The Medical News Report
February, 2015, #37
Samuel J. La Monte, M.D., F.A.C.S.
For a monthly free subscription email me at:
This is the month for love. It is always a great time to love one another,
especially in these difficult times that we live in. Love of your God, love of
our country, family, and friends is always in vogue. Happy Valentine’s Day!
This is the beginning of the 4th year of my report.
I have relearned an enormous amount of medical information and updated my
knowledge in the last 5 years. I hope I have brought you much needed information
to allow you to be more informed about many medical subjects and to encourage
become your own health advocate.
I have stated that you must become a serious partner in your own healthcare in
this era of patient-centered care, ad nauseaum. Always discuss any of my report
information with your doctors. Thank you for reading!!
Subjects for February, 2014
New Information on Controlling Lipids:
fat blocker) plus
provide better control for cholesterol levels—a reversal of findings; exciting
research on once a month injection for bad cholesterol
A Major Transformation in Mainstream Medicine-what
you need to know
2—our military and the public; acute grief, complicated grief, and depression
4. Another chapter on
and cluster types
A footnote: I apologize for not including side effects of prostate cancer
treatment this month.
Next month, I will report on this.
There are two important issues in play:
Statins and a fat blocker ezetimibe (Zetia),
an intestinal fat blocker,have been proven to lower LDL/ cholesterol levels
better when added to statins than statins alone as reported at the recent annual
American Heart Association’s meeting. A drug, Vytorin (Zetia/simvastatin),
combines these two drugs, and was very popular until studies a few years ago
reported that the fat blocker did not improve cholesterol levels (lower LDL and
higher HDL) any better than a statin alone. (It is always better to take fewer
drugs, if for no other reasons of one drug interfering with another. In fact, if
you take several meds per day, you have increased that possibility greatly.)
If your statin is not controlling the cholesterol (LDL less than 100mg/dl, you
might talk with your doctor about considering adding Zetia to the statin instead
of increasing the dose of the statin to stay away from the higher doses more
likely to cause muscle damage (up to 5% of patients).
The second issue comes from recent studies and guidelines for cholesterol
that were supported by some national Cardiology organizations. They stated that
the actual level of cholesterol was not as important as just taking a statin and
managing other co-morbidities that increase the likelihood of cardiovascular
(heart attacks, etc.) and cerebrovascular disease (stroke). This has been
since these recommendations were published.
extensively reported on thesestatin guidelines in past reports.
However, in recent reports, it is clearly stated that the lower the cholesterol
the better. The ratio of the LDL/HDL is also important. The
use of statins to treat cholesterol
was covered in previous reports as well.
Lowering the cholesterol (triglycerides-need other meds) and blood pressure can
reduce the risk of heart attack, stroke, and death by as much as 25-35%. It can
reduce the risk of a recurrent stroke by 40%.
There are also studies that report taking more than one cholesterol lowering
drugs (fibrates, Lovaza, niacin, Lopid, fish oil) can increase the chances of
side effects of statins (muscle problems), therefore that will be taken into
consideration when deciding to take other cholesterol lowering medications.
Zetia is not in this group and does not cause muscle damage. BTW, a recent study
regarding fibrates and Lovaza for reducing triglycerides stated that Lovaza
alone was just as effective. Taking as few meds as possible is wise!! Drug side
effects and cross-reactivity are a real problem!
Blood studies to keep an eye on if taking statins—liver and kidney studies every
6 month checkups of liver studies is now
recommended (after a couple of baseline studies prove to be normal), but perhaps
yearly makes good sense. Talk to your doctor.
The European Society of Cardiology recommends the following if you are having
side effects of statins:
a. Take a break from the statin for 10-14 days.
b. Switch to another statin and a lower dose.
c. Take it easy when exercising, as this can aggravate the muscle side effects
(even muscle cell death).
d. Take the supplement, Co-enzyme Q-10, to possibly prevent side effects of
e. Take magnesium supplements. The dose was not cited, but it is very important
for muscle metabolism.
f. Avoid grapefruit juice if taking statins, as it can
the absorption of statins and cause toxicity.
g. Avoid these drug interactions with statins (Cardarone, Lopid, Mevacor, HIV
drugs, antifungals, the antidepressant nefazadone (Serzone).
Some of these additional drugs have not shown additional benefit in reducing
cardiovascular disease or death. This is still being studied.
Exciting new Research! A monthly injection to reduce bad cholesterol (LDL)!
There are two competing drug companies working hard to get approval for their
new approach to lowering cholesterol. It is the use of
to block the release of LDL-cholesterol from the liver by blocking a protein
once a month injections
apparently with a great influence on lowering cholesterol in those who have
statin intolerance or who can’t reduce their cholesterol with statins and Zetia
alone. Adding this injection showed as much as
63-75% more reduction if added to the usual drugs or even alone.
I suspect the injection will be very expensive, the 2 drug companies estimate
that there will 36 million Americans who will potentially qualify for its use.
There is even a
being studied to reduce cholesterol, and I will have more to say about that in
the near future.
Like it or not, mainstream medicine listened once again to the academicians, and
they have created a new mantra--guidelines
for medicine care.
What does this mean? Because medicine has continued to be more and more
complicated, academic medicine has been pushing to create guidelines and
(guidance is a better word) for the diagnosis and treatment of most medical
diseases and disorders.
I have spent the last 4 years working on guidelines for post-treatment
surveillance and management for cancer survivors for primary care doctors
(PCPs). Family doctors are not usually comfortable monitoring cancer patients.
They need guidance to get comfortable with this responsibility, if they accept
it. This has become necessary because of a shortage of oncologists, and it isn’t
going to get any better, even with nurse practitioners and PAs. Cancer doctors
are reaching out to the PCPs to follow patients as they get past the first
couple of years of close monitoring. That does not mean you are not to see your
oncologist. This is also happening across the fields of medicine. It is also
necessary with nurse practitioners without direct physician supervision (19
states have legalized the practice).
Guidelines (or better termed guidance-NOT RULES) for physicians to follow are
being created. Is this cookbook medicine? In a way it is. Doctors are trained to
use their considerable knowledge and experience to decide what is best for
patients, but many err and
do not follow up-to-date
recommendations. Hence the guidelines!! Most specialty medical and surgical
organizations are busy creating guidelines for just about every disease. On the
surface, these guidelines are just what is needed, because they come from
that have proven ability to accomplish the mission. That means a research
project(s) has to back up what is recommended.
The drawbacks I see:
1) Will a doctor be in trouble if they don’t follow the guidelines? I suspect,
the doctor will have to document why they went another route. This takes time,
and could expose the doctor to scrutiny by the legal profession and federal
regulations. If these are guidelines and not rules, they should not be strictly
held to these guidelines. This could create problems.
2) How often will these guidelines need to be updated? This process of
evidence-based medicine could become very difficult to stay current (and
costly). I am concerned that articles in the medical literature are already 1-3
years old when they are published. Updating them will be a chore. That is why
doctors go to conferences to hear the latest or read it online as I do. That is
the value of my Medical News Report.
3) Will hospitals insist that these guidelines be followed? (Insurance
companies, federal medicine--Medicaid/Medicare)? Will reimbursement be a factor?
These are worrying practicing doctors. The pressure being put on doctors today
is going to reach a boiling point.
4) These guidelines are not perfect. It was just reported that guidelines for
diagnosing Celiac disease miss many new patients who don’t present with
diarrhea. Only 27% of patients in a recent study reported that diarrhea was the
presenting symptom. Anemia, osteoporosis, and abdominal bloating were more
common. This changes the playing field, and only points out that
constant updating of guidelines
are absolutely necessary if we are to lean more heavily on guidelines in
Last month, I discussed some of the salient points on this disorder, which has
devastated so many of our returning military heroes, but this disorder is even
more common in regular Americans.
A. General information
Post-traumatic stress syndrome
says it all. It is a certified psychiatric disorder that occurs in as many as
of those in combat, however, anyone (male, female, or child) is at risk to this
if they experience a
stressful event for example from a death, accidents, rape, sexual harassment,
natural disaster, or actual military experiences, family traumas, etc. Even
emergency personnel can experiencePTSD.
The PTSD Foundationwww.ptsdusa.orghas
a questionnaire on their website that can be filled out and submitted and
evaluated and returned to you. Check it out.
There are different categories that must be present to meet the criteria for the
Pre-existing mental disorders can complicate these criteria.
Those who are going into harm’s way need to be screened by the military for high
risk (research is ongoing). This has not been done in previous wars, and not
even the current military engagements in the Middle East.
Most of PTSD research in the last decade has been performed on recent veterans
(Middle East conflicts), and the older literature is 20 plus years old (Vietnam,
Korea, WWII). That literature pointed out that 37% of WWII vets had PTSD, 80%
Korean vets, and 67% of previous POWS. The VA puts out an 8 page booklet for
patients and families:
More senior veterans are suffering just as much from previous wars, and they
have been somewhat ignored compared to recent veterans.
Statistics for men and women experiencing a trauma and the chances of
experiencing PTSD are in this diagram.
Bless Chris Kyle
Go see American Sniper, about Chris Kyle, a true American hero, who had 4 tours
in the Middle East. His PTSD was well portrayed and how it affected him and his
family. It is a true tragedy that he was murdered by a veteran suffering from
PTSD after he was discharged. Chris was trying to mentor this vet. God bless our
There is a significant percentage of the population that hascriteria for PTSD,
but have not been disabled by them. Only
40% of those with symptoms in the military seek treatment, and 60% going
undiagnosed and treated. Suicide has taken the central stage as the lethal
complication of this disorder with attempting or completing suicide.This
will be discussed in detail next month.
It is estimated that one third of the homeless are veterans. This is a national
tragedy that has been overlooked by the VA. The VA has been in trouble for
decades and finally the longstanding mismanagement and incompetence have been
brought out by a whistle blower….Big government breeds these drawbacks. It is
still difficult to get service connected for PTSD, and even years go by before
they get disability benefits if at all. Hopefully that will change.
Women, who have had
throughout their military career have been especially overlooked, as so many are
afraid to come forward because of the ridicule they receive from male military
superiors and/or repercussions. The military has recently labeled it
to include unwanted contact, sexual innuendo, groping and rape, but lack of
paper documentation has created a real impediment. 10% of the military are
female now (2.2million). More than 280,000 females have returned from
deployment. VA health centers only recently opened women’s rest rooms(gives you
an idea of how far they have to go). Many VA clinics lack staff to even treat
sexual assault. (ref.--Institute of Medicine). Just this month, the VA announced
they would open mental health services to reservists and the National Guard.
Imagine the numbers!! Women are encouraged now to apply for disability for prior
sexual events. It has been a “dirty secret” and unfortunately rampant even to
It is no longer a man’s military!
In the general population 33,000 Americans die each year of suicide
(attempts are hard to estimate) with 7.7 million with PTSD (an estimation).
5000 vets commit suicide each year.
More than half of all people will experience at least one traumatizing event in
their lifetime. In the military, most on the front lines are exposed to multiple
for just one year between the ages of 14-18 have a 25% risk of PTSD. 60% of
foster care who experienced sexually abuse, and 42% who were physically abused
will have PTSD. These rates demand more funding for more extensive research on
prevention, identification, and treatment of PTSD.
The recovery rate from PTSD for veterans is only 28.2% compared to the general
population which is 47%.
B. Symptoms (some
of the major)/
Signs of PTSD:
Avoidance or numbing of memories
of the event.
from sudden noises or memories. PTSD causes an overactive adrenalin response and
influence future responses to be over-reactive.
4. High levels of
(can be confused with an anxiety disorder).
more likely to have PTSD, and with the sexual harassment issue added, the
numbers reported will escalate.
6. Patients try to
avoid talking about events,
avoiding thoughts and emotions even developing amnesia except during a
if less than 3 months,
if more than 3 months, and
if years later.
7. Although, the emphasis is on veterans, these symptoms include those innatural
or terrorist disasters, mobbing,catastrophic health issues such as cancer and
vascular (heart stroke) survivors, shootings in classrooms from demonstrations,
schools, movie theaters, violent acts, family violence and emergency/ ICU
is very common.
create an acute episode, death of loved ones, serious injury, etc. which create
intense fear, horror, or powerlessness.
another cause for children and adults. Conceivably being
trigger the problem. There are recent studies that quoted a 3X greater chance of
as a means of coping in patients with PTSD.
In fact, the greater the number of PTSD symptoms, the higher the food addiction.
(Ref. JAMA Psychiatry)
9. When these events occur they are felt in the
(not as a past event).
10. Those with PTSD have a hard time coping with routine or non-combat life
family dysfunction issues.
They can have adverse behavior in the children to manage their own emotional
dysregulation. Children experiencing these traumas can lead to PTSD when they
Acute Grief, Complicated Grief, and Depression
I have discussed signs, symptoms, and management of depression in previous
15 (bullying), 13 and 8 (bipolar and unipolar depression).
Depression very commonly occupies a major aspect of patients dealing with PTSD,
and be the mechanism that creates fertile ground for suicide attempts and
completions. It must be differentiated from acute grief and complicated grief.
After a traumatic event, especially the loss of a loved one will necessarily
create the emotion of grief (bereavement), which is normal, however when it
becomes prolonged and extreme, it is defined as complicated grief, and it
requires assessment and consideration for treatment.
Here are certain key points in complicated grief:
10-20% experience complicated grief losing a partner, and it is even higher with
the loss of a child, if the death is sudden, if it occurs from suicide,
homicide, or an accident, and is highest in women over 60. There is a fine line
between complicated grief and depression, and therefore must be assessed by an
specialist. This type of grief increases the risk for substance abuse and
suicidal ideation. It can lead to health issues and last 1-2 years or more. With
acute grief, the person remains in reality, whereas in complicated grief, it may
create an inability to accept the reality of the death, isolate themselves, with
the loss of a sense of self.Friends and relatives become frustrated that the
person remains in this emotion. These victims have a higher percentage of
pre-existing emotional problems. This is also true for PTSD.
These disorders are a spectrum withoverlap of these conditions. That is why I
am covering all of these disorders together.
is the answer. There are many types of therapy, and it requires experts to
determine the best type.Ref. NEJM, Jan 8, 2015; Merck Medicus
D. Genetics/Neuroendocrine abnormalities--Research
There is a
to depression and PTSD, estimated to be about 30% of the variance. Depression in
a parent increases the risk of PTSD, depression, and suicide. There is some
evidence a part of the brain in these patients have a smaller
(part of the limbic system of the brain—emotional center). The
is involved as is the
These areas are involved in the neurotransmission of chemicals such as
serotonin, norepinephrine, dopamine,
and others. When these levels of chemicals are interfered with, depression can
occur. There is also evidence that there are lower levels of
in these patients, which can suppress the
(loss of memory) in PTSD. It has recently been demonstrated that with third
trimester traumas, the cortisol levels in their infants is lower than normal,
and could create health issues in the neonate. (I will discuss adrenalin
andcorticosteroids when I report on the adrenal gland, in the ongoing series on
It is also known that the 60% of these genetic variances overlap with panic and
anxiety disorders as well as the influence on the body by alcohol, nicotine, and
substance abuse dependence.
(gamma-amino-butyric acid) is a major inhibitor of neurotransmitters in the
brain. Abnormalities of this receptor gene and a severe childhood trauma may
increase the severity of PTSD in that person when they reach adulthood. This is
ongoing research. There is also
linked to PTSD and may be the reason this syndrome is more common in females.
There is an opposite reaction of these chemicals in major depression that does
not include PTSD. Although depression can be part of the syndrome, these levels
are not commonly checked in clinical practice, but the symptoms will allow the
clinician to appreciate which is the major issue and where the treatment should
PTSD costs the VA (the taxpayer) $48 billion per year to diagnose and treat PTSD.
Next month, I will report on the dynamics of suicide and treatment of these
References—American Psychiatric Association
Crisis line is 1-800-273-TALK
For a general discussion on headaches and migraine, I refer you back to Report
# 26 and #29,
are well named, and by far are the most common type.
pain begins with spasm in the muscles of the upper neck which creates pressure
and tightness in the entire neck and shoulder group of muscles. Most people show
tension somewhere in their body, and the neck and shoulders is by far the most
common area. Half of the population has this type sometime in their life. It is
twice as common in females. Oddly, most patients don’t necessarily realize the
tension is coming from the neck, because the pain is the predominant symptom
which is usually felt as a tight band around the head (left slide)
In addition to major posterior (back of the neck) neck muscle tension, there are
muscles in the forehead (frontalis) and temples (temporalis) that spasm and
cause the pain by squeezing on the sensory nerves of the lining of these muscles
and in the scalp. Some describe it as pressure or a throbbing pain. It can be
confused with a migraine, and in my practice, I felt that many of these types of
headaches had a vascular component, thus the name
but these headaches are not associated with auras, neurological abnormalities,
visual changes, or nausea and vomiting (symptoms are typical migraine). They are
not as incapacitating as migraines, but can be severe. They can come and go,
while migraines do not.
of tension headaches can occur from too little sleep, missing meals
(hypoglycemia), anxiety, anger, eye strain, and a host of cervical abnormalities
(arthritis, pinched disc, sitting in one position too long at a computer, even
sleeping with the neck in an improper angle). See slide on the right above!
The physician needs to rule out migraine, sinus headache, and neurological
causes, and other types of headaches, but the diagnosis is usually made with the
history. CT and MRI scans are normal. The American Headache Society (via the
American Board of Internal Medicine Foundation) is calling for fewer CT and MRI
scans in stable headaches or ones that are clearly migraine, however, as pointed
out in the medical internet site Medscape, that is controversial since
a fourth of brain tumor patients can have isolated headaches.
The other ¾ have associated seizures, cognitive abnormalities, and other
neurological symptoms. I would suggest that the decision be made by your primary
care and/or a neurologist.
II. Cluster headache, another type of vascular headacheoccurs
on one side of the head and are severe. They often can be associated with pain
behind or around the eye with
The eye may be
and it can be associated with a runny nose on the side of the headache.
It rarely can be associated with a
on that side,
on the same side of the face, and usually lasts from 15 minutes to as long as 3
hours.The pain can radiate into the jaw and neck, possibly confusing it with a
tension headache. These are one of the few headaches that are more common in
males 4:1. These are much rarer headaches, but are somewhat classic in
presentation when they occur.
Even other symptoms of a migraine may occur, but movement does not make the
headache worse and nausea and vomiting is rare, which is very common in
migraines. These headaches occur in “clusters
up to several separate times in one day, or every day for several days or weeks
and then not appear for days or months.
With an MRI, there may be dilation of the ophthalmic (eye) artery and there may
some PET scan abnormalities in the cavernous sinus (venous blood cavity inside
the skull). The cause is unknown, but clearly this is an atypical type of
vascular headache. Activation of the trigeminal nerve (a cranial nerve (through
the hypothalamus) that sends sensation to the face in three branches) can create
many of the signs of a cluster headache.
Triggers can come from alcohol, histamines, stress, menstruation, nitroglycerin,
and even smoking (nicotine).
Clearly other neurological abnormalities (brain tumor) including migraines need
to be ruled out.
Consider an ophthalmology or neurological consult.
III. Treatment of tension headaches
can be as simple as acetaminophen (Tylenol), NSAIDS (Aleve, Ibuprofen, etc.)
muscle relaxers (Soma Compound, Flexeril, Valium, etc.). Evaluation of the neck
with X-rays can demonstrate many of the abnormalities (cervical arthritis, disc
narrowing, etc.). If there are symptoms (numbness) radiating into the arm or
hand with or without weakness, a more thorough evaluation by an orthopedist or
neurosurgeon may be in order. Physical therapy, acupuncture, heat, ice are
valuable. Antidepressants help as well. Chiropractic management is also commonly
sought and can be quite helpful.
help—more sleep, relaxation methods (yoga, meditation, massage), better
nutrition, less caffeine, deal with stressful situations, express yourself, and
regular exercise is a great outlet.
IV. Treatment of cluster headaches
acutely can be helped with breathing oxygen with a mask and can relieve the
headache in 70% of patients. Injectable sumitryptan (Imitrex) or
dihydroergotamine (Migranal) (both are migraine medications), Corticosteroids,
verapamil (Calan), lithium (Eskalith), valproic acid (Depakin), melatonin, and
topiramate (Topamax) all have been effective.
Heart patients can have complications from the sumitryptan and ergotamine, and
there are many medications that have cross-reactivity especially with selective
serotonin reuptake inhibitors (SSRIs-antidepressants). With intractable cluster
headaches certain deep brain stimulation procedures are being studied.
(American Headache Foundation)