The Medical News Report

August, 2015, #43

Samuel J. La Monte, M.D., F.A.C.S. 

www.themedicalnewsreport.com

It is my pleasure to offer you the opportunity to learn more medical information to give you a feeling of empowerment that will make you more proactive with your own healthcare. I see a bleak future for medicine in terms of individual personal care. You are going to become a number, not given information unless you seek it and demand it. Knowledge is power, and you must assist your doctor in your healthcare to stay healthy and well. I hope with these monthly reports, this knowledge will inspire you to read even more about your individual health needs.

Subjects for August:

1. New concepts in the management of Obesity-Part 1 of the Series

2. The high cost of “Breakthrough Drugs”…You are going to be upset!Some personal observations!

3. Gastrointestinal Series-Part 5-The Stomach Functions and Disorders (Endocrine and Digestive Functions)

4. Can a Vitamin treat Skin Cancer—Vitamin B-3

5. Follow up on Macular Degeneration-risk factors!

6. Follow up on the VA scandal!

7. Do you know the health value of statins?

1. New Concepts in the causes and treatment ofObesity—“the disease”—Part 1

Recently the medical profession has recognized being overweight as a disease. There are practical reasons for this, mainly dealing with obesity as a real disease takes us away from thinking of it as a weakness in character, etc. just like alcoholism was once considered. Insurance will cover more issues in managing obesity. It is imperative that physicians address this epidemic (which they are not!). Look at the multifactorial nature of this disease in this chart:

Unfortunately, many physicians do not do a good job of this because trying to get patients to lose weight is no more successful than trying to get patients to stop smoking. The success rate of permanent weight loss has a terrible track record. With diminishing time per visit with the doctor, the visit consists of managing the results of the weight…..hypertension, type 2 diabetes, heart and neurovascular disease, lipid reduction, and many more not the primary problem. Physicians have become pill pushers because they aren’t reimbursed for managing this complex problem. The environment includes so many factors including the availability of exercise opportunities, economic status, parents willing to provide healthy meals, and psychological aspects, etc. are just a few. Medical practices that provide PAs or nurse practitioners will enhance the ability to properly manage weight issues.   Patient centered coordinated care facilities give the best chance for success with these patients. A holistic approach is necessary to address this increasing national crisis. It is not just America that is getting heavier. Ireland is the number one European country with a society who will see 90% of Irish overweight by 2030.

I have previously discussed obesity in some detail.

www.themedicalnewsreport.com report #24 and #26

       These are parameters for the diagnosis of obesity!

Waist size is also a critical measurement and is much easier for patients to monitor their success.

Since obesity causes more diseases than any other disease, it is appropriate to update our knowledge!

It is the second most common cause of cancer and the results of obesity cost $35 billion in 2014 in Florida alone (Gov. Scott’s entire 2015 state budget is only $74 billion).

We are in a dilemma!! We don’t want our government dictating to us about what we should and should not eat, smoke, drink, etc. and yet the results of these behaviors are killing us and costing us billions. We want to curtail our costs, but allow the borders and other countries to flood our country…..and then we pay for them to have healthcare, etc.

The rights people insist in equality for all, and yet forget about our individual responsibility to take care of our health and our children’s health. How can we stand by and allow this, if we really want the best for ourselves and families? We as parents must provide healthy nutritious foods for our children and grandchildren including monitoring their weight, insisting on more daily exercise and less electronics. Parents must also lead by example. An overweight parent or doctor has little desire or ability to be hypocritical and expect something out of their children or patients when they don’t lead by example regardless of the topic.

Here are more frightful statistics. A European study found men only have a 1/120 chance and women 1/124 chance in losing at least 5% of their body weight (and keeping it off for years). (A loss of 5-10% of total body weight is recommended for obese patients). Men have a 1/8 chance of keeping the weight off for one year. Reference—American J. of Public Health

This is exactly why it is becoming clear that bariatric surgery is THE BEST OPTION for those who have tried and failed with more conservative treatment plans.

Topics that need to be discussed in the next few reports:

A. The influence of the environment and weight gain in children and adolescents in Part 2 next month.

B. Better knowledge about stomach hormones (leptin and ghrelingoverning our feeling of hunger and fullness)

C. Obesity’s effect on fertility and sex hormones.

D. Eating disorders(binge, bulimia, etc.)

E. The chemical reasons for gaining weight, including the effect of sugar substitutes.

F. New information on the effects of weight on the liver-steato-hepatitis, fatty liver, and cancer.

G. The latest in treatment including medications and bariatric surgery, including novel treatments including an analysis of effectiveness of weight loss programs (Weight Watchers and Jenny Craig the best).

H. AMA and Endocrine Society guidelines for treating Obesity

This can be you!

Obesity increases the risk for all these diseases!(comorbidities) below:

2. The high cost of “breakthrough drugs”! You are going to be upset! (Some personal observations)

Breakthrough drugs are those that have recently been approved that will make a major impact on the course of a particular disease. The top 10 are costing billions of dollars, and that means it is costing the taxpayer too. Of course, Big Pharma needs incentive income to explore new drugs. But the price has gone way too far. NO longer can I accept the rationalization of needing billions to do research on future prospective medications.

Some of these drugs include Hepatitis C drugs Sovaldi and Harvoni; Keytruda for cancer; Eylea for macular degeneration, Kalydeco for cystic fibrosis, Optivo for kidney cancer, new targeted agents for melanoma and other cancers, and Praluent for reducing LDL-cholesterol. These 10 drugs will cost Medicare $31 billion, Medicaid $15.8 billion, and health exchange plans $2.1 billion totally over $50 billion over the next 10 years.

If you want more information on these drugs click on:

www.fiercepharma.com/story/us-poised-spend-50b-just-10-breakthrough-meds-10-years/2015-06-09

I have harped on Big Pharma for years, and I have to admit, there are times I am completely ambivalent about the benefit of new drugs and the absolutely disgraceful cost to patients, insurance companies, and the federal government (our tax dollars). As a healer, I want to help patients get and stay well, but I don’t want them to go bankrupt (over 2 million Americans are filing because of unpaid medical bills—now the #1 cause in the U.S.—more than credit card debt or unpaid mortgages).

Our own governmental regulations for extensive clinical trials and drug approval are a problem in itself sometimes taking as many as 10 years. This unnecessarily raises the cost to Big Pharma. Much of that is created by lawyers ready at a moment’s notice to sue these pharmaceutical companies should side effects occur.  We want drug safety for sure, but medicine is and always will be an inexact science.

There is a new fast track system for drugs to be FDA approved that are clearly showing better results than other therapies. It is a good attempt to cut through the red tape and get these drugs to the American public. We are all aware of these drugs being approved by other countries years before they are in the U.S. What is the difference?? Lawyers!

Healthcare has just become such an enormous business, and Big Pharma’s stockholders want more and more return. There has to be a balance between cost and benefit. There is a simple answer for the Americans that have the most diseases….our Congress should negotiate drug prices in Medicare (they do for Medicaid) like all  other countries do. Lobbyists for Big Pharma are the reason we aren’t. They have ruined our government! They alone have corrupted our politicians and made a disgrace our Congress. When our Congress has less than a 10% favorability rating, there is a massive problem. THIS IS ALL FIXABLE IF WE INSIST ON IT. Call your politicians!

The cost of prescription medicine roseto 13% of the total healthcare dollar expenditure in 2014, and the cost of these “breakthrough drugs” is going to make it rise even faster.

Sovaldi, the new drug to treat hepatitis C will cost us $7.9 billion in 2014. This is the highest cost for any drug on the market and is the leading “breakthrough drug”.They rationalize over $100,000 cost a year per patient on the basis of the cost of expense of caring for these patients due to the high incidence of cirrhosis and the eventual need for a potential liver transplant.  Hepatitis C is the most common indication for a liver transplant today.

Our next president better be prepared to address this problem head-on. I will not vote for anyone who is not interested in changing the Medicare policy on the cost of drugs.

3. Gastrointestinal Series continues—Part 5—The Stomach:

A. Endocrine functions—the “hunger” hormones—

    Ghrelin (Leptin); Gastrin

B. Digestive functions—acid and enzyme stimulation

C. Common Disorders of the stomach

We continuethe Gastrointestinal Series, and need to review the anatomy and physiologyof the stomach to understand it’s function.I suspect you were not aware of hunger hormones and the complex nature of the digestive system. There will be some overlap with the Obesity Series, but this is on purpose!

I. Anatomy:

The anatomy of the stomach is pretty simple. I have already discussed the sphincter between the esophagus and the stomach (gastro-esophageal), but there is also a sphincter between the stomach and the small intestine (pyloric sphincter). Babies can be born with obstruction of the pyloric sphincter (pyloric stenosis) sometimes necessitating surgery to relieve the obstruction.

The stomach has 3 smooth muscle layers(see drawing below) that contract and relax to massage food into the small intestine (duodenum). When these muscles contract, the gastro-esophageal sphincter must close and the pyloric sphincter must open to allow food to pass into the intestine and not reflux back into the esophagus. There is a condition called gastroparesis, that occurs in diabetics and those with spinal cord injuries because of weakness or paralysis of these stomach lining muscles. The drawing below defines the different parts of the stomach and the 3 layers of smooth muscle.

Clarification:(There are 2 types of muscles—Smooth and striated---smooth muscles surround organs and striated muscles are the muscles of the body for movement of the skeleton)

II.Functions of the Stomach:

a) Temporary storage for digestion to begin--The stomach is not just a reservoir for food to pass into the intestines. It is a storage pouch for food while valuable enzymatic action is breaking down the foods (assisted by pancreatic enzymes and gall bladder bile acids) before they pass into the small intestine for absorption into the blood stream.

b) Acid and Enzyme production. Hydrochloric acid is produced (activated by the stomach hormone- gastrin) and its primary function is to activate enzymes that digest protein, milk products, and fat. The enzymes (pepsin, rennin, and lipase) do the real work. Stomach cells also produce mucus and bicarbonate to protect the stomach from its own acid and enzymes. Otherwise the stomach would eat itself!

c) A substance (Intrinsic Factor) is secreted by the stomach parietal cells (same cell that produces acid) to allow absorption of Vitamin B-12 (cyanocobalamin). Without this intrinsic factor, which allows digestion and absorption of B-12, pernicious anemia occurs. I will discuss this and all the common anemias when we get to the discussion of blood disorders in the future. With some of the techniques for bariatric surgery, there can be profound deficiency of B-12 and folic acid and must be replaced. Even the anti-acid pills can reduce B-12 absorption.

c)Ghrelin is a hormone that is secreted by the stomach and tells our brain we are hungry (appetite hormone). It is one of two of the HUNGER HORMONES. The other is Leptin, which tells us that our hunger has been satisfied (feel full)and is produced and secreted by fat cells in the body. These hormones are critical in the development of obesity, which will be discussed under the current obesity series next month).

d) Gastrinis a stomach (duodenum, and pancreas) hormone that stimulates the production of stomach acid. It is stimulated by distention of the pyloric portion of the stomach, vagal (nerve) stimulation, partially digested protein, and high levels of calcium. I will discuss this again when I report on the pancreas in our gastrointestinal series.

d) Peristalsis, which is a coordinated muscular movement of the stomach to empty the stomach contents. The rugae (means ridges) of the stomach are rows of irregularity of the lining created by the smooth muscle that contracts and relaxes to move food into the small intestine (duodenum). These rugae allow more surface area for food in our stomach to be digested. It also allows for the stomach to greatly distend (stretch).

The drawing below demonstrates the rugae, the muscle layers, and the pylorus and its sphincter.

Rugae  

The basic type (carbohydrate, fat, and protein) of food determines how fast peristalsis (gastric emptying) will occur. Carbohydrates move the fastest, protein second, and fats the slowest through the stomach. Fats are the most complex to break down and need more time in the stomach for adequate digestion. That is partially why we feel hungry faster with ingestion of carbs and satisfied the longest with a fatty meal. Carbs stimulate insulin, and ghrelin is regulated by insulin. This complex peptide will be discussed with the obesity series.

Absorption of food substances occur in the small intestine, which will be discussed next month.

III. Disorders of the stomach:

Gastritis—This disorder may be the most common affliction of the stomach. It is caused by inflammation of the stomach lining because of imbalance of the stomach juices.

    A. Causes of gastritis:

a)Food, Beverages, Food allergies—alcohol, spicy foods, and food allergy. Lactose and gluten allergies, and testable allergens. 

b)Medications--aspirin, NSAIDs-Ibuprofen, Aleve, aspirin, antihistamines can cause irritation and even bleeding leading to an ulcer.Many medications and foods have influence on the acidity.

c) Bile reflux—bile from the gall bladder and enzymes from the pancreas can cause severe gastritis especially with vomiting.

d) Infections—

---Bacterial--H.pylori(Helicobacter pylori). H.pylori can cause gastritis, which can lead to peptic ulcer disease. In fact , it is the most common cause. (next month we will discuss peptic ulcer disease)

---Toxins/Food poisoning--Bacillus cereus (botulism), Salmonella, Shigella, E.coli.,Camphylobacter, and Staphylococcus. The most common cause of food poisoning in the US is caused by Clostriumperfringens. If you are healthy and have a normal immune system, most will recover from these infections.

---Viral—known as gastroenteritis, Noroviruses are the usual culprit when this disease runs through a family (no pun intended). These are usually self-limited and are treated symptomatically.Hepatitis A can also cause gastrointestinal symptoms as part of the infection of the liver.Rotoviruses are the most common in children throughout the world.

There are vaccines in some countries and the US against viral gastroenteritis. Talk to your doctor if you are going to endemic countries about proper vaccinations.

     ----Other causes--Parasitic infection can cause severe gastritis or gastroenteritis. Amoebic dysentery is probably the most common parasite although Giardia infection can occur in drinking from any stream. The biggest concern is amoebic hepatitis. These require specific treatments, and I will cover them when we get to parasitic infections sometime in the future. Hepatitis A can be contracted from contaminated foods and food handlers. There is a vaccination to prevent this infection. The same CDC website above will tell you what vaccines are recommended for specific countries and regions of the world. There are even areas that prophylactic medication is recommended to take (ie. Malaria).

A recent study reported that psychological stress increases the likelihood of gastroenteritis by 30% and subsequent irritable bowel syndrome. Stress is frequently a significant factor in disease initiation, because stress lowers your immunity making you more susceptible to contracting a disease.

D.Symptoms

It is characterized by belching, bloating, upper abdominal pain, nausea, even vomiting (including blood), and symptoms similar to heartburn (dyspepsia). It can be mild or severe. It can be treated with anti-acids, Pepto-Bismol, Zantac, and a variety of medications that neutralize the stomach secretions. There are medications that can relax the stomach (Bentyl) and intestines to relieve bloating and pain. If diarrhea co-exists, Lomotil is good choice.  Paregoric worked wonders when I was young, but it sure tasted terrible.

E. Complications

Dehydration, anemia, and ulcers can result from prolonged and recurrent gastritis.  Diagnosing an H.pylori infection is very important and can be treated with amoxicillin or one of the erythromycins. Blood tests and or cultures from the stomach (endoscopy) usually identify the culprit. I will discuss H.pylori in more detail next month when peptic ulcer disease is discussed.

Discontinuing medications, alcohol, and certain foods is a great start. Hydration is key while in the acute phase of gastritis.

If symptoms persist over 48 hours and you are not able to keep fluids down, it is time to see your doctor. A multitude of other diseases from appendicitis to colitis must be ruled out.

  Next month, I will discuss peptic ulcer disease, gastroparesis, and other diseases of the stomach. It should be obvious that when the gastrointestinal tract is involved, finding the exact place of trouble is the key, as it is not uncommon for more than one area of the gut to be involved. 

4. Can a Vitamin help prevent or treat Skin Cancer?

Basal cell Carcinoma

   Squamous cell carcinoma

2 million Americans are diagnosed with skin cancer annually. I have discussed squamous and basal cell cancer in a previous report:

www.themedicalnewsreport.com #5

Vitamin B-3 is composed of niacin and nicotinamide. Niacin is well known as a vitamin to reduce cholesterol, migraines, and diarrhea from cholera. Niacin is also converted to nicotinamide in the body. This part of Vitamin B-3 does not lower cholesterol, but can be used to treat diabetes, and 2 skin conditions (bullous pemphigus and granuloma annulare). It has been used to treat schizophrenia, cognitive troubles due to Alzheimer’s disease, and other various diseases. It is also used as a topical treatment for acne vulgaris. You have to read all of the uses to believe it….I doubt anything that has that many uses, but it is in the medical literature.

A chemist at the University of Connecticut is working on creating compounds with this special type of vitamin B-3 that might help prevent these common skin cancers (NOT melanoma).

 A study in Australia gave 500mg of niacinamide (also known at nicotinamide) orally and found that there was a 23% reduction in the formation of actinic keratosis, the precursor to non-melanoma skin cancer, in just 9 months. The patients selected in the study had 2 previous non-melanoma skin cancers in previous 5 years.

 Currently, squamous and basal cell carcinoma of the skin must be surgically removed or irradiated. I must have removed over a thousand of these cancers during my 30 years of practice, practicing in the Sunbelt (Florida), many requiring special reconstructive techniques since they were on the face and head. It would be very helpful to discover a compound that could topically prevent some of these without surgery or radiation.

 The American Cancer Society is currently funding research to find better treatments for these skin cancers. Click on:

5. Macular Degeneration---Follow up *** risk factors, diet, and supplements

Subretinaldrusen in Dry (DMD)

Macular degeneration

In follow up from the discussion on macular degeneration, wet (neovascular) and dry (subretinal deposits), the most common cause of visual loss with aging, there are some additional risk factors to discuss  I discussed the recommendation for vitamins and anti-oxidants to take to maintain good sight last month:

www.themedicalnewsreport.com #42

Just this week, I read some more information about the mechanism how lutein and zeaxanthin(these are carotenoids) are protective. These chemicals are deposited in the macula where they boost macular pigment optical density that is lost in aging. They reduce photo-oxidation of the retina. Lutein is even more important in the peripheral retina and zeaxanthin’s effects are primarily deposited in the central retina.  They also reduce inflammation and immune responses in the retina. Taking either supplements or a diet rich in fresh green vegetables will help slow macular degeneration and the formation of cataracts as well. Zeaxanthin also is also found in corn and tangerines. Eat your grits!!

Other valuable trace minerals and vitamins for visual health!

Zinc is another important antioxidant necessary for good vision.  Copper has been added as a routine visual supplement, because higher doses of zinc can lead to copper deficiency anemia. Great sources of zinc include pumpkin seed, wheat germ meal, beef, veal liver, crab, and oysters.

Regular consumption of omega 3-fatty acids in fish (salmon, tuna, mackerel, and sardines) is helpful for general cardiovascular health and good vision. These fatty acids help in macular degeneration and in an immune disease which includes dry eye syndrome (Sjogren’s Syndrome).

Vitamin E also helps slow down macular degeneration in some studies. It is found in sunflower seeds, vegetable oils, wheat germ, and vitamin E enriched cereals.

Vitamin C from fruits and tomatoes also may slow down the process of macular degeneration.

Flavonoids from wine, apples, tea, berries, and nuts are powerful antioxidants. These help slow down the progression of cataracts (opacification of lens of the eye) and may slow down other eye diseases.

Mega-doses of these supplements will only send the extra right out of your kidneys. Stick with the recommended dosage.

Cardiovascular disease and AMD--There is an association between coronary artery disease (especially 3-vessel disease), stroke, hypertension, and smoking doubling the risk of this eye disease including early onset. This association is stronger in men.

It should be obvious that good nutrition is the key to preventing or slowing down many diseases including eye disease. This is evidence based medicine.

Reference:

European Society of Retinal Specialists

Medscape—General Surgery

6. Follow up on the VA Scandal

Last month, I touched on several aspects of the enormous embarrassment regarding the VA scandal over delaying appointments up to a year or more. This has been a crisis since the recent Middle East wars. I could fill a book on the failed departments of our government, and it just comes down to incompetence by the current administration and their outdated regulations for protecting federal employees. Until these changes occur, we are putting lipstick on a pig.

If you can’t do your job, you are fired!!

The USA Today wrote an article on the latest problem the VA is having about filling positions in the VA system. 41,500 job vacancies for physicians, nurses, and other medical personnel are currently causing more expense since veterans are having to see private doctors. 1.5 million veterans had to see private doctors because of this problem……………..or maybe that is the answer…..privatize the VA, and get rid of the feds.

Veteran’s private healthcare cost the taxpayer $7.7 billion last year, leaving a shortfall of $2.6 billion reported by Deputy Secretary Sloan Gibson. An emergency approval by the Congress was necessary to shift funds within the VA to cover the expense. How could they not see this coming?

Only a very few administrative staff have been fired and some are still on leave with pay. Who is going to clean house and give these veterans the timely care they so richly deserve? The ball once again goes back to the current administration. One more department oozing with incompetence.

‘Til next time!

7.  Did you know.....the statin’s amazing value?

In 2013, the American College of Cardiology and the American Heart Association recommended an increased use of statins to reduce cholesterol to drop the number of cardiovascular events. The latest 2015 recommendations just came out and have increased indications for their use. Did you know they estimate that if the 10 million Americans that are not taking them and should, the U.S. potentially will see 40,000-63,000 cardiovascular events in the U.S. annually? The recommendation is to lower the LDL-cholesterol by 50% and increase the HDL-cholesterol by 15%. Prevention is and always will be the answer to healthcare.

This concludes the August Report. I hope you are having a great summer and staying cool. I will continue in September with heat strokes, an update on female “Viagra”, vascular stents update, another part of the gastrointestinal series on peptic ulcer disease, and continuation of the series on obesity.

As always, stay healthy and well, my friends!!

Dr. Sam