The Medical News Report #60

January 2017

Samuel J. LaMonte, M.D.,FACS

www.themedicalnewsreport.com

samlamonte@gmail.com

Subjects for January:

1. Cancers caused by the HPV virus

A. Update on vaccination to prevent HPV (Gardasil)

    B. HPV positive oral cavity and throat cancers

    C. HPV positive genital cancers (cervical, vaginal, vulvar, penile, and anal)

2. Botox injections-the many uses today

3. Gastrointestinal Series-Part 15- Gut bacteria and it role in health and

 disease (H.pylori, C.diff)/fecal transplant update/update on probiotics

4. Urinary System Series-Part 4-Kidney and Bladder Stones

5. Yoga vs. Physical Therapy for back pain

 

Happy New Year 2017

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

Latest News!!!!!

  The United States Congress just recently passed a $6.3 billion bill to fund cancer research including brain science, faster drug approval, fund mental healthcare, and combat opioid abuse. This bipartisan supported bill was dubbed the 21st Century Cures Act. $4.8 billion of the $6.3 billion goes to the NIH to support cancer research and the Beau Biden Cancer Moonshot project. Good news!

1. Cancers caused by the HPV virus-Genital and Head and Neck cancer (oral and throat)

A. Introduction to HPV and the vaccine to prevent it

39,000 Americans suffered a cancer caused by the human papilloma virus (HPV), an increase of 17% from 2008-2012, and 300% increase since the 1980s, according to the CDC. This clearly is linked to a change in recent sexual practices in the past few decades. 59% of these cancers occur in women.

  Practices such as increased oral sex and more promiscuity in certain groups have led to this increase.  Shaving the pubic hair increases the risk of a sexually transmitted disease. These types of practices have consequences. This information was recently reported in the Journal of Sexually Transmitted diseases, Dec. 5, 2016. Shaving or waxing causes tiny nicks in the skin increasing transmission of STDs potential during sex.

   91% of cancers of the female cervix(13,000), 69% of vulvar cancers (3500), 75% of vaginal cancers, 63% of penile cancers, 90% of anal cancers (5000), and close to 70% of oral and oropharyngeal cancers (15,738) are thought to be caused by contact with the HPV virus from human contact. These stats make oral and throat cancer the most common HPV related cancer!

This virus is 100 times more infectious than HIV to put it into perspective. 80% of these cancers are caused by 2 of more than 300 types of the virus—type 16 and 18.

B. Vaccination to prevent HPV--Gardasil

  The American Cancer Society recently updated their recommendations (I am a member of that ACS Guidelines Development Group), the American Academies of Pediatrics and Family Practice, and American College of OB-GYN also recommend the 3 dose series vaccination, however more recently, it has been recommended that certain groups only need 2 doses:

1) All children beginning at ages 11-12using the HPV-9 valent vaccine (this covers 9 types of the virus). *CDC says two doses up to age 15.

2) The vaccine should also be given to males ‘til age 21. For men having sex with men and other high risk groups, the vaccine should be given up to age 26.

3) The vaccine should be given to females until age 18,if they did not receive the vaccine earlier or did not complete the series.

4) In women ages 18-26, an informed decision is recommended rather than an automatic recommendation by the organizations.

* The CDC just came out with a recommendation for 2 not 3 doses of vaccine for children under the age of 15, with the second dose 6 to 12 months later. This will increase cooperation with parents. It may take some months before the other organizations agree to endorse the CDC’s change. The ACS has just modified their guidelines just as the CDC has recommended.

The effectiveness of the vaccine drops considerably at these older ages since sexual activity would have already begun. These patients must be advised that their risk of these cancers may continue, especially ages 22-26.

There is a 30% chance women will test positive for HPV if they are not vaccinated until ages 19-21, whereas if vaccinated before the age of 17, there is a 75% chance of vaccine effectiveness. After 21, the effectiveness of the vaccine drops 50% using the latest data enclosed in the ACS supplemental evidence review summary.

  Vaccination against HPV can spare over 28,000 Americans annually from developing these cancers.

C. Another Advantage of Vaccination

The Journal of the National Cancer Institute recently stated that another benefit of taking the vaccine is the need for less screening for PAP smears and or testing for HPV on exam. They are recommending that Pap smears can be performed every five years starting at age 25-30 if the monovalent or bivalent vaccine is administered as a youth. If the newer 9 valent vaccine was used, Pap smears plus HPV testing is recommended only every 10 years starting at age 25-30. Currently Pap testing should begin at the age of 21 every three years. 

   I will discuss the anti-vaccination issue in the near future.

D. The Commercial Vaccines

Gardasil-4 and 9 and Cervarex-2 are commercially available and FDA approved (2007 for females and 2010 for males). They do cost a few hundred dollars, but there is a federal program for free vaccination in the uninsured and underinsured up to age 18. This would encompass half the population.

Rates of vaccination are still low considering the benefit. The vaccine needs to be promoted as an anti-cancer vaccine and not just an STD (sexually transmitted disease) preventative. 70 organizations including the American Cancer Society make up the Coalition Roundtable for HPV vaccination to prevent these specific cancers.Recent  studies have found no link (of the vaccine) to ovarian failure, chronic fatigue, Guillain Barre’ syndrome, and other issues put forth by certain conspiracy groups.

It is a shame the anti-vaccine advocacy group is denying their children the value of lowering the risk of these cancers.

Males were more recently included in the recommendations for vaccination for several reasons:

a) Throat cancer was added to the list of HPV linked cancers, and these cancers are much more common in males.

b) Transmission from male to female increases the likelihood of infections considering the number of sexual partners people have had in recent decades. 

c) The LGBT community has an increased infection rate.

E. Evidence the vaccine is working

To date, there has been a drop in rates of anogenital warts in males who have been vaccinated. It is too soon to definitely prove a drop in female genital and head and neck cancers. Receiving the vaccine does not guarantee a person will not get a HPV linked cancer. Also, if a young person has had sex, the chances of prevention drop because they might already be infected with HPV. Once infected, the vaccine is of no value.

The 9 valent vaccine is recommended since it is more inclusive of the number of types of HPV.

F. High risk groups include immuno compromised patients from disease or medication, those with HIV, transplant patients, children with a history of sexual assault, and men having sex with men.

The number of sexual partners increases the risk for HPV infection. A national survey stated that half of women over 19 have had 4 or more sexual partners.

G. Percentage of adolescents being vaccinated

  60% of adolescent girls and 42% of males currently have had at least had one dose of the three recommended doses of vaccine. Why do parents want to skip a cancer preventing vaccine?

H. HPV positive Genital Cancers

1) Introduction

Cancers of the cervix, vagina, and vulva occur primarily from the HPV virus. That is why HPV testing has been added to the Pap smear testing. The HPV vaccine can prevent the majority of cervical cancers, but is not very valuable once the patient has contracted the HPV virus having vaginal, oral, or anal sex. This is increased in girls having sex early and or with multiple partners. Women over 30 are less likely to become infected. Using condoms decreases the risk but does not eliminate it. Vaccines at older ages are less effective (22-26).

 2) Even women who were vaccinated still need to have routine screening.

 3) By far, the most common genital cancer is cervical, a part of the uterus. Cancers of the vagina and vulva are much less frequent.

  4)Transition from normal cells to cancer

Cancers usually transform from normal cells and over time transition to dyplasia (in-situ cancer) to invasive cancer. Not all patients with pre-cancerous changes will develop invasive cancer. Also it can take a few years for lesions to advance to invasive cancers, however, some can progress in less than a year.  Catching it at the very earliest stage will usually allow the best chance for cure.

 5) The Pap smear can detect these abnormal cells before they are invasive. Cells are examined under a microscope to look for changes. The cervical surface is scraped for the specimen. It is important not to douche, use lubricants, or vaginal medicines 2-3 days before an exam. 

 

Pap smears evaluate  surface cells of the cervix

6) Technique of Pap smear

 

 

 

 

 

 

 

 

 

The Pap smear is not perfect and that is why adding the HPV test has been recommended. Pap smear results are  reported three different ways:

   a-- no evidence of intraepithelial abnormalities or malignancy

   b-- epithelial cell abnormalities—this means that the cells could be pre-cancer or cancer. This will require a biopsy. 4 quadrant biopsies are performed through a procedure called colposcopy. Other procedures include a cone biopsy, which requires the entire end of the cervix to be superficially removed. It can be used to treat the abnormality if the cervix does not appear to have invasive lesions. A thin lop of wire is hooked up to an electrical apparatus to cut the tissue away. It can be performed also with a scalpel or laser.

  A cone biopsy may be recommended and requires taking a core of the cervix out to evaluate. This could treat severe precancerous lesions.

c— the Pap shows cancer cells

    7) Discussion

  If the cells on the Pap smear are minimally abnormal, a repeat test will be performed in one year or sooner.

  If the abnormal cells are glandular in origin, curettage (D&C) of the inside of the endometrium (uterus) is performed. I will discuss endometrial (uterine) cancer in another report.

  If the cells show cancer, a hysterectomy will be recommended depending on the extent of the cancer.

    8) HPV gene testing can now be performed to analyze the DNA and its subtypes. The ACS recommends this test above age 30. The HPV test does not replace the Pap smear. If the test is positive for type 16 or 18, and the Pap smear is positive, biopsy will be necessary. Most of the cervical cancers are positive for these two subtypes.

  If the HPV test is positive for these subtypes and the Pap smear is negative, repeat testing in one year is recommended. A positive test does mean a woman has had an infection from HPV, but not necessarily cancer.

9)American Cancer Society Recommendations for Cervical Cancer Screening:

   --- All women starting at age 21 should be tested for cancer of the cervix. From age 21-29, every three years is recommended.

   --- At age 30-65, every 5 years, a combined Pap smear and HPV test; or just the Pap smear every 3 years.

   --- If a woman 65 or older has negative tests for 10 years, no further testing is recommended without any history of endometrial or cervical cancer.

   --- If a woman has had a hysterectomy for other than cancer, they can stop having routine testing.

   --- Even women who have been properly vaccinated (2 doses now), should follow the same guidelines.  

 10) Types of cancers

Because there are two different types of cells on the surface of the cervix, 2 different types of cancer called squamous cell carcinoma and adenocarcinoma occur.

 11) Incidence and risk factors

HPV causes most of the cervical cancers. 13,000 cases were diagnosed in 2016 and 4100 died according to the American Cancer Society. Thanks to Pap smears, the incidence has diminished over the years.At one time, there was a 50% mortality rate. By far, many more pre-cancers are diagnosed than invasive cancers. Besides the HPV virus, other risk factors include smoking, immunosuppression (HIV, transplant patients, and those on drugs to treat cancer, autoimmune disease), recurrent chlamydia infections (sexually transmitted), a diet low in fruits and vegetables, long term use of contraceptives, having had 3 or more pregnancies, being younger than 17 with first pregnancy, being overweight, or a family history of cervical cancer. From infection to cancer:

12) Staging of cervical cancers are based on extent of the cancer, involvement of lymph nodes, and metastases as all cancers are classified.

  If caught in an early stage, as many as 93% live at least 5 years or longer. At an advanced stage, only 15% live that long.

  13) Treatment includes a complete hysterectomy (uterus and ovaries) for early cases, and if more advanced, a more radical surgery is recommended (removal of lymph nodes and surrounding pelvic tissue with chemo (cisplatin, 5-FU, Taxol, or Gemzar) and radiation in selected cases.

Newer targeted therapies (Avastin) are also being used.

  For a more extensive discussion, click on the American Cancer Society’ website:  www.cancer.org

Then search for cervical cancer guidance.

 For details on vaginal or vulvar cancer, please go to the ACS’ website as well.

 

I. HPV positive Oral and Oropharyngeal Cancer

    I co-authored a journal article on guidelines for the care of cancer survivors, who have completed head and neck cancer treatment (Ca-Cancer Journal, May, 2016). As a head and neck surgeon, this is the type of cancers I specialized in during my 30 years of practice.

 

 

  Anatomy of the Head and Neck

Slide A shows a metastasis in the left neck (note lump); Slide B shows a cancer in the base of the tongue in front of and to the right of the epiglottis (flap-like tissue); Slide C shows the mass in the tongue and neck (red spots).

1)600,000 cases of head and neck cancers occur annually worldwide and 300,000 deaths occur. Type 16 is the most prevalent strain of HPV virus to be associated with some of these head and neck cancers (oral and throat).  As many as 5,000 cases occur each year in the U.S., and over 70% are linked to the HPV virus (human papilloma virus). Tobacco and alcohol were traditionally thought to be the cause of throat cancers, but now should be considered co-factors. Sexual contact is implicated as the route for transmission.

2) Exciting research

Recent studies from France have reported a gene variant that makes these patients less likely to contract oral or oropharyngeal cancer with a positive HPV cancer. Genetic loci linked to oropharyngeal cancer are limited to the HLA (human leukocyte antigen) region. This gene is known to be associated with immune regulation. A certain allele on the gene appears to provide resistance in developing these cancers. It apparently interferes with the prolongation of an HPV infection, thus reducing the risk of developing a HPV cancer. This is hard to follow, but if there is a protective gene variant, vaccines could include these specific gene variants. This discovery could be very valuable in the future in all HPV associated cancers.  Ref. Nature Genetics, October 17, 2016.

3) Although it is not known why HPV oral and throat cancers are much easier to treat, the statistics are clear. There is a 5 year survival rate of 85% of HPV-positive cancers compared to HPV-negative cancers (60%).

  Because the HPV positive cancers are easier to treat, clinical trials are under way using less aggressive therapy (less chemo and lower doses of radiation). 

 4) Even though the numbers of head and neck cancer make up just 3-4% (over 50,000 cases) of all cancers in the U.S., it is a devastating cancer to contend with and the treatments cause serious side effects, many of which are long term or permanent. Interference with speech, swallowing, dry mouth, serious dental complications, and cosmetic deformities are but a short list of challenges facing these patients and their doctors.

 5) Symptoms include areas that ulcerate, bleed, swell, and cause swallowing and speech difficulty, pain, hoarseness, and airway obstruction to name a few. If any of these symptoms persist, it is advisable to see your doctor.

 6) Treatment

As in all cancers, the earlier the cancer is diagnosed the better chance of a cure and perhaps less invasive treatment. Staging as in all cancers is critical to follow the guidelines for therapy. Early cancers may be surgically removed with or without further therapy (chemo or radiation). Even trans-oral robotic surgery is used in these tumors.  More advanced tumors can be reduced in size with chemo and or radiation, which may allow for surgical resection. Reconstruction has become very sophisticated and improved quality of life. This includes pedicle skin flaps and free flaps.     

  Newer techniques in radiation therapy (IMRT-intensity modulated radiation therapy) over the past decade or so have helped decrease side effects. Proton therapy is being tested (rather than ionizing radiation) to find out if it is better tolerated. Currently, chemotherapy is used in addition to radiation, which increases side effects. 

Protontherapy the newest technique used in the head and neck area, however, is triple the cost. We still need head to head comparison research between proton and IMRT before it will be recommended by the national cancer organizations.

Esophageal cancers have now been identified as HPV positive, and they have distinct genomic mutations, which will help in selecting targeted or immunologic drugs in the future. This is brand new information, as we find more and more cancers that are HPV positive. Reference- J. Medical Genetics

 

2. Botox injections—the amazing number of diseases that it helps

You are not going to believe the number of diseases that this toxin can help!

Botulinum toxin (Clostridium botulinum) causes serious food poisoning and paralysis (botulism). It is a very potent neurotoxin, and in refined preparations properly administered can help almost any disease that causes over-excitement of nerves. Even normal nerves can be temporarily weakened or paralyzed for a period of 2-4 months. Everyone is aware of its use in facial wrinkles (1.6 million Americans last year), but that is only the beginning.

When I was in practice, I first became aware of this treatment for spasm of the eyelids (blepharospasm), and in the 1990s, it was introduced for frown lines particularly in the forehead and wrinkles on the outside of the eyes. It was finally FDA approved in 2002 for wrinkles.

  As a result of radiation to my neck for throat cancer, over the years I began having involuntary spasms of my neck muscles as damaged nerves regrew with abnormal firing of these nerves (torticollis-a form of cervical dystonia). I asked my partner to inject my neck muscles (platysma) with Botox to relieve the spasms, and it worked quite well, and as expected after a few months, I had to have repeat injections. Eventually, I asked him tosurgically cut these nerves and that fixed the problem.

1)How does Botox work?

  Since Botox can block nerve impulses in any muscle, it became apparent that any spasm oriented disease could possibly be helped with Botox.

Botox blocks acetylcholine at the neuromuscular junction (the chemical necessary for transmission of impulses to create a muscle contraction). At the correct dose, muscles can be relaxed or even temporarily paralyzed.

The drawing (above) demonstrates the junction (inset) of the nerve as it connects with the muscle cell. Acetylcholine completes the circuit!

2) Cosmetic use of Botox

    

Every 3-4 months, these areas of concern can be reinjected. It is critical to seek treatment from a board certified plastic surgeon, ophthalmologist, facial plastic surgeon, or dermatologist. There are many doctors who have taken advantage of this office procedure. Even laymen have gotten hold of inferior forms of Botox and stage “Botox parties”.

Be sure you don’t get sucked into someone (even doctors) who is not adequately trained. Improperly injected, it can cause paralysis of the eyelid(s), face, or even generalized weakness should the drug accidentally be injected into a blood vessel. Injection site redness is not uncommon, but the area can become infected. Expert injections are necessary to get uniformsymmetrical  results.

  Deep wrinkles on the outside of the lids (squint wrinkles) may need Botox plus fillers or laser removal to get the best results. 

As the use of Botox expanded, it became clear that blocking the sensory nerves between the eyebrows could relieve migraine headaches in some. It has been used in pain management widely for pinched nerves from spine disease, and many other causes of chronic pain. The list of diseases continues to expand. Insurance covers some of these medical issues. Prior approval is recommended.

  Over time, Botox started being used for spasms everywhere, from bladder spasms to leg spasms in patients with neurological diseases such as multiple sclerosis, diabetes, Parkinson’s disease, etc., and nerve pain.

3) Products used

  There are 4 formulations approved for treatment of various abnormalities (3 types of the A formulations-Dysport, Xeomin, and Botox; and 1 type B formulation-Myobloc.

Botox is also valuable for those suffering from excessive sweating (hyperhidrosis) by injecting Botox into the sweat glands in the armpits. 

4) The four most common medical conditions treated with Botox

  They are cervical dystonia (neck spasms), blepharospasm (spasms of the eyelids), leg spasticity, and headache(tension and vascular). However, there are other numerous conditions approved by the FDA including:

Strabismus-cross-eyes, achalasia (spasm of the esophagus), bruxism (severe clenching of the teeth at night), conditions causing pain in the skin from pinched nerves or abnormal nerve conditions (neuropathy), bladder spasms, vaginismus (painful contractions of the vagina), movement disorders following stroke, cerebral palsy, vocal spasms causing abnormal staccato speech (spasmodic dysphonia), and anal fissures (relieves the spasm in the rectal sphincter allowing healing and passage of stool).

  The list continues to grow. Even though in inexperienced hands, complications can occur, they are rare and not permanent, since the Botox wears off.

  I will continue to report on the latest in cosmetic procedures in the coming months.

 

3. An update on gastrointestinal bacteria and how it influences our health; fecal transplants; update on probiotics

A. Bacteria and health

Research has proven the amazing benefit of bacteria that lives in our gastrointestinal tract. It is now known that it is responsible for a large part of our immune system. It can create harmony in the body if certain bacteria are present in a certain percentages. This is called the normal flora from our mouth to the other end.

B. When bacteria create disease

When different bacteria are present or are in different proportions in our system, certain gastrointestinal diseases occur (Crohn’s, Celiac, lactose intolerance, ulcerative colitis, IBS-irritable bowel syndrome).

There is evidence in animal models that certain bacteria may influence diseases such as Parkinson’s disease.  These diseases can actually be controlled with implants of certain bacteria called fecal transplants, which can be inserted in the gut or taken in pill form. Taking probiotics has not helped these patients.

C.Do probiotics help normal healthy people?

For the normal healthy person, the results are still out whether probiotics are of value, however, taking them while on antibiotics, for instance, is frequently recommended without actual scientific evidence that it helps.

Trying to find the right probiotic bacterial balance, best commercial product, dosage is still being studied. The best preparations contain 5 different types of bacteria. Remember, these bacteria cannot be dead if they are going to benefit.

Taking probiotics to prevent oral fungal infections (thrush from candida) and vaginal yeast infections when taking antibiotics was something I recommended when I was in practice, but it was off-label as far as the FDA was concerned, and I am not recommending it without your doctor’s consent. (“off-label” means a specific drug or supplement is not FDA approved for these specific problems). There is further discussion of probiotics to come in this report.

D. Hospital Acquired infection-Clostridium difficile

1) When strong antibiotics are used in or out of the hospital, or used for a prolonged time, the bacterial flora in the gut is killed or at least altered, so that certain “opportunistic” pathogenic bacteria take over in the gut and cause watery diarrhea, fever, nausea, abdominal pain, and even death in the chronically ill. These are symptoms of acute pseudomembranous colitis.

2)The most common hospital acquired gut infection is caused by Clostridium difficile.Many peoplehave C. diff in their guts normally, but when the balance of bacteria changes in the bowel, bacteria like this one can cause colitis. 

  3) The C. diff genome with the typical helical form of its DNA

4) Transmission of C. diff

This infection is commonly transmitted from patient to patient in the hospital unfortunately by the hospital staff, in equipment, bed linen, by unwashed hands of doctors, nurses, cleaning crews, and visitors. One study reported that 38% of these infections occurred from in-hospital transmission.

   5) Prevention

Prevention is the key to keeping these infections to a minimum. Hospital infection committees are constantly working on improving the cleanliness of the hospital, but everyone coming and going to see patients must be extremely mindful of potential transmission of these infections. Hand washing is the key way to prevent this infection.

    6) Risk factors for C. diff infections

Those at higher risk are those having gastrointestinal surgery, the chronically ill (cancer, kidney, etc.), in nursing homes, those with weak immune systems, those on PPIs (proton pump inhibitors to reduce acid) for reflux and gastric problems, older patients (>65), and those taking antibiotics especially if used for a prolonged time.

    7) U.S. Healthcare cost of hospital acquired infections

$4.8 billion dollars in healthcare cost are incurred each year from 500,000 acquired infections (and 29,000 deaths) as reported by the CDC, who have announced this is a national priority.

8) Curbing the unnecessary use of third and fourth generation antibiotics is another way to prevent these infections. These antibiotics include cephalosporins, vancomycin, tigecycline, linezolid, imipenem, meropenem, and fluoroquinolones. Avoiding these antibiotics has decreased hospital C.diff infections by 27% in a recent study.

9) Treatment of C. diff infections

    a- Stopping antibiotics will reduce symptoms in about 25% of patients in 2-3 days. If that does not work, specific treatment is necessary.

   b- Antibiotics for a full 14 days ofmetronidazole (Flagyl)usually tried initially. In about 25-35% of patients another round of treatment is necessary or an alternate antibiotic is necessary such as vancomycin or fidaxomicin.

   c- Probiotics and maximum hydration are also recommended. There is a recent study that taking probiotics may help prevent inflammation of the small intestine (radiation enteropathy) when radiation and 5-FU is used for a gastrointestinal cancer. Talk to your doctor about their use during any chemotherapy agent and any treatment to the gut. More information about the radio-protective capability of providing good bacteria to the gut is forthcoming.

For information on probiotics please click on:

www.themedicalnewsreport.com #9, #19

    d- Alternative therapies such as fecal transplants are showing great promise. Predicting who will respond to treatment and who is likely to recur has been found to be linked with the makeup of gut bacteria prior to treatment.

    e- If certain gut bacteria are low in numbers or absent, it may require more aggressive treatment. Recurrence is common (60%).

      f- Future treatments

Targeting toxins produced by C. diff is being investigated to avoid antibiotics to treat this infection. Newer antibiotics, further ability to use fecal transplants more effectively, and reduction of overuse of antibiotics all will take us in the right direction for the future.

E. How can diet influence our gut bacteria?

  What does the normal person do to protect themselves from gut infections? Except for the high risk patient, a normal diet rich in fermented foods is advisable. Typically foods (alcohols and sugars) use yeast for the fermentation process for digestion, although there are some foods that use lactobacillus bacteria to ferment foods. Those foods include sauerkraut,yogurt, sourdough breads, soybean paste, cocoa products, cod liver oil, sour cream, fermented tofu, cultured dairy products (i.e. kefir), certain fish sauces (Garum), miso, Korean soy sauce, Tabasco sauce, and Worcestershire sauce. For a complete list click on:

https://en.wikipedia.org/wiki/List_of_fermented_foods

F. The other gut bacteria causing disease--Helicobacter pylori(H.pylori) causes peptic ulcers

1)This bacterium is the cause of peptic ulcers(stomach and duodenum), and can lead to stomach cancer. It was once thought that stomach ulcers were caused by stress and eating spicy foods.

2) The ulcer is diagnosed with bariumupper gastrointestinal X-raysand or a gastroscopy (looking directly into the stomach with an endoscope).

3)Two thirds of the world have this bacteria in their stomachs, however, most do not cause ulcers or sickness.

4) The bacterium causes damage to the lining of the stomach, which allows stomach acid to create ulceration. Heartburn or an “aching feeling” is the most common symptom, although bloating and burping can occur. Ulcers can bleed and cause dark tarry stools and even acute bleeding (vomiting and or diarrhea) requiring hospitalization. Anemia can be present.

5) Diagnosing H. pylori

Tests for H.pylori can be performed with a blood (antibody) test, a breath test (urea), a stool antigen test, or a biopsy of the stomach lining. This testing is usually recommended only for those with an ulcer.

6)Guidelines for treatment of H.pylori

There has been a recent update for management of H.pylori due to increasing antibiotic resistance.

a--The initial treatment is clarithromycin (Biaxin), metronidazole (Flagyl), amoxicillin, or tetracycline for 2 weeks.

      b-- Choice of antibiotic should be based on local antibiotic resistance.

      c-- Bismuth subsalicylate tablets or liquid (Kaopectate, PeptoBismol).

       d-- PPI inhibitor (Dexilant, Nexium, Prilosec, or Prevacid); the use of PPIs should be only in areas of the country that do not have high clarithromycin resistance (higher than 15%) and the success of treatment that is greater than 85%.

       e-- The antibiotic, Floxin, should be used only as a salvage therapy if other antibiotics fail.

f-- The routine use of probiotics to reduce adverse events is not recommended.

     7) Risk factors that increase the likelihood of H.pylori peptic ulcer disease

  NSAIDs such as aspirin, ibuprofen, Aleve, etc. can cause ulcers and will aggravate any ulcer or gastritis. Smoking and eating spicy foods can also aggravate this condition.

  It is very difficult to prevent this bacterium, however, drinking clean water, washing one’s hands before eating, and avoiding raw or undercooked food may help.

Reference-NEJM, 2016

  For those of you expecting me to discuss MRSA infections (Methicillin resistant Staphylococcal aureus), this is an acquired infection frequently in the hospital but not a gut bacteria origin. I will discuss this infection in the future.

Reference –CDC, Mayo Clinic, Medline

G. Link between gut microbes and response of immunotherapy to treat cancer

There is a link between the body’s immune system and how it responds to cancer. Recently studies have shown a more successful response to certain immunotherapeutic agents (biologic agents-immune checkpoint inhibitors) with certain specific gut bacteria especially in those who have a very diverse gut microflora. It is known fact that a large portion of our immune system is influenced by these bacteria. As we explore this as a possible preparation before immunotherapy or chemotherapy and predict responses, we may be able to improve responses to treatment in the future.   

H. Fecal Transplants and treating disease

  The strongest evidence to date that fecal transplants are effective is in the treatment of diarrhea caused by Clostridium difficile,. It is 90% effective in current clinical trials. It is also being used for inflammatory bowel disease and other functional gastrointestinal diseases (irritable bowel syndrome). Actually this form of treatment was first described in the 4th century in China for severe diarrhea. It has been used as a retention enema and other routes. It is known that there are different types of bacteria in the gut of these types of patients, and it is the goal of this therapy to restore a more normal bacterial flora in the intestines.

  Although still experimental, there is great hope that this will become a viable treatment for bowel diseases where there is an alteration in bowel bacterial flora.

  The future of fecal microbiota transplantation looks bright. The safety is compelling and it is only a matter of time that this will be perhaps widely used as a very successful medical treatment. After all, it is nothing more than glorified probiotics.  BMJ-Gastroenterolgy-2016 

 

4. Genitourinary Series-Part 4—Kidney and Bladder Stones

A. Introduction

Stones (nephrolithiasis) that occur in the urinary system are very common. There are many people who pass stones and never know they do. But for those who have symptomatic stones especially in the ureter, know how painful they can be. This size of stone can frequently pass out through the system. If the stone is less than 5mm, there is a 90% chance a person will pass this stone; if between 5-10mm in size, there is a 50% chance. Above 10 mm, these stones will likely require removal.

Stones need to be analyzed for chemical content which may point to certain underlying issues. 85% of stones contain calcium (oxalate or phosphate). Analysis of certain chemicals in the urine will also give clues to increased risk as well. Excess calcium, uric acid, citrate, and magnesium increase the risk of developing stones.

    

B. Anatomy and Pathophysiology of the kidney

  The ureters connect the kidney with the bladder and transfer urine into the bladder. These tubes have smooth muscle in the lining, and therefore have the capability of “milking” substances that traverse the ureter.

In the drawing below (left) and the IVP (intravenous pyelogram-a dye X-ray) demonstrate the anatomy.

The IVP above demonstrates dilation of the system from apparent stones blocking the opening of ureter to the bladder. This has dilated the pelvis of the kidney (the drainage portion of the kidney which connects to the ureter) and the ureters. In this case, these stones are large enough that they will not pass and must be removed.

Various tests can be performed to demonstrate abnormalities of the urinary system. CT scan, MRI, IVP, and even X-rays of the abdomen (KUB) can demonstrate stones.

  Most stones are opaque (show up on X-rays) because the stones contain calcium. Anatomy of the kidney below demonstrates how the blood flow comes into the kidney and filters through the renal pyramid exchanging chemicals such as urea, sodium, and potassium into the system. The fluid flows out into the pelvis through an intricate tubular system. 

The kidney performs multiple services including filtering byproducts metabolized by the liver from the blood through the kidneys. 

 Stones tend to form in the pelvis of the kidneyand can be too large to pass into the ureter as demonstrated on aCT scan with contrast (below right). The drawing left demonstrates where stones tend to lodge. If smaller, they will pass into the ureter and can get “stuck”in the ureter at any pointbecause of size or spasm in the wall of the ureter.  Bladder stones can also occur, but usually form in the bladder itself.

    

If a stone stays lodged for some time or a stricture (narrowing) occurs in the ureter from a stone injuring the ureter, the kidney can dilate (hydronephrosis) and can cause permanent damage and failure of that kidney’s function. The IVP I showed above had hydronephrosis.

Hydronephrosis can occur from pressure from a pregnancy, tumor, or other abnormalities. Below is a drawing of this abnormality.

    

C. Symptoms of urinary stone(s)

If a stone is caught in the ureter, spasm can occur causing intense sharp shooting or aching pain in the flank, abdomen, or lower back. This pain can be intense and sudden.

Also frequency of urination, appearance of blood in the urine, pain on urination, and nausea/vomiting can occur. Fever and chills implies an infection.

D. Causes of stones (nephrolithisasis)

Stones are made up of salts and minerals. The majority of stones contain calcium oxalate and phosphate (85%), uric acid (10%), struvite (usually from infections), and cystine (an amino acid elevated in patients with cystinuria) make up the majority of these crystalline stones. The pH(acidity) and chemical composition of the urine influence what type of stone forms, and the kidneys regulate the level of these salts and minerals that can occur in the urine.

E. Risk factors affecting the formation of stones

  They include hydration status, a family history of stones, genetics, and certain underlying medical conditions. Patients with elevated blood calcium including those who take calcium supplements, metabolic diseases, certain renal diseases, hypervitaminosis D, hyperparathyroidism, and prolonged inactivity all increase the risk of stones.Patients that have uric acid stones must be worked up for gout.

F. Incidence

  5.2% of the population has kidney stones, which has increased over the past few decades for unknown reasons. Stones are more common in whites and males. Men experience stones between ages 40-70 and women in their 50s. Men are more likely to form bladder stones. A person who has had one episode of stones is more likely to have another.

G. Bladder Stones

  If the bladder is not completely emptied, this will predispose to the development of bladder stones. Repeat infections, prostate enlargement, or any problem that keeps the bladder from completely emptying (weakness of the pelvic floor-prolapse, paresis, or paralysis).

  These stones may not cause symptoms, but can cause discomfort in the lower abdomen or into the genitals, blood in the urine, or frequency of urination.

  Cystoscopy (rigid scope or flexible) can easily be performed to inspect the bladder for abnormalities including stones.

    

H.Treatment

  1. Medical

Alpha blockers (that treat hypertension and prostatic enlargement) can help pass stones twice as likely (49%) than control groups as reported in a recent study by the British Medical Journal. The authors suggested that patients with pain from ureteral stones (<5mm) should be prescribed an alpha blocker to see if they can pass their stones before resorting to more aggressive treatment.

  Those with uric acid stones (10% of stones) can potentially have these stones dissolved with medicines that turn the urine alkaline (pH 6.5-7.0) such as potassium citrate and sodium bicarbonate. Placing patients with hyperuricemia on anti-gout medicine will block the production of uric acid and prevent these stones and treat the arthritis. For more information on gout, click on:

www.themedicalnewsreport.com #5

 

   2. Shock wave dissolution (lithotripsy)

Stones less than 2cm (0.787 inches) are best suited for lithotripsy. Pregnant women, those with kidney infections, bleeding disorders, and other abnormalities are not candidates. Some form of anesthesia will be necessary since the procedure will be painful. It can be performed as an outpatient or as an inpatient.

The machine produces shock waves that can disintegrate stones, as seen above, preventing the need for surgical intervention. Some type of anesthesia is necessary, and a day or two in the hospital is usually planned. Extra hydration is necessary to flush the shattered stone(s) out of the system. However, if unsuccessful, additional treatments will be necessary.

  Many are placed in a water bath to absorb some of the shock.Patients are up and about in a short time and can resume normal activity in a few days.

  Success in 75% of patients is expected.

  3. Ureteroscopy and basket removal or with forceps

  A special endoscope is introduced through the genitals into the urethra into the bladder. The tiny scope is then introduced up into the ureter to remove the stone(s). Stents (small tubes) may also be necessary to relieve obstruction from strictures and injury to the ureter. A basket or forceps is used to remove the stones as seen below.

    

    

A nephrolithotomy requires a small incison (nephrostomy) in the flank exposing the inside of the kidney and the stone is removed with an endoscope.

An open procedure may be necessary for larger stones.

 I. Prevention

  Hydration is essential to prevent stones (8-10 glasses of water/24 hours). Diet includes a low sodium, low fat, low red meat, and high fiber diet.

High doses of Vitamin C, berries, green vegetables, beets, and squash and tomatoes can increase calcium oxalate stones.

References-WebMD, medicinenet.com

 

5. Yoga vs.Physical Therapy for Chronic Back Pain

There is good research evidence that yoga properly performed can relieve chronic back pain and reduce the need for medication. As a huge advocate, I can personally verify this statement that carefully performed yoga can strengthen the core, which is the key to relieving back pain. It is mandatory to strengthen the abs to have any chance of strengthening the back.

  At the annual meeting of Academy of Pain Management, 2016, Dr. Robert B. Saper presented findings to verify similar results from these two modalities. The key is supervision of any stretching and strengthening exercises. It can be very intimidating to go into a class of people much more advanced in yoga positions. Just as a physical therapist would start slow with someone with chronic pain, so should anyone doing yoga.

  The yoga classes were weekly 75 minutes with close supervision. This was compared to a weekly 60 minute session with a physical therapist. Each type of therapy continued for 12 weeks. Certain basic poses and exercises were recommended at home. 50% of the patients were clinically improved at least 30% and dropped their intake of medication from 50% to 20%.

  You should discuss this with your doctor and consider starting with physical therapy (Medicare only pays for 12 sessions per year), and once you are improving discuss adding yoga as a life-long regimen. Once you get the hang of it, you will certainly enjoy it.

Reference Medscape-Neurology, Sept, 2016

Cat-Cowl

 

Downward Facing Dog

 

Pigeon Pose

 

Bridge Pose

 

Supine Twist

 

I have had cervical,thoracic, and lumbar back surgeries, and yoga has relieved my chronic back pain. To stabilize the back and prevent injury, core strength is the key (balancing the strength of the abdominals and back muscles) along with proper stretching poses combined with the isometric value of holding these poses. Abdominal exercises will strengthen the core such as these two poses:

Plank pose

Low boat pose

If you want to see a separate video of each pose (over 50 poses) log on to www.yoga.com/poses

This completes another report and bringing in the new year as well. We are hopeful 2017 will be the beginning of a new era in American exceptionalism. God bless our country.

The subjects for February, 2017:

1. Human Abuse Series-Part 1-Bullying

2. Body image issues-body dysmorphia

3. Immunotherapy—the latest treatment for cancer

4. Palliative care and hospice care

5. A profile of today’s physician

6. Congestive heart failure