The Medical News Report

June, 2017, #65

www.themedicalnewsreport.com

Samuel J. LaMonte, MD, FACS

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Subjects for June, 2017:

1. Human Abuse Series-Part 5-Nursing Home Abuse

2. Cosmetic and Reconstructive Breast Surgery

3. BladderCancer

4. Heart Valve Disease-Part 2-Surgical management

5. A “Quick Note” Series- Sun screens vs umbrellas to prevent sunburn; Epipen expiration date-product still ok!

Buchart Gardens, Victoria, Canada

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, care instructions, 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

The Super Moon on November 16, 2016

1. Human Abuse Series-Nursing Home and Elder Abuse

A. Statistics

Senior and nursing home abuse continues to be serious problem.More than 2 million seniors live in nursing facilities, and many of these facilities are abusing their patients.

 It is reported by www.Nursinghomeabuseguide.org that 1 in 10 elderly people will experience some form of abuse during their later years, and yet the overwhelming majority are not even reported. More than 30% of all nursing homes(5,280 facilities) have reported abuse cases according to the U.S. House Government Reform Committee accounting for over 9,000 instances of abuse over a 2 year period (1999-2001) in an older report. With more seniors living longer, the trends are surely increasing. Over 5million seniors are reportedly abused each year in the U.S. whether in senior centers or not.  Older women are more likely to be abused than men.

Elder abuse is more common when families have elders living with them especially in lower income families.

  Physicians are mandated to report any form of child or adult abuse!

  In 2010, there were 40 million Americans (13% of the population) over the age of 65 and 6 millionover 85 years of age. In the next couple of decades the percentage of people over 65 is expected to rise to 19% of the entire population.

B. Abusers of seniors in nursing facilities and at home

Over half of attendants in senior facilities admit to abuse or neglect of these elders at one time or another. Residents often harm other residents. This abuse often occurs when the patient is unattended. Adult children and grandchildren are at fault in most of the cases.

C. Caregivers as abusers

  More caregivers are taking care of their parents and loved ones at home, and statistics are showing that more elders are dying at home. The stats on Alzheimer’s disease patients show that those who died in nursing homes or long term-care facilities declined from 68% to 54% from 1999 to 2014. Putting more pressure on caregivers can creates more frustration and financial distress which can lead to abuse. 

Often caregivers at home do not have the resources or skill to care for the elderly in a proper manner. Handing the responsibility over to a nursing home facility is a big step in trust.  Caregivers are often strapped with the responsibility which may or may not be welcome. NEJM Journal Watch, May, 2017

Risk factors for increasing caregiver abuse include severe stress, burnout, drug abuse, depression, and financial hardships. Patients with more serious dementia or disabilities are at higher risk.

D. Types of Abuse

  When it comes to eldercare, caregivers can abuse by neglect, physical harm, sexual abuse, mental cruelty, physical restraint, verbal abuse, deprivation of food and water, over-sedation, and financial exploitation.

Older people will not usually call the authorities reporting abuse, especially if they are dependent on the caregiver. They also may not be able to communicate well because of dementia, disabilities, or paralysis. Patients feel helpless to the situation and keep quiet especially if there is no alternative living opportunity. This can hold true for nursing homes as well.

E. Warning signs of abuse to look for!

Signs of physical abuse includeunexplained bruises, welts, scars, evidence of broken bones, sprains, or dislocations, drug abuse, not taking medicine, appearing withdrawn, abnormal rocking back and forth, broken eyeglasses, signs of restraints (rope marks on the wrists), or refusal by a caregiver to allow a relative to see the patient or makes excuses why a elder person can’t be seen. It is imperative that visitors and relatives keep these warning signs in mind especially when several of these signs are present.

F. Signs of neglect

Neglect is very difficult to spot without being conscious that this may be occurring. Signs of this type of abuse may include weight loss, malnutrition, or dehydration, bed sores, unsanitary conditions of surroundings or soiled clothing, and obvious body odors from lack of bathing.

G. Financial Fraud

  Relatives need to be aware of financial exploitation by callers, the internet, and even family or nursing home staff. It is estimated that this type of abuse is costing seniors $2.9 billion a year. This is a crime and should be called “theft from a vulnerable adult” including exploitation. Most states (12 do not have laws that include exploitation as a crime) have laws against elder abuse, but need to be strengthened.Elders are extremely vulnerable to this type of abuse. Signs might include unpaid bills (because their account is empty, significant withdrawals from the person’s accounts, suspicious changes in wills, giving someone power of attorney, insurance policies, and titles to properties. Many seniors will not divulge their mistakes, so families need to be mindful of this issue, helping to manage their money if necessary.

  These seniors will never recover from these fraudulent crimes. Taking away security from an older person robs a person that will last the rest of their lives leading to loss of trust, confidence in others, self-confidence, and independence.

  There is no formal government-run system for complaints and intervention. Many of these crimes go unreported. These crimes need to have stiffer sentences!!

H. Beware of common nursing home behavior by seniors

    Nursing home residents, as they deteriorate commonly complain about people stealing from them, which may be true or from loss of memory for items in their room. Adaptation to the nursing home experience takes time, and behaviors by otherresidents may be positive or negative which can influence the patient’s happiness in the new environment. Accusations about the staff may or may not be true. Frequent visits and getting to know the staff is critical in getting a level of confidence in them.

I. What can families do?

  Family should consider themselves as team members along with the staff in making the senior as comfortable and happy as possible. Facilities that are full service tend to make transitions much easier starting with assisted living before entering a nursing home facility. However, assisted living is expensive and families have to be willing to pay the price since insurance may or may not pay.

  What can a concerned relative do to prevent elder abuse? They must listen to seniors and their caregivers, intervening when abuse is suspected, and know the warning signs.

J. Caregivers for seniors-burnout

Caregiver burnout is a serious issue and may require additional support from other friends and family. Adult daycare may be valuable if the patient is not a good candidate for assisted living, or nursing homes. Families must pitch in to assist the primary caregiver, report suspected abuse, and discuss this with the senior’s doctor.

  Caregivers need to be praised and helped. Their benefit to society is immense. The number of unpaid hours of caregiving provided weekly in the U.S. is 1.2 billion hours according to a study in the Publication, Population and Development Review, 2015.

Seniors fight to keep their independence and giving into going to a nursing facility can be quite a challenge.

  For more information go to www.helpguide.org

Elder abuse hotlines are available:

1-800-677-1116 for help (eldercare locator)

There is an agency that handles these issues—Adult Protective Services.

  Choosing a good nursing home is a serious issue, and it requires interviews, inspecting the facility, talking to residents, and checking out credentials, and ratings, and reviews online.

2. Cosmetic Breast Surgery (augmentation, lifts, reduction, post-mastectomy)

A. General considerations

15.6 million females had breast augmentation in the U.S. in 2014 and that number continues to climb, according to the American Society of Plastic and Reconstructive Surgeons.

  In 2013, 8200 breast augmentations were performed on girls ages 18-19. The desire for cosmetic breast and genital surgery has become an everyday occurrence as women see their gynecologists. For young women, some doctors have become concerned that unrealistic expectations about their breasts and genitals had become a real issue.

  Is it the “Victoria Secrets” syndrome with the desire for copying these bulimic women? Is it the males, who expect perfect bodies of their mates? Is it the internet (social media) that provides ready access to “perfect girls” and an easy way to bully those vulnerable young women? Is it that girls are maturing earlier?  I suspect all of the above.

  Education about developing bodies is clearly lacking. No matter how mature a girl appears, completion of the hormonal process is necessary. Most ethical plastic surgeons would be very cautious about operating on anyone younger than 18 years of age.

Cosmetic breast surgery has been around for decades and some are medically necessary. Women that have asymmetry of the breasts often request reconstruction to create symmetrical appearing breasts. Inverted nipples can be reversed as well. Reconstruction after breast cancer surgery has been discussed previously.

  Deciding the amount of enlargement of breasts is a critical issue to be discussed with the surgeon. Most surgeons I know prefer C cup enlargement unless the patient is larger and can accommodate larger D, DD, etc. cup size. The larger implants can create more complications.  Most women want to have a figure that compliments the whole body, not just the breasts. Women want to look good in clothes primarily, although men may influence the size of implants.

B. Placement of implants

  Breast implants can be placed behind the breast tissue but above (submammary) the surface of the pectoralis muscle or deep (submuscular) to that muscle.

Contracture around an implant is often an issue and is reported less often when the implants are placed below the pectoralis muscle (submuscular).

C. Measurements

  Since breasts are often different shapes and sizes, these measurements are critical in being able to create symmetry with different sized implants.

D. Incision choice—sub-mammary implants are usually placed through an incision around the edges of the nipple(peri-areolar incision). For sub-muscular placement, the incision can be placed through the arm pit (axilla) or below the breasr (crease at junction of breast and chest wall).

E. Implants with nipple reduction

Nipple reduction is often necessary. Implants could actually overemphasize large nipples.

G. Breast implant size decision

  There are many systems to help determine the best size implant for each woman (and transgender men). 3 basic  measurements are critical to decision making:

Breast width, nipple to inframammary fold distance, and skin stretch must be included in breast implant size determination. Implant sizers are generally discouraged. Of course, the final decision must come from the patient.

The system of selection always depends on patient preference, scientific measurements, and surgeon artistry. Other considerations include breast implant shapes and styles, breast asymmetry, patient height, weight, body shape, hip width, personality, and even geographic demographics.

H. Choosing the right implant

1- The Safety of Silicone

Silicone implants require that a person be 21 years of age (18 for saline). After 40 years of experience, except for capsular fibrosis (making a breast harden), the efficacy and relative safety of breast implants is similar to any clean elective surgical procedure. Aside from lawyers getting rich on supposed systemic illnesses caused erroneously by implants, there continues to be no scientific evidence of systemic immunologic diseases such as lupus, arthritis, etc.

  Silicone is actually a metal and silicone is a polymer consisting of silicon plus oxygen. Medical grade silicone is an extremely pure product. The same complications can occur regardless of the type of implant (Silicone, saline, combination, etc.). In 2008, 53% of implants were saline (47% silicone). Silicone rubber implants can be single or double layered, smooth or textured (less popular since they can wrinkle easier and can leak), barrier coated, or urethane foam covered (the latter has not been available in the U.S. since 1990). The double lumen implants consist of a saline cavity under a silicone covering.

  There is no evidence that silicone implants can cause breast cancer. However, implants can prevent the early detection of cancer and special techniques to screen the breasts. Always tell your mammogram doctor there are implants present, so that the radiology department can use special techniques. However, studies have not seen an increased incidence of breast cancer in women with breast implants.

  Although extremely rare (231 cases worldwide), a non-Hodgkin’s lymphoma can occur in patients with implants, and it appears to occur much more commonly with textured surface rather than smooth surface breast implants. It is so rare, the connection is difficult to define other than stating it is possible, and patients need to be informed. The FDA does not recommend removing implants for this rare occurrence.

  Rats injected with silicone gel developed myeloma (a plasma cell cancer), and there is a very small number of patients who develop monoclonal gammopathy, which increases the chances of developing myeloma. These few patients are now in a registry carefully monitored by the NIH (National Institutes of Health). Patients with this gamma globulin abnormality have an increased risk (16%) of developing myeloma in the next 30 years of life after placement of implants. That is the potential link.

  Silicone gel filled implants have been approved by the FDA since 2006.

  2-Saline filled implants

  The silicone sac implants are filled with sterile saline at the time of surgery instead of silicone gel. Permanent tissue expanders have been used to remove or increase the amount of saline but are not generally available in the U.S.

  Saline implant size can be adjusted at the time of surgery for asymmetrical breasts, but do not feel like breast tissue as well as silicone. They are less useful for breast reconstruction after breast cancer surgery.

  The newer 3^rd generation silicone gel implants have a second barrier of diphenyl silicone that has eliminated “bleeding” or leaking of silicone gel. The latest since 2006 is the “memory gel” implant, which has a thicker lining and more cohesive to prevent leaking. However, it is said to feel doughy. So it is always safety vs. feeling like the “real thing”.

3- New approved implant—the soft touch implant

NatrelleInspira Soft Touch implant has just been approved by the FDA for post-cancer reconstruction and cosmetic augmentation. Allergan, the company for several types of implants offers a variety of firmness to be used in a variety of factors including the amount of breast tissue remaining, consistency of each breast, etc.

www.natrelle.com/#

J. Breast Lifts (mastopexy) with and without implants

K. Breast lift with implants

L. Breast lift and reduction without implants

M. Options for incisions based on the shape of the breasts

To lift a breast the nipple must be placed higher on the breast after removing breast tissue and skin around the nipple, below the nipple, or in various geometric excisions as shown in these drawings.

N. Contraindications of breast implants

Since as high as 95% of women who have cosmetic augmentation are said to be satisfied, plastic surgeons appear to do a fairly good job of weeding out those with unrealistic expectations, have psychiatric issues, are having the procedure to please another, or are not healthy enough to undergo this procedure. This requires an experienced, seasoned surgeon. Make sure your surgeon is board certified with the American Society of Plastic and Reconstructive Surgeons.

For those who wanted their implants removed, 85% had them replaced. This speaks to the satisfaction of the majority of women.

O. Complications

1-Reoperations

Close to 3% of patients may require repeat surgery. The most common reason is capsular contraction. Remember, implants are foreign materials to the human body. It is the result of normal scar formation, and when a scar matures, it can shrink causing contraction of the tissue surrounding the implant, which can cause dimpling, lines visible on the surface of the breast, and sometimes deformity. This scar contracture is probably the body’s attempt to extrude the implant which is a normal process just like walling off a splinter in the finger. Asymmetry of the breast is a concern, and it may require reoperation.

  Contracture can occur soon after surgery or late. If it occurs early, it is thought to be due to a low grade infection from Staphylococcus epidermidis, but it cannot be confirmed. Contracture is not a health risk, but if the implant becomes extremely firm, it can be very uncomfortable and undesirable and esthetically.

2. Silicone Capsular Rupture

If rupture of the silicone implant capsule is known, it is recommended they be removed. Many, however, are silent and confined to the implant capsule and surgical pocket. An MRI is the best test to diagnose rupture.

  After pregnancy, difficulty with lactation may occur in women with small breasts or those with peri-areolar incisions.

3. Capsular fibrosis

  As the body senses the implants as foreign, just like a splinter in a finger, the tissues surrounding the implant attempt to “wall” off the implants creating a layer of scar tissue, which can contract and cause the breast to feel much firmer than the opposite breast. The dominant hand side tends to have more trouble with capsular fibrosis. This can cause discomfort and require removal.

   4. Infection

  Wound infections are very rare, but if they occur, the implant may have to be removed.

P. Breast reconstruction post-mastectomy

The timing of reconstruction is a critical decision to make. There are many factors to consider. Immediate vs waiting one year, etc. depends on the extent of the cancer and being sure there is no evidence of recurrence. Prophylactic bilateral mastectomies for women with heavy family history and or BRCA gene mutations are all considerations.

  There are several reports confirming that patients with DCIS (ductal cancer in situ) have a higher rate (3 times higher) of second surgeries compared to those who have invasive carcinoma. Conservative surgery has led to reoperations for persistent (positive margins) or recurrent cancers. Reoperation for cancer comes with significant physical, psychological, cosmetic, and financial challenges. It begs the need for serious discussion regarding options in patients with DCIS. One study cited positive margins of cancer were still present in 16.4% of the patients. The reoperation was 14.4% re-excision and 3.2% mastectomies in one study.

Regardless, if cosmetic reconstruction is desired, these issues are germane to our discussion and whether immediate reconstruction is really prudent. I will address DCIS in a future report, because this is such an important subject. A subtotal mastectomy with reconstruction from using a implant spacer over time to increase the skin, which is followed by a silicone implant. The other breast had a breast lift to create closer symmetry.

Bilateral mastectomy with reconstruction

The left nipple was recreated using skin from the inner thigh with tattooing for color match.

Q. Impact on insurability

A few insurance companies refuse to insure women who have had implants. Check with your carrier before considering implants.

Reference:

American Society of Plastic and Reconstructive Surgery

3. Bladder Cancer

Different Stages of Bladder Cancer

A. General Information

  About 80,000 bladder cancers occur annually in the U.S., are much more common in men (60,000 vs 20,000), and are twice as common in whites. They account for 5% of all cancers. 9 out of 10 occur in people over 55 years of age. 16,000 (20%) died of their disease in 2016.

  Bladder cancer is a very treatable cancer if caught early, but it can spread beyond the bladder if not detected early.

B. Anatomy

The bladder wall is lined with a special type of cell called transitional cell. These cells are the origin of most bladder cancers when exposed to carcinogens that occur in the urine. The bladder collects urine from the kidneys through the ureter. The bladder has a very muscular wall, which allows expansion and retention of large volumes of urine. Because it is a thick wall, it prevents early penetration of the wall in earlier cancers. Depth of penetration determines the stage of the disease----0-IV seen below:

Anatomy of the bladder

C. Risk factors for bladder cancer

  1) Smoking is the most important risk factor for bladder cancer. It is estimated that half of all bladder cancers are caused by smoking. Smokers are 3 times more likely to develop bladder cancer.

  2) Workplace exposure is a known factor if chronically exposed to dyes containing certain aromatic amines (benzidine and naptha). Those who work in the production of leather goods, painters, machinists, printers, hairdressers, and truck drivers are at higher risk because of chemical exposures.

In the 30s and 40s, those who painted radium on dials of watches and clocks used tiny paint brushes, and they licked the brush to obtain a fine point on the brush. There was an outbreak of bladder cancer in these workers.

3) Medications/Herbs that increase the risk of bladder cancer

Pioglitazone (Actos), a diabetic treatment, may increase the risk (63% risk reported) of bladder cancer although controversial as reported in the British Medical Journal. Up to a quarter of diabetics take this drug. (Safety number 1-800-FDA-0178). It does decrease the risk of stroke and heart attack in diabetics. A similar drug, rosiglitazone (Avandia), does not appear to increase the risk.

  The herb family, Aristolochia, has an increased risk of bladder cancer and kidney toxicity. Some species are well known in Eastern medicine for weight loss, arthritis, swelling, snakebite treatment, etc.

  4) Arsenic in drinking water

  5) Recurrent infections of the bladder may be linked to a rare cause (squamous cell carcinoma).

  6) Schistosomiasis is a parasitic worm that can get into the bladder and cause recurrent infections is a risk factor where that parasite lives (Africa, Middle East).

  7) Multiple bladder cancers—Bladder cancers can occur in other areas of the bladder. For patients who have one cancer, they are at a higher risk for a second separate bladder cancer. These can occurpotentially  from seeding of an earlier cancer with local treatments.

  8) Family history of bladder cancer is a factor. It may because smokers are more common in family members. A small number of genetic mutations create an increased risk.

  9) Chemotherapy agents and radiation--cancer patients who take the chemotherapeutic agent, Cytoxin (a very common treatment), and those who have had pelvic radiation are also at an increased risk.

D. Signs and Symptoms

Early bladder cancer may be silent as many cancers frequently are.Blood in the urine (pink, orange, or red) is the most common sign of bladder cancer, but by no means diagnostic, as there are other reasons that cause blood in the urine (hematuria). Blood picked up on a routine urinalysis is not uncommon before a person can visibly see blood in their urine.  Pain is not usually a symptom of cancer, but urgency to urinate may be present along with other symptoms similar to prostate enlargementsymptoms.

E. Tests to perform

A urinalysis may show red blood cells, white blood cells, and protein. Urine cytology if ordered may show malignant cells under the microscope. A urine culture to detect infection would be appropriate if symptoms suggest an infection. Urine examination for tumor markers can be performed as well (tests are available-BladderChek, BTA, Urovysion).

  If symptoms of bladder trouble occur, it would be advisable to see a primary care physician, or see a urologist for a direct inspection of the bladder (cystoscopy) in the office. Special tests can be added to the routine cystoscopy, such as a fluorescence blue light cystoscopy, which is performed by placing a drug in the bladder that cancer cells take up and glows blue on inspection.

If a mass is seen on cystoscopy, a biopsy will be taken. If no tumor is seen but highly suspected, several random biopsies around the bladder may be taken to discover microscopic cancer.

F. Pathology Results

The depth of cancer wall invasionis critical to stage the cancer as seen in a drawing below. If superficial in depth, it will named non-invasive, and if deeper, invasive.

  It is also important to know how malignant the cell is. This correlates with survival. Cancers are graded (low-grade/high grade) and the degree of cellular differentiation (well or poorly differentiation) on that basis.

G. Imaging studies

A variety of X-rays, scans, and dye studies can be ordered to look at the entire urinary system and define the tumor and look for any evidence of spread.

The dark area is the tumor

H. Classification of tumor size and spread

All cancers are classified with the TNM system. T=tumor size, N-lymph node involvement, and M=metastases present. This classification coincides with stages and determines the type of treatment options

I. Treatment by stage of diseases (0-IV)

Stage 0

These include non-invasive cancers that have not invaded the bladder wall and only involve the lining.

  A trans-urethral removal using an endoscope can remove these superficial cancers with close follow up.

Intra-vesicular treatments-this is an infusion of a vaccine against tuberculosis called BCG that is an immunologic therapy. This therapy is fairly effective in preventing recurrence and is more effective in flat non-invasive cancers than instilling chemotherapy (mitomycin) agents directly into the bladder (the day after surgery). Chemotherapy instillations are performed once a week for 6 weeks. The BCG does have more side effects (flu-like symptoms, gastrointestinal symptoms including jaundice, and difficulty urinating).

  Only when there are numerous early individual bladder cancers would removal of the entire bladder be considered (cystectomy). Cystectomy is normally reserved for advanced or recurrent cancers.

Stage I

These cancers have invaded the connective tissue layer but not the muscular layer. These can be removed by resection through the urethra just as Stage 0 cancers. However, a repeat resection is usually recommended several weeks later, as recurrence is high with only one resection.

If the tumors are “high grade” and multiple, a radical cystectomy may be recommended. A partial cystectomy may also be recommended as seen below.

Partial cystectomy

Stage II

These cancers have invaded the muscle layer of the bladder wall. The same treatment as above is performed to remove the cancer therapeutically but also to examine the extent of the cancer. Lymph nodes surrounding the bladder may be removed to determine if there is spread to them. Chemotherapy may be given prior to surgery (neoadjuvant) or after surgery (adjuvant). This assumes there is a chance of spread outside the bladder, and therefore systemic chemotherapy is indicated. Radiation therapy also may be recommended in addition to chemotherapy.

Stage III

  These cancers have grown outside the bladder to the surrounding structures (uterus, ovaries, prostate, colo-rectum) in the pelvis. The trans-urethral approach is performed to determine the extent of invasion. A trans-abdominal radical cystectomy (removal of bladder, uterus, ovaries, prostate) is performed later to remove the bladder and surrounding tissues. Neoadjuvant (before surgery) chemotherapy is often performed to shrink the cancer to make the surgery easier. Adjuvant (after surgery) chemo may also beconsidered to prevent recurrence. Radiation may also be considered, especially if the patient is not a good surgical candidate because of health issues.

Stage IV

The cancer has grown to the outer walls of the bladder and may have invaded the pelvis and lining of the abdomen (peritoneum). Radical surgery may be considered after a course of chemotherapy prior to surgery (neoadjuvant chemo). If there is distant spread, chemotherapy and radiation therapy may be recommended in addition to immunotherapy (i.e. atezolizomab). Clinical trials should also be considered.

J. New and experimental treatments

Photodynamic therapy is a laser procedure to remove the cancer. Gene therapy is being tried in clinical trials.

K. Bladder reconstruction for urinary function

 When the bladder is removed, a piece of small intestine is used to create a connection from the ureters to a stoma created in the abdominal wall (ileal pouch/ileal stoma). This is connected to a urine bag (drawing 1).

  In some cases a neo-bladder (using intestine) can be constructed and connected from the ureters to the abdominal wall (drawing 2) or to the urethra (drawing 3). All three options are seen in the drawings below.

L. Survival Rates/Recurrence rates

  50-80% of bladder cancers recur. The treatments of early cancers are very effective in controlling the cancer, but because they spare the bladder from being removed, they are very likely to recur. This makes lifetime surveillance necessary and one of the most expensive cancers to treat. 

  Nearly half of the patients are diagnosed when the cancer is confined to the inner aspect of the bladder wall and have close to a 96% 5 year survival rate. I will discuss kidney cancer next month. 

Emedicine.net, Medscape, MD Anderson Cancer Institute, rxlist.com

4. Heart Valve Disease-Heart Valve surgery

About 65,000 heart valve replacements are performed yearly in the U.S. The valves can have congenital deformities, have wear and tear over the decades, and begin to leak or obstruct the flow of blood.

In April, I reported on the diagnosis and medical management of heart valve disease. I reviewed the anatomy of the heart, blood flow through the heart and lungs, and the function of the valves. For review, please click on the April report: The Medical News Report #63

A. There are 5 options for replacement described by the American Heart Association’s website:

1. Mechanical valve`

2. Tissue Valves (human or animal)-bio-prostheses

3. Ross Procedure-swapping the pulmonary valve for the aortic valve

4. TAVI/TAVR procedure-(trans-catheter aortic valve replacement- (performed through a blood vessel)

5. Newer surgical options-experimental

  The treatment of choice depends on the valve needing replaced, severity of symptoms, and risks to the patient based on the clinical condition and age of the patient. Factors to consider are durability of the new valve and long standing relief of symptoms and return of good heart function.

Note--Although replacement of the valve is most common, repairing the valve is being performed on selected patients.

B. Closed (non-invasive) vsOpen (invasive)Procedure

There are two basic ways to surgically treat valvular disease-invasive (open) and non-invasive (closed). Coronary stents or bypass surgery may be performed at the same time.

  a) Non-invasive-Closed procedure-Transcatheter procedures(TAVI/TAVR)-performed through a major blood vessel (through the groin or arm).

   Replacing the aortic valve using the TAVI has been refined and is now a common way to treat this disease.

  The aortic and mitral valves are the most common valves replaced. If the valve is narrowed from disease it is called stenosis and if the valve leaks, it is called regurgitation (insufficiency).

b)Open Procedures

1. Mechanical

  Mechanical valves run a higher risk of blood clots requiring blood thinners (anticoagulants) for life. These valves usually last a lifetime. More than 80 models have been produced since the 1950s. Bi-leaflet (left) and ball valve (right) options:

Bi-leaflet valve

Ball valve

2. Bio-prostheses (Tissue grafts)

Tissue valves do not last as long as mechanical valves.

These biologic valves are often attached to a synthetic scaffolding, as seen above. These animal valves are preserved in glutaraldehyde (similar to formaldehyde) to preserve the valve and prolong the inevitable degeneration (calcification) of these valves. Valves placed in younger patients tend to last only 10 years or so and will need replacement. Older patients (over 65) rarely need a replacement.

Pig valves are actual valves harvested from pigs, whereas cow (bovine) valves are made from the pericardium of the cow.

  The early failure of these valves is 4-6%.

Failure of the valve to function can have catastrophic consequences and require emergency surgery. Surgeons decide choice of valves based on their experience and many other factors.

  If a patient can’t take anticoagulants, a bioprosthetic valve is a better choice, since mechanical valves require lifelong anticoagulants as stated above.

  Mechanical valves are being used with increasing frequency. These valves reduce the complications of tissue (biologic) valves including a higher death rate as a result of complications including valve failure, endocarditis (infection) of the valve, valve thrombosis (clotting), thromboembolism, and mechanical hemolytic anemia (valve chews up blood cells).

  3. Ross Procedure

 The Ross procedure is defined as taking the pulmonary valve from the same patient and swapping it out for the damaged aortic valve. The damaged aortic valve is then put in the site of the pulmonary valve. The damaged valve works well enough to provide adequate heart function since the pumping power of the right side of the heart (right ventricle) is much less than the left side of the heart (left ventricle). It is easier to pump blood into the lungs than it is to pump blood out to the entire body.

  If the Ross procedure is performed in a child, the valves will continue to grow to mature size, and over time the valves hold up. 

  4. TAVI/TAVR procedure

TAVI=Trans-aortic-valve implant

TAVR=Trans-aortic-valve-replacement

a. Video of actual procedure

The American Heart Association has a WATCH, LEARN, AND LIVE interactive cardiovascular library that demonstrates how an aortic valve is placed via a peripheral artery, usually the femoral (groin) or brachial (arm) artery. This animated video will show you how it is done. Go to the American Heart Association website to find this animation.

www.heart.org/HEARTORG/Conditions/More/HeartValveProblemsandDisease/What-is-TAVR_UCM_450827_Article.jsp#.WQEKdorKM8

b. Procedure:

 The trans-arterial non-invasive procedure does not replace the damaged aortic valve, rather the old valve is left in place and the new valve is wedged inside the old valve, which will function well. This replaced balloon valve is run through the major artery in the groin (femoral). The femoral artery approach is the most common. An alternate route can be performed through a small incision in the chest wall.

The catheter with the balloon valve is then placed into the site of the damaged aortic valve. The valve is crimped over the deflated balloon.

  Once the balloon is in place, the balloon is inflated which is used to dilate the narrowed valve. The balloon is deflated, and the new valve is left in place. The balloon and catheter are removed leaving the new valve to function immediately.

c. Why use the TAVI?

  This is an excellent choice for those patients unable to have open heart surgery. It has many advantages:

  a) Minimally invasive with no large surgical incision

  b) Improves circulation

  c) Improved life expectancy

  d) Shorter hospital stay

  e) Does not usually require the patient to be placed on a heart/lung machine or stopping the heart during the procedure.

  Indications for this procedure include those who are at moderate risk or who cannot tolerate open heart surgery (usually older patients). These patients must be placed on anticoagulants for life. The risk of failure, stroke, heart attack, blood clots, bleeding, and death must be accepted.

5. Research innovations

  When newer devices are tried, they are usually limited to more severely disease patients, who might not be good candidates for the usual methods. This is true for severe aortic stenosis, since these patients are usually in their 70s and 80s. Newer trans-arterial devices keep improving, but are beyond the scope of this report. This approach decreases the complications for older patients, and with improvements, more patients will be candidates.

C. Clinical outcomes of valve replacement

  1.Mitral valve replacement requires an open heart procedure.

There is little difference in outcomes for mitral valve replacement using a mechanical or tissue valve. The mortality in one large study was 26%. There was a slightly higher risk of bleeding using the mechanical valve but tissue valves are more likely to need replacement. Studies report 50% of the patients are alive at 10 years and 22% at 20 years.

    2. Aortic valves can be approached as an open procedure or the trans-catheter route. Certain requirements are necessary to be a candidate for either of these procedures. Many of these patients would die or have serious quality of life issues, therefore, even with significant mortality and potential side effects, they must accept this and do everything they can prepare for surgery, and follow carefully the post-surgery instructions.

  I was unable to find legitimate outcomes for aortic valve surgery. Results depend on so many factors, so this needs to be discussed with the cardiac surgeon.

5. “A Quick Note” Series—

Sunscreens vs Umbrellas to prevent sunburn

Epipen (Adrenaline injector) expiration date-still good

A. Comparing Sunscreens to umbrellas on the beach

Sunscreens reduce the risk of melanoma and non-melanoma skin cancers (basal and squamous cell carcinoma), sun damaged skin, and acute photosensitive skin disorders.

There are groups in the U.S. that are reluctant to use sun screens due to perceived but unsubstantiated health risks. Conspiracy websites are full of stories about a variety of subjects all designed to make the public suspicious of everyone. These same websites have promoted unsubstantiated claims of health risks regarding sunscreens.

With public concern for the safety of sunscreens, the study was performed comparing sunscreen (SPF 100) to beach umbrellas. 84 subjects volunteered to either use the sunscreen or stay under a beach umbrella for 3.5 hours on a beach in Texas in August. The people were similar in skin type and easily sunburned. 24 hours later, the two groups were examined for sunburns. 78% under umbrellas were sunburned while 25% that used sunscreen were red.

  Ultraviolet light can bounce off water sending rays under umbrellas, and therefore umbrellas alone are not very protective. Reapplying sunscreen every 2 hours (recommended) was performed in this study.

  Those who do not trust sunscreens are not protected with beach umbrellas. Many fair skinned people should use sunscreen and stay under umbrellas as well. There are clothes now that provide sunscreen protection and should be considered.

Squamous Cell Melanoma >

<Basal cell Melanoma

I have discussed skin cancers and melanomas in the past. For a review please click on:

www.themedicalnewsreport.com#5, #10, #16, #19 (melanoma)

www.themedicalnewsreport.com#5 (basal cell and squamous cell cancers, sunscreens)

Medscape April, 2017

B. EpiPen expiration date-can it still be used?

The Annals of Internal Medicine (May, 2017) have reported a study on the adrenaline injector EpiPen to still be at least 84% effective 50 months after the expiration date. Although there is some loss of concentration of adrenaline, there is still a significant amount present.

  Considering the high price of this life-saving medication, using the injector past its expiration date at least for several months should not be of concern.

  Of course, discussion with a physician is recommended.

Next month, I will once again provide you with some interesting subjects

1. Cosmetic genital surgery popularity

2. False and Positive laboratory tests

3. A Quick Note Series-Joint replacement revisions-the latest; Signs of Depression

4. Heart Block—electrical abnormalities

5. Kidney Cancer

Stay healthy and well my friends, Dr. Sam