The Medical News Report

January, 2018, #72

www.themedicalnewsreport.com

 Happy New Year 2018

A New Year’s Resolution

  I am going to be more active this year, and that includes attending more yoga classes. Yoga has meant the world to me, because it has allowed me to play golf and be pain free (neck and back) most of the time. I have reported on yoga and shown most of the standard yoga positions and which muscle groups they affect in previous reports (see subject index). Some of them came from: www.yoga.com/poses

Another comprehensive discussion on the medical benefits of yoga is also available through a national website written by Jenn Miller. Please click on this website to motivate you to incorporate yoga into your day. It will be the best New Year’s Resolution you ever make.

www.jenreviews.com/yoga/

Please get serious about more exercise in 2018, and consider attending regular classes of yoga. Enjoy reading this fine article by Jenn Miller. Thanks and Happy 2018!!

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Subjects for January, 2018

1. Late Breaking News—A new injectible treatment for opioid and alcohol addiction

2.  Dry Mouth Syndrome and dental disease—coping and treatment

3. Hereditary Syndromes that can cause cancer—genetic testing

4. New guidelines for estrogen therapy for menopausal women

5. People with silent atrial fibrillation are at significant risk of stroke

6. Social Anxiety Disorder—so common!

7. Ear Wax impaction-a common problem

8. Interstitial Cystitis-A painful bladder disease especially for women

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 the 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. Get copies of medical tests and if there is an electronic medical record, learn to use it.

Thanks!! Happy New Year!! Dr. Sam

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1. Late Breaking News

  Vivitrol injection for opioid and alcohol addiction

  The FDA has approved a monthly injection for treatment of opioid (and alcohol) addiction disorder (moderate to severe) based on a study that reported a 40% abstinence rate compared to a placebo (5%). This is a big step in the right direction in addressing the treatment of opioid and alcohol addiction. These are medical illnesses and need to be treated as such.

  The medication is a sustained release naltroxone (380 mg) given intramuscular every 4 weeks. This medication (oral form) was approved in 1984 for opioid addiction and 2006 for alcohol dependence. It blocks the pleasure center in the brain when these substances are used and reduces cravings. It is now available as a monthly injection, which prevents daily intake and manipulation of the dose schedule. The oral form was not very successful because of compliance by addicts, and it is also too easy to skip doses.

  I have discussed this issue at length including the use of buprenorphine and methadone, overdose, and heroin/fentanyl use.  www.themedicalnewsreport.com #47 , #58, #70

  Requirement for eligibility include:

1-must be off the opioid or alcohol for 7-10 days

2-cannot be used in withdrawal

3-must not be allergic to the drug

4-patient must not have significant liver or kidney damage

5-must not fail a urine test for opioids and alcohol

6-must not be pregnant or be a nursing mother

7-not recommended for older and very young patients, because there are no studies that have been carred out on elderly patients or those under 18 years of age.

  Mild nausea for 2-3 days is the most common side effect.

  Ideal candidates are those in a comprehensive treatment plan, understand this is not a substitute for a treatment plan, and who is willing to abstain from these substances for 7-10 days and undergo detox if needed prior to injections. Patients also must understand that if they use opioids, they may overdose at lower doses of opioid since these patients have had the drug out of their system for a time.

  I suspect there will be a limited number of physicians using this medication for awhile, so ask your doctor or contact a alcohol and drug rehabilitation center.   

Reported in the NEJM-Psychiatry, 2017

Office of Alcohol and Substance Abuse Services AddictionMedicine@oasas.ny.gov

2. Dry Mouth Syndrome (Xerostomia)

Writing about this disorder has personal and professional significance to me, because while I was a head and neck surgeon for 30 years in Florida at age 50, I also had the misfortune of developing a base of tongue cancer in 1991. I was treated with twice a day radiation therapy and developed a severe dry mouth from the radiation to my throat and neck including the saliva glands, which were in the field of treatment. Since it is permenant, I still suffer to this day from dry mouth and have had multiple dental complications even in the face of aggressive dental prophylaxis.

  It is such an impediment to have to take a sip of water with every bite of food just to have enough fluid in my mouth to mix with food to be able to adequately chew and swallow. Without fluid or some substitute in my mouth, my speech becomes impaired. These are classic things that are taken for granted until they are taken away from you.

  Hundreds of medications, cancer treatments, and salivary gland diseases all can cause what is technically called xerostomia (pronounced zero-stomia). This disorder is a serious cause of dental disease including periodontal disease and dental decay.   

A. Dry mouth syndrome has all or some of these side effects and potential consequences:

1) Difficulty chewing and  swallowing food 2) Choking on food with aspiration into the lungs 3) Difficult speech without liquids 4) Dehydration is a daily issue (1-1.5 liters of saliva is produced per day) 5) Constant dry mouth sensation  6) Burning sensation of the tongue 7) Frequent sore throats 8) Dry and cracked lips 9) Bad breath 10) Loss of some taste (saliva assists taste) 11) Dental decay, abscesses, gum disease, and periodontitis-- gingivitis can send bacteria into the blood stream and infect heart valves (infective endocarditis-Streptococcal viridians 12) oral fungal (candida) infections, chapped lips, fungal angular cheilitis (also called perliche)-redness and soreness of the corner of the mouth 13) pain and swelling in the saliva glands from thickened saliva and salivary duct stones that can block the tubes that drain saliva into the mouth.

B. Diseases and disorders of the salivary glands

  Inflammation of the salivary glands can also reduce saliva. They include diseases such as *Mikulicz disease, **Sjogren’s syndrome, salivary stones that can block the parotid gland ducts, and tumors of the glands that may present with a dry mouth and other local symptoms. These diseases must be treated. An ear, nose, and throat surgeon is specially trained to care for these problems.

  Salivary glands include pairs of glands: parotid, submandibular, and sublingual as seen in the drawing below. Mikulicz disease and Sjogren’ Syndrome are diseases of the salivary glands (and also tear glands in Sjogren’s).

C. Content of Saliva—its importance and function of each component

Saliva is comprised of 99.5% water, plus electrolytes (sodium, potassium, etc.), mucus, white blood cells, proteins, enzymes (amylase and lipase), and antimicrobial agents such as immunoglobulins (IgA), and lysozymes. These enzymes digest proteins and sugars in the mouth that are critical in preventing tooth decay.

  a) Water content

The water component of saliva is essential in rinsing food off the surface of the teeth (including the mucus content of saliva) which allows food to glide over the oral mucosa and easily down the throat. Without it, it is necessary to take a sip of fluid with each bite of food to substitute what is normally present—an extremely annoying issue for thousands of sufferers. These can be a problem during chemotherapy and alter taste.

    b) The mucus content of saliva—proteins and enzymes

  Salivary mucus contains valuable proteins and immune products (IgA) that help loosen the bacteria from the teeth and gum surface. They also neutralize viruses, bacteria, and enzyme toxins. The enzymes in mucus (amylase and lipase) help destroy the bacteria and sugars that feed the bacteria that allow dental decay. Without this protection, acceleration of the tooth decay process occurs.

  Salivary liquid allows food to flow smoothly over the tongue and down the throat as well. Without this function, it is very easy to choke on food during swallowing. 

  Another important function of saliva is to assist with taste.

    c) The buffering(maintaining a normal ph) effect of saliva

  Saliva also provides a buffer (neutralization) for the pH (acid content) of the mouth. The average pH of saliva is 6-7, and without adequate salive, the pH can drop to 5.5 or lower allowing demineralization of the enamel of the teeth, the hard outer protective lining of teeth. The buffering (neutralizing) of these acids in the mouth also prevents an environment that bacteria thrive in.

  Saliva also contains urea, another buffer product of saliva, which breaks down ammonia released as a byproduct of bacteria, which can be toxic to the gums. 

    d) Biofilm thickness of saliva

  Even the thickness of the saliva on the teeth is important for dental health. It is called the biofilm thickness. The thinner the biofilm, the greater risk for dental and gum disease.

    e) Fluoride carried by saliva

  Saliva is critical in maintaining the physical integrity of tooth enamel in many ways including carrying fluoride in saliva necessary for stabilizing the dental minerals necessary for the health of teeth. Ingested fluoride (from fluoridated water, toothpaste, rinses, etc.) is concentrated in saliva and helps protect the teeth. 

     f) Saliva’s value in healing

  The overall content of saliva also plays a role in healing oral injuries and diseases such as canker sores. Without saliva, a negative environment is set up for dental disease.

D. Sugar and tooth decay

  Sugars are an integral part of the tooth decay process. Bacteria feed off many sugars and other nutrients that coat the teeth. Tooth brushing eliminates some of these chemicals, as does irrigations and flossing between the teeth. I personally favor dental irrigators in addition to flossing to dislodge food missed by flossing.

Xylitol

  The sugar, xylitol, cannot be used by bacteria, and therefore, is commonly used in chewing gum suitable for those with a dry mouth. It would be my wish that sugar- containing chewing gums be taken off the market, and be replaced with xylitol, because of the damaging effect on the teeth even in those with normal saliva. Chewing gum can stimulate saliva, so a xylitol-containing chewing gum is a good idea. 5-10mg per day of xylitol is necessary to be effective in fighting tooth decay. Read the labels on xylitol containing products to be sure this amount is consumed daily.

According to several sources, there are over 500 medications that can affect the production of normal saliva. Some of the common groups of medications are antidepressants, antihypertensive drugs, anxiety drugs (benzodiazepines), antihistamines and decongestants for allergy, reflux meds (proton pump inhibitors), opioids, cannabinoids (marijuana), and diuretics. Discuss with your physician and dentist about stopping a drug or drugs to see if dryness of the mouth will improve. Do not stop a prescribed medication without medical supervision and talk to your dentist.

F. Conditions that cause dry mouth

  There are many medical conditions that affect salivary flow and volume. These diseases include salivary diseases (Mikulicz syndrome, Sjogrens syndrome, etc.), Alzheimer’ disease, Parkinson’s disease, diabetes, rheumatoid arthritis, mumps, and even hypertension. Nursing homes are full of dehydrated people with dry mouths. For a complete list, check on the internet. 

G. Treatment for Dry Mouth

  For those who develop dry mouth, a dentist is imperative in assessing any dental or gum damage. If a person is a mouth breather (which aggravates a dry mouth), an evaluation for causes of nasal obstruction is recommended, and if a snorer, seek an evaluation for obstructive sleep apnea. If on CPAP for apnea, be sure a humidifier is added to the machine.

  There is no cure for dry mouth unless a medication can be stopped. Otherwise, it is a matter of coping with the disability and using optimal hydration, oral lubricants, and preventing dental diseases.

H. For patients undergoing radiation therapy

  If a patient is to undergo radiation of the head and neck, it is critical to see an experienced dentist familiar with radiation and head and neck cancer. Pre-radiation consultation is a necessity. An intensive plan of dental prophylaxis is necessary. If there are dental issues prior to radiation, they must be treated. If there is severe dental and gum disease, extractions may be necessary. Follow up during and after radiation is critical for life! Because of radiation dental decay over the first few years after treatment, I have had to have every tooth in my mouth crowned (over $30,000).

  The current technique of radiation is much better than I had in 1991, and at least some of the salivary tissue is spared with current radiation techniques which should lessen the dry mouth problem. Make no mistake, if teeth are radiated, there will be consequences regardless of the amount of salivary flow.

  Because the mouth will be extremely sensitive and painful (mucositis) while undergoing radiation (and certain chemo agents), the use of a dental irrigator with proper additives will clean the teeth more efficiently than brushing. Rinses with fluoride will likely be recommended as well. There are solutions called “magic mouth wash” that may be recommended during the treatment phase and for an extended time after treatment. These mouth washes contain antibacterial, antifungal, cortisone, fluoride, and other ingredients to assist in cleansing a painful mouth from radiation and chemo.

I. Foods and liquids to avoid

  Alcohol, caffeine, certain fruits (can burn the mouth), mouth wash containing any alcohol, tobacco, hot sauces, and marijuana will aggravate a dry mouth. Eating bread can be a challenge and swallowing should be performed with extreme caution to prevent choking.

J. Treatment options for gum disease and dry mouth

  Since a dry mouth may lead to dental decay, gum disease and periodontitis, the treatment is the same regardless of the cause of a persistent dry mouth. Prevention is always the best and any regimen must see a dentist and dental hygienist for routine cleanings and examination (preferably 3-4 times per year). Early intervention of dental issues is a must.

  Here are some options for treatment: 

1) Sialogogues (drugs that stimulate saliva)

  These products are parasympathomimetic drugs (i.e. pilocarpine-Salagen and Evoxac), but there are side effects such as flushing of the skin and sweating (sweat glands have the same nerves as salivary glands) that may be unacceptable. They actually stimulate the nerves that innervate the salivary glands. If the salivary glands are destroyed by disease or radiation, these stimulants will be unsuccessful.

2) Chewing gum containing xylitol. As mentioned above, this sugar cannot be used as an energy source by bacteria and therefore is safe to chew. It does stimulate saliva to some extent, and the act of chewing massages the salivary glands to squeeze saliva out (if some saliva is still present). 

Be sure the chewing gum contains a maximum amount to (5-10 mg per day) of xylitol.

Check out this website: https://www.xylitolpreventscavities.com/products/xylitol-chewing-gums.html

There are many products that contain xylitol, and this is just one of them. Do the research and make good choices for you and your family.

3) Lozenges, rinses, sprays

There are many products available over the counter or online. Oral sprays or gels are my preference. Patients often must carry a water bottle for sips to combat dryness. I am never without a water source.

4) Flossing and irrigators

When there is poor saliva volume, the teeth are dry and food and bacteria can more easily stick to the teeth. Flossing after every meal is the best technique to combat plaque (bacteria that stick to teeth), however, dental irrigators will assist in the process. Using both might be optimal. Dental irrigators will clean in the crevices where floss cannot reach especially just under the tooth-gum line. They are essential when the patient’s mouth is too sore to tolerate a toothbrush.

5) Hydration is incredibly important. Patients without saliva are dehydrated. Saliva produces one liter of fluid  per 24 hours. At least 8-10 glasses of water per day is suggested.  If a person’s urine is dark yellow, the person is dehydrated.

6) Fluoride toothpaste/gel, toothbrushes

  Why is fluoride important? It is nature’s tooth decay fighter. It makes the enamel of the teeth stronger. It can also help rebuild enamel by remineralizing the tooth’s surface. By taking fluoride into the body through foods and water (fluoridated water), it is secreted in normal saliva giving continuous benefit to the health of teeth. Studies show that it reduces the risk of cavities by 25% in children and adults. Tooth paste has been fortified with fluoride since 1960 and has been responsible for a major reduction in dental decay.

  Brushing with a fluoride containing toothpaste and flossing after every meal is very important and its importance must not minimized.

  Most people rinse their mouth out after brushing which eliminates a significant amount of fluoride in the toothpaste. It is recommended to spit part of the toothpaste out and rinse the tongue but leave a residual amount of paste on the teeth for prolonged protection. Toothpaste containing prescription-strength fluoride should not be swallowed to prevent toxicity. A person should abstain from fluid or food intake for as long as possible after brushing to prolong this fluoride residue on the teeth. In between meal treats (especially with sugar) will continually challenge the teeth to decay.

  An electric rotary/oscillating toothbrush is superior to a regular toothbrush in getting rid of plaque, and always using a soft brush to prevent excessive abrasion of the enamel regardless of type.

  Do not share toothbrushes!! Ever!!! Change toothbrushes  at least every 3 months.   

  Dentists often prescribe fluoride toothpaste or gel containing 1.1% fluoride as additional help for those who do not have adequate saliva or for those at increased risk of decay.

   Fluoride gel treatments performed in the dentist’s office may be recommended. It is common to prescribe either fluoride gel trays at night at bedtime or prescription fluoride toothpaste at bedtime for more serious cases. A minimum should be swallowed to prevent fluorosis, a condition of mottling of the enamel, much more common in children.  

Fluorosis

OTC toothpaste contains 0.15% compared to 1.1% prescription fluoride toothpaste.

7) Additional help

Especially for those with a dry mouth and/or are mouth breathers, a cool mist humidifier by the bedside at night is very helpful. As mentioned above, if a person has obstructive sleep apnea, the addition of a humidifier connected to their CPAP machine is an important help. Coating the mouth at bedtime with a dry mouth lubricant, gel, or spray described below also is helpful.

8) Product reference for Dry Mouth Syndrome

  A dear friend of mine who is an internationally known speaker and motivator for oral cancer survivors, Eva Grayziel, is an oral cancer survivor herself (like me), was kind enough to share a fantastic poster with all of the products available online or in the pharmacies. Judy Bendit, RDH, was coauthor of this poster. Thank you both!

Eva is a big supporter of the Oral Cancer Foundation and is present in many of their events around the nation.

Support the Oral Cancer Foundation

Dry Mouth Products 2017

Ref.--The Journal of Contemporary Dental Practice, Mayo Clinic; Oral Cancer Foundation; Medscape 

3. Hereditary Cancer Syndromes—Screening; BRCA gene mutations in men—high risk for cancers

About 5-10% of all cancers have genetic mutations. Only some of the genetic mutations have been discovered and many are yet to be discovered. Screening for these syndromes is quite important for families who are at higher risk for developing cancer often earlier in their lives before standard screening is recommended. These syndromes point to the importance of knowing a person’s family history. It also points to the need for expert genetic counseling, which has created a flood of patients seeking their expertise and genetic counselors are in great demand and are scarce.

  There are many internet sites that offer genetic testing, and I have enumerated what genetic mutations are commonly offered. When there is a genetic abnormality(s) on a report, this creates a need for counseling to decide a course of action for the family.

BRCA suppressor gene mutations

  This genetic abnormality in the BRCA 1 and 2 gene mutation (Breast Cancer) creates a high risk of breast (85%) and ovarian cancer (55%) in families. This was brought to the attention of the public by actress Anjolie Jolie. I have discussed this in detail. Click on

www.themedicalnewsreport.com #14 , #27, #42, #56

Until recently it was not known to also be a risk factor for men. A study cited on Medpage (an online medical journal) that men are 8 times more likely to develop certain cancers especially melanoma and prostate cancer if BRCA positive. But now other cancers have been added including colon, pancreatic, and male breast cancer.

  17% of the men in this study who were positive for the BRCA gene mutation developed cancer, many at an earlier age than the general population. 

  The American Urological Association has reported that as high as 20% of men with prostate cancer exhibited some kind of DNA mutation.

  6% of Israeli Ashkenazi Jews are carriers for the BRCA gene mutation, mostly BRCA 2. As this issue has become more important, the University of Michigan has opened a BRCA gene mutation for men to screen them more frequently and earlier than normally recommended.

  There also appears to be a higher incidence of BRCA gene mutations in metastatic cancers, implying that the cancers that spread may be more aggressive because of the genetics.

  The bottom line is this: if a man has a positive family history for breast cancer, they should seek consultation to have a genetic study. There is even a prostatic gene mutation panel that can be ordered. Just having a genetic mutation alone must be correlated with other familial factors.

  General population screening is not recommended, however, in groups such as just described, it certainly should be considered if certain cancers exist in families.

  Today, oncologists order genetic profiling to direct their treatment (not to screen for cancer) since these genetic abnormalities can predict response to certain treatments. In clinical trials and advancing disease, testing has become a more important factor in determining choice for treatment.

Medpage, May 15, 2017

Lynch Syndrome

  These families have a non-polyposis syndrome creating a higher risk for colon and uterine cancer.

Cowden Syndrome

This syndrome is characterized by having non-cancerous growths in the skin and mucous membranes (hamartomas). These families have a genetic mutation (PTEN) causing an increase risk of breast, thyroid, and uterus cancer.

Other Syndromes

Neurofibromatosis (Von Recklinghausen) causes tumors along the sheath of nerves in the body and brain.

Li Fraumeni Syndrome increases the risk of multiple cancers including breast cancer.

Von-Hippel Lindau causes cancers of the eye, brain, and spinal cord.

Gardner Syndrome causes cancers in the gastrointestinal tract.  

Summary

  Patients who have 2 or more family members with certain cancers should consider genetic counseling before going online and getting tested for genetic mutations. Large cancer centers usually provide this kind of testing and have the greatest experience in guiding patients.

Reference: MD Anderson Cancer Institute

4. New guidelines for estrogen therapy for menopausal women

The North American Menopausal Society has revised their 2012 guidelines for estrogen therapy for women who become pre-menopausal with symptoms. This discussion with your doctor should take place as soon as menstrual periods become erratic, symptoms appear, or there are medical reasons for an induced menopause.

Previous in-depth discussion of menopause in 2 previous reports:

www.themedicalnewsreport.com #15, #55

Guidelines:

Note that last comment! There has been concern by some women for continuing estrogen therapy for extended periods of time. The risk/benefit discussion must always be understood before going forward with any new guidelines discussed with a patient’s doctor.

NEJM Journal Watch, June, 2017

   5. Asymptomatic people with Atrial Fibrillation are at higher risk of stroke

I have discussed atrial fibrillation previously and should be reviewed: www.themedicalnewsreport.com #59

  There are many disease states that create no symptoms until a complication occurs that could be fatal. Atrial fibrillation is an example in some cases.

  A recent study reported on 6011 patients and 69% were without any symptoms and most did not know they had atrial fibrillation. Those asymptomatic patients were twice as likely to have a stroke (15%) compared to those who had symptoms and were under treatment. TIAs (transient ischemic attacks) occurred more often (19%) vs. 10% in the symptomatic group.

  This suggests the argument for early detection with routine EKGs and physical exams in older people. A doctor can also hear the rhythm abnormality with a stethoscope.  The reason that A-Fib patients with symptoms will have fewer complications is because they are on anticoagulant therapy to prevent emboli from the heart sending a clot to the brain causing a stoke.

  Symptoms of atrial fibrillation include palpitations, lightheadedness, dizziness, general fatigue, rapid or irregular heartbeat, fluttering in the chest, chest pressure, and faintness. All of these could be very mild and if a patient ignores them, a patient is putting themselves at unnecessary risk.

  Patients may start with intermittent A-Fib, and therefore be missed on exams and tests by doctors.

  Patients also need to know the symptoms of a TIA and or stroke. Symptoms of a TIA are the same but dissipate.

6. Social Anxiety Disorder

I have reported on general anxiety disorder in the 50^th Medical News Report, and I would suggest you review this report. Click on: www.themedicalnewsreport.com #50

  Social anxiety disorder is a subtype of generalized anxiety and is very common. Most of us have had experience with getting nervous before a speech, a test, a sport activity, etc. However, when that anxiety is intense and keeps one from performing well, it must be addressed. People who have a fear of being scrutinized by others to an excess, and when fear of failure is not controllable, counselling should be considered.

  Social anxiety disorder affects up to 13% of the population and is characterized by an intense fear of being viewed negatively. Those who have this disorder are at increased risk for generalized depression and substance abuse.

  Unfortunately, most people would not seek help for such a problem. This is one of those disorders that must be brought up by the physician when a patient seeks help for a co-existing condition such as depression, panic attacks, etc.

  Since time is limited when seeing a primary care physician, it is incumbent for the patient to bring up such issues as social anxiety, or it will be more difficult to treat depression, etc.

  Social anxiety disorder begins at an early age (about 13 years of age) but is often overlooked for years.

  There are three common co-existing conditions that should be understood—1) depression 2) substance abuse potential 3) avoidant personality disorder. How many teenagers avoid contact, stay in their rooms, and fear being judged by others? Impaired social skills, thoughts of suicide, and avoidance of personal relationships, and difficulty in school or work are not uncommon. When asked, over a third of these people will admit to these issues. They are often described as shy.

  Genetic and environmental factors are common. If parents suffer from this disorder, their children are at higher risk. Neurobiologic abnormalities (circuit dysfunction in certain parts of the brain having to do with serotonin production) are suggested as the cause, as are many disorders such as depression, general anxiety, etc. Further study is needed in the area.

  Key screening questions must be asked by the physician, the parent, the caregiver, or the spouse.

1) Do you avoid social situations and activities?

2) Are you fearful or embarrassed in social situations?

3) Do you take illicit drugs or drink alcohol to feel more normal and acceptable in social situations?

4) Do you feel depressed? (frequently depression will mask social anxiety disorder).

5) What are friends saying on social media?

Treatment

  Cognitive psychotherapy is the first-line of treatment with about 50-65% success and longer lasting results.  However, since most patients refuse formal therapy, as in most of the less severe psychological disorders, primary care physicians are faced with treating most of these patients with anti-depressants (SSRIs) and benzodiazepines (Xanax, Valium, etc.). The results may be faster, but do not last as long as cognitive psychotherapy.  Attempts still need to be made to get patients to see a counselor (psychologist, psychiatrist), especially if the symptoms continue or recur. Coordination with school authorities and counselors is critical.

7. Wax Impaction-A very common problem-solutions

12 million office visits per year in the U.S. occur annually because of wax impactions in the ear causing a variety of issues including hearing loss, a sensation of fullness, itching, popping, infection, and even izziness if pressed against the eardrum. Between Medicaid and Medicare, reimbursements of $46 million annually are paid for removal of wax impactions. 1/3^rd to 2/3^rd of nursing home patients who are over 65 have this problem and with superimposed impaired hearing, wax impactions are a serious issue. 

  Ear wax is created by skin cells in the ear canal sloughing off which accumulates in the canal are prevented from migrating out of the ear. There is normal migration of the wax out of the canal, and can be felt as it comes out in small amounts at a time, but using q-tips can push the wax further into the ear canal and create an impaction.  

  Keeping water out of the ear is wise so that the wax does not mix with it and swell the wax blocking the canal even more.

  Before performing any home remedy, it is suggested that the primary care doctor examines the ears to see if wax is present and the extent. Most primary doctors will irrigate the wax out if asked. It is important to know if there is a history of a hole in the eardrum (perforation), recurrent swimmer’s ear, or other known pathologic processes. If they are not equipped to clean ear wax, consult an ENT doctor.

  Home Remedies (read the instructions in the package insert carefully). A person must realize that they make the situation worse, if it happens, seek immediate help before an infection sets up.

Bulb irrigation with drops to liquefy the wax

  Murine has a good kit. If you chose to use this system or other similar kits, warm the drops slightly before placing in the ear. Fill the canal and place a piece of cotton gently in the outer ear canal to prevent the drops from spilling out. Wait 20 minutes and irrigate with a full bulb using a combination of warm water and vinegar (3/4 cup of warm water added to ¼ cup of warmed white vinegar). With the ear turned down (not up), irrigate in an upward stream to allow the wax to come out. If it does not in 2-3 attempts, I would suggest a consult with your doctor.

Never use cotton tips as they will push the wax deeper into the ear canal.

Never put anything bigger than your elbow in your ear!!!

Do not use a forceful irrigation like a water pik. I recently saw a screw like applicator (below) to clean the ear wax and I have to condemn it.

As an ENT surgeon for 30 years, I have seen many injuries to the ear canal from home remedies, so don’t be foolish. It is best to see the doctor. Seeing an ENT physician is the best choice, because they have instruments, irrigators, and binocular visual instruments, and the most experience.

  These suggestions should be discussed with your doctor before proceeding. This is just information, and not meant to be followed without approval of your personal doctor.    

8. Interstitial Cystitis- a painful bladder disease especially for women

This disease is also called bladder pain syndrome characterized by pain, pressure, and discomfort of the area above the pubic bone in the lower abdomen and perineum associated with the usual urinary tract symptoms of an infection (frequency, urgency, nocturia, blood in the urine, etc.) and painful intercourse. Women have this disease 10:1. 3-7% of Americans have this diagnosis.

  This disease is often associated with other pain syndromes such as allergies, irritable bowel syndrome, fibromyalgia, etc. including depression and poor quality of life.

  The cause of this disease is not well understood, however, autoimmunity is suggested.

Cystoscopy findings

Scarring and small multiple hemorrhages are found frequently.

  First line therapies-

  Patient education regarding this disorder to understand the issues and cooperate with several symptomatic measures, including hydration, using pyridium to relieve pain, bladder training, relaxation techniques, and other coping measures.

  Second line therapies-

Amitryptyline-a tricyclic antidepressant has helped in many cases helping pain and urgency symptoms.

Cimetidine-a histamine receptor antagonist seems to help with pain and nocturia. 400 mg twice a day is recommended.

 Hydroxyzine-(Vistaril, Atarax)-this is an antihistamine with sedating characteristics, which may its main feature, especially if taken at night.

PPS-Pentasanpolysulfate sodium-(Elmiron)-This is the only FDA approved drug for bladder pain from this disorder.  100mg three times a day is recommended.

Operative treatments-

  50% DMSO (dumethylsulfoxide) is the only FDA approved medication that can be instilled into the bladder. Heparin (anticoagulant) and hydrocortisone, and lidocaine derivatives can be instilled simultaneously. These treatments are performed every 1-2 weeks for 6-8 weeks.

  This is a chronic condition that will need to be followed long term.  

This completes the January, 2018 report. Next month, the February subjects will be:

1) Treatment of prostate cancer versus close observation

2) Infection risks in patients with cardiac implantable devices

3) Questions to ask at the time of discharge from the hospital

4) e-cigarettes and smoking cessation success-an update

5) Cancer survivorship series—second cancers and continued pain after treatment

6) oral manifestations of systemic disease

Stay healthy and well my friends, and have a great 2018, Dr. Sam