The Medical News Report

July, 2015, #42

www.themedicalnewsreport.com

Welcome to this month’s report. It is becoming increasingly necessary to refer you back to previous reports to prevent repetition as updates on previous medical information are reported in the current medical literature. Also, it never hurts to review previous reports when there are several parts to a subject. For instance, this month, I will resume our discussion on the endocrine system, and it will be necessary to review this system before continuing onto the organs that make up this complex major system. Enjoy these subjects! Enjoy America’s birthday!

1. The BRCA gene mutation—value of prophylactic removal of ovaries and tubes; recent updates

2. The Veteran’s Administration Scandal-an update

3. Return to the Endocrine System-Part 4-the pancreas-the insulin producing islet cells of Langerhan

4. The Gastrointestinal Tract-Part 2-Esophageal Cancer

5. Macular Degeneration of the Eye-another major cause of blindness

6. Falls caused by excessive medication-blood pressure medicine- new BP levels recommended for people over 70!

We are so fortunate to live in the best country in the world. Celebrate our country’s birthday and thank God for our good fortune. Let us hope we can respect each other and not let our differences get in the way.

This is what is happening in my neighborhood!

1. BRCA Gene Mutation patients-recent updates for those at risk for breast and ovarian cancer!

New research has proven the value of removing the ovaries and tubes soon after being treated for breast cancer. The prophylactic procedure can potentially prevent future breast and ovarian cancer. I have discussed breast cancer at length in previous reports and also discussed the BRCA gene mutation as a major biologic marker for cancer of the breast and ovary. We also know that if a person has this mutation, they are at increased risk for other cancers that need surveillance, such as esophageal and colorectal cancer. There are other hereditary syndromes that have an increased risk of breast cancer. This is to remind those of you who have recently subscribed and want information about the BRCA gene mutation that won’t be repeated in this report, please click on my medical reports  #17 and #27

For the breast cancer series:

Medical reports #21, #22, #23, #24 and #26

Several reports were dedicated to the breast cancer with the latest information. Also, if you know anyone with this issue, feel free to offer my website. You can also refer to the subject index on my website and look under breast cancer for the specific reports pertinent to that discussion.

prophylactic mastectomies with reconstruction and endoscopic removal of the ovaries and fallopian tubes, because she has a heavy family history and the BRCA 1 genetic mutation. Over 80% of these women carriers are at risk for breast cancer and 50% plus for ovarian cancer.

It was recently reported that removing the ovaries and tubes may also improve survival in those BRCA carriers with breast cancer (early-Stage I and II) in women 65 or younger. The study followed 345 women for an average of 12.5 years. Most of these procedures were performed to prevent ovarian cancer at the time, but now studies report that removing them is associated with a 56% reduction in the risk for death from breast cancer.

This study suggests that to prolong survival, BRCA carriers (there is BRCA 1 and 2) should consider removal of the ovaries and tubes as soon as possible after the diagnosis of early breast cancer. It also underscores the importance of testing all women with an early stage breast cancer for the BRCA gene mutations.

These issues require a complete family history, and it would behoove us all to research our family’s medical histories. Without autopsy, families may never know the hereditary problems that they may face in the future. Also, many family members are not willing to share their pasts. With the era of genetic testing, it has become a necessity, and I encourage everyone to dig into their medical genealogy. NEJM,2014; J. Clin. Oncol, 2014

You may need a magnifying glass to read this, but it is recommendations from the federal task force on risk assessment for those who want to explore this issue.

2. The VA Scandal continues!

We have read about the VA scandal. What a tragedy. It has been going on for as long as I have been in medicine one way or the other. When I was doing rotations as a resident at the Oklahoma City VA, I was told that 2 year old flooring would be replaced in all 10 stories. I asked

There are many panels of genetic testing now available, but make no mistake, having a genetic marker that is increased for breast cancer, requires this information should be addressed by a genetic counselor deciphering the test results. Do not order these tests unless you are willing to see a genetic counselor and are willing to follow through with the consequences of knowing genetic information. Other than the BRCA gene mutations, there are many other minor genetic abnormalities that should be ignored at this time until they are of clinical importance.

There will be updates in the near future, and I will report them as they are cited.

 These are the USPTF (US Preventative Task Force) recommendations for BRCA gene mutation risk assessment, testing, and counseling!

President Obama promised that the mismanagement of the Veteran’s Administration would be solved. It was reported that yearlong wait times for patients were not uncommon and that even patients died before they were served. The solution was supposed to get veterans an appointment within 30 days or give them authorization to see a private doctor if they lived 40 miles or further from a VA clinic. The New York Times reported that the wait times are 50% longer.  Not one manager was fired; not one scheduler was fired; some were put on administrative leave with pay, and only the Chief of the VA was forced to step down…..a typical federal move for misconduct of a department in our government.  Has this problem and mismanagement improved? No!!!!

The budget for the VA is $160 billion and were given $9 billion more to expand the medical staff. The answer is not more money….another typical answer to a governmental problem. Fiscal responsibility, better management, and individual administrative accountability is needed….and if not, get rid of them. Quit protecting federal employees if they do not do their job! We would have never known about this if it had not been brought to the media by a concerned physician in one of the Arizona VAs as a whistleblower.

 During my surgical residency, I was assigned rotations at the Oklahoma City VA. It was a top notch facility and the care was superb, but the money was being misused even back in the 70s. The training there was also fantastic. I owe the VA system!

 I was told certain floors of the hospital would be closed to replace thousands of feet of flooring, but the floor was still in perfect condition. I was told by an administrator friend that if they did not use that money, the feds would take that from them reducing their annual budget. I was appalled but in no position to make waves. This kind of stupid management has gone on forever, I suspect. They were just playing the game. When it comes to federal spending, regardless of department, the abuse by their administrators has been almost accepted as a norm to protect their annual budgets.

President Obama promised this mess would change. The only thing that has been publicized is increasing medical and nursing staff, which was needed years ago before the current war began. Increasing access to the thousands of returning active and retired veterans has flooded the system, but the VA should have anticipated this. What happened, in my opinion, is older veterans were pushed aside to care for the recent younger veterans.

As the number of women increased in the military, the VA Clinics did not again anticipate their specific needs. They did not even have separate bathrooms for them in some VA facilities, as hard is that is to believe. This female issue has been improving slowly, but has a long way to go. Also the lack of adequate psychological services must be dealt with. Psychiatry numbers are shrinking and hiring enough psychiatric doctors is a real challenge.

Is this the way we pay tribute to our brave men and women who have died, been injured, and disabled defending our country???  These administrative issues have been a dirty secret for decades and must change.  It is not about the dedicated doctors and nurses and the care they provide to our veterans. They are not the problem.

The government’s answer to their problems is always increasing the budget, not becoming more efficient. The changes must come from the top.

 I have relatives and some friends who have had a very positive experience in the VA system, so the quality of care is not really in question as much as the administrative abuse which continues today by the same protected abusive employees. Not firing all of those involved in scandals would have made an example for those not willing to go by the rules. Federal employee’s jobs are too protected by federal laws. That has to change too. Talk to your representatives!!

3. The Endocrine System Part 4-the Pancreas—Hormones produced-the insulin producing Islet (beta) cells of Langerhan and the Glucagon producing alpha cells

As pointed out in the preamble, it will be necessary to review the definition and functions of the endocrine system to go forward with the rest of the endocrine system. This report will consider the endocrine part of the pancreas. The endocrine organs, by definition, all produce hormones. I have previously reported on the regulation of this system by the brain (hypothalamus) and pituitary, and reports on the thyroid, and the parathyroid glands. (Medical reports #31, #32 and #34)

The pancreas consists of 2 functional and separate parts, the digestive part and the hormone producing part. The hormones that are produced are insulin and glucagon--the two main hormones.

To review, the function of glands in the body, there are 2 types: exocrine and endocrine.

Exocrine glands send substances that travel through a duct (tube) and reach their target to provide necessary substances that include the digestive part of the pancreas, sweat glands, milk glands of the breast, and salivary glands to mention a few. Exocrine glands excrete a specific substance (pancreatic enzymes, saliva, sweat, and milk).

Endocrine glands (pituitary, pineal, thyroid, parathyroid, thymus, pancreas, adrenals, and sex glands) secrete a hormone that provides the body’s functions and must travel through the blood to reach its often multiple targets.

The pancreatic endocrine glands (only 5% of the volume of the pancreas)) secrete 2 main hormones: insulin (beta cells) and glucagon (alpha cells) that come from the Islet Cells of Langerhan.

There are 3 other hormones that are produced are secreted by the pancreatic endocrine cells: somatostatin, gastrin, and VIP (vasoactive intestinal peptide). The somatostatin regulates other hormones such as insulin and glucagon. Gastrin regulates a certain cell in the stomach that produces acid (acinar cells). The VIP hormone helps the intestine absorb and secrete water.These will discussed as part of the gastrointestinal series.

Anatomical position--The pancreas lies behind the stomach and a tube(pancreatic duct)from the gland drains pancreatic enzymes into the small intestine via thebile duct.  The liver (hepatic) ducts drain bile acids and concentrate them in the gall bladder, which also secretes them into the bile duct. The bile duct meets the pancreatic duct, whichcombined creates the common bile duct. These combined secretions spill into the small intestine (duodenum) and combine with the acid from the stomach to digest food. Next month, I will be discussing the stomach and digestion.

Below is the anatomy of the bile system as it receives contributions from the pancreas, the liver, and the gall bladder.

I will discuss the liver and gall bladder in the future.

 The hormones insulin and glucagon regulate the blood sugar in our bodies; insulin lowers the blood sugar and glucagon raises it.

Below is a drawing of the anatomy of the pancreas.

The above drawing demonstrates these small glands in the pancreas that produce insulin (beta cells). This hormone lowers the sugar in the blood. There are another group of cells (alpha cells) in the pancreas that secrete another hormone called glucagon, that raises the blood sugar in the blood by stimulating certain cells in the liver that converts stored glycogen into glucose. Sugars are not stored as glucose, rather they are converted to glycogen in the liver and are converted back when the body needs glucose.In other words, these two hormones work in opposite ways to balance the blood sugar level and keep it within normal range.

When factors create too much insulin because of “insulin resistance” type 2 diabetescan occur. If antibodies form against the cells that make insulin (Islet cells of Langerhan), type 1 diabetes occurs. If you want to review the mechanisms of diabetes and the complications,refer back to several previous reports: #15 and #26

Tumors of the pancreas occur, and most are adenocarcinoma of the pancreatic tissue that originates from exocrine cells. One in sixty six Americans will develop this cancer. Although rare, the islet cells (endocrine cells) can also develop tumors. I will discuss the endocrine tumors this month and the common pancreatic cancers when I discuss the digestive pancreas in the gastrointestinal series.

The pancreatic endocrine tumors are called islet cell tumors or neuroendocrine tumors. 90% are not malignant. These tumors can be functional or non-functional. Functional tumors will often secrete excessive hormone and cause symptoms that are caused by the specific hormone. Functional insulinomas, for example, secrete insulin and the patient likely will have hypoglycemia. A glucagonoma creates high blood glucose and mimics diabetes with symptoms from mouth ulcers to swelling of parts of the body.  Gastrinomas secrete too much gastrin which stimulates certain stomach cells that produce excessive acid and cause acid indigestion, reflux, diarrhea and pain(Zollinger-Ellison Syndrome). Somatostatinomas suppresses a variety of hormones and can cause many symptoms from diarrhea to diabetes.

If the tumors are non-functional, they usually present to the doctor with pain and yellow jaundice as the tumor enlarges. 

Endocrine tumors can cause watery diarrhea, pain, weight loss, headache, nausea, sweating, and a host of symptoms that require a thorough investigation of the whole body. They are diagnostic dilemmas and must be thought of or can be missed for some time.

However, the rare (10%) malignant endocrine tumors will kill if not removed. Steve Jobs had such a malignant neuroendocrine tumor. He chose alternative therapies instead of standard treatment that cost him his life (a good lesson for those that don’t believe in modern medicine and choose to believe that alternative medicine is better than mainstream therapies).

Next month, I will discuss the adrenal glands (adrenaline and cortisone) and its disorders.

4. The Gastrointestinal System Part 2—Esophageal Cancer

Because of increasing weight of Americans and subsequent reflux disease, I am concerned that this cancer may increase in incidence. The ACS statistics show a slight increase in whites but is decreasing slightly in blacks. I feel this is due to better access to care.

It is the 6^th leading cause of death and higher in blacks, but between the ages of 45-70, white men represent the greatest number of cases. 18,170 cases were diagnosed in 2014 and account for 1% of all cancers and the 5 year survival rate is currently 20%.

The top 5 risk factors for esophageal cancerare obesity, gastroesophageal reflux, Barrett’s esophagus, tobacco smoking, and excessive alcohol consumption.  General population screening for this cancer is not recommended, however, as I have discussed previously, persistent gastric reflux must be evaluated, which usually includes endoscopy to see the extent of disease including ruling out strictures, precancerous lesions, cancer and erosions.

This cancer usually occurs just above the diaphragm (that separates the lungs and heart from the abdominal contents) in the lower one third of the esophagus.

Thebarium swallow test (below left) demonstrates the classic “apple core effect”. The second photo (right) shows a resected esophagus with a large esophageal cancer. Survival correlates with this tumor not penetrating the muscle layer of the esophageal wall and spreading elsewhere. 

Symptoms of esophageal cancer are not specific and most patients are not diagnosed early because of it. Most assume they just have chronic indigestion and reflux. If diagnosis is delayed, these tumors are more advanced and the cure rate is much lower. Pain and difficulty swallowing are the most common symptoms pointing to cancer.

Endoscopy must be performed to assess the extent and tissue type (both squamous cell and adenocarcinoma occurs, the former more common in the US).40 % survive if the tumor is resected and there are no visible metastatic tumors. Unfortunately, metastases can frequently show up later. 

The treatment most commonly recommended today is chemotherapy(Placlitaxel/Carboplatin) plus radiation therapy prior to surgery. The surgery requires removing the entire esophagus through a chest incision and abdominal incision. The stomach is surgically mobilized and pulled up into the chest up to a lower neck incision and the hypopharynx (lower throat) and thenconnected to the throat re-establishing continuity of the gastrointestinal tract. It is a difficult complex surgery and recovery takes months, but if the tumor is completely removed, there is a fairly good chance for survival. Only large centers with experienced surgeons should be considered if this procedure is necessary.

A short video from the Mayo Clinic should be watched to understand the surgery, risks, and side effects of reconstruction: www.youtube.com/watch?v=jepSww8mpJV

Endoscopic removal is being tried but is very difficult and is only for the very experienced surgeons.

The side effects of having this procedure include severe reflux into the throat and aspiration of stomach contents into the windpipe (bronchus). Sleeping in the sitting position may be necessary to prevent aspiration. Dumping syndrome occurs because food contents get into the intestine so quickly that diarrhea can occur suddenly. Adaptation by the patient does occur amazingly well.

Pre-cancerous or Barrett’s esophagus can be addressed by one of several techniques (endoscopic sleeve removal of the lower portion of the esophageal mucosa, photodynamic therapy, radiofrequency ablation, or cryotherapy).

The key to this cancer is to prevent it (good medical treatment of reflux, weight loss, smoking cessation, and minimal alcohol.

This is a great patient resource on the guidelines for patients and families:

www.nccn.org/patients/guidelines/cancers.aspx#esophagus

Next month, I will discuss the stomach disorders in the continuing Gastrointestinal System Series.

5.Macular Degeneration (AMD) of the EYE-another serious cause of blindness

Last month, I reported on glaucoma, and this month the subject of macular degeneration, another eye disease that robs vision as we age. Both can be hereditary, but glaucoma is an ocular pressure problem, whereas, macular degeneration is a retinal degenerative disease.

To understand macular degeneration, we need to review the anatomy of the eye. The retina is at the back of the eye, which converts an image to energy with photoreceptive cells and transmits this image via the optic nerve to the brain for recognition.  The macula is an area on the retina that has the sharpest (central) vision. Any problem with vision in this area will create a serious change in sight or visual acuity.

The drawing (below right) demonstrates how light is transmitted through the pupil onto the retina. A cross-section of the retina shows the familiar rods and cones of the retina, which convert that light into a signal sent to the optic nerve.

The macula is the area of sharpest vision,(the photo above left). This photo of the retina would be what a doctor views with the ophthalmoscope or a slit lamp through a dilated pupil.  The drawing to the right above is a cross-section of the eye demonstrating the complex anatomy of the layers of the retina made of photoreceptive cells.

Macular degeneration is the most common cause of severe visual loss above age 60. The loss is severe because it is in the central part of the visual field. The right photo below is a fluorescein imaging photo of the retina demonstrating the vessels as they spread over the retina. Note also the vessels to the retina arise from around the optic nerve from the ophthalmic artery, the first branch of the internal carotid artery.

The cause of macular degeneration is unknown.

Dry AMD-drusenFlourescein dye image of retina

   Visual Representation of AMD

There are2 forms of macular degeneration-wet and dry.

The wet form occurs when abnormal blood vessels grow from under the retina (choroid) and invade the macular area. This leads to leaking of blood and fluid from the vesselscausing scarring and rapid visual loss. An early symptom that a patient might notice is seeing straight lines as wavy and blind spots. Wet AMD is much less common (about 10-20% of AMD).

The dry form occurs when the macular area begins to thin out abnormally from aging. Deposits of yellow or white matter (as seen in the photo of the eye above left) are seen in the area of the macula. These deposits are called drusen and are probably lipid in composition from degeneration of the tissue as well as scarring.

The dry form is by far the more common AMD, accounting for up to 80- 90%. This affects both eyes. This form progresses much slower than the wet form. (Drusen can be seen on the retinal exam in normal people, but if they are numerous and larger, there is much higher risk of developing AMD.)Drusenoccurs in an estimated 7.3 million people in the U.S. With visual loss in the central vision plus drusen, would indicate as macular degeneration.

1.8% million Americans over 40 have one or both forms of AMD. Those who have severe visual loss usually have the wet form.

Risk Factors for AMD are genetic and environmental factors including smoking tobacco, age over 50, obesity, family history, race (Caucasian), cardiovascular disease, high cholesterol, type 2 diabetes, and poor nutrition with lack of fruits and vegetables.

There are genetic tests that can be performed but are not ready for prime time. However, in the future, genetic variations are going to play a bigger role in selectivity of treatments. These genetic alleles account for up to 50% of the patients as reported by the National Institutes of Health website. It should be noted that these genetic variations don’t cause AMD but have been associated with subgroups that respond better or worse to certain treatments. So there is a gap in understanding the cause and the genetic variations that are being found with research.

The diagnosis can be confirmed with a) a retinal exam with numerousdrusen, b) visual acuity loss in the central visual field, c) a fluorescein dye angiogram to determine the extent of damage. The OCT test is an angiogram using fluorescein as shown in the above photo and is necessary to determine the thickness of the retina and other anatomical considerations. Early diagnosis is essential.

  Treatment for AMD

1)Diet, antioxidants, and vitamins: good nutrition, fresh fruit and vegetables, not smoking, losing weight, maintaing the blood cholesterol in the normal range and taking certain vitamins and supplements as recommended by the National Eye Institute:

Lutein and zeoxanthine, two carotenoid supplements have improved vision in some of these patients if their blood levels are low.They are now recommended instead of beta carotene, because beta carotene increases the risk of lung cancer in smokers, so smoking cessation is a must. High doses of Vitamin E can increase the risk of cardiovasculardisease, so be sure and discuss this with your primary healthcare provider as well as your ophthalmologist (retina specialist).

2)Eye injections-----Eylea, Lucentis, Macugen, or Avastin injections monthly. These drugs are biological medications called monoclonal antibodies that inhibit new vessel formation. These injections are placed into the eye to reduce the proliferation of new abnormal blood vessels by countering a growth factor (VEGF-vascular endothelial growth factor) in the development of vascularity. This medication may slow down the progress of new blood vessels formation in wet AMD and may help the vision. These medications may be more effective in certain genetic groups as determined by genetic testing. (These same biological medications are being used in cancer treatment to block new blood vessel formation created by hormones secreted by some tumors to starve the cancer.)

3) Laser treatments-high energy lasers are used to destroy vessels in selected cases.

4) Photodynamic therapy is a type of laser that can coagulate certain vessels on the retina that are causing AMD. A dye is injected into the blood stream and then a cold laser is used to treat these abnormal vessels. This treatment is reserved for a select group of patients because the treatment can cause potential loss of retinal vascularity and subsequent visual loss.

5)Submacular surgery may be used to displace an abnormal vessel away from the macula.

6)Retinal translocation may also be recommended in highly selected cases. This surgical procedure moves the macular area of the retina away from the abnormal vessels and then a laser is used to destroy the vessels.

7) Telescopic lens implantsare also used in selected patients. A tiny plastic tube with certain lens are implanted into the eye to improve the distance and close up vision that will magnify the field of vision.

The disease can recur even with successful treatment. Wet macular can cause severe permanent visual loss, whereas dry macular causes slow progression, and the loss is usually not as severe. Reading and driving can be compromised in more severe cases.

FAST FACTS ABOUT VISION LOSS:

Vision problems occur in 11 million Americans above age 12. There are over 3.3 million individuals above 40 who are either legally blind in at least one eye or have low vision. One of the leading causes of blindness is age related macular degeneration and is the most common type of severe visual loss in those 60 and over.   

An overview of macular degeneration can be found at the Mayo Clinic website: www.mayoclinic.org/disease-conditions/maculardegeneration/basics/con-20075882www.eyesight.org/

6. Falls from blood pressure medicine-new guidelines for BP levels for people over 70

After looking in the mirror, I decided to lose some weight last winter. I just cut down the size of every meal, cut out some in between meal treats, and especially late night snacks. With this weight loss and having shoulder replacement surgery, I started having problems with dizziness upon standing. In fact, it got worse, and I passed out and fell a few times. I had been slack on checking my own BP at home, but when I started checking it, I was running 105/65 and lower.

I checked my blood pressure in the lying and standing position, finding that it dropped even lower when I I stood up. These pressures should be about the same in a healthy individual.

 I went to a cardiologist, and as expected, took me off my blood pressure medicine completely.  My weight loss and postoperative status had brought my blood pressure back a normal range without needing the blood pressure medicine. It only took a 25 plus pound weight loss for this to occur.

 After about 2 weeks, I began to resolve the issue of dizziness and lightheadedness when I stood up. In fact, a month later, my blood pressure still had remained around 140/80. That pressure is perfectly normal.

 This is just one example of a side effect from medications. Dizziness and unsteadiness is a very common side effect of many drugs. It is very important to monitor your symptoms carefully when taking new medications or have certain changes in your body such as weight loss. Read about the potential side effects of any medication you take….prescription or over the counter medication.

Over the pastfew years, the American College of Cardiology recommended tighter control of blood pressure. 140/80 was recommended but even some doctors recommended tighter control, even 120/70 or lower, assuming a person was not having any symptoms. Never stop or adjust medication dosage without consulting your doctor. 

Now new recommendations from the ACC for people over 70

150/90 is now recommended as the goal and anything under 120/80 is considered too low, as stated on the internet site Medscape (Dr. Louis Lipsitz, Harvard Medical School). As patients age, falling becomes an increasing problem, and having a drop in blood pressure when standing up is quite common. To maintain a slightly higher blood pressure will give the patient a little more margin for safety. Of course, this is up to your personal physician where he or she wants your blood pressure readings to be maintained.

Everyone should monitor their BP morning, noon, and night occasionally to observe the daily variation. Always take your blood pressure after sitting quietly for 10-15 minutes.

If the doctor adds medicines (i.e. enlarged prostate type medicines may lower the BP and sinus medicine may increase the BP), there could be an effect, and it is a good time to check the BP at home. Getting tested at the doctor’s office can give higher than your normal readings because of the “white coat syndrome” or not resting before the test. Knowing the fluctuations of your BP is important.  Also note how you feel at those readings (tired, dizzy, lightheaded, blurry vision, etc.).

A recent study found that ACE inhibitors and calcium channel blockers can actually create fewer falls compared to other categories of blood pressure medicine. They tend to not drop the BP when you stand up. This study did not specifically point the finger at the other types of anti-hypertensives (diuretics, beta blockers, angiotensin blockers or alpha blockers).

For a review of the classification and a discussion of anti-hypertensives: Medical report #8

Please talk to your doctor about this and never act on anything you read in these reports unless they approve.

References: Medscape, Heartwire, J. Hypertension

This completes the July 2015 report. Enjoy the holiday with friends and family and be careful with those fireworks. Next month, I will report on costly breakthrough drugs hitting the market, stomach physiology and disorders, new concepts in treating obesity,  vitamin to decrease the risk of skin cancer, life expectancy in 2015, and the adrenal gland (the cortisone and adrenaline gland).

STAY HEALTHY AND WELL, MY FRIENDS, Dr. Sam