The Medical News Report

April, 2018, #75

www.themedicalnewsreport.com

Subjects:

1. New Guidelines for hypertension

2. Diseases of the nails

3. Options for Chronic pain management series—Part 1—Non-opioid medications; Defining Integrative Medicine

4. Obese women have higher rates of congenital malformations in their newborns

5. Deciding about second breast mastectomy to prevent future cancers

6. A look into the future to answers for the healthcare crisis—dr. Eric Topol

Dear Readers,

  Welcome to another edition of the Medical News Report. I appreciate everyone that reads some or all of the articles each month. In looking at causes of disease, inflammation plays a significant role as one of the causes of many diseases including arthritis, cardiovascular disease, diabetes, infection and even cancer. What you eat has more influence on inflammation than most anything. Foods that promote inflammation need to be minimized in our daily diet, and processed foods lead the pack. The other killer is stress, and getting a handle on this is easier said than done, but must be addressed. Examine your lives, and see if you can manage the stress of your daily lives better. Daily exercise will help relieve stress and even reduce inflammation by boosting the immune system and reducing blood pressure. It will pay big health benefits over your life! Enjoy one of the best months all year! April rocks!! Dr. Sam

Bouchart Gardens in Victoria, British Columbia

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

   Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, instructions for care, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

  Now, on with the information!! Thanks!! Dr. Sam

1. New Guidelines for the diagnosis of Hypertension

  Hypertension is the most modifiable and common risk factor for cardiovascular disease. And yet there are thousands of Americans that do not know what their blood pressure is (you should be checking it at home) and certainly what is too high or low and what is normal.

  To prevent heart attacks, heart failure, strokes, and kidney failure, it is critical to maintain a normal blood pressure. As one ages, hypertension is extremely common (age 75 and over---men 79% and women-85% have hypertension). Even though the levels of blood pressure correlate closely with cardiovascular disease, older patients must be treated with a closer eye on the risks (especially lightheadedness and falls) and benefits of tight control of blood pressure.  

  I have reported on this subject in several reports and advise that you review them. The basics of hypertension and the 5 classes of anti-hypertensive medications have not changed. To review hypertension and the 5 classes click on:

The Medical News Report #42 , #51, #56

Guidelines for all ages

  Although the American Heart Association recommends the same treatment regardless of age, it does state that treatment may have to be modified for older individuals with other illnesses and frailties. Also it states that those over 70 frequently have high systolic blood pressure and not diastolic elevation, which may not need to be treated, but the decisions are up to the patient’s doctor.   

  Sustained hypertension over time is the biggest risk factor for CV disease, however, even intermittent hypertension can raise the risk of heart attack and stroke. There are many diseases that can cause or aggravate blood pressure elevation including excessive salt, obstructive sleep apnea, being overweight, alcohol abuse, and stress (especially anger). Genetics play a role as well.

Stage 1 Hypertension

   The above chart demonstrates that a blood pressure over 120/80 is considered high but does not necessarily need to be treated. It is, however, a warning and must be monitored closely at home. The diagnosis of hypertension begins with  130-139/80-89 (Stage 1 hypertension) and should be treated with non-drug means defined below. This stage was previously termed pre-hypertension. Below are recommendations for non-medication treatment.

According to this new definition of stage 1 hypertension, 46% of American adults have hypertension.

Stage 2 Hypertension

  Pharmaceutical treatment should begin with 140/90 or greater.

Stage 3 Hypertension(Emergency Hypertension)

  A blood pressure of 180/120 is considered emergency hypertension and needs immediate treatment.  

Additional risk factors

  Another factor that has been added to the list by the American Heart Association is the 10 year risk of cardiovascular disease. More aggressive treatment should be considered if there is cardiovascular disease present in addition to hypertension. Hypertension is one of the most common reasons for heart disease, but if there are additional causes, treatment must be more aggressive.

  Everyone should have a blood pressure monitor at home and test it based on doctor’s instructions. To measure the blood pressure, a person should sit quietly for 10-15 minutes before testing (not after a meal or drinking caffeine).

Side effects of more aggressive blood pressure treatment

 Treating with blood pressure medicine at lower blood pressure levels may cause more side effects such as light headedness or fainting especially when standing up after sitting for awhile. As always, close attention to daily blood pressure measurements will assist the doctor in determining the aggressiveness of treatment. Patients must assist the doctor with a log of readings to determine proper treatment.

Another change in the guidelines from AHA

  The AHA no longer recommends beta blockers in first-line treatment for hypertension. There are other classes of anti-hypertensives that are preferred. The list includes metoprolol (Toprol, Lopressor), atenolol (Tenormin), etc. These medications may be added to milder anti-hypertensives if the blood pressure is not well controlled.

JAMA, NEJM, American Heart Association

  A footnote—A common antihypertensive medication, hydrochlorothiazide (Diuril), used for at least 6 years increases the risk by 29% for skin cancers by increasing the skin’s sensitivity to ultraviolet sun rays. For those taking this water pill, commonly used to lower the blood pressure, should realize they will sunburn more easily and will eventually have almost a third more risk for developing basal and squamous cell carcinoma of the skin in the years to come. Even though melanoma was not mentioned, it is well known that recurring sunburns (especially in the young) increase the risk of melanoma. American Journal of Dermatology

2. Diseases of the Nails

Diseases of the nail are not uncommon and may give a hint that there is a systemic disease yet to be diagnosed (diabetes, etc.). Fungal disease is the most common nail disease.

I. Fungal disease of the nail

  The deformity of the nails is called nail dystrophy, and the most common cause is fungus of the nails. The medical term for fungal disease is onchomycosis. This is one of the most common diseases in humans--10% of the population, 20% of 60 year olds, and 50% over 70 years of age.  

  Nail fungus is characterized by discoloration and thickening of the nail bed, and even crumbling or loss of the nail. The nail may be yellowish or the top layer may display white or yellow markings on the nail. When extensive, the nailbed can even be painful.

  The most common type of fungus is a group called dermatophytes and the disease is called dermatophytosis. Fungal cultures can be taken if there is a clinical need.

  Predisposing factors include trauma to the nails, diabetes mellitus, anyone who is immunosupressed*, and those with decreased blood flow to the lower extremities from atherosclerosis (PAD), over 65, male, and even swimming in a public pool or frequently taking showers in common bath facilities such as gyms, etc. It is often associated with athlete’s foot of the skin usually between the toes. *(Patients with immunosuppressive diseases such as HIV-AIDS and those on immunosuppressive drugs for cancer, arthritis, etc. are at risk.)

  It can occur from wearing artificial acrylic nails and or from contaminated equipment at nail salons. Even sharing nail files, clippers, etc. can create a problem. Not wearing socks (or changing daily) with shoes or wearing athletic shoes daily can be the source. It is best to alternate sorts shoes if possible.

Athlete’s foot comes from feet not getting enough ventilation, sweating, and not rotating shoes frequently. Poor care of the toenails is also a factor.

Athlete’s foot (tinea pedis)

This is the same fungus that causes jock itch and ringworm. The treatment is topical. Keeping the feet dry, wearing socks that absorb sweat, rotating shoes, etc. will all help prevent fungus.

  Recurrence (as high as 50%) is common because the same predisposing factors usually persist.

Treatment of nail fungus

  A. Topical therapy

     a)  Over the counter topical therapy(OTC)

  Treatment for fungus of the nails, athlete’s foot, jock itch, and any area of fungus on the skin, (i.e. under pendulous breasts) can be treated with topical therapy. Vinegar is not a reliable treatment.

  OTC topical medications include sprays and topical antifungal preparations such as Lamisil, Tinactin, Lotrimin, Sporanox, Diflucan, and Gris-Peg, clotrimazole may work. There are other preparations such as Fungi-Nail and many preparations that contain (undecylenic acid) that is not as successful. Recurrence is common, therefore, be sure that factors contributing to the fungus are in check.

     b) Prescription topical therapy

  A prescription containing ciclopirox (Penlac) which penetrates the nail to treat the nail fungus has become a successful topical choice. Paint on the nail for 7 days (remove with alcohol after the medication dries), and repeat for up to a year. The nail bed must be dry before application and nail polish cannot be used. Penlac may be effective with thinner nails.

    There are now 2 newer options of topical medications that can penetrate the nail—tavaborole (Kerydin) and efinaconazole (Jublia). These are also very expensive as well and as yet may not be covered by insurance. Check with insurance and pharmacist regarding which drugs are covered. Consider one of the discount apps (Good RX, etc.) on your phone for a 50% discount.

A local dermatologist suggested an alternative topical solution for more minor infections. They recommended crushing one pill of the prescription oral antifungal medication (terbinafine) and combine it with an over-the-counter liquid anti-fungal preparation called undecylenic acid 25% oil (1 fluid oz.). Apply the liquid to the affected nail once daily for 3-6 months depending on the response. If there does not appear to be a response, more aggressive treatment is recommended.

B. Oral prescription medication—Terbinafine (Lamasil) is the first line of treatment, but must be taken for at least 3-6 months or even longer for resistant nails. Since oral medication deposits in the root of the nail, the entire nail must grow out completely before treatment can be stopped, and the visibly abnormal nail has to be trimmed away. This is a topical preparation is valuable for jock itch and athlete’s foot.  

  Be sure the nail clippers are cleaned each time they are used to prevent re-contamination and spread (also to others).  

  Sporanox, another choice, can cause significant cross-reaction with other medications, and many doctors use (off-label) fluconazole instead.

Length of treatment for nail fungus

  The general rule for treating nail fungus--toenails require longer treatment (twice as long) as the fingernails. The fingernail usually takes 3-4 months for it to be replaced by a new nail and possibly 6 months or more for toenails or if the nail is quite thickened.

Side effects of oral antifungal agents

  Organ damage may occur from oral anti-fungals especially liver and kidney damage. This must be considered and discussed before taking this prescription. Blood tests should be performed prior to administration and during treatment to determine pre-existing conditions.  

  Removing the nail is rarely indicated but will allow application of anti-fungals to the nail bed.

   Laser and photodynamic therapy is heavily marketed, but it is too early to know how effective it is. It selectively heats the fungus and potentially kills the fungus. It is also expensive, and insurance may not cover it. A laser can also burn holes in the nail to expose the nail bed to apply topical antifungal agents. The nail may never look normal again, so discuss with the dermatologist.

  Recurrences are not uncommon no matter what treatment is used. Underlying diseases such as diabetes should be investigated.

Prevention

  Here are some recommended tips:

Use antifungal sprays frequently, wash hands and feet after touching or cutting the nails, dry feet after showers or a bath, use trustworthy nail salons, don’t wear artificial nails often, don’t share nail equipment, avoid walking barefoot in public places, and change socks and shoes often. Open-toed shoes are helpful. Pedicare—buy own instruments and take them to the salon.

Mayo Clinic, medicinenet.com, WebMD

II. Systemic diseases with nail abnormalities

  Nail dystrophy is defined as nail deformity, and it has many causes including primary nail disease such as fungal disease just discussed. Below are examples of other nail dystrophies caused by systemic diseases. The nails are nothing more than modified hair, and therefore hair may also show evidence of disease with a variety of issues. I will discuss hair in a future report.

B. Clubbing of the Nails

Note that these nails seem to roll over the tips of the finger. Clubbing has been associated with lung and heart disease, and less commonly cancers of the lung, endocrine diseases, liver, and gastrointestinal diseases. This case shown above is called Hamman-Rich syndrome (chronic pneumonitis).

  Patients with these abnormalities deserve an extensive workup for all systems that could have disease in them.

C. Anemia

Anemia

normal nail

Brittle and pale nails are signs of anemia. Normal nails are pink and if the nail bed is pressed with a finger, they blanch and immediately return to pink. Anemic nails would not. A complete blood count should be performed and if anemic, further evaluation is indicated. It also can indicate malnutrition.

E. Below is called the yellow nail syndrome and can indicate a lung disorder, diabetes, fungus, yellow jaundice (liver), or nerve damage.

F. Brown lines in the middle of the nail as shown below can indicate Addison’s disease (deficiency of cortisone from disease in the adrenal glands). These are deposits of melanin are created by deficiency of cortisone in the adrenal glands.

G. The above photo are splinter hemorrhages under the nail and disease of the heart valves should be looked for (subacute bacterial endocarditis).

Transverse white lines can be caused by heavy metal poisoning, chemotherapy, Hodgkins’s disease, thyroid deficiency, and other diseases.

I. Pitting of the nail may indicate psoriasis (below).

J. Ridges of the nails may indicate vitamin deficiency

K. These images are cases of nail malignant melanoma. Any pigmentation under the nail must be evaluated by a dermatologist. These are serious. Below those pics is an unusual growth of the nail bed that was an amelanotic melanoma, melanomas without pigment. Biopsies with special histology stains are necessary to diagnose them. This requires removal of the finger and evaluation of the lymph nodes in the armpit or groin for spread.

Reference: Medscape

III. Ingrown toenails (onchocryptosis)

A.

B.

C.  Removing nail (1)

D.  Removing nail (D)

E.

People with diabetes, neuropathy (numbness) of the feet, and those with vascular disease need to be extremely careful not to develop ingrown nails. The infection (paranychia) created by this deformity (photo A. above) can create a serious threat to the viability of the toe. Pain, swelling, and redness are the symptoms and need to be soaked in Epsom salts to prevent spread of the infection. Seeing a podiatrist is recommended for treatment.

  Treatment for early problems might include soaking the toe and allowing the nail to become pliable. Slipping a small piece of cotton under the nail (photo B. above). If conservative methods fail, partial removal of nail might be recommended (photo E.) or complete removal in more severe cases (photos C. and D.).

  Ingrown toenails (usually the big toe) occur from malfitting shoes, trauma, and very commonly trimming the corners of the nail improperly (photo G. below). The nail grows into the flesh of the toe inside of on the surface and tends to curve into the toe flesh as seen below (H. below).

  Proper foot care includes proper nail trimming (photo G.) is key, and if a person cannot perform this task, please see a nail technician or podiatrist. 

G.

H.

3. Options for chronic pain management series—Part 1—

A. Overview of the Opioid crisis

B. Non-Opioid Medication options

C. Integrative Medicine Approach--difference between complementary and alternative approaches

A. The Opioid Crisis

  The opioid crisis began in the early 2000s with an increased per capita of opioid use by 7.3% from 2007-2012. 259 million narcotic prescriptions were written in 2012 alone (latest data). There is no excuse for this increase.

Definition of opiate, opioid, and narcotics

  An opiate is a drug naturally occurring from the poppy plant (pure extract is opium). An opioid is a broader term including those drugs that are synthetically created in a lab that mimic the natural substances. There is an area in the brain that have opioid receptors that create the euphoria and pain relief in the body. Both naturally occurring opiates and synthetically produced opioids can attach these receptors. There are new medications that can attach to these sites that do not excite the euphoria receptors as much (i.e. naloxone, buprenorphine), which are used to treat addiction. Narcotics is a general term indicating any drug that can affect mood or behavior and sold for non-medical purposes especially an illegal one.

  Evidence from the medical literature supports short term efficacy of opioids for reducing acute pain, but the use in chronic pain has not been well substantiated as beneficial.

  Although there has been national emphasis on the opioid crisis, great benefit in managing chronic pain, narcotic abuse, addiction, and overdoses will take years. The number of patients who have moved to street drugs (heroin and fentanyl) to feed their addiction has led to thousands of overdoses and deaths. The issue is such a multifaceted problem and efforts to date have been ineffective. The State of Florida just passed into law that pain medication can only be written for a 3 day supply (7 days if written medically necessary by the physician on the prescription). This will create a hardship for deserving patients and physicians. It remains to be seen how this will affect the crisis.  

  For extensive information on the opiates and the crisis, please click on:

The Medical News Report #47 , #58, #70, #72 

B. Overview of this series

  It is estimated that as many as 100 million Americans are in chronic pain every day at a yearly cost of $600 billion annually in lost productivity and health care expenditures according to statistics from the Institutes of Medicine. Many feel that the reason for the opioid crisis is because of the treatment of chronic pain has been inadequate. Relying on only pain medicine to treat pain is totally inadequate and must change.  

  In part 1 of this series, I will report on the options for chronic pain management using medication emphasizing non-opioid drugs. There is a movement to emphasize an integrative approach to medicine by combining a variety of clinical methods to address pain.

  In future parts of this chronic pain series, I will report on other major therapies.

For lumbar surgery: The Medical News Report #52

For surgery on the cervical spine: The Medical News Report #21

C. Defining the difference between complementary and alternative medicine

  If medical therapies include additional treatments besides a specific FDA approved or standard therapy, it is called complementary therapy. If a treatment is used instead of a recognized standard therapy, it is called alternative therapy. Both physicians and patients must be willing to discuss all therapies where appropriate. Unfortunately, insurance is not following suit to support this effort. Wake up Congress!!3.

D. Attempts to reduce the use of opioids with Integrative Medicine

  Physicians are being encouraged to consider these complementary and alternative treatments to help reduce the dependence on opioids. There are also new substitutes for opioids that are very good and much less addictive (buprenorphine) for those who are already addicted and want to reduce their dependency. Work with your doctor as a team to find the best approach to your pain.

  Psychological illness must be addressed if a patient suffers from chronic pain, since pain will be made worse by underlying anxiety, depression, etc.

E. Opioids are not superior to non-opioid medication for chronic pain—new studies

  Recent studies have cited that opioid medication (hydrocodone, vicodin, oxycodone, etc.) is no more effective than non-opioid medications in treating chronic pain for conditions such as arthritis of the spine, hips and knees, which will be discussed in this report, as reported in the JAMA medical journal. We will discuss non-opioid medications that are as effective.  

  It is difficult to convince patients to switch to non-opioids for their chronic pain management, and it will be even more difficult for patients to accept non-opioid medications for chronic pain relief, but we must try since new studies have proven that opioids are no better than non-opioids for chronic pain (low back pain).

  Because of the crisis, these newer studies are a welcome edition to the medical literature and give doctors ammunition to provide to patients that these addicting medications are not superior to over the counter medications in many cases of chronic pain. It also opens the door even wider for consultation with other providers, which this series will report on.

F. The unintended consequences of addressing the crisis

  Unfortunately, many primary care physicians and even pain management specialists now are refusing to prescribe popular opioids (hydrocodone and oxycodone) for any type of pain. With de-emphasis on opioid prescribing, the swing of the pendulum can create unintended consequences. A lot of patients are now suffering and do not know where to turn. Unfortunately, some will turn to the purchase of illegal street drugs (heroin, fentanyl, etc.).  

  The good intentions of addressing a crisis with restriction like limiting the prescribing of opioids is good on the surface, but the unintended consequences will create a nightmare for deserving patients who need more powerful pain medications. 

G. Most alternative approaches fall into 2 categories:

1) natural therapies (herbs, vitamins, minerals, and probiotics)—there is little reliable evidence based research that proves there are specific therapies can control pain.  

2) mind or body practices (meditation, yoga, etc.)—there is evidence that these therapies are of some value and may have equal success in treating certain types of chronic pain as pain medications (opioid and non-opioid).  

  According to a 2012 National Health Interview Survey, 17.7% of American adults use a dietary supplement other than vitamins and minerals. The survey also cites chiropractic and osteopathic manipulation, meditation, yoga, and massage therapy are among the most popular mind and body practices. All these practices will be discussed in this series of reports.  

  This study stated that 38% of adults use these alternative methods with 83 million Americans spending $33.9 billion out-of-pocket expenditure (11.2% of the total healthcare costs).

H. All chronic pain is not the same

Thermogram showing muscle pain (red)

Treating pain is a very complex issue, and trying to make general statements about successful approaches to different types of pain is quite complex. There are different pathways to pain. I will discuss skeletal and boney pain, essentially using chronic low back pain as the model. Treating fibromyalgia, for example, is very different than a pinched nerve in the back or pain from an injury.

   Medscape (internet medical journal) cited a large study regarding these medications and certain types of pain they are useful in.

I. Common Types of pain 

  The most common types of pain include musculoskeletal (muscle and joint mainly), myofascial (sprains mainly), fibromyalgia (non-specific pain with over sensitive tissues), neuropathy (diabetic, drug induced nerve damage with certain chemotherapeutic agents), post-herpetic neuralgia (shingles pain can be permanent), radicular pain (from pinched nerves in the spine), and complex regional pain syndrome (CRPS).

  The National Institutes of Health created a National Center for Complementary and Integrative Health in 1999 to study the safety and efficacy of these methods having funded over 2500 research projects. Many other studies have cited the value of these complementary methods.

  Here is a list of types of pain and a variety of pain relieving medications:

J. Major categories of medication for pain management

  These are categories of non-opioid medications. It is often appropriate to use one or more of these together or even in combination with lower dose opioids under careful supervison of a physician. These medications have their own side effects and need to be understood.   

  1) Non-opioid pain medications

      Acetaminophen (Tylenol) accentuates hydrocodone and is of some value when added to other medications including NSAIDs. It is easy to take more than the recommended dosage and cause severe liver damage. 2 extra strength Tylenol contains 500mg and 4000mg is the maximum dose/24 hrs. That means only 8 pills can be ingested in 24 hours.

      Aspirin (325mg) 2 pills is an excellent short term pain medicine if a person’s stomach can handle the irritation (NSAIDs as well). It is not recommended for continuous use because of the risk of ulcers.

      NSAIDs (non-steroidal anti-inflammatory drugs) include naproxen (Aleve), Ibuprofen, celecoxib-Celebrex, Voltaren, Indocin etc.) are the most common. The NSAIDs are superior to Tylenol and are the mainstay in managing chronic pain, but will have to be supplemented with other medications and other alternative therapies, even opioids.

  Not everyone can take these anti-inflammatory drugs. It causes significant stomach irritation, aggravates reflux, can raise the blood pressure, and cause liver and kidney damage if taken over a significant period of time. Prescription NSAIDs such as Voltaren and Indocin are powerful medications that can reduce pain, but must monitored for these side effects including kidney and liver damage.   

  2) ARIs (monoamine reuptake inhibitors)

  This group includes mostly anti-depressants, as they have been found to be effective in some cases of chronic pain.  The main amines secreted by the brain are serotonin, norepinephrine, and dopamine. Not only do anti-depressants level out these brain chemoreceptors in treating depression but also help pain by interefering with neurotransmission in pain fibers.

  There are 2 familiar groups-

      a) Tricyclic antidepressants-Norpramin, Silenor, amitrptyline, Tofranil, etc.  (Norpramin was most effective) 

      b) SSRIs/SNRIs—serotonin reuptake inhibitors--Celexa, Prozac, Cymbalta, Lexapro, Zoloft, Wellbutrin, Paxil, etc. Consult the internet for actions, side effects, etc. Higher than normal doses may be required, and some of the side effects can make this group less desirable for patients. This study cited Cymbalta as the better of these for chronic pain.  

 3) Membrane stabilizers

  This group includes anti-convulsants (anti-seizure) such as gabapentin (Neurontin) and pregabalin (Lyrica) have a place in certain types of chronic pain (especially neuropathy) and refer patients for alternative options much earlier instead of relying on addictive medications. I am not talking about acute self-limited pain, rather as pain continues and becomes prolonged, the mindset of the physician must change to consider alternative options.

  These gabapentin-type drugs are now in the top ten most prescribed medications in the U.S. and yet have some significant limitations for the relief of pain with significant side effects.

  Unfortunately, many patients will require higher doses of these medications to relieve pain, and with it comes some potentially serious side effects including dizziness and muscle problems (tremors, slurring of speech, and coordination difficulty), cognitive dysfunction (memory, concentration, problem solving, etc.). Do not drink any alcohol with these medications as the side effects are magnified.

  Taking these drugs with opioids may interact adversely.

  4) Muscle relaxants

  This is a diverse group of medications that relax the major muscles when in spasm. When a nerve is pinched, it sends excessive neural input to muscles causing spasm. These medications fall into two groups—one for spasticity caused by diseases such as cerebral palsy, spinal cord injury, multiple sclerosis, etc. The other is for temporary muscle spasm caused by the majority of pain seen in the doctor’s office.

  3 medications are FDA approved for spasticity (baclofen(Lioresel), dantrolene (Dantrium), and tizanidine (Zanaflex).

  6 muscle relaxants are FDA approved for general muscle spasm (carisoprodol (Soma), chlorzoxazone(Parafon Forte), cyclobenzaprene (Flexeril), metaxolone(Skelaxin), methocarbamol(Robaxin), and orphenadrine(Norflex). There are others if you log on to drugs.com. There is insufficient solid research that these muscle relaxants are very effective. They also can cause significant drowsiness.

   5) Other valuable medications

  Oral cortisone has been proven to help radicular pain in a dosepak form. It reduces swelling in pinched nerves and should be considered in these cases.

  Valium and Xanax are benzodiazepines (anti-anxiety), not a classic muscle relaxant, but is very helpful off-label medications especially when combined with NSAIDs.

  Topical patches

     Lidocaine patches and capsacin patches have shown value for chronic pain after 2 weeks, however, they were not much better than placebo. Volteran patches (also available as an oral NSAID) were valuable after 8 days of use. The Volteran patches are prescription and also can be prescribed as a cream.

  Botox (Botulinum toxin A) is only FDA approved for certain types of spasticity, but is used in off-label issues widely such as migraine and other neuropathies.

  Cannabis extract is also being used for spasticity and is approved where medical marijuana is legal for pain and several diseases. More states are legalizing marijuana (17) (and many medical use), and in this study, it was successful in relieving pain over 4 weeks. I suspect THC extracts will become an important complementary treatment for chronic pain.

  Ketamine, a potent sedative, has been used commonly in veterinarian practice (I used it to perform research experiments on animals in medical school), but more recently has been used in the treatment of acute depression and now in pain as a topical 10% preparation. There is a new form of ketamine being tested that does not have much euphoric effect that may be very helpful.

K. Summary

  The list of non-opioid medications keeps growing as the medical profession struggles to treat pain with lower doses of opioids and alternative (and complementary) treatments. Next month, I will begin to report on the practitioners who provide a valuable addition to the management of pain—chiropractic physicians.

A word of caution to parents!!

  Parents must be responsible when they have prescription medications in their home, because the children are stealing them at a record pace. Lock them up and when not needed, destroy them (preferably not down the toilet, since our water system has measurable amounts of drugs in them).

  Next month in part 2 of this series, I will begin to discuss other alternative therapies to control chronic pain with a report on chiropractic care. 

Reference:  Drugs.com, theoncologynurse.com, Medscape, The National Health Interview Survey

4. Obese women experience higher rates of deformed newborns

A recent study by the British Medical Journal reported there is a correlation betwee pregnant women’s weight and the risk of congenital malformations in their babies. Women with a BMI of 18.5 to 24.5 (normal range for women), they were compared to women with an elevated BMI of 25 to 40. As the BMI rose, the rate of deformed babies rose proportionately. The most common malformations existed in the nervous system, heart, gastrointestinal tract, genitalia, and limbs.

  According to the U.S. Government, obesity rates in adult women are staying the same in the last few years at 40%, but there has been a 1% increase to 18.5% for children. What is alarming is the greatest increase is in ages 2-5. Obesity is determined by the body mass index. Those women that are the most overweight are in their 40s and 50s. 45% for women in this age group are considered obese.

  The need for weight management to prevent these congenital malformations is obvious, and the responsibility lies on the backs of the women and their OB doctors. Women who have been overweight since childhood have the hardest time getting weight off when they become pregnant. Women know to stop smoking and not drink alcohol, but their weight is even a more potent risk factor. BMJ, May, 2017

  I have discussed weight management issues in a series of reports in previous issues. This includes how to calculate a person’s body mass index. Click on: www.themedicalnewsreport.com  #43, #44, #45, #46, #47

 5. Deciding on a prophylactic mastectomy on the opposite breast

BRCA positive patients

  I have discussed breast cancer in depth including prophylactic mastectomy on the opposite breast but in only those who had a positive family history (immediate) and are positive for the BRCA gene mutation. In these patients, a prophylactic (contralateral) mastectomy of the second breast has been 95% effective in BRCA patients in preventing cancer in the other breast. Additionally, consideration for ovary removal (oophorectomy) is also a consideration with reducing the chance of ovarian cancer by 90%.

BRCA negative patients/no immediate family history-- strictly out of fear!!

  There are far more women choosing opposite breast mastectomies strictly out of fear and who have no immediate family history or genetic mutations. This is in the face of a known very low percent of women developing a second cancer in the other breast.

  Cancer is scary. I know (I had throat cancer in 1991), but the rate of women undergoing these unnecessary operations is of concern. It is interesting that younger more educated white females with insurance are choosing second breast mastectomy more than any other group.

Certain cancers have increased risks

There are women at higher risk

  There are those women who are BRCA negative but have a breast cancer with increased risk of a second breast cancer (triple negative, or DCIS), have an immediate family member with breast cancer, or were younger than 50 at the time of diagnosis. All these cases are currently being considered for prophylactic breast surgery and research is ongoing.  

Controversy

  The chance of a woman developing a second breast cancer is relatively rare, but has sparked great debate about having preventative (prophylactic) opposite (contralateral) breast mastectomy with or without reconstruction (most do reconstruct if relatively young). Developing a second breast cancer from treatment of the first cancer is very rare.

Ongoing Research

  Legitimate research has reported that those with a primary cancer without a family history and a negative BRCA gene have little value in removing the other breast. It is also known that opposite breast mastectomy has no value in preventing the primary cancer from recurring or metastasizing.

  There is ongoing research following thousands of women who have had one breast cancer are being followed for a second breast cancer. The results are not complete.

  Sadly there are many women who still have the second breast removed without any proof of benefit. The issue of breast symmetry may be part of the reason.

Other genetic mutations exist

   There are, however, other circumstances that need to be considered, because there are less known genetic mutations that may have not been tested, such as PALB2, BARD1, RAD51C, PTEN and require a multiplex panel testing of all genes. There are patients who do not know or have access to family history, and there are those that have more difficult cancers such as triple negative cancers.

Triple negative breast cancers

  These breast cancers are defined as cancer cells that test negative for estrogen receptors, progesterone receptors, and HER-2 (human epidermal growth factor receptor type 2). It limits the choices for treatment of the primary cancer requiring more radical surgery since the survival rate is not as high. Because triple negative cancers usually recur within 5 years, some might consider waiting a few years to perform the second breast surgery. These are all controversial issues.

Age matters, DCIS

  One study involving women who were known not to have BRCA 1 or 2 but had a positive family history, and were diagnosed before they were 55 had a 10 year cumulative risk of breast cancer in the opposite breast of 6.7%. Those with DCIS (ductal carcinoma in situ) have a 4-8 fold increase risk of a second breast cancer in one study, and many are proceeding on with second mastectomy.

  Go into the subject index on my website and look under breast cancer. There are many reports on breast cancer from A to Z.

Below is a list of risk factors for developing a primary (first) breast cancer:

1) a first degree relative with breast or ovarian cancer.

2) genetic mutations in BRCA 1 and 2 (plus other mutations).

3) menstrual cycle before age 12.

4) age (the older the more likely); under 55 years of age increases the risk of a second breast cancer.

5) no pregnancy or late pregnancy; no breast feeding

6) taking contraceptives or hormone replacement therapy (estrogen/progestins)

7) Northern or Eastern European (Askenazi Jewish or African American)

8) A previous breast cancer including DCIS-ductal carcinoma in situ or a previous breast biopsy with some abnormal cells but not cancer

9) High intake of alcohol, fat, and minimal exercise including obesity

10) Dense breasts

11) Chest radiation for any reason (i.e. lymphoma in young)

12) Those that took diesthylstilbesterol (DES) up until 1971 for miscarriages

Risk factors for developing a second breast cancer are:

1) A previous breast cancer especially DCIS, triple negative breast cancer, or a previous ovarian cancer.

2) Genetic factors—mutations (BRCA 1 or 2), strong family history of breast or ovarian cancer, other mutations (PALB2, BARB1, RAD517). There are 28 genes that have a possible link to increasing the risk of cancer (must see a genetic counselor).

3) For women who have had a mother or sister with breast cancer before the age of 55.

4) A family with multiple members with breast cancer.

5) Those with lobular carcinoma in situ (not really cancer yet) still have a higher risk for cancers in both breasts.

6) Those women who received chest radiation before the age of 30.

There is intensive research in this areas, because of the increasing number of prophylactic opposite (contralateral) breast mastectomies.

Women are aware

  All women are quite aware of this issue. The first consideration should always be to focus on being cured of the first (primary) breast cancer.

  For those that have an estrogen positive cancer, endocrine therapy can prevent recurrence or a second breast cancer by about 50% (Tamoxifen, Raloxifen, exemestane). For other types of cancers (triple negative) this option is not available because the type fo treatment.

Consideration for the additional surgery

  For those with increased risk factors, prophylactic contralateral mastectomy may be a consideration. It starts with knowing the family history and then having genetic evaluation for mutations.

  A woman and her family cannot navigate this issue without genetic and oncological expertise from specialists who deal with this frequently (at a major cancer center).

  Worrying about recurrence, spread and a second breast cancer will always be present. Letting that fear push a woman into a decision without all the facts (and knowledge) should be avoided.

  Second opinions should be considered. The added risk of additional surgery on the opposite breast plus reconstruction is no small task or risk. There are many added potential complications to consider including additional wound healing issues, infection, and poor cosmetic results from reconstruction all while worrying about controlling the primary cancer.

   It always comes down to a decision between the patient and the doctor with all the facts, hopefully with love and support of family and friends. The final word on this subject has not been published.

Ref: American Cancer Society, NCI, Fred Huchison Cancer Center (Seattle), NCCN, NEJM

6. A technological answer to the healthcare crisis as it appeared in the Wall Street Journal —by Dr. Eric Topol

The future of medicine is going to be very different and just in time. With fewer healthcare providers, electronic medical records, and the internet, a patient’s ability to stay in contact with their doctors will be electronically aided by a bonanza of technology For example, the Tricorder X, a device out this year works on your phone that will take retina scans, blood samples, and you can breathe into it for lung functions and samples of chemicals in the body including analysis of 54 biomarkers that can identify almost any disease in the body. This allows real time evaluation of the blood, chemistries, blood pressure measurements, EKG, and other bodily functions. It will allow onsite management of many medical conditions.

  Listen to what Dr. Eric Topol has to say about how technology will streamline medicine. A cardiologist at Scripps Medical Center in San Diego, he has been at the forefront of electronic technological advances in medicine. 

The Smart-Medicine Solution to the Health-Care Crisis

Our health-care system won’t be fixed by insurance reform. To contain costs and improve results, we need to move aggressively to adopt the tools of information-age medicine---The Wall Street Journal

ILLUSTRATION: BRIAN STAUFFER

By 

Eric Topol

July 7, 2017 12:04 p.m. ET

301 COMMENTS

The controversy over Obamacare and now the raucous debate over its possible repeal and replacement have taken center stage recently in American politics. But health insurance isn’t the only health-care problem facing us—and maybe not even the most important one. No matter how the debate in Washington plays out in the weeks ahead, we will still be stuck with astronomical and ever-rising health-care costs. The U.S. now spends well over $10,000 per capita on health care each year. A recent analysis in the journal Health Affairs by the economist Sean P. Keehan and his colleagues at the federal Centers for Medicare and Medicaid Services projects that health spending in the U.S. will grow at a rate of 5.8% a year through 2025, far outpacing GDP growth.

Our health-care system is uniquely inefficient and wasteful. The more than $3 trillion that we spend each year yields relatively poor health outcomes, compared with other developed countries that spend far less. Providing better health insurance and access can help with these problems, but real progress in containing costs and improving care will require transforming the practice of medicine itself—how we diagnose and treat patients and how patients interact with medical professionals. In medical training, private sector R&D, doctor-patient relations and public policy, we need to move much more aggressively into the era of smart medicine, using high-tech tools to tailor more precise and economical care for individual patients. This transition won’t be easy or fast—the culture of medical practice is famously conservative, and new technology always raises new concerns—but it has to be part of the solution to our health-care woes.

Radical new possibilities in medical care are not some far-off fantasy. Last week in my clinic I saw a 59-year-old man with hypertension, high cholesterol and intermittent atrial fibrillation (a heart rhythm disturbance). Before our visit, he had sent me a screenshot graph of over 100 blood pressure readings that he had taken in recent weeks with his smartphone-connected wristband. He had noticed some spikes in his evening blood pressure, and we had already changed the dose and timing of his medication; the spikes were now nicely controlled. Having lost 15 pounds in the past four months, he had also been pleased to see that he was having far fewer atrial fibrillation episodes—which he knew from the credit-card-size electrocardiogram sensor attached to his smartphone. 

This is a sensor pad (below) hooked up to a personal smartphone that can print out a EKG rhythm strip

This records the heart rhythm and can be sent to the doctor. It has been FDA approved.

It costs $199 with a $99 subscription annually.

This is a portable ultrasound machine that can be hooked up to a smart phone marketed by www.KardiaMobile.com

A person can run this instrument over any part of the body and see organs in their body. This can be sent to their doctor for evaluation.

In my three decades as a doctor, I have never seen such an acceleration of new technology, both hardware and software, across every dimension of medical practice. I have also had the opportunity to advise and collaborate with several companies on these developments. The new tools are not just more powerful, precise and convenient; they are more economical, driven by the information revolution’s ability to deliver, as Moore’s Law holds, ever-increasing computing power for less money. 

Consider the biggest line items in the 2016 national health-care budget, according to Mr. Keehan and his colleagues: more than $1 trillion for hospital care, $670 billion for doctor and clinician services, $360 billion for drugs. And compare the often sorry outcomes: more than 1 in 4 patients harmed while in the hospital; more than 12 million serious diagnosis errors each year; a positive response rate of just 25% for patients on the top 10 prescription medications in gross sales.

We don’t have to resign ourselves to this outrageous situation. Smart medicine offers a way out, enabling doctors to develop a precise, high-definition understanding of each person in their care. The key tools are cheaper sensors, simpler and more routine imaging, and regular use of now widely available genetic analysis. As for using all this new data, here too a revolution is under way. Algorithms and artificial intelligence are making it possible for doctors to rapidly apply relevant medical literature to their patients’ cases, while “natural language processing” (that is, talking to computers) holds the promise of liberating them from keyboards during office visits. 

One obvious practical effect of these developments will be to replace hospital stays with remote monitoring in the patient’s home. The Food and Drug Administration has already approved wearable sensors that can continuously monitor all vital signs: blood pressure, heart rate and rhythm, body temperature, breathing rate and oxygen concentration in the blood. The cost to do this for weeks would be a tiny fraction of the cost for a day in the hospital. Patients will be able to avoid serious hospital-acquired infections and get to sleep in their own beds, surrounded by family.

We do more than 125 million ultrasound scans a year in the U.S., at an average charge of well over $800—that’s $100 billion. But we now have ultrasound probes that connect with a smartphone and provide exquisite resolution comparable to hospital lab machines. It is possible to examine any part of the body (except the brain) simply by connecting the probe to the base of a smartphone and putting a little gel on the probe’s tip. When I first got a smartphone ultrasound probe last year, I did a head-to-toe “medical selfie,” imaging everything from my sinuses and thyroid to my heart, lungs, liver, gallbladder, aorta and left foot.

That experience came in handy when I recently developed pain in my flank. Seeing my very dilated kidney on my smartphone screen helped to confirm the diagnosis that I had a kidney stone. The CT scan later ordered by my doctor showed a nearly identical image, but the charge for that was $2,200. If this single tool was used in a typical office visit, a large proportion of expensive and unnecessary formal scans could be avoided.

Smart medicine can also bring some sanity to how we handle medical screening, which today results in an epidemic of misdiagnoses and unnecessary procedures and treatments. The leading culprits are routine tests for breast and prostate cancer for individuals at low risk for these diseases. Because the tests have such extraordinarily high rates of false positives, they result all too often in biopsies, radiation and surgery for people in no medical danger.

It would not be hard to use screening tests in a more discriminating way, for the much smaller population that really should worry about certain serious health problems. Genome sequencing for an individual—identifying all three billion base pairs in a person’s genetic makeup—can now be done for about $1,000, and we know a great deal about which genes predispose someone to conditions such as cancer and heart disease. Guided by genomic risk scores that can be determined with an inexpensive device known as a gene “chip”—and, of course, by family histories and clinical examinations—doctors could spare many families from the ordeal of unnecessary treatment while making a dent in the $15 billion spent each year in the U.S. on mass screening for breast and prostate cancer.

Routine use of individual genetic information could also allow us to prescribe drugs more effectively, avoiding the waste, in clinical time and in money, caused by medications that misfire. More than 130 drugs in common use have an FDA label for DNA data—that is, they provide peer-reviewed research instructing doctors about dosage, side effects and potential responsiveness for patients with particular genetic profiles. But with rare exceptions outside of some cancer treatment centers, doctors in the U.S. don’t obtain such data before prescribing drugs. That’s a shame, because the relevant genetic information for each patient could be determined easily and inexpensively from saliva DNA at an office visit or even a pharmacy. 

For its part, the drug industry needs to make genetic information available for far more drugs by making it a regular part of testing. This R&D effort would be inexpensive relative to the cost of developing a new drug, and it could make medications far more efficient, upping the response rate and averting dangerous side effects.

Smart medicine can also transform the doctor-patient relationship. Most medical services today are still provided in the traditional outpatient setting of a doctor’s office. It takes an average of 3.4 weeks to get a primary care appointment in the U.S., and there’s little time allotted for each visit. Most doctors provide a minimum of eye-to-eye contact as they busily record the session on a keyboard.

The frustrations and inefficiencies of this system are obvious—and unnecessary. In the era of telemedicine consults, there is no reason to wait weeks for an appointment. For the same copay as an office visit, connection with a doctor can occur instantly or within minutes. With increasing use of patient-generated data from sensors and physical exam hardware that connects with a smartphone, the video chats of today will soon be enriched by extensive data transfer.

Indeed, obtaining patient data solely from the occasional office visit is no way to get a full picture of someone’s health or to assess their medical needs. As more people generate and maintain their own medical data, they will carry this information around with them, no longer leaving it in the exclusive domain of doctors.

At the Scripps Research Institute, we are working with the support of a National Institutes of Health grant and several local partners to develop a comprehensive “health record of the future” for individual patients. It will combine all the usual medical data—from office visits, labs, scans—with data generated by personal sensors, including sleep, physical activity, weight, environment, blood pressure and other relevant medical metrics. All of it will be constantly and seamlessly updated and owned by the individual patient.

Such medical data belongs to us rather than to our doctors—it’s about our bodies, after all, and we generate and pay for much of it. But it will also make our medical care more exact, more precisely tailored, as we move from doctor to doctor, depending on our needs at a particular moment. It will make unnecessary the billions of dollars spent each year in the duplication of labs and scans. Personal medical data—stored in a cloud or using blockchain technology, a kind of digital ledger—also will be more secure and relatively immune to hacking, compared with data sitting on massive servers.

Having such data readily available will be vital to reaching the next stage of smart medicine, with virtual medical coaches. Just as we have adopted Alexa, Siri and Cortana for daily activities, we are headed to a time in the years ahead when our continuously updated personal medical data will provide health guidance. Consider the diabetic whose blood sugar sensor indicates that control is slipping because of lack of sleep or physical activity, or the asthmatic whose sensors show reduced lung function before any symptoms occur, so that she can adjust her medications. Refined feedback, through text, voice or avatar, will ultimately lead to better prevention and management of medical conditions.

The revolution in patient data will empower doctors too, particularly as artificial intelligence matures into practical technologies. Researchers at Google DeepMind and Stanford University have recently shown the great potential of “deep learning”—computers that grow ever smarter through the continuous analysis of new data—for accurate interpretation of medical scans, pathology slides and skin lesions, on par with doctors. In a paper last year in the Journal of the American Medical Association, authors Andrew Beam and Isaac Kohane, specialists in biomedical informatics, calculated that advances in artificial intelligence now make it possible for computers to read as many as 260 million medical scans in a day, at a cost of $1,000. The advances in diagnostic power would be enormous, to say nothing of the cost savings.

So why have we been so slow to adopt and encourage these potential solutions? Medicine is hard to change, especially when reforms threaten established modes of payment and the customary control of patients. And like everyone else, doctors are seldom eager for extensive new training. But our current course of medical spending and practice is unsustainable, and no change in how we handle health insurance is likely to alter that reality. 

Fortunately, serious ventures in smart medicine are well along. My colleagues and I at the Scripps Research Institute are leading the Participant Center of the NIH’s Precision Medicine Initiative, which is currently enrolling one million Americans. Volunteers in the program will be testing many of the new tools I have described here. The recently formed nonprofit Health Transformation Alliance, which includes more than 40 large companies providing health benefits to 6.5 million employees and family members, intends to address the high cost of health care by focusing on, among other things, the sophisticated use of personal data. 

Physicians will also need to be trained to use the new technologies, from interpreting genomic data to using a smartphone for ultrasound. The FDA recently announced a broad initiative to foster innovation in digital health devices, with the intent to streamline the regulatory review process. 

But more could certainly be done to move us toward better health outcomes at lower costs. Perhaps some enterprising member of Congress will propose a Frugal Health Care Innovation Act, providing government incentives for technology, research and implementation. Such public support for electric cars has rapidly changed the face of the whole auto industry. American medicine today is no less antiquated than the Detroit of a generation ago, and it needs to find its way into the present century.

Dr. Topol is a cardiologist and professor of molecular medicine at the Scripps Research Institute in San Diego and the author of “The Patient Will See You Now: The Future of Medicine Is in Your Hands” (Basic Books, 2015). He consults for Illumina and Apple on some of the issues discussed here, sits on the board of directors of Dexcom and is a co-founder of YouBase.

This completes the April, 2018 report. Next month, the May, 2018 subjects will include:

1) Chronic Pain Management Series 2—Chiropractic physicians

2) Update on blood clot removal after stroke—extended time

3) Homeless issues—medical consequences

4) Insomnia

5) Healthcare costs

6) Low level lead causing a surprising 400,000 cardiovascular deaths annually in the U.S.

Stay healthy and well, my friends, Dr. Sam