The Medical News Report

September, 2018, #80

Samuel J LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects:

1. Updates—

   A. Big News--Dosage of aspirin and heart protection relates to weight

   B.New warnings about taking aspirin and NSAIDs (i.e. ibuprofen or naproxin). Aspirin vs oral anticoagulants and intracranial hemorrhage

   C. President Trump convinces Pfizer to delay price increases on 40 drugs

   D. Epipens in short supply; FDA just approved a generic

   E. First Marijuana-derived drug approved by the FDA; Synthetic marijuana is killing people

   F. New blood test to help select smokers for a screening CT scan of lungs to detect early cancer

2. Lyme Disease—the most common vector-borne disease in the U.S.

3. Diagnosis and treatment of Inflammatory Arthritis including a serious form-Spondylitis of the back

4. The rise of Nurse Practitioners; the changing face of primary care medicine and the nursing profession

5. Lifestyle Factors could add 10 years to your life (Life style and life expectancy)

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. Big News on Medical Issues

 A. Critical information—Dose of aspirin for prevention of cardiovascular disease based on weight

  A new report, in the journal Lancet, analyzed 10 studies on aspirin dose and cardiovascular risk prevention. Most adults taking a baby aspirin (81mg) weighing more than 154 pounds are not being well protected from cardiovascular disease. People weighing less than 154lbs. had a 23% primary prevention rate, whereas those over that weight had neglible prevention compared to placebo. Patients over 154lbs. had to take 325mg to get a 17% preventative benefit.

Enteric coated aspirin and smoking may also make the aspirin less effective in preventing heart disease.

  The theory is that heavier people have more of an enzyme called esterases that break down aspirin. Although low dose daily aspirin does block thromboxanes that make platelets less sticky, the heart benefit is just not there.

  The modest protection against colorectal cancer is also dose and weight dependent. 

Side Effects of aspirin

  Bleeding and stomach irritation are also a consideration for anyone taking aspirin. There are reports, however, that dose and weight also correlates with these side effects as well, meaning heavier people have fewer side effects.

  However, if a person is having surgery, the number of days aspirin should be stopped before surgery is up to the surgeon. Patients may need to stop aspirin as much as 10 days prior to surgery. Dentists usually ask patients to be off aspirin for 3 days. When I performed ENT or plastic surgery on the face, I wanted my patients to stop aspirin, NSAIDs, Omega-3, vitamin E, St. John’s wort, and any oral blood thinner for 10 days prior to surgery. However, if a person has a heart valve or stent (and is on blood thinners including aspirin), it should be discussed with their cardiologist before stopping these medications. It becomes a risk/benefit issue.      

B. Aspirin and NSAIDs

  There have been precautions announced before by the FDA about combining aspirin and other NSAIDs* especially ibuprofen (Motrin) or naproxen (Aleve). There are millions of people taking a prophylactic 81mg baby aspirin to prevent cardiovascular events as discussed above. But when patients develop pain, they frequently reach for the most common over-the-counter pain medications while taking aspirin as well.

  NSAIDs act by reversibly inhibiting cyclo-oxygenase-1 better known as COX-1, and this effect interferes with the cardioprotective capabilities of aspirin. Aspirin works primarily by affecting the stickiness of platelets which prevents clotting to some extent, since a blood clot forms partially by platelets sticking together (platelet aggregration) in conjunction with certain clotting factors.

  Because of the opioid crisis, people are taking more  NSAIDs to relieve pain since their doctors are not prescribing opioids as freely. This creates a problem for those who are using aspirin to prevent cardiovascular events. Talk to your doctor about this.

Ibuprofen and nighttime urinary urgency

  I have stumbled upon a use for ibuprofen I had not heard of. It was in a health article in my local newspaper. Patients were claiming that taking 200 mg of ibuprofen before bedtime kept them from getting up at night so often to urinate. It actually helped me. Talk to your doctor about this if you are having nighttime urgency which wakes you up.

Comparison of aspirin versus oral anticoagulants (NOAC)* and the risk of intracranial hemorrhage

*NOAC=novel oral anticoagulant

  Because of the ease of taking the new oral anticoagulants and decreased risk of intracranial hemorrhage rather the higher risk of taking Coumadin, most physicians have switched away from Coumadin.

  NOACs are often prescribed to prevent embolism from non-valvular atrial fibrillation and deep vein thrombosis(DVT), however, there has been concern for an increased risk of intracranial hemorrhage compared to using aspirin 100-325mg, which is just about as effective (now dose of aspirin is based on patient’s weight).

  Patients with an ischemic stroke have a 15 times higher risk of hemorrhagic stroke on anticoagulants.  

  A new study just came out comparing aspirin and taking oral anticoagulants, rivaroxaban (Xarelto) 10mg and 15-20mg and apixaban (Eliquis-5mg twice daily).

  This study found that at a lower dose of Xarelto (10mg) or 5mg twice a day of Eliquis did not increase the risk of intracranial hemorrhage compared to aspirin. However Xarelto at 15-20mg did increase the risk.

Dosage of these NOACs is critical in these patients, because at a higher dose, hemorrhagic stroke is of greater concern with these new oral anticoagulants. However, if the treating physician can keep the dose at the lower level, the risk was the same as taking a whole adult aspirin daily. Keep in mind the dose of aspirin is also in play.      

C. President Trump convinces Pfizer to delay drug price increases

  President Trump on July 10 convinced the CEO of Pfizer, the largest pharmaceutical company in the world to delay by 6 months July price increases on some 40 drugs. Trump stated that the administration is working on drug pricing plans and the price increases would complicate his plan. This comes at a time when many drug companies had planned to decrease their prices in response to Trump’s pricing plan that began in May. Pfizer manufactures such drugs as Humira, Lipitor, Advair, Lyrica, Viagra, Celebrex and many others that brought them revenues of $3.13 billion in 2017. They must be controlled and negotiating with Big Pharma for Medicare drug prices is a must.

  Also President Trump can make hospitals divulge transparent prices for hospital procedures. It only takes his signature to make it happen. Congress does not need to weigh in.

  Getting drug prices down has been one of President Trump’s campaign promises. It needs to happen. Reference--Reuters  

D. Epipens—generic just FDA approved  

  There is a national shortage of Epipens, which are autoinjectors of epinephrine (adrenalin) for patients who have an acute allergic reaction to environmental and food  substances and such things as bee stings.

  Recall that the manufacturer was sanctioned for raising the price 6-fold of these injectors to over $600 for a package of 2. Although it is not clear why there have been manufacturing problems, I suspect it may be in part payback by the owner of the drug company Mylan (made by Impax Laboratories) when Congress called them out for the high price.

  The FDA just approved a generic epipen and epipenjr., so the cost shuld be less, but many generics are still outrageous in cost. There is another product being produced as an alternative to epipen that should be out soon. 

  CVS announced they would sell a generic version called IPXL-Adrenaclick for $110 for a two pack, but there is a $100 drug manufacturers coupon which makes the cost $10. Check with CVS.

  There is another company that makes adrenalin autoinjectors, Auvi-Q, but may not be covered by insurance, therefore, check with your insurance. I think it may be more expensive.

Malfunction of some Epipens

  A recent article stated that some of these Epipens do not work either because of malfunction of the injector or the viability of epinephrine. The expiration date must be noted! They must be kept in a cool dry place 68-77 degrees (not left in a hot car). It is recommended that people carry 2 just in case.  This is of great concern. Be sure you watch a you.tube instruction video on how to use them.

  There have been shortages of many medical supplies and drugs in the last few years (now even injectable opioids). Many of these manufacturers are outside the U.S., and if possible, our government needs to play a more active role in seeing to it that medical products are available and encourage insurers to cover alternative drugs. 

E. The FDA has approved the first marijuana-derived drug; Synthetic Marijuana (and other botanicals)

  The FDA has approved an oral solution of cannabidiol (CBD) (Epidiolex), which is derived from marijuana and hemp plants and are approved for those 2 years and older with a seizure disorder from 2 rare disorders (Dravett Syndrome, Lennox-Gastault Syndrome). It is a start with the feds! Once there is a FDA approval, doctors may choose to prescribe off-label for other medical issues. This is the drug that is already being used as medical marijuana, because it has very little euphoria effects but still is chemically active to treat a variety of authorized illness including seizure disorders, glaucoma, multiple sclerosis, spasticity from disorders, and is helpful in some patients with pain.   

Synthetic marijuana (Spice, K2) 

  Synthetic made marijuana (MJ) sold over the counter in “head shops” have caused 202 cases of serious bleeding. This synthetic cannabinoid has been found to be laced with rat poison, which is similar to Coumadin (brodifacoum) and causes serious bleeding. This crisis has occurred from Illinois to Florida. Anyone who has smoked or ingested this product needs to have clotting studies performed immediately.

  Spice or K2 is psychoactive since the chemicals bind to the same receptors as that cause a “high” similar to MJ. It can also create palpitations, intense anxiety, nausea, vomiting, confusion, poor coordination, and seizures.

  Be aware that products that can be bought online and in special shops can be dangerous. Be aware and spread the word. I just recently warned you about Kratom a couple of months ago. The younger people are the ones using these chemicals the most. Be aware!

Reference--CDC Alert

F. New blood test to select smokers for low dose CT scan screening for lung cancer

  There is a new simple blood test that measures 4 circulating proteins* that are elevated in lung cancer, but can occur with other diseases as well.

 (* the 4 proteins are cancer antigen 125, carcinoembryonic antigen (CEA), cytokeratin 19, and a precursor to surfactant protein B)

Lung Cancer Screening Guidelines

  In 2013 several medical organizations recommended low dose radiation CT scans in people age 55-74 (some say 79) who had smoked the equivalent of 30 pack years  (that could mean 1 pack per day for 30 years or 3 packs a day for 10 years), and those who have quit within 15 years and are still in good health.

  Recent studies indicate there has been a dismal 2% of those eligible getting screened and it needs to be repeated annually. Why? Some smokers are afraid to know, some doctors are not screening their patients, insurance may not cover the CT scan, and some are just too lazy or in denial to get tested. Others cite the concern of a false positive and having to undergo an unnecessary lung biopsy, which a real concern.

  There was also another problem. The original criteria for choosing candidates was only screening half the patients who actually developed lung cancer, such as those who do not smoke but are exposed to environmental hazards.

  Those screened from the original group, had a death rate reduced by 20% according to the National Cancer Institute because the cancer was caught in an earlier potentially curable stage. Half of those now diagnosed will live only one year, so we have a got to come up with screening methods to catch these cancers before there are any symptoms.

  It is estimated that 155,000 Americans were diagnosed in 2017. 57% will had Stage 4 cancer with only 16% of lung cancers being diagnosed at an early stage. These people had a chest X-ray for other reasons which accidentally discovered the cancer.  We must diagnose this cancer earlier with screening methods.

  The new blood test was developed from known lung cancer patients. In this study, 42% with positive proteins in their blood developed lung cancer in this research project. This study is a few years from becoming clinically available, but points out once again, that a simple blood test in the future may predict cancer whether the cancer can be seen or not. Biomarkers are the future of cancer screening. NCI, ACS, JAMA, Jul, 2018

  It is critically important that the benefits and harms of screening. Too many doctors do not take the time to discuss this critical issue before helping a patient decide to have a screening test.

2. Lyme Disease—the most common vector-borne disease 

  Vector-borne diseases have tripled in number from 2006-2016 in the U.S., and 96,000 cases were reported in the in 2016. As our country grows so do diseases.  

  Vector-borne diseases are defined as diseases that occur from arthropods that transmit infectious pathogens from one species to another that include ticks, mosquitoes, fleas, flies, mites, etc. 

  Arthropods are invertebrate animals with their skeletons on the outside of their bodies. The above categories are some of these arthropods, but also include spiders and crustaceans (crabs, shrimp, etc.).

  Infected pathogens include bacteria, viruses, parasites, etc. and these vectors spread these diseases through these vectors.

Tick-Borne Diseases

  The top 5 vector-borne diseases from ticks are Lyme’s disease, Rocky Mountain Spotted fever, Babeiosis, anaplasmosis, and erlichiosis. The first 2 are most common in our areas of the country. I will limit this report to Lyme disease

Lyme Disease—Lyme Borreliosis

  First described in Lyme, Connecticut, when several children came down with a mysterious form of arthritis, the CDC states that 30,000 cases are reported to them annually making it the most common vector-borne disease in the U.S., but it is estimated that over 300,000 cases occur annually because the majority of cases are not reported.  

  The number of cases have tripled in the past 20 years.  Lyme disease is most common in the Northeast, North-Central, and Northern California, however, it is now reported in all 50 states. 

  The deer (black-legged) tick is the vector that bites rodents and deer and then transmits the disease to humans and other animals (mostly dogs). Dogs are given medication monthly to attempt to protect them from fleas and ticks. People who are outdoors are prone to be bitten by ticks, but without using DEET pesticide spray and protective clothing, they are prone to being exposed to ticks in high grass and wooded area. The black-legged deer tick, carries the bacterium called Borrelia burgdorfera. 

Symptoms

  There may be several days (average of 7 days) before any symptoms or rash occur. Fever, headache, and fatigue (mimicking flu) are most common followed by a bulls-eye rash around the tick bite called erythema migrans (drawing above) that spread out as far as 12 inches or more but can become generalized. As symptoms progress even though they are non-specific and can be confused with many other diseases such as multiple sclerosis, lupus, fibromyalgia, etc.), therefore an extensive evaluation may be necessary to rule out other diseases.

  The CDC states that 10-20% of patients will go on to experience serious systemic symptoms. 

  If left untreated, infection or an immune response to the infection can spread to the heart, joints, lymph nodes, and nervous system. Paralysis of nerves (facial and others) can occur, neuropathic pain, dizziness, and memory loss, and severe fatigue is often debilitating. Arthritic symptoms can be prominent especially the knees. Palpitations and arrhythmias can occur with heart muscle infection.

Testing for Lyme’s Disease

   A two step test is required using an enzyme assay (ELISA). If the first test is negative, nothing further needs to be done. If positive, an immunoblot test is performed. Both tests must be positive for a confirmed diagnosis, because other diseases may make the first test positive. These tests detect antibodies to the bacterium.

Treatment

  Lyme disease can usually be prevented if properly diagnosed early with proper blood testing and antibiotics (doxycycline or cetrioxone for 2-4 weeks) within 10 days of the bite. Amoxicillin and cefuroxime are also mentioned as alternative antibiotics. Also if the rash stays confined to the bite instead of becoming generalized, there is less likelihood statistically that generalized systemic (disseminated) symptoms will occur.

  There is no agreement about using antibiotics later in the disease. I suspect, most physicians would give it a trial of 2-4 weeks, in my reading.

  JAMA Dermatology(August, 2018) reported on a study from the UK that stated if antibiotics are prescribed (doxycycline 100mg twice a day orally or IV ceftrioxone 1 gram daily for 14 days), the outcome of the disease was the same whether there was disseminated disease or not after one year of observation. Approximately 6% did not respond to treatment in one year in both groups. Studies do not validate that longer courses or second courses of antibiotics change the effects or course of the disease. There is, however, some disagreement with this statement.

Chronic Lyme’s disease (Post Lyme disease syndrome)

  The reality is that many patients go undiagnosed for a period of time and do not receive antibiotics soon enough thus opening the door to a chronic form of the disease, even though the CDC does approve of this term.

  Because the bacteria affect the immune system, other co-infections may occur and must be treated as well.

  The systemic symptoms (described above) are not necessarily actual infection spread, rather, they may be caused by an immune response, just as rheumatoid arthritis is caused by the body’s immune reaction to some insult.  

  Some of the systemic chronic effects of Lyme’s should be treated based on the actual symptoms and not with continued antibiotics. Depression, anxiety, fatigue, sleep difficulty, etc. comes with any difficult to treat illness and must be addressed as they would if they were not connected to Lyme disease.

  If arthritis persists, those with certain genetic markers respond to NSAIDs and hydroxychloroquine. I suspect other new biologic treatments have been tried (Enbrel, etc.)

  There are websites that recommend natural therapies using a variety of herbs, supplements, and alternative therapies, but I could not find any good research evidence that they are any more effective than placebos.

Prevention  As with any infection, the best way to control the disease, is to prevent it with proper clothing and DEET spray, careful examination of animals and people examining themselves and their children once inside, follow specific instructions for removing ticks, if bitten, see you doctor and if possible bring the tick to them for identification and get tested if it is a deer tick.

What about a vaccine?

  There was a vaccine 20 years ago, but thanks to the anti-vaccination folks, false claims that the vaccine caused auto-immune reactions (that was in vogue 20 years ago with silicone breast implants), and lack of physicians  encouraging vaccination, the vaccine was taken off the market. There is currently a new vaccine being tested.

JAMA Dermatology, emedicine.net, WebMD, CDC

In future reports, I will discuss other vector-borne diseases from mosquitoes and other varmints.

3. Diagnosis and treatment of Inflammatory Arthritis—a special look at Spondylitis

Types of Arthritis

  There are over 100 types of arthritis, however, 5 are the most common: osteoarthritis, rheumatoid arthritis, psoriatic arthritis, gouty arthritis, and lupus arthritis.

  There are other serious causes of disease that must be ruled out in the workup of anyone complaining of joint pain over weeks to months. After I report on the standard workup of these patients by a rheumatologist, I will discuss a very serious type of arthritis called spondylitis. Although all can be crippling, spondyloarthritis is very severe, especially ankylosing spondylitis (spine fuses).

  I have written on most of these types, but will concentrate on how to diagnose these different types. The workup is based on the usual—the history including the family history. At what age did it begin, what joints are involved, and are there other signs and symptoms outside the joints, such as skin, eye, salivary gland disease, heart, kidney, neurological symptoms, etc.

Causes—trauma vs inflammatory    

  Millions of Americans suffer from joint pain either from a traumatic event(acute or chronic) or an inflammatory cause. Osteoarthritis is caused by repeat trauma to joints from sports, professions prone to damage of the joints, and accidents. Osteoarthritis is the most common type (31 million cases in the U.S.) and for a review of osteoarthritis as well as rheumatoid types, click on:

www.themedicalnewsreport.com #10 and #11

  If fever occurs, it is more likely rheumatoid arthritis with nodules under the skin, anemia, fatigue, and may have inflammation in the heart or lungs.

  The inflammatory causes of arthritis especially rheumatoid, psoriatic, gouty, and lupus have been in previous reports as well:

www.themedicalnewsreport #5

www.themedicalnewsreport #7

www.themedicalnewsreport #40

Workup for Arthritis

  The workup involves laboratory tests and imaging depending on the areas of involvement. There are several tests that can often help differentiate them:

RA factor, anti-CCP(anti-cyclic citrullinated peptide), ESR (erythrocyte sedimentation rate), CRP(C-reactive protein), ANA(anti-nuclear antibody test), HLA-B27, CBC, creatine kinase, Complement tests, cryoglobulins, ANC, cytokines (T-cell proliferation, interleukins, TNF(tumor necrosis factor), and ANCA (antineutrophil cytoplasmic antibody). For an explanation of these tests and the diseases they may have positive results, I refer you to WebMD under arthritis.

  All these tests tend to identify aspects of the inflammatory process, which is the underlying cause. These inflammatory chemicals (T-cell lymphocytes-a white blood cell- secrete cytokines and other inflammatory markers such as interleukins, etc.) are the basis of the above tests.

  Radiographic studies do not correlate well with many arthritic cases, and should not be ordered until conservative treatments have failed.

Treatment

  Determining an exact diagnosis will assist the rheumatologist in coming up with the best possible treatment as the therapies overlap in many cases.  

  All of the best treatments are aimed at decreasing the inflammation in the joints which in some are immunosuppressive medications often used in cancer, transplants, and inflammatory bowel disease.

1) Treating with medications-- acute and chronic pain is an important issue especially since these patients are high risk for addiction—

  If there is a significant fluid buildup in a knee, reoving the fluid (arthrocentesis) may relieve pain. Evaluation of the fluid may be diagnostic (i.e. gout). Weight loss, exercise, strengthening, and stretching is critical in most arthritic cases.

a- NSAIDs-nonsteroidal anti-inflammatory drugs (aspirin, ibuprofen, naproxen, Celebrex, etc.

b- Acetominophen (Tylenol) should not exceed 3000 mg per day and liver studies shoud be monitored if taking large doses daily. One Extra strength Tylenol is 500mg!!

Note Chondroitin Sulfate or glucosamine  is not recommended by the American Academy of Orthopedic Surgery. 

c- Opioids are frequently necessary but must be monitored carefully. Tramadol should be used as it is the mildest of opioids.

d- Corticosteroids are often necessary to control the inflammation

e- Chemotherapy (Disease modifying antirheumatic drugs)--methotrexate (Rheumatrex) which interferes with DNA synthesis, repair, and cellular activity. It is used in rheumatoid and psoriatic arthritis.

f- Biologic agents—are made from living organisms or its byproducts and include antibodies, interleukins, and vaccines. They target certain cytokines such as anti-tumor necrosis factor(TNF). Newer agents include those that target specific mediators of rheumatoid diseases rather than suppresses the immune system. They include adalimumab (Humira), etanercept(Enbrel), infliximab(Xeljanz), and golimumab(Simponi), rituzimab(Rituxin), which control RA by destroying B-cell lymphocytes (there T and B-cell lymphocytes in the blood)

g- Non-biologic agents (Janus-associated kinase-JAK), a newer agent works by blocking a cellular signaling pathway that stops cells from making components that cause inflammation (Tofacitinib), an oral medication. Side effects include severe infections, liver damage, drop in blood count, etc.

h- Treatment for Gouty arthritis is a special cirmcumstance in that an amino acid is not broken down (uric acid) and accumulates in the blood and deposits in the joints especially the big toe (podragra) and causes severe acute pain with swelling, redness, limited range of motion, and is very severe. Treatment differs in an acute attack and chronic control.

Acute attacks of Gout

  Colchicine is the standard of are although there are side effects (fastrointestinal). Higher dose NSAIDs are helpful although there side effects as well that must be monitored. Corticosteroids may be necessary when the above meds are not tolerated.

  Chronic control of Gout

  Keeping the levels of uric acid is necessary to reduce the risk of acute attacks, although stress may be an uncontrollable factor. Xanthine oxidase inhibitors prevent uric acid from accumulating. Allopurinol drugs (Zyloprim, Aloprim) and Uloric are standard therapy. Increasing excretion of these amino acids is important as well. Probenencid (Benemid) and lesinard (Zurampic) will increase kidney excretion of these uric acid.

  It is very important to limit alcohol, fructose containing drinks, increase hydration with water, reduce intake of red meat, organic meats, and seafood which contain purines, which are the precursor of uric acid metabolism.

Mayo Clinic

2) Physical therapy and exercise programs to maintain range of motion

  I recently discussed physical therapy regarding their value. Depending on the specific joints and muscle groups involved, a tailored program of exercise, weights, and techniques will supplement any medical treatment of arthritis. Without strengthening of the muscles around an inflamed joint, there is little chance of becoming pain free. I recently have been working hard with a physical therapist to strengthen my neck and upper back muscles complemented by massage therapy, and twice weekly yoga classes. There are no short cuts, and a patient must be motivated to work extremely hard (long term) with therapists to reach realistic goals. Chronic pain can bew managed with the right steps.                                                                              

3) Uses of braces, splints, and canes to prevent joint stress and injury

  Physical and Occupational therapy may prescribe certain orthopedic appliances to prevent injury, maintain balance, and increase patient’s mobility. This is a very sophisticated area for therapists to utilize, and are tailored to the specific needs of each patient. 

4) Surgical correction

  Surgical correction of arthritic conditions covers the gamut of orthopedic procedures. I have addressed most of these procedures on other reports. Please consult my SUBJECT INDEX on the homepage of my website.

5) Management of other organs involved

  If there are special types of arthritis such as psoriatic arthritis, the skin must be addressed, in Sjogren’s disease, the salivary glands have to be managed, and in gout and lupus, other organs must be monitored for damage to the heart (myocarditis), kidney (failure), lungs (bronchioltis), eyes (iritis, uveitis), muscles (myositis), blood vessels (vaculitis).

Spondylitis

Spondyloarthritis (SpA) begins after the age of 40 but only occurs in 5% of patients with low back pain, but considering over 31 million Americans suffer from this, it is a major health problem (620,000).

  The Berlin criteria (require 3 out of 4) for the diagnosis of SpA include:

1) Morning pain and stiffness for longer than 30 minutes,

2) Improvement with exercise but not rest

3) Alternating buttocks pain

4) Waking up the second half of the night with pain.

5) A blood test for HLA-B27 will be positive in some of these patients (they carry this abnormal gene, but other genes have been identified as abnormal)

6) Family history of SpA

7) Some younger patients may present with heel pain, pain and stiffness of the wrists, ankles, and even pain in the ribs.  

  This is a severe inflammatory arthritis in the low back and pelvis ultimately leading to fusion of the vertebrae (called ankylosing spondylitis). Newer classifications include a peripheral type of spondylitis that involves the hands, wrists, shoulders, and knees, ankles, and feet. The blessing in disguise is that once fusion of the spine occurs, it becomes less painful, but the deformity is permanent.

Other known forms of arthritis can overlap with SpA including psoriatic arthritis, and also can be associated with inflammatory bowel disease. 85% have some type of rash before they develop clinical spondylitis. 

If the sacroiliac joint is involved, it is unlikely to be degenerative osteoarthritis. The drawing (above right) shows degenerative disease with disc narrowing, lipping of the vertebrae, and angulation

(scoliosis)-below X-ray.

  X-rays, CTs, and MRIs are used to diagnose SpA.

These patients may respond to the same biologic agents and NSAIDs as other forms of arthritis outlined in this report earlier. Surgical correction, however, is rarely beneficial, but there are 4 possible indications: 1) severe angulation of the cervical spine interfering with eating and swallowing 2) instability of the spine 3) Neurologic defcit from nerve impingement 4) a combination of any of these factors. 

  Depression is a serious problem for these individuals. A recent study reported that 1/3 of them suffer from this psychological condition.

  Spondylitis can be a serious disease and needs frequent attention from a variety of therapeutic practitioners.  

Medpage, March, 2018

4. The rise of Nurse Practitioners (ARNP)* and the changing face of primary care medicine and the nursing profession

*ARNP=Advance Registered Nurse Practitioner

  The U.S. is currently facing rising healthcare costs and a medical doctor shortage. The U.S. Congress has proposed to increase funding for increased numbers of doctors being trained through the Graduate Education Act, but that is a minimal long term fix and will not solve the problem. There is even a proposal to have a medical school that provides  the first year free of charge (taxpayers will pay). New York University School of Medicine just announced that private contributions will provide free tuition for all 4 years of medical school. There is hope that other universities might solicit private contributions to fund other medical schools, as the debt incurred by a new physician can reach over $200,000. This will open new doors to those who would ignore medical school because of the debt.

  The Association of American Medical Colleges stated in the June 23, 2018 NEJM that despite a 16% increase in graduate medical education, they projected that the supply of physicians will increase by only 0.5% per year between 2016 and 2030. To fill the gap, we are seeing more and more foreign medical graduates entering into the workforce in the U.S. as well. Also osteopathic physicians are increasing in numbers to fill the gap (will report on D.O.s and M.D.s in a future report), who have similar education to M.Ds.

A. The rise of nurse practitioners and impact on the nursing profession and primary care medicine

  Many people are comfortable seeing a nurse practitioner or PA (physician’s assistant) instead of their actual physician (MD or DO) including me for “routine care”.

  As a physician, I have some concern when there is little direct physician supervision and consultation in the office. Of course, with experience, a nurse practitioner would be less in need of supervision based on the relationship between physician and ARNP.  I will also report on physician assistants (PA) next month, another rapidly rising and important profession.

  These healthcare professionals are filling the doctor shortage gap, especially in communities who can’t afford (or do not want to pay to attract a doctor to their small town). That is how nurse practitioners got approval from states to practice alone. There are 17 states (mostly in the Western U.S.) that allow nurse practitioners to practice without any supervision of an M.D.(or D.O.) with the same privileges of a doctor in primary care medicine.

  Primary care medicine is slowly losing M.D.s because physicians want to practice more specialized medicine (and make more money), and it is estimated that as many as one third of primary care physicians are retiring in the next 10 years. In my opinion, Family Medicine is the most difficult specialty, because to keep up with the rapid information coming out, is an impossible task.

  Medicare and Medicaid are not properly reimbursing these vital physicians and are planning on gradually reducing all doctor’s pay and changing to an outcome-based payment for medical services.

  The numbers of ARNPs and PAs have increased 22% in the last decade and as that occurs, payments for their services (less than physicians) will reduce healthcare costs. But it will change the face of primary care as fewer physicians are entering family practice creating a void in the field of family medicine with physicians.

  We are seeing hundreds of acute care facilities in malls, drug stores, and free standing facilities etc. and this trend will continue creating a need for ARNPs.     

  The field of family practice may become preventative and maintenance in character which could likely increase consultation with specialists, which could raise the cost of healthcare offsetting any benefit of reduced costs in primary care medicine. It may also make access to specialists more difficult as their office appointments are flooded.  

  A recent study reported that the proportion of ARNP providers rose from 17.6% in 2008 to 25.2% in rural areas and from 15.9% to 23% in urban areas. The proportion of physician providers decreased from 69.4% to 60.3% in rural areas and from 74.2% to 66.3% in urban areas.

  In 2016, there were 920,397 physicians and 157,025 ARNPs. By 2030, a third of the healthcare providers will be ARNPs, and currently 8 out of 10 ARNPs work collaboratively with physicians in primary care practices. An experienced healthcare practitioner is going to provide good medical care, regardless of whether they are a physician or a nurse practitioner. But family medicine was not intended to be a triage form of healthcare. Early diagnosis is the key to most illnesses being cured, and experience allows practitioners to have an index of suspicion about potential underlying diseases. This is where experience counts!

  A 2012 study cited that 41% of physicians were working with ARNPs. I would expect that is approaching 50% now. I am in favor of nurse practitioners filling the gap in the healthcare access in physician’s offices, but their education may need further expansion if they are going to replace physicians in primary care. ARNPs are taught with a nursing model, not a physician model (PAs are taught with a physician model). That may need to be modified. 

Reference—Journal of Health Affairs, 2018 by the National Institute of Nursing Research; NEJM

B. Hospital Nurse Shortage-another unintended consequence of the growing profession of ARNPs

  Although it has been calculated that currently there is a 6% shortage of full time RNs, the shortage is much more severe in actual hands-on nursing care in hospitals outside of specialty units. As the opportunity for advanced nursing degrees has greatly increased over the past few years, an unintended consequence is coming into play—a shortage of regular staff nurses willing to work in hospitals and specialty units—essentially the bedside nurse, the cornerstone of healthcare.

  As physicians are retiring in record numbers for a variety of reasons, so are some of our dedicated most experienced nurses. The lure to become a healthcare provider rather than a regular nurse is changing the complexion of the quality of nurses at the bedside and creating a shortage.  

  To be a licensed R.N. requires a 4 year degree, whereas associate degree nurses require 2 years and practical nurses-LPNs-require 3 semesters of schooling.

  Many of the 4 year RNs are hired to run hospital floors or specialty units and are forced into “pushing paper, documenting care rather hands-on care”, thanks to enormous unnecessary governmental regulations (same for doctor’s offices). Nurse’s aids and less qualified staff are actually taking care of the patients in many cases.

Training of Nurse practitioners

  Nurse practitioners are advanced practice nurses (APNP) that are trained in the nursing model rather than the physician model. Physicians attend 4 years of medical school and then residency of 3-6 years.

Educational pathway for NPs:

There are now other training options for NPs including online course programs and now a fast track program that only requires 2 years, and these people do not even need to have gone through nursing school. That has always been a prerequisite to be a registered nurse (RN) before becoming an advanced practice nurse practitioner(APNP). This concerns me!  

  The range of salary for a nurse practitioner is $72,000 to $140,000, and the average nurse salary is $66,000.

  This issue has nothing to do with the dedication and caring nature of the nursing profession. Nurses have always been the most important aspect of actually administering patient care and are the cornerstone of healthcare!!  

  Associate level nursing training (in community colleges) is suffering (2 year degree nurses called ANDs), and it is this group that is most needed in caring for patients at the bedside. The salaries of these crucial nurses must be increased to encourage more dedicated people to seek this option in nursing.  

  4 year baccalaureate nursing degrees have become stepping stones to advanced nursing degrees which leads them into administrative nursing, nurse practitioners, and academic positions at the expense of floor nurses, which are in great demand, but will the hospitals settle for less skilled nurses because they cost less?

  Licensed practical nurses, as pointed out in a recent Medical Economics journal article, are better prepared to care for patients at the bedside (because of their time spent doing actual hands-on care while in school) than R.N.s in some cases.

  Another issue is the lack of nursing educators. This shortage will also have a a major effect on training our vital nurses.

Industry steps up to fill the shortages of providers

  With these shortages in physicians and certain nursing careers, companies are only too happy to fill the gap. As CVS (Caremark) has purchased Aetna Insurance Company, there will be a major move to continue to open more minor acute care clinics in CVS (and Walgreen’s, Walmart, etc.) stores with non-doctors staffing them. Other major pharmaceutical giants like Walgreen’s also are purchasing the pharmaceutical managing companies, which are the distributors of medication (the middle management companies that determine where drugs are sent and how much they cost). Expect for Walgreen’s to follow suit in the future purchasing insurance companies.

  Physicians are trained to pick up diseases that may be not be so obvious to the less trained practitioner. The government has been pushing the name “healthcare provider” for years rather than patient care by physicians, subtly changing the concept of general medical care to non-physicians. It is happening!!

  When seeing an NP or a PA, you have a right to ask to see the physician (if there is one in the office), even if you have to return another day. Be proactive!!

NEXT MONTH I WILL REPORT ON PHYSICIAN ASSISTANTS!

5. Lifestyle factors could add 10 years to your life

(Life Style and Life Expectancy)   

  It seems so simple to change certain bad habits, lose weight, exercise, and minimize stress, but here is a study that says you might be able to add 10 years of life. Middle aged men with 5 low risk life style factors were studied over 30 years and compared to the same number with no low risk factors.

  The 5 factors were 1) a healthy diet 2) never smokers 3) moderate to vigorous exercise (at least 30 minutes per day) 4) moderate alcohol consumption 5) and a healthy BMI (body mass index).

  Each factor reduced risks for all-cause, cancer and cardiovascular mortality. Those subjects that had none of these risk factors had a 74% reduced risk for all-cause mortality.

  The researchers estimated that women at age 50 without the risk factors lived 14 years longer than those with the risk factors reaching 93 years of age whereas men extended their life by 12 years reaching the age of 88.  

Personal comment

  Middle aged people do not appreciate how great older age can be without disability, the burden of surviving a cancer (or not), not having physical limitations because of being overweight, having sleep apnea, or having debilitating heart and vascular disease, etc.

  Younger people think they are bullet proof and even middle aged people do not think about the consequences later in life of their life style habits. What is it going to take to convince people to live a healthier life? The problem is these issues impact healthy people too because we all pay for those who abuse their bodies all their life and are the primary reason for escalating healthcare costs. And yet, by and large unhealthy people, after they reach Medicare age, pay the same basic costs as healthy people do. There are no penalties for people who do not take responsibility for their health. Why not? Life insurance penalizes smokers, etc. Freedom is not free!

  Want to live 10 years longer? Shape up, live healthy and you will be rewarded, but don’t wait!!

Ref. Nurses Health Study and Health Professionals Follow up Study in the journal Circulation, April, 2018

This completes the September report. Next month, the October subjects are:

1) Late Breaking News—A. New device to prevent gastric reflux into the throat and lungs; B. Benefits of coffee; C. Children and obesity D. Patients and websites from the doctor’s office

2) Physician Assistants

3) The FDA-approval process and fast-tracking; Off label medications and FDA regulations; Biosimilar medications

4) What happened to the U.S. Diplomats in Cuba a year ago?

5) Chronic pain management series—Part 6—Psychological and physical treatment—the mind/body connection

Stay healthy and well, my friends, Dr. Sam