The Medical News Report #64
Samuel J LaMonte, MD, FACS
Subjects for May, 2017:
Supplements; The Best Fish to Eat (and worse)
Coffee vs Tea and cardiovascular health; caffeine vs decaf;e-cigarettes; new guidelines for prostate cancer screening
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
Subjects for May, 2017:
I have had 2 friends, and a grandmother succumb to MM, and 2 friends are fighting it currently. I dedicate this report to them.
I. General information
This is a malignancy of the white blood cell called a plasma cell with no known cause. Plasma cells are normally part of the immune system. They create a spectrum of diseases that produce abnormal proteins in the blood that cause organ abnormalities including malignancy. These proteins are called immunoglobulins.
2. Understanding how the immune system can turn against us
Lymphocytes (type A and B) are the main blood cells that flow throughout our body and produce immunoglobulins to fight infection. They are found in the blood stream, bone marrow, and lymph nodes. Plasma cells, one type of white blood cell, derived from certain types of lymphocytes (B-cells), are found primarily in the bone marrow and produce large amounts of antibodies (immunoglobulins such as IgA, IgG, etc.). These cells normally, when exposed to antigens, stimulate antibodies.
When the plasma cells become malignant, the immunoglobulins produced overwhelm the system as does the plasma cells in the bone marrow as shown in this drawing.
When plasma cells become aggressive and overgrow in the bone marrow, they crowd out the other normal cells, including red blood cells, white cells, and platelets. The result leads to anemia, increased infections, and bleeding.
3. The Spectrum of plasma cell diseases
Not all abnormalities of the plasma cell cause cancer. There is a spectrum of abnormalities caused by plasma cells that can occur including Waldenstrom’s macroglobulinemia, plasma cell solid tumors (plasmacytoma), and plasma cell leukemia. By far the most common disease caused by plasma cells is multiple myeloma.
Myeloma cells also affect bone strength by signaling a a type of bone cell that is responsible for dissolving bone which releases calcium (osteoclasts)speeding up the resorption of bone, which can lead to fractures and elevated blood calcium levels.
MM secretes abnormal proteins that are injurious to the kidneys (Bence-Jones protein) and can be found in the urine in abnormally high rates, which can be detected.
Myeloma cells usually secrete a specific type of protein (globulins) in the blood, and on a test called electrophoresis, it will show a spike in that protein (monoclonal gammopathy). This abnormality can also occur in Waldenstrom’s macrogloulinemia, and other gammopathies that are not MM. However, these patients need to be monitored closely for the eventual development of MM. Myeloma cells can also form chains of proteins called amyloid (the substance that is also found in Alzheimer dementia).
An isolated tumor made up of plasma cells (plasmacytoma) can also occur anywhere in the body and is usually treated with radiation therapy. These patients will also have to be monitored for the development of MM.
4. Incidence and risk factors for developing MM
MM accounts for 13% of all blood cancers causing 20% of the deaths caused by blood cancers. MM accounts for 1% of all cancers.
Over 30,000 Americans develop MM each year and over 6,000 die of their disease, usually from a superimposed infection or kidney failure.
Patients are usually 65 years of age, men are slightly more likely to develop MM, and it is twice as common in blacks. People who have had radiation are slightly more likely to develop MM. Although most patients do not have relatives with MM, if a family member (parent or sibling) has had the disease, it raises the risk 4 fold. There has been no relationship to workplace hazards, but it is higher in obese patients.
II. Diagnosing MM
1. Presenting symptoms
Patients are rarely diagnosed in the early stages of this disease, however, occasionally a routine lab tests will raise suspicion.
Although many patients do not have significant symptoms, bone pain (back, hips, and skull), pathologic fractures(one third of the patients), and what might appear to be osteoporosis (but are actually lesions in the bone) are the most common symptoms when they do occur. Collapse of vertebrae can cause neurologic symptoms with spinal cord compression (pain, weakness of the extremities, and numbness). Anemia causes paleness and fatigue, infections (frequently pneumococcal), symptoms of thicker blood, (hyperviscosity), and hypercalcemia (will be described below). Neuropathies can occur from nerve invasion or compression causing pain and or numbness.
2.Blood and urine tests
The blood count may show anemia (low red cell count), a low white blood cell count, and a low platelet count.
As mentioned above, an elevated calcium level in the blood may occur, which could cause kidney stones, thirst, excessive urination, kidney damage, dehydration, belly pain, and even severe constipation. These symptoms are very vague. In fact they sound more like diabetes.
In some patients, if there is secretion of large amounts of protein, it can lead to the hyperviscosity syndrome, and if the blood thickens enough, it can cause confusion, weakness, and symptoms mimicking a stroke.
Kidney damage is caused by excessive blood proteins trying to filter through the kidneys creating renal failure (elevated creatinine, and BUN).
Infections especially pneumococcal pneumonia can occur and are difficult to treat because the patient’s white count is decreased preventing a good defense against the infection.
Patients who develop amyloid deposits have all the symptoms of the organ that is attacked (heart, liver, spleen, tongue, and skin.
The C-reactive protein test may be elevated, which is an indication of inflammation in the body but not specific to MM.
Electrophoresis is performed to check the immunoglobulins, and in MMclassically shows an elevation of one of the immunoglobulins (monoclonal gammopathy). Note the spike in a specific gamma globulin.
The urine can show excessive protein (Bence-Jones protein) with the collection and analysis of a 24 hour specimen.
3.Bone marrow biopsy
A large bore needle is introduced into the marrow space in pelvic bone (iliac crest) and the contents are aspirated for examination. It is diagnostic for MM if the bone marrow contains as much as 60% plasma cells of the all the cells present.More recently stem cells are being taken from the peripheral blood in a special procedure.
4.Flow cytometry of bone marrow aspirate
Another immunochemical test helps determine if myeloma cells are present in the bone marrow.
5. Genetic tests
The DNA of these myeloma cells can help determine if there are any abnormalities in chromosomes to define the phenotype of the MM. If there is a genetic alteration, this indicates a high risk patient.
6.Biopsy looking for amyloid
A skin biopsy can be of value in some patients, or if a mass is present anywhere in the body, it can be biopsied as seen in this biopsy (above) of a lesion in the esophagus. Even a needle aspiration of cells in a lymph node is helpful.
7. Imaging studies
myeloma in femur
punched out lesion
X-rays, bone scans, and MRI also are extremely valuable in assessing lesions in the bones. PET scans are useful.
Note the lucent area at the top of the skull (arrow). This is a “punched out” classic lesion from myeloma.
Since amyloid often affects the heart, testing the function of the heart looking for abnormalities may increase the suspicion for MM because of deposits of amyloid in the heart muscle.
III. Smoldering MM—to treat or not to treat?
There is a well- known phase of MM that is asymptomatic but is picked up incidentally with blood tests, etc. Smoldering MM is defined with any of these abnormalities:
a) Plasma cell count in the bone marrow of 10-60% of all cells present
b) High levels of one of the immunoglobulins (monoclonal gammopathy)
c) The presence of Bence-Jones light chain proteins in the urine analysis
These patients have a normal blood count, normal calcium levels, and no evidence of amyloidosis. There is great debate when these patients should be started on treatment. Some recent studies report better control with early intervention.
If amyloidosis is found, this may the first indication of MM, however, by itself is not diagnostic of MM.
IV. Active multiple myeloma
Staging of disease
Staging how advanced the disease has gone at the time of diagnosis (as in all cancers) allows guidance for treatment and an analysis of prognosis for the future. Treatment is complex and with advances in research, it is changing rapidly. The overall 5 year survival rate is 46.6%.
There are 2 staging systems, and the newer system is much simpler based solely on the beta-2-globulin and albumin levels (International Staging System) in the blood and urine, which implies how active the myeloma cells are producing protein.
The more established system (Durie-Salmon System) is based on a) the amount of beta-2-globulin in the blood and urine, b) the calcium levels in the blood, c) the amount of bone damage from the myeloma, and d) the blood count (degree of anemia).
In addition to staging for prognosis, other factors that are taken into consideration include kidney function, age, how fast the myeloma cells are growing (myeloma cell labeling index), and certain chromosomal abnormalities (genetic changes).
Chemotherapy and other classes of medications are combined to provide the best control of MM. The choice may change as side effects occur which would require adjustments in treatment.
With recent advances in medication and bone marrow (stem cell) transplants, the survival has risen from 2-3 years to over 8 years. However recurrence is very common requiring maintenance therapy post-treatment and post-transplant.
1. Chemotherapyincludes using one or more of the following medications:
The timing and length of treatment is a complex management issue requiring very experienced oncologists. When one drug fails to prevent progression, reduce the abnormal proteins, or decrease the percentage of plasma cells in the bone marrow, etc., this requires switching chemo agents and or any of the medications listed below.Melphalan is the usual starting place.
2. Corticosteroidsare frequently used in addition to chemo and immunotherapy.
3. Immunotherapy-- thalidomide (Thalomid), lenalidomide (Revlimid), and pomalidomide (Pomalyst). Thalidomide has proven very effective in treating MM, however, long term use creates considerable neuropathies. This has led to greater use of Revlimid in combination with Velcade.
4. Proteasome inhibitors—these medications block enzymatic action of myeloma cells that keep them under control—bortezomib (Velcade), carfilzomib (Kyprolis), and ixazomib (Ninlaro).
5. Bone marrow transplantation stem cell therapy)
Candidates for autologous (patient’s own marrow) bone marrow transplantation are those under 65 years of age, in good condition, without major ongoing complications from MM or therapy. This is stem cell therapy extensively discussed last month in my April report.
With the immunotherapeutic agents now available for treatment (Thalidomide and Revlimid), with the addition of aproteasome inhibitor (Velcade,etc.), these are the go-to drugs preparing someone for transplantation.
Procedure--High dose chemotherapy and even whole body radiation may be necessary to kill most of the myeloma cells before infusing stem cell transplant cells. Even though the stem cells may be retrieved from the bone marrow, more recently they are obtained from the blood. They are stored for several months before being given tothe patient and may require 2 transplants 6 months apart. There are several trials using allogeneic transplants (from others), but still investigational.
Patients who have MM are more prone to other cancers including certain types of leukemia and myelodysplastic syndrome.
Once the patient is in some kind of remission, maintenance therapy is needed.
The mortality rate in these transplant patients is 20-30% at 5 years post-transplant, and if they develop host-vs-graft disease 50-70%. These patients are facing a median survival of 8-10 years, since there is no cure for this cancer. But there is great hope for the future as the survival has certainly increased with all the advances in cancer research.
A. Alert for heart patients
Almost 60,000 cases of vitamin toxicity are reported annually by poison centers. 1 in 5 Americans admit to using herbal medications at one time in their lives. Interactions with certain prescription medication continue to be a major concern especially for heart patients. One article in the Journal of the American College of Cardiology, 2017, cited green tea, hawthorn, ginseng, gingko biloba, and garlic interacting with certain heart medications. In addition, other herbals that may interact include cranberry, European elder, goldenseal, licorice root, St. John’s wort, and salvia militiorrhiza. Many doctors are not aware of these herbs or their interactions, so ask them to research them for you if you want to take them and are on heart medication, anti-hypertensives, or diuretics. Certainly, discuss the wisdom of taking these.
B. Some common herbs, vitamins, and dietary supplements
a) Garlic can cause bleeding, therefore, it should be discontinued 7-10 days before major surgery. (Discuss with the surgeon!) Many take daily garlic pills or cloves for cardiovascular benefits, however, it is still unclear if it benefits that system.
b) Oncology patients should be warned that vitamins such as A,C, and E can interfere with anti-cancer medications. Vitamin B3 (niacin) may inhibit the synthesis of LDL cholesterol. Vitamin E can inhibit the absorption of Vitamin A and K. Vitamin K may inhibit the effectiveness of oral anticoagulants (blood thinners). Vitamin E can inhibit one of the steps in blood clotting, has been shown to increase the risk of prostate cancer in healthy men.
c) Vitamin B-12 is present in milk products, eggs, poultry, and meats. To absorb Vitamin B-12, an intrinsic factorsecreted by the stomach, is necessary to be present. Patients with gastrointestinal disorders may have a deficiency in that factor leading to a B-12 deficiency. Bariatric surgery patients may require B-12 supplements. B-12 deficiency causes pernicious anemia.
d) Folic acid can prevent spinal cord abnormalities in newborns if taken during pregnancy. It also can decrease homocysteine serum levels, which can increase coronary artery disease.
e) St. John’s Wort can interfere with certain drugs that protect transplants patients from rejection, certain anti-viral agents that treat HIV-AIDs, and can interfere with the absorption of certain statins (Lipitor). It is used to treat mild depression, however, it has not proven to be effective in moderate or severe cases.
f) Cinnamon has shown some effectiveness in lowering blood glucose, although the American Diabetes Association does not recommend it. There are significant studies under way to prove that Ginseng can reduce insulin resistance. Aspartame (artificial sugar substitute) can increase insulin resistance, and there is some evidence that it may be a risk factor in cancer.
g) Green tea may improve cardiovascular health by decreasing LDL-cholesterol, and increasing HDL-cholesterol. Decaf works too.
h) Almost half of cancer patients take multiple supplements without telling their oncologists. The potential interactions with certain chemotherapy and other cancer drugs demands these supplements be discussed with their oncologists. Unfortunately, only a quarter of oncologists bring up the issue, and many oncologists are not trained in the effects of supplements. As a caregiver or cancer survivor, please bring this subject up!
i) Tumeric is a commonly used supplement for its antioxidant, anti-inflammatory effect. There are clinical trials currently addressing its effect on chemotherapy. It is already known that it interferes with Cytoxin and Doxorubicin which are common chemotherapy drugs.
j) Dong quaiis a Chinese herb is used in the Orient for menopausal, menstruation cramps, and circulation issues. Since it has estrogen like properties, women with estrogen positive breast cancer should not take this herb.
k) Boswellia, an Indian herb is used in Aryuvedic medicine. It is used as an anti-inflammatory substance used in diarrhea, inflammation, and arthritis.
These Oriental and Indian herbs have not had controlled human studies to prove their value.
C. The best and worst fish to eat
One of the main concerns in eating fish is the mercury content. Pregnant women and children need to be especially careful in consuming more than 2 helpings of fish per week. The rest of us that eat fish frequently need to be aware of some risk. Consuming fish from the Far East is a little trickier and more dangerous. The grocery stores are filled with fish from China, Vietnam, Taiwan, and other countries. The growing conditions in these countries frequently can come from extremely contaminated waters. Veterinarians caution against treats from the Far East for our pets.
The EPA and FDA have created a chart on 62 varieties of fish and categorized them as “best, good, and avoid”. For pregnant women, no more than 8-12 ounces per week is recommended. Children should have much less depending on age and body weight.
The “best” fish for anyone from the U.S. waters to eat are shrimp, salmon, pollock, canned light tuna, catfish, tilapia, and cod.
The “good category” includes yellow fin tuna, Chilean seabass, and halibut.
The “avoid” category (at least for pregnant women and children) includes tilefish from the Gulf of Mexico, shark, swordfish, bigeye tuna, orange roughy, marlin, and king mackerel.
Fishermen catching local fish should be aware of the local information available and so should all of us.
Fish is an excellent source of protein, but all fish have some mercury in their tissues, which cannot be destroyed by cooking. Mercury is a heavy metal toxic to the brain in sufficient amounts. Fish, however, is low in fat, and many people consume fish several times a week. This report is not meant to discourage people from eating 8-12 ounces of “best or good” fish 2-3 times per week as part of a healthy diet.
Reference from FDA report January 17, 2017 www.fda.gov
A recent study by the University of North Carolina stated that because parents refuse to vaccinate their children as well as adults refusing vaccines, it cost $7.1 billion in healthcare costs in 2015. This is another unnecessary cost that the U.S. does not need with our current healthcare crisis.
This study included 14 different viruses including mumps, measles, chicken pox, hepatitis, HPV, tetanus, rubella, pneumococcal, and meningococcal diseases. The greatest cost arose from influenza (only 43% get the flu vaccine). Reference-- Health Affairs, Oct.12, 2016
Addressing the problem with the public—what works?
Coercion has been the traditional way of addressing the resistance issue. Compulsory public health laws have been passed including fines, exclusion from school, but almost every state offers liberal medical, religious and philosophical difference exemptions.
Since Michigan had one of the lowest vaccination rates in the nation, they tightened their exemption rules requiring families to consult personally with local public health departments before obtaining an immunization waiver. Waivers plunged 35% in one year. This prevented the state dealing with religious or philosophical objections. Only California, West Virginia, and Mississippi disallow non-medical waivers.Anti-vaccination groups and activist parents have taken advantage of these exemptions leading to outbreaks of unnecessary childhood diseases. There are major complications from these diseases including miscarriage, encephalitis, meningitis, orchitis (testicle), pneumonia, deafness, etc. However, some of these same diseases have been blamed on these vaccines. In fact, the number of studies could be stronger to put some of these issues to rest. The issue of autism has been studied in depth, and there is no direct connection to vaccines.
Vaccine refusal has reflected a diverse and complex array of beliefs and attitudes including mistrust of the medical profession. Christian Scientists have been a very vocal opponent.
California is just the third state to get stop non-medical (religious and personal objection) exemptions in 2015 and is considered the best way to address this national issue.
To maintain “herd” immunity there must be near universal vaccination. However, some physicians are reluctant to insist all their patients be vaccinated for fear of retribution. More education, persuasive methods, and studies disproving links to autism, etc. will continue to be necessary to help with understanding and decision-making for well-meaning and yet misguided parents.
Trust and comfort in decision making is harder today thanks to social media and extreme activism. Added to these factors comes a need for safer, more effective, and affordable vaccines. There are still patients who get the childhood disease even in the face of vaccination (i.e. mumps). NEJM, Oct. 6, 2016
The main concerns with the anti-vaccine groups have been published by the CDC. To access these specific issues and the discussion, log on to: http://www.cdc.gov/vaccinesafety/concerns/
There is also a good discussion on common questions asked on this website. You must go to the website to see these questions discussed. Copying this page did not allow for linkage.
A.Influence of TV ads and consumer requests for prescriptions
Since medications are the subject of this report, there was a study that just came out about direct to consumer advertising and its impact on public consumption. It followed the impact of testosterone ads andfound that for every household exposure to one TV ad monthly resulted in an increase of new prescriptions of about 1%. Patients are definitely requesting more prescriptions after being exposed to direct advertising to the consumer. In March, I reported on this unfortunate ability to get around the FDA by declaring the free speech lane. I have my own concerns about this, but it is up to you the consumer to decide if Big Pharma is allowed to brain wash us with fancy ads on TV. This puts extra pressure on doctors to deal with this issue too.
B. Drug/Herb interactions
This is a valuable resource from a good friend of mine at Sloan Kettering Cancer Institute, Dr. Barrie Cassileth
Interactions between prescribed medications are not uncommon and potentially a serious concern. There is also an issue with herbs and medication. The interactions can occur in many ways: a) decrease the effectiveness of either drug b) decrease or increase the absorption of the drug c) create a toxic effect d) inactivate either drug.
The chance of drug interactions increases when multiple drugs are swallowed at the same time!! If you take more than 5 medications at the same time, it is advisable to spread their intake out over the day. Consult your pharmacist and doctor about this.
C. Drug/Drug Interactions
The absorption, storage, and elimination of drugs can be influenced by other drugs and certain health conditions (especially stomach, intestine, liver and kidney). Even the presence or absence of stomach acid can influence absorption. Some vitamins are fat or water soluble. Dietary fat may be necessary for certain vitamins to be absorbed (Vitamins A, D, E, K, and zinc).
D. Know and understand what is prescribed
It is important to read package inserts to follow directions about the drug when and how a drug should be consumed. There are many drugs that cannot be taken with certain other drugs especially antibiotics, antifungals, and certain heart and anti-depressants.
Taking medications with or without food is an issue as well. Be sure this issue is discussed and understood. Also certain foods should not be consumed around the time of ingestion. Grapefruit is a good example. It should be on the instructions of the prescriptions, but it is wise to check the package insert, talk to the pharmacist and or doctor. Pharmacies have so many technicians helping out that it is becoming difficult to talk with the actual pharmacist. Be persistent!!
Over the counter drugs can prevent absorption of certain medications, such as antacids and antibiotics. Dietary supplements may also interfere with certain medications, so be sure this is researched.
There are many internet apps now that are valuable to help with these issues. The major drug store chains have these apps, WebMD, Medscape, etc.
E. Example of drug interaction
Cancer preventative and SSRIs
Tamoxifen is a widely prescribed medication for estrogen positive breast cancers as an adjuvant treatment, which is converted to a potent enzyme (CYP2D6) to be effective. Certain anti-depressants such as paroxetine (Paxil) and fluoxetine (Prozac) inhibit this enzyme, and therefore if a woman is currently on this cancer recurrence preventative, these SSRIs may make Tamoxifen less effective. Other SSRIs such as citalopram (Celexa) and sertraline (Zoloft) do not inhibit tamoxifen and should be considered as appropriate SSRIs for these patients.
F. Drug adherence
Non-adherence for patients taking their medications as prescribed is a significant issue. Not taking heart medications has contributed to 125,000 preventable deaths in cardiovascular disease annually. 50% of patients are guilty of poor adherence in taking their heart medications. Often patients do not complete their entire course of antibiotics, which can lead to resistance of bacteria.
F. Important information
When doctors do not have time to discuss the prescriptions they write, the system suffers and so do patients. Do not leave the doctor’s office without knowing exactly why a prescription was written, how and when to take the medication, drug interactions, side effects, and when to call the doctor or call 911. Read about the medication in the package insert or on the internet, as discussed above. And be sure you are receiving the correct medication from the pharmacy!!
G. Remembering to take medications
A routine schedule of when to take medications is critical to prevent forgetfulness. Keep reminders visible, use reminder apps, and never double up on medication. If a dose is missed, take it as soon as possible, and get back on schedule. If it is time for the next dose, however, do not take 2 doses. Take all the medication prescribed and do not keep medications where children and teenagers can access them. Do not share medications with others. If a dose is adjusted based on certain variables, such as blood sugar level, blood pressure measurement, be sure the instructions are followed.
H. Patients with disabilities
If a patient has any mental or cognitive issues, they should never go to the doctor alone. Other factors to be considered are level of education, ethnicity, language barriers, health literacy, access to pharmacists, and ease of swallowing medications are all factors.
I. Side Effects
The occurrence of side effects which create doubt in taking the medication can lead to stopping the medication, and therefore, and notifying the doctor is critical for an alternative and other advice.
J. Cost of medication
If a patient cannot afford the medication when they pick up the prescription, immediately call the doctor for a less expensive alternative. Unfortunately doctors do not pay attention to the cost.
K. Stopping medication
Never stop a medication without notifying the doctor. Some medications must be stopped by tapering off the medication. SSRIs are a good example, since withdrawal symptoms will be quite unpleasant and even dangerous.
If help is needed in adhering to medication schedules, please ask the primary care physician for home healthcare assistance.
Journal of the American College of Cardiology, 2017
Child Sexual Abuse
April was National Child Abuse Awareness Month!!
A. Child Sexual Abuse
Child sexual abuse is a form of child abuse that includes sexual activity with a minor. A child cannot consent to sex under any circumstance. Sexual contact does not need to occur. It may include fondling, exhibitionism or exposing oneself to a minor, intercourse, masturbation in front of a minor, obscene phone calls, texts, or other internet communications, possessing, producing, or sharing child pornography. Sex abuse can be oral, anal, or genital, including sex trafficking, or any sexual conduct detrimental to a child physically, psychologically, or emotionally.
93% of child sexual abusers are known to the victim. Manipulation, power, or intimidation over these victims is common. Sexual activities imposed on children represent an abuse of the caregiver’s power over the child. Seemingly innocent playfulness and non-contact can lead to more and more sexual play and eventually to blatant sexual assault. These predators are very clever in gaining the trust of a child over time.
Pediatricians must be on the alert to subtle signs of abuse. Interviewing a child and caregiver separately may be required to illicit what might really be going on. Children can be threatened not to divulge the sexual abuse by an adult. They can threaten to harm the family and or the child. The threat may be implicit by implying loss of friendship with the person if they divulge the sexual activity. This may illicit fear, anxiety, or depression in the child.
Common behaviors because of sexual abuse by the child may include: a) phobias b) sexualized behaviors c) sleep disturbance d) changes in appetite e) change in school performance f) regression of behavior becoming more infantile g) acting out behaviors h) truancy i) social withdrawal, isolation, sadness, or depression.
Pediatricians should perform genital exam if sexual abuse is suspected. There may be physical signs of sexual activity, however, the exam is usually normal. Testing for STDs and urinary infections must be performed.Early puberty may be occur in sexual abuse cases. Stress, including sexual abuse can accelerate stress hormones leading to early maturation and early menstrual periods.
Other forms of abuse may well not be present.
Consent for sex from a juvenile is not possible and is sexual assault by definition. The incidence of sexual abuse as a child in women is thought to be as high as 20% and 5-10% in men. Sexual abuse is thought to represent as high as 9% of all child abuse cases. Blacks are twice as likely to be victims of child sexual abuse. 24% of children are as young as 3 years of age.
Sexual predators must be dealt with harshly. Incarceration has actually decreased the rate of child sexual abuse by those who seek out children for sexual abuse. These predators are sick and reforming them is a real challenge. Registering as a sick offender is required.
PTSD is not uncommon when these children and adolescents are freed of the secrecy and burden of abuse. Treatment of psychosomatic illnesses may likely be necessary for an extended time. Transitioning into teenagers and adults may be particularly difficult considering the hormonal changes taking place. Substance abuse, alcoholism, depression, and suicidal attempts are higher in these juveniles even as they grow up. Even rates of smoking, poor self-rated health, obesity, physical inactivity, and high numbers of sexual partners is not uncommon. With this comes a 2-4 fold increased incidence in STDs.
As hard as it may be, if child sexual abuse is suspected, the pediatrician and the authorities must be notified.
Reference Medscape-Child Sexual abuse
The Hotline for child abuse is 1-800-4-A-CHILD (422-4453). There are sources of help for (foster, adoptive, or genetic) parents who have had a child sexually abused. Look up http://www.childwelfare.gov
Counseling for these victims is critical as these patients will carry the guilt and shame for a lifetime.
Sex Trafficking Hotline 1-888-373-7888
2.4 million people worldwide are victims of sex trafficking generating $32 billion annually according to the UN. In the future, I will report on prostitution and sex trafficking.
Munchausen Syndrome by Proxy
This was described in 1977 as parents who, by falsification, cause their children innumerable hospital procedures by providing false information or induces a child illness, leading to unnecessary testing, hospitalizations, procedures, and treatments. This maltreatment is difficult for the caregiver to accept, and will require special counseling.
Frequently the caregiver will fire the doctor suggesting this syndrome, and go from doctor to doctor. Doctors have to be aware of this syndrome, when symptoms are inconsistent, remarkably complex, and when the parent is not in the room cannot be verified by the child.
The parent insists on extensive investigations. Injury to the child may occur to create symptoms. Even an underlying issue of sexual abuse can be present, which brings out false claims by the child. There appears to be more focus on the caregiver than the patient. The parent may be asking for donations online, and the caregiver may seem to be extremely knowledgeable about illnesses or in the medical field. These caregivers often lavish attention on the child while the doctor is in the room but stop abruptly when alone with the child.
Common symptoms reported are those not able to be substantiated and are totally dependent on the caregiver, such as, vomiting, diarrhea, abnormal movements, seizures, and food allergies.
Ask for a pediatrician who is experienced in child abuse, and if necessary, call Child Protective Services. This is not a violation of HIPPA regulations since a child’s life and welfare are at risk
As women continue to be treated more as equals by men, more women (and yes some men) have come forward with horror stories in their own homes, workplace, and out in public. Think of the pinch by Italian men as a woman walks down the street, or an employee is put into an uncomfortable situation with a boss or fellow employee. Is the casting couch still going on?
I ran across an interesting blog (NEJM Journal Watch-New England Journal of Medicine), discussing harassment, and would recommend you read it.
Times have changed and harassment of any kind has come to the surface with the creation of human resource departments in businesses. Yet, there is still a huge problem that needs to be addressed everywhere. Truly this is a serious form of bullying.
The results of sexual harassment create a negative work environment and decreases in productivity, psychological issues, loss of jobs, and is best brought to the surface and handled in a professional manner.
Toleration from more prominent and well thought of employees creates a toxic situation, so that these individuals are given a pass for their transgressions, whereas “less valuable” employees are fired on the spot.
Unfortunately this issue can be misused in certain cases with fraudulent charges and create stress in the work environment and even affects employee evaluations, promotions, and bonuses.
This issue is truly a healthcare item that needs to be explored when a person seeks help for depression, anxiety, and loss of work efficiency.
True sexual abuse is the other end of the spectrum, but still harassment.
C. Sexual Assault in women
National Sexual Assault Hotline
Sexual Assault is unwanted sexual activity with force, threat, or taking advantage of a person not able to give consent, according to the American Psychological Association. When it is immediate, of short duration, or infrequent, it is called sexual assault.
Sexual assault occurs every 98 seconds in the U.S. (321,500) annually. The majority of sexual assault occurs in people under the age of 30.
1 out every 6 women has been the victims of attempted or completed rape in their lifetime. 82% of juvenile rape victims are female, and 90% of adult rape victims are female. 4.3% of women in the military are raped. The highest rates of rape occur in American Indian and Alaskan natives.
1 in 33 men have been the victims of attempted or completed rapes. 1 out 10 rape victims are male. 21% of transgender people have been victims. It is estimated that 80,600 prisoners are raped each year (60% initiated by prison staff).
A recent study of traumatic brain injury in female militaryveterans found that all too often the reason for injuries was from intimate partner-caused abuse including sexual abuse. NEJM
Amazingly, rapists have rights too. 31 states allow them to sue for visitation or custody. And the worst statistic is that 97% of rapists never see jail time. OMG!!
PTSD is common to almost all victims, including suicide attempts, depression, and are more likely to abuse drugs and alcohol, have work related difficulties, and intimacy issues.
Only 30% of sexual assault is reported!! If you know someone who has been sexually assaulted, please take them to the ER for a rape-kit and document the assault. This is very important if a woman is going to press charges.
D. Genital Mutilation
This devastating practice is tied in with religion, cultural practices, and has now come to our country because of the influx of refugees especially from Africa.
A Detroit doctor, Jumana Nagarwala, an emergency room doctor at Henry Ford Hospital, was arrested and charged with 200 counts of genital mutilation in 7 year olds, a common practice in African countries, which is outlawed in the U.S.
These children were being brought from all over the country. Trying to be generous with our immigration policies has created unintended consequences. Medscape News, April, 2017
This child’s clitoris (partial), labia, and vulva have been removed. These young children are permanently scarred for life. What kind of human can do this to a child in the name of religion or culture.
As a regular yoga class fanatic, I recommend you try doing these poses for 1 minute each!! Amazing results! Check with your doctor before doing these poses.
A. Coffee vs Tea and cardiovascular health
B. Caffeinated vs Decaf drinks
D. Prostate cancer screening changes
A. Coffee vs Tea
Comparisons of coffee and tea drinkers have been reported previously. A recent study in the American Journal of Medicine compared drinkers of these two beverages, at 62 years of age, comparing increasing, decreasing, or having a neutral effect on the calcium deposits in the coronary arteries and the rate of cardiovascular events. Calcium plaque is known to increase coronary events. Tea (black or green) and coffee, both with caffeine were compared with a mean follow-up period of time of 11 years.
Tea consumption had a positive effect by decreasing the progression of calcium deposits and fewer cardiovascular events. Coffee had a neutral effect. Sugar and cream added to these drinks were not reported.
In other reports, tea drinkers tend to have more laid back attitudes and lower blood pressure but paradoxically report more stress than coffee drinkers.
A study in the Journal of Molecular Psychiatry reported how much coffee drinkers consume is genetically determined. Coffee drinkers are more addicted to their beverage than tea drinkers, and are more productive and stubborn. Levels of caffeine tend to be higher in coffee than tea, which may be the reason for higher addiction rates.
Black and green tea also lowers LDL-cholesterol and triglycerides and these benefits may be related to the flavonoids (an antioxidant)in tea leaves. Steeping tea leaves provides the tea the greatest benefit. Excessive amounts of tea may damage the kidneys, therefore, moderation is recommended. Herbal teas do not have these flavonoids. This was reported in a Harvard health publication.
WebMd reported less type 2 diabetes, dementia, and Parkinson’s in coffee drinkers. They also reported fewer strokes and heart rhythm issues, however, tea seems to benefit people more by decreasing coronary artery calcification. All of these findings are observational and therefore the research is not as strong.
Coffee does have strong anti-oxidant-nutrients.
B. Caffeine vs Decaf
Of course, caffeine itself can raise blood pressure and therefore moderation is recommended and hypertensive patients should talk to their doctor about it. Both tea and coffee can cause stomach irritation.
The decaffeination process can be performed in 4 ways. Green coffee beans are steamed and then rinsed with certain solvents (methylene chloride, ethyl chloride,activated charcoal, and more recently supercritical carbon dioxide). This process is repeated to remove the required 97% of caffeine to be classified as decaf. These solvents are carcinogenic, however are removed from the decaf process before the end of the process. You can imagine there are those who would use this information to condemn decaf products. Normally carbon dioxide is a gas, but increasing the temperature and pressure on the gas will convert it to a liquid. This process prevents the need for solvents and is used to rinse the beans removing most of the caffeine.
Decaf products are reported to raise cholesterol, but using a paper coffee filter will remove the chemicals supposedly responsible (kahweol and cafestol). Reference-Livestrong
All of these studies are not well controlled and therefore must not be taken as gospel. The good news is moderation with either of these beverages is not harmful whether with or without caffeine. If a person has blood pressure or heart issues, even more caution is in order when drinking any caffeinated beverage. Remember, even decaf is not devoid of caffeine (8-14 mg per cup vs 70-140mg in caffeinated drinks). Starbucks has more caffeine than most. Popular lattes contain 2 shots of expresso (31mg caffeine equivalent to a can of coke).
Some reports say that up to 400mg of caffeine per day is acceptable for normal healthy people. Talk to your doctor about the amount of coffee or tea you should consume.
C. An update on e-cigarettes
Young people who smoke e-cigarettes have found a new way of experimenting with nicotine and other substances. 1 out 4 youngsters who use e-cigarettes now perform “dripping” with their apparatus. They use liquids containing various chemicals and drip it on the hot coil inside an e-cigarette which forms an intense vapor and gives them a stronger “hit” of what they are vaping. Leave it to Beaver!!
D. Prostate cancer screening-new guidelines
The USPSTF (United States Preventative Services Task Force) has in the past recommended against prostate cancer screening for normal healthy asymptomatic males. Recall the American Cancer Society recommended that the decision be left up to the patient and his physician ( I am on the screening guidelines committee at the National American Cancer Society).
After further study, the federal agency has agreed with a change in guidelines for men 55-69. They now recommend it be left up to the patient and doctor after a discussion about the risks and benefits of screening. They do not recommend screening after 70 years of age. The reason is that most men will die of some other disease before prostate cancer diagnosed in their 70s would kill them.
Please remember, these are just guidelines, not rules. Most 70 year old men has prostate symptoms, and it is impossible to distinguish them from just large prostate or a cancer. I would think most men and physicians would still discuss the pros and cons of performing a PSA even after 70 if their symptoms warranted it. Talk to your doctor.
NEJM-Journal Watch, April, 2017
This completes the May, 2017 Medical News Report. Next month, the subjects for June are:
1. Human Abuse Series-Part 4-Nursing Home and Senior Abuse
2. Cosmetic and Reconstructive Breast Surgery
3. Heart Valve Disease-Part 2-Surgical intervention
4. Kidney and Bladder Cancer
5. A “Quick Note” Series-Should patients with joint replacement and antibiotics to cover dental procedures?
6. One way drug companies keep generic prices higher…they destroy them! Big Pharma exposed!
I continue to enjoy researching and writing these reports, and I hope you have too. Stay healthy and well, my friends, Dr. Sam