The Medical News Report # 49

February 2016

Take care of your heart!

Happy Valentine’s Day!!  Have a great February!

Subjects for February 2016, #49

1. Psychoses--Schizophrenia—diagnosis and new treatments

2. The Hippocratic Oath— “when in doubt, do no harm”; the” poly pill”; are you aware of “double booked” surgeries by some surgeons at Academic Institutions

3. New Healthcare Screening Guidelines for youth

4 STDs-Sexually Transmitted Diseases—Part 4-- (bacterial, protozoan, fungal, and parasitic causes)

5. New information about a gene mutation for Alzheimer’s disease

6. Update on guidelines--Statins for Diabetics by age!

7. Brand new Guidelines for Nutrition!

1. Psychoses--Schizophrenia—diagnosis and new treatments    

There has been a change in classification of what used to be placed in simplistic categories of psychoses and neuroses. The new classification is much too complicated for the average layman. The new categories are classified based on symptoms and treatment response. It is beyond this report to try and explain the new classification, as this was done by medical diagnosis coders for the purpose of reimbursing the psychiatric community. For you and me, let’s stay more simplistic. This means that I will make generalizations about psychoses.

  The definition of psychosis is characterized by abnormal thinking and perceptions. In general, patients lose touch with reality frequently with delusions and hallucinations (auditory, visual).  Causes of psychoses include:

1) Schizophrenia 2) Bipolar disorder 3) Schizo-affective disorder 4) Psychotic depression.  Certain drugs, alcohol abuse, brain tumors, brain infections, and strokes can also cause these psychotic-like symptoms.   

You may have seen the fabulous movie, “A Beautiful Mind”, a wonderful movie starring Russell Crowe regarding the life of Nobel Prize winner in Economics, Dr. John Nash (photo below left). He suffered from schizophrenia; so did Vincent Van Gogh (below right-a self- portrait).

Figure 1

Special brain scans show different brain activity in normal and schizophrenic people. Note the major difference in the frontal lobe between a normal and schizophrenic brain.

  Schizophrenia affects all ethnic groups affecting both sexes equally; it usually beginning at 16-30 years of age, but many people go undiagnosed for years. It can run higher in families with the disease.

Diagnosis of Schizophrenia--To be diagnosed, a patient must meet the Diagnostic and Statistical Manual of Mental

Criteria for the diagnosis of schizophrenia--There must be at least 2 symptoms for a month with at least some disturbance for 6 months:

Figure 2

Studies on twins have demonstrated actual anatomical differences in the brain in Figure 2 above. Note the difference in the size of the ventricles (this is where cerebrospinal fluid flows—the black holes). Two brain chemicals may be out of balance (glutamate and dopamine). In fact, gene variant of glutamate (GRM3) has been discovered and is associated with a 3-fold increase in schizophrenia and bipolar disorder. This gene is found in 1 out every 200 people. Treatment must be focused on all these chemical imbalances. There is still a lot of work to be done.

  Genetics and environment may play a role, but there is no test to diagnose this mental illness. Viral infections, older fathers, maternal complications, sexual or physical abuse as a child all have been linked by some observational studies. Recognition of suspicious behavior and social isolation in a teenager is thought to be potential warning signs of later developing schizophrenia.

  With any mental illness, the patient is the last to reach out for diagnosis and treatment. Caregivers must be proactive in seeking information and professional help for their loved ones.

  Because people with mental illness are much more likely to abuse drugs and alcohol, their symptoms are frequently brought out by this overlapping of disease and abuse.

Reaching out to these agencies is a good start for caregivers and those concerned about a friend or loved one.

 There are several types of schizophrenia:

Treatment begins with the fact that it is now being treated as a brain disease rather than as a psychological disorder.  The American Psychiatric Association categorizes this disorder differently, however, I have tried to simplify this for you.

  An integrated approach to treating this disease is the recommended technique.

The latest studies show a significantly better outcome using talk therapy as the primary treatment and medications secondarily. This will put more demands on a medical system seriously lacking in sufficient numbers of psychiatrists. This will by necessity lean on the fields of psychology and social psychology. I predict that psychiatrists will hire psychiatric-PAs and nurse practitioners in their office to assist in the therapy sessions. 

  Treatment with Medication:

   The primary goal of these medications is to block the effects of neurotransmitter especially dopamine and serotonin. They, however, do not block glutamate, and now that there is proof of a glutamate gene variant, we need new treatments focused on affecting glutamate. Typical and atypical antipsychotics are used to treat this disease. The first generation (typical) drugs were Haldol, Stelazine, Thorazine, Prolixin, and Mellaril. Side effects of movement abnormalities (tics, tremors, muscle spasms, and slurred speech) can occur in 70% of patients.  The newer second generation medications are preferred because they have fewer side effects. They are:

The FDA just approved another partial dopamine and serotonin blocker for schizophrenia and bipolar disorder, Vraylar, which will hopefully have even fewer side effects.

  Management of these second generation medications is still a challenge. Some of these movement side effects can still occur. Weight gain is more likely with these newer medications. Managing these side effects (also nausea, dry mouth, constipation, drowsiness or restlessness) requires skill and experience by psychiatrists. The biggest challenge is encouraging patients to stay on their medications. Frequent contact and collaboration with primary care physicians is a must. Some studies cite that as many as 50% of patients go off their meds because of side effects or they are convinced they aren’t working. It may require a trial of several of these meds before the best medication with the best dosage is found.   

  Antidepressants may also be recommended especially when depression and suicidal ideation is playing a role.

  Cognitive psychotherapy is also recommended by psychiatrists. Many of these patients need special living support and even special job support.

  There is no cure. Medications may stop working and a change may be required. It is quite a challenge to keep these patients functional and employed.

  Complications of schizophrenia are common: suicide, self-injury, anxiety, phobias, depression, substance abuse, poverty, homelessness, family conflict, inability to work, social isolation, and being a victim of abuse

Tips for the family:

1. Encourage the patient to stay on medication!

2. Go to doctor appointments with the patient.

3. Being supportive, respectful, and understanding of the disease.  

 The University of Maryland has a concise website for treatment and side effects:

www.umm.edu/health/medical/reports/articles/schizophrenia

Also the Mayo Clinic website is quite helpful:

http://www.mayoclinic.org/diseases-conditions/schizophrenia/basics/definition/con-20021077

  I have already discussed bipolar disorder, which is being diagnosed more commonly these days. You should take the time to read about this disorder: www.themedicalnewsreport.com #12 and #13

2. The Hippocratic Oath—“When in doubt, Do No Harm”; Effects of the “The Poly-pill”; Double Booking Surgery!

Having read an article on the concern of overmedicating the population, I am reminded of the oath I took, when I graduated from The University of Oklahoma Health Science Center. Stronger and more effective medications are being prescribed to better control our health issues. However, with tighter control, side effects can be an issue. The expense vs. benefit is also a factor, like it or not. If we don’t become stewards of the healthcare costs, we are going to bankrupt the system no matter what system we have.

  Taking multiple medications is a risk for cross-reactivity between medications, blocking the effects of each other, increasing side effects, and expecting all these medications by the handfull to be digested properly . This includes supplements. All these drugs have to go to the liver to be processed (broken down, detoxified, etc.), and as we age those processes may get more sluggish.

  In an article on the subject of polypharmacy, the authors describe big gaps in knowledge regarding the reliability of medications:

1) The short term clinical trials vs the long term use of the meds. If the trial length was for 1-2 years, how will these medications affect us over the years? Most research does not include long term effects.

2) The age of the research of the common drugs can be decades old. Studies of drug interaction with newer medications will not have been performed. It has been only recently that drug research included its effect on a patient with declining liver and kidney function.

3) If a drug is prescribed after an acute disease occurs (i.e. heart attack), will the drug have the same value as time passes and the disease becomes more chronic?

4) There is a concern regarding the age of participants in a research study. Does the research apply to the elderly population?

5) There continues to be lack of head to head comparison research for similar drugs. If a generic drug costs $50 a month, but a new brand name comes on the market at $600 a month, is the value to your body worth the price difference. I smell Big Pharma!!

6) 25% of seniors take at least 5 prescription drugs daily. The effect of taking multiple meds simultaneously (nicknamed “the polypill”) has not been studied.

7) Is your doctor really analyzing every medication you take and how it might be influencing your body? When I was recently on Plavix, I noticed considerable fatigue, and when I discussed this with my doctor, he said he was not aware of that side effect. Even the package insert did not mention it as a common effect. Does your doctor discuss with you the possible interaction of the meds you take?  Does he or she expect you to ask them instead?

  Ask your doctor about how the pills you take may influence each other and you over time. Are the meds you take worth the cost and is there a less expensive alternative? Are you doing your best to do what you can to keep yourself healthy?

Medscape-General Surgery-Dr. John Mandrola, Sept. 2015

Double booking of surgery—are you aware of this?

  On another note, the famous Massachusetts General Hospital was caught double booking surgeries for one surgeon. Centers that train surgical residents are expected to participate in the surgery, but the attending surgeon should be there to direct the residents and be scrubbed in to have a major role in the surgery. It appears, some of the surgeons at Mass General were essentially going back and forth between 2 operating rooms and the residents were actually performing the operation. That is fine as long as the patient is informed of this practice, but apparently they were not at Mass General. There has always been a hierarchy in surgical training. The more experienced the resident, the more they get to do, but with the close eye of the attending surgeon. If residents did not perform any surgeries before they graduated, they would not be prepared for private practice.

  This practice of double booking is being addressed and is no longer allowed in Boston.

  I bring this issue up, for those of you who go to teaching hospitals. I would suggest you bring this subject up and ask who is really doing your surgery.  

NEJM, July 2015

3. Recommendations for adolescent screening for disease

 The CDC states the following concerns about children and adolescents: health preventive screening is inadequate and highly variable!

1. Half of infants who failed a hearing test did not have documented follow up testing.

2. 1 in 5 children ages 10-27 months of age have not had developmental screening according to parental reports.

3. 2/3 of children 1-2 years of age have not been screened for lead poisoning.

4. 1 in 4 children ages 3-17 did not have a documented blood pressure reading.

5. 60% of sexually active adolescents have not had a chlamydia (STD) screening.

6. 1/3 of adolescents have not had their smoking status documented. For those who tested positive for tobacco, 80% had no smoking cessation services.

7. I will add another issue that needs much greater attention: HPV vaccination (Gardasil) for boys and girls 11 or 12 years of age to prevent several types of cancer. 4 out 10 girls and 6 out of 10 boys have not been vaccinated. 25% of parents deferred vaccination when their doctor suggested it. PHYSICIANS MUST BRING THIS UP AND PARENTS (GRANDPARENTS) MUST if the doctor doesn’t!! THERE ARE NO EXCUSES! For information on HPV vaccination:

www.gov/vaccines/who/teens/vaccination-coverage.html

 The American Academy of Pediatrics recommends the following:

1. Cholesterol screening-ages 9-11 and 17-21 should be tested especially with a family history.

2. Anemia screening is no longer recommended routinely.

3. Universal screening for HIV between ages 16-18. The CDC recommends testing be at 13.

4. Screening for drugs and alcohol should be performed annually from ages 11-21 years of age.

5. Annual screening for depression from ages 11-21.

6. A pelvic exam and Pap test is no longer recommended until age 21 except in immunosuppressed youth, or those who are HIV positive.  Reference—CDC.org

4. STDs-Sexually Transmitted Diseases-Part 3- bacterial, protozoan, parasitic, and fungal causes

I have reported on the guidelines for health screening from the USPTF (U.S. Preventative Task Force) many times. In 2014, they recommended all women 24 and younger be tested for chlamydia and gonorrhea on an annual basis with the routine pelvic exam. (that was just covered under adolescent screening in the previous subject).  

  A recent study reported by the CDC that more people are declaring that they are bi-sexual (women-5.5% and 2.0% of men) in the 18-44 age group. This impacts STDs greatly. If you have paid attention, a large proportion of STDs occur because of the gay, lesbian, bisexual, and transgender population. Why is this important? There are those who have sexual contact with this community and don’t necessarily know who they are dealing with. Unprotected sex is more common in this group, which is atrocious considering the incidence of STDs. Who is to blame? Can education about STDs and unprotected sex help? The CDC sure hopes so, but it continues to be a significant challenge due to ignorance and desiring not to wear protection.

A. Bacterial causes of STDs

1. Chancroid—Haemophylus ducreyi

   This STD is most common in uncircumsized males and rarely occurs in this country, but with the influx of immigrants, this could become more prevalent. The demographic is changing, thanks to the current policies.

   It causes an open painful sore on a man’s penis similar in appearance to syphilis. Syphilitic sores (ulcers) are usually painless however.  In women, symptoms of discharge, pain on intercourse, with urinary frequency are present but not severe. These symptoms are clearly not specific to chancroid, as they are common to most STDs in women.

Treatment--Antibiotics (erythromycins, cephalosporins, and ciprofloxin) will cure this STD.

2. Chlamydia—Chlamydia trachomatis--This is one of the most common STDs. This STD must be diagnosed and treated to prevent younger women from fallopian tubal disease and difficulty in getting pregnant or having dangerous ectopic pregnancies. It and gonorrhea should be tested annually on all girls up to age 25 including all gay, lesbian, and bisexual individuals throughout their sexual life. This is recommended by the federal government.

Photo of Chlamydia  bacteria

This can be contracted from women and men who are infected from vaginal, oral, or anal sex. It can be transmitted to newborns during vaginal delivery. If a woman is pregnant and near delivery, the expectant mother must be treated to prevent transmission.

  Condoms and monogamy are the best ways to prevent chlamydia, but abstinence is the only way to be sure.

  Complications from infection--Many individuals have no symptoms, but the usual symptoms of vaginal or penile discharge with urinary symptoms can occur. Because of the lack of symptoms, pelvic inflammatory disease (PID) is a real threat. This topic deserves a separate discussion in the future as this damages the uterus, ovaries, and tubes. In males, epididymitis can occur (this is the tube that carries sperm from the testicle and can scar creating difficulty with getting a woman pregnant).

Treatment--A test must be run to diagnose this disease. The treatment of choice is Azithromycin.  Doxycycline can be used as well.

  There 3 variants of this gram negative bacterium. One of the most common forms of blindness (8 million worldwide) is caused by one of these variants (trachoma) and lymphogranuloma venereum, another STD.

3. Lymphogranuloma venereum (LGV)

  This disease was uncommon until 2003, when a group of gay men spread the disease throughout the Netherlands and Europe, and eventually to the United States. This infection occurs from a break in the skin or through an intact mucous membrane (mouth or anus) and travels to the lymph nodes. The primary stage can cause an ulcer on the genitals or inside the anus. The secondary stage occurs 10-30 days later when the lymph nodes in the groin enlarge and frequently will abscess.

  A blood test (complement fixation) serology test can diagnose this STD.

Treatment-- Antibiotics (same as in Chancroid and Chlamydia) include the erythromycins (Azithromycin) and tetracyclines (Doxicycline).

4. Granuloma Inguinale—Klebsiella granulomatis

  This STD causes painful genital ulcers and within a month can cause those areas to form painless nodules (granulomas), which eventually bursts causing drainage.  This is very commonly misdiagnosed as syphilis and is

endemic in certain third world countries. However, with immigrants filling our country, it will be just a matter of time.

Treatment is the same as the above STDs.

5. Gonorrhea—Neisseria gonorrhoeae (The Clap)

  This common STD affects people primarily from ages 15-24, and is another STD that should be annually checked for in this age group. It can affect the genitals, mouth, throat, and eyes. It is estimated that 850,000 new cases occur annually in the U.S. It is not uncommon in senior communities (The Villages) and nursing homes. Many men and women are asymptomatic. However, the most common symptom is a discharge from either sex. Untreated, it is frequently the cause of pelvic inflammatory disease in women and strictures in men (from epididymitis). It also can cause arthritis, dermatitis, tenosynovitis and uveitis (an eye disease) and even meningitis or cardiac infections.

The “drip”   

Drops are put in every newborn to prevent neonatal keratoconjunctivitis.

Treatment-- should include 2 antibiotics, since drug resistance has become an issue over the past decade.  This should include a cephalosporin (ceftriaxone 250mg IM---cefixime is alternative) and erythromycin (azithromycin 1 gm orally) as a single dose. Doxicycline is an alternative if allergic to either of these classes of antibiotics. Patients with gonorrhea are frequently co-infected with chlamydia further supporting the recommendation of dual therapy. Complicated cases demand more treatment.

  If treatment does not seem to work, it is probably because of re-infection. Follow up is critical. Also from a societal standpoint, sexual contacts must be named, which frequently does not happen.  

6. Bacterial Vaginosis (BV) occurs when increases in certain bacteria (anaerobic) in the vagina disturb the balance of the normal bacteria (lactobacillus). This is the most common vaginal infection in ages 15-44. It is most likely to occur when a woman changes sex partners, has multiple sex partners, or has sex with other women.  Frequent douching can also cause BV. Technically, bacterial vaginosis is not an STD, but increases the likelihood of contracting other STDs.

  Women may be asymptomatic or notice a fishy smelling discharge with burning and itching, although, these symptoms are common in all STDs. A Gram stain of the discharge will demonstrate these gram-negative anaerobic bacteria. Most normal bacterial in the vagina are gram- positive in character.

  Comment: some genital bacteria in men and women may be incompatible and may cause BV. Condoms will help if this is thought to be an issue. There is no scientific way to prove this theory, but when no cause for vaginal discharge is found, this may be a presumptive diagnosis.  

Treatment--Metronidazole pills or gel. Also, Clindamycin cream at bedtime is effective. An alternative is Tinidazole orally.  Half of the cases will recur within 12 months. It has been stated that bacterial vaginosis can increase premature labor, and therefore, treating before delivery (controversial), C-section, or IUD placement is recommended by some.   

7. Mycoplasma genitalium 

   This has recently been added to the list of bacterial causes. It causes urethritis (infection of the urethra in men), but can cause infections of the female cervix in 10-30% of the cases.

Treatment is a single 1gram dose of azithromycin (an erythromycin), although the CDC notes rapid resistance is occurring. In that case, moxifloxicin 400mg for 7-14 days is effective.

8. Syphilis—Treponema pallidum

(ulcer is called a chancre)

56,431 cases of syphilis were reported in the U.S. in 2013, compared to 47,532 of HIV. The painless ulcer is called a chancre, and it can occur on the penile shaft, the vulva, vagina, and anus (lips and mouth). It can also be transmitted to an infant at birth. The average time from infection to an ulcer is 21 days, but it can occur 3 months later. 75% of syphilis in 2013 occurred in men having sex with men.

Stages of Syphilis

I. Primary Syphilis—the chancres are usually painless as opposed to other STD ulcers. The ulcers heal in about 3-6 weeks regardless of whether it is treated or not. If the primary infection is not adequately treated, the primary stage progresses to the secondary stage.

II. Secondary Syphilis—A non-itchy rash and sores in the mouth, anus, and vagina are the hallmark of secondary stage.  The rash usually occurs on the palms of the hands and feet, and is a brownish red rash and can be faint. Large gray or white lesions can occur in the mouth, armpits, and groin called condyloma lata.  A wide variety of symptoms can occur from swollen lymph nodes to patchy hair loss. If not diagnosed and treated, it will progress to the third stage (latent or tertiary syphilis).

Rash of secondary syphilis, palms

III. Tertiary (Latent) Syphilis--this stage will occur in 15-20% of those not previously treated will develop symptoms in the internal organs. It is called early latent if symptoms appear within the first 12 months, and late latent after 12 months up to 20 years later. If it occurs in the brain, dementia will occur and must be tested for in anyone diagnosed with dementia.

  Neurosyphilis—involvement of brain can occur at any stage of syphilis causing unusual behavior and dementia.

  There is a significant chance HIV may be present as well, and anyone with a positive syphilis test would be automatically tested for HIV. Anyone with an open wound would be very vulnerable to other forms of STDs.  All pregnant women should be screened for syphilis because it can kill a fetus or have a baby born with Congenital Syphilis. Tests in the third trimester and at delivery should also be performed routinely. Unfortunately, syphilis rates are on the rise, therefore, cautious testing in high risk groups is mandatory.

Diagnosis can be confirmed with several different tests, but the VDRL and RPR tests are standard.

Treatment of Syphilis--A single IM injection of long acting benzathine penicillin 2.4 grams is still the treatment of choice and will cure primary and secondary syphilis while 3 weekly shots are recommended for tertiary (latent) syphilis. The damage already done by the late stage of syphilis will not reverse. If allergic to penicillin, consultation with an expert to decide alternative antibiotic treatment versus desensitization from a penicillin allergy. You can click on these websites and then do a search:       www.webmd.com      www.cdc.org

 B. Fungal Causes of STDs

1. Candida albicans (yeast infection)

  Candida is the most common fungal infection of the vagina. Itching is the most common symptom followed by soreness, pain on intercourse and urination. 75% of women will have this infection some time in their lives. This fungus normally grows in the mouth, the vagina, and the digestive tract. It is the overgrowth of this fungus creating an imbalance with the normal bacteria that lives in these areas that creates the infection.

  Although yeast infections are not classically considered an STD, about 15% are transmitted to the sexual partner especially if a male is uncircumcised.

  Risk factors include those who take antibiotics, steroids, birth control pills, are diabetic, wear silk panties, take very hot baths, frequently douche, using pads or changing tampons very frequently during a period. Feminine sprays, wearing tight jeans frequently, and wearing pantyhose also can increase the risk of a fungal infection.

Treatment--is usually with vaginal cream or suppositories. There are many over-the-counter products. Terconazole (Terazol) suppositories can be prescribed by your doctor. Clotrimazole, micronazole, butaconazole and many other azole drugs all can be prescribed as suppositories or creams.  Condoms may also be helpful while getting over an infection.

2. Jock itch (Tinea cruris)

  This fungus can be sexually transmitted. This is caused by the common fungal class Trichophyton or Epidermophyton, but also can be caused by Candida or certain bacteria. Heat is the main offender caused by wearing tight underwear or not changing them often enough. This can cause athlete’s foot as well. Topical sprays or creams from the same family of drugs just described will usually suffice, but recurrences are common, especially in diabetics, those overweight, or have some type of disease that either causes immunosuppression.

Treatment—Lotrimin (an OTC cream combination of cortisone and clotrimazole (an antifungal) is the most common drug used. Ketoconazole or Lamisil are also effective. Keeping the groin dry is the key. For those overweight, this is a challenge. Intertriginous (overlapping skin) areas of the body are very prone to this type of fungal infection. Diabetics are especially prone to these infections including athlete’s foot (the same fungus).

E. Protozoan causes

1. Trichomonas (trichomonas vaginalis) infections is the most common non-viral cause of vaginal infections sexually transmitted affecting 3.7 million women. 13% of black women suffer from this STD compared to 1% of whites.

Trichomonas

It is very common in women with other STDs. Men can get urethritis, bladder or prostate infections. It causes a foul yellowish-green discharge. Screening for this infection is indicated in any woman presenting with a vaginal discharge. Anyone diagnosed with trichomonas should be tested for HIV, as 53% of those with HIV also have trichomonas. 

Treatment-- requires prescription oral medication—Metronidazole, Tinidazole. Avoid alcohol while taking this medication.

Any patient with an STD should make their partner(s) aware of the issue and see their doctor.  Although there are no federal or state laws requiring a person to inform their partners, it could set up a civil lawsuit especially with HIV, herpes simplex infections as they incurable. Knowingly transmitting HIV is a criminal act.

D. Parasitic Causes (Scabies, Body Lice, Intestinal parasites

1. Scabies (bed bugs)

  This is a highly contagious parasitic disease that is caused by the mite Sarcoptes scabiei creating an intense itchy red bumpy rash in the hair bearing areas of the body (genitals and scalp most common) usually worse at night. Although not always contracted by sexual contact, bed sheets or contaminated clothes can be the culprit. It can be epidemic in nursing homes, hospitals, institutions, etc.  Animals are not the source, as they have different type of mites. The mite burrows under the skin and is actually in each of the red bumps. The bumps can blister and crust.

  There can be a delay for symptoms to occur up to 2 months. During that time and when symptoms are present, a person is infectious. Skin scrapings under a microscope will identify the mite or eggs.

  Treatment requires the topical placement of the scabicide from head to toe each night for 7 nights. Permethrin (Elimite) is the treatment of choice and is approved down to 2 months of age. An alternate less desirable therapy is Lindane, a 1 oz lotion, used only once from head to toe (do not ingest), however, it can cause seizures and has caused death rarely.  

2. Intestinal parasites

  These parasites can be transmitted with anal intercourse and are seen in males having sex with males. It is diagnosed in a stool sample. GI symptoms may occur and for gays that would raise suspicion. Depending on the parasite, specific treatments will be prescribed. Amoebic  and Giardia are the most common intestinal parasites diagnosed. Metronidazole treats both diseases

Entamoeba histolytica

Giardia lamblia

3. Head and Pubic Lice (crabs)

  This disease is commonly called “the crabs” because of the appearance of the mite and are also STDs, but also can be transmitted using another’s comb or hair brush, being in contact with clothes, towels, or sheets that contain these lice. Head lice are caused by Pediculus humanus capitus. Pubic lice are caused by Phthirus pubis. Intense itching in the head or groin of individuals occurs and can be treated with OTC meds-permethrin (NIX, A-200, RID, Elimite), the same medication for scabies.

Photo of pubic louse (crabs)

Reference for all STDs at the Center for Disease Control : http://www.cdc.gov/std/

5. New information regarding a gene mutation linked to Alzheimer’s disease (AD)

  In my recent discussion on AD in October, I described the APOE-4 gene that is a lipid gene that increases the likelihood of elevated cholesterol, but it also (in certain people) increases the likelihood of deposits of amyloid, one of the two proteins that is found in specific areas of the brain in AD patients. For the general discussion on AD: www.themedicalnewsreport.com #12 and #45

Now there is another new gene (ILTRAP) that is involved with the immune activity of certain brain cells (microglia) that clean up the degenerative products in the brain. Cytokines are chemicals that are involved in the body’s inflammatory process. Researchers reported in the journal BRAIN that this gene interferes with how effective this brain cell functions. Patients with this gene variant deposit more amyloid in the brain (temporal lobe) over a 2 year period than those without the gene variant. It is thought  this gene variant has an even stronger influence than the APOE-4 gene in amyloid deposits.

  The closer science gets to understanding the actual process that causes AD, the sooner we will have a treatment that can stop or at least slow down this disease. It is pretty clear that the protein, amyloid, is involved.

  Support Alzheimer’s disease research:

The Alzheimer’s Foundation—1-866-232-8484 or

http://www.alzfdn.org/ContributetoAFA/makeadonation.html

Aurora Borealis—Canadian Rockies

6. Updates for Statin use in diabetics based on Age

  The intensity of statin treatment for lowering LDL-cholesterol has become refined since there are several strengths and choices for therapy. It is recommended that the LDL remain below 100mg/dl, and some say down to 70mg/dl, if heart disease is present.

  The National Endocrinology Association have recently made recommendations for type 2 diabetics based on 3 age groups. Since heart and stroke disease tops the charts on death of all Americans and certainly diabetics, these guidelines are valuable for all of us.

Less than 40 years of age---low or moderate intensity statins are recommended for diabetics with any of these factors--- elevated cholesterol, hypertension, smoking, or overweight (now BMI of 23 instead of former 25 for Asian-Americans). It is becoming clearer that waist size and body mass index have been a little too generous.

High intensity statins if the diabetic has cardiovascular disease.

If diabetics have no risk factors other diabetes, statins are not recommended id under 40.

Over 40-under 75---moderate intensity statins are recommended if no additional risk factors are present, however, if other risk factors exist, high intensity statins are recommended.

Over 76---moderate intensity statins for those with no additional risk factors and high intensity for everyone else.

Additional recommendations for diabetics:

1) The frequency of testing for lipids is determined by the severity of abnormality. Everyone needs to be tested before the age of 40.

2) The blood pressure levels—140/80. These levels keep changing-it was 130mmHg and now 140mmHg for the systolic. The diastolic has been raised from 80 to 90mmHg. This is more realistic and safer to prevent the BP dropping quite low upon standing.

3) Limit the time for sitting to 90 minutes a day with daily exercise. This is the first time I have seen emphasis on the amount of sitting, which is now known to increase the risk of death.

4) The glucose range to keep good control for diabetics is 80-130mg/dl (changes from 70-120).

5) The ADA (American Diabetes Association) does not recommend using e-cigarettes for smoking cessation.

6) HgA-1c (hemoglobin A-1c) is a blood test that reflects how well diabetes is being controlled (blood sugar levels)  over a 6-8 week period. Keeping the level below 7 is still recommended for adults, but the level for children has been changed to 7.5.

These are very important new recommendations, so be sure and discuss this with your doctor if you are diabetic.

Reference—ADA (the American Diabetes Association)

7. Brand new Guidelines on Nutrition, #1 Diet, #1 Weight Loss Program

Congratulations America!! The average number of calories consumed by adults per day is 3770 calories! More than any other country in the world!!

  The Departments of U.S. Agriculture and Health and Human Services just reported new guidelines for optimum nutrition. It should be noted, as I have noted over several reports, sugar is the most serious culprit when it comes to maintaining a healthy diet. Read carefully:

Just out: The U.S. News and World Report analyzed 41 diets and the best overall diet is the DASH DIET (for the past 5 years), and #2 was TLC diet. The Weight Watchers Program is the best weight loss program for its simplicity and ease to follow. All healthy diets include fruits, vegetables, limit the sugar and starch, eat more fish and chicken, less meat, and limit salt intake to one tsp per 24 hours (that is total including salted foods). If you choose a program to lose weight, and it is helping you, it is the best for you. Click on:

www.webmd.com/diet/20150106/best-diets-ranking

Reference: NEJM, Jan, 2016

  This completes the February report #49. Next month will be my 50^th report, a milestone for me. That is 50 months of reports!! It has been my pleasure!

  If you would like a subject discussed, feel free to request it. Always discuss any information you read in these reports with your doctor and let him or her make the decisions. Of course, you should be active in deciding any healthcare moves. It is your body!!

  Next month, the subjects will be 1) insured and uninsured patients-a comparison 2) a follow up after the ACS’ new guidelines for mammography in the average risk woman 3) liver cancer 4) time to quit smoking! 5) some myths about dieting 6) anxiety-diagnosis and treatment and 7) menopause.

One more thing:

Stay healthy and well, my friends, Dr. Sam