The Medical News Report

April, 2015, #39

www.themedicalnewsreport.com

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

Subjects:

1.Medical News in Brief

Fast Food; Are you a Heavy Drinker?

    Is your Scalp itchy?Causes!

    BPA-the dangers of a toxin in plastics

    Medical Debt-a common cause for bankruptcy

Cyberdating/Sexual Abuse

Is there a Cancer Vaccine?What about polio virus killing

brain cancer? The 60 minutes show

Postoperative Complications for common surgeries

 New evidence of efficacy for Chrondroitin Sulfate and

    Glucosamine in knee osteoarthritis

    Recent information about dietary cholesterol

Angelina Jolie and preventative surgery-breast/ovary

    An update and more!

2. What you need to know when you are discharged from the hospital—10 issues

3. Shoulder Replacement Surgery/Rotator Cuff Injuries- Part 1

4. Suicide in the Young (heard of choking in schools?)

Aurora Borealis

1. Medical News in Brief

    a. Fast Food consumption

Reference: Ohio State University

    b. What defines a Heavy Drinker?

Men who have 15 or more drinks (1 ounce per liquor drink, 4oz of wine, and 8oz of beer) weekly  and women who drink 8 drinks per week are considered heavy drinkers by the CDC.

One of the most sensitive questions to ask about whether the amount of alcohol a person consumes is a problem or not. Ask,at any time, does a person drink more than they planned? Does a person have a strong desire to cut down but can’t?  Does alcohol interfere with any life issue (home life, work or friend issues? DUIs? If a person answers yes to these questions, the amount a person is drinking isn’t the issue……it is an alcohol problem, and that means help is needed. 

References—CDC; Center for Alcohol and Addiction studies at Brown University

   c. Scratching your itchy Head? Causes!

What are the most common conditions?

              Psoriasis of the scalp                       Ringworm  

---Psoriasis (there are several types-this is plaque psoriasis. This must be treated by a dermatologist. I will discuss next month with psoriatic arthritis.

---TineaCapitis(ringworm) is a fungus and is contagious, from person to person, objects (clothing) to a person, and animal to a person. Griseofulvin and turbinafine (Lamisil) are the two most common treatments.

---Head Lice       This is very common in children, but adults can be infected from them, bed sheets, clothes, etc. Quell shampoo is the best treatment. This can affect any hair bearing area and in the pubic area it is called “crabs”, but is the same body louse that infects the scalp. All these areas should be treated either with OTC meds or prescriptions like malathion lotion

---Allergic reactions (hair dyes, eczema, atopic dermatitis)

Steroid shampoos will take care of it. It can be severe and mimic any rash. If the rash is getting worse, see a dermatologist.

  Reference:  Cleveland Clinic

    d. What is BPA? (Bisphenol-A)- a toxin in plastics

Here is another reason not to drink sodas frequently. This is the chemical you may have heard of that is contained in most plastic and aluminum containers (unless it specifically states it is not). It can raise the blood pressure. According to the American Heart Association, as few as 2 beverages from a BPA-lined container can cause significant cardiovascular problems. It is also not recommended to microwave in these plastic containers, as the chemical leaches out into the fluid or food.

     e. Medical Debt

A real concern comes from being baffled by medical bills. Talk to your doctors, labs, and hospitals about a payment plan. The Urban Institute reported that 35.1% of people with credit records had been reported to collection agencies.

    f. Cyber-dating Abuse/Sexual and Physical Violence

The first study to report on cyber-dating is worrisome! The Children’s Hospital of Pittsburgh reported in the Journal of Pediatrics on cyber-dating abuse among young people. The authors were surprised that there was an overlap with sexual and physical abuse in dating relationships and the use of the internet. The study of teens ages 14-19 were assessed for those who were seeking care for abuse of some kind. Victims reporting abusive partners were using mobile apps, texting, and other social networks and repeatedly contacting them to see their whereabouts and who they were with. Stalking them, in other words! These victims were experiencing being slapped, choked, and forced to have sex by a dating partner. Talk to your kids and grandkids about the possibility of abuse via the internet.

    g. The Cancer Vaccine--Stagnant HPV (human papilloma virus) vaccination rates are leaving our children vulnerable to 6 types of pre-cancers and cancers (cervix, vagina, vulva, penis, anus, and oropharynx). The oropharynx includes mouth, tongue, and upper throat.  It causes genital and laryngeal warts as well.

79 million Americans are currently infected with HPV. The rates are increasing and so are the cancers. It is estimated that 26,000 cancer cases are occurring from this virus each year.

Routine HPV vaccinations are recommended for both boys and girls ages 11-12 and for women and men into their early adulthood. Once infected, the vaccine won’t help. It is given in a 3 shot series over 6 months. The vaccine can prevent as many as 90% of these infections. Most of the initial infections are asymptomatic and can be acquired even from kissing. Getting a child vaccinated does not give them permission to become sexually promiscuous, as some naïve parents suggest. It prevents only the virus that causes cancers, and does not protect from all of the other STDs. (STDs will be a topic in the next few months).

Source-Moffitt Cancer Center of Tampa, Dept. of Women’s Oncology; NEJM

    h. Can the polio virus cure brain cancer?

I hope you saw the 60 minute feature on treating glioblastoma of the brain with a modified polio virus, injecting the virus right into the brain tumor. If you missed it click on

www.cbsnews.com/news/using-polio-virus-to-kill-cancer-60minutes/

This study has been going on at Duke Cancer Center for many years and is now in phase one of three in potentially curing glioblastoma brain cancers by injecting various amounts of this modified virus right into the brain tumor. It is one of about 10 treatments available, mostly in clinical trials, that are immunologic treatments that are showing great success. This polio virus has kept a few patients in remission for over 3 years, when the cure rate of this tumor is dismal. Attacking the cancer’s immune system is nothing new, but has shown great hope for the future of aggressive cancers from brain to prostate cancer. Even this polio virus will eventually be available to a variety of solid tumor patients.  Look for a discussion of these immunologic treatments in the next few months.

    i.  Do Post-Operative Complications affect the Mortality rate of patients?

A new study reported by British Journal of Medicine reported that if there is a postoperative complication (wound infection, infection from an IV or urinary catheter, pneumonia, bleeding, heart attack, stroke, renal failure, pulmonary embolus, thrombophlebitis, failure in results of the surgery, etc.), which occurs 23% of the time, that it increased the mortality rate by 28%. If infectious complications are the cause, the mortality risk was increased by 95%. These patients were followed for 28-96 months.

This is why proper preoperative preparation, meticulous surgical sterility, proper protection from hospital employees and health care professionals is so important. Pre-operative checking for MRSA (Methicillin resistant Staphylococcus Aureus) infection in the nose of the patient is becoming commonplace. If there is a resistant Staph germ in the nose of the patient (without causing infection), it must be eradicated before surgery.

Since Medicare no longer pays the hospital for treatment of complications or readmissions for complications, this has increased strict adherence to the regulations of hospital infectious disease control committees. If you see a breach in sterile technique, hospital workers don’t clean their hands coming in or out of a hospital room, etc. they should be reported immediately to the supervisor. That includes those that clean your room, bring you food, nurses, aids, doctors, X-Ray technicians, and visitors.

It is critical that patients with chronic disease, which might complicate a surgical procedure, should be in optimal condition. Those who are diabetics, overweight, have heart, lung, or renal disease are at an increased risk for complications. It is up to your doctors to get you in the best condition for elective procedures. Of course, acute disease demands more of a patient and their doctors.

    j. Glucosamine and Chondroitin Sulfate for painful knee osteoarthritis. This drawing below demonstrates chronicosteoarthritis of the knee. Note that the cartilage has worn away on the inside of the knee joint and on the inside of the patella (knee cap). There is narrowing of the joint space, which creates minimal cushioning of the end of the bones of the tibia and femur. This causes pain and swelling, stiffness, and loss of range of motion.

I have previously reported on studies that the combination supplement was not particularly valuable for chronic osteoarthritis. Now, in theAnnals of Rheumatology, it was compared with Celebrex (an NSAID arthritis prescription) for painful osteoarthritis of the knee and found to be equally effective. Chondroitin nourishes cartilage and if it is partially eroded from severe arthritis, it might be as effective. But the earlier it is treated, the better. There is no study that has both Celebrex and the supplement taken simultaneously.

It is because research can differ from previous studies that I report on the latest information in the medical literature. Confusing as it is, it is a good example of why to depend on tried and true medications.

    k. New information on dietary cholesterol

I am not satisfied that the media did a good job about differentiating between cholesterol and other bad fats like trans-fat and saturated fat. Unsaturated fat is much safer for all of us. If you want more indepth discussion about these fats, I refer you back to www.themedicalnewsreport.com/5/24/30

     l. Angelina Jolie and her preventative surgeries from breast and ovarian cancer!

Angie has announced that she had her ovaries and fallopian tubes removed for the same reason she had her breasts removed (mastectomy-shelled out and implants placed). She has a very powerful genetic mutation called BRCA-1 (there is a 2), which gives her as high as 87% chance of developing breast cancer in her life, and as high as 59% of ovarian cancer. I have reported in depth on her breast cancer and its treatment:

www.themedicalnewsreport.com/#22-23-24-26-27-28

Now she has had the other female organs removed. She had no medical reason for a hysterectomy, so she had an endoscopic procedure to remove the ovaries and fallopian tubes.

It is not the only alternative women have. Close observationis viable alternative as well. Also, taking Tamoxifen to greatly reduce the influence of hormones on the breasts also will reduce the chance of being diagnosed.

Angie had 3 close relatives have breast and ovary cancer (mother, grandmother, and aunt). With this heavy family history plus having the BRCA-1 gene mutation, it was clearly a defendable decision. But if a woman finds that she has a BRCA gene mutation without a family history and were under 45, jumping to surgery should be carefully thought out with the other options considered.

It has not been common knowledge that removing the ovaries decreases the risk of breast cancer by 50%, because it takes away the hormonal influence on the breast tissue. In fact, in the past, removing the ovaries (female castration) with an advanced breast cancer was a common recommendation. Now, Tamoxifen is used to remove the hormonal influence of the ovaries.

Now, that she has had a salpingo-oophorectomy, is there still a chance she can be diagnosed with breast or abdominal cancer. YES! There is no way to remove every vestige of breast tissue and even if the ovaries and fallopian tubes are removed, there are still many potential  ovarian cells may have implanted in the abdomen. But the Journal of the National Cancer Institute in 2009 stated removing the ovaries and tubes, reduces the risk of breast cancer by 50% and ovarian cancer by at least 80%.

General testing for BRCA gene mutation is not recommended without a history of breast or ovarian cancer in immediate relatives. However, women are putting more pressure on their physicians to be tested.

Knowing this information, without any added risk factors, will cause an enormous amount of anxiety and also will put a lot of pressure on every female in that family. The test is very expensive and is not covered without a positive family history.

Angie will have to take hormonal replacement to prevent menopausal consequences. She is only 39 years of age. That also will help prevent premature vascular disease.

Those with prostate cancer in the males of the family also increase the risk of breast cancer in the females. Also breast cancer patients have an increased risk of colorectal cancer.

In the next few months I will report on ovarian/uterine cancer, and cosmetic as well as reconstructive breast implants including the controversies that have come and those that have gone.

2. What you need to know when you are discharged from the hospital. 10 issues!

Just having had surgery and been in the hospital, I read with interest an article at this website:www.kevinmd.com

A patient needs to know a lot of information when they are being discharged from the hospital. Many hospitals do a good job with this, but what is missing is your doctor sitting down with you and defining what exactly was done, how your results are looking, and what you need to do since you will be at home in most cases.

1. Handouts for post-hospital care are a must. These should be discussed to make sure you understand them, not just handed a document that you may never read.

2. What prescriptions will you need for pain, instructions for bowel and bladder care, diet, amount of ambulation, position in bed, and aids for ambulation, shower, toilet, etc.

3. Your primary care doctor needs a written or electronic summary of your hospitalization, discharge instructions, their role in postoperative care and how other medical issues will play a role in your recovery (checking blood sugars, blood pressure, temperature, etc.). It is best to check in with your PCP shortly after discharge.

4. What to look for regarding possible complications: fever, swelling, bleeding, constipation, urinary retention, bandage change, drainage or bleeding from a wound, shower, shortness of breath, chest pain, abdominal swelling, leg swelling, coughing up blood or yellow mucus.

5. Side effects of prescriptions and possible interaction with current meds must be discussed.

7. When do you go straight to the emergency room without calling? Chances are calling an ambulance is the safest option.

8. Using your spirometer is crucial to prevent atelectasis (tiny collapses in the lung that predisposes to pneumonia).

9.The better you are educated (and your caregiver), the more likely your post-hospital experience will be positive.

10. Chances are you will not get half of what I have cited here unless you ask for it!!! Be proactive and be sure you are informed. 

Most of this comes from being a surgeon for 30 years of private practice and being a patient more times than I care to enumerate.

3. Shoulder joint replacement and rotator cuff surgery, part 1 of 3

There will be 3 parts to the shoulder discussion .

Part 1-The anatomy and function of the shoulder will be covered this month plus the testing of rotator cuff function.

Part 2 (next month) will include shoulder problems in general, joint replacement surgery, rotator cuff injuries and treatment. Part 3 will continue with completion of that discussion and rehabilitation after injuries and shoulder surgery (joint and rotator cuff).

Having just had my shoulder joint replaced with a titanium implant, and knowing the interest in rotator cuff injuries, I wanted to share some personal and factual information on the shoulder.

This is my actual X-ray showing the prosthesis in place.

The anatomy must be understood to be able to follow this subject. It is the amount of movement or rotation of the shoulder girdle that creates such a challenge for treatment. Full range of motion allows one to have 360 degrees of motion in some directions. Throwing a ball requires an amazing amount of function from the joint and the 4 main rotator muscles to do it effectively.

Figure 1

Figure 3

Figure 2

Figure 4

Figure 5

The drawing on the lower right shows a frozen shoulder caused by chronic inflammation of the capsule of that joint, just like in the knee. There is a cartilage and ligamentous tissue around that joint as can be seen in the upper left, called the labrum. This maintains the joint connection. See two lower photos (Fig 1 and 6)

Figure 1 repeated

Figure 6

To create stability of the joint, however, takes an enormously complex set of muscles and tendons. It also has to allow rotation of the arm. The front and back view of the muscles of the shoulder are seen in Figure 1 and 2. The largest muscle is the subscapularis m., which begins on the inside of the scapula and inserts on the anterior head of the humerus. There is a muscle on the back of the scapula that does the same thing and attaches on the posterior (backside) aspect of the head. It is called the infraspinatus m. Just above the joint, the supraspinatus m. can be seen between the clavicle and the scapula in Fig 1. The connection of the clavicle to the scapula is called the acromioclavicular joint. Below in Fig 7, that connection between the clavicle and scapula demonstrates what a separated shoulder looks like.  I have had a Grade III separation which includes a second ligamental tear (coracoid-clavicular) from a football injury requiring surgery back in college on my other shoulder.

Figure 7

There are other muscles and tendons that complete the muscular and fibrous connection (Teres minor) seen below in Figure 8.

The rotator cuff is actually a combination of muscles and their tendons that attach the scapula to the humerus as seen below in Figure 8.

To examine the rotator cuff, 4 muscle functions are necessary to be tested.

The 4 muscles of the rotator cuff consists of:

1) Subscapularis m.

2) Supraspinatus m.

3) Infraspinatus m.

4) Teres Minor

Figure 8

The rotator cuff is a complex set of tissues that allow for range of motion of the shoulder. Injuries to this complex will be discussed next month.

To test for rotator cuff function requires the following tests below:

1. With the arm outstretched, push the arm down.

       2. With the elbow close to the body, pull the wrist out.

       3. With the elbow in front of the body, press the

forearmdown.

       4. With the elbow at right angles from the body, move

The shoulder up and down.

Next month, I will report on shoulder disease and injuries, in general, and the procedures for replacing the joint and rotator cuff injury and treatment. Rehabilitation and recovery will be covered in part 3 the following month.

4. Suicide in the young

The last 2 months I have reported on PTSD and depression in the general population and in military veterans.

www.themedicalnewsreport.com/#37-38

 I also began the discussion on suicide. Every day we hear about some tragic example of suicide with people killing  their families and then taking their own lives. We hear about men, women, and children strapping a bomb to their bodies and blowing themselves up to kill their supposed enemies. This week, a depressed pilot committed suicide and took 150 innocent lives flying into the side of a mountain in the Alps. He was depressed and yet medical personnel were not allowed to report it to the airlines.

The suicide rate for girls and young women in the US continues to rise, at a far faster pace than young males. Girls tend to repeat attempts more than boys. The rate for boys and young men has risen since 2007 too, and it still remains 3 times higher than females from ages 10-24. The cause of this rise is not known, but hanging themselves or other forms of suffocation is on the rise.

There is a well- known trend happening in schools called “the choking game”. This has become frighteningly common. Thousands of Facebook pages and twitter have made this commonplace, choking on the internet.1 in 10 kids in high school have either considered it or tried it. 79,000 Canadians youths are reported to have tried it. A recent movie on the Lifetime channel showcased this tragedy happening to our youth.

Click on http://stlouis.cbslocal.com/2014/08/05/deadl/2014/08/05/deadly-choking-game-spreads-among-teens-on-social-media/

There is an actual video of this.  You will not believe how common it is…Death or brain damage is happening when their brains lack oxygen during the choking. These risk takers choke themselves or their friends until they pass out, giving them an “out of body experience” and euphoria.  This is outrageous. I hypothesize that Robin Williams performed this and accidentally killed himself instead of actually committing suicide. It is just my opinion. He hung himself on a door knob.

Orgasmic asphyxiation is a well-known sexual aberrant practice and can lead to death or brain damage.

Some of these kids are accidentally killing themselves and become a suicide statistic. Some are brain damaged, because they have fallen and hit their heads. I will report on this in more depth at a later date.

Drug overdose (poisoning) is still a more common method used by young females than males, but, in my opinion, the suffocation methods are the reason for the recent increase.

Overall, only 8% of suicides occur from poisonings/overdoses.Talk to your kids and grandkids about choking, as this has become trendy and very dangerous. They know all about it!!  Don’t put your head in the sand.

The rate of suicide in young females is now 3.4 per 100,000. The rate for young males is 11.9 per 100,000 with leveling off in the last few years. There is a 4:1 ratio in favor of boys. The highest rate of suicide for males, however, is 45-54 years of age. Young males use firearms more commonly than girls (56% of all suicide victims use a firearm). Folks, lock up your guns. These are stats from the CDC.

www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf

3.7% (8.3 million) of the adult population report having suicidal thoughts in the past year. 1% of the population have suicidal plans and 1 in 25 attempts complete the act.

32,000 suicides a year make a statement!

Considerations for treatment---

It is reported that 90% of people who commit suicide have some mental illness. Untreated depression is most common. There are certain other traits that tend to be common in these patients: a) personality and mood disorders {antisocial, narcissism, borderline} b) substance abusers c) baseline anxiety disorders d) poor maternal relationship e) poor social adjustment f) eating disorders g) bullying.

Our society is failing our citizens regarding mental health! Mental illness has been in the closet long enough. We must encourage people to get help and not ridicule them when they do. Think of mental illness as another chronic disease like diabetes or heart disease. The medical profession is to blame as well. Our healthcare system just does not allow time or compensation for in depth discussions with primary care doctors. We are a pill pushing system. Talking to patients has been replaced by a computer thanks to our current unnecessary documentation by our healthcare system.

Dealing with negative life experiences (death, divorce, separation, child custody, serious illness, terminal conditions, serious accidents, pain, loss of hope, homeless, financial stress, victims of abuse, drug and alcohol abuse, bullying, eating disorders, non-suicidal self- injury {cutting} and academic defeat) creates a huge need for some type of interventional therapy.

Bullying is another increasing cause of suicidal attempts because of internet access and the cruelty of teenagers (cyber-bullying). Reputations are trashed in the stroke of a key. Loss of self-esteem, depression, feelings of outcast and loneliness strongly contribute in this outrageous behavior.  

Since heredity is a powerful factor, anyone with a suicide in their family should be on alert for their increased risk if life deals them a tough road. There is a 4-6 fold increased risk from heredity. Children with a parent who have attempted suicide have nearly a 5 fold increase risk in attempting suicide. There is a strong effect of offspring mood disorder with impulsive aggression as a precursor. Early assessment and intervention in families of parents with mood disorders and a history of attempts is a must. Young people with prominent irritability, impulsivity and aggression must be treated to achieve better emotional regulation and reduce the risk of suicidal impulses. 

The methods recommended for those with suicidal ideation include therapies that start with treatment of depression.

These methods include the following:

It was emphasized that exercise, proper nutrition, and organized daily activities can counter negative thinking. Each patient must find tools to cope with these haunting negative thoughts. 

How do you screen for increased risks for suicide in young people? It starts with PARENTS. There is only knowledge, being alert for behavior and academic changes, addressing these issues with their children, and getting professional help. Monitoring their friends, their habits, and practices will keep you more informed. If that is not done, parents are just playing “Russian Roulette” with the future of their children.

For the military, there is a new experimental trial attempting to predict those at highest risk. This method has classified 5% of soldiers at higher risk, and research has shown that 53% of military suicides come from this 5%.

The Annals of Internal Medicine reported a 32% decrease in suicide attempts in adults from talk therapy, but not in teens. Trying to talk to a teen is a real challenge. Cognitive therapy, however, has a 50% chance of helping younger adults and teens. Johns Hopkins Psychiatry reported that with 6-10 sessions of counseling resulted in 27% fewer attempts and 38% fewer deaths in their patients.

With depression affecting one in six Americans and costing $30-44 billion per year, this epidemic must be addressed by our government, our society, our doctors, and every parent. Dealing with depression will fight suicide as well.

References: JAMA Psych,2014; Annals Int Med, 2014; Lancet Psychiatry, 2014;MedPage Psych, 2014, CDC

NATIONAL SUICIDE PREVENTION LIFELINE 1-800-TALK

Thus ends another report for my readers and friends. Spring is a welcome sight to us all. Have fun! Stay healthy and well, my friends, Dr. Sam