The Medical News Report

March, 2015, #38

www.themedicalnewsreport.com

Samuel J. La Monte, M.D., F.A.C.S.

For a monthly free subscription email me at:

samlamonte@yahoo.com

    

My, how time flies!! It is already the Ides of March. This report is chocked with so much good medicalinformation, you are going to want to share it. I am happy to report it to you.Winter down our way has been cold but Sky Valley has had 18 inches of snow just this week. My shoulder replacement went well, and I will be discussing the subject next month. For now we have many timely subjects. It is time to wear some green. Happy St. Patrick’s’ Day!

Subjects for March:

1. Walgreen’s of Illinois has lawsuit upheld for invasion of privacy; NY Attorney General show massive fraud on ingredients in supplements in many chain stores!!!

2. It is time to Quit-Smoking issues-facts, cessation aids, e-cigarettes, the latest on bad side effects of marijuana and hospital admissions in Colorado (the mile high state for real)

3. Healthcare gone crazy!

4. Yoga improves cardiovascular disease and more!

5. A close look at different medical treatments for osteoarthritis of the knees-from the least beneficial to the best

6. The diagnosis and treatment of strokes-Part 1-Intrarterial removal of a clot after a stroke vs. medical therapy

7. Suicide, Depression, and PTSD

8. The Side Effects of Prostate Cancer treatment—is there a big difference between treatments? Does testosterone cause cancer?-a brand new study; final comments about groundbreaking current research that far exceeds any clinical trial in recent history.

Having been a surgeon for 30 years of private practice and 12 years teaching surgical residents gave me a broad experience in medicine, but I always wanted to stay up on the latest information on all subjects in medicine. That was and is impossible, but with the internet today, there are many very valuable sites that I trust to give me unbiased information. Those references are also on my website under references. Many that I refer to require a paid subscription and password to read, and I can’t provide that to you, but when I can I will always give you the reference should you want more information than I provide. Thank you.

1. Illinois lawsuit upheld against Walgreen’s for invasion of privacy, Massive Fraud on ingredients in supplements in chain stores!!!!

Where did the ethics and professionalism go in this country? It seems like a simple situation, but it is repeated everyday in this country, and whether it is the government, a business, or a thief, it is all the same. Reference is from the Indiana Business Weekly IBJ

The NY Attorney General’s office performed a massive testing of health supplements at Target, WalMart, Walgreen’s, and GNC. They tested for theDNA in the supplement in the bottles and found only 21% were filled with the proper supplement. Only 4% was found at WalMart. Six supplements were randomly tested St.John’s Wart, Echinecea, Garlic, Vallerian Root, GingoBiloba, Ginseng, and Saw Palmetto.

The Attorney General’s office required certain brands pulled from the market. For those of us who depend on supplements, we are just naive to expect these stores to sell us what we expect in the bottle. This is one more glaring reason why we need to depend on real food rather than supplements, which have no federal regulations or FDA oversight. It is a shame, and even though, I hate federal overregulation, this is a place the FDA must take over. The Food and supplement industry has too much influence on our lawmakers. This information was reported by the New York Times on February 3, 2015.

2. It is Time to Quit!!! Tobacco issues—facts, cessation aids, e-cigarettes/vaping/marijuana fallout in Colorado

Overall smoking has dropped to 17.8% in adults. That is the lowest level since the 1980s. Smoking fewer cigarettes is also down. But for those who are still struggling to quit, please don’t stop trying. It is the most addictive habit there is. Some say it is as hard to quit as heroin. The nicotine site in the brain is extremely close to the narcotic site, and it is this site that gives pleasure from these addictions. Cocaine is also at this site in the brain.

Obamacare does provide for smoking cessation with no co-pay for treatment modalities (support groups, prescriptions for Nicorette, nicotine patches, and medications. Here are some facts:

 

Whether e-cigarettes actually help people quit is still controversial, however it appears to be as effective as nicotine gum or patches. However, theTobacco-Free Kids Coalition reports there has been 156% increase in poisonings from e-cigarettes in youth. If there is a use….there is a risk of abuse.

E-cigarettes is still in question as to its safety, and if the tobacco industry is backing it, you can be sure they will benefit from young people starting with these electronic cigarettes and transitioning to cigarettes when they are old enough to buy them. 

Marijuana           update!

 

A hospitalist blog (Hospital Leader) just out www.blogs.hospitalmedicine.blog states that hospitalists in Colorado are seeing a doubling of admissions for toxic marijuana side effects including paranoia, hallucinations, memory loss, and other cognitive deficits. This is happening in Colorado, where pot is legal. Long term deficit is expected and will certainly enhance any psychological pre-existing problems. Emergency departments are seeinghyperemesis syndrome causing severe nausea and vomiting. Many know that pot for chemotherapy induced nausea is valuable, but the dose is critical to relieve rather than cause nausea. Pot-laced food will double the time for symptoms (6-8 hours vs smoking 2-4 hours), and today pot can be much higher in THC (up to 12%).

The Colorado police have seen a 400% increase in DUIs and public intoxications from pot consumption. It also has brought $50 million in new tax dollars. There are several states voting on legalization. Regardless, prescribed use of medical marijuana is still a valuable treatment.

A review of the aids to help quit smoking should start with a serious desire to quit whether it is for medical or personal reasons. Going “cold turkey” will give you less than a 5% chance of staying quit. A consultation with your primary care professional is mandatory, so that you know your options.

Mr. Reagan would not do this today!

Here is a list of advisable actions to quit smoking tobacco:

1. Pick a quit date.

2. Decide if you want to try a medication to assist your withdrawal symptoms (Zyban) or utilize a medication that actually competes for nicotine receptors in the brain (Chantix). There are other medications that are anti-depressants, which help as well, although they are off-label (not specifically approved for quitting smoking) such as Elavil (one of the older but very useful medications). Withdrawal is real, and you need support and understanding from family and friends.

3. Nicotine replacement aids (gum, patches, etc.) are helpful in weaning you off the tobacco. There are decreasing doses of nicotine in these products. A drug called Cytisine has been recently studied comparing it to the value of nicotine, and wins over nicotine. This drug has been available in Eastern Europe for years. It is not yet available in the US, but will be soon.

Keep it in mind for the future. It competes with nicotine receptors in the brain and is effective.

4. Avoid triggers (alcohol, after a meal, stress, etc.)

5. Get rid of reminders (ashtrays, etc.) and have all your smoke-smelling garments cleaned, the carpet, drapes, bedspread, your car, etc. Once you stop smoking you will realize what the rest of us have been smelling….yuck!

6.Substitute oral cravings (carrots, celery, brush your teeth, chew gum, but skip sugary products).Try, try, again! If you slip, don’t beat yourself up; just start again.

7. E-cigarettes are controversial. There has been one small study that showed it was effective in helping smokers quit, but the act of smoking itself is part of the psychological addiction. Addiction is defined by a psychological and physical dependency that creates withdrawal. The fact that many of the vapor shops have so many flavors makes it a little too attractive to younger people.

The tobacco companies are banking that a certain percentage of those who “vape” are going to switch to cigarettes and other tobacco product. It is big in college towns and so are hookah shops, which are tobacco pipes sucked through water. Recent studies have shown they are even more dangerous than cigarettes, and yet most people think it is safe. Cigars are just addictive if inhaled, and nicotine is absorbed by the oral mucosa, so there is no safe tobacco product.

Very few cigarette smokers can switch to cigars and stay off cigarettes.  This ad is such a joke. Old one obviously!!

Are you kidding me!!

3. Healthcare costs going crazy! Medicare needs reform.

Has Obamacare been successful in reforming medical care? There have been positive moves (pre-existing and not limiting a top to an insurance payout), and it has expanded Medicaid, which is admirable, but it has opened it up for more illegals and is straining the state’s budgets. The Supreme Court will decide soon if reimbursements can be made to state run medical exchanges or are unconstitutional. The cost of care continues to rise, and we keep getting flooded with illegals, so take out the word “affordable” in the so-called “affordable healthcare act” ACA. Paying different prices for the same procedure is not right. Look at this graph on payouts for echocardiograms (from $393 to $407). The hospitals charge wildly different. Why does billing differ so greatly from the payout? Hospitals need to charge what Medicare pays.

The US spends 17% of the GDP or about $9000 per person on healthcare in this country. Japan spends $4000 per person (9.7% of the GDP). The US has gone crazy in medicine, and it is because it is big business.

Hospitals are running medicine today, and they are looking at nothing but the bottom line. The charge you see for various hospitals for a simple 30 minute echocardiogram charges from $403 in North Dakota to $5,435 in New Jersey. Note in the graph above that Medicare pays about $400. Why do they charge so much when Medicare (by law) requires hospitals and doctors to accept what they pay and cannot bill the patient for the difference? They do this to show how much they write off at the end of the year and can charge other insurance companies and bill the patient for the difference. Also, for non-Medicare patients, the patient may have to pay the whole fee, if they have not met their deductible. Why are fees so high for such a simple test? The New York Times had an article on the subject on 12-16-2014 that made it pretty clear. The cost of an echocardiogram machine is only about $30,000, whereas a MRI costs millions, so they make a killing on the net for such simple tests to counterbalance the expense of the costly machines.

Echocardiogram technology now is allowing the test to be performed on a smart phone, so tell me the charges should be over a few hundred dollars?

It is a scam, but they get away with it. It is articles like this one that is going to force us into a one-payer system. Can we trust our government to be fair to us regarding the rules and regulations they will go crazy with if they are running the show? No one knows. But with Obamacare costs increasing in many cases, and the entire healthcare system costs escalating, it will only be a few years before it will be clear that Americans can’t afford our own system including Obamacare. It was nothing but a prelude for the future for a one-payer system (in my opinion). So, enjoy your Medicare while it lasts, because the future “Medicare” for all will look nothing like what we enjoy today.

I pray I am wrong, but nothing I read makes me want to change my mind.

4. Yoga improves cardiovascular disease risk factors

I have reviewed the concept of yoga in past reports:

www.themedicalnewsreport.com/32/33

There is a measurable improvement in cardiovascular disease risk factors by decreasing cholesterol, systolic blood pressure and weight loss. Asana type of yoga was studied to prove the value. It is only recently that these studies have given more medical credence to the value of this ancient Eastern practice. Since I am a huge advocate, I am pleased to report this to you with scientific backup. The psychological value is of great value as well. Strength and flexibility is without question. It has made my shoulder replacement much easier. You must get started!!It is an alternative to aerobic exercise if a person is not able to tolerate that type of exercise. Reference: European Journal of Preventative Cardiology.

5. A close look at different medical treatments for osteoarthritis of the knees

Having had many years of generalized osteoarthritis, I have become very familiar with the various treatments for this aging/traumatic induced type of arthritis. I had knee cartilage surgery, numerous injections over a few years with a hyaluronic acid viscous fluid into my knees and ultimately knee replacements. I have now had to have a shoulder joint replaced. Joint replacements today are so successful and last much longer than originally thought. But early on when the knees start hurting and we are diagnosed with early osteoarthritis, what works?

Having closely evaluated a head to head analysisagainst acetaminophen(Tylenol),NSAIDs-non-steroidal-anti-inflammatory drugs (naproxen, ibuprofen, Celebrex, etc.), intra-articular injections of Synvisc, the study ranked these treatments: the least effective is acetaminophen (Tylenol), next are the NSAIDs (all were equally effective but the convenience of dose, the side effects of stomach irritation, kidney status, and cost were not considered), so over the counter NSAIDs are pretty much equal. Let me remind you that if you take these daily, have your doctor check your kidney functions, as these drugs can cause damage over time (I got into trouble with Indocin). TheSynvisc knee injections are reserved for patients with advanced disease, but really work for at least 3 months in many patients. If they don’t, knee replacement is the next step. Tylenol is the least valuable and high doses will injure your liver. Reference: Annals of Internal Medicine, 2014.

6. Intra-arterial removal of a clot causing a stroke (ischemic type) vs. traditional medical therapy.

Even though I have discussed silent strokes vs TIAs in report #27,

www.themedicalnewsreport.com/27

there is a new report in the NEJM that bears recognition. In the past, it was felt to be of minimal value to remove a clot from an intracerebral blood clot in one of the main arteries, however, a new study showed a 13.5% better chance of less permanent physical side effects from a stroke if in selected cases a catheter is introduced into the artery that is blocked from a fresh clot and narrowing due to atherosclerosis. Removing the clot can re-establish blood flow better in some cases than clot-buster drugs. With this in mind, I would like to review the diagnosis and current recognized FDA approved treatments for these types of strokes.

There are two types of stroke (ischemic and hemorrhagic). About 80% are ischemic with a better prognosis than a hemorrhage from a vessel in the brain. The differentiation between these types is critical before treatment can be instituted. This diagram shows the difference in the two types.

7. Suicide, Depression, and PTSD

The National Suicide Prevention Lifeline is

1-800-273-8255

As pointed out last month in the February 2015 report

www.themedicalnewsreport.com

PTSD predisposes anyone to suicide. 5000 veterans commit suicide each year in the past decade (the Middle East wars), but policemen, firefighters, post-ICU patients, and emergency personal are at an increased risk as well. 7.5% of those with PTSD will experience suicidal ideation with attempts or completing the act. Multiple deployments, facing death, watching friends die, being injured, captured, abused, humiliated, etc. all predispose to suicidal ideation. Any type of severe stress, acute or chronic (as discussed last month) can lead to PTSD, depression, and suicide. That goes for a personal experience or a witness to these events. Males are twice as likely to kill themselves as females.  Depression (and mood and personality disorders) is the most common factor in suicide accounting for over half of suicides. That makes mental illness the number one offender. Untreated, it is a serious healthcare matter. The homeless, poor people, unemployed, and even those discriminated against have increased risk for this behavior. Suicide is more common than homicide!!

30,000 Americans (5,000 vets) commit suicide every year.750,000 is the estimate of attempted suicides. 15-40% of victims leave a suicide note. Genetics plays a role in 38-55% of suicides.

90% have mental illness at the time of their suicide death, and most are depressed. If a patient is admitted to a psychiatric facility, there is a lifetime risk of 8.5% for suicide. There is a 14% higher risk with schizophrenia, while mood and personality disorders have a 20 fold risk, especially bipolar disorder and borderline personalities (I have reported on bipolar disorder in the 13threport:

www.themedicalnewsreport.com/13

Warning signs of an attempt include:

Depressed, sad most of the time, talking or writing about death or suicide, feelings of hopelessness or helplessness, strong anger or rage, feeling trapped, socially isolated, impulsiveness, change in personality, substance abuse, grades suddenly dropping in school, no interest in activities, giving away prized possessions, writing a will suddenly, excessive guilt or shame, or acting excessively reckless. Being gay, or having had a traumatic brain injury. With all these signs, suicide screening does not change health outcomes.

The main reason to commit suicide is to relieve pain in their life (physical or mental).40% of patients committing suicide saw their primary care within a month. Can PCPs pick this up? Only with more time in a visit, which is not the case.

Factors playing are: a death, divorce, separation, breakup, losing custody of a child, illness, chronic pain, serious accident, loss of hope, victim, abuse (verbal, physical, mental), feeling trapped, legal issues, horrible disappointment, not living up to expectations, bullying, low self-esteem, and despair. As you will remember, many of these factors can predispose to PTSD, and the overlap is obvious.

Psychotherapy(selective types) is necessary for potential stabilization and prevention of suicide as is PTSD. Talk therapy is especially helpful in PTSD. As a nation, we must de-stigmatize going to a psychiatrist or psychologist. Access to these professionals is getting harder, as the number of people increase in this country and we are experiencing a greater shortage. If you know someone who fits these profiles, attempt to help them get treatment. Hotlines for suicide have not proven especially helpful, but it may assist someone to get help. Never give up!!

There is a bill that soon will be introduced by Congress called the Clay Suicide Prevention Act for Veterans that will address the VA programs and how they can improve access and treatment for veterans with PTSD and high risk for suicide.

Thank you President Obama for just passing legislation to better help vets with suicide prevention!

8. Prostate Cancer-Part 6--The management of side effects of prostate cancer treatment; Are there major differences between different types oftreatment? Late breaking News—does testosterone cause cancer?

I have touched on the side effects of prostate cancer treatment before in several previous reports:

www.themedicalnewsreport.com/32/33/34/35/36

This is the sixth and final installment. Often times, patients tend to lean toward a type of treatment because it purported to haveless side effects. Let us examine this by first defining the main side effects of treatment.

The side effects first and foremost depend on the extent of the cancer. Fortunately, most men are diagnosed while the tumor is still confined to the gland so that a curative therapy can be used. The side effects come from the primary treatment but also from the medical treatments.Many men will need medication to suppress any testosterone from being produced by their body (testosterone is felt to be able to fuel the tumor to grow). These have side effects as well.

The side effects that most men are concerned with are and can occur from any treatment option:

1. impotence-temporary or permanent, partial or complete.

2. Urinary symptoms—incontinence, obstruction, stricture.

3. Bowel symptoms—incontinence, stenosis, ulceration.

4. Feminization effects from anti-androgen medications.

These issues can occur early and or late (after a year). The age of the patient plays an obvious role in this situation. There may be distinct differences of how important impotence is between a 50 and 75 year old man (not that it is ever NOT important).

Even fertility could play a role if a younger man is in a position if having a child is an issue. No one wants bladder or bowel symptoms, but they are frequently present for part of the first year, but hopefully will abate with time.

With a prostatectomy that does not spare the nerves for an erection, there will be impotence. If the tumor requires a radical surgery, that is going to be a side effect. On the other hand, if radiation is chosen, there could be a chance that the nerves might make it through the therapy, but if the tumor is too large, the chances of recurrence are too high, and surgery would be the logical choice.

I suspect the lion-share of controversy lies in the nerve sparing prostatectomy (usually robotic) vs. type of radiation therapy for earlier less large and less aggressive tumors. Remember, size is not everything, since the PSA and the Gleason score can help predict how malignant the tumor is and will dictate how aggressive the therapy needs to be.

I have already defined the different types of radiation in previous reports, and at this time, it appears most patients are opting for more targeted therapy (IMRT or proton). But there is still no good study that can state one or the other is better or has fewer side effects. Until further research has proven superiority, I have to state the facts…there is no significant differences in these modalities regarding side effects, except that bowel side effects are more common with radiation.

How can impotence from a primary treatment (radiation or surgery) be treated? It is treated just like any impotence (drugs, pumps, injections, implants, rings, etc.) and I have reported on these in the 24th medical news report.

www.themedicalnewsreport.com/24

How successful these modalities will be depends on many factors including age and pre-cancer status. If one does not work, consider another.

Libido is another issue. Anti-androgen medication will diminish a man’s sex drive. So will depression worrying about it. Counseling may be helpful in these cases. An understanding wife will be necessary for maximum performance always.

Urinary symptoms---the radiation can narrow the urethra from the bladder causing a poor urinary stream. So can obstruction from a large prostate, and may require a trans-urethral resection (TURP) of scar or prostate tissue to relieve the problem, just like in a benign enlarged prostate.

Incontinence will require adult Depends for a period of time, as leakage is fairly common for various periods of time. If it continues, there are exercises (Kegel) and standard surgical procedures for incontinence. I have addressed this type of surgery in report #20, 21

www.themedicalnewsreport.com/20,21

Kegel exercises are very important to strengthen the pelvic floor and are necessary for erections and controlling urinary flow. It is recommended 5-6 times a day with 20 repetitions (just try to tighten the anus and you get the drift. Hold the position for 5 seconds). Click on:

www.mayoclinic.org/healthy-living/menshealth/in-depth/kegel-exercises-for-men

These procedures can be done to change the angle of the urethra with the bladder, just like in benign cases (usually in women who have had pelvic relaxation from pregnancies).Start before treatment begins and continue right through treatment if possible. Of course, check with your doctor about this. After treatment, it will take 6-8 weeks to re-strengthen the pelvic floor muscles.

Infections may occur and need antibiotic therapy. If the bladder can’t empty well, infection can be a result.

Rectal and anal problems are more common with radiation, as the prostate is too intimately anatomically positioned with the rectum. Burns, ulcerations, recurrent inflammation can all cause diarrhea and significant discomfort. Anal problems from stenosis or pre-existing hemorrhoids or fissures will need close attention. Fecal incontinence can be a problem as well, and may need a procedure to tighten the anal sphincter. Topical medications are necessary in most cases.

Feminization issues(loss of male hormone) will create menopausal symptoms well known to women, but breast enlargement can be painful and cosmetically unappealing. Treating the symptoms of menopause (mood swings, hot flashes, etc.) in men is difficult, because they can’t have testosterone, but other supplements and anti-depressants may help. Do not take any supplement without your oncologist knowing.

These side effects are usually temporary and occur long term in only 6-7% of patients, depending on the age and general health of the individual. Remember, no cancer treatment is still a good choice in many men, whether it is close surveillance or skillful neglect. Some studies state that as many as 40% of men should strongly consider this.

Final Comments: I have probably posed as many questions as answers reporting on this cancer. Early diagnosis is always better, but if the grade and stage of a cancer is very early, and the man has fewer than 10 years expected to live, there is a real possibility that active surveillance is a good choice. Overtreatment in this category is shamefully high especially in older men with other medical issues. The NCCN Journal studied 3001 men in this category, and found that 67% were probably unnecessarily treated. Of course, doctors are going to provide patients with options, but bias does play a role.

The average cost in treating complications from the treatment averaged $18, 827 over 5 years, and the cumulative cost is estimated to be $58 million. Avoiding just 80% of those patients from being treated would save $1.3 billion per year nationally. Overtreatment is real. Be sure you get multiple opinions before agreeing to treatment if you are in this category. That means most over 70 years of age.

Finally, if you have treatment, be sure to educate yourself and always keep asking questions. Even if the disease is metastatic, chances are pretty good a man will die of something else. As always, it is between you and your doctors. Even deciding to check a PSA later in life is controversial, so be informed. I hope these reports have helped. I encourage comments. Contact me at

samlamonte@yahoo.com

This concludes 6 parts on prostate cancer.  If you want more information, the Johns Hopkins booklet is a good one. I used it as one of my references.

www.healthafter50.com/bulletins/prostate_bulletin_5/main_landing.htlm=EPH_141119_001&st=email

LATE BREAKING NEWS!

Does testosterone cause prostate cancer?  A study in the Jan, 2015, Journal of Urology, studied 1000 men for 5 years and did not find a significantly higher number in the group receiving male hormone for erectile dysfunction, etc. to develop prostate cancer. What happens at 10 and 15 years has yet to be reported. It is always a serious discussion when using testosterone. If this is so, why do they recommend taking anti-androgen medications after prostate cancer primary therapy? Because prostate cancers can grow faster with testosterone! But if there is no cancer present, it does not appear to CAUSE THE CANCER. If by accident, one is on testosterone, and independently develops a prostate cancer, the testosterone must be stopped. Being followed closely while on testosterone seems to be a must. The series ends but questions continue……

Now, for an update on amazing research that has just been reported at the American Society of Clinical Oncology. What if you could tell a man with metastatic prostate cancer that with new research he can live at least an average of a year longer if he starts treatment with ADT (androgen deprivation therapy) plus docetaxel, a new chemotherapy agent. The combination prolongs resistance to drugs that suppress testosterone and gives the average patient an additional 57 months of survival compared to 44 months with just one or the other treatment. This is historic, because many clinical trials are declared great success with prolongation of survival by just a few months. Folks, it is this kind of research that we have to give a standing ovation!!!

To end the series on prostate cancer, it is fitting to report on the American Cancer Society’s guidelines for following these cancer patients over the years. These survivorship guidelines are the very ones I have been working on for the past 4 years. Breast and head and neck cancer are coming in the next few months. The article appears in Ca-the cancer journal published by the American Cancer Society.

 

Happy Saint Patrick's Day!

Erin Go Bragh

Gaelic for “Ireland Forever”

Stay healthy and well my friends! Dr. Sam