The Medical News Report

September, 2016, #56

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for September:

1.A new and exciting treatment for Insomnia

2. Concierge Medicine-current status

3.The Genitourinary System—Part 1--Kidney functions and testing

4. The Gastrointestinal System—Part 13-the Large Bowel-Colorectal-functions and diseases-new guidelines for the treatment of acute diarrhea

5. Update on Breast issues-Contraversial Areas-Bilateral Mastectomy for unilateral breast cancer; BRCA gene Update! Cancer screening for women with dense breasts

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

   Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, instructions for care, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

  Now, on with the information!! Thanks!! Dr. Sam

New information on routine testing and routine annual physical exams

  Since I have been reading multiple medical journals each month to prepare the monthly reports, I am becoming acutely aware of the effort put out by the federal government to discourage routine screening tests including pelvic exams and yearly annual physical exams. Trust me, some practices do not provide enough evidence that the cost far outweighs the benefit. But, the underlying theme is to reduce the cost of healthcare (a good thing), but another theme is clear to me….creating guidelines that become rules and taking decision making out of the physician’s hands. With rules come consequences resulting in refusal of insurance coverage. Pre-approval by insurance of many tests and procedures today have created blockade and extra work for your doctor, which takes time away from your visit. On the surface, guidelines are very good as medicine has become so complex, but making them rules is going too far, and that is where it is going, in my opinion.

  Doctors are trained to pick up abnormalities on routine exams and taking that away from them and you is an invasion of the sacred bond of the doctor/patient relationship. Creating cookbook medicine may be ok for PAs and nurse practitioners, as the feds are working hard to replace primary care with these providers.

  I hate to say it, but it is just paving the way to socialized medicine.  Organized medicine is split on supporting a one payer system. From what I read, there is a continuous push towards it.  This is my opinion! Feel free to email me your opinion.

  REQUEST FOR DONATIONS FOR THE LUCAS 2 MACHINE

  For those of you who live in or around Rabun County, Georgia, I would like to thank everyone who supported the Larry Hatchett Benefit Golf Tournament, put on by Susan Cillo and Larry Van Scoy. The proceeds went for the purchase of the Lucas 2 mechanical chest compression machine.

Larry and Susan

For those who had the good fortune of knowing Larry, who ran Greg’s Tire in Otto, North Carolina, he was everyone’s friend. He always had a smile on his face, and knew almost every customer by name. He and Susan (photo above) were a couple for several years, dear friends,and unfortunately he died of a sudden heart attack in his early 50s. Susan wanted to raise funds to help heart attack victims have a better chance to be resuscitated and make it to a medical facility.

  We are all familiar with CPR when the heart stops beating. Having resuscitated many individuals over my 30 years of practice, it is the most fatiguing effort I ever experienced. This machine was developed to take the place of a human performing chest compression, which must be performed 100 times a minute.

Part of the funds for this $15,000 machine wereraised at the event in Sky Valley recently. This machine will be donated to CMS for Rabun County, Georgia in loving memory of Larry.

  Please make your tax deductible contribution to:

In memory of Larry Hatchett

Rabun Medical Foundation

P.O. 1187

Clayton, Georgia, 30525

1. A new device for the treatment of insomnia just FDA approved

A new device for treating chronic insomnia (the Cereve Sleep System)has just been FDA approved. It will be commercially available in 2017, however, the cost has not been released.

This device reduces the latency (the length) in Stage I and II sleep, which is prolonged in many people with insomnia. Patients can’t “turn off their brain” and go to sleep.This device may be the answer for many with this chronic medical condition. Abuse of sleeping pills and sedatives is often a problem. The results of chronic loss of sleep have multiple health consequences.

Because the frontal lobe of the brain stays more active in those with insomnia, the device was created to slow the brain waves by cooling the patient’s forehead thus potentially giving them a deeper more restorative sleep.

Doctors specializing in Sleep Medicine, at the University of Pittsburgh, found that at a very specific therapeutic range, this device reduces the activity of the frontal cortex as reported in controlled clinical studies.

This prescription approved device uses a software controlled pad worn on the forehead to cool over the frontal lobe of the brain. Randomized placebo controlled studies on 230 patients using (electroencephalogram) brain wave studies proved that the time from awake to stage I sleep and to stage II was enhanced bringing on restful sleep much faster. The quality of sleep improved over 30 days. Below is a conceptual drawing.

55 million Americans suffer from insomnia and 9 million are routinely taking sleeping pill subscriptions annually. Stand by for its availability!! It sure would be a simple solution to a serious health problem.

Reference--Medscape-General Surgery, June 9, 2016

For more information on insomnia, I reported on this subject in the 23^rd and 24^th Medical New Report.

Reference- http://www.cerevesleep.com/press-release.aspx

2. Concierge Medicine

  Most people have heard about concierge medicine, and the American Academy of Family Practice announced that 2% of its 68,000 members are in the business of direct care (concierge medicine). This is also known as “retainer” medicine. For a flat fee, the services of a primary care doctor or general internist for specific care can be obtained, defined by the doctor or company they work for.

There are 3 primary types of concierge medicine:

1. Fee for Service--a yearly fee paid monthly, quarterly, or monthly that gives the patient access to office visits. Vaccinations, labs, X-ray, and medications may be separate.

2. Fee for Extra Care—This type of care is the same service as #1, but extra services may be billed to insurance. This may include same day visits, access to immediate phone or texting to the doctor, with no co-pay. This plan is eligible through savings plan proposed by the Republicans.

3. Hybrid model—this type (for a monthly fee) provides services that insurance or Medicare does not cover. This may include phone calls to the doctor, Facetime, Skype, emails, newsletters, annual physical or wellness exams. Photos can be texted to the doctor for evaluating as well (skin issues, swellings, cuts, etc.). Doctors that see non-retainer patients can provide these services too.

The cost services

The cost for up front expenses for care range from $1500-5000 per year depending on the area of the country and size of the cities.

 Others charge by the month. For $100 cash a month (for example), the physician will see your primary care needs including certain basic labs, certain medications, with visits on the phone, in person, or on the internet. Others charge more for the first visit (example- $225), $125 for follow up visit, and then $50 per month.  Some provide house calls.

  Insurance is not involved, but for a person who has $5-10,000 deductible, it could easily make sense, and thus their Obamacare or private insurance would essentially become a catastrophic policy. Patients could be on Medicaid or even Medicare and choose this extra service primarily for access, since that is becoming an real issue.

  There are private companies that provide some of these services now on the phone or internet even if they also provide insurance.

Advantages of Concierge doctors:

1) You will have access to the doctor 24/7. Some will shunt you to a nurse practitioner first.

2) Time spent with a visit will be longer than the average regular doctor. Patients can call the doctor on the phone and actually talk to the doctor (or assistant). 

3) These doctors limit their number of patients to 1500 or so, whereas most primary doctors have upwards of 5000 patients to care for just to make an adequate living.

4) Obamacare has been a boon to these doctors because of poor access, high deductibles, and little contact with their doctors makes this option viable. Trying to get a doctor’s office to call you back about lab results, concerns, etc. has become a serious drawback to the current healthcare system. Long waits, short visits, and good communication have become real issues thanks to federal and insurance regulations smothering the doctor’s time.

  Contact the American Academy of Private Physicians to find out the best doctors in your area. www.aapp.org/

MDVIP is a popular organization to check out. www.mdvip.com/

* Before signing up, visit the office and have a discussion about the services available (night visits, house calls, waiting time for a routine visit/urgent visit, etc.). Ask if they will file insurance for coverage of extra services not covered by this particular doctor.

  Chemistry with your doctor is critical, and if you have a good doctor you like and have had a good experience with them already, stick with them. Also affiliation with a large specialty group is very valuable.

3. The Genitourinary Tract Series—Part 1— Kidney Function and tests

There are body systems to rid us of bodily waste products. The main systems are the bowel, liver, and kidneys. Without detoxification and elimination, our bodiescould not sustain life. Beginning the series on the kidney and bladder, it is appropriate to review the complex functions of this system.

A. Anatomy

The kidneys lie behind the abdominal cavity in a space called the retroperitoneal space (the flank), deep to the back muscles.

  The urinary system includes the kidneys, ureters, bladder, and urethra. The ureters are the slender tubes that pass urine from the kidneys to the bladder. The urethra passes from the bladder to the outside at the end of the penis or just above the vagina. The anatomy is seen on the left drawing and a cross-section of the kidney on the right. 3

The kidneys are about the size of your fist and are paired organs. The renal arteries supply blood (25% of the total output by the heart) to the kidneys. They selectively filter 180 liters of plasma per 24 hours from the blood with the waste products removed in the urine.Electrolytes (sodium, potassium, and chloride), urea, creatinine and uric acid are the primary waste products.But just as importantly, they reabsorb proper amounts of glucose, water, and amino acids to maintain balance.

The functioning unit of the kidney is called the glomerulus. This drawing shows how the blood circulates through the kidney and after the waste products are removed, the rest of the blood returns via the renal vein.

B. Functions of the Kidneys

1) remove waste products from the blood 2) balance the body’s fluids normalizing the salt (sodium, potassium, and chloride) levels  3) release hormones that regulate blood pressure (renin/angiotensin)4) produces an active form of vitamin D that promote healthy strong bones 5) control the production of red blood cells (erythropoietin).

C.Kidney Function Tests

The major tests to determine kidney function are:

1) Creatinine

This is the breakdown product of creatine from muscle—normal values<1.2mg for women and <1.4mg for men

2) Glomerular filtration rate (GFR)- 90 or greater

3) Blood urea nitrogen (BUN)-normal range 7-10.

The BUN measures the nitrogen in the blood. Protein breaks down to waste products including urea nitrogen, which is broken down in the liver and then excreted by the kidneys. 

Creatine phosphate supplies energy to muscle and is a good indication of kidney function, as it requires good kidney function to remove it via the urine.Its breakdown product (broken down by the liver) is creatinine, which filters through the kidneys.

 4) Creatinine clearance

This test requires a 24 hour collection of urine plus a blood test for creatinine. As the name implies, it measures how well creatinine can pass through the kidneys into the urine. Normal clearance is 97-137 mg/ml for women, and 88-128 mg/ml.

5) Urine tests are:

a-The UA (urine analysis) tests for protein, albumin, and glucose in the urine.

   b-A test for infections-in the urine, bacteria can be seen using specific stains (gram stains), and cultured to diagnose an infection coming from the kidneys and or the bladder.

c-A urinedipstick test can detect blood, protein, sugar, ketones, and as many as ten chemicals.

  In a later report, I will discuss kidney failure, dialysis, and kidney transplants.

D) Control of the amount of fluid in the body.

There is a pituitary hormone stimulator called antidiuretic hormone (ADH), which controls how much the kidneys need to remove or retain fluid to maintain adequate hydration.

E)The renin/angiotensin system

These are hormones that are secreted into the blood stream that control the blood pressure. Some of the antihypertensive medications work by reducing these hormones.

F) Vitamin D and calcium metabolism

Vitamin D directly influences the levels of calcium in the blood and retaining or eliminating excess calcium depending on the body’s need (bone metabolism, etc.)

G) Red blood cell formation and the kidneys

The kidneys make and secrete a hormone called erythropoietin, which stimulates the protein, hemoglobin, which makes the blood red. It is the chemical in red blood cells that carries oxygen.

  These functions are important to understand as we discuss the diseases of the urinary system.

  Next month, I will report on infections of this system. When I discuss bladder issues, I will review its functions.

References—Healthline and WebMD

4. The Gastrointestinal Series—Part 13—The Large bowel (Colo-Rectal)-function and diseases-new guidelines for the treatment of diarrhea

The colon begins as the small bowel ends right where the appendix is located.  Symptoms from the colon can occur anywhere in the abdomen.

A. The parts of the colon are:

 1) Ascending colon on the right side of the abdomen

 2) Transverse colon as it goes from just under the liver to under the spleen on the left

 3) Descending colon as it goes into the pelvis

 4) Sigmoid colon as it goes deep into the pelvis the left of and behind the bladder

5) Rectum which ends with the anus.

B. Functions of the colon

 1) Absorb water, electrolytes (sodium and potassium), and vitamins,

2) Processes indigestible fecal contents (fiber),

3) Stores the remaining food not digested by the small intestine, and

4)Eliminates the remaining digested food a as feces. By weight, feces is 30% bacteria, 30% undigested food and fiber, 10-20% fat, and other inorganic matter.

5) Function bacteria in the colon

The colon has significant normal bacteria (100 trillion) that break down the fecal contents and mix with colonic mucus. The bacteria feed on the fiber ingested.  Abnormal bacteria in the colon are thought to be partially responsible for many of the colonic diseases and will be discussed in the future.

 6) As pointed out in previous reports, the motion of the colon is called peristalsis, which moves the contents along the gut. If the peristalsis is too rapid, diarrhea occurs; if too slow, constipation occurs. Many of the diseases of the colon create abnormal peristalsis interfering with the final phase of digestion.

7) With abnormal movement of the colon and an imbalance of function, gas (flatus), spasm, diverticuli,and inflammationcan occur.

 8) The main diseases that occur in the colon are due to the imbalance of functions of the colon. Immunological issues play a significant role in these diseases as well. The most common diseases of the colon are irritable bowel syndrome (IBS), diverticuli (diverticulosis)diverticulitis (infected diverticuli),colitis ,ulcerative colitis, colon polyps, and cancer.

9)Diseases of the Colon

a-IBS—irritable bowel syndrome, Celiac disease, lactose intolerance

  This disease is thought to be caused primarily by stress, however, it is thought that some gluten and lactose sensitivities play a role. To rule out a gluten allergy (Celiac disease), biopsies must be performed to diagnose abnormally flat villi (lining cells) that occur from inflammation created when a person eats food containing gluten. I discussed IBS, lactose intolerance, and Celiac disease in detail in the 14^th report: Medical Report #14

Celiac disease also inflames the small bowel as well as other diseases can.

  b- Diverticulosis/Diverticulitis

Diverticuli are small bulges (outward) the intestinal lining. About half of all people have some diverticuli after 60 years of age. Although most do not have symptoms, cramps, bloating, and constipation do occur. The cause is not known, but it is thought that increased pressure in the colon is an underlying cause.

  Fiber in the diet is the secret to normal bowel function. Diverticuli are more common in patients with IBS (irritable bowel disease).

  A colonoscopy or barium enema test can demonstrate these diverticuli.

  The best treatment for mild symptoms of diverticulosis is a) high fiber diet (fruits, vegetables, beans, and whole grains), b) high water intake, c) exercise, d) bulk fiber products such as Metamucil, and taking time for a bowel movement without straining. A daily bowel movement is not necessary.

Colonoscopy view of diverticulosis

When a diverticulum becomes inflamed it is called diverticulitis. It can cause severe abdominal pain, nausea, and marked changes in bowel habits. If fever occurs with abdominal tenderness, you must see your doctor, which may require hospitalization and possible surgical removal of the disease.

Complications include abscess, intestinal obstruction, and a fistula (the diverticulum can rupture and cause abnormal connections to the outside of the bowel or bladder). All of these complications can lead to peritonitis, which is an emergency.

Risk factors include a low fiber diet, smokers, aging, high fat diet, obesity, and medications that can cause constipation, including steroids, NSAIDs, and opiates.  

  c- Colitis has been discussed in the 14^th report (link above).

  d- New guidelines for the treatment of acute diarrhea:

5.Breast Cancer issues—Controversial areas

1-Bilateral mastectomy for unilateral breast cancer

2-BRCA gene update

3-Dense breastshave higher risk of breast cancer

  I have previously discussed the subject of breast cancer extensively. For those reports, please click on: Reports #21, #22, #23, #24, #26, #27

1-Bilateral mastectomy-the dilemma

Because of the fear of recurrence and second cancers,  younger women are more often requesting both breasts be removed when a single breast cancer is present with little proof it is of any value. This pertains to those with early ductal carcinoma in situ, early breast cancers, and those without invasive cancers, excluding those with other risk factors, such as genetic markers, family history, and more invasive disease.

Younger women (especially educated white women)want to diminish their chances of another cancer understandably, however, removing most of the breast tissue in both breasts does not guarantee a recurrence, or the occurrence of metastatic disease. It does reduce the risk in the contralateral (opposite) breast by 95% in genetic cases (no studies on non-genetic cases).

  The overall risk of a second separate cancer in the other breast is only 3-9% and that includes all cases.Therefore, considering double mastectomy should be well thought out with their oncologists and even a second opinion.

There are higher anxiety rates in women who seek bilateral (double) mastectomy, and significantly higher surgical complications.

  However, after one year, those with bilateral mastectomy and implants are more satisfied with the appearance of their breasts. It appears cosmetic considerations are the driving force as the concern in many cases along with fear.

2. Women with the following genetic risk factors should consider prophylactic bilateral mastectomy:

1) BRCA gene mutation especially with a family history

2) Lobular (as opposed to ductal) carcinoma in-situ with a strong family history

3) Li-Frameni syndrome etc. (rare disease that has high percentage of multiple cancer

http://www.lfsassociation.org/li-fraumeni-syndrome-awareness/?gclid=CJrX9d24384CFdgBgQodLHQFeQ —this and other genetic causes only account for only 5-10% of breast cancers)

4) A woman with a previous breast cancer

  A woman has to weigh the psychological aspects of worry versus body image and sexual side effects. 

For further information, click on:

http://www.cancer.gov/types/breast/risk-reducing-surgery-fact-sheet

  Since MRIs have been used in breast cancer, the rate in prophylactic (opposite)mastectomy has increased greatly. The reason is the high false positive rates showing suspicious spots in the other breast, thus encouraging the “better safe than sorry” concept. Only 1.8% of breast cancers are present in in both breasts simultaneously as reported in an older study.

3. Contralateral prophylactic mastectomy

Having the healthy breast removed is called a contralateral prophylactic mastectomy (CPM). It can mean a total removal or a nipple sparing mastectomy removing as much breast tissue as possible. The nipples may lose sensation with this surgery even if spared.

Rates of CPM have risen from 1.8% in 1998 to 4.8% in 2003. Women choosing a mastectomy (total or subtotal) instead of a lumpectomy rose from 4.2 to 11.0% for the second breast to be removed. These women are younger, more educated, and white. Cosmetic appearance, as I said, is a part of the equation in deciding for this extended procedure. Having the second breast removed lowers the risk of having cancer in that second breast, but data prove there is no change in the survival rate and is not routinely recommended.

  The risk of developing a second separate cancer in the average woman with breast cancer is3-5%, and having a second breast removed does not lower the chances of spread (metastases)to other parts of their body. Also, a double mastectomy does not guarantee another breast cancer anyway, as there are still microscopic breast cells left behind.

   Unfortunately, some doctors recommend CPM without telling the woman all the facts including complications of surgery. Amazingly, with a doctor’s recommendation, the insurance companies are frequently paying for it without questioning the justification. 

  The important point to be made is that every woman has a right to make her own decision, but it needs to be made with proper information (informed consent—risks, hazards, etc.). Quality of life (psychological sexual concerns), appearance, and fear of the most remote chances of another cancer are driving the decision of many white, educated, young women as reported in the literature.

Reference- Clinical Journal of Oncologic Nursing, 2015

4-New information about BRCA gene mutation in women

  I have also discussed BRCA subject as well: www.themedicalnewsreport.com Report #27

  It has been 20 years since the BRCA gene mutation was discovered. 3-4% of breast cancers are caused by the BRCA gene mutation and 15% of ovarian cancers.

  Angelina Jolie has an80% chance of developing breast cancer in her lifetime and a 39% of ovarian cancer based on her BRCA1 gene mutation and family history of first and second degree cancers (mother, sisters).

Women have a 1 in 400 chance of having that gene mutation. In just the last 20 years, the rate of a prophylactic bilateral breast removal has risen from 9% in 2003 to 24% in 2014 for those with BRCA.

5-Alternative newnon-surgical treatment for BRCA gene mutation positive people

There are now tailored treatments for these BRCA specific cancers, namely, the PARP inhibitors. This stands for poly- ADP-ribose polymerase, a drug that affects this gene mutation. This drug can also be given to their family members as well, who have the gene, potentially preventing surgical removal of the breasts and ovaries.

  We know a heavy family history plus this mutation confers an 80% chance of developing breast cancer and without the gene. Other women with a strong family history, even without the gene have a 40% chance of developing breast cancer in their lifetime.

  Just looking at the genomic sequencing by itself is not the only consideration, rather, investigation and testing of family members is very important. There are also protective alleles and modifier genes that can also change the risks.

The bottom line is careful evaluation by an expert genetic counselor, not just a surgeon or oncologist.

When considering a surgeon, be sure they are up to date with the latest oncologic breast surgical techniques and reconstruction for the best cosmetic result.

6-Dense Breasts and cancer risk

Dense breasts are placed into 4 categories:

1- Large amount of mammary gland and fibrous tissue (scattered fibroglandular) in the breast

2- heterogeneously dense (a mixture of fibroglandular and fat) breast

3-extremely dense

4-a breast primarily made up of fat.

Recent studies report that doctors can’t agree on the denseness of breast tissue or which category to place a woman as high as 17% of the time. This creates a challenge for routine X-ray screening mammograms, and frequently requires additional imaging to be sure a non-palpable mass in the breast is suspicious for cancer.

Ultrasound testing is the most common second test recommended and breast tomosynthesisis fast becoming a close third. This new imaging procedure is a 3-D mammogram compared to a 2-D regular mammogram. You can see the cancer is more defined with the 3-D technique in the photos below.

The fibrous and nodular tissue in the breast creates difficulty in reviewing a routine mammogram.  While only two X-rays are taken with a routine mammogram, the 3-D technique requires 11 views, thus the radiation dose and cost is significantly higher.

  The advantage of tomosynthesisis a 41% increase in detection of invasive cancers, 15% reduction in recall cases, and 29% increase in detection of all breast cancers. But, it also increases unnecessary biopsies for false positives.

The American College of OB-GYN feels reporting this information to women increases stress and leads to many additional tests. If a woman has extremely dense breasts, additional tests are usually recommended. Medicare does pay for all these tests, however, private insurance may or may not. Justification by the doctor is necessary to get prior approval.

  Many states require radiologists to communicate the denseness issue to women, and since 37% of women have dense breasts, this opens the door to frequent additional testing. Unfortunately, radiologists differ in as high as 17% of the time regarding the degree of denseness.

The National Cancer Institute does state that all women with dense breasts need additional screening. Deciding which women need additional testing is the key! For more information, click on:

http://www.cancer.gov/news-events/cancer-currents-blog/2015/dense-breasts-screening

Women with dense breasts are 4-5 times more likely to develop breast cancer. It may be because there is so much more glandular tissue to develop cancer in, but the real reason is unknown. However, overweight women have a higher rate of density, and obesity increases the risk of breast cancer.

  The issue of breast density is an important risk factor for women, and there are going to be changes in recommendations for testing in the near future. As soon as there is new information, I will report on it. I am on the committee to review the current literature for the American Cancer Society (screening for higher risk women).

  I have addressed some controversial issues. I hope it motivates you to discuss these with your doctors.

Next month, the proposed subjects will be;

1) The Adrenal gland- a continuation of the Endocrine System Series 2) Alcoholism 3) Colonoscopy and fecal testing for polyps and cancer 4) Kidney and bladder infections 5) Ovarian cancer

Fall is beginning and football!!

As always, Stay healthy and well, my friends. Dr. Sam