The Medical News Report
February, 2019, #85
Samuel J. LaMonte, M.D., FACS
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a) Medical News Flash
b) Statins-value after age 75?
c) Medicare Spending; Millennial’s preference for healthcare
d) Coca Cola and other companies considering adding marijuana chemicals in their products
e) Valsartan recall—other antihypertensive medications recalled because of cancer causing contaminants
IMPORTANT REMINDER!!!! PLEASE READ!!!
I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.
The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns. You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.
Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.
Thanks!! Dr. Sam
a) News Flash from the AMA News
---Modern Healthcare, a subscriber publication, report that hospitals are beginning to provide transparency for hospital services and procedures mandated by CMS (Centers for Medicare and Medicaid Services) as of January 2019. Prescription drugs and health plan transparency is also part of the initiative by Alex Azar, HHS* Secretary. We have a long way to go! *HHS=Health and Human Serives--
---Telemedicine is expanding rapidly and will provide services in areas of need such as mental health services for teens. As usual, insurance coverage is lagging behind, varying from state to state, but beginning to respond according to a report on NPR-1/7-2019.
---In 2017, 63.6% of teens have used flavored tobacco products in e-cigarettes. The concentration of nicotine in e-cigarettes can be much higher than cigarettes and are very addictive. This is one more attempt by the tobacco industry to addict another generation to nicotine to sustain their industry. The latest e-cigarette very popular with the youth is made by and marketed as JUUL, a modern appearing e-cigarette that looks like a USB plug-in. The FDA is attempting to force these companies to cease marketing flavored liquids in e-cigarettes, but will they be successful? Reuters 1/7/2019
---Current Flu activity is picking up in January after a slow start as reported by 19 states. 7 million reported cases have occurred (double that considering how few people go to the doctor with the flu). The Influenza A-H1N1 is the most common country wide, except in the South (including Alabama, Georgia, and Florida), the Influenza A H3-N2 is the most common and usually the infection is more severe. The viruses this year appear to be less severe with fewer hospitalizations. CDC, Jan, 2019
---Drug prices have recently skyrocketed due to manufacturer’s price increases after agreeing to a short moratorium of price increase requested by President Trump. Big Pharma is laughing at our administration as they have all other previous administrations as lobbyists buy our U.S. Congress with millions of dollars of donations to our greedy uncaring politicians. Shame on our Congress.
b) Statins after age 75—questionable value for those without current heart disease
Statins for cholesterol lowering are currently recommended for healthy elderly people (being defined as those 75 and older) to prevent cardiovascular disease, however, there is little support for this recommendation if the person does not currently have demonstrated heart disease as reported in the British Medical Journal, Sept. 2018. However, for those with type 2 diabetes or cardiovascular disease, there is good research to suggest continuing statins until age 85.
There are many medications that are continued by elderly people with little value and are more likely to create more harm (side effects) than benefit.
I have written about patients having a serious discussion with their doctors about continuing certain medications, vitamins, and supplements after the age of 75. Many medications may be reduced in dosage, if not discontinued, because the metabolism slows with age, many drugs are not processed by the body as rapidly. Have that discussion!
With the cost of many drugs today, elderly people should not be burdened by taking multiple medications unless absolutely medically necessary. Talk to your doctor, because little research has been performed on elderly people to prove value of many medications in the elderly. Most drug research and its benefits/harms are studied on middle aged people with few additional diseases.
c) A progress report on Medicare spending; cost of healthcare compared to other developed countries—what you need to know; my opinion!
Healthcare Spending—why so high?
With 2018 in the rearview mirror, I thought it would be valuable to look at Medicare spending since it accounts for 15% of all federal spending and is 20% of all healthcare spending.
The main reasons for the cost of healthcare in the U.S. is because we are free enterprise country, and it is very difficult to control private industries. The free market allows for the difference in cost compared to socialized countries. The price of labor and goods, including pharmaceuticals and medical devices, and the huge administrative costs to implement federal regulations, including the required electronic medical record, etc. are the major drivers of costing the U.S. a doubling of the cost over the 10 other high income countries.
You can forget the quality of care most Americans have with private insurance or Medicare. To provide equality of care (which will never happen even in a socialized system in our country), those who pay taxes will pay for the other half who don’t and lose the quality they have been accustomed to.
For those that can’t afford additional healthcare insurance, (the two-tier system I have often referred to), they will suffer from a socialized system. The millennials (18-34) already want it, and the rest of us will just have to accept it because we will get outvoted in time, since they are the largest growing population in the U.S. Can their minds be changed? Not with most academic institutions force feeding them progressive and socialist ideology.
The method in which Medicare makes payments to doctors and hospitals is changing over time from fee-for-service to payment based on quality and outcome of a particular service to a flat fee per patient (bundling) per year. As in the past, private insurance has followed suit. But there are still some gaps that must be addressed.
The current system puts too much pressure on the primary care physicians and there are pricing distortions with specialists. 7% of the healthcare dollar is spent on primary care in the U.S. compared with 20% in other countries, who have better healthcare outcomes. The U.S. system also does not put enough pressure on patient responsibility (i.e. lose weight, stop smoking, stop drinking, take medicine as prescribed, follow doctor’s orders, etc.).
Primary care physicians are not given enough authority to limit specialist referrals (that was the goal for HMOs), and this can create animosity between patient and primary care. This is particularly a problem when the primary care provider is not a member of a large medical center corporation. That is why most medical centers hire their own primary care, but their salaries tend to be lower, while putting most of the accountability for patient outcomes on them and giving them even less authority to decide who gets a specialty referral. This is one of the reasons doctors are abandoning primary care.
Who wants to get a college degree, spend 4 years in medical school, and 3-4 years in a family practice residency to make $160-180,000 a year (and have $150,000 in debt for schooling)?
The high cost of healthcare rests with the specialists and their procedures, with expensive diagnostic workups, and yet, with new (expensive) innovations and high priced medicines coming out constantly, how do you tell a doctor not to use or recommend them?
Balancing quality of care with spending has been a huge challenge. Can it be attained? This will take sacrifice from carriers, providers, and patients. We need a Congress to work this out with the healthcare field. As long as lobbyists are allowed to influence Congressmen, I am doubtful this will happen. The political parties sure are not on the same page. With continuing influx of immigrants (legal and illegal) and the population increasing, without reducing Medicare drug prices (like every other country does), there is little chance of getting spending under control.
The government created the Accountable Care Organization (ACO), which was designed to recruit medical centers to sign up for a specified time and not incur any overages on cost hoping that these centers could curtail costs without reducing quality, increasing efficiency, and keeping patient satisfaction high, however in most cases, it failed. JAMA, September 18, 2018
Many incentives are being looked at including better patient access and more convenience (such as after-hours appointments, etc.), electronic communication with providers, teleconference, and phone call visits. Millennials are demanding these changes.
Kaiser Permanente reported that 45% of millennials (18-34) had no primary care doctor (28% for those 30-49, 18% 50-64, and 12% for those 65 and older), preferring urgent care facilities and drug store retail clinics. Based on this market research, CVS, Walgreen’s, etc. will continue to expand that market in their drug stores. How are providers motivated to see more patients with extended hours, and at the same time receive less pay? Since the young think they are “bullet proof”, most will be fine with this type of care, but where will they go when they start developing chronic or serious illnesses?
Reward must go to both provider and patient, and yet, patients are being asked to take a greater share of financial responsibility with higher copays and larger deductibles, which was one of the failures of Obamacare.
Even with the current system, I am afraid the good ole days of Medicare are coming to a halt with expectations rising for patients to take on more financial responsibility and cost, which means higher cost-sharing with Medicare.
We must protect the quality of care without cutting off people for procedures (rationing) just because of age and other arbitrary criteria. Socialized medicine requires rationing!
There is a lot at stake and who controls Congress will determine the future of healthcare. Right now, it looks as if the Democrats will have a lot to say about the direction of healthcare, especially since the Republicans never seem to quite get on the same page. Your vote has never counted more with the future of our country at stake.
Medscape Medical News, August, 2018.
d) Coca Cola is considering marketing a drink with cannabis as an ingredient (and other products)
Remember, Coca Cola started out containing cocaine. Wow!! Bloomberg recently reported that Coca Cola may add CBD, cannabidiol, the low psychoactive chemical in marijuana to be added to their cola. It is all about the buck! The food industry is also strongly considering additives of marijuana derivatives. Stay tuned!
e) Valsartan lots recalled because of cancer causing contaminants—and other antihypertensive medications
There are many recalls of medications that are not well publicized. The drug, valsartan (Diovan), is a new drug which has shown great promise for the treatment of congestive heart failure, high blood pressure, and cardiomyopathy. I recently reported its value in a previous report, if you want to know more information on heart failure, hypertension drugs and the drugs used to treat them including valsartan, click on:
The contaminant found was NDEA (N-nitrosodielthylamine) and is present in certain lots of valsartan and losartan (with hydrochlorohyazide) produced by Torrent, Tiva, Mylan, and Aurobindo Pharmaceuticals. This is a known cancer causing contaminant in the family of nitrosamines.
Review your meds and check with your pharmacy and doctor, if you are on either of these meds. Too many patients do not know the names of their medications and do not have a list in their purse, billfold, or cellular phone. You should expect a refund if you were prescribed the above drugs.
This is a good reminder to stay on top of your medications.
withdrawal and alcoholic hepatitis
A. Alcohol Withdrawal Syndrome
Who is at risk to develop alcohol withdrawal symptoms? The Clinical Institute Withdrawal Assessment has 10 symptoms they rate to determine a diagnosis of withdrawal which include: tremors, anxiety, sweating, nausea, vomiting, rapid pulse, headache, insomnia, irritability, confusion, and high blood pressure. These worsen over 2-3 days, and can last for weeks in some.
Delerium Tremens (DTs) is the most severe form of withdrawal. With the DTs, a fever occurs, with various types of hallucinations (visual, auditory, tactile, etc.), and seizures. A death rate of 1-4% occurs, and is an emergency requiring immediate medical attention.
The CDC defines heavy drinking and those at risk for alcohol withdrawal syndrome as more than 8 drinks for women per week and 15 drinks per week for men!!
One drink=1.5 oz of liquor
5 oz of wine
8 oz of malt liquor
12 oz of beer
Binge drinking increases the risk of this syndrome, alcoholism, and blackouts.
The earliest signs someone should be aware of is hand tremor, irregular heartbeat, dehydration, and fever.
This syndrome is treated with hydration, benzodiazapines (Valium, Librium, Xanax, and Ativan). Thiamine and magnesium supplements are frequently necessary as these and other vitamins are depleted with a sick liver.
B. New Medication to treat Alcoholism and Withdrawal Syndrome
a) Stages of Alcoholism and the Alcoholic Personality
Opioid addiction research has been a tremendous boost in treating alcohol addiction, since the brain centers of addiction and euphoria for drugs are the same for alcohol. They are all drugs, and the brain cannot discern the difference when the receptors are stimulated. Many of the drugs that are on the list below are helpful treating both narcotic addiction and alcohol abuse disorder.
There are 5 stages of alcoholism: 1) occasional abuse and binging 2) Drinking to relieve stress, depression, etc. 3) social changes occur from drinking 4) alcohol dependence increasing volume to get the same effect 5) addiction—drinking not for pleasure but to fight withdrawal with both psychological and physical dependence.
Certain personalities are more prone to alcoholism including obsessive compulsive disorder, ADHD, low self esteem, anxiety disorders, perfectionistic tendencies, guilt, shame, impulsivity, dependent people, self-pity, and those who blame others for their misfortunes.
b) Medication-assisted alcohol therapy
The ideal medication would be one that can be started while the alcoholic is still drinking, and allow them to either stop or slowly stop drinking. Many of the new drugs can meet that goal, therefore, these meds are a great advance.
The goal of medication is to normalize brain chemistry, block euphoric effects of alcohol (and opiates), relieve physiological cravings, and normalize body functions without the negative effects of an abusive substance.
These suggested medications may cause some euphoria but much less than the drugs or alcohol. Because of this, some officials have a problem with that, but it is of definite value for those who struggle maintaining abstinence.
Another important type of medication is one that reduces craving after a person stops drinking by stimulating these brain centers. Acamprosate (Campral) is one of the newest medications. Naltrexone (*ReVia, Vivatrol) has been proven to reduce consumption of alcohol, and disulfiram (Antabuse) are the leading medications currently being used but more recently are no longer the first line approach. * ReVia and Vivatrol are the brand names, and naltrexone is the generic name!
Topiramate and gabapentin are suggested if the above drugs are unsuccessful.
Psychosocial therapies are still the mainstay of addiction therapy plus support groups such as AA, however, that may not be enough to prevent relapse. 40-70% relapse within a year!! For addicts to stay clean and sober, they must abstain from all forms of addicting substances since it is known that opiates increase the rewarding effects of alcohol, nicotine, and other narcotics.
The therapeutic process occurs from manipulation of a neurotransmitter substance called dopamine. These antagonist medications reduce the effect of dopamine in the brain. Other mechanisms of action have been proposed.
Those with a genetic family history tend to handle alcohol somewhat differently. They demonstrate lower levels of beta-endorphin levels in the brain, but have increased endorphin levels in response to alcohol consumption. Naltrexone is more effective for those who have normally higher levels of beta-endorphin, therefore, patients without a family history will respond somewhat better through this mechanism. Naltrexone is FDA approved, but there are other medications that are being used “off-label” that are effective.
It has been proven that psychosocial therapy plus naltrexone is superior in preventing relapse. The intensity of psychotherapy correlates better when using these medications especially if coping skill training was added. However, a major obstacle to success in using naltrexone is the fact that patients know they will not feel the euphoric effects of the alcohol, therefore, patients must still be motivated to totally abstain from alcohol.
Acamprosate (Campral) has been proven to work by interfering with another neurotransmitter stimulant, glutamate, as an antagonist to these receptors in the brain. One study showed 43% abstinence rates with this medication compared to placebo controls of 21%.
Serotonin is another neurotransmitter that is affected by a well-known group of anti-depressants (SSRIs and SSNIs). These selective serotonin receptor inhibitors can help suppress the desire for drinking through this mechanism. However, without additional psychotherapy, they are not very effective and the dose needed to be effective may be higher than usual.
Buspirone (BuSpar), an anti-anxiety medication, affects the receptor 5-HT (hydroxyl trptophan), a subtype of serotonin. It may work also simply work by reducing the anxiety surrounding the need to drink and the anxiety which is magnified when sober. Ritanserin (Tolvon) and Ondansetron (Zofran) also act in a similar manner. NIH (National Institutes of Health)
Disulfiram (Antabuse) causes severe nausea and vomiting if alcohol is consumed, and expecting patients to remain on this medication is somewhat optimistic.
There are some suggested recommendations against use of specific medications such as antidepressants, benzodiazepines (anti-anxiety meds), don’t use acamprosate in patients with renal disorders, and naltrexone in patients with acute hepatitis or hepatic failure or patients who also use opioids.
It is unfortunate that a small percentage of patients are being treated with these medications since very few primary care physicians are trained to use them. Spread the word!!
Treating patients with alcohol abuse disorder who have underlying psychiatric illness is very challenging and more psychiatrists must be willing to treat these two overlapping disorders. American J Psychiatry, Jan, 2018
National Institutes of Health; WebMD
C. Alcoholic Hepatitis
Alcohol is toxic to the liver, and over time with excessive alcohol intake, it can create inflammation in the liver, which is the definition of hepatitis. It also increases fat deposits in the liver (fatty liver) which cause inflammation. It is aggravated by binge drinking and continued drinking. Once inflammation occurs, this will lead to fibrosis of the liver called cirrhosis. This disease occurs in about 35% of alcoholics and can occur in moderate drinkers.
Alcoholic hepatitis is seen in those with genetic factors, a history of hepatitis B, and C. It can occur in patients with hemochromatosis (excessive iron increased in liver causing disease). It also occurs in those who are malnourished, overweight, and occurs more commonly in women.
Symptoms are similar to any type of hepatitis-nausea, vominting, yellow jaundice, fever, fatigue, weight loss, loss of appetite, pain and swelling in the abdomen. They may have confusion and easy bruising from loss of Vitamin K and other clotting factors. Notice the yellow color of the conjunctiva-jaundice.
Key recommendations for evaluation and treatment:
1. Drinking greater than 3 drinks a day for men and 2 drinks a day for women increases the risk of alcoholic hepatitis.2. Liver tests and an ultrasound of the liver are indicated.
3. Alcoholic hepatitis can lead to kidney failure, therefore kidney functions must be performed.
4. Corticosteroids may be used to reduce inflammation.
5. Severe cases should be considered for *liver transplant.
6. Baclofen is helpful in preventing alcohol relapse.
7. Patients are prone to bacterial infections.
* Transplantation can be considered after 6 months of alcohol abstinence, but social support rehabilitation availability must be part of the decision making. A recent study from the journal Gastroenterology cited an 87% 3 year survival after transplantation for those who were clinically well enough to undergo such a difficult procedure. However, 34% went back to drinking alcohol at 3 years.
Pathophysiology of MS
It has been a few years since I have reported on multiple sclerosis, but the basics are still the same, therefore, I would ask that you review the basic information about this serious neurologic disease. There are 400,000 cases in the U.S., and 10,000 cases each year are newly diagnosed. Click on:
Mechanism of disease
In review, this disease affects the fatty lining (sheath) of nerves, creating loss of nourishment to the actual nerves causing defective neural signaling, which affects the nerves to the eye, brain and spinal cord. There is an unknown autoimmune reaction against the myelin (a protein) in the sheath called demyelination. There is no known cause for this immune reaction anymore than why people develop rheumatoid arthritis. A specific nerve cell (oligodendrocyte) creates the myelin sheath (drawing left).
The sheath is attacked by the immune response. The drawing (above right) shows the difference in a normal nerve and one affected by MS. The sheath is irregular with loss of the myelin in places with resultant scarring.
Recent studies have shed more evidence that MS lesions are characterized by an inactive center and a rim of activity cells responsible for demyelination (degeneration of the myelin sheath of the nerve) and correlates with progression of MS proven bt special MRIs to detect early disease and more aggressive therapy. Ref. The Journal Multiple Sclerosis, Dec., 2018
MS is the most common disabling disease of young people (usually diagnosed between age 20-40) with more than 400,000 cases in the U.S. (Multiple Sclerosis Foundation) with about 10,000 new cases each year. 3-5% are diagnosed before the age of 18. Twice as many women are diagnosed MS as men, however, males frequently have a more serious type. Caucasians are more likely to develop MS than other races.
Symptoms are subtle, sometimes for years, leading to years of misdiagnosis. The average time it takes to verify a diagnosis of MS is 10 years. Numbness in different areas of the body, visual symptoms (double or blurred vision), balance and dizziness issues, muscle weakness (and or spasms) and fatigue that come and go (remissions and exacerbations) are some of the most common symptoms. Less common are speech and cognitive difficulty (40-70%), mood swings and depression, trouble walking, sexual dysfunction, bladder and bowel symptoms. Insomnia is very common in these patients.
Risk Factors/Genetics-new information
Family members-one study found there was a significant number of female family members who demonstrated decreased vibratory sensation in the lower extremities even without demonstrable disease. Surveillance of family members is recommended. The Healthline website stated that 15% of these patients have a family member with MS.
There is no known genetic defect yet but it is estimated that if a family member has MS, their offspring has 2-5% risk of developing MS. Identical twins have a one in three chance of developing MS. Also another study cited evidence that if there is a family history, the patient is more likely to have an increased chance of severe brain damage on MRI scans. Lesions can occur anywhere.
Smoking, infections, low levels of Vitamin D (often present in MS patients), and infections with EBV (Ebstein Barr Virus-infectious mono) are now known to be risk factors. The shingles virus is being studied. MS is not contagious!
Other risk factors (mild) include a diagnosis of certain thyroid disease, inflammatory bowel disease, and type 1 diabetes mellitus and other autoimmune diseases. This is not surprising since MS is an autoimmune disease.
It is interesting that when women get pregnant, their symptoms frequently disappear but return a few months after giving birth, implying estrogen is involved.
A common trigger for many autoimmune diseases is stress, mental or physical. Heat is particularly stressful on these patients, since many are not able to normally get rid of heat in their body and can make them very prone to heat exhaustion and relapse. Getting overly tired also can bring on an episode.
A new study demonstrated that food allergies could trigger an attack of MS. Control of these allergies would be recommended.
Clinically Isolated Syndrome (CIS)—the first symptom(s) of MS
This is one of the MS disease courses, referring to the first episode of neurologic symptoms that lasts 24 hours and is caused by inflammation or demyelination of the nerve(s), which can be a single neurologic symptom (monofocal) caused by one lesion or more than one neurologic symptoms (multifocal), such as isolated optic neuritis or associated with numbness, weakness, dizziness, etc.
The development of CIS may or may not proceed to a clinical diagnosis of MS. Obviously, a neurologic workup is indicated in all cases suspected of MS including an MRI, which is diagnostic in most cases. An evaluation of the cerebrospinal fluid may show oligoclonal bands, which are special cells that are seen is diagnostic for MS as well.
If CIS occurs, it may be recommended to start treatment immediately with a disease modifying therapeutic agent (discussed later).
Types of MS
There are different types of MS—4 (these are the revised types)
1-Relapsing/remitting is the most common (means symptoms go away or get better but come back which may be the same symptoms or new ones). 85% are initially diagnosed with this type. Relapses usually occur every 9-12 months.
2-Primary Progressive (slowly progressive with no relapses or recovery-about 10% of people).
3-Secondary Progressive (progressive with or without remissions; no recovery);. It is called secondary because most of the people with primary progressive eventually are diagnosed with this type.
4-Progressive/Relapsing (5%-the least common) characterized as worsening from the beginning with no recovery. There may be acute episodes with or without some recovery.
5-Non-progressive (this is not considered a type of MS by the MS Society but should be in my opinion)-There are people (such as my wife) who were diagnosed with relapsing/remitting type initially that do not progress as they age. A Swedish study reported there was a 22% chance of non-progression after age 40 and an additional 14% after 50. Therefore, if a woman or rarely a man lives into their 50s, there is over a third of those who will never progress!! Looking back at these patients, they had the mildest symptoms to start and had milder relapses. Another name for this group is NEDA (no evidence of disease activity) by neurologists. For the first time, the goal in treating many MS patients is to get them into this category with no evidence of activity rather than just controlling the disease.
The first episode is called the clinically isolated syndrome characterized by one or more symptoms that lasts for at least 24 hours and then resolves. Obviously, most are not diagnosed with the first episode.
The diagnosis is made with an MRI scan, which shows classic holes in the brain, and depending on where these defects are present, it will determine the symptoms. These MS lesions are called plaques. The third MRI below right shows spinal MS.
Tracking the progress of MS
Clinical history of progression is the most common way neurologists follow MS patients. Standard MRIs are used to evaluate the holes seen in the brain caused by degeneration of brain tissue, position, and number.
A new experimental monitoring method is checking for levels of iron in specific areas of the brain using special MRIs. Specifically, MS patients have higher levels of iron in the deep gray matter structures (basal ganglia) and lower levels in the thalamus.
Brain atrophy is another method to monitor MS patients but it is independent of iron brain levels. Low iron levels in the thalamus are thought to be due to death of iron-rich oligodendrogliocytes (the cell involved in providing myelin enrichment to the lining of nerves). These findings correlated with disability in these patients. Time will tell if iron levels are a better way to follow MS patients, and are also being used to distinguish Parkinson’s disease from other tremors and are being used to predict progression of Alzheimer’s disease.
There has been great progress in treatment options since I last reported on MS in 2012. The mainstay in treatment still providing anti-immune and biologic therapies, but there are some excellent improvements. These treatments are extremely expensive. My wife’s Avonex (an older treatment) costs an outrageous $6300 for weekly injections for a month, a medication that is over 20 years old.
Just recently the FDA approved ocrelizumab (monoclonal antibody)—IV infusion every 6 months, which is 95% more effective than Avonex and has dropped the relapse rate by 50% in remitting/relapsing MS.
The first FDA approved treatment for pediatric MS is fingolimod (Gilenya), which is superior to the interferon treatments, with 85% relapse-free periods of over 2 years according to a recent report in the NEJM-Journal Watch, October, 2018
Both the B and T-cell lymphocytes are involved in the immune inflammatory process, and the latest treatment addresses the B cell response in MS. MS is treated similar to other immunologic or malignant conditions.
With these treatments, they have changed the course of progression in a significant percentage preventing those with primary types from progressing to secondary types of MS from 50% progressing to about 1% per year. Even though many patients require canes and wheel chairs eventually, their disability has been lessened and their progression slowed with better quality of life.
b) Vitamin D is still thought to play a role in MS and Vitamin D3 is recommended even without a deficiency by most neurologists (including my wife’s). Some studies suggest that MS patients may have less severe symptoms on a maintenance dose of vitamin D3 and may have a protective effect against MS. The connection may lie in D3’s positive effect on the immune system. There is also a connection between more cases of MS in northern colder climates with less sunshine (Vitamin D).
The Institutes of Medicine normally recommend for ages 19-70, 600 IU daily of D3 and 800 IU for those 71 and older. If deficient, it takes 50,000 IU weekly for 3 months to return the vitamin D levels to normal. I have not found a uniform recommendation from neurological organizations regarding the dose of Vitamin D3 in MS patients. High levels of Vitamin D can be toxic, and therefore, levels must be followed.
c) Treatment of symptoms and disability
As one might expect, there is a tremendous amount of time and expense treating the neurological consequences of MS. Rehabilitation and physical therapy is critical in keeping quality of life optimal. Weakness and spasticity must be addressed. Occupational therapy is critical to keep patients as independent as possible.
Some of the most common complications of MS are muscle stiffness, fatigue, weakness and or paralysis of the lower legs, speech and swallowing difficulties, bladder (incontinence)/bowel dysfunctions(constipation), psychological issues (most commonly depression), and even seizures. All these issues affect daily life and must be constantly addressed and managed.
Stem cell research is now being used in clinical trials (not FDA approved) on a select number of patients who are not responding to the standard medications (remitting/relapsing and progressive types). A collaborative study (5 countries) presented 55 patients who were treated with a stem cell transplant who were medication failures (and the control group of 55 patients who were treated with medications only). The results were quite amazing. After one year, the stem cell group had only one patient that relapsed and the control group (treated with medications only) had 39 out of 55 relapsed. These patients are currently being followed for 5 years. (Presentation from European Society of Bone Marrow Transplantation, 2018)
Stem cell treatment can have serious side effects and those issues must be weighed when considering stem cell treatments.
This is a technique used to replace the previous immune system in these patients, which created the disease in the first place. The results are encouraging but still not FDA approved as a standard treatment. For a discussion on stem cell transplants, please click on
Some countries already offer it, but the quality control is not known. Unfortunately, with our governmental regulations, it will take years even with the fast track system. Unfortunately, patients become desperate and are seeking these transplants in other countries with no guarantees and are very costly. If medications are controlling the disease, it would be foolish to not stick with them.
A blood test that identifies a protein that is released by damaged nerves is being studied. Hopefully in the future that will help with selection of patients for specific treatments. Diet, exercise, and stress management all seem to be helpful in controlling symptoms. The influence of the gut bacteria (microbiome) on MS is being studied as well, as these bacteria play a key role in our immune system.
These patients are considered good candidates for medical marijuana especially for spasticity.
About two thirds do not wind up in a wheel chair and can lead very successful normal or near-normal lives. It is stated that on average, MS shortens the life span by about 7 years. But with the current success using newer therapies and exciting research, optimism is high in controlling MS relapses and increase the number of patients who do not progress.
National Multiple Sclerosis Society, Healthline, NIH
A. Biomechanics of a golf swing
B. Common injuries
C. Golf exercises for a better swing
This is the first part of a series on sports medicine, a specialty in medicine devoted to sports injuries and prevention. In part one, I will discuss golf, and future parts will include injuries and treatment of various sports. Part 2 will be on runner’s injuries coming in June.
* To illustrate all the anatomy and specific injuries of the entire body would require a very long report, and therefore, I will refer you to previous reports on the anatomy of various parts of the body.
A. Biomechanics of the golf swing
To understand golf injuries requires a look at the 5 phases of a golf swing—1) takeaway 2) forward swing 3) acceleration 4) early follow through 5) late follow through
During these phases, one must look at the muscle action of the forearm, shoulder, scapula (shoulder blade), and trunk using EMG (electromyography).
a) Shoulder and scapula
To protect the shoulder joint (glenohumeral), fast coordinated action is required by the firing of the rotator cuff and scapular muscles (the most active are the supraspinatus and infraspinatus). The subscapularis is most active in takeaway.
The trunk muscles are not used much in takeaway, but all are involved in acceleration to generate power (not the arms). As the swing goes forward, the left gluteus maximus (right handers) maintains stability from the forward thrusting of the right sided muscles.
The left forearm muscles extensors are most active during acceleration in amateur golfers. The forearm muscles of the trailing arm also are active. The trailing forearm muscles are very active as the swing proceeds forward.
d) Hip and Knee
Pelvic rotation must be initiated with the forward swing by the trail hip extensors and abductors in conjunction with the lead adductor magnus. The lead hamstrings keep the knee flexed to provide a stable base for pelvic rotation. This should happen slightly before the hips and shoulders kick in and rotate. This sequence of muscle contraction and relaxation is necessary for a correct golf swing. Creating muscle memory for the correct sequence takes constant practice since it is not natural.
B. Common golf injuries (J.Am.Acad.Orthoped.Surg., May, 2018)
An ounce of prevention is worth a pound of cure, they say. Golf demands such an unusual set of muscles, tendons, and flexibility to swing in such precise sequence to perform the golf swing correctly. As we age, that all starts going away unless we play regularly and perform proper exercises.
The American Golf Foundation reported that 25.6 million people play golf in the U.S. Most of golf’s injuries come from overuse of body parts in the swing. Many go untreated and become chronic.
The higher rotation of the lead hip creates significant stress on that hip which can lead to injury. 46% of the injuries were sustained during the golf swing in one study with the highest rate of injury (24% of the 46%) occurring at the point of golf ball impact with the low back sustaining the most injuries followed by elbow/forearm, and then by shoulder/upper arm, and foot/ankle.
Too much play or practice and poor swing mechanics are the most common reason for injury. Warming up for 10 minutes or less correlates with higher rates of injury!
High handicappers tend to try and generate more power with the arms rather than their trunk rotation. Overuse of the arms tends to torque the spine much more aggressively leading to spinal injuries. Greater body balance usually achieved by lower handicappers allows greater trunk rotation on the downswing and higher club head speed.
a) Shoulder injuries
The golf swing requires a coordinated effort of the rotator cuff and scapular muscles. The shoulder is a common source of pain mostly due to rotator cuff disease and subacromial impingement of the leading shoulder, which occurs when the rotator cuff impinges between the greater tuberosity and the acromium process causing rotator cuff tendonitis and partial tears. These injuries shorten the follow through of the swing. Rotator cuff muscles: Supraspinatus, infraspinatus, subscapularis, teres minor (and major not shown)
Injury to the acromioclavicular joint in the lead shoulder is not uncommon. Glenohumeral instability, superior labrum lesions and disorders of the biceps can all occur.
Arthroplasty (total joint replacement), rotator cuff repairs, and arthroscopic repairs of certain tendons and joint labrum tears are fairly successful in experienced surgical hands. 23/24 patients with total joint replacement (average 52) returned to golf in an average time of 4.5 months.
b) Elbow injuries
Gripping the club to tightly or hitting the ground behind the ball can cause strain in the elbow especially the lead elbow forearm flexors usally causing lateral or medial epicondylitis (“tennis elbow”) as shown above in the drawings. Cortisone and plasma rich injections have variable results but usually will relieve pain.
It takes several weeks for this injury to completely heal, and once back hitting the ball, adjustments must be made to prevent reinjury. Forearm straps are very helpful to prevent further damage in milder injuries. A change to a more flexible shaft also should be considered. Some suggest a baseball grip. Considerable attempts with conservative measures are necessary (rest, braces, NSAIDs, injections, specific exercises, etc. Surgical repair involves separating the joint ligaments and in some cases reattaching them after debridement of injured tissues.
For a report on elbow injury and treatment click on:
c) Wrist injuries
Extensor (back of) wrist injuries usually tendonitis occur most commonly on the lead wrist most commonly hitting the ball fat (hitting the ground) or hitting out of a heavy rough. Conservative measures are usually adequate, however, endoscopic tendon repair may be necessary. CT scan may be necessary to rule out a stress fracture of one of the small wrist bones (the hook of the hamate bone) and may require excision.
d) Low back injuries
The low back is the most commonly injured body part in golf. The swing and rotation of the body equals to 8 times the person’s body weight. These injuries are usually cumulative over time from continuous load bearing. It most commonly occurs from the trail arm, shoulder, and trunk rotation. Ruptured discs are the most common, but fractures can occur and over time superimposed osteoarthritis may narrow neuroforaminal canals causing nerve impingement.
I refer you to previous reports for management of low back pain, surgery, etc.
e) Hip Injuries
Acetabular labral tears from the rotational velocity of the hip, especially the trailing hip, can occur. Improving lead hip rotation will prevent over-rotation of the trailing hip and injury. The labrum is cartilage lining the hip socket, as shown below in the right drawing.
With improved arthroscopic techniques, some of these tears can be handled more conservatively. Osteoarthritis will occur over time and may lead to hip replacement.
f) Knee Injuries
Knee injuries are rare (only 4-9%), and cartilage tears are the most common injury. However, most are strains that can be managed with rest, heat/cold, NSAIDs, cortisone injections, and braces. Injections such as Synvisc gel into the knee can also provide temporary relief for a few months (now available for shoulder joint injections). Total knee replacement may be necessary over time and continued overuse. This is even being performed robotically.
g) Ankle injuries
The ankle is more likely injured from a slip or fall. Most from the golf swing are managed conservatively.
Golf is non-contact sport but the muscular, ligamental, and joint strength and flexability requirements are significant especially demanding a precise coordination of moves from the arms, shoulders, back, knees, feet and ankles to perform a smooth transition through the golf swing called tempo. Rotation and transition through the golf swing has been described. The most common injuries occur to the back and arms. Strengthening exercises and pre-golf stretching is vital to minimize not only acute but chronic injuries.
C. Golf stretches to prevent injuries
Everyone would like a better fluid golf swing and prevent injury. Here are some stretches you should consider:
1. Stretch the shoulder
2. Stretch the quadracepts (thigh)
3. Stretch the back
4. Stretch the hamstrings (Back of thigh)
5. Stretch the hips
6. Stretch the hip and back
7. Stretch the front of the foot and hip flexor
8. Stretch the wrists
10. Stretch the shoulders
11. Stretch the core
These stretches need to be held for 30 seconds without pain and repeated. Do these before going to the course or before practicing or before the first hole while waiting to tee up.
These photos come directly from the Mayo Clinic Housecall, a great resource.
A. Vaginal (uterine) bleeding-common causes
B. Endometriosis and Adenomyosis—they are different
C. Fibroid disease
A. Causes of vaginal bleeding—pre, peri, and post-menopausal
Determining Menopausal status –a new test now available
There is a new FDA approved test to determine the status of menopause (Elisa test). It measures a hormone (anti-Mullerian) that rises after the final menstrual period, and could be valuable in circumstances such as when to stop contraceptives or when vaginal bleeding might be more likely from cancer or other causes rather than a false menstrual period. FDA news Release, October, 2018
Vaginal bleeding or spotting is a very common issue, and may be caused by STDs (sexually transmitted diseases) especially after intercourse or douching. Spotting between periods is not uncommon but if it persists, an evaluation is necessary. Infections of the cervix, blood clotting disorders, hypothyroidism, and chronic liver or kidney disease must be ruled out. Fibroids and polycystic ovaries also may causing abnormal bleeding. Cancer must be ruled out.
The most common cause of post-menopausal bleeding is gynecologic cancers and fibroids. Gyn cancers include uterine, cervical, ovarian, and rarely vaginal cancers.
Menopause is defined as the absence of menstrual periods for 12 consecutive months. Perimenopause is defined as the period of time when the levels of estrogen tend to fluctuate. 25% of women during this time will have heavy menstrual flow but should not have bleeding between periods. If it persists, evaluation might be necessary. Any bleeding after menopause is abnormal.
Diagnosing and treating menopause has been discussed previously
Other less common causes include polyps in the uterus or cervical canal. These are benign but can cause spotting or excessive bleeding. Endometrial atrophy (thinning of the lining of the uterine wall due to low estrogen levels from menopause and can cause bleeding. Endometrial hyperplasia (thickening of uterine wall) can also occur. This can occur from an imbalance between too much estrogen and not enough progesterone. It can lead to cancer.
Vaginal atrophy (thinning of the vaginal wall) can cause bleeding during intercourse.
Occasionally sexually transmitted disease (STD) can cause bleeding including Chlamydia, gonorrhea, or herpes simplex.
Diagnosis can be made with transvaginal ultrasound to check for these abnormalities. Endometrial biopsy will diagnose intrauterine abnormalities. D&C (dilatation and curettage) will also provide valuable answers.
Treatment of uterine bleeding
If cancer is diagnosed, I refer you to last month’s report.
For those disorders created by low estrogen levels (which occur with menopause), estrogen replacement is the answer, whether in the form of vaginal creams, suppositories, or even oral estrogens. Vaginal estrogen rings or tablets can be used. Progestin vaginal pills or shots can be the answer depending on blood levels of hormones.
Polyps and hyperplasia can be removed endoscopically.
WebMD, American College of Gynecology
B. Endometriosis and Adenomyosis—they are different
This disease occurs in up to 10-20% of women.
Endometrial implants occur in and on the uterus, around the ovaries, fallopian tubes, on the bladder surface, colon, rectum, and lining of the pelvis (peritoneum). It is thought that abnormal tissue cells travel down the fallopian tubes into the abdomen from the uterus (retrograde menstruation), thus creating implants throughout the pelvis. The actual cause is unknown, but does run in families.
The symptoms include excessive cramps during the menstrual period (dysmenorrheal), pain on intercourse (dyspareunia), cyclic pelvic pain, abnormal or heavy flow, bleeding between periods, infertility, fatigue, pain on urination, painful bowel movements during the menstrual period with diarrhea, constipation, and nausea. These endometrial implants are responsive to the monthly cycle and swell, bleed, and cause inflammation and cause symptoms during the menstrual period wherever they implant. Ultimately, they cause scarring which can lead to pain at any time.
Endometriosis is estrogen dependent (does not occur before menarche of after menopause),
Girls who have their first menstrual period before the age of 11, short menstrual cycles, and heavy periods that last 7 days or more, have a family history, give birth after 30, and are white are more prone to developing endometriosis.
Risk of cancer
Although rare, there is an increased risk of endometrial cancer, and a 50% increased risk of ovarian cancer.
There are 2 reasons for these patients developing cancer: a) increased susceptibility to cancer, especially ovarian, and b) malignant transformation of endometrial implants.
a) increased risk of developing cancer--although only a theory--patients with endometriosis make up 50% of infertile women, and not having babies increases the risk of ovarian cancer. These patients are at an increased risk for ovarian (90% increase) and breast (30% increase) cancer, and non-Hodgkins lymphoma (40% increase). Endometrial cancer occurs in less than 1%. National Cancer Institute
b) malignant transformation of endometrial implants
2.5% of these patient develop malignant transformation (usually clear cell adenocarcinoma) in the implants in the uterus and in the pelvis (ovaries, fallopian tubes, pelvis ligaments, colon, and even abdominal surgical scars. There is a type of ovarian cancer that is called endometrioid carcinoma accounting for 20% of all ovarian cancer (the other 80% are called serous carcinoma), and those who have their initial endometrial implants on the ovaries are particularly prone to this histologic pattern of cancer.
Symptoms that might indicate cancer are accelerated growth of these lesions causing an increased number of symptoms. It is known there are some genetic ties between these endometriosis and cancer.
Trans-vaginal ultrasound (right drawing) to diagnose endometriosis.
Endometriosis. Above (left) are potential implant sites.
The other way to diagnose these lesions is with endoscopic viewing with biopsy and or removal (below).
Many other diagnoses can be confused with endometriosis
Patients often are misdiagnosed with overactive imagination, irritable bowel syndrome, depression, stress, anxiety, periodic pain, chronic fatigue, polycystic ovary syndrome, etc.
1—Pain control can be difficult but NSAIDs are preferred and hopefully there will be a lower risk of opioid use and abuse since this is a chronic illness, and these patients are at risk becoming dependent on opioids.
2—Hormonal—predominantly progesterone containing medications including contraceptives, vaginal rings, and patches that contain progestins (and some estrogen). Danazol is commonly prescribed to prevent a woman from having periods and thus prevent the time when the symptoms are at their worse. There are progesterone markers that may guide the physician in using Danazol and be able to predict more success. Reference--NIH
There is a new FDA approved oral hormonal treatment—elagolix(Orilissa). It is a gonadotropin-releasing inhibitor (this inhibits the stimulating hormone from the pituitary) and is helping pelvic pain and pain during sex. Talk to your doctor about this new therapy. NEJM-Journal Watch, August, 2018
There are side effects of hormone therapy and need to be discussed with a woman’s doctor.
3—Tamoxifen is normally used after breast cancer is treated, and is recommended for 5 years, but this aromatase inhibitor is a potent anti-estrogen medication and effective in endometriosis, but is used only in cases that are not controlled by other medications.
4—Supplements are limited in their value but many have been tried including fenugreek, fish oil, vitamin B1, ginger, valerian root, and zinc. Gluten free diets help some in one study. Coffee and caffeine have not proven to have any effect on endometriosis.
4—Surgery is indicated when medical therapy cannot control symptoms or a mass develops from one of the implants, bowel obstruction or bladder scarring requires it.
Techniques include laparoscopic procedures to remove scar tissue, rapidly growing masses of endometrial implants (endometriomas or chocolate cysts of the ovaries), large cysts that might rupture, with or without using a laser may require a hysterectomy, removal of the ovaries, and fallopian tubes, and even the uterus.
Hormonal replacement therapy will likely be initiated in younger women.
Recurrence can be an issue in up to 30% of patients.
Medscape, July, 2018
Adenomyosis differs from endometriosis. Endometriosis is defined as uterine lining cells that are misplaced outside the uterus, and adenomyosis is defined as endometrial cells that penetrate the lining into the uterine muscle. Both are defined by where the endometrial lining cells are located.
When adenomyosis occurs, the uterine wall thickens and causes pain and bleeding. It also is found in cases of infertility.
This disorder can occur simultaneously with endometriosis, and hence the confusion. It is estimated that 42% of endometriosis cases also have adenomyosis. Both are common in child bearing age women, up to 20%. Both diseases may be asymptomatic (1/3) and the others will have pain, pain on intercourse, abnormal bleeding, enlarged uterus, and a high chance of infertility. Isolated adenomyosis may be hard to diagnose. Ultrasound is recommended and if negative, an MRI may be necessary.
If hormonal therapy does not work, hysterectomy will be necessary in both these diseases. If desired, there are less aggressive treatments for adenomyosis including laser ablation and endoscopic removal of the implants.
Menopause usually alleviates the pain from adenomyosis whereas endometriosis may still cause symptoms.C. Fibroid Disease
80% of women have fibroids by the age 50 years of age, according to the National Institutes of Health. Fortunately, they are benign. There are various names for fibroids based on the cells in the benign growth and the location (leiomyomas, fibromas, myomas). They can occur in the muscular wall of the uterus (most common), on the mucosa (inside) or outside on the surface of the uterus.
The cause is unknown, but there are factors that influence the development—female hormone, family history, and may rapidly grow during pregnancy. Black women, women 30-50, and those who are overweight.
Symptoms are similar to endometriosis—excessive bleeding, pain, increased urination, painful intercourse, pressure and swelling in the lower abdomen.
Diagnosis is made with ultrasound (below left) and MRI.
Treatment includes regulating the female hormones with medications that increase production of pituitary gonadotropin-leuoprolide (Lupron) and lower the levels of estrogen and progresterone, which will stop menstruation and shrink fibroids.
IUDs containing progestin, NSAIDs (Aleve, Ibuprofen), and birth control pills all will help.
In more severe cases, endoscopic removal is successful, and hysterectomy may be indicated.
There minimally invasive procedures such as cryo-removal, or embolization to stop the blood supply to specific fibroids. Ref: Healthline.com
This completes the February report. Next month the March, 2019 report will include:
1. Medical Updates
2. Differences in MDs and DOs; Differences in Ophthalmologists, Optometrists, and Opticians
3. Health Fads, Failures, and Fixes
4. Lasik Surgery—riskier than you think
5. Syncope (passing out)
As always, stay healthy and well, my friends, Dr. Sam
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