b, and 1c (indicating no spread to other organs, to
bone, and to other organs).
If you want to see how complicated this system is, but
absolutely necessary. See below:
The American Cancer Society explains staging on their website as
D. OPTIONS FOR TREATMENT
chance to cut is a chance to cure”.
Robotic surgeons call their surgery
“nerve sparing”,however, the tumor may
dictate that a nerve can’t be spared.
Even if the nerve is spared, it may be
injured and temporarily not function.
The current studies are difficult to
analyze, but in general, robotic surgery
has fewer side effects than a radical
prostatectomy. If one compares the
results of cure and side effects by a
VERY EXPERIENCED robotic surgeon to a
less experienced surgeon, there can be a
big difference in side effects. Robotic
surgery can be recommended if the tumor
is confined to less of the prostate,
thus giving a better chance for sparing
the nerves for erection and bladder and
bowel control. This is appealing to
younger men for obvious reasons. If the
tumor is extensive, a more radical
procedure will probably be recommended.
However, all treatments will have these
side effects to some degree.
don’t have to be cut on”. Radiation has
about the same percentage of side
effects as surgery, except since the
rectum is irradiated, there are usually
more intestinal side effects.
There are two different isotopes used (photon vs proton).
Proton delivers more defined radiation
to the gland sparing surrounding
tissues, thus appearing to be superior,
but follow up 2 years later has not
proven that there is any difference in
results regarding cure and side effects,
temporary or permanent.
How serious side effects are depends on individual patients,
therefore, it will be difficult to make
the comparison between the two leading
techniques for prostate cancer (IMRT vs.
PT), but ongoing studies are under way.
We must go by the research evidence, not
what well-meaning patients say. The
cost for proton therapy is 3 times as
expensive as IMRT. The equipment costs
millions more than IMRT, and most big
cancer institutes are investing in them,
but there are other cancers where the
proton therapy is definitely better, so
it is no surprise they are adding proton
therapy. This is big business.Either
treatment is covered by Medicare, but I
am anticipating seeing a cut in
reimbursement for proton therapy (IMRT=$
12-15,000 vs PT=$35-40,000). Robotic
surgical equipment and technical costs
are not covered more than a radical
prostatectomy (the hospitals eat cost),
so why would Medicare pay so much more
for this technique when it so far has
not proven to be significantly better?
Who is greasing the palms? With
healthcare reform trying to reduce
costs, there is no excuse.
Complications and side effects need special consideration. I will
discuss this next month.
You need to know the treating physician’s personal complication
rates, the percentage of side effects in
their patients, and what can be done
Very enlarged prostates---Some
men have such large prostates, it may be
recommended to shrink the gland before
any treatment can be performed. This can
achieved by oral medication (5 alpha
reductase inhibitors shrink the prostate
and keep it from growing, but not the
cancer—Proscar, Avodart, and Jalyn). I
will discuss the subject of enlarged
prostates (benign) in a future report.
If the disease is confined to the prostate and does not penetrate
the capsule, a curative treatment will
be recommended with a greater than 90%
(up to 99%) chance of cure regardless of
whether surgery or radiation is chosen.
If the disease has spread locally or to the nearby nodes, a more
aggressive treatment plan will be
Radical prostatectomy either with robotic or open surgery is
offered.It is beyond the scope of this
report to discuss surgical management in
The radical prostatectomy is approached in 2 ways, either through
the abdomen or perineal (between the
scrotum and the anus), as seen in the
For a video animation of the procedure for Robotic Da Vinci
There is less trauma to the tissues,
less bleeding, and potentially less
trauma to the nerves, and it is
performed endoscopically through tiny
incisions in the abdomen.
Incision with the Da Vinci Robotic Surgical Technique
RADIATION THERAPY—different options
Radiation treatments vary as well. It is based on the technique
and the isotope used. Standardexternal radiation (convolutional radiation therapy,
(intensity modulated radiation therapy),
brachytherapy (radiation needle implants) and other variations using photons
are all being used. IMRT is the most
popular although a study from the
internet site,Medpage, in 2013 reported
no benefit over the standard RT, and
felt the difference in cost did not
justify the more advanced type of
Proton Therapy requires less radiation, because of the precision
of protons, and the tumor is the only
organ receiving radiation (except for
some scatter), as opposed to IMRT that
does irradiate some of the surrounding
tissues slightly. Keep in mind, most of
these patients being treated with
primary RT are those with earlier less
advanced prostate cancers. The cure
rates are similar, but are the side
I have read a huge number of articles about the pros and cons of
each of these treatments. The best
medical journals state there is
advantage of proton over the other
techniques of radiation for the
treatment of localized prostate cancer
regarding cure or side effects, but most
compare after 2 years. It may be there
are fewer temporary side effects, but
there are no reports yet to settle the
There is ongoing research to compare these techniques (IMRT vs
PT) in different age groups, stages, and
percentage of side effects. In time, one
technique may be proven to be better
with more cures and less side effects in
the next few years.
Dr. Nancy Mendenhall,etal, a recognized authority in radiation
oncology at the University of Florida,
recently wrote an article (Journal of
International Radiation Oncology)
reporting on 200 patients (which is a
small number) who were treated with
proton therapy, and these patients had
an excellent response with a low percent
of side effects just as efficient as
A recent study reported that proton therapy has already added
$350 million to healthcare costs in the
I am confident these outstanding doctors would not support proton
therapy as another excellent option for
several site specific cancers. We just
can’t say it is any better when it comes
to prostate cancer treatment YET.
Being informed is vital to make a good decision.
Many patients will be placed on lifelong anti-testosterone
hormone therapy to help prevent
recurrence. Most of these tumors are
meaning the tumor can be accelerated by
male hormone. It is not thought,
however, to cause prostate cancer. Side
effects of this hormonal treatment will
cause some breast tissue growth and
tenderness, loss of some body hair, and
other feminizing side effects.
CONSIDERATION FOR NO TREATMENT
This is a real consideration for both the doctor and patient
especially if the tumor is less
malignant, deemed to be slow growing,
and the age of the patient is 75 or
older. The overall health of the patient
is a very serious consideration. These
tumors likely will not be the cause of
death. Why put up with side effects from
treatment especially incontinence. The
family must understand this is a
Metastatic disease will be discussed in
Loss of sense of smell (anosmia) and the
risk of dying
The sense of smell is one of the 5 senses (smell, sight, taste,
hearing, and touch). We gain great
pleasure in smelling great food, wine,
flowers, and it is a defense against
harm such as the smell of smoke, etc.
Without it, the quality of life is
affected. Smell is necessary for taste.
These two senses are integrally
associated with each other. Getting a
cold will cause the sense of smell and
taste to diminish, even though the taste
nerves are intact.
Losing the sense gradually happens with aging, and occurs more in
some than others. However, those that
lose itFASTER are three times more
likely to die from cardiovascular
disease.This is an indicator that strongly correlates, so if you have
smell troubles, get checked for
The University of Chicago reported that over 3000 patients from
ages 57-85 were studied for the sense of
smell. 5 years later, 430 were dead, and
39% of those who developed loss of smell
died compared to 19% who did not. This
makes it a more potent risk factor than
heart failure for heart attacks.
is one of
the twelve cranial nerves
actually an outpouching of the brain,
starting in the limbic system of the
brain (amydala), which is the center for
emotion. It is a fact that smells give
true emotional pleasure. Have you ever
had a massage while inhaling fumes of
lavender or eucalyptus oil? Yum! After
60, more than half of the population
starts to slowly lose this sense. That
is dangerous if you can’t smell gas or
smoke (something to think about with
folks up in age if they live alone).
twelve cranial nerves (see above).
The first cranial nerve is the
This nerve, known as the olfactory
bulbs, traverses the floor of the
anterior cranial vault traveling through
small holes (cribriform plate) in the
skull to the nose, which is the weakest
point of the skull and prone to damage
with head and facial injuries. Loss of
smell with head injury is not uncommon
if the fracture occurs in this area.
As the smell nerves travel to the lining of the upper nose
(superior turbinate in the below
drawing), there are chemoreceptors in
the lining (mucosa). These are the
sensors that send signals to the brain.
Obstruction of the upper nose from polyps, allergic swelling, or
inflammation from colds and sinusitis
can interfere with smell and taste.
These disorders are the most common
cause of loss of smell. However,
medications and head or nasal trauma can
anosmia (the medical term).
Of course age is a factor. In fact,
there are 60,500 neurons in the
olfactory nerve at age 25 and only
14,500 at age 95. Women have more fibers
than men. 90% of Alzheimer’s patients
have significant abnormalities of smell
and taste, because of neurodegeneration.
Causes of anosmia
Head trauma, nasal/sinus disease, anesthesia, medications, toxic
chemicals exposure, antidepressants,
heart meds, antibiotics,
anti-inflammatory meds, cocaine,
neurological disease (MS, Alzheimer’s,
Parkinson, etc.), or radiation to the
area can cause the loss of smell. At
times, the cause is unknown.
Treatment of anosmia
Nasal cortisone and decongestants may help if nasal allergies are
severe. Zinc has long been thought to
help, but there has never been a good
study on the subject. B vitamins also
are important for good nerve function.
Is a blood test coming to detect future
In the Journal of Experimental Biology,
that it is possible to look at the
genome of human lymphocytes and see
breaks in the DNA that will predict
possible cancers in the future or at
least those that are higher risk. If you
had this test, and you were a smoker,
would that convince you that your habit
may be harming your DNA and might cause
cancer sometime in the future? Would you
quit? Would you lose weight, would you
exercise, would eat correctly? All of
the above clearly increase the risk of
cancer and cardiovascular disease and
yet 17% still smoke, obesity is
epidemic, and most do not exercise
Comparing normal patients to cancer patients show very different
DNA character, in that specific breaks
in the DNA can be shown in cancer
patients. Of course, this is just one
experiment, but likely will be the first
of many to come.
Reference: The Journal of Federations of Experimental Biology,
Is it time to switch doctors? Common
complaints of patients!
In an era when patient-centered care is being encouraged,
patients deserve to have a SATISFYING
and GOOD relationship with their
doctors. In my, opinion, this takes
time, honesty, and sometimes stating
your expectations with your doctor.
Primary Care Physicians (PCP), P.A.s,
and Nurse Practitioners tend to be more
down to earth and friendly. Patients
that are referred to a specialist may be
disappointed that they are more
business-like and appear more distant.
Remember, you already have a long
relationship with your PCP, and it will
take more than one visit to get to know
a new doctor. Everyone has particular
likes in a physician. But there are
expectations that are pretty
standard.Here are common complaints:
1. The wait time is excessive (does the staff come out and explain why the doctor
is running behind?) One way to prevent
this is to be their first patient on the
2. Won’t answer your questions or does not explain to
situation and why they have chosen a
certain treatment. You must be willing
to tell them you do not understand.
Don’t be embarrassed or feel you are
asking “stupid” questions.
3. Rude or condescending. If you are being talked down to, don’t put up with it. Tell the
doctor or the staff.
4. Not treating my health concerns as urgent. No
illness is trivial, but doctors are
seeing sick people all day, and they can
assume more minor problems are not
urgent. Tell the doctor you are very
5. Not being kept informed. If you are waiting weeks to find out test results, that is not
acceptable. On the other hand, some
tests have to be sent to special labs,
and take longer. Call the office and get
an explanation why it is taking so long.
Also, with electronic medical records,
it should not be a problem getting
records from another doctor in the
future. That is why I recommend patients
consider a clinic or affiliated
practice, because all the doctor’s
records are stored on the same computer
system. However some electronic record
systems are not compatible with others.
I have access to my own records through the group of doctors I
see (Northeast Georgia Medical Group). I
was in a large multispecialty clinic
(165) in Pensacola, and not only did I
have access to the other doctor’s
records, we were all partners. That is
the great value being in a
multispecialty group practice.
6. Made patient’s feel uncomfortable. If you do not have a good working relationship with the doctors
and their staff, you are not going to be
happy. The staff can be the real
problem. Tell your doctor if the staff
is not meeting your expectations.
7. Not sure advice and care is totally adequateor
satisfactory. If I felt that way, I
would be gone in a second.
8. Did not respect me or my needs. This is a deal breaker.
9. Did not feel there was mutual trust. Be
honest with each other. Never lie about
taking meds or doing what the doctor
instructed. Never withhold information
regarding taking illegal drugs,
excessive alcohol, or taking
10. Angry if you ask for a second opinion.
11. No eye contact, staring at the computer or medical records instead of you. This
created a real problem for me recently,
and I fired my cardiologist. Because the
record keeping is so intensive, doctors
are filling out the record while talking
to you. One of the principles of medical
OBSERVATION BY THE DOCTOR.
Many subtle signs of illness can be
picked up with this technique. Ask them
to put the computer down or switch
doctors (or at least tell their staff).
Doctors are so pressed to fill out more
documentation, thanks to Obamacare.
12. Dismiss my caregiver or friends and relatives that come with me. There is a reason
someone brings another person into the
office. It usually is for reassurance
but also to have a second set of ears.
Remembering what the doctor said is a
These are common complaints and if you have checked many of these
off, it is time to look for another
doctor. Because many doctors are not
taking new patients that are Medicare or
Medicaid, think twice and see if you can
remedy the problem.
I don’t usually give advice, but I did this time. Doctors are
human and under more stress thanks to
our healthcare system. Most are no
longer in charge as they have become
employees. There is managerial pressure
to see a minimum number of patients,
create a certain revenue stream, with
numerous other standards. You may be
seeing the transition of the healthcare
professionals. How is it working out for
I am not making excuses for doctors who do not have a “bedside
patient care is a “two way street”.
If a patient is demeaning, arrogant,
does not follow instructions, does not
take their medicine as prescribed,
doesn’t take responsibility for their
own behavior, the patient is missing the
partnership with their doctor(s) that
creates the best experience for both
patient and doctor.
Life expectancy continues to climb
Even though the average weight of Americans continues to rise, so
has the life expectancy. In 2012, men
lived an average of 76.4 years and women
81.2 years. With the type 2
diabetes/obesity epidemic, I would
rationally wouldconclude that the life
expectancy will start plateauing,
however, not yet. There will always be a
lag in these statistics.
Reference: National Health Statistics Center
What is the optimum systolic blood
pressure to maintain when being treated
The internet site, Medscape, this month reported that on optimum
blood pressure level for patients.
Although both the systolic and diastolic
blood pressures are very important, the
latest recommendations state that
systolic pressure between 130-139mm of mercury is optimum. You
have probably been told 140/80 is
optimum. These new guidelines are
different for different groups. This is
your doctor’s decision.
The hard part is keeping the blood pressure constant. It is
Hard, exercise, anger, etc. raise the blood pressure . The only
way we could know how our pressure rises
and lowers during the day. It is well
known with obstructive sleep apnea, the
pressure can rise to dangerous levels,
and when blood pressure rises we are
more at risk for a heart attack or
stroke. Keeping calm and pacing yourself
is probably the best you can do to keep
your pressure (and pulse) in the normal
Blood pressure medicine has a bell
shaped curve as it works. I check my
blood pressure at night and first thing
in the morning. Strokes and heart
attacks occur frequently during the
early morning hours, therefore nighttime
pressure is just as important as
daytime. Here is what the Harvard Health
Everyone should have a blood pressure monitor at home. They are
available at any pharmacy.
THIS COMPLETES THE 2014 REPORTS. WHAT A
YEAR! WE WILL CONTINUE TO PROVIDE YOU
WITH THE LATEST UPDATES AND INFORMATION
IN MEDICINE AND HEALTHCARE. Merry
Christmas and Happy Holidays!
STAY HEALTHY AND WELL, MY FRIENDS, DR.