The Medical News Report #73

February, 2018

www.themedicalnewsreport.com

Subjects for February, 2018—shorter subjects

1. Best Diets Annual Report--January, 2018 U.S. News and World Report

2. February is Heart Month

3. Surgery versus observation (surveillance) in localized prostate cancer in men 75 and younger—a new 20 year study

4. Infection rates and other consequences of cardiac implantable devices (pacemakers and defibrillators)

5. Important questions to ask at the time of discharge from the hospital

6. New information on smoking cessation methods

7. Cancer Survivorship Series—Part 2—recurrence and second independent cancers—a call for lifelong continuous surveillance for survivors

8. Oral manifestations of systemic disease

9. Is there any help to prevent dementia in older people?

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. And see your doctor at least yearly.

  Thanks!! Dr. Sam

1. The best diets for 2017 –Annual U.S. News and World Report.

The article website is:

https://health.usnews.com/best-diet

  Highlights include the DASH Diet and Mediterranean Diet which tied for the best overall diet. Multiple categories are provided including best weight loss diet, best diabetic diet, etc.

   There is a link to every diet in this article, so take the time to download it. The website is above.

2. February is Heart Month

February is Heart Month!! It is a great reminder to get your heart checked. Make an appointment with your doctor and talk to him or her about considering an EKG, especially if you are over 50 years of age. Blood pressure checks are very important including actual physical heart examinations by your doctor. As always, family history will dictate to some extent the aggressiveness of a cardiac evaluation including testing for elevated cholesterol, glucose (sugar), and other liver and kidney tests. Talk to your doctor about being over-weight, smoking, having hypertension, etc.

  Below are some statistics that are important to keep in mind since cardiovascular disease (CVD) is still the #1 killer of adult Americans. CVD includes heart disease, stroke, and peripheral artery disease (PAD). The best heart healthy diets are described in the latest best diets report just mentioned above .

  Men develop CVD about 10 years earlier than women is more common in blacks. Below there are some important facts avout CVD:

Early detection is critical to prevent permanent injury to the cardiovascular system. Other tests such as ankle-brachial index, a blood test called C-reactive protein, and tests for the amount of calcification in the coronary arteries are not routinely recommended (USPSTF) at this time, but are used to assess risk.

Journal of the American College of Cardiology

American Heart Disease

3. Localized Prostate cancer---surgery vs observation —a new 20 year study

I have written extensively on prostate cancer and suggest if you want in-depth information, please click on the website:

www.themedicalnewsreport.com #33 , #34, #35, #36, #38

Decisions regarding options for care

  One of the most controversial issues in prostate cancer is deciding whether to carefully observe a cancer and treat it only if it becomes more aggressive or progresses. This is  especially true for older men 75 years of age and older.

  Most younger (than 75) men choose standard treatment (surgery or radiation) for various reasons including the risk of recurrence. It is known that much younger patients are more likely to have a more aggressive tumor, however not all are aggressive and some are very slow growing. Longevity (life expectancy) comes into play with more senior patients, and it is easier for them to consider observation.

  Doctors can determine the aggressiveness of a cancer using pathological analysis from multiple prostate biopsies (called the Gleason score), plus the PSA level, and MRI scan results. If a cancer is localized (inside the capsule of the prostate, in just one smaller spot), most patients underwent surgery or radiation if younger in age than 75.

Position of the prostate cancer determines staging. Note the T-1 cancer is considered localized and not into the capsule. As the cancer progresses, it invades into the surrounding structures.

  Now a new study has compared radical surgery with observation for men 75 and younger. It has taken time to follow these men (average follow up 12.5 years) over an extended time to see if the mortality was higher in those undergoing radical prostatectomy or in those who were observed. Cancers that started slow but eventually progressed, can still have definitive treatment and be cured. Guidelines for observation, repeat biopsies, MRIs, etc. may vary with cancer centers.

Results of the Study

  A 20 year study followed 700 men who were randomized to have either surgery or observation (the option of radiation was not in the study). Results showed that only 7% actually died of their prostate cancer in the surgery group and 11% in the observation group, considered statistically similar.

  The all-cause death rates (over those 20 years) were 61% in the surgery group and 67% in the observation group, but again the difference was not statistically significant.

  Those who were observed had a higher progression rate of their cancer as one would expect, but half were asymptomatic and the cancer progressed only inside the prostate still allowing for curative surgery. Only 20% of those initially observed ultimately had surgery and rarely after 5 years. This saved a large number of men having surgery.

  Androgen deprivation therapy is commonly used to prevent recurrence or suppress the growth of tumors in the prostate (similar to using tamoxifen in women with breast cancer).

  Androgen deprivation therapy is an anti-hormone treatment (Lupron, Zolodex, Trelstar, etc.). It was used twice as often in the observation group (21% vs 44%) to prevent either progression or recurrence. (Most men are put on androgen deprivation therapy if the prostate cancer is more aggressive after surgery or radiation).

  There are significant side effects from suppressing androgen in males, and would be more significant in younger men. This must be part of the discussion when deciding options for care.

  Adverse side effects from surgery were more common in this study as expected than those that were observed. Allowing progression of a cancer could cause more obstruction of urine flow. Erectile dysfunction, rectal issues, and incontinence were the most common long term side effects in those treated with surgery. These side effects have to be considered if surgery (radiation) is chosen.

  This study confirms that the risk of dying from prostate cancer is low and observation should be an option if the cancer is localized and fits the criteria for a less aggressive cancer.

  It is critical to consider the parameters discussed in this report to determine how aggressive a cancer is and whether observation, surgery or radiation should be considered. The above study did not compare radiation with observation and a study is needed.

  Second opinions are wise when considering all 3 options.  

Decisions to make (PSA), observation vs treatment

  Death caused by prostate cancer is less than 4% in patients younger than 75 and even lower if over 75 (they die of unrelated causes). 80% of prostate cancers are considered to be slow growers based on pathological analysis and testing.

 It is the decision of doctors and patients whether to screen for prostate cancer with a PSA test in the first place, and now there is another decision to make. Now there are 3 options to consider (observation, surgery, or radiation) at ages younger than 75.

    With continued research, hopefully doctors can more effectively separate low grade from high grade cancers and treat accordingly. As we continue research on genetic markers, this will likely shed significant light on this difficult subject.

NEJM, July, 2017

4. Infections and malfunction of cardiac implantable devices (pacemakers, defibrillators)

Pacemaker with wires into the heart

The pacemaker and defibrillator business is thriving with more seniors living longer. With greater numbers of devices comes increasing numbers of infected and dysfunctional implants.

  The overall incidence of infection is 1-4% in adults (slightly higher than joint replacements), but with increasing numbers being implanted, the rate of infection is increasing. 70-80% are implanted in patients 65 years or older.  The inpatient mortality in these patients is 2% because of their underlying cardiac disease.

  Infection in the implant is a ruinous complication and is more common after a previous replacement. Infection is the reason for removal and replacement in 70% of the cases. Replacement of batteries is another reason. Signs of infection were present with fever and elevated white blood cell count. Staph, strept, E.coli, and pseudomonas infections have been reported.

  Anyone with an implant who develops a fever for no obvioius reason must be checked for an infected implanted cardiac device.

  The patients requiring these devices are in some degree of cardiac decompensation (usually some type of serious heart block or arrhythmia), and these devices are in most cases life-saving. It is estimated that over 3 million Americans currently have these implants.

  More recently wireless pacemakers are being used (mostly experimental), which would potentially prevent having wires directly implanted into the heart muscle thus eliminating a major source of infection.

  Infections can occur along these wires called vegetations similar to what occurs on heart valves and can cause heart valve infections as well (endocarditis).  Infections in the pocket where the implant is placed can also occur but is less common. The infection creates local damage and seeds the blood stream with bacteria. A significant percentage will grow bacteria from blood cultures. These infections usually occurs over the first year.

  Antibiotics are recommended prior to implantation to prevent infections based on studies from the 1990s.

  Removal of the wires is relatively easy during the first year, but later removal is difficult due to scarring around the wires necessitating procedures to release the wires from the scar (commonly lasers are used).

  Risk factors for implant malfunction include male sex, younger age, severity of the patient’s condition, repeat placements, significant gum and dental disease (periodontal), and the absence of prophylactic antibiotics.

  In patients with pacemakers and defibrillators, it is critical for patients to discuss with their cardiologist about prophylactic antibiotics when having other operations and dental procedures to prevent seeding of bacteria into the implants.

  It is important for patients to understand the risks and benefits of any procedure, and this is no exception.

Reference—American Heart Association, National Institutes of Health

5. Important Questions to ask at the time of discharge from the hospital

It is critical to be prepared to leave the hospital with all the correct information to prevent post-hospital complications.

Here are some important questions to ask before leaving:

   a) Do you have the correct medication list with dose and schedule? Are there any new medications that might interfere with current ones?

  Patients and or family members must bring pill bottles, a list of their medications to the hospital, or call the primary care doctor for an updated list. If certain meds must be stoped prior to surgery, be sure those instructions were followed prior to hospitalizationas they may need to be stopped 7-10 days (stopping aspirin, Omega 3 fatty acids, anticoagulants, St. John’s wort, etc.) and ask when to restart them.

   b) Are there instructions for an altered diet, activity and exercise, bathing, dressing changes, bed elevation, etc.

   c) There is often more than one treating doctor, but it is important to know that the primary treating doctor knows about these treatments from all consulting doctors (ask the nurse to check). Which doctor is responsible for post-hospital instructions, and which doctor(s) are to be seen after discharge and when?

   d) Will any lab tests need to be scheduled post-hospital before returning to see the doctor(s)? Has the patient been anticoagulated? Be sure to know any limitations because of this medication.

   e) Are there written post-hospital instructions. Do you understand them? Who is primarily doctor responsible for me after discharge?

   f) Resting in the hospital can be a challenge with vital signs being taken around the clock. Talk to the nurse about  sedatives if needed for rest and perhaps a prescription after discharge. Weakness from bedrest, surgery, medications must be addressed. Do you need home physical or occupational therapy to get back on your feet?

   g) Do you need any special supplies after discharge such as a bedside commode, crutches, anti-embolism stockings, etc.?

   h) Ask for a summary of the hospitalization (even if it has be emailed or mailed), diagnoses, post-hospital management plan, prescriptions needed to be called to the appropriate pharmacy (have the phone number), etc.

  This information may not be available unless you insist. Be sure you ask for the least costly prescriptions, because if you don’t, you may stroke out from the price. Shamefully, most doctors do not have a clue about the price of drugs. The squeaky wheel gets oiled!!

   i) Who do you call if there is an emergency or there are questions, and what phone number? If the doctor is in a group, who is on call for your doctor?

   j) What complications would need immediate attention after discharge (bleeding, fever, shortness of breath, excessive pain or swelling, etc.?

Ref-- Suneel Duhad M.D. in www.kevinmd.com  March 2017

6. New Information on smoking cessation methods

  There is a significant amount of new information about smoking cessation methods and their effectiveness.

  Here are the previous reports I have written regarding e-cigarettes:

www.themedicalnewsreport.com #25 , #28, #50, #53, #64

  It is still important to note that teens who use e-cigarettes, hookahs, cigars, and smokeless tobacco are twice as likely to start smoking cigarettes within a year. Use of multiple methods raises the risk to 4 times. E-cigarettes come in many flavors attractive to children. Do not let your young people experiment with vapes, e-cigarettes, or nicotine addicting methods.

Adults and smoking rates/mortality

  The number of adults who smoke is still dropping resulting in a lower mortality rate from smoking-related cancers dropping 5% since 2005. Most quitters are age 25 to 44. But there still are 15.5% of adults in the U.S. still smoking and are disproportionately male, those with disabilities, no insurance or on Medicaid, the LBGTQ Community, and those who live in the South and Midwest. CDC Statistics, 2017

  90% of those who try to quit smoking do so “cold turkey”. Even stopping for a day will get a person on the road to quitting. The American Cancer Society still has a successful program to stop smoking—The Great American Smokeout—the third Thursday of November. It gives potential quitters a target date to pick. Check it out at www.cancer.org

Status of e-cigarettes

  The British Medical Journal (BMJ), July, 2017, cited 161,000 participants that were studied to find out about their use of e-cigarettes in trying to stop smoking. Results concluded that since 2014, the number of adult users of e-cigarettes has increased dramatically. This study included current smokers (11.5%) and recent quitters (19%) who were current e-cigarette users. Men were more likely to use e-cigarettes as were younger age groups.

The results reported that 8% of e-cigarette users were successful in quitting, whereas only 5% who were trying to stop with other methods (gum, patch, pills) were successful. This is only one study and needs to be replicated for the FDA to be convinced. They have postponed deciding approval til 2020. That usually means insurance will not pay until approved.

  The study results may not be very impressive (8 vs 5%), but it represents just one of the first studies to show the value in smoking cessation. The low rates of staying off tobacco underscore the enormous task it is to kick nicotine addiction. But smoke free environments have helped plus the introduction of quit-smoking aids.

  It is interesting that younger people are more successful at quiting than older people. Users of long time nicotine addiction takes it toll.

  The inserted cartridges in e-cigarettes are available in decreasing concentrations of nicotine, so people are able to withdraw from the addicting chemical at their own pace.

  Some will stay on a maintenance low concentration of nicotine in their e-cigarettes for prolonged periods and many will for years to come. At least they are not inhaling the carcinogens in a cigarette. The long term effect of continuing to consume nicotine with e-cigarettes has not been studied.

  For those who struggle with smoking cessation, e-cigarettes are apparently a legitimate method to try, but there still needs to be a heavy dose of motivation to quit. Relapse is common, so do not be discouraged.

Link between nicotine addiction and depression, symptoms of nicotine abuse disorder

  It is well known that there is a link between nicotine addiction and depression. It would stand to reason that smoking cessation is more difficult to attain in this group.

  There are greater symptoms of nicotine withdrawal in depressed patients. Smoking cessation and depression must both be addressed . It is twice as likely for depressed patients to be addicted, and more likely to relapse if the person tries to quit.

  Physicians should ask if there is concomitant depression in any patient desirous to quit. Withdrawal symptoms can include using tobacco to relieve or avoid symptoms which might aggravate depression.  

  There are 11 symptoms defined by the Diagnostic and Statistical Manual of Mental Disorders for any substance abuse (narcotics, alcohol, including tobacco):

The strongest predictors for nicotine addiction are the time to first cigarette in the day and total cigarettes per day. Those that start their day with a cigarette have the hardest time quitting.

New information on best treatments

  Nicotine replacement use increases the quit rate by 50-70% at least initially even though only 5-8% stay quit. In depressed patients, the use of anti-depressants and counseling is necessary prior to and during attempts at smoking cessation. The use of the oral medications are anti-depressants.

  Skin patches provide the most constant steady rate of nicotine into the blood stream and have a higher compliance rate but are not as successful in relieving some of the cravings. Using more than one method can be tricky (because of overdose of nicotine), and guidance from the physician or smoking cessation counselor is clearly necessary. Using the oral medication (plus a patch and occasional use of a lozenge is recommended by MD Anderson Cancer Institute cessation counselors.

  There is a new nasal spray (one to two doses per hour—maximum of 40 doses per 24 hours) available in addition to the known methods.

  This study did not address the addition of bupropion (Wellbutrin, Zyban) or varenicline (Chantix), which is an antidepressant and is also successful in assisting smoking cessation in addition to using nicotine replacement methods. Adding these medications enhance the quit rate, but there are no studies yet how much more successful.

  Nicotine replacement may be required for 6 months or longer and may require low dose maintenance therapy for years. Regardless of techniques, there is a 50% relapse rate for those who quit.

  90% of people still go “cold turkey” when they decide to quit.

  Behavioral therapy achieves a 60-100% cessation rate and a one year cessation rate of 20%. Add exercise to the program, and it is even more successful. Medscape, Dec., 2017

FYI

  Hypnosis and acupuncture are no better than placebo as reported in recent journal articles (but remember placebos can help as many as 20% of people).

  Nicotine addiction is as hard to kick as heroin, because these chemicals stimulate the same craving centers in the brain.

  For best results in kicking the habit, consult your doctor for oral medication consideration plus at least one nicotine replacement method, and counseling. With this combined method, you have more than a 20% chance of staying quit.

7. Cancer Survivorship —Part 2—recurrence and second cancers—a call for lifelong constant surveillance

We define a patient with cancer as a survivor from the time of diagnosis to the end of life!!

  Today, a good percentage of patients are living for years after their original diagnosis of cancer enjoying a good quality of life. Cancer for many can be thought of as a chronic disease. Cancer survivors in the U.S. will number 20 million by 2026 (15 million in 2016), according to the American Cancer Society. It has been quite a victory for oncology, patients and families, although we have a long way to go until we conquer cancer.

  Thanks to screening, early diagnosis, and improved treatments, most cancers can be cured in over 80% of the cases. A third is due to screening and two-thirds are due to treatment advances according to the latest data.

  There are exceptions to taking a victory lap, because early diagnosis is not possible in some cancers, and it is because these cancers do not create early symptoms. Lung, pancreatic and ovarian cancer are examples. With these particular cancers, there are to date no cost effective screening methods for the general public (there are tests for high risk groups). Even some of the screening methods have been questioned as reliable or do not necessarily need to be discovered until smptoms occur (i.e. prostate-PSA).

  For those who have success in either controlling or curing their cancer, these patients will experience significant side effects from their treatment. Most are aware of treatment side effects during the process, but some of these side effects don’t even show up for months or years.

  I have already discussed chronic fatigue in cancer survivors (Part 1 of the cancer survivorship series) in the 54^th Medical News Report. Click on the website:

www.themedicalnewsreport.com #54  

Cancer recurrence and second cancers

  Our enemy is formidable. Two of biggest fears survivors have is recurrence of the original (primary) cancer, but they also have an increased risk of a second cancer separate from the first. This risk is greater than the general population. Genetically, those that are diagnosed with cancer are more prone to other cancers even when, there is no known genetic marker. But even a recurrence or a second independent cancer is not a death sentence.

  Cancers of the respiratory tract have risk factors that increase the chances of a second respiratory cancer. For example, a smoker who develops a head and neck cancer has an increased risk of being diagnosed with lung cancer, but there is also a 15% chance of developing another separate head and neck cancer especially if they keep smoking.

  According to the JAMA Oncology Journal, approximately 25% of Americans 65 years and older and 11% of younger patients who were previously diagnosed with cancer will have one or more cancers at different sites.

  Breast cancer patients with genetic markers (BRCA) at risk for a second independent cancer in another site in the breast. This has led many women to undergo a preventative mastectomy in the other breast. Also, if the cancer is BRCA gene mutation positive, ovarian cancer risk is 50-65%, with a higher risk of colon cancer than the general population. More recently if a man has a female family member with the BRCA gene mutation, it has been discovered they are more prone to developing prostate and male breast cancer.   

Long term surveillance is critical

  These are examples of why it is so important to have intense surveillance for years after a survivor’s initial treatment. Survivorship guidelines are critical to follow these patients with a plan. Oncologists are also reaching out to primary care providers to assist in these survivorship issues as the number of oncologists is not increasing to keep pace with our increasing population.

  Patients who undergo chemotherapy and or radiation therapy for any reason have a higher risk of developing leukemia. Therefore, routine blood counts are critical in following these patients.

  Risk reduction and screening plays a critical role in preventing recurrence and second cancers. These risks vary with the cancer. Early detection of a recurrence or a second independent cancer will give the patient the greatest chance of control or cure.

  As many as a third of cancer survivors stop seeing their oncologists within 5 years after treatment. With this knowledge, it would be prudent to maintain contact with them or a willing primary care physician who is trained to follow cancer survivors and their risks. There are training modules for primary care physicians provided by the George Washington Cancer Institute in cooperation with the Amercian Cancer Society that I (and a group of dedicated volunteers) spent 5 years working on thanks to a CDC grant. Here is the website: http://www.cancer.org/treatment/survivorshipduringandaftertreatment/index

What can a cancer survivor do to reduce their risks of recurrence or a second cancer?

  Risk reduction is essentially the same as it is for the first cancer. A proper diet, weight management, smoking cessation, less alcohol consumption, sun protection, and exercise are positive moves to reduce risk. Protected sex, and vaccination for hepatitis B can also reduce the risk of a HPV or other viral induced cancers.

  It is known we can prevent as much as 50% of cancers with better lifestyle behaviors, screening, and vaccination. Education is also the best way to prevent cancer.

 Don’t forget the rest of the body

  Most importantly, routine followup for survivors is critical to not only check for recurrence but new cancers in other areas of the body. Survivors cannot get tunnel vision for theoir cancer and forget routine screenings and whole body checkups, as another cancer (and other diseases) can be diagnosed early and cured. Surveillance is for life!

Great news about progress in cancer of the lung

  There is great news about treating lung cancer. As most know, it is a deadly disease with dismal cure rates. The most common type is the non-small cell squamous cell carcinoma. I recently reported on immunotherapy for advanced disease describing good benefit over the usual chemotherapy. A recent report cited nivolumab (Opdivo-a check point inhibitor immunotherapeutic drug with PD-1 expression) has extended advanced patient’s life span from a 5 year survival rate of 16% to as high as 43%. This is huge!! This drug is outperforming any medication for advanced disease in the lung. If you want to read about immunotherapy, please click on: www.themedicalnewsreport.com #61  Reference: The American Journal of Clinical Oncology, July, 2016, The American Cancer Society, The National Cancer Institute; JAMA Oncology, 2017

Later in the year, I will continue the cancer survivorship series-part 3-chronic pain in cancer survivors

8. Disease Manifestations in the Mouth

  The mouth is lined with a mucosa that is the same throughout the gastrointestinal tract and therefore signs may occur in the mouth implicating a lower GI disease. It is also commonly involved (sometimes the earliest sign) in skin diseases, and other systemic diseases.

A. Gastrointestinal diseases

    1-Ulcerative Colitis--5-10% develop aphthous ulcers, angular stomatitis, and hemorrhagic ulcers of patients.

     Angular Stomatitis    

2-Crohn’s disease—50% present with some type of oral lesions including diffuse lip, gum, and mucosal swelling. Fissures at the corner of the mouth (angular cheilitis shown above) are common. Granulomas can develop in the mouth appearing as bumps in the mouth.

    3-Gastrointestinal Reflux—oral complications occur in 18-28% of patients with reflux. Acid reflux back into the mouth at night causes damage to enamel of teeth, sore throat, a sensation of a lump in the throat from acid irritation including swallowing difficulty. Treatment with PPIs (proton pump inhibitors—Prilosec, Prevacid, Dexilant) is necessary to combat the acid and will improve the symptoms. Dexilant is the best but a tier 4 drug (expensive).

B. Liver Disease

Chronic liver disease usually implies cirrhosis caused by alcohol, hepatitis, and other toxicities. Frequently because of bleeding tendency from loss of vitamin K, hemorrhages in the mouth can occur. Bleeding gums is common. Jaundice will turn the mouth yellow (the whites of the eyes too). Hepatitis C has a higher incidence of lichen planus (2-4 fold increase). This skin disease causes papules and plaques, which can occur in the mouth as well. Lichen planus often causes these oral manifestations.

C. Medications causing oral cavity issues

    a. Biphosphonates (Fosamax, Didronel, Zometa, Boniva, Reclast, etc.) for osteoporosis can cause osteonecrosis of the jaw. Below is an area of exposed bone which is draining. There is dead bone present which must be removed by an oral surgeon. Alternatives to treat osteoporosis would also be appropriate

Monilial (fungal) infection

Antibiotics cause fungal infections in the mouth

The above slide is a monilial (yeast) infections treated with oral antifungal medications (Nizoril, Diflucan, etc.). Probiotics may also help if started when antibiotics are begun.

  Many drugs can cause sores in the mouth especially antibiotics and chemotherapy which can cause fungal overgrowth and extreme soreness, white patches that may be rubbed off but return.

  Chemotherapy or radiation mucositis is very common with certain chemotherapeutic agents or radiation to the mouth for cancer of the oral cavity and throat. This must be treated by a knowledgeable dentist and oncologist with oral rinses, pain medication, combination mouth washes (magic mouth wash), and liquid diet. It is extremely painful and unfortunately a common reason patients decide to stop chemotherapy. Below is a cancer on the edge of the tongue and severe mucositis on the right slide.

Squamous cell cancer

mucositis

Herpetic gingivostomatitis

Viruses

 The above slide demonstrates small bumps that bust easily and create small ulcers that are painful. This is herpetic gingivostomatitis. The herpes virus can cause fever blisters on the lips but also create multiple ulcers in the mouth and must be treated with one of the acyclovir oral medications (Zovirax, Valtrex).

This photo above shows the back of the throat with numerous pockets of pus caused in this case by the Cocksackie virus, the most common virus caused by hand, foot, and mouth disease. It usually can last 1- 2 weeks and will resolve but is very painful. Local non-alcohol containing rinses will help while they resolve and the so-called “magic mouthwash”, which is a combination of steroids, antibiotics, anti-fungal agents, etc.  

  The Cocksackie virus can be confused with infectious mononucleosis caused by the Ebstein-Barr virus (photo below left), but usually the tonsils are still present and involved. It is also confused with strept throat (photo below right). There is no actual treatment, but liver function studies and evaluation for an enlarged spleen is necessary. Below is a typical appearance of mono on the left slide

The above slide demonstrates soreness with mild ulcers in the mouth that are enlarging with hemorrhages in the mucosa. This is an example of a skin disease which affects the mouth—pemphigus  vulgaris, which is present in 50-70% of patients.

  This “lacey” appearing white plaques could be monilia but in this case, it is lichen planus, an immune disease which also affects the skin. The white patches can’t be rubbed off.

This photo above is a methamphetamine user. Dental decay and periodonititis are usually severe and will require major dental rehabilitation. Attractive isn’t it? Cocaine can do similar damage.  Medscape

9. Can doctors prevent dementia in older people?

  Recently, the NEJM (New England Journal of Medicine) Journal Watch reviewed a multitude of articles in an attempt to answer the question—“Is there any help for older people in preventing dementia?” The answer is—there is no magic bullet for this terrible affliction.

Here is some recent information:

a) Aerobic activity and resistance training helps those with cognition in normal people but not those already diagnosed.

b) There is no medication (prescription or OTC) that will reverse or slow down dementia. This includes a long list of off-label medications, supplements, and vitamins.

c) Cognitive training does not improve cognition in the general population of those with dementia.

  There is intense research in this field, however, we are not there yet. The mysteries of a degenerative disorder that afflicts an increasing number of Americans has yet to be unraveled.

  There is evidence that a nutritious diet, regular exercise, not smoking, limiting alcohol, not abusing illegal substances, and maximizing management of chronic illnesses may help prevent the onset of dementia in some selected patients, but the amount of time it takes to prevent dementia is undetermined. It only makes sense that the healthier a person is, the more likely dementia will be delayed if it is going to develop.

Annals of Internal Medicine, 2017     

This completes the February, 2018 report. Remember, this is Heart Month!! Be kind to yours!!

Next month the March, 2018 subjects will be:

1) Health and Spirituality

2) Forms of tendonitis—Plantar Fasciitis and Tennis Elbow

3) Medical Errors; Medical Malpractice 2016

4) Epilepsy—treatment of seizure disorders

5) Should the FDA ease up on off-label use of drugs?

6) Medical benefit of coffee

7) Many U.S. children will be obese by age 35

As always, Stay healthy and well, my friends, and Happy Valentine’s Day.  Dr. Sam

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