The Medical News Report

March, 2019, #86

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects

1. Medical Updates

  a) Top ten causes of death in the U.S.

  b) Time for doctor visits shrinking!

  c) FDA announces greater oversight over dietary supplements

  d) The JUUL e-cigarette sales going through the roof—causing a nictotine war with other manufacturers

  e) Supreme Court blocks Maryland from trying to prevent drug gouging by Big Pharma! Are you kidding??

2.  The controversy over Ovarian Cancer Screening for all women

3. Nosebleeds (Epistaxis)

4. Syncope—Part 1—fainting/passing out—diagnosis and treatment

5. Sexual assault/harassment update

6. Difference between Doctors--M.D.s and D.O.s; defining allopathic, homeopathic, holistic, naturopathic, and ayurvedic treatments! Eastern Medicine; a new designation medical doctor physician assistant (A.P.)-beware!

7. Lasik Surgery—higher risk than you think!

Which one are you enjoying?

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. I encourage everyone to seek a primary care physician. 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 give you more comprehensive care. Always write down your questions before going for a visit.

Thanks!! Dr. Sam

Subjects for March 2019:

1. Medical Update

a) Top ten causes of death in U.S.

b) Doctor visit time shrinking!

  Spending time with your doctor is shrinking. Perhaps, you will get to spend more time with the nurse, PA, or nurse practitioner. Being prepared before going for a doctor’s visit is critical. Insist on your visit is fulfilling your expectations.  Here is a study from a publication Aviation Health:

c) FDA upping its surveillance over dietary supplements—will it help?

  The risks of taking over-the-counter dietary supplements are getting riskier according to the FDA as reported in the Washington Post.

  As always the supplement industry continues to omit harmful ingredients on their labeling and steps over the line claiming false and misleading benefits. Recommended doses are not research evidence-based. Alzheimer’s disease, memory enhancements, erectile dysfunction, and muscle building supplements are just a few that are being targeted by the companies.

  The supplement industry sells over 80,000 powders and pills to the public, a $50 billion industry. FDA Commissioner, Dr. Scott Gottlieb, said that the agency is planning policy changes that will safeguard the public better since the Regulatory Act in 1994 was enacted. These supplements are only regulated by the food industry, not the FDA.

  The NEJM* reported 23,000 emergency room department visits thanks to side effects of supplements. *NEJM=New England Journal of Medicine

  Lets hope this is a real move for better safety and not just governmental public relations. 3 out of 4 people take supplements with little security that they are taking a reasonable dose, that it is safe, or even a little bit effective more than a placebo.  

d) JUUL e-cigarette sales  have gone through the roof causing a sales war with other manufacturers—our kids are at risk!

JUUL e-cigarettes have cornered the market (70% of total U.S. sales) with a very appealing device to adults but unfortunately to kids as well. The rise in the use of e-cigarettes is so strong that it is negating the decrease in cigarette sales.

  The sales of e-cigarettes are expected to reach $9 billion this year. Although, it may be a somewhat effective tool in smoking cessation for adults (10-20%) with decreasing doses of nicotine in cartridges, kids are getting their hands on these cartridges with more nicotine than are in cigarettes, and that computes to increasing addiction to nicotine and raises the risk of them switching to cigarettes, a known killer causing several cancers.

  E-cigarettes are still not recommended by the FDA as a smoking cessation technique unless the approved methods are not successful (nicotine replacement products-nicotine gum, patch, lozenges, and anti-smoking medications-bupropion-Wellbutrin or Zyban, Varenicline-Chantrix, clonidine, nortryptiline).

e-cigarettes increasing their nicotine content

  The average e-cigarette vaping liquid has 1.5-2% concentration of nicotine, and if there 3% vaping products contain 3%, they are considered to be “superhigh”.

  JUUL entered the market in 2015 with concentrations as high as 5% in most flavors, which are very appealing to kids.

  Each cartridge provides 200 puffs similar to a pack of cigarettes. Flavored e-cigarette’s use in children, adolescents, and young adults has been labeled epidemic by federal health officials. So why does this health hazardous product remain in vaping stores and sold to young people? No regulation!

  A recent survey reported that 63% of users who are ages 15-24 did not even know their e-cigarettes contained nicotine!  

  14 other manufacturers are now trying to compete with  JUUL by increasing their nicotine levels in their e-cigarettes to as high as 6% and are marketing JUUL- compatible pods. There are now 71 pod based products on the market.

  The FDA has just got to step in and control tobacco. The lobbyists must be banned from our Congressmen, who are mere pawns of these and other industrial lobbyists such as Big Pharma. I am not a big government person, but there are times when the American people should be protected from those companies who are selling potentially dangerous products by our U.S. government officials. Medscape News Feb. 8, 2019.

e) U.S. Supreme Court blocks Maryland from trying to prevent drug gouging by Big Pharma! Are you kidding??

  As hard as it is to believe, Reuters News Service just announced that the U.S. Supreme Court has rejected Maryland’s appeal of a federal appeals court’s decision in 2018 which struck down a law aimed at preventing price gouging by pharmaceutical companies.

  This deals a setback to the power of the states to rein in prescription drug costs. What has happened to our country, as President Trump is trying to rein drug costs, our Supreme Court Judges side with Big Pharma?

  This began in 2015 when a drug company raised the price of an anti-parasitic drug, Daraprim, from $13.50 to $750 per pill.    

2.  Controversy over Ovarian Cancer Screening for low risk women

  Screening guidelines for cancer is separated into 2 distinct groups: the general population with little risk for specific cancers, and those that have risk factors. Both groups should be considered otherwise healthy individuals without obvious ovarian disease or symptoms.

People who have a family history of some cancers  increases a person’s risk of developing that cancer. There are genetic syndromes, genetic mutations, and certain underlying medical conditions, and certain other factors that might put a person in a higher category of risk.

  There is another factor that must be considered—few tests are cost effective for screening general populations or the tests are not sensitive enough to be totally reliable.

  Such is the case of the blood test CA-125 for ovarian cancer. 0-35 units/ml is normal. 75-80% of ovarian cancers have an elevated test. It is an expensive test  considering the number of ovarian cancers that are diagnosed each year (over 22,000 annually). The other test commonly used to diagnose ovarian cancer is a transvaginal ultrasound. Currently, neither test is recommended as a screening test for ovarian cancer for the healthy general population of women. The cost varies widely, but one reliable site stated the test cost $150, but I have seen much higher rates.

  For a discussion on ovarian cancer, please click on my website: www.themedicalnewsreport.com/57

Risk Factors

  If family members (first degree relatives) have had ovarian or breast cancer, that puts a woman possibly in a higher risk category. Most medical organizations only consider parents or siblings as first degree relatives and are close enough genetically to be considered high risk. However, more than one family member with these  cancers increases the risk even more.

  With all the genetic tests available to the public, the interest in purchasing these genetic tests for disease risks has skyrocketed. What families do with this information remains to be seen, as there is a shortage of genetic counselors.

  If a family member has a *BRCA gene mutation, there is a 50-60% chance of developing ovarian cancer (as high as 80% chance of breast cancer), and some women, such as Angelina Jolie, have chosen prophylactic removal of both breasts (with reconstruction) and ovaries. This is obviously a serious discussion one would have with an expert.

*BRCA gene 1 an 2 are genetic mutations--BRCA=Breast Cancer

Risk Factors for Ovarian Cancer  

  Infertility, endometriosis, post-menopause hormones, and some (not all) studies indicate a link with IVF (in vitro fertilization), a woman diagnosed with breast cancer after age 41, a first degree relative with ovarian cancer, family history of breast cancer, Ashkenazi Jewish relatives with a history of breast cancer, and BRCA gene 1 or 2, or Lynch syndrome (non-polyposis colon cancer).

  90% of ovarian cancers secrete Ca-125, a protein, however, 2-3% of post-menopausal women secrete this protein as well. Researchers are working on newer techniques and strategies to use this genetic marker.

  Currently, the USPSTF* does not recommend testing for ovarian cancer for the general population because of the relative low incidence of ovarian cancer. It requires 100-150 women to be tested for one ovarian cancer to be found. Also 30 unnecessary diagnostic operations will be performed to diagnose just one cancer.

  Screening is recommended to reduce the number of deaths from a cancer, and ovarian cancer does not fit into that category, primarily because the harm versus benefits just doesn’t add up.

*USPSTF=United States Preventative Services Task Force

  However, the USPSTF has just officially recommended testing of families who have a member with the BRCA 1 or 2 muated gene, and if positive consult a genetic counselor. 

  Memorial Sloan Kettering Cancer Institute in NYC does not recommend Ca-125 testing or transvaginal ultrasounds, however, they recommend an annual pelvic exam. Some organizations are even walking away from annual pelvic exams.

  For those with a calculated 3-6 times greater risk, the above tests are recommended. Please consult the Memorial Sloan Kettering Cancer Institute website regarding risk factors. Also the American Cancer Society discusses this issue on their website and does not recommend ovarian cancer screening for the general population.

www.cancer.org

  Hollywood celebrities appear on women’s TV shows (i.e. Ellen DeGeneres specifically with Ellen Pompeii recommending it for all women) and encourage mass screenings using CA-125. There are also some women’s groups who are encouraging women to be tested at the detriment of those who will get false negative or false positive tests. With the cost not covered by insurance for those without a high suspicion of ovarian cancer, it is still not practical to test general healthy populations of women.

Other conditions causing an elevated CA-125

  There are conditions other than cancer that create an elevated CA-125 including endometriossis, liver disease, menstruation, pelvic inflammatory disease, pregnancy, and uterine fibroids. Mayo Clinic

  Some women with ovarian cancer never have elevated CA-125 (over 10%), and about half of women with early stage ovarian cancer do not have elevated levels.     

  Genetic testing with counseling is a serious issue and must be well thought out before a person and their family embark on that venture. Genetic testing without consulting a genetic counselor is not recommended.

  Summary—using CA-125 and or transvaginal ultrasound to test general healthy populations of women does not reduce deaths due to ovarian cancer.

3. Nosebleeds (Epistaxis)

Causes

1. Most common-- dry nasal membranes, nose picking, and excessive blowing.

2. Not uncommon—sinusitis, aspirin (and other drugs that thin the blood), nasal allergies, bleeding disorders (hereditary and drug induced), oral and injectible blood thinners, excessive use of nose sprays (i.e. Afrin), common colds, deviated nasal septum, trauma to the nose, and foreign bodies especially in children.

3. Less common—alcohol, hereditary blood vessel disease, blood clotting disorders, leukemia, nasal and sinus tumors, nasal trauma, nasal septal perforations (snorting cocaine and other drugs), pregnancy, hypertension, immune diseases affecting the nose (i.e. Wegener’s granulomatosis) and environmental toxin causes.

  An Ear, Nose, and Throat Surgeon is required to evaluate the patient by examining the nasal airway for evidence of abnormal vessels, erosions, ulcerations, crusts, tumors, and examination of any evidence of abnormal drainage from the sinus openings. A hole in the anterior septum is likely from snorting drugs especially cocaine or other illicit drugs.  The back of the nose (nasopharynx) requires evaluation and is best evaluated with an endoscopic examination or indirect mirror examination, which is routine in an ENT doctor’s examination.

Anatomy of the nose

Most nose bleeds are in the anterior (front) portion of the septum in Kiesselbach’s triangle (see drawing above left).

Treatment for simple (anterior septal) nosebleeds

Local treatments for anterior nosebleeds

  If there is a nosebleed from the anterior part of nose (Kisslebach’s triangle), constant pressure should be applied by pinching the nose for several minutes and is usually effective. Seek medical attention if that does stop the bleeding.

Techniques to stop anterior nosebleeds   

  Anterior nosebleeds include cauterization (usually a silver nitrate stick with topical anesthetic-photos on the right below) or electrocautery of broken blood vessels in the anterior nasal septum (see drawing above drawing with area circled). (most from nose picking and excessive blowing), cleaning of crusts, frequent lubrication with ointments, humidifier by bedside at night, no blowing or picking, and follow up to make sure the area is healing.

Laboratory tests

  Those with recurrent nosebleeds should have blood clotting studies to rule out a clotting defect, red and white blood cell count, liver, kidney, thyroid, and diabetes tests.

Hereditary causes presenting with nosebleeds

  Most everyone knows about Hemophilia A (Factor VIII deficiency), a life threatening bleeding disorder, treated by replacing some of deficient Factor VIII clotting factor.

  The most common hereditary blood clotting disorder, however, is von Willebrand disease, and is often misdiagnosed. These people usually present with excessive bleeding after minor trauma to mucosal surfaces from surgery and dental procedures.

  The defect is from a gene vWF (von Willebrand factor)  which is located on the 12^th chromosome, and is inherited as an autosomal dominant trait in most. This protein is also physically linked to Factor VIII, a major clotting factor.

  A standard blood clotting study (partial thromboplastin time-PTT) can disclose the bleeding disorder. The PTT is usually prolonged in von Willebrand disease, and further investigation will discover the defect.

  These patients usually have a history of nosebleeds, easily bleeding gums, and bruising.

  This hereditary factor (vWF) influences the stickiness of platelets in the blood to form a clot. This is similar to how aspirin works on the blood platelets.

  For patients with von Willebrand disease who require surgery, a medication (desmopressin) can be administered to prevent bleeding.

  1 in 100 people have this hereditary deficiency, however, it is usually mild, and only becomes apparent when a person is challenged by surgery. Women who have a history of excessive menstrual periods may have the defect, and this defect is more common in those with type O blood, who have lower mean levels of this factor.       

Allergy and sinus disease; Sleep apnea patients

   Nasal and sinus allergies must be treated to prevent chronic swelling of the mucous membranes, which predisposes to nosebleeds commonly caused by excessive blowing, nosepicking, and abuse of nasal sprays (Afrin or cortisone sprays). Addressing inhalant allergies is highly recommended.   

  A cool mist humidifier at night is most helpful in the winter when the heat dries the room air including the nasal membranes, which can cause crusting and bleeding.

  If a person uses CPAP (continuous positive air pressure) for obstructive sleep apnea, adding a humidifier to the machine is crucial plus use of a *cleaning machine for the mask to prevent infection is recommended.

*So Clean 2 CPAP cleaner-$319

  Many people take a daily baby aspirin (81mg) as a heart disease preventative, which thins the blood and can predispose to nosebleeds. Other NSAIDs (Aleve, Ibuprofen, etc.) can also cause bleeding issues including high dose Omega 3 supplements, and many other over-the-counter supplements. People on anticoagulants are especially prone to nosebleeds.

Severe Nose bleeds (Posterior Nose Bleeds)

Posterior nosebleeds (in the back of the nose) can be very serious. These patients will have significant bleeding down the back of the throat coming from the back of the nose.

  There are often underlying causes of these serious nosebleeds. Acute hypertensive episodes brought on by a variety of issues including poor control of blood pressure,  alcohol abuse, drugs (illicit-methamphetamine, cocaine and prescription opioids) that raise blood pressure. Posterior nosebleeds are an emergency and need to be sent to the emergency room.

Most of these patients will be treated with the insertion of an anterior/posterior balloon in the nose (above drawing), but it is painful when those balloons are inflated and requires hospitalization for immediate reduction of blood pressure and pain management from the nasal balloons is absolutely necessary.

  These balloons cause swelling of the soft palate and throat and pain meds predisposes to obstructive apnea with potential cardiac deterioration from low oxygen levels and depressed respiration. These patients are placed on oxygen with cardiac monitoring. The balloon will need to be in place for several days.

  Patients admitted to the hospital for epistaxis frequently have underlying diseases such as cardiovascular disease, alcohol abuse (alcohol withdrawal during hospitalization), hypothyroidism, rheumatoid arthritis, and even an underlying malignancy. Nosebleeds can be very serious and life threatening.

Surgical management of posterior epistaxis

  Upon occasion, in persistent cases with continued bleeding, a direct ligation of  major arteries that supply blood to these nasal areas is necessary.

  There are 3 major vessels (that come from branches of the external carotid artery) that need to be addressed based on the location of the bleeding. The anterior and posterior ethmoid arteries can be accessed through an external incision in the corner of the eye, as seen in the photo below (arrow).

In my experience, having performed these procedures numerous times, the more common artery that bleeds is the sphenopalatine artery, because most of the severe posterior nosebleeds come from the inferior (bottom) part of the nose.

The arrow below points to this sphenopalatine artery.

This artery can be accessed through the maxillary sinus (see the drawing below) with a incision above the gums and teeth under the lip. The front wall of the sinus is removed and part of the back wall. Behind the back wall of the maxillary sinus is the sphenopalatine artery and its main branches. Note the arrow below for the surgical approach. These vessels are ligated with tiny hemoclips under an operating microscope. The right drawing below shows the space where the sphenopalatine artery lies (arrow) behind the maxillary sinus. This is a very successful procedure and stops life threatening bleeding.   

If these procedure are unsuccessful, ligation of the external carotid artery is necessary through the neck in very rare cases.

If a patient has von Willebrand disease, they should not must not take NSAIDs (Aleve, aspirin, etc.), and any medication that thins the blood unless they are directed by their physician.

Reference—Medscape and personal experience

4. Syncope—Part 1--fainting or passing out—diagnosis and treatment

  When a person passes or “blacks” out, even for a very short time, the range of disorders that needs to be ruled out is vast. In 2018, the European Society of Cardiology updated their 2009 guidelines and provided the primary care physician, emergency physicians, and cardiologists with revised guidelines for diagnosing and managing these patients.

Definition

  Syncope is defined as a transient loss of consciousness due to a sudden temporary reduction of cerebral blood flow with rapid onset, short duration, and complete spontaneous recovery. The lifetime chance of developing syncope is 50% especially as one ages. Serious injury from fallls can occur when syncope occurs including lacerations, head injuries, and extremity fractures, especially hip fractures.  

Emergency measurements

  When someone is unsure of the cause of a patient passing out, it is best to call 911. Emergency measures can include oxygen, giving an IV glucose injection to rule hypoglycemia, EKG monitoring, airway protection, raising or lowering the blood pressure if necessary, use of a defibrillator (AED), and evaluation of certain blood chemistries.

  Most syncopal episodes are quite short (seconds) in duration and depending on how a person feels, deciding to call 911 may be delayed to the detriment of the patient. Males are particularly resistant. Wives and family must insist.

   If chest pain occurs or mental disorientation after a seizure (for instance) is present, assume the patient needs emergency medical attention.    

Key evaluation recommendations are as follows per the European Society of Cardiology:

1. Initial diagnostic evaluation includes a complete history of exactly what happened, how often it has happened in the past, and circumstances surrounding the episode such as standing up rapidly, during urination, after feeling chest symptoms, the use of alcohol or other substances, extreme heat exposure, dehydration, a family history of syncope or seizures, or experiencing an acute emotional issue. Also a patient’s medications may be the cause.

2. Physical examination must include BP measurements in lying, sitting, and standing position. Heart arrhythmias, carotid bruits-noise in the artery (the doctor can hear this with a stethoscope indicating stenosis (narrowing) of the carotid artery), evidence of anemia (paleness), and a host of other signs.

3. Telemetry (cardiac monitoring) is indicated in high risk patients (in the ER--cardiac monitoring, Holter monitor at home) to diagnose heart irregularities.

4. Carotid sinus massage may be indicated in patients older than 40 in patients with vasovagal syncope (but not in those with carotid artery disease).  This is a type of neurological fainting caused by reflex stimulation of a receptor in the middle of the neck in the carotid artery that will drop the heart rate and blood pressure (there is also a chemoreceptor called a carotid body). This is caused by an acute emotional experience such as seeing blood (for instance). The vagus nerve in the brain maintains heart rate and blood pressure through sensors in the body such as the carotid sinus. When the blood pressure and pulse drops from reflex vagal stimulation, syncope will occur, and unless the patient lies down quickly, a seizure will occur from low oxygen to the brain.

  Massaging the mid neck as shown above will raise the blood pressure and revive the patient if a vasovagal event occurs. Many times, just lying the person down will revive the patient too. Most people will not be comfortable performing this carotid sinus massage. 

5. Echocardogram should be peformed in patients with known heart disease or suggestive of it.

6. Specific blood tests (CBC, arterial blood gases to test oxygen levels, troponin blood levels for heart damage, and D-dimer to rule out a pulmonary embolus) are indicated based on clinical suspicion. Hypoglycemia (low blood sugar) must be ruled out.

7. Other cardiac physiologic testing may be required based on a history of heart attack, those with cardiac arrhythmias, or patients with palpitations prior to syncope (indicating irregularities of the heart). This may include an exercise stress test.

8. Blood pressure measurement lying down, sitting, and standing to rule postural orthostatic hypotension (POTS). There are patients who become very dizzy when they stand up, because the blood pressure drops significantly. There are disorders associated with POTS including autonomic nervous system malfunction, which will be discussed next month.

  There are a variety of disorders that need to be ruled out. Medications can create this issue, therefore, patients must see their doctor, which may require an extensive workup in persistent and more serious cases. (This issue will be discussed next month in more detail).

Types of syncope

  a) Neurologic based syncope

    This is a reflex type of fainting and the most common type mentioned above (vasovagal syncope).

   b) Cardiac causes

  This is a more serious type of syncope and can lead to sudden cardiac death. This is the cause in 10% of the cases. Irregularities (arrhythmias), heart valve disease (especially aortic stenosis), diseases causing bradycardia (slow heart rate), occurring with exercise, pulmonary embolism, heart failure, and atrial fibrillation all can cause syncope.

  Being over-medicated can cause the problem especially blood pressure medicine, a good reason not to maintain blood pressures on the low side, so that there is no margin for safety. People over 60 are more prone to drops in pressure when standing.

Warning signs (presyncopal symptoms)

  Patients should be aware that fainting is about to happen in many occasions. Feeling strange, a warm feeling, a cold sweat that comes out of nowhere, slight nausea, lightheadedness may tip a person off, and as fast as a person can must sit down on the floor or better lay down. If driving or in a precarious situation, you must assume the worst and take immediate action before disaster occurs by pulling off the street, lowering the seat, and call 911. Lying down is a must to prevent passing out.  

  70% will have a previous history of fainting, have lightheadedness, etc.  It is recommended these people be managed as aggressively as those who completely pass out. 

Treatment

  Most neurological reflex vasovagal syncopal episodes do not need treatment (even carotid artery massage) except immediately lying the person down to prevent a seizure. Recognition of a person’s chances of fainting is mandatory and avoidance of situations that might bring them on is critical.

  If there is mental confusion after a syncopal episode, a seizure may be the cause. An EEG will need to ordered and based on the workup, antiseizure medication may be recommended. 

  The diagnostic workup will dictate the treatment. If a patient tries to be overzealous about keeping their blood pressure too low, they are prone to syncope. That is why, even though the guidelines for blood pressure management may be 120/70, for older patients they need to consider 130/80, but that is the decision for the  treating physician.

Reference--European Society of Cardiology, The American Heart Association

Orthostatic hypotension

  This is a large subject to cover and will be discussed next month. However, if this is present (drop in blood pressure when standing, precautions must be taken while a workup is under way including compression stockings, hydration, medications (vasopressors) to raise blood pressure (midodrine, fludrocortisone). The causes and workup will be discussed next month in Part 2.

Emedicine/Medscape  

5. Sexual harassment/assault update

Sexual harassment 

  As women continue to be treated more as equals by men, more women (and yes some men) have come forward with horror stories in their own homes, workplace, and out in public. Think of the pinch by Italian men as a woman walks down the street, or an employee who is put into an uncomfortable situation with a boss or fellow employee. Is the “casting couch” still going on? What about “ruffies” (Rohypnol), the date rape drug so commonly used in the bar scene?

  Times have changed and harassment of any kind has come to the surface and not tolerated with the creation of human resource departments in businesses. Yet, there is still a huge problem that needs to be addressed everywhere. Truly this is a serious form of bullying. It also can be abused with threats and manipulation in certain circumstances.

  The results of sexual harassment create a negative work environment and can decrease in productivity, psychological issues, loss of jobs, and is best brought to the surface and handled in a professional manner.

  Toleration of sexual harassment from more prominent workers or employers can create a toxic situation for those who are in fear of losing a job if they come forward.

  Unfortunately this issue can be misused in certain cases with fraudulent charges and create stress in the work environment and can even affect employee evaluations, promotions, and bonuses.

  This issue is truly a healthcare problem that needs to be explored with open conversation when a person seeks help for depression, anxiety, and loss of work efficiency. Physicians must ask the question…are you suffering from sexual abuse or harassment?

Sexual Assault in women

National Sexual Assault Hotline: 1-800-656-4673

Sexual Assault is unwanted sexual activity with force, threat, or taking advantage of a person not able to give consent, according to the American Psychological Association. When it is immediate, of short duration, or infrequent, it is called sexual assault.

  Sexual assault occurs every 98 seconds in the U.S. (321,500) annually. The majority of sexual assault occurs in people under the age of 30.

  1 out every 6 women has been the victims of attempted or completed rape in their lifetime. 82% of juvenile rape victims are female, and 90% of adult rape victims are female. 4.3% of women in the military are raped. The highest rates of rape occur in American Indian and Alaskan natives.

  1 in 33 men have been the victims of attempted or completed rapes. 1 out 10 rape victims are male. 21% of transgender people have been victims. It is estimated that 80,600 prisoners are raped each year (60% initiated by prison staff).

  A recent study of traumatic brain injury in female military veterans found that all too often the reason for injuries was from intimate partner-caused abuse including sexual abuse. NEJM

  Amazingly, rapists have rights too. 31 states allow them to sue for visitation or custody of children. And the worst statistic is that 97% of rapists never see jail time. OMG!!

  PTSD* is common to almost all victims, including suicide attempts, depression, and are more likely to abuse drugs and alcohol, have work related difficulties, and intimacy issues. *PTSD=posttraumatic syndrome disorder

  Only 30% of sexual assault is reported!! If you know someone who has been sexually assaulted, please take them to the ER for a rape-kit and document the assault. This is very important if a woman to find out if the person is exposed to STDs and strengthen their case should they be willing to press charges, however, getting women to go to the authorities is very traumatic and requires encouragement and support.  

   I have previously reported on sexual harassment as a major health hazard. But in this current environment, lives are being ruined every week because of this issue and have become political. Believing accusations 15-30 years later is at the center of the issue, and it appears, because people are afraid to come forward or don’t want to be accused of lying, they hide these wounds for years until others come forward. Exposing their lives to defense lawyers is very traumatic.

  Since the current environment tends to believe accusers without real evidence (although a great percentage of those coming forward seem very credible) lives are being ruined by hearsay. Investigations are a necessity, and people must be considered innocent until proven guilty. But the outcome of this issue hopefully will reduce the incidence of harassament and assault.

  There is quite a bit of hypocrisy involved these days, and until there is a non-political even playing field, it is difficult to stand still when the media spills their guts all over the paper for certain groups, and it is back page information for others.

  Regardless, those who have been sexually harassed are carrying scars that, for most, do not heal. Women’s groups have formed to advocate for these victims.

  The January JAMA reported by researchers at the University of Pittsburgh asked a group of midlife (ages 40-60) female study participants if they had ever experienced these sexual traumas. The researchers wanted to investigate these traumas and whether they correlated with health consequences over the rest of their lives.

  Their findings suggested that there is a true correlation between poorer physical and mental outcomes statistically significant over a group that had no history of sexual harassment of some kind.

  There are many factors that make outcomes more or less serious such as the gravity of the trauma (assault vs harassment), length and duration of the harassment, whether it had been repeated, and by whom. There is no way to group all these traumas into one neat package. But the health consequences are real.

  It is well known that stress kills and causes health consequences. These women ages 40-60 filled out  extensive questionnaires. 19% reported workplace sexual harassment, and 22% reported a history of sexual assault with relatively little ovelap in the 2 groups. They were not the same women.

  Women with sexual harassment had a 2 fold increase of hypertension relative to women who reported no sexual harassment. There also was a 2 fold increase in insomnia and sleep problems, a 3 fold increase in depression, and 2 fold increase in anxiety. There was no association differences in race, ethnicity, age, economic status, medication use, physical activity, or alcohol use. None were smokers These findings are lower than known national statistics.

  National statistics report 36% of women report sexual harassment, but this is an overall statistic.

  Those with sexual harassment tend to have physical consequences whereas those who were sexually assaulted tended to have more psychological consequences.

  Chronic stress is known to interfere with the autonomic nervous system which is linked to damage of the blood vessel walls, which would increase cardiovascular disease. This study did not report on this issue.

Men are sexually assaulted and harassed too

  Men are harassed and assaulted as well, and it is thought that their consequences would be consistent with these findings. It is known that most males are assaulted or harassed as children whereas many more younger women are traumatized especially in the workplace. A grave example is the epidemic of young boys being sexually assaulted by Catholic priests which has been a global issue, and for most of us, feel has not been handled well at all by the Vatican. For years, payoffs out of court were used to keep sufferers quiet. Millions of dollars have been paid out by the Catholic Church.  

  Because awareness of this grave issue has been brought to the public in so many instances since the Hollywood tragedies, women and men should feel more empowered to come forward with any type of harassment or assault.

  Those who experience a toxic work environment must report any issue and or get out of that environment. Easier said than done, but this problem must stop before it escalates. Seeking counseling is a crucial step to learn to deal with the consequences of this issue.

  Physicians should ask their patients if they are being harassed or assaulted, because most will not volunteer this issue (and I don’t mean just having a question on a document filled out by a patient). As stated in this research, overreporting is rare and underreporting is common.

6. Difference between Doctors-- Medical Doctors (M.D.) and Doctors of Osteopathy (D.O.);

Defining allopathic, holistic, homeopathic, naturopathic, ayruvedic, and Eastern Medicine approaches to health; a new designation—medical doctor physician assistant (A.P.)-beware

Comment

  With the addition of millions of immigrants over the past decade, our population has expanded and with the number of Medicare recipients and expanded Medicaid recipients, our healthcare system has lagged in keeping up with the current health needs of our country. With this trend, more M.D.s retiring early, and other factors (burnout, loss of autonomy as employees, federal regulations, etc.), we are now forced to accept lesser trained health care professionals to provide primary care, emergency department care, pediatrics, etc. Nurse practitioners, P.A.s and foreign trained physicians are being called on to fill the gap, which concerns many that the quality of our care may not be the same (although some studies deny that).

  I have recently reported on Nurse practitioners and physician assistants. We are now seeing more and D.O.s joining M.D.s in group practice. There is even one state that has provided a special license to Caribbean medical doctors who can’t pass our country’s exams to practice in this country. They are called medical doctor assistant physicians in Missouri. This trend is troubling. Lets look at these practitioners.    

Difference between M.D.s and D.O.s ?

  When I was in medical school, D.O.s (Doctors of Osteopathy) did not work with M.D.s. They had the reputation of being chiropractors with more medical training. However, over the past few decades, the training became one and the same with M.D.s, and D.O.s now qualify for residencies throughout the U.S. in D.O. hospitals but also in M.D. medical institutions.  Most D.O.s have abandoned chiropractic techniques as the mainstay of their practice. There still is confusion. I discussed Doctors of Chiropractic in a previous report (see Subject index on the website).

  In addition to a similar medical curriculum that medical schools provide, D.O.s are trained in musculospinal diseases and spinal manipulation similar to doctors of chiropractic, but they are elective classes. The basis of osteopathic medicine training was originally based on diseases being either caused or influenced by the musculoskeletal system. Over time, Osteopathy blended its principles with that of their Medical Doctor peers.

  D.O.s are traditionally more holistic than most traditional allopathic medical doctors (M.D.). D.O.s are trained to be more preventative than allopathic physicians (M.D.s) who approach disease by prescribing medications, performing surgery, and practicing in specialty areas other than the traditional primary care physicians. The lines have blurred between D.O.s and M.D.s over the past few decades.

  Prevention should be an integral part of any D.O. or M.D.’s practice, but some are better than others about stressing preventative health measures. 56% of D.O.s are in primary care (family practice, internal medicine, and pediatrics), while 44% are specialists. Only 305 of M.D.s are in primary care. Almost half of D.O.s are women, and half of medical students today are women. D.O.s make up close to 9% of licensed physicians, but are increasing rapidly. Medical centers promote specialists because that is where the money is.

  When seeking medical care, one must do their homework and seek the opinion of their trusted primary care doctors, whether D.O. or M.D.

Defining different types of medical therapy—

 homeopathic, holistic, allopathic, naturopathic, ayruvedic therapies, Eastern medicine

  The lines between these different approaches to treating disease have blurred as many of these therapies are used by a variety of practitioners. Certainly, the training of these practitioners varies widely. M.D.s and D.O.s may practice a variety of these different approaches, but the basic training is different with these other practititoners. When health care providers get in the “real world”, most doctors begin to realize patients have preferences too and biases.

  The wise primary care doctor should incorporate many of these approaches depending on the individual patient’s needs. That is not to say that people today don’t seek out specific approaches for their medical needs by those who practice exclusive specific approaches. These alternative practitioners have varying quality of training and national standards are lacking.

  Because traditional medicine has been the leader in research, many of these other therapies do not have much proof that they work any better than the placebo effect on medical issues. What patients believe will help them is powerful and proven because of the placebo effect. Here is a glimpse at these different approaches to healthcare.   

  Homeopathy embraces the body’s natural response systems by either encouraging the body to cure itself using natural substances such as plants and minerals to treat the ailment or by attacking the root cause of the illness. It encourages the body’s own natural defenses to cure the illness. The evidence of effectiveness in the medical literature does not support many of the alternative methods of a homeopathic doctor. Yet, there is a large number of followers of these practitioners.

  Holistic medicine stresses that the whole person should be evaluated including the physical, psychological, and social aspects of the person that may be contributing to the disorder. Below is the classic holistic model.

The holistic approach is practiced by many different practitioners, and many D.O.s, M.D.s, and Doctors of Chiropractic are using these approaches including acupuncture, massage therapy, yoga, aromatherapy, meditation, supplements, etc.

  The mind/body connection is emphasized but psychosomatic medicine is also an integral part of traditional medicine especially with primary care providers. Specialists are less likely to step out of the bounds of their training, which leaves a huge responsibility on the backs of the primary care providers. As fewer M.D.s and D.O.s are choosing primary care, soon there will be more nurse practitioners and P.A.s shouldering the responsibility with physicians as consultants in family medicine. 

  It makes total sense to include the “whole person” when considering the number of disorders that are caused by a combination of immune abnormalities, psychological illnesses causing physical disease, and many other factors that deserve consideration.

  In other words, the lines between all these different practitioners is blurring some, but traditional medicine bases its treatment on scientific evidence based research, and many of these alternative methods would be utilized more but insurance has yet to get on “band wagon”, reducing their utilization because they are looking for evidence of value. That is not to say they may be effective in selected patients, but there is a huge gap in knowledge, proof, and the benefit of the placebo effect may be the only real effect. Some patients would say, “who cares, as long as I feel better”.

  Naturopathy is another term that bases its principles on the theory that diseases can be successfully treated or prevented without the use of drugs, rather by techniques such as control of diet, exercise, and massage. Again, there is not much solid scientific evidence that these techniques work for treating illness as the sole method, but common sense would tell anyone, this concept should be incorporated in treatment plans. Diet, stress management, mental health, and exercise will benefit many illnesses and disorders. Unfortunately, most naturopaths are anti-vaccination, anti-medication, and anti-surgery.

  Ayurvedic medicine is an approach that originated in India and is also a holistic approach to health and wellness emphasizing the mind/body connection. These practitioners believe that every person in the universe is made of 5 elements-space, earth, fire, air, and water. These elements combine to create the three forces of energies or doshas (Vatta, Pitta, and Kapha). These forces control how the body functions, and illness occurs when these 3 forces are out of balance. Depending how the imbalance occurs will determine the type of illness or illnesses a person will have.

  Treatment plans are designed to address these forces to return balance by cleansing the body of impurities (undigested food) achieved by blood purification, massage, medicinal oils, herbs, enemas, and laxatives.

  The FDA warns that 1 out 5 of their products contain toxic metals (arsenic, mercury, lead, etc.) which may be quite unhealthful and toxic to children.

  There no national standards or approved training programs in the U.S.

  Chinese Medicine depends on harmony and balance and energy in the body. I discussed this when discussing acupuncture in a previous report. The life energy that runs through the body (Qi) and is always on the go and moving. Treatments are based on creating and maintaining these life energies or the flow of Qi. There is a belief there are opposites that control the body—the Yin and Yang. When these are balanced, health is the result.

  Cupping, acupuncture, and tai chi, and moxibustion (burning dried mugwort on specific sites on the skin sometimes placed on the end of acupuncture needles), herbs, and other methods are used to create balance. Be sure to go to a certified Eastern medicine practitioner who practices this method of healing.

  At the end of the day, common sense, seeing qualified practitioners, who are board certified and well trained in certified medical centers are the best approach to healthcare. However, these alternative methods may have their place in specific circumstances. Going on faith, testimonials, and insufficient evidence must be measured against sound proven medical methods. Too many people die using these alternative methods rather than accepting traditional medical treatments. When a person is considering alternative methods, it is strongly advised to discuss this with their trusted physicians.  

  I always trust my primary care doctor to steer me to the right group of doctors (and hospitals) and then pick them based on their specialty qualifications and experience.

WebMD

A new program- Medical Doctor Assistant Physicians (A.P.)(these are not P.A.s) The watering down of healthcare quality!

  As physicians are fleeing primary care due to  overwhelming federal regulations, cumbersome electronic medical records, and federal bureaucracy, there continues to be a gap in care that even nurse practitioners and physicians with well trained P.A.s (physician assistants) cannot fill. And burnout in physicians has reached near 50% causing a drain on the medical professional pool.

  Out of desperation to find doctors, a new program was approved in 2014 only in Missouri creating a new category of licensure for these “healthcare providers” called A.P.s (Assistant Physicians) This got by the Missouri Academy of Family Physicians according to this Medscape report.

  This program should not be confused with the field of well trained P.A.s.

  The pool of medical students came from Caribbean medical schools and flunked exams to qualify to work in the U.S. The State of Missouri brought these “doctors” into the state and required that they spend 30 days with a sponsoring M.D. or D.O. They were then allowed to practice within 50 miles of the sponsoring doctor (without direct supervision). The physicians who are sponsoring these assistant physicians are being well paid by the state. 

  Only 42% of those who attended overcrowded medical schools in the Caribbean passed qualifying exams to  practice in the U.S. That left 58% of doctors unqualified to be in this country, but the State of Missouri chose some of them to come to their state to become A.P.s.

  A medical student from the Caribbean wrote a blog stating that those who qualify to be entered into this Missouri training program in the U.S. do not have near the experience and training that medical schools do in the U.S. His recommendation is to steer clear of a doctor who was trained in a Carribean medical school. To read this scary communication, click on: www.kevinmd.com/blog/2017/03/truth-caribbean-medical-schools-html

  Currently there is no surveillance or review for these providers. Fortunately other states have rejected this program including Florida. The Association of Medical Doctor Assistant Physicians website states they are qualified to practice primary care, pediatrics, internal medicine, and ob/gyn according to Medscape as published in JAMA*, October 23, 2018

JAMA-Journal of the American Medical Association 

7. LASIK Surgery—more complications than advertised

Approximately 9.5 million Americans have had LASIK surgery, thinking it was a quick trip to 20/20 vision. LASIK (Laser Assisted in Situ Keratomileusis) means reshaping the cornea. In 2017, 700,000 eyes were treated. Average cost is between $1000-3000 per eye, and insurance does not cover it. Globally refractive surgery is expected to increase from 4.3 million to 5.5 million procedures a year from 2018 to 2023.

  It is used to correct near and far sightedness, and astigmatism. 

  The cornea is reshaped using a laser or microkeratome (a blade device). A flap of cornea is cut and peeled back exposing the middle section of the cornea, which is reshaped using a computer-controlled laser to vaporize the irregularities. The top layer of the cornea is replaced over the treated area. Below shows the procedure.

There is a video at www.fda.org (search LASIK) which provides information about the procedure, potential side effects, and complications. There is also a reporting mechanism on the website for problems that occur from the surgery. This website should be seen before considering LASIK. It is FDA approved of course, but their role is determine whether a product is reasonably safe and effective. The procedure is classified as a Class III device by the FDA, which means it poses a high risk to patients.

  The decision to accept the procedure is between a patient and their doctor. The FDA continually follows the progress of LASIK monitoring post-marketing data.   

  Many patients have had to live with blurred or double vision, dry eyes(20%), chronic pain (20%), sensitivity to light (40%), and difficulty driving at night (33%). How long these side effectslast varies, and for some they are permanent. Some have had life changing effects with loss of work from the disability with social isolation, and depression (rarely suicide).

  One study found that half of the patients developed some distorted vision, and one third had dry eyes. Some had to still use glasses from time to time. But the vast majority have expressed satisfaction with their results eventually. Although I needed a small repeat in one eye, I had 20/20 vision within 3 months. Every patient is different and the degree of abnormal pathology to be addressed with LASIK varies. Selection of patients for any procedure is the key to great success.

  A study at Ohio State University submitted data to the FDA and found that the majority of the 4500 patients in the study had 20/20 or 20/40 six months after the surgery but 20% still had some dry eye symptoms. Dry eye syndrome is common anyway, and therer are many diseases and medications that cause dry eye.

  Approximately 20% had halos, blurred and double vision, glare, and trouble driving in the Ohio State University study. The dryness actually worsened to 40% by a year.

  Long term or late complications point to the possibility of needing cataract surgery earlier and the development of corneal ectasia, which is thinning of the cornea from the planing effect of the procedure on the middle layer of the cornea. 6 months later 40% were still bothered by some of these symptoms to some extent.

Bulging of the central portion of the cornea can create a condition called keratoconus and raise intraocular pressure (glaucoma). The problem is patients who eventually develop glaucoma can have higher eye pressures because of the thin cornea and potentially complicate treatment. Also those with LASIK may have higher intraocular pressures because of the thinner corneas.  Below is a representation of some of the side effects of LASIK.

It is interesting that the autoimmune dry eye syndrome (keratoconjunctivitis sicca) is increasing in our population. (I reported on it in the Medical News Report, June 2018). Could this be related to the boom in LASIK surgery? Although a different process, it could be worsened by LASIK. Patients with pre-existing dry eyes should strongly consider whether they should seek LASIK surgery.

  If eye pain persists, ophthalmologists now believe it is neuropathic pain from damage to the nerves to the cornea. It may be permanent.

  Summary

  Correcting astigmatism of the eyes, which cause refractory abnormalities essentially because of warping of the cornea, can be corrected for both near and farsighted patients. People who are nearsighted must have their corneas smoothed out (the curvature is reduced) and those with far sightedness must have the curvature increased.

  The message is that any surgery has possible short-term and long term complications. LASIK surgery is no exception, and even though the risk overall is about 2% for serious long term complications (vision loss), some studies are telling a different story. Ask your surgeon how many complications does he or she have and how long does he or she follow his patients after LASIK surgery. And the all important question….would you have this procedure? Ever notice how many eye doctors wear glasses?

This completes the March, 2019 report.

The April, 2019 report will include:

1. Postural Orthostatic Hypotension (drop in blood pressure when standing)—Part 2 on Syncope

2. Medical consequences of electronic social media devices

3. Medical Updates--several

4. Explanation about marijuana plants and their chemical properties and value.

5. New treatment for glioblastoma (cancer) of brain

As always, stay healthy and well, my friends, Dr. Sam