The Medical News Report

May, 2019, #88

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

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Subject for May, 2109

1. Medical Updates

    a) New recommendations for doctors to screen for intimate partner abuse

     b) Life expectancy dropping for the second straight year! Why?

     c) The UN, WHO, and the World Bank strongly pushing global universal healthcare—thought you should know!

     d) Know the dangers of fluoroquinolones (antibiotics such as Cipro)—FDA new warnings

     e) New study once again dispels the myth of autism from vaccines

2. Hernias

3. Abnormal Sweating—Hyperhidrosis; Hidradenatitis supprativa

4. Contact lens—the latest information

5. Lyme Disease—numbers are rising

6. Testicular Disorders—cancer

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

Kuekenhof Gardens, Amsterdam

1. Medical Updates

a) New recommendations for doctors to screen for intimate partner

As can be seen from the insert above, abuse comes in many forms, and intimate partner abuse is one of the most underreported forms of abuse. Recent recommendations to physicians are to screen for this type of abuse, since patients will not volunteer such abuse. Will they?

  Recent studies have reported that 37% of women and 31% of men have experienced sexual violence, physical violence, or stalking by an intimate partner. 23% of women and 14% of men have experienced severe forms of these abuses.

  Three types of consequences occur from abuse—injury, need for medical attention, or post-traumatic syndrome (PTSD). 1 in 4 women experience one or more of these and 1 out 10 men have. Prevalence is highest from ages 18-24, sexual minorities (LBGTQ—lesbian, bisexual, gay,transgender, and queer), Native Americans, non-Hispanic black women, and those with mental and physical disabilities. Add the elderly!

  There is overlap between sexual violence and human trafficking as well, which will be discussed in a later report.

  Sexual violence in adolescent relationships lead to the same in adult relationships.

  Those who impose this kind of violence tend to use abuse drugs, alcohol, and certain medications to subdue and control their victims. Victims suffer chronic medical consequences over time which will bring these patients to their doctors. Doctors must have an index of suspicion and enquire about the issue.

  Below is a list of conditions that present as a form of abuse that are common. Note all the ob/gyn problems.  A keen index of suspicion by the healthcare personnel is crucial, and questions need to be asked.

Effects on children

  Children from domestic violence may carry scars for life including physical and mental disorders. They also are more likely to abuse their partners as adolescence and adults.

  Other social conditions parallel this issue including poor housing, food shortages, substance abuse, and mental illness. Home visits may shed a great deal of light on this subject.

  The Department of Human and Health Services recommends all women of childbearing age be screened for sexual assault/harassment or other forms domestic violence and should be referred for counseling. This includes all primary care physicians—family practice, internal medicine, pediatrics, and ob/gyn. Women in immediate danger must be referred to shelters for women and children, and the authorities may need to be contacted.  

  I have reported on domestic abuse in two previous reports, and for more detail, please click on:

www.themedicalnewsreport.com #62 , #65

Outward signs of abuse

  If a patient has bruises, is extremely timid to discuss any intimate issues, or appears intimidated by a spouse in the room (including the partner answering for the patient inappropriately), the physician (or staff) should excuse the partner for a more private discussion to hopefully get the patient to divulge forms of abuse. To screen for such abuse might prevent future serious injury or death in the future. Many of these patients, especially women have no place to go and must seek help from women’s shelters. There are hotlines available for those who are being abused.

There are short and long term consequences from abuse of any kind on the victim and their children. It is more common than depression, diabetes, and breast cancer in women to make my point. Serious injury is much more common in women than men.

  A danger assessment should include these questions:

Reference—NEJM, Feb 28,2019

b) Life expectancy dropping for the second straight year

  For the second straight year, life expectancy has dropped. The average age of longevity is currently 78.7, whereas most developed countries, it is 80.3 years. This may not correlate with quality of life.

  The main reason comes from the rising number of deaths from fentanyl () overdoses, the lethal opioid coming over our borders from China to Mexico thanks to the cooperation of Mexicans (and Canada) transporting it through our porous borders. With the crisis at the border, you can imagine how easy it is to smuggle drugs across the border. OMG! Fentanyl is being laced in heroin and cocaine, and is one hundred times as potent as heroin. You think pushers know the concentration of the dope they are peddling?  

  It is almost impossible to catch the transporters, because a shipment is so small. While a 30 mg dose of heroin can kill a adult, it takes only 3mg of fentanyl to kill a person (a few grains of substance).

  A 30 lbs. shipment is like a weapon of mass destruction. It is being mixed with less pure heroin to make it more potent. Users don’t realize the illicit substance is mixed with the heroin. Lower prices and easier access has become a real problem. And with the pressure on doctors to limit opioids to needy patients, it is easy to see where they are going to go for drugs. Prescription opioids are as much as $20-50 a pill on the street and harder to come by, and heroin for a 6 hour high is $10-20. The annual cost of addiction to heroin is $54,000.

  This crisis is a long way from being controlled, and I am not sure it ever well until we get our borders controlled and provide enough mental health support (facilities, counselors, less incarceration in general prison facilities, and more treatment).

 c) The UN, WHO, and the World Bank strongly pushing global universal healthcare—thought you should know

  Many international organizations are pushing universal healthcare, which means socialized medicine, and many of these countries are already socialized. The UN, the World Health Organization, and the World Bank are three who have adopted resolutions to prevent patients from having to pay for healthcare at the point of delivery.

  Most countries are already socialized with enormous tax burdens on those who pay taxes. Since just a little less than 50% of adults in the U.S. do not pay taxes, half of the country will be footing the bill for over half of those living in this country. Estimated cost $32 trillion over 10 years for socialized medicine.

  Globalism is being promoted all over the world, and the U.S. cannot afford to pay for socialized medicine in our country much less take on the world. One universal understanding is that there will be significant rationing of care, loss of an entire insurance industry with loss of millions of jobs, and will cost trillions of dollars to run.

  Many poor countries will have to rely on contributions from other wealthier countries.

  The radical left has forced more moderate Democrats to accept this plan, and it will be the number one issue for the 2020 national election. Over half of millenials support single payer healthcare, and other groups are pushing for Medicare starting at 50 years of age. 

  Regardless of where you stand on this issue, it will create one of the most controversial issues that will certainly split our country even more.

The Guardian.com

d) FDA warnings about the antibiotic, Cipro, and other fluroroquinolones

  The antibiotic, ciprofloxin (Cipro) is a very common antibiotic prescribed. In fact I just took 10 days of it after a surgical procedure. These are very effective antibiotics and commonly used for urinary tract infections, cellulitis, bone infections, swimmer’s ear, gangrene, gall bladder infections, lung infections, diverticulitis, and traveler’s diarrhea.

  They cover what is called gram negative bacterial infections. Diabetics may have some interference with their oral hypoglycemic medications. However, there may be a price to pay.

  Common side effects are nausea, diarrhea, dizziness, lightheadedness, headache, and insomnia, and it is especially true for the elderly. It can kill the good bacteria in the gut and promote C.diff., a serious intestinal infection.

  Now the FDA has added some other warnings including tendonitis, Achilles tendon rupture, and even more recently aortic blood vessel dissection and potentially rupture. Sudden nerve damage (neuropathy) is also a risk. Shooting pains, weakness, or numbness in the extremities are some of the most common symptoms.  What this implies is that there is interruption of collagen production, which is the primary protein in tissues of the body including the skin, blood vessels, the GI tract, and even the eye. Patients with any disease that might increase the risk of these complications should not be prescribed these drugs unless absolutely necessary.  

  There are other options that should be tried first. This is a discussion you should have with your doctor. It was noted in one study that these medications do not need to be used for a prolonged time, as over 50% of these complications occurred with just 10 days of use.

  The warnings from the FDA are going against the Infectious Diseases of America’s recommendations for use in patients with drug resistant Streptococcus pneumonia, a common cause of community acquired pneumonia. (A good reason to get the pneumonia shot). As high as 30% of patients will have resistance to other common antibiotics such as doxycycline (and tetracycline) and macrolides (erythromycin, clarithromycin, etc.). of course, this is an exception to the casual use of the flouroquinolones.

  This is a blow for medicine, since these medications are very effective. This impacts a huge number of patients. Evaluation of the aorta (ultrasound) might be a good thought if this antibiotic is necessary.

Medpage, FDA, WebMd

e) New study once again dispels the myth of autism from vaccines

  Since 2010, when a quack doctor named Andrew Wakefield with undisclosed financial interests in making the claim that there was a link between autism and vaccines, the rise in anti-vaccination advocacy has skyrocketed. Conspiracy theorists abound on the internet based on this quack’s article and millions of followers are still refusing vaccines including for their children.

  About 90% of the population get vaccinated. Numerous studies continue to refute the link, but convincing those who believe today in conspiracies has been a hard sell.

  Parents are still refusing vaccinations on the basis of religious, personal, and medical reasons. These must be reviewed.

  Measles, for example, was all but eradicated by 2000, but now there are numerous outbreaks of measles in the U.S. 206 cases have been reported in just January and February this year in 11 states (now over 400 cases in the U.S.).

  Danish researchers and epidemiologists followed more than a half million children born from 1999 through 2010 and found no increase in autism from receiving the MMR-mumps, measles, and rubella vaccine. This study was touted by Dr. Saad Omer, Professor of Global Health, Epidemiology, and Pediatrics at Emory University in Atlanta.

  Childhood diseases cause a variety of serious serious side effects include orchitis (testicle inflammation can cause sterility), encephalitis, meningitis, inflammation of the ovaries which can cause sterility, mastitis (inflammation of the breasts), and profound deafness ( I saw patients with this while in my ENT practice).

  Measles can cause pneumonia, encelphalitis, meningitis, middle ear infections, miscarriages, thrombocytopenia (low platelets and bleeding) according to the Mayo Clinic.

  Rubella (German measles) contracted by a pregnant woman can cause the congenital rubella syndrome causing multiple birth defects including heart defects, microcephaly (small head), stillbirth, miscarriage, and premature birth. This is passed on to the unborn baby from the mother especially in the first 2 trimesters.

  There are side effects of any vaccine which can include high fevers causing a febrile seizure, very rarely encephalitis, and other issues. These are cited by the CDC, which is the best source to check. www.cdc/vaccines

  There is a National Vaccine Injury Compensation Act which can compensate those who develop serious side effects from vaccines. 1-800-338-2382

  There have been 18 year olds who defied their parents decision to have vaccines and sought vaccination. These young people were thought of as dangerous to their peers, and were shunned by them.

  Measles killed 110,000 people globally in 2017. The vaccine is highly effective. The CDC has a how-to for teenagers to catch up on their vaccinations.

2. Hernias   

  Hernias are diagnosed 1.5 million times a year and a third undergo surgery and are the most common surgical condition encountered in a primary care doctor’s office. The lifetime risk for men to develop a hernia is 27% (women 3%). The most common area in the body is the groin. There are anatomical reasons for these hernias, which will be explained. The main concern for a hernia being dangerous is the possibility of a loop of bowel getting caught (incarceration) in the defect and causing intestinal obstruction, as pointed out below in the drawing.

Risk factors include being overweight, heavy lifting, frequent straining from coughing or during a bowel movement, pregnancy, aging, family history, or premature birth. 

  Hernias can be painful and are often the reason a patient presents to the doctor, but most are asymptomatic and are diagnosed if the physician includes checking for them in the annual examination. There may be a bulge in the groin but most times there is not. Smaller hernias can be the most dangerous because of the risk of it being unknown and a small loop of bowel getting caught when a person strains in sports, lifting objects, from a smoker’s cough, etc. If a hernia is present, it is critical the bowel can be physically reduced completely (pushed back into the abdomen).

  Many hernias can be watched over time and the decision to operate will be based on several factors including pain, interference with activities, and concern for a loop of bowel not being completely reduced back into the

abdomen. One large study stated that about 70% of hernias will ultimately require operation.

Abdominal Wall hernias

  The drawing above show where a hernia may occur. The upper abdomen in the midline can occur and are called ventral (epigastric) hernias, incisional, umbilical, direct and indirect hernias, and a femoral hernia.

  Ventral hernias are caused by separation of the two rectus abdominus muscles in the abdominal wall in the midline. Incisional hernias from previous abdominal surgeries also account for some of these.

  Umbilical hernias occur from a weakness of the tissues aroud the belly button where the umbilical cord is cut at the time of birth.

   Children and even infants can have all these hernias from congenital weaknesses in these areas.

  Inguinal or groin hernias occur in the inguinal canal where the testicles descend from the abdomen into the scrotum.

  Inguinal hernias are called direct and indirect based on how the bowel tries to travel to the surface of the abdomen or groin.

  Direct hernias find a weakness in the floor of the inguinal canal and indirect hernias enter the inguinal canal through the deep inguinal ring. These two types are in the drawing below. Indirect hernias can present as a mass in the scrotum as seen below. This drawing shows how a loop of bowel can herniate into these anatomic weaknesses.     

Treatment

  Surgical repair is classified into open and minimally invasive (endoscopic or robotic), however, the latter technique is usally reserved for bilateral hernias, or recurrent hernias due to a higher complication rate. The competency and experience of the surgeon has a lot to do with the success rates. Complications include post-herniorrhaphy pain, occurring in 10-12% of cases. The cause is uncertain but nerve impingement, scar tissue, or reaction to foreign prosthetic material lead the possibilities. Treatment of pain is managed with NSAIDs, nerve blocks, GABA analogues(gabapentin), antidepressants that help pain, and operative intervention (neurectomy, nerve placement stimulator, neuroma excision, mesh and suture excision). This JAMA article did not provide ample evidence these techniques were uniformly successful. JAMA. September, 2018.

  Large hernias may require a prosthetic mesh sewn into the defect since the tissue may not be strong enough to be repaired or the tissue may not be able to be surgically repaired because of the size of the defect. 

Below is an example of an endoscopic approach to the repair of a hernia using tiny puncture wounds to work through. Most endoscopic procedures heal faster, but require an experienced skillful surgeon.

You must see Kuekenhof Tulip Gardens!

3. Hyperhidrosis (Abnormal Sweating); Hidradenitis Supprativa

  Millions of Americans suffer from excessive sweating for a variety of causes. Patients may sweat excessively from the armpits, hands, and feet, or anywhere there are sweat glands. There are many options for treatment (drying medications, Botox injections, and endoscopic surgical procedures on the nerves that innervate sweat glands-ETS, but insurers are hesitating to cover this disorder and have (as usual) had an impact on what physicians prescribe especially with new treatments such as a medicated cloth that was recently FDA approved (i.e. gylcoprronium cloth-- Qbrexza). United Health Care considers it a cosmetic issue, for instance.  

  Patients usually are referred to dermatology, although primary care doctors certainly are capable of treating them.

Contrasting exocrine versus endocrine glands

  The exocrine system includes sweat, oil, salivary glands, pancreas, liver, gastric glands, the intestinal, mammary, lacrimal glands, and prostate. Exocrine glands by definition excrete fluid through ducts onto the surface of the skin or internally. By contrast endocrine glands, by definition are ductless and secrete hormones into the body from organs like the thyroid, ovary, testes, pancreas, and adrenal glands, etc.

  There are two types of sweat glands in the skin—eccrine and apocrine. Eccrine glands respond to temperature and apocrine glands respond to emotion. Eccrine glands leak out of the sweat pores and apocrine glands become active at puberty and leak out through the hair follicle as seen in the drawing below.

In contrast, there are also oil (sebaceous) glands in the skin. Oil glands lubricate the skin and prevent dryness and aging of the skin, however, the sun and aging reduces oil production predisposing to wrinkling and sagging of the skin as collagen becomes less elastic and thins.

The drawing on the right above shows how the anatomy of the hair, sweat, and sebaceous (oil) glands are situated in the skin (dermis).

  Sweat glands are very important to help regulate the body temperature. When sweat comes to the surface, evaporation cools the surface of the skin as the skin temperature rises from blood vessel dilation and creates skin flushing. When heat stroke occurs, for example, the victim stops sweating.

  Abnormal sweating as defined can occur from temperature elevation (ambient or internally) and or emotion (scared, pain, or anxiety). It is called hyperhidrosis, which can cause psychologic, emotional, and social stress. 2-3% of the population and becomes a problem by the age of 13. It causes multiple issues that interferes with the quality of life of the patient and those close to them.

  Sweat glands are innervated by the parasympathetic nervous  system through cholinergic nerve fibers (the other system is the sympathetic system, which innervate the cardiovascular system). These glands can be stimulated by both systems. Sweat glands are most numerous in the palms of the hands and soles of the feet and the body has about 2.5 million sweat glands.

  The cause is usually not from a serious underlying disease, although certain neurologic, endocrine, and infectious causes rarely can occur. Most of these patients are normal healthy people except for stress of the disorder, which for many can be significant.

Treatment

  To reduce sweat, treatments must address the cholinergic nerve supply to the sweat glands.

Over-the-counter (OTC)

  Most antiperspirants contain aluminum chloride, however, there are prescription strength aluminum chloride products available. Deodorant products are designed to primarily combat underarm odor, caused by bacterial contamination of the sweat and oil glands.

  Medications include anticholenergics designed to shut down the nerve supply to the sweat glands. The classic drug is atropine. These medications interfere with the chemical acetylcholine, which inhibits parasympathetic nerves. Although not specifically prescribed for sweating, Robinul is effective as an off-label med. It is commonly used for stomach pain die to spasms. It does reduce sweating and therefore takes away one of the body’s defense again heat.

  It does interfere with anti-fungals and most anticholinergic drugs cause some dryness of the mouth, and slight vision difficulty (affects the pupil), occasional dizziness, headache, muscle pain, and nausea, which can be more severe in older people.

  Oxybutynin is used for bladder spasms but will reduce sweating and also make it more difficult to empty the bladder in some people.

  Drysol is the aluminum chloride prescription strength antiperspirant.

  Hytrin is antihypertensive but also can reduce sweating and make it easier to urinate. It is in the same group of drugs called alpha-adrenergic inhibitors as is Flomax, which is commonly prescribed for men who have prostatic enlargement and voiding problems at night.

  Gabapentin is an anti-seizure medication commonly used for neuropathic pain, but can reduce sweating.

  For more choices, search for anticholinergic drugs that treat hyperhydrosis.

  Botox, the botulinum toxin that has multiple uses also will paralyze the nerves that make the sweat glands contract and thus reduce sweating. It is injected into the areas of excess sweating and lasts 3-4 months, but again is off-label and not FDA approved for hyperhydrosis, like almost all of the above medications. This is why insurance frequently might refuse to cover them for this disorder.

  Iontophoresis is commonly used by sending mild electrical currents into the sweat glands requiring several sessions of 25-45 minutes several times a week until the sweating subsides and then the sessions can be scheduled as needed. It probably is blocking the gland openings temporarily thus preventing sweating, but may cause enough blockage to cause inflammation in the glands. Any of these treatments listed above may also do the same. Iontophoresis is commonly used by physical therapists to treat sports injuries.

Hidradenitis Supprativa (infection and groin and armpit sweat glands)

  This is a difficult infection to treat affecting the armpits and groin, and occasionally other areas.

It usually begins as pimples in the armpit or groin. Blackheads and cysts form. Infection begins in the hair follicles in many cases. As the deeper acne like lesions begin to heal, there is scarring, which leave thickened skin with lumps in affected areas. This acne like infection occurs in the folds of skin and can occur on the buttocks, upper thighs, and under women’s breasts.

  Occasionally, skin cancers can occur. Boils can occur, and over time some of these lesions can create channels to the skin (fistulas) draining foul smelling fluid.

  Patients who are overweight, smoke, and women are at higher risk.

  The infection begins in the hair follicles and there is an exaggerated immune reaction to the infection. This is characterized by episodes of infection with freedom of infections at times. This does not come from poor hygiene. It tends to run in families in about a third of the cases.

Treatment

  Antibiotics, acne washes, and bleach treatments are the main stay of treatment. In resistant infections, biologic agents may be recommended—adalimumab (Humira). Cortisone injections in the cysts may be used. Birth control pills may help women. Methotrexate is used in severe cases. Radiation treatments have been used.

  Surgical removal of the affected area is a last but necessary resort to remove the sweat glands in the affected area.

  Weight loss can be helpful. 

American Academy of Dermatology

4. What you need to know about contact lens

There has been many advances in the area of vision correction. I recently described what optometrists do and also the latest information about Lasik surgery, but not all people are good candidates for surgery or can’t afford it, so either glasses or contact lens is what is left.

  Most prefer soft contact lens, but there are those who cannot have their vision corrected with a soft lens (someone with severe astigmatism or keratoconus).

Soft Contact Lens (correct near and far sightedness, and age related near vision (presbyopia), astigmatism, and some corneal irregularities (keratoconus).

There are several types of soft lens:

1. Daily wear lens—are to be worn during the day and taken out at night and cleaned and placed in a lens solution. Some can be used for 2 weeks, 1 month, and even 3 months, but are to be cleaned each night before discarding after the prescribed time period.

2. Overnight (extended) wear lens— some can be worn for up to 30 days including while you sleep. Infections are a risk since they are on the cornea for a week. There is even a 1 and 3 month lens which are to be removed at night and cleaned.

3. Disposable lens—can be worn for a day, a week, or a month and then discarded, depending on the type of lens they are. They do not need to be cleaned. They are the most expensive. They are the most convenient.

Rigid gas permeable contact lens

  Rigid gas-permeable contact lens can correct vision when soft lens can’t. They breathe better, so oxygen can reach the cornea and may prevent redness better. Having worn both hard and soft lens before undergoing Lasik surgery, most people would not want to wear hard lens unless necessary but in some provide very crisp vision especially if a person has a severe amount of astigmatism (warping of the cornea).

  Those who are out in the elements experience more challenges with contact lens. If your vision is stable, hard lens are still a good bet and will last 2-3 year.

Specialized Contact Lens

1- Hybrid lens—these lens have a hard inner shell with a soft perimeter. These can correct near and far-sightedness, astigmatism, age-related near vision (presbyopia) and keratoconus. They are a good bet for those who have trouble with traditional lens.

2- Bifocal or multifocal lens—are available in soft and hard varieties. I used these and love them, because I did not need readers. These lens correct all kinds of vision issues including age related near vision issues (presbyopia).

3-Color tinted lens—can change eye color, block glare, and compensate for colorblindness.

Most recently, the FDA approved lens that have UV light protection.

4-Scleral contact lens are larger rigid gas permeable for severe irregular or distorted cornea.

5-Orthokeratology are special rigid lens worn at night to change the curvature of the cornea, so during the daytime, vision is clear without the lens.

6-Special lens coatings that treat the surface of many contact lens to be more slippery and more resistant to infection.  

Risks of contact lens

  Infection is not uncommon and injury to the cornea including corneal abrasions can occur.

  Good hygiene (wash hands before cleaning and removing) is a must, cleaning lens when recommended, not using water or saliva to wet the lens, not letting lens dry out. Removing lens at night if it is recommended, changing lens solution when recommended, changing eye lens cases, and replacing lenses when recommended

  Any change in vision, blurring of vision, pain, discharge, swelling or redness of the eye or lids should alert the person to see their optician. Avoid over the counter contact lens.

  Poor fitting lens can occur and must be adjusted. Keep eye appointments!

Mayo Clinic, 2018  

5. Lyme Disease

Classic bullseye rash

Deer Tick—Ioxides scapularis

There are 300,000 Americans diagnosed with Lyme disease each year. The disease is caused by Borrelia burgdorferi (in the U.S.), and 4 other deer tick species causing a serious long term disease if not promptly treated with antibiotics.

  These ticks are in all 50 states, but most common in the Northeast and Midwest. They are endemic in forested regions of Asia and most of Europe.

  About 20% of these ticks carry the disease. It usually takes as long as 24 hours for the tick to feed on a human to infect them. These ticks secrete a numbing chemical in their saliva, so you will not feel the bite, and after being outdoors, look for them. Careful proper removal is necessary to remove the part of the tick embedded in the skin feeding on blood.  Lyme disease cannot be transmitted person to person, however, it can survive in the patient’s blood when donating blood, and therefore patients should not donate blood while being actively treated with antibiotics.

  To prevent disease, spray clothes and body with DEET. Check animals for ticks who accompany you into the forest or fields.

These are the B.Burgdorferi spirochete under dark field microscopy. To remove the tick, use tweezers and grab the tick as close to the skin and pull directly up out of the skin. Clean the skin with alcohol.

  Within 3-30 days, a rash will occur in patients usually with a bulls-eye rash (seen above) at the site of the bite and spreads as far as 12 inches in 75% of patients. However as many as 20-30% do not have a bulls-eye rash, but may have a non-discrept rash in that area of the body Tick disease is most likely in the late spring and summer.The rash can occur in more than one area. Flu-like symptoms (fever, chills, fatigue, and body aches) accompany the rash, and might be indistinguishable from any viral illness. Joint pain can occur. Not all patients will realize they have been bitten by a tick.

Post-Treatment Lyme Disease Syndrome (PTLDS)--complications

  10-20% of patients develop severe neurological and other system symptoms. This may occur in patients who were treated appropriately.

  Many neurological symptoms can persist for months and years. This includes a sterile (aseptic) lymphocytic meningitis (especially in children), temporary paralysis, numbness or weakness in the limbs, and impaired muscle movement. Some of these patients had negative tests or were not diagnosed with Lyme until the spinal fluid was tested. British Medical Journal, May, 2018

  Less common but still serious is chronic fatigue syndrome, fibromyalgia, extreme skin sensitivity or pain anywhere in the body which fits into a constellation of symptoms called Hypersenstivity Syndrome, eye inflammation (iritis), and hepatitis. These symptoms overlap many diseases, therefore, the workup for patients with these symptoms should include Lyme disease.  

  The earlier antibiotics (doxycline, amoxicillin, or cefuroxime for 10-14 days)) are prescribed, the better chance of preventing long term side effects. If neurological symptoms are present, IV antibiotics for up to a month may be necessary.

  Even without persistent symptoms, Lyme disease can spread to many parts of the body causing arthritis and multiple neurological symptoms including headache, cognitive issues (memory, concentration, problem solving, etc.). This is thought to be an autoimmune response. A recent study included an increase in blood cancers, and non-melanoma skin cancers.

Testing for Lyme disease 

  Patients presenting with these symptoms even years later and must have Lyme disease ruled out. The test to diagnose Lyme disease is the ELISA test, which detects antibodies to the deer tick. It may be a false negative or positive, so it should not be the sole test to diagnose this disease. Another option, the Western blot test, also detects antibodies to the deer tick. None of these tests are 100% accurate.

  There are many ongoing clinical trials using different regimens of antibiotic therapy including pulse therapy (intermittent IV therapy), and new treatments.

  It is critical that an expert in treating Lyme disease be consulted.

Treatment of certain complications

  Oral antibiotics (doxycycline) are usually successful, however, if there is a serious complication such as meningitis or encephalitis, IV therapy and hospitalization may be required. Some information about specific sites:

Carditis—these patients usually only need antibiotics, however, if there is a heart conduction abnormality, hospitalization and temporary cardiac pacing (pacemaker) may be necessary.

Arthritis—This usually is an autoimmune reaction to the infection and require NSAIDs and perhaps hydrochloroquine to relieve symptoms although they may be quite persistent and may not resolve.

Neurological symptoms usually respond to antibiotics.

Prognosis of Lyme disease

  Most patients treated will have a full recovery unless treatment is delayed or the disease is not discovered. 2 of 10 patients may still be infected in the heart and bladder even with negative tests and 28 days of doxycycline with symptoms. Keep in mind the disease may become apparent 3 days to a month after being the tick bite. Persistent infection will require repeat antibiotics, but there is controversy about its effectiveness in late cases. Varying degrees of joint and neurological damage may persist, which is called Chronic Lyme Disease.

Consult the website rightdiagnosis.com; Rheumatology Advisor, CDC

6. Testicular cancer

Understanding about the function of male hormones (androgens) 

  Although not as common as many cancers, the testes (plural for testicle) have a very important function—produce sperm for the fertilization of the ovum from the female ovary. The major endocrine hormone, androgen, has two main types of hormones, the male hormone testosterone (dihydrotestosterone) responsible for providing male traits such as secondary sexual characteristics for males beginning at puberty, male patterns of hair, facial and pubic hair, development of the testicles, scrotum, penis, and prostate, promotion of sperm, male muscle pattern, and a deeper voice due to certain structural changes in the vocal cords. It also strengthens bones, increases penis size, male libido, male fat distribution, has a positive influence on the heart, and may play a role in male behavior also influenced by the environment.

  There is influence for male development from the adrenal glands (they sit on top of the kidneys) as well, and there are also adrenal androgens—androstenedione produced also by the testes (and ovaries). It is thought that this has direct influence on the pituitary stimulating hormones (gonadotropins) that signal the testes to make androgens.

  Another adrenal androgen is dehydroepiandrosterone, is a primary precursor of estrogen. So there is some overlap in male and female hormone precursors and is important when a tumor of the testicle, ovary, or breast is under the influence of male or female (estrogen) influence. These sources of hormone need to be suppressed by inhibiting their production using certain hormone supressors (i.e. tamoxifen for breast cancer, Lupron (and other name brands)for prostate cancer.

  These adrenal androgen have been abused by athletes and are banned by the U.S. Athletic organizations as is testosterone.

Regulation of male hormone   

  The amount of production of androgens is controlled by the hypothalamus in the brain which has direct influence on the pituitary to raise or lower stimulating hormones in the cells in the testes, adrenals, and ovaries in women.

  In other words, the hypothalamus tells the pituitary when and how much testosterone needs to be produced by the testes. Small amounts are also secreted in the ovaries and adrenals of females, and as estrogen stops being produced in women at menopause, there may be more obvious effects of testosterone in females (facial hair, deeper voice, acne, etc.). Polycystic ovaries also can produce abnormal amounts of testosterone.

Tumors of the testicle

Cancers of the testicle account for 5% of all cancers.

Types of cancer—Seminoma, non-Seminoma, Others

  There are several types of cancers that occur in the testes. 90% of these cancers are germ cell tumors, divided into seminoma and non-seminomas. Although these two types occur about equal in number, often both cell types are present in the same tumor.

 The most common types of testicular cancer occur between the ages of 25-45 (classical seminoma), and rarely spermatocytic seminoma, which occurs most commonly at age 65.

  Non-seminomas comprise of 4 types—embryonal cell (40%), yolk sac, choriocarcinoma, and teratomas. Some of the embryonal cell carcinomas secrete the hormone HCG or alpha-fetoprotein (AFP), which can be tested with a blood sample. Yolk sac carcinomas occur in children and also secrete AFP.

  Some of these seminomas secrete a hormone (human chorionic gonadotropin-HCG), which can be detected easily with a blood test and can be used to follow the levels when treating the cancer (levels should decrease).

  There are other cell types which are rare and can be fast growing. Lymphoma is a systemic cancer that can also occur in the testicle and is the most common type of cancer that is not seminoma or non-seminoma.

Metastatic tumors

  Tumors from other organs can metastasize to the testicles, however, lymphoma is the most common, mostly in older men. Young boys with acute leukemia can have leukemic tumors in the testes.

Cancers of the lung, prostate, melanoma, and kidney can metastasize to the testes.

Common presentation of a testicular cancer

  Since younger men frequently don’t see a primary care doctor (40%), and many doctors do not include a testicular exam in a routine physical sadly, most masses are found by the individual while examining their own testicles. They may be painful or feel just like a swelling.

  However, according to the Testicular Cancer Society, 42% of men do not know how to examine their testicles. It is also stated that as many as 40% will not seek medical attention even when they feel it is a serious issue out of embrassment. For instructions on how to examine the testicles, log on to the American Cancer Society’s website:

www.cancer.org/cancer/testicular-cancer

Risk factors for cancer

1) undescended testicle (testicle did not drop from the abdomen as it does normally during fetal development down the inguinal canal); 3% of boys have this condition; having surgery to place the testicle in the scrotum may decrease the risk.

2) Family history of testicular cancer

3) HIV infection

4) Carcinoma insitu of the testicle (precancerous condition)

5) Previous history of having testicular cancer in the other testicle-3-4% of men will have a second cancer

6) Certain ethnicity/race—4-5X greater risk in whites

Early detection

  Self exam is recommended monthly and should be part of a regular physical examination. Any swelling or a lump in the testicle should alert a man to have it examined. Most tumors should be discovered before they metastasize.

  Other benign conditions can cause swelling including a hydrocele (fluid filled sac) or varicocele (abnormal collection of blood vessels). Inflammation of the testicle is much more common caused by an inflammatory response in the testicle or the tube from the prostate to the testicle (epididymitis). Any of these conditions can cause pain or a heaviness feeling and will be discussed next month.

  If the tumor secretes HCG (human chorionic gonadotropin hormone), it can cause breast enlargement in males, and those with gynecomastia should be examined for testicular cancer. A rare testicular cancer (Leydig cell tumor) can secrete androgen (male hormone) and cause early puberty with pubic hair and deepening of the voice in a child.

Diagnosis can be made by examination with the addition of an ultrasound which would show a solid mass.

Blood tests, as mentioned above, include the cancer marker AFP (alpha fetoprotein, and HCG (human chorionic gonadotropin) hormones. An enzyme LDH-lactic dehydrogenase may be elevated if the tumor has spread. A variety of imaging studies can detect metastases and better define the tumor in the testicle.

  Biopsy is rarely done to prevent spread. It can be taken prior to orchiectomy, the definitive treatment initially.

  MRI or PET scan may be used to rule out spread. Metastases most commonly spread to the abdominal organs (liver, lymph nodes), lung, and brain.

Treatment of testicular cancer

  Surgery—orchiectomy is usually performed if localized that would include the spermatic duct and other surrounding tissues.

Radiation may be used after a seminoma is removed to treat the lymph nodes in the groin and pelvis.

  Chemotherapy is commonly used if the tumor is large and possibly suspected that it may have spread even though scans are negative or have proven mets. Cisplatin, Bleomycin, Etoposide, Paclitaxol are some the chemotherapeutic agents used. Most tumors are sensitive to these agents.

  Stem cell transplants are occasionally recommended with high dose chemo.

5 year survival rates

  Localized-99%, regional spread to nodes-97%, and distant spread-73%

Sex after testicular cancer

  Although there may be erectile dysfunction and impotence from surgery with radiation and or chemo, it does not necessarily mean permanent impotence and or erectile dysfunction. Counseling for erectile dysfunction and methods to overcome it including treatment for depression and a feeling of loss of masculinity may be necessary. Talk to a physician regarding freezing sperm prior to treatment for later pregnancies.  

Reference-- American Cancer Society, Testicular Society

This completes the May, 2019 report. The June report will include:

1. Medical Updates

2. Running injuries—Sports Medicine Series—Part 2

3. Cancer Survivorship Series—Part 5—Hair loss, premature cataracts, infertility, eye and ear side effects, and skin cancer

4. Testicular disorders (non-cancer)

5. Myopathies

Stay healthy and well, my friends, Dr. Sam