The Medical News Report, #46

November, 2015

www.themedicalnewsreport.com

  

Happy Thanksgiving and Blessings to You and Your Family

If you would like to be placed on my confidential mailing list, email me at samlamonte@yahoo.com

 

Subjects for November:

1. The rising cost of healthcare! Can we believe Medical Research findings?

2. The Obesity Series-Part 4-obesity and organ disease-Eating Disorders-Binge and Night Eating Syndrome, Bulimia

3. STDs-Part 2-Sexually Transmitted Diseases-Viral infections/ Statistics on sex in adolescents and teens

4.Gay, Lesbian, Bisexual, Transgender--the psychological and medical issues-?genetic markers predicting sexual orientation

5. Pulmonary Embolism—Diagnosis and Treatment

 

Just in!! Most of the probiotics recommended for patients with bowel disease including Celiac Disease contain gluten, even though they state they are free of gluten. You just can’t trust over the counter supplements!! Talk to your doctor!

Blood moon!

 

1. The rising healthcare costs as reported by CMS (Centers for Medicare and Medicaid Services); Can we believe medical research and their frequent reversal of recommendations?

An editorial!

CMS has recently reported that healthcare costs will continue to rise 5.8% each year (2013-2023) up from 4% from 2008-2013. The total cost will reach $5.4 trillion(19.6% of gross domestic product) up from $2.1 trillion in 2013. The main reason for the rise is the expanded insurance coverage because of Obamacare (additional 8.4 million insured), plus faster economic growth, and the aging of our population. The fact that we are a free market gives industry the right to set prices. Because of increasing use of services by Medicare recipients, driving the cost up by 6.3%, the Medicare trust fund will run out in 2030, and the government has already said it will be able to only partially fund it. Guess who will fund the rest? Listen carefully to the presidential candidates’ solution.

Private insurance will rise much slower because of cost shifting with higher co-pays, higher deductibles, narrower provider networks, and the introduction of excise tax on higher premium policies. 90% of the private health insurance plans are HMO, limiting your choices. Prices to see doctors in large groups are decidedly more expensive across the country. All of this puts stress on the individual.  More responsibility must be put on the patient and the doctor to follow guidelines for best practices and rid the system of defensive medicine and overuse of unnecessary procedures and outdated practice attitudes. NEJM Journal Watch, 2015

As long as our government keeps allowing more people to come to our country, we will all bear the costs of this decision.

Physician fees and clinical services will rise by 68% over the next 10 years and hospital spending by 79%. By 2024, Medicare and Medicaid will pay for 40% of all healthcare costs in this country. Single payer is not far beyond that.

Big Pharma spends more money on direct to consumer advertising than they do on research. Why? Because our government lets them do it. Spend the money on research, and let the doctor decide what you need instead of an ad on TV.

The Medicaid drug prices are negotiated by the feds with Big Pharma. Why not Medicare? Lobbyists are the reason! (Big Pharma, hospitals, lawyers, etc.), SuperPACs! These people have too much power and need to go in my opinion. It has ruined our free market system. If you don’t like this system, talk to your politicians. Everyone is fed up with Washington D.C. for a reason….they are on the take and they do not represent their constituents both Democratic and Republican. We, the people must change that.  If you don’t, Bernie Sanders or someone like him will be running a socialized America. Healthcare costs can be controlled with a strong Congress supported by a strong American President.  Somebody has to pay for it, and we don’t have enough billionaires to fund our system with outrageous taxes. The middle class will be hit too. We will all suffer.

With the Federal budget deal the Republicans and President Obama are working on, they are talking about reducing federal subsidy to Medicare and Medicaid. That will affect personal costs for these programs.  

CMS would not comment that the Accountable Care Act in fact has NOT been a success from the stand point of being “affordable” or cost saving. What a surprise! Draw your own conclusions. Feel free to email me about this issue. If you have the answer, I would love to know it.  Reference –Health Affairs Publication, July, 2015

Reversal of medical decisions coming from recent research!

Another issue that deserves comment is the recent reversal of recommendations on several medical issues. Just this past month, the federal government regarding the intake of fat has reversed its stance on fats. Suddenly, whole milk and eggs are ok. Suddenly, we need to have tighter control of our blood pressure, and now a person with heart disease needs their LDL-cholesterol down as low as 75mg/l or lower. Should we consider recommendations for taking an injectable anti-cholesterol medication that will cost several thousand dollars a year? These changes are very confusing to the public and to the doctors, just as conflicting cancer screening guidelines.

Let me remind once again:

1) Become knowledgeable and proactive about your health and medical issues. Do your research but always question what you read including my medical news report. Question your doctor about their recommendations. 

2)Time is needed to be sure guidelines and recommendations coming from the experts are really panning out. Also, we can’t trust just one study on a subject. The findings must be reproducible.

3) Do these recommendations really change our medical risks substantially to have to pay more for a newer drug?

4) Remember, increased healthcare costs will hit the individual more and more, so never just say, “noproblem….my insurance will cover it”.

5) Eat healthy, reduce red and processed meat, however to maintain or lose weight, the key is not what you eat……..it is how many calories you consume!! Moderation is the key to good health.

6) Don’t depend on health supplements, because you don’t have a clue about their actual content, contaminants, proven dosage, or proof of claims. Remember, there is no control of these supplements. CVS, Walgreens’, GNC, and health food stores sell them to make money!!

I am currently taking an online course provided by the editorial staff of the Harvard Business Review and the New England Journal of Medicine on the potential answers to these perplexing problems of rising healthcare costs. I will share their incite next month.

Some things are better than medicine!

 

2. The Obesity Series-part 4-How being overweight affects the organs-a review—Eating Disorders

 

    

Obesity is defined as a body mass index of greater than 40 for men and 30 for women. Having more than 25% of fat in the body in men and 33% in women define obesity as well.

It should be stated that patients with a weight problem should never be discriminated against, and should be treated AS ANY OTHER DISEASE. No physician should walk away from assisting patients with weight issues. Treating the organs that obesity affects without a holistic approachwould be a mistake. This disease demands whole body and mind care. The disease of Obesity is not a dirty word any more than heart disease is!

The major factors of obesity influencing the development of co-morbid conditions:

1) Body mass index—based on height and weight- greater than 30 for women and 40 for men. Click on this website to calculate your BMI.

www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

2) Increased intra-abdominal pressure caused by increased fat in the omentum of the intestine. (see drawing below)

3) Fat distribution (abdominal fat is the most dangerous)

4) Age at onset of obesity (the younger the age, the greater chance of subsequent medical diseases influenced by obesity)

5) Waist circumference (greater than 40 inches for men

and 30 inches for women)

 

The omentum is the tissue investment of the intestines. It has the blood and lymphatic vessels that supply and drain the bowel wall. It is theorized that fat accumulates there to prevent fat accumulating around other more vital organs. Once that omental fat accumulates to excess, fat will then begin to accumulate around the heart, in the liver, kidneys, etc. This is the basis for the Spillover Metabolic Theory.

There are very few organs of the body that are not affected by being overweight. There are other factors (co-morbidities), genetics, environmental and physical that influence major organ disease. We are all concerned about how our future lives will turn out, what changes in our quality of life will occur, and how it will affect fertility, potency, our psyche, limitations for athletics, social acceptability, pain and disability from orthopedic complications.

Almost all of us struggle with our weight or have family that does. As an underlying factor for disease, all of us are touched by the effects of our weight. For those who have a distorted body image, bulimia, binge eating, and other aberrant behavior may surface.

THE ORGANS/HOW THEY ARE AFFECTED BY OUR WEIGHT

1. The Skin—Actually the skin of overweight people look better, because fat under the skin nourishes the surface and prevents fine wrinkling and sagging, at least for a time. In fact, liposuction is necessary to contour the face and body, because the contour is hidden by the fat, whether it is a double chin, love handles, large hips, thick ankles, or a large belly. These all can be helped with liposuction. However, liposuction is no substitute for weight loss. For those that lose a huge amount of weight, lifting weights to help reshape the body will help, but will need re-contouring surgery of varying types. When I discuss cosmetic surgery in the future, I will address all these procedures, as I have had considerable experience in this area.

Because Type 2 diabetes occurs in most heavy people, leg ulcers from poor circulation are a significant risk, due to stasis of blood flow in the veins in the legs.

Because of pendulous breasts and excessive skin folds, yeast infections are very common. Even decubitus ulcers are increased in the morbidly obese and can occur more easily after surgery with being confined to bed rest or lack of adequate mobility.

2. The Endocrine System-hormones can be affected by obesity. Many patients have imbalance or reduction of hormones and infertility can be affected in both sexes. Many women think their thyroid levels must be abnormally low if they are overweight, but the fact is, it is not a big factor, but should be checked. Breast cancer is increased in women who are overweight, thought to be increased by increased storage of estrogen Also, I have previously pointed out that fat cells are endocrine in function putting out leptin and ghrelin, the hunger hormones, are frequently out of balance.

Type 2 diabetes is epidemic in these patients, and I have discussed diabetes at length previously.

3. Respiratory/The Airway—obstructive sleep apnea (OSA) is a very serious complication for an airway that is diminished in size by excessive fat. Even though surgical reduction of the tissues in the airway can be successful in many patients, weight loss is necessary. Otherwise, CPAP or BIPAP is the treatment of choice.  Surgery for many of these patients can be quite successful (another one of my favorite procedures) and in selected cases make CPAP more effective. In some severely obese patients, they may require a permanent tracheostomy when the breathing machines can’t be tolerated or the pressure necessary to relieve the airway obstruction is too high. 

With increased abdominal pressure and physical pressure on the diaphragm, it is hard for the lower parts of the lung to expand and get adequate oxygenation. The risk of lung infections, bronchitis, etc. is a constant threat. The Pneumovax vaccination is recommended to prevent pneumococcal pneumonia. When lung infections do occur, recovery is prolonged and can be complicated.

For extensive discussion on sleep apnea, click on:The Medical News Report on Sleep Apnea

4.The Cardiovascular Systemis one of theworst hit systems causing a plethora of diseases from atherosclerotic heart disease, arrhythmias (especially atrial fibrillation), coronary heart disease, cerebrovascular disease, heart failure, heart attacks, strokes, and lower extremity varicose veins with increased risk for clots, emboli, and stasis skin disease.The earlier obesity in childrenbegins, the greater chance for vascular disease.

5. The Gastrointestinal Tract is also affected, especially at the gastroesophageal junction. The increased intra-abdominal pressure and stretching of the junction causes GERD (reflux), and is difficult to treat, as I have discussed in the GI series. Digestion is disturbed especially with heavy meals causing increased stress on the digestive secretions of the pancreas, gall bladder, and liver to handle such a load. Fatty liver from high cholesterol and triglycerides can be quite severe leading to steatohepatitis, a disease which will be discussed in the GI series on liver diseases. Non-alcoholic fatty liver has been diagnosed in 70% of obese patients, which can lead to fibrosis (cirrhosis). There is no screening test for fatty liver, although a liver ultrasound is being used by some doctors. It has just been reported that fatty liver with inflammation and fibrosis (scarring-cirrhosis) is at least partially reversible with as little as 5% loss of body weight.

Pancreatitis is more common, especially during pregnancy, and with excessive abdominal pressures, can cause blockage of pancreatic secretions and inflammation. Constipation is a chronic problem from inactivity, as is hemorrhoidal disease. Gall bladder stones and recurrent infection frequently leads to cholecystectomy.

6. The Kidneys are affected primarily through the effects of Type 2 diabetes, and because of increased pressure on the urinary bladder, incontinence is quite common with prolapse.

7. The Genito-Urinary tractis also quite affected with large babies (heavy people tend to have big babies, especially diabetics), excessive stress and pressure on the pelvic structures leading to a variety of pelvic prolapse, incontinence both urinary and anal.

8. Orthopedic disease is epidemic. The weight created on the spine and joints is enormous requiring a variety of treatments, already discussed. There is an increased incidence of osteoarthritis in both weight bearing and non-weight bearing joints. Adiponectin and leptin are hormones secreted by fat cells that regulate low grade inflammation by increasing cytokines which are linked to arthritis and spondylitis. It is also known that high triglycerides increase the development of osteoarthritis and tendonitis. A recent study points out an increased incidence of lumbar spinal stenosis occurs in those significantly overweight, clearly related to the excessive stress put on their backs from being heavy. It is not known that weight reduction can improve these arthritic conditions.

9. Cancers of the breast, prostate, and colon are increased. Next month, how obesity can cause cancer!

10. Surgical complications are a huge subject, and with healthcare going the way it is, more patients will be refused surgery because of it. Increasing cardio-respiratory complications is a real threat. Recovery is prolonged, and that will cause increased time in the hospital and readmissions which will create decreased reimbursement for the hospital and the doctors. This issue is becoming a reason for denying patients surgical procedures.

11. Psychiatric issuesSelf- image is a major issue and not being accepted as a youth, bullying, attempting suicide, and turning to illegal drugs and alcohol are a risk. Depression is quite common and unfortunately, many anti-depressants can cause weight gain, which makes compliance taking these meds difficult. Counseling as part of an overall program is a must if a patient is motivated to lose 5-10% body weight.

12. Neurologic Issues—The National Institute of Aging reported that being obese or overweight at age 50, regardless of other factors (sex, co-morbidities, etc.) will increase the risk of earlier onset of Alzheimer’s disease by 6.7 months. Brain studies have cited that there is a greater number of the neurofibrillary tangles and increased amyloid deposits in the brain in these patients. See the discussion of Alzheimer’s disease in last month’s October report.

13. Metabolic Syndrome- This syndrome is epidemic in those significantly overweight.

The chart below defines the criteria for the Metabolic Syndrome:

The apple shape has a higher risk for organ disease from being overweight!

Binge eating disorder

This disorder frequently leads to obesity in 2/3 of the patients. If a person frequently eats a large volume of food in a short time, they may be at risk for this disorder. These patients frequently are depressed, anxious, or have mood disorders (bipolar). They complain of heartburn and IBS (irritable bowel syndrome), suffer from gallstones, Type-2 diabetes, and cardiovascular disease frequently. Emotional eating includes secret eating, eating until the person is “miserable” and extreme dieting can lead to binge eating. Keeping a diary of caloric intake is recommended in the treatment of these patients. Approximately 6 million Americans suffer from this disorder at some time in their lives, men more likely in middle age. Cognitive behavioral therapy is recommended.

Vyvanse (lisdextramphetamine) used for ADD, can curb cravings, and reduce the number of binge days.

Night eating syndrome (a different eating disorder) is defined as waking up and eating a meal to get sleepy and then going back to sleep. It is thought to be a remedy for insomnia in these patients. Interestingly, they also eat more slowly and not necessarily a lot. They may wake up several times and eat snacks each time. Sleep walkers canhave an eating disorder that occurs at night without their memory of eating.

Bulimia is an eating disorder with similar psychological issues (guilt, depression, but they purge after eating. It is not part of binge eating. They abuse laxatives, diuretics, and frequently over-exercise. Reference—WebMD

Better engagement by clinicians--Once again, it is imperative that physicians get more engaged in being actively involved in weight management. It is a big problem, and patients need to insist their physicians spend more time in encouraging and monitoring the patient’s weight loss progress. The effect on organs is amplified the longer a patient is overweight or obese, especially when the issue begins in childhood or adolescence.

Part 5 next month will explore the reason why obesity increases the risks of certain cancers.

 

3. STDS-sexually transmitted disease-part 1-

Viral Infections-genital herpes, human papilloma virus (HPV);Statistics on Adolescents having Sex!

 

Unprotected sex and using illegal injectable drugs  increase the risk of STDS.65 million Americans are currently suffering from incurable STDS. There are many more millions that have treatable STDs.

Having an STD does not make a person bad in any way. Unprotected sex happens for lots of reasons, and can happen to monogamous relationships. It can happen between individuals having contact with other humans. They do occur more frequently with careless behavior, those with multiple partners, and are much more common in the LGBT community. The incidence and prevalence of some of the STDs is below. In this report, I will discuss viral causes.

STDs from all causes:

Bacterial---Chancroid, Chlamydia, Gonorrhea, Granuloma inguinale, Lymphogranuloma venereum, and Syphilis

Viral---Genital herpes, Human papilloma virus (HPV), Hepatitis B and D (infrequently A, C, and E), HIV-AIDS, and Molluscumcontagiosum

Protozoan---Trichomoniasis

Fungi---Jock itch and Yeast infections

Parasites---Scabies and body lice-crabs

Sex in Adolescence and Teenagers

Almost half of high school students are sexually active and less than half use protection. The average age of having sex, for the first time, is 17, with oral sex not being considered sex by many young people. Blacks have sex earlier and use protection less often. Those who do have sex are also the same group who report more substance abuse, depression, and lower levels of education.  Those who delay sex correlate it with a more stable family life, communicate about sex with their parents, and are more religious.

4% of 15-19 year olds gave birth in 2009.  Birth rates in this country are 8X more common in the U.S. than any other developed country. 16.8% of abortions occur in this age group. I will discuss HIV next month. Click on this website for more information about sex in the youth:www.advocatesforyouth.org/publications-a-z/413-adolescent-sexual-behavior-i-demographics

Diseases that are transmitted by sexual contact, whether oral or genital, or using infected materials (needles, sex toys, contaminated clothing, etc.) define STDs.

Viral causes of STDs

1) HPV-human papilloma virus

2) Genital Herpes—Herpes simplex

3) Hepatitis B and C (A and E are more infrequent)

4) HIV-AIDS (Human infectious virus-autoimmune infectious deficiency syndrome). This month, I will discuss HPV and genital herpes. Next month, hepatitis and HIV-AIDS!

 

1) Human Papilloma Virus (HPV), genital warts and cancer

 Who would ever believe you could “catch cancer”, and yet with 20% of the public positive for HPV, it is. We know that almost all genital cancers (cervical, vaginal, penile, and anal) and as high as 70% of oral/oropharyngeal cancers are caused by certain strains of this virus that is easily transmitted (even with kissing). 20 million are infected and 6.2 million are added to that statistic per year.50% of sexually active men and women are infected with HPV sometime in their lifetime.

Genital warts are caused by certain strains of HPV as well. I have diagnosed these warts in the oral cavity, throat and even the vocal cords, when I was in practice. They look like little clusters of cauliflower- like raised lesions. Since oral sex became more prevalent, oral exposure is certainly no surprise nor is oral lesions.

Genital warts can be treated with prescription topical medications (Aldara, Condylox, or trichloracetic acid). Laser treatments, liquid nitrogen, or even cauterization also are effective for control but rarely cure.

It is stated that HPV is 100 times easier to catch than HIV. It is now the most common STD in America!!!

The Link between HPV and cancer

Research has never completely proven how HPV causes cancers, but it’s association with cancer and genital warts is overwhelming, it is considered the cause, and parents must have their kids vaccinated to prevent this virus in young people before they are sexually active. There are already early studies to prove protection in those vaccinated. Cancers caused by HPV according to the CDC:

For parents regarding the vaccine, click on:

www.cdc.gov/hpv/parents/vaccine.html

The answer for the young is Gardasil or Cervarix—HPV vaccination is a Must For ALL GIRLS 12-26 and BOYS 12-21, before becoming sexually active. This vaccine will prevent most of these genital cancers (we don’t know about oropharyngeal cancer yet).6% of youth have sex before age 13, so don’t be naïve parents and grandparents

Today, only 57% of girls and 35% of boys have received at least one dose of vaccine. The main reason kids are not getting vaccinated is their doctor did not recommend it!!! Come on Doctors! This is a very safe vaccine for those who question vaccines. A recent study has proven no increase in miscarriages for those vaccinated. Ask your adult children if they have vaccinated your grandchildren, and if you have young children, see to it that they receive the vaccine and the 2 boosters.

Once you have been infected there is no treatment. Many will carry this virus in their body the rest of their life, however, a percentage will rid themselves of the virus spontaneously. Most young people will never know they have become infected, how, or when. That is why vaccination before becoming sexually active is absolutely necessary. For those against vaccination, get over it! There is little or no risk of having your children vaccinated.

Condoms can prevent this virus most of the time, but HPV can still be contracted because of oral genital contact.

I will discuss cervical and other genital cancers at a later date. There are new studies out that report reversal of precancerous cervical cancer using the vaccine therapeutically. This is very exciting.  NEJM

2) Genital HerpesHerpes simplex

20% of the population has genital herpes. Any sexually active person can contract herpes simplex viral infection. Do not confuse this with Herpes Zoster (that is the chicken pox virus that also causes shingles). There are 2 strains of Herpes simplex, Type 1 usually is the culprit in oral herpes whileType 2 causes most of genital cases, however, either strain can cause oral and or genital herpes (fever blisters) infections. These blisters occur on the shaft of the penis, vulva, vagina, near the anus. Contact with an ulcer that is actively secreting the virus will likely infect a person. However, people with genital herpes can shed the virus long after the ulcers heal, because the virus can secrete through intact skin. Washing the hands frequently will help prevent spread to the eye, as this virus can cause corneal ulcers and even blindness. They are very hard to treat and can require a corneal transplant.

 

 

Genital herpes ulcers

 

Herpes (fever blisters)-lip

 

Activation of this virus can occur with exposure to the sun, stress, illness, and menstrual periods in women. When the virus is not causing ulcers (dormant), it lives in the ganglia of nerves supplying sensation to the skin. When activated, the virus travels down the nerve to skin and erupts. That is why patients feel pain in that particular nerve distribution frequently pain similar to sciatica with hypersensitive skin.

Note the ganglion of the nerve as it comes out of the spinal cord

There is no cure for the herpes virus, however, there are excellent medications to either prevent eruption and ulceration or shorten the course (a course is usually 7-10 days) of ulcerations. The ulcers on the genitalia are very painful. Hypersensitivity of the area frequently occurs right before the blisters erupt. If you have that sensation, it is time to start an anti-viral agent such as Valtrex or one of the acyclovir medications used to treat this infection.

  The number of outbreaks of herpes usually can lessen over the years, but stress can bring the ulcers back any time in the person’s life. The only way to be potential way is to have safe sex using a condom, although that may not protect in all cases. Having these ulcers increases the risk of contracting HIV from a positive partner. 

Pregnant women who have genital herpes have an increased risk of miscarriages from this virus. Coverage with acyclovir before delivery is recommended, as transmission to the infant can cause serious illness.  Be sure and tell your OB doctor you have herpes.

The annual new infection rate is 20 million Americans mostly in the younger population. The CDC estimates there are 110 million cases of Herpes Virus 2 in the U.S.

Although there is intensive research to find a vaccine that will cure this virus, there is no commercially available vaccine.

Treatment to prevent outbreak or shorten the course of infection include 3 oral medications. Intravenous acyclovir can be used in severe cases and is used in herpes encephalitis, newborn infections, and in immuno suppressed patients with Herpes Zoster. Topical medications do not work!

Acyclovir—(Zovirax)

Famcicyclovir—(Famvir)

Valacyclovir—(Valtrex)

The first infection requires 7-10 days of medication. Subsequent infections usually require 3-5 days. It is imperative that these infections be treated as early as possible. Having a refillable prescription on hand is recommended. This is called intermittent therapy.

Suppressive therapy requires daily medication. If a person has frequent outbreaks, this might be a good option. 70-80% of outbreaks can be prevented and in many no further outbreaks will occur. Taking daily therapy may decrease the likelihood of sexual transmission to a partner.

Being truthful to a partner about having genital herpes is mandatory to prevent unexpected transmission. It is a delicate issue. Think it out before bringing the subject up.  The use of condoms even with suppressive therapy is recommended. 50% of partners do not get infected. 75% of partners do not have active disease with ulceration even though infected, suggesting they have subclinical infection.

Unlike HPV, Herpes simplex virus (HSV-1 and 2) do not cause cancer.

For more information click on: http://www.webmd.com/search/search_results/default.aspx?query=genital herpes

Next month, I will discuss hepatitis B and C and HIV-AIDS, This will be followed by bacterial, fungal, protozoan, and parasitic causes.

 

4. LGBT-Lesbian-Gay-Bisexual-Transgender—medical and psychological issues—New information regarding genetic markers and sexual orientation

I discussed the transgender issue last month. There are some unique medical issues that this group contends with. It is not all about having sex with the same gender, but risky behavior increases risk for many health issues.

The big news regarding sexual orientation was just reported pointing to genetic markers that may determine sexual orientation in males 70% of the time. This was reported by the American Society of Human Genetics. The more the human genome is investigated, the more information about the individuality of humans is discovered (CIITA and KIFF1A genes). This is a study that will require much more investigation. It should not be misconstrued that there is going to be a treatment for this gene variant. It does mark the first time that the genome was used to deal with sexual desire and orientation.

LGBT Adolescents and Sex

This group tends to engage in more promiscuous sex and different sex behaviors (group sex, etc.). 67% of adolescents who are LGBT report having sex (69% in bisexual) compared to about half of whites. This group also uses condoms less frequently (33%). All this adds up to more exposure to STDS including HIV, hepatitis, HPV, and Herpes simplex. Refer to these infections in the STD section.

There are many facts to learn about this group including the discrimination, bullying, and social acceptance issues that this group experiences. For the facts, click on:

https://www.dosomething.org/facts/11-facts-lgbt-life-america

About a third of same sex couples are now married, and as marriage licenses are available in every state, that percentage will increase. Numbers of marriages have tripled in the last year. That is good news, since that will drop the multiple sex partner issue that continues to create medical issues. There is no reason why that will eventually mirror heterosexual rates of marriage. Acceptance of same sex marriage has doubled since 2000. Obviously, certain religious groups will still object, but even that group will come around eventually, at least at some level. As Dolly Parton said, “ I am supportive of same sex marriage because they deserve to be as miserable as the rest of us”.

The LGBT community is at greater risk for: HIV, Syphilis, Hepatitis B and C, Chlamydia and Gonorrhea (throat, penis, vaginal, rectum). The CDC recommends this community be regularly tested for all these infections. 75% of syphilis cases come from the LGBT group.

Men and women can develop genital papillomatosis (genital warts) from HPV exposure and are 17 times more likely to develop anal cancer. Laser treatment of these lesions can control the disease, but do not cure them, as recurrence is common.

Vaccines for Hepatitis A, B, C, and HPV should be given.

These viral STDs are discussed in the STD infection and treatment portion of this report.For more information, click on: www.cdc.gov/msmhealth/STD.htm

This community suffers from several social and psychological issues including discrimination, increased STDs, suicide, violence, substance abuse, and mental health issues.

Lesbian and bisexual women tend to have more obesity than the general public and that means an increase for all the disease obesity brings. They also smoke more and have more stress. These issues increase the risk for breast, ovary, colon, and lung cancer. Because this group skips routine health screenings, there is an increase in cancer of the cervix. Polycystic ovary syndrome is more common (causes hypertension, insulin resistance, infertility, obesity , and appearance issues).

Lesbian and bisexual women have and increased risk of 1) Bacterial vaginosis 2) Genital herpes 3) Gonorrhea 4) Chlamydia 5)Trichomonas 6) Genital warts (HPV).

The most important message for this community is….do  not hide these issues from the doctor. Be open so that they can increase surveillance for the diseases that are more likely to occur. Do not skip health screenings, flu shots, etc. The doctor is your advocate!

 

5. Pulmonary Embolism—Diagnosis and Treatment

 Last month, I discussed clots that form usually in the lower legs, although they can occur in the pelvis (especially in pregnant women) and other veins in the abdomen.

The path of the clot from the leg to the lungs travels to the inferior vena cava to the right side of the heart into the lungs as shown in the drawing below. 

Pulmonary clot (embolus)

When this clot lodges in a distal pulmonary vein, it blocks the normal exchange of venous blood to the lungs for oxygenation (which eventually flows out of the lungs to the left heart ventricles and to the body).

Symptoms of a pulmonary embolism are anxiety with clammy or bluish skin, with chest pain radiating into the arms or jaw, rapid breathing, shortness of breath, irregular heartbeat, thready pulse, and coughing up pink or bloody sputum.

The PERC rules which doctors use to diagnose a pulmonary embolism:

1) hemoptysis (spitting up blood) 2) age greater 50 3) Oxygen levels in the blood less than 95% on room air 4) previous history of DVT 5) trauma or surgery in past 4 weeks 6) history of taking estrogen 7)one leg is swollen

Diagnosing a pulmonary embolism may require a chest X-ray, blood tests (D-Dimer), a CT angiogram, a pulmonary  arteryarteriogram, MRI, special venous ultrasounds. An EKG and or echocardiogram usually will be performed in the workup to rule out a heart attack or heart failure. Also pneumothorax (collapsed lung), pneumonia, or dissection of the aorta must be ruled out with these tests.

One of the most common tests performed is the CT scan angiogram to visualize the clot in the pulmonary vein as shown in the helical CT (left) and the spiral CT scans (right) below.

 

 

TREATMENT

The embolus is a blood clot and will cause damage to the lungs if not removed or dissolved. Anticoagulants (Heparin, Coumadin, new oral anticoagulants) and in some cases a clot buster (t-Pa-tissue plasminogen activator) will be used based on the severity of the individual case. The mortality is cut in half with thrombolysis (dissolving the clot), but 9% did have some bleeding from the treatment compared to 3.4% for anticoagulants.

In life-threatening cases, a catheter may be introduced into the groin and is used to retrieve the clot (clot retrieval --embolectomy).

Indications for tPa

There are three factors that will possibly create the need for tPa: 1) heart failure created by the clot 2) a severely blocked pulmonary vein 3) Low blood pressure or shock. tPa can be given in a vein or administered via a catheter which is inserted directly into the pulmonary artery.

Anticoagulants

IV low molecular weight heparin (Lovenox) or IV heparin works immediately and therefore will likely be used in addition to oral Coumadin since it takes Coumadin 5-7 days to work. These anticoagulants can be switched to one of the new generation FDA approved oral anticoagulants: Pradaxa, Xarelto, Eliquis, and Savaysa

3-6 months of anticoagulants is usually necessary to treat and prevent further emboli, however, as always, follow your doctor’s recommendations.

In the case of a patient needing surgery while on Coumadin, normally some type of bridge therapy (i.e.aspirin) is recommended around the time of surgery), but since the bleeding from this type of therapy is quite possible, the most recent recommendation I have read, states that stopping the Coumadin a few days prior to surgery without bridge therapy is acceptable unless it is determined that some specific cases just can’t proceed without some type of bridge therapy. It is not recommended to administer Vitamin K acutely (the antidote), as there is some rebound hypercoagulability issues that could raise the risk of another embolus. Of course, this would be the decision of the individual doctors on the case.

Reference JAMA Internal Medicine, May, 2015

Bleeding from all of these anticoagulants is the main concern as it can be very serious. The antidote for t-Pa is aminocaproic acid, protamine sulfate for heparin, Vitamin K for Coumadin. The antidotes for the newer anticoagulants will be discussed, when I report on these anticoagulants all at once in December.

If anticoagulants cannot be used and in some recurrent cases a vena cava filter may be considered. This may prevent further clots from the legs or pelvis.

Prognosis

Survival depends on 1) the underlying health of the patient 2) size of the embolus 3) the cause of the embolus 4) the ability of the diagnosis to be made and successfully treated. Up to 400, 000 cases per year go undiagnosed.  Even when the diagnosis is made, there is still a 20% mortality rate.

It is also important to differentiate acute recurrent thromboemboli from chronic residual deep vein thrombosis. MRI direct thrombus imaging can tell the difference. Continuous anticoagulants are very important to prevent these emboli, but if residual clots. Unfortunately, this MRI technology is not readily available in most emergency rooms. 

Prevention

Compression stockings while in the hospital or mechanical leg compression, postoperative IV heparin, and ambulating frequently while in the hospital or at home all can potentially prevent DVT and pulmonary embolism. Smokers are at an increased risk, as well as women on estrogen or birth control pills. These issues must be managed.

This concludes the November MNR. I pray that you have a wonderful Thanksgiving with your family and friends. I also pray for our country in these perilous times. I ask for protection of our military, our law enforcement officers, our children, and all those in need.

Next month, I will report on the following subjects. Don’t forget I have a SUBJECT INDEX available for researching subjects in previous reports.

 

1. Obesity Series continues—the link of weight to cancer

2. Gastrointestinal Series continues—upper GI bleeding and peptic ulcer disease

3. Blood thinners—all you need to know

4. STDS-sexually transmitted disease-part 2-viral causes—Hepatitis B and C; HIV-AIDs

5. New recommendations for Chronic Sinusitis treatment

   The balloon procedure!

6. Answers from the Harvard Review and NEJM on how to fix our healthcare costs

ENJOY YOUR FAMILY!!!

God Bless our Military, Our Police, our Medical Professionals, and our Country—Thank you for reading my report!

Stay healthy and well, my friends, Dr. Sam