The Medical News Report

August, 2018, #79

www.themedicalnewsreport.com

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Subjects for August, 2018

1. Late breaking Medical News in Cardiovascular disease

   A.  Does treating Atrial Fibrillation prevent future Strokes?  

   B. Fitness can’t counteract Fat in heart attack study

   C. Many people take too many medications that can cause/aggravate depression

2. The best medicine—the animal/human bond

3. Knee Joint Replacement

4. Robotic Surgery—Is it worth it?

5. Options for chronic pain—Part 5—Physical and Occupational therapy, Exercise techniques (yoga, pilates, etc.)

6. Medicare Financial Outlook Worsens; Cost of healthcare for undocumented immigrants

7. Varicose veins

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. Late breaking Medical News

  A. Does treating Atrial Fibrillation prevent future strokes?

  B. Fitness can’t counteract Fat in Heart Attack study

  C. Many medications may cause/ aggravate depression  

A. Does treating Atrial Fibrillation prevent future strokes?

Note the difference in rhythm in the EKGs

  Diagnosing atrial fibrillation (AF) is critical to prevent future strokes and other cardiovascular complications, but once it is treated either with medication, cardioversion, or ultimately ablation, what happens to the risk of stroke?

  Atrial fibrillation is a heart irregularity (arrhythmia) that causes symptoms and is a leading cause of emboli (blood clots moving from the heart to the lungs or brain). It is very common (5% of the population over 69) and must be thought of when having palpitation, light headedness, or chest symptoms. Shortness of breath might alert there has been an embolus.

UK researchers compared 11,000 AF patients who had clearing of their atrial fibrillation to 22,000 people who never had AF. These participants were followed for 3 years and those who had resolved AF still had a 60% higher incidence of future stroke.

  Of course, those with untreated AF have an even higher incidence of stroke. But it clearly shows that resolving AF does not necessarily prevent all future strokes compared to those who never had AF. Most patients with AF have active cardiovascular disease whether the AF is resolved or not and would be more likely to have a higher incidence of cardiovascular disease.

  This study clearly points to the need for treated AF patients to still stay on anticoagulants long term. That could include aspirin and or oral anticoagulants (Eliquis, Xarelto, Pradaxa).

  Another reason to stay on anticoagulants is that atrial fibrillation may return, therefore monitoring for recurrence by a cardiologist is necessary, and now there are simple EKG patches that can be worn to allow remote monitoring. There may or may not be symptoms with AF, therefore, patients should not depend on the way they feel. Stroke can be the first symptom. 

  People need to be on the lookout for irregular heartbeats, but most people are not aware of them unless they feel their pulse carefully for at least a minute. If there is any doubt, please contact a doctor. Blood pressure and careful evaluation should be a part of any doctor visit.  

  The U.S. Federal Advisory Task Force does not recommend routine EKGs for asymptomatic patients, a person must consider AF if they have symptoms of palpitations, dizziness, lightheadedness, and chest symptoms. Of course getting an EKG with an annual routine physical is up to a patient and their doctor as one ages.

  I have discussed atrial fibrillation, how it occurs, and its treatment previously, so for a review, click on:

www.themedicalnewsreport.com/59/72

  If a person has stopped anticoagulant therapy after successfully being treated for AF, talk to your cardiologist about restarting anticoagulants since this study in the British Medical Journal, May, 2018 has shown the need.  Although it is not known how many patients stay on anticoagulants after being successfully treated in the U.S., but in the UK a relatively small number continue.

B. Fitness can’t counteract Fat in Heart Attack study

  You would think if you stayed in decent physical shape that being overweight might be cancelled out and the rates of heart attack might be lowered with a good fitness program. However, a Norwegian study found being overweight even in the face of being physically active did not lower the incidence of heart attack.

  There has been an ongoing debate for years about the value of exercise and lowering health risks, and what role factors such as inactivity, extra body fat, heredity, smoking, poor diet, and excess alcohol play in developing cardiovascular disease. Most studies prove that not having these habits or genetic tendencies will lower cardiovascular risk.

  However this study took all these issues into consideration, and excessive weight was still the most potent factor in preventing a person from lowering their risks of heart attack.

  However, comparing low category exercise (walking, gardening, etc.) with moderate exercise (bicycling, running, etc.), there was 13% less likelihood of developing a heart attack in people who perform moderate exercise regularly. The problem is most people overweight may not engage in moderate exercise.   

  This study and others have confirmed that a high BMI* will prevent the benefit from being active regarding heart attack risk (unless a person is willing to engage in moderate exercise), but this study should not inhibit people overweight from increasing their exercise methods and being more active for other health values. Besides, with inactivity and being overweight heart attacks will increase.

  BMI* is not a perfect measure of obesity but it is a fair indicator (not as reliable for very muscular men) easily used in research. Waist measurement and weight-to-hip ratio are other very good indicators since abdominal fat directly correlates with cardiovascular disease risk.  It does put the bullseye on losing weight, and exercise must be an integral part of any weight loss program.

BMI* is commonly used to calculate risk and uses the height and weight to come up with the figure. You can search many sites online that will calculate your BMI. One problem is that as people age they lose height for various reasons which would raise BMI artificially.  

  I hate the term obesity, because it is such a negative term and with it comes bias and discrimination. But the way medical research and even the CDC determines medical risk is with weight in the categories of under weight, normal weight, overweight, and obese. I simply must report the facts. BMI ranges are the same for men and women over 20 years of age. 

*BMI--18.5-24 is normal range

           25-30 is considered overweight

           over 30 is considered obese

  Based on BMI, 71% of men and women are either overweight or obese in U.S. if over 20 years of age according to the CDC and 21% of young people ages 12-19 are obese.

  There are no free rides! We just have to do the best we can do to change our eating and exercise behavior if we want live a long healthy life. Otherwise we may “pay the piper”.

Reference Medscape, Tromso Study in Norway, CDC

C. Many routine medications cause or aggravate depression

  Depression is a common problem that has gripped this country due to a number of factors including loss of jobs, unemployment, economic turndown, substance abuse, genetics, environmental influence, etc.

  5% of adults are estimated to be diagnosed with depression, but it is estimated that 29% are undiagnosed or untreated.

  Many commonly prescribed medications have depression as a side effect, and they have been discussed in an article in JAMA*. If patients are concomitantly taking more than one medication that might cause depression, the risk rises. It is estimated that 15% of elderly adults are taking 5 or more prescribed medications concurrently. Nursing home patients take an average of 7 concomitantly.

 *Journal of the American Medical Association

  Those medications cited in this study include:

    Hormonal contraceptives,

    Beta-blockers (blood pressure),

    Anti-seizure medications including the gabapentins-(Neurontin) and pregabalins(Lyrica)-used for neuropathy and chronic pain,

    Muscle relaxants (i.e. cyclobenzaprine(Flexeril),

    Proton pump inhibitors (i.e. Prilosec, Prevacid, Nexium, Dexilant, etc.),

    NSAIDs (i.e. ibuprofen, Aleve, etc.),

    Opioids, sedatives, sleep aids,

     Antidepressants (i.e. Zoloft, Wellbutrin, Paxil, etc.)—even thoughts of suicide in a small percent

     Benzodiazepines--Anti-anxiety medications(Xanax, Valium, etc.),

     Cortisone-containing medications.  

   Researchers used data from 26,000 adults in the National Health and Nutrition Survey from 2004-2014. A number of medications known to have potential depressive side effects were evaluated in these patients.

Results

  Of the participants who took none of these medications (the control group), depression was diagnosed in 5% of patients, which is the national average for a diagnosis of depression. If the patient took one of these medications, depression occurred in 7%, and if taking 2 or more of these medications concomitantly, there was an incidence of 14% of these patients.

  The diagnosis of depression was based on a survey of 9 questions, but these were self reported, and the patients were NOT diagnosed by a psychiatrist. These are observational studies and subject to error, but it does put the spot light on the fact that patients are taking too many prescriptions and over the counter drugs, vitamins, and supplements. Cross-reaction with medications become numerous the more a patient consumes, and if a patient becomes depressed, maybe the first thing to consider is stopping some of the medications, if medically safe. BUT NEVER STOP A MEDICATION WITHOUT A DISCUSSION WITH A PERSON’S PRIMARY CARE PHYSICIANS. 

  The federal advisory committee (USPSTF) recently recommended screening adults for depression and providing adequate services for follow-up treatment.

JAMA, June 12, 2018; www.drugs.com

2. Some of the best medicine—the animal/human bond

  I have had animals most of my life since I was a small child. At one time, I had 3 cats and 2 labadors. I now have one special little dog, Oliver, who is 14, deaf and blind from cataracts, but still going strong. He is such a love!

For those who do not have animals in your life, there are many reports that provide the value of an animal in the home and might prompt a family to consider adopting a pet.

  There are obvious medical reasons not to have animals, primarily allergies, financial, and disability that would prevent a person from properly caring for these precious creatures.

  There are animals that have extremely low dander and don’t shed and cause less allergic reaction. Deciding on a pet in the home, of course, would be a decision a doctor (allergist) might have to make. Even if a dog does not shed and have less dander, saliva is still a source of allergic reaction, so do talk to a veterinarian about choice of pet.

  Multiple research studies have proven that pets can lower blood pressure, anxiety, and depression. They are a big hit in nursing homes, and can bring a smile to anyone’s face. They provide people purpose in taking care of them (a basic human need), companionship, prevent loneliness, provide protection, and are a great source of entertainment. 

  Service dogs have become an important therapeutic tool for patients with PTSD, people with diabetes, seizures, mental retardation, and those with a host of psychiatric and physical disabilities and conditions.

Role of neurohormones and bonding of animals to humans

  Below is an article with summary points regarding the physiological and psychological effects of the human-animal interactions and the role of the neuropeptide hormone oxytocin.

Oxytocin, a neuropeptide, is secreted by the brain (hypothalamus, and posterior pituitary). It plays a role in social bonding, sexual reproduction, and after childbirth by contracting the uterus after birth. It is secreted by stimulation of the nipples in breast feeding and is involved in the production of mother’s milk. It is involved with bonding child to mother. It is also thought to bond people (romantic attachment) and even animals to other humans. Studies as the one above have shown oxytocin secretion occurs when animals and humans interact. Animals have an antidepressant effect as well, which may be one of the reasons animals have a positive psychological benefit on humans.  

Service, Companion, and Therapy Dogs

  Unfortunately, some people are abusing the “service dog” label so that they can take them anywhere and has become a real issue for the airlines, retail stores, and other public places. Please honor those who have registered and trained service dogs. These dogs have been specially trained to care for specific needs of patients, and even though there are those who can’t afford to have their dog trained, abuse of the service dog label program has created issues similar to people parking in a disabled parking space.

  There is a USA Service Dog Registration website.  Service dogs must be specially trained and certified to be labeled a service dog. The training is extensive and is customized to the person’s needs. Campanion dogs are not service dogs, but every bit as valuable.

  Speaking of service to our communities and country—These dogs are always there to protect us, love us, and make our lives safer, not to mention serve our country. Drug sniffing dogs are instrumental in protecting us, which is a very important service dogs can provide.

There are no words……

  There is a loving and dedicated four legged animal out there just waiting to change your life!

We all know what unconditional love is, but if you don’t, get an animal and you will soon find out. Animals can sense a person’s emotions, smell the scent of illness or drugs, and can be of great help in getting people through rough times, help cope with difficult illnesses, and always be there for a person and a family.  

  Comfort, companionship, and love are a trio of values that are hard to beat. Think of the value of an animal who has the capability of sensing a seizure about to come on, when a diabetic is about to have hypoglycemia or a high blood sugar needing more insulin, but pets desire to love at all costs.

  If a person is having a difficult medical issue, consider an animal to help them cope. The value of knowing an animal is totally dependent on their humans has value, because it gives people purpose. That is a powerful human trait to have and a gift for the animal.

  There are so many animals in shelters waiting for someone to rescue, and they will return the favor.

  Loneliness is a killer and can be helped with an animal companion. You are never alone with an animal in the house.

  Animal visits to nursing homes are a great success. There are many programs that provide visits to needy people of all kinds.  

  When I don’t want to take my daily walk, I know that little guy of mine needs to get his exercise, and then I hit the pavement. Sometimes the motivation comes more from my Oliver than me. That helps me to stay healthier. Animals have been proven to keep people healthier.

  Anxiety is another health issue that can be calmed by an animal. Hug that precious furry thing and find the “nerves” can come down a notch.

  I have had friends decide to not get another animal because they could not stand to see them get sick, get old, and die. What if we said that about having a mate? I hate seeing my dog slow down since he is 14, but the joy he has given me and my family is unmeasurable, and even though I will grieve when it is his time, I will always be glad my life was more special because of Oliver and my other pets.

  The medical benefits of having an animal in the home can not be overemphasized, and I am glad to see so many groups utilize pets as a form of therapy.

There are animal organizations that would appreciate a donation to train dogs for those less fortunate. I have donated to Canine Companions for Independence at www.cci.org and ASPCA, the American Society for the Prevention of Cruelty to Animals www.aspca.org

  Another non-profit is 4 PAWS FOR VETERANS at www.4pawsforability.org

3. Knee Joint Replacement-the latest updates

The above drawing demonstrates a normal knee, one with osteoarthritis, and a replaced knee.

  I have had both knee joints replaced (at the same time), therefore, between my personal knowledge and the medical literature, it provides me the latest information about joint replacement, I will report on the progress in replacement knee surgery.

  There is no substitute for knee replacement, however, Synvisc injections (hyaluronic acid gel) every 3 months into the knee spaces gave me about 2 years before replacing them. They are a jelly like substance.  Endoscopic cleaning out of the knee joint of debris, microfracture of the cartilage, etc. are only temporary measures. Choosing temporary procedures is a decision a  patient and orthopedic surgeon must make, but may have value temporarily, but will likely not prevent total replacement in most cases.  

  I have discussed most common forms of arthritis in previous reports (see subject index on website), as this disease is the main cause of degenerative changes in the joints. Repeated trauma is usually the underlying cause of osteoarthritis regardless of the area causing loss and tears of cartilage with eventual erosion leading to bone on bone disease. Patients with rheumatoid arthritis also have joint

diseases, but osteoarthritis is by far the most common.

  Tearing the cartilage of the knee predisposes the joint to lose the cushion provided and keep the femur off the tibia. Once the joint space is lost and there is bone on bone, the likelihood of replacement is great since pain will continue to worsen.

Bowlegged results of severe knee arthritis

Osteoarthritis (loss of joint space)

  The joint space narrows as the cartilage thins and is destroyed which causes pain. Note the difference in the X-rays above. There may or may not be ligament damage. That is another subject.

Conservative Therapy First                    

  Long before considering knee replacement surgery, the use of NSAIDs (non-steroidal anti-inflammatory medications-Aleve, Voltaren, Indocin, Celebrex, etc.) is critical to slow down the arthritic process. Wearing a knee brace will also help especially when active in sports. Exercise programs, stretching, etc. will help to keep the supporting structures of the knee is very helpful. If a person is younger and needs a replacement, the realization of a repeat surgery must be discussed.

  Orthopedic surgeons suggest that patients put replacement off to hopefully prevent a repeat surgery, but people are living so long, there will be many who will face a repeat surgery when they are in their late 70s and beyond. Additionally, athletes are tearing up their bodies at a younger age and need replacements earlier.

X-rays--Bone on bone with total loss of the medial joint space is demonstrated below left.

Answer these questions before considering a joint replacement:

1) Have you tried every possible conservative approach and treatment? Have they quit working?

2) Do you have significant pain from the joint(s) which has interfered with your life, work, and quality of life.  Do you have night pain that wakes you?

3) Have you had to retire from work, play, and other social events in your life that has decreased your ability to cope with your knee disease?

4) Are you healthy enough to have surgery? Can you handle and are willing to do the rehab? Do you need to lose weight? Do you have osteoporosis? What does your doctor say?

5) Do you realize there is needed preparation for surgery, including exercises to strengthen your muscles around the joint to be replaced? Classes for these exercises are usually offered. Are you willing to perform these exercises?

6) Have you talked to a physical therapist before surgery about the extensive rehabilitation that is required after surgery, even in the face of significant postop pain? Is your caregiver educated about their role and accepting of the responsibility? 

7) Do you realize that joint replacements wear out (about 20 plus years now) and may have to be replaced?

8) Do you have help at home for a few weeks for household chores, meals, helping to the bathroom, etc.?

9) Will you need to bank your own blood for the procedure (for double knee replacement), in case it is necessary from significant bleeding with surgery?

10) Do you realize there are complications possible with this surgery usually in less than 5%? Infection, blood clots in legs, emboli (blood clots) to the lungs, bleeding, dislocation of the joint, fracture of the bones around the joint, respiratory complications such as pneumonia, anesthesia complications, including death. 

11) Would you consider going to a rehab facility after surgery for more intensive therapy if necessary? (I highly recommend it). Can you have home physical therapy?

12) Do you realize it will take several weeks to recover, observe an intensive home exercise program, and at least 2- 3 months before you will be able to return to more normal activity? Certain sports that require pivoting may have to be given up permenanently. There is no sense in wearing out those titanium knees early. I gave up tennis but was able to take up golf.

13) I am a big yoga advocate, but do not stretch out  knees too aggressively, as dislocations can occur.

Technique

Note the implant in place above left. The right drawing above shows the top of the tibia has been cut off to provide a flat surface to place the metal and plastic components of the artificial joint. The rough surface of the femur is shaved off to accept the upper portion of the implant.  Note below that the implant has a projection that is hammered into the middle of bone for stability (seen in drawings). The interface is the plastic (Teflon) component.

This plastic component can wear out and need replacing. Although, when I had my knees replaced in 1999, I was told that these prostheses would only last 10-15 years, however, I am having no problem after 19 years, and most of the newer prostheses will last 20-25 years based on multiple factors (reinjury, obesity, etc.).

Note that there is a plastic component attached to the back of knee cap (patella) below to protect it from the titanium portion of the prosthesis.

The ligaments and tendons are preserved to provide stability to the knee. 

Postoperative Course

  You will be up on your feet with assistance to walk the hospital halls the day after surgery, like it or not. A spinal epidural for pain control for the first couple of days is very helpful. After that significant pain meds are necessary for the first week or two. The goal is not being pain free, rather, getting pain under control and still be able to mobilize.

  Taking pain medication 30 minutes before a physical therapy session is wise. Preventing blood clots using anticoagulants, compression stockings and a CPM (continous passive motion) machine is very helpful to keep the knee moving not only to begin the tough task of getting range of motion back in the knee and prevent blood clots in the legs and creating an embolism.

Below is a valuable postoperative tool—CPM (Continuous passive motion), an apparatus that is programmed to automatically move the knee every few seconds and keep motion going in the joint from the beginning. Without frequent movement, the joint will freeze up and prolong return to the new normal.

Rehabilitation with tough physical therapy is critical to get full range of motion back in the knee, but it can be done with a positive attitude. Recovery is amazingly fast with adherence to postoperative exercises sanctioned by the therapist whether with home visits or in a rehab facility. Aqua-aerobics can be very helpful.

  An over the toilet potty chair is recommended as is a chair in the shower is very helpful. Sleeping with the leg(s) bent and elevated was very helpful to me. It took 3 months to really feel like I had recovered (both knees), walking without pain, and after 1 year, I was back playing sports regularly. Leg strengthening exercises must continue permanently to maintain the integrity of a replaced knee .

  Favoring the other leg is not recommend, as walking as normal as possible is important to not put stress on the opposite hip joint, as this can cause acute and or chronic hip pain (bursitis).

  Consideration for a bone density test should be discussed and vitamin D blood levels checked before surgery. Osteopenia (decreased bone density) increases the risk of fracture.

  A therapeutic massage therapist (or a physical therapist) can work on the knee scars and help eliminate knee edema to allow better range of motion.

On the left photo is a typical swollen knee at 6-8 weeks. Above right is the eventual scar and knee appearance several months after surge

Success of surgery

  The 10 year success rate for replacement surgery is 90-95%. I am almost 20 years since my replacements and am still going strong with complete mobility and no pain. I can’t play tennis, or play basketball, but I still can walk, swim, play some golf, and go to yoga classes. I never regret having my knees replaced….and I am pain free!

4. Robotic Surgery—Is it worth it?

The photo (above right) demonstrates robotic abdominal surgery using the robotic arms to perform gastric bypass surgery. The instruments are inserted into the abdomen through puncture wounds just as in standard endoscopic surgery.

  Robotic surgery was introduced 25 years ago. Although there have been a few thousand articles regarding this innovation, there have been very few randomized trials published to compare it to regular endoscopic surgery (mostly open technique). The latest was published in the journal Lancet, and compared robotic surgery with open surgery for prostate cancer and found no difference in early results. There are even fewer long term results reports.

  Everyone is familiar with endoscopic surgery, which has been a tremendous advance in lessening hospital stay, recovery time, fewer complications, less pain and disability. But robotic surgery is newer and with 4000 surgical robots in current use in the U.S. (FDA approved), those surgeons are going to push robotics, but there has been few reports to suggest they are superior. The technique requires very special training and experience as well.  

  Currently about 4% of surgery is robotically performed compared to 96% using laparoscopic surgery. Gall bladder, hernia, colon, total hysterectomy, and prostate surgery are the most common robotically performed.

  As in laparoscopic surgery, the skill of the surgeon correlates with the outcome, time and cost of surgery. In the study cited above, there was one bright spot for robotic surgery when comparing to open surgery, in that there were fewer readmission rates (15% compared to 23%) to open surgery. But it would be fairer to compare robotic with laparoscopic surgery, and I am still looking for the benefit.

  When attempting to perform nerve sparing prostate cancer surgery, robotic surgery was touted as superior in results, but over time, a better ability for patients to regain sexual potency has not held up in some studies.   

  In a time that healthcare costs are astronomical, there is no question that this advance is much more expensive—3-4 times more expensive.

  As in any advance in surgical techniques, its superiority should be questioned because of the extra cost. One area that is encouraging is in pediatric surgery.

  There are 3 areas that robotic surgery has gained a foothold—abdominal gastrointestinal, urological, and gynecological surgery.

  At this point, it is clear that laparoscopic (endoscopic) surgery has proven to be a very valuable advance over open surgery, but it is still unclear, based on the 3-4 times higher cost, that robotic surgery is superior to laparoscopic surgery.

  The experience of the surgeon continues to drive results, so if a patient is considering robotic surgery, a major discussion with the surgeon regarding experience, numbers of cases that were clearly more valuable, length of time in the hospital, complications, and results compared to laparoscopic surgery.

Journal of the American College of Surgeons

5. Chronic pain series—Part 5—Physical and Occupational therapy, exercise modalities (yoga, pilates, aerobics, weight training, etc.)

Update on the opioid crisis

  My book club is reading a fascinating account of how the opioid crisis got started in the U.S. I will summarize some of the high points in a later part of this series. It will give you a better understanding of the role Mexican families (black tar heroin) easily flowing back and forth across our borders to quickly spread the drug throughout the U.S, how Big Pharma lied to doctors about the addictive risk of oxycontin, how treating cancer patients with opioids spread to using it for chronic pain, how accreditation for hospitals pressured doctors to overtreat pain, why white kids were the target, how greedy pill mill doctors wrote millions of prescriptions to addicts and when doctors started refusing to prescribe opioids, many turned to the streets where heroin was readily available. The book is called Dreamland, by Sam Quinones.

  As I write on this chronic pain series, I continually find more information coming out about the opioid crisis. In the latest MEDPAGE TODAY internet journal, reports that half of those who become addicted to opioids have a past criminal history (DUI, jail, disorderly conduct, etc.). If they withdraw in jail, they do not have a chance for detoxification and preventative treatment. Detoxification by itself actually increases the likelihood of repeat addiction unless access to rehabilitative services including relapse prevention medication (suboxone) is allowed. This is a flaw in the criminal justice system, and when they are released from prison go right back to heroin. A better coordination between healthcare services and the prison system is sorely needed.

  Those most likely to abuse were white, low income, and have a chronic disability, severe mental illness, and who were prescribed opioids for their pain. Treating opioid users in prison will decrease overdose deaths after they are released. More to come.

  The CDC cited 42,000 opioid deaths in 2016, and we must get a handle on this crisis, especially since most heroin users started with prescription opioids.

  I have previously reported that physical therapy and regular yoga sessions are comparable in value for treating chronic back pain, and we need many more comparison studies. There are new studies that state that NSAIDS are as effective as opioids for chronic back pain. This is welcome information, and it tells the patient there are more conservative measures that work without the risk of opioid abuse and potential addiction.  

More Options for Chronic Pain Management--Physical Therapy (and Occupational Therapy)

  Physical therapy (physiotherapy) is one of the allied health professions that has been the backbone of rehabilitation. It requires a referral from the treating doctor or surgeon to be qualified for a number of sessions (shamefully only 12 per year). I have been to many therapists and have found them to be extremely well trained and capable of directing therapy not only in their office but also home visits or setting up specific exercises to maximize benefit for the patient to carry out at home. Many surgeons will direct the physical or occupational therapist for home sessions, especially shortly after surgery, when it is painful and difficult to go to an office. When I had my left shoulder replaced, home visits from an occupational therapists were instrumental in my speedy recovery.

  But physical therapy is by far not just for postoperative care and rehabilitation. Patients in chronic pain are some of the best candidates for physical therapy consultation and tailored regimens to combat casues of pain.

  Physical therapists are experts in understanding the anatomy and physiology of the musculoskeletal system and putting that knowledge into practice with a variety of techniques and regimens that will combat the cause of pain. BUT, IT IS CRITICAL TO UNDERSTAND IT IS THE PATIENT’S RESPONSIBILITY TO CARRY OUT THOSE EXERCISES AND REGIMENS PRESCRIBED THE PHYSICAL THERAPISTS AT HOME. Having the attitude that all the work will happen at the therapy center is a serious mistake, and the homework they prescribe a patient must be performed as directed at home in between sessions at the therapy center. Otherwise, the benefit will not occur or be limited. The directions for strengthening or increasing range of motion, etc. may require the programs prescribed to be in place permanently. Motivation and perseverance is mandatory or a patient is probably wasting their time. This goes for most programs that require physical activity as a form of treating chronic pain. It must be understood that chronic pain may be permanent and therefore so will the therapy to combat it!!  

What is the difference between physical and occupational therapists?

  Physical therapists are primarily concerned with the source of an injury and how to combat it with therapeutic measures, while occupational therapists are primarily concerned how an injury or disease has interfered with daily activities and direct therapy to regaining or adapting to lost or impaired activities (eating, grooming, cooking, dressing oneself, etc. This is a very simplest statement, and depending where a patient lives may determine which therapist is seen. In many cases, both may be involved in recovery of a disease, disorder, or injury.

  I am currently seeing an amazing physical therapist who is working with me to cope with a variety of chronic pain problems that resulted from radiation treatments to my neck and sports injuries. He has provided me with a variety of exercises and techniques to combat loss of certain muscles in my neck and shoulders from scarring and paralysis of certain nerves (spinal accessory nerve, XI) that make it difficult to keep my head up without pain and fatigue in my neck and upper back.    

  There are many subspecialties in this physical therapy including sports, musculoskeletal, neurology, speech,  wound care, geriatric, orthopedic, women’s health, cardiovascular and pulmonary, and pediatrics. Who is seen will be determined by the treating physician(s).

  Most physical therapy departments in hospitals, rehab centers, and outpatient facilities have an array of highly trained dedicated personnel to assist a patient depending on the prescription from the treating physician.

  These therapists provide many of the options I have discussed in this series including massage, stretching, weight training, electrical stimulation, heat and cold therapy, ultrasound, manual therapy for edema, palliative care, etc.

  McKenzie physiotherapy is a common practice followed by many therapists. I am currently performing some of these exercises in this commonly used program, but should only be performed under the direction of a physical therapist trained in this method. For more information, click on www.spinehealthphysio.au/mckenzie-method-exercises/

  Physical therapists may have bachelor’s, masters, or doctorate degrees that allows sub-specialization.

  There is a medical specialty called Physical and Rehabilitation Specialists who are MDs or DOs, who take residencies and fellowships in this area of expertise. Most of these physicians head up Rehabilitation Centers and provide guidance over physical and occupational therapy programs for patients. There is a great deal of research backing their techniques in rehabilitation.   

  Some of these centers also employ pain management specialists, occupational therapists, can consult chiropractors, and other professionals.

  There are physical therapy assistants that help with the actual individual treatments in major centers.

  All these professionals are highly trained and accredited to be able to perform any type of physical or occupational  therapy.

  As you can see, this is a huge field, and needs to be even more utilized, however, insurance limits the number of sessions, which can be a great disservice to patients and physicians. This is true of most of the complementary treatments for chronic pain. This must change in addressing the opioid crisis. It will take leadership from our Congress. Is that possible?  

Exercise types (yoga, pilates, etc.)

Exercise

  There is nothing that can add to a person’s longevity than regular exercise. The American Activities Guidelines for America states that we need 150 minutes a week of moderate exercise or 75 minutes of vigorous activity and fill our plate half full of vegetables and fruits. Walking, jogging, bicycling, sports activities, weight training all are important for weight management, diabetic control, and maintaining the strength and stamina it takes to get through each day. These are also very important for chronic pain management, because we must have good tone in our muscles to have any chance that a pinched nerve or muscle problem will get better with any type of treatment.

 Exercise on the other hand in some studies found that it does little to stop the progression of dementia, but that does not mean these folks can’t benefit in other cardiovascular ways (NEJM, Journal Watch, May 31, 2018).

  Quality sleep, controlling stress, and exercise must be included in any regimen to maintain maximum health and a good quality of life.

  If recovering from an illness, it would be wise to consult some type of trainer or therapist to create a program of recovery. The last thing anyone wants to do is overdo it early in recovering or getting back to a sport or activity. Admitting as we age we have to accommodate to our body’s changes is not easy and is frustrating. If we have chronic pain, there is nothing more discouraging than injuring ourselves as we are trying to include some type of exercise as an additional form of pain management.  

  I have gone to yoga classes regularly for years, and even though I continue to struggle with chronic spine pain, I have been able to keep it under control with regular stretching and yoga classes (and physical therapy). The strengthening of the muscles and joints with isometric exercises and stretching are at the core of yoga and will allow patients with chronic pain to enjoy some of the activities that they have given up. It requires discipline, learning to concentrate on breathing (a key in yoga), and not overdoing it so that it causes injury and get discouraged. Previous reports on yoga: www.themedicalnewsreport.com #33 , #60

Health benefits of yoga

    a) Chronic pain

  Before starting classes, please ask your doctor if they feel you are healthy enough to go to classes. Hypertension and glaucoma may prevent a person from performing head down poses. It will take time before a person can work up to performing the poses for an hour or so. Do not get discouraged. It is a tremendous form of rehabilitation after surgery or injury. However, be sure the surgeon clears you for such programs. You may want to start with physical therapy and then progress to yoga. Strengthening the core is the key to controlling back pain. If you have weak abdominal muscles, there is no way for back pain to be controlled. Posture will improve with time. Standing up straight requires great coordination of abdominal, hip musculature, and back muscles. Yoga also improves balance. Even performing these positions with the help of a wall will get a person started.

  I have cited studies to prove that yoga is equal to physical therapy in helping back pain.

   Additional advantages of yoga 

     b) Cardiovascular 

  3 hours of yoga per week for a year improved adipokines, which are proteins secreted by fat cells, that promote inflammation. Lowering the amount of adipokines in fat cells with exercise will result in a lower blood pressure, reduced waist lines, and improvement in the metabolic syndrome (diabetes, hypertension, elevated blood lipids, and abdominal obesity). By downregulating these proinflammatory adipokines, improvement in these risk factors for heart disease occurs. Individual variation would be expected and other co-existing risk factors and the ability to persist in doing yoga three times a week for a year all would play a role in evaluating the benefit of yoga, but it does motivate people to get into yoga classes as a form of exercise to improve their overall health including reducing stress and at the same time improve pain.  Medscape, Feb. 12, 2018

   c) Urinary incontinence

  Yoga has had many valuable health benefits, and here is another one….urinary incontinence. It may not be associated with pain management but deserves mention.  A study was reported at the most recent American Urological Association women with an average age of 65 and compared women who went to 2 yoga classes plus one home session per week for 3 months. Compared to the controls, these women dropped their number ol bladder leaks from 27 leaks to 7 per week. That is a 76% improvement.

  Most yoga classes spend a considerable time working on stretching and strengthening the pelvic and hip musculature. Even work on the abdomen and back require isometric contractions of the pelvic muscles and those that attach including the upper thigh, back, and abdomen. It is essentially performing Kegel exercises.  

  A third of women over 50 have some degree of urinary incontinence, but fewer than half seek treatment according to a study reported at the American Urological Association Annual Meeting, May, 2018

  I have reported on bladder problems including incontinence. Click on:

Pilates

In my classes, I perform a combination of yoga and Pilates with light weights called fusion yoga. The main difference between yoga and Pilates--yoga holds poses using more isometrics while Pilates performs repetitions in and out of the pose. Hand weights are often used for increased strengthening. Pilates is more difficult but can increase strength, endurance, balance, and stamina even more than yoga. I would start with yoga first.

Aerobics

  There is nothing better for the body than an exercise that gets the heart rate up (running, swimming, step aerobics, lifting weights, pilates, tai chi, calisthenics, and even yoga). This increases the body’s ability to use oxygen to fuel the muscles to function at a higher level. However, brisk walking has been shown to be as effective to maintain good health, and stay in “shape” as aerobic exercise. Before performing exercises that raise the heart rate and blood pressure, check with your doctor to be sure you do not have a medical condition that would be aggravated by more strenuous exercise. Start slow and increase as the body allows. Also, the summer heat is a stress in itself.

  Aqua-aerobics is a fabulous non-weight bearing exercise. Pool weights allow for quite a workout, which I do as well. Those with arthritis are missing an opportunity to stay in shape and reduce chronic pain without weight-bearing. In fact, after my knee replacement surgery, it was recommended.  

Weight training

  The sophistication of machines in gyms is designed to allow anyone to lift weights and at their level of ability. Repetitions slowly performed are valuable to strengthen all the muscles supporting bone and joints. Most gyms have trainers available to be sure people use the machines correctly. A program of work can be created by them and be customized for anyone. This time of year is a perfect time to hit the gym since it is so hot.

  All of these exercise programs will improve your health, lower stress, and help combat chronic pain. As complex as pain is, the treatment regimens are just as complex and finding the right program may include several types of therapy. Pain is not static, and programs must be adjustable to prevent increasing pain and injury.  

Walking

  The best form of execise for most of us and the easiest to stick with it, is walking. Vigorous walking for 30 minutes 5 times week will accomplish the definition of a vigorous program and help pain. In fact, it will even lower the risk of all-cause mortality, and is even recommended to cancer survivors to lower their risk of not only pain, but cardiovascular disease which may be caused by treatments such as chemotherapy and radiation.   

6. Medicare Financial Outlook Worsens; Healthcare costs for undocumented immigrants

Medicare Financial Outlook 

  Medicare financial conditions may be on life support sooner than thought. Higher hospital costs and lower tax revenues that fund the program are the reason. Previously the Medicare board of trustees predicted it would run out of money in 2026.

  Factors that reduced tax revenue were lower wages for Americans and, therefore, less Medicare withholding. Think about those who receive cash for work and don’t even pay into the fund (most illegals and many part time workers). The aging of the population and legal immigration numbers are putting us in the poor house regarding Medicare and even Social Security (funds available until 2032). Penalties are gone from the  Obamacare (individual mandate), and the economic downturn during the Obama years are all factors. Now that the economy is on an upturn, hopefully that will reverse some of the deficit, but it will take a few years. Social Security has already announced they can extend the time before default by 2 years thanks to the economic upturn. The shear number of Medicare recipients has been a major factor, and that people are living long enough to be a recipient for 20 years or more. The fund was never intended to be used for that long.    

  Special funds paid to hospitals for uninsured patients takes away from federal funds that could go to Medicare.

  Treasury Secretary, Steve Mnuchin stated that President Trump’s effort to cut taxes, ease federal regulations, and improve trade deals will also help reverse the trend. Of course, the Democrats blame Trump (reduction of taxes), and the Republicans blame Obama (Obamacare and letting jobs and industry go out of country) for his years of economic turndown.

  Look for Trump to encourage Congress to cut Medicare spending during the next decade, by reducing payments to doctors, nursing homes, and other providers.

  Medicare provides health coverage to more than 58 million people including seniors and disabled. It has added 13 million recipients since 2013. Total Medicare expenditures were $710 billion in 2017.

  What does this mean for those recipients. They will pay more for Medicare monthly.

  Congress has never let the trust fund go bankrupt, but in the 1970s, the program came within 2 years of insolvency. But expect turmoil and the “ Goose that laid the golden egg” may get fried.  Medscape, June, 2018

Healthcare Costs for undocumented immigrants   

  Regardless of political ideology regarding undocumented immigrants, there is a huge cost burden for them being in this country, and it impacts everyone’s access to health and the healthcare costs of every legal U.S. tax payer. Separation of parents from their children have become a hot political and ethical topic. There are very few people who do not have a strong opinion. What about the child abuse of dragging children from Central America to our borders? How many children are killed in that journey? What type of healthcare have these children received since birth? What happened to following our laws? Clearly the immigration issue has got to be solved and yet our Congress will not tackle this, because the two sides won’t budge on certain aspects of the issue. Can our government not come to some compromise? That means each side has to give and take. Making children a political football is a shame. We have got to get back to some bipartisan cooperation, but the radical left and right are making that very difficult.  

  The cost of illegal immigrants in the U.S. is $113 billion a year ($1,117 per person) according to the American Federation of Immigration Reform. And yet, the National Research Council estimates there are 11 million illegals, and the cost is $346 billion annually, which is 3 times that estimate. Who do we believe?

  According to the Center for Immigration Studies estimates the current healthcare cost for illegal immigrants is $4.3 billion annually from flooding our emergency rooms and clinics. Medicaid cost estimates to cover just 3.1 million illegal immigrants is $8.1 billion, and there are 11 million of these people.  

  Regardless, there is a huge healthcare cost for those who cross our borders. There is no current figure to estimate how those that bring heroin into our country are impacting healthcare in our country when 42,000 overdose deaths annually and millions have lost their jobs and become dependent on government entitlements. What about the communicable diseases they bring into our country? What about the harm to U.S. citizens including murder? What about long term care costs? For those who want our borders open, who is going to pay?   

  Californians are trying to pass single payer healthcare that will double the state costs for healthcare, because they want to include all illegal immigrants. 2.5 million of the 11 million illegals live in California. Healthcare costs are the responsibility of the states, because Obamacare (a federal program) strictly prohibited healthcare coverage for illegals. Several states, however, have obtained waivers for uncompensated costs to hospitals and clinics from Medicaid.

  European countries are also being overwhelmed by the influx of immigrants and have serious problems with Muslims refusing any type of care from female medical personnel. Consider that half of the doctors are female and there is a great percentage of nurses that are female.  I do not know if this is true in the U.S.

  Many immigrants have AIDS, syphilis, and other communicable diseases, especially tuberculosis and tropical diseases which have created a burden on personnel who have to help these people.    

  There are many confusing articles on the internet and each side of argument for funding these people cites chapter and verse Fact Check substantiation of their claims.

  The cost for covering all uninsured and underinsured people in the U.S. was $41.1 billion in 2011, and hospitals are not allowed to ask people if they are undocumented or not. Hospitals only calculate what is non-reimbursed for indigent care. Hospitals are absorbing a lot of these costs and pass it on to us, or as mentioned get special funding from the government even though it is a state responsibility.  

  Hopefully our immigration reform can be addressed by our Congress and come up with a compromise system  trying to be as humanitarian as we can be without being taken advantage by those who game the system.   

 7. Varicose Veins

    Varicose veins are nothing more than dilated veins, regardless of where they occur in the body. The most common are dilated leg veins and hemorrhoids, but they occur in the lower esophagus from hepatic failure (varices), or anywhere there is obstruction of venous flow, back pressure, or gravity. There can be congenital emalrgement of veins, etc. I will limit this discussion to varicosities of the lower extremities.

  I have discussed this issue as it applies to pulmonary embolism, the most serious risk. Click on my website:

www.themedicalnewsreport.com #46

  There are many other considerations and treatments to discuss about varicose veins. Note the valves in the veins (drawing below) and what a healthy leg looks like compared to one with varicose veins.

There are deep and superficial veins in the legs. There is communication between them called perforator veins that have valves that prevent free flow between them. When we stand up these valves close as stated above, and if they don’t, those valves become ineffective allowing deep venous blood to flow into the superficial system causing dilation over time.

  Those who work all day on their feet are much more prone to developing varicosities (like surgeons and nurses). With more and more pressure on the superficial leg veins, varicosities form.

  Stasis dermatitis can occur as well, causing discoloration of the skin from pressure on the skin and edema. Eventually this skin can ulcerate, especially in diabetics as seen below.

Over time, blood can pool in these veins and cause inflammatory phlebitis and or a blood clot may develop which can travel to the lungs (emboli) in the pulmonary arteries.  This is a medical emergency.

Pulmonary embolism can carry a 25% chance of death. They usually come from the deep veins. Symptoms include sudden shortness of breath, chest pain worsened with a deep breath, lightheadedness or fainting, rapid pulse, or coughing up blood.)

Risk factors for phlebitis and embolism include obesity, sedentary lifestyle, prolonged inactivity (such as bed rest after surgery), birth control pills, smoking cigarettes, patients with heart failure (because of limited lung and heart failure), certain cancers or blood diseases (polycythemia) that thicken the blood, inflammatory bowel disease, injuries to the leg, pregnancy, and varicose veins.

  Immediate attention is necessary especially with deep vein thrombophlebitis. The physician will need to decide if the deep or superficial veins are involved. Ultrasound can locate a clot. There is a blood test called D-Dimer that can measure a substance that is released as a blood clot dissolves. Occasionally, a venogram (dye study) is necessary to detect a clot.

Prevention

  Do not sit for long periods of time, especially with the legs bent at the knee. If a person has a risk factor, be especially aware of sitting too long, talk to your doctor about aspirin therapy and leg exercise. Wearing compression socks or hose is helpful when standing for prolonged periods.

Treatment of phlebitis

  Treatment includes aspirin to thin the blood, and relieve pain (Aleve or Ibuprofen). Leg elevation, warm compresses and compression stockings are indicated. Home care may suffice if there is superficial phlebitis, but hospitalization may be necessary if the deep veins are involved. Prolonged bedrest should be avoided unless severe. Antibiotics are rarely necessary. If phlebitis is recurrent, blood thinners on a long term basis are usually required (oral anticoagulants-i.e. Xarelto, Pradaxa, Eliquis).

Treatment of blood clots in the leg veins

  There have been 2 philosophies about treating deep vein thrombosis (clot).

1) Surgical Approach--direct injection of anticoagulants into the veins to break up the clots using a catheter to remove the clot or suction the clots out to prevent blockage and embolism to the lungs.

Note the balloon in the vein (above) which can be used to remove the clot.

2) Medical Approach--oral anticoagulants with compression stockings, leg elevation, and heat to dissolve the clots.

  Unfortunately, 50% of both groups developed post-thrombotic syndrome (PTS), characterized by swelling of the lower leg, leg pain, hyperpigmentation, and breakdown of the skin (ulcers). However, there was more major bleeding in the surgical group (1.7% vs 0.3%). There tends to be less bleeding with the medical approach.

  If vascular doctors can overcome the bleeding complications, surgical extraction may be recommended  more in the future.  

  The goal of therapy regardless of approach is re-establish blood flow out of the leg veins and prevent emboli. To date, there is not a clear advantage with either approach. 

24 months after the event, there has been little difference in quality of life issues (swelling, pain, skin changes, etc.) with either approach.

  At present, The American College of Chest Surgeons recommends anti-coagulant therapy over catheter directed thrombolysis unless gangrene is imminent.  NEJM, Dec,. 2017

Treatment of varicose veins

  Since the advent of laser therapy for varicosities, vein stripping is rarely indicated. A laser is inserted via a catheter through a tiny puncture, and the laser injures the endothelial surface on the inside which makes the vessel collapse and scar. This procedure may need repeating if certain varicosities are resistant or pressure creates new connections that fill the vessel through another route. I have had this performed and it was very successful. Over the years, some new varicosities have formed but much less prominent. There are endoscopic vascular techniques that can also be used. There are vein centers now that specialize in these procedures. Microsclerotherapy (use a chemical to inject tiny veins) for spider veins is very effective. Lasers can be used as well. Before and after of varicose veins and spider veins.

Reference:

  e.medicine.net, WebMD

This completes the August, 2018 report. So much information!! I hope you had time to consume most of it.

Next Month, the September report will include:

1) Late Breaking News--The dangers of aspirin and NSAIDs together; Dangers of synthetic marijuana; The shortage of Epipens; A new blood test to help screen people for lung cancer

2) The cancer survivorship series—cancer pain

3) Spondylitis—a serious form of arthritis

4) The shortage of bedside nurses and the rise of Nurse Practitioners

5) Life Style factors can add 10 years to your life

Stay Healthy and Well, my friends, Dr. Sam