The Medical News Report

September, 2019 # 92

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects:

1. Human and sex trafficking—multiple causes

2. More on Medicare For All

3. Medical Updates—a) No low dose aspirin for people with out known heart disease b) HPV virus infection in young non-smokers and vocal cord cancers c) persistent cough and gastric reflux-new treatment d) New nasal spray for acute depression-Esketamine  e) New drug to treat daytime sleepiness from obstructive sleep apnea or narcolepsy

4. Nasal Allergies—new approach to treatment

5. Psychotic Disorders and Schizophrenia

6. Cancer Survivorship series--#4—Side effects of cancer treatment; complementary treatments

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

Subjects for September, 2019:

1. Human and Sex Trafficking—multiple causes-fast rising travesty

Human trafficking in the U.S. has increased as the U.S. Southern Border immigration issue has not been adequately addressed by our Congress (now making it a political football). However, this has been around forever, and that is just one factor.

  Human trafficking encompasses so many aspects of society—pornography, crime, child abuse, drug abuse, rape, prostitution, forced marriage, selling of body organs, sexually transmitted disease (STDs), slavery, and forced labor.  This primarily involves women and children.

  Fresh off the suicide of the monster Jeffrey Epstein, we have a look into the psychological manipulation of young girls, who were making money and made to feel special by a very rich man, who took advantage of no telling how many young girls. They were initially treated well, so that by the time Epstein wanted them to perform sexual acts, he had gained their confidence. These girls knew they were playing with fire but the excitement of the situation clouded their immature minds. In this country that is rape because of their age.

  Clearly, he had a sick, twisted mind, and he deserved more than suicide (if it was!). He was as evil as those human traffickers bringing humans over the border in truckloads and selling them.

  Many people think they are coming to America to be free and that turns out to be far from the truth. This is today’s slavery trade….the most inhumane way of treating another human. Where do these people go? They are sold as sex slaves, workers on farms, etc.  They are locked in brothels, factories, and made to provide commercial sex against their will. They are forced to take narcotics and become addicts, which then becomes a technique of control by those who own them.

  Runaways and homeless youth are vulnerable to trafficking. A study in Chicago, reported that 56% of prostitutes were initially runaways.

  Foreigners are particularly vulnerable with those who manipulate their work visas, lie to them about favors they never receive, etc. Many of these people have paid a large fee to be brought to this country and promised freedom and “the American Dream”.

  Victims of prior abuse including domestic violence, psychological trauma, sexual assault, war and conflict in their home country, and social discrimination are also risk factors making them vulnerable to this form of abuse.

  It is estimated that there are currently 40.3 million victims of human trafficking occur globally, according to the International Labor Organization.

  There is a NATIONAL HUMAN TRAFFICKING HOTLINE

                               1-888-373-7888

  Sexual abuse is rape!!! 1 in 6 women in America have experienced rape. 44% of sexual abuse occurs before the age of 18.  

  Clearly DRUGS AND IMMIGRATION ISSUES are frequently interwoven into sex trafficking, prostitution, and until these  of these crises are better controlled, THIS CRISIS WILL CONTINUE! 

  Forced labor is a $150 billion business annually according to the International Labor Organization. This includes coercing children into becoming soldiers in the Middle East.

  In 2012, it was estimated that 21 million people were trapped in slavery world wide. 22% are sexually exploited. This includes forced child labor in certain countries. Migrants are particularly prone to this abuse.

  Human trafficking is thought to be one of the fastest growing activities in trans-national criminal organizations. This issue is one of the biggest human rights violations.

  Atlanta, Georgia is thought to be the core of trafficking due to the size of the airport. But with the use of children to cross the southern border, this has become another area of access to children for trafficking. Parents are selling their kids for adults to get across the Southern U.S. Border, often never to be seen again. South Florida is also known as another hotbed for this issue.

  The use of massage parlors, hotels, and adult theaters are obvious red flag areas.

In 2018, Florida alone had 367 cases of human trafficking reported, the third highest state in the country. Consider there were 2,133 calls to the Florida Abuse Hotline in 2017-18, up 147% in the last 4 years. It was reported nationally, that children comprise 1/3 of all victims. (Wikipedia and Selah Way Foundation).

  Although condemned by most countries, religions, etc., there are countries who do not have much legal enforcement of these issues including Russia.

  It is estimated that sex trafficking affects 4.5 million humans worldwide. This includes forced marriages of children (a tradition in some countries even today). 

  Human organ sales from human trafficking most frequently involves forceful removal of kidneys, although many are killed and all their organs are harvested. This is big black market business especially between Europe and the U.S. Organized crime has contacts in most countries.

  Clearly, a global effort is necessary, since trafficking often involves sending these victims around the world.

  Florida Governor Ron DeSantis has taken the lead in setting new standards in the area of human trafficking and protection of children. Awareness is a key ingredient in that the public must get more involved when something suspicious to observed.

These young girls rarely get help when psychotherapy and medication can be so valuable. Ridding their body’s of illicit drugs is only a start. www.goodtherapy.org

2. More on Medicare for all; the pros of single payer system

  I had considerable interest and comments regarding last month’s report on Medicare for all and healthcare, which clearly is at the top of the list for many of the top Democratic candidates and the far left. VP Biden  wants to refurbish Obamacare including returning the mandatory requirement for all Americans to buy insurance, which was declared unconstitutional.

  It would not be that difficult to come up with some solutions if our Congress (bipartisan) could deal with uninsured and underinsured people first and leave the rest of healthcare alone until that part is agreed on. Do not be surprised to see some of the candidates to start moving more to the right if Biden continues to lead the pack. Single payer just doesn’t have enough broad support.

  I am interested in furthering the discussion on single payer socialized medical care for all Americans (illegal immigrants as well).

  I  see this Democratic primary to be a 3 way race—Biden, Harris, and Warren. Warren has the most momentum recently.

Example of a socialist country

  I think the following story about a Danish teacher will shed some light on what it is like in a socialized country:

The bottom line is that medical care for all people for less money, no copays, and no deductibles, without loss of quality is a myth.

  Unfortunately, the Republicans don’t have a plan either (Trump says he will unveil his plan after he is re-elected) which makes most of us believe that there is no solution of any kind. You get what you pay for! There is no such thing as free, because someone is paying for it.

  Only 50% of the country pay taxes and will not tolerate the tax increase to cover the over $30 trillion (over 10 years) price tag to cover a single payer socialized healthcare system.  Supporting single payer and open borders will not win a presidency in 2020. Also, with that kind of price tag, where will money be available for infrastructure and other priorities for our country?

  The World Health Organization has promoted universal healthcare for 1 billion more people by 2023 continuing to base its promotion on the basis of it being a human right  that promotes equity, quality, and affordability. All globalists promote universal healthcare, but where is the word financing in the equation? Most public health advocates also support this care model, since the academic community is largely extremely liberal. Lancet, January, 2019

  Have you heard of Saul Alinksky, one of the first real radicals in our country? He wrote the “bible” for community organizers on how to create an environment for the government to take over the lives of the people, whether socialism or communism.

  Below is a short bio of Saul Alinsky:

Where did the concept of community organization and radicalism get its start in the U.S.?

  Saul Alinsky is often linked to creating steps to a socialistic society, which includes a single payer federal healthcare program.

  This original community organizer was the author of the 1971 book “Rules for Radicals”.  He did undergraduate and postgraduate work at the University of Chicago. I am sure Dr. Bill Ayers found his work fascinating. Hillary Clinton did her master’s thesis on Saul Alinsky. Most forget that President Barack Obama (originally) proposed a single payer system but had to settle for Obamacare, thanks to a Republican Congress (and he started out as a community organizer).

32 of the 33 civilized countries have some form of universal healthcare. Can America accept it?

  Although Snopes states that the rules for the creation of a socialistic society came from the “Communist Rules for Revolution”, not Saul Alinsky, it really does not matter who created them, but it is important to see what factors are necessary for a transformation.

Rules for Radicalism

Below are the 8 rules for creating a socialistic state, no matter who wrote them, but they follow Alinsky’s Rules for Radicals written in his last year of life. He was the original community organizer, long before Barack Obama. Read about the 8 levels of control of the people to create a social state:

Last month, we looked at the negative effects of a single payer healthcare system if adopted in the U.S. This month, it is only fair to look at the positive aspects of a single payer healthcare system.

  Univeral healthcare was begun in Germany in 1883. Scandanavian countries have been severely infiltrated with open borders primarily by Middle Easterners, and their healthcare systems have struggled ever since. Immigration greatly influences healthcare access and quality.

A socialized healthcare system requires:

1) A strong well-run healthcare system with no financial burden on the recipients. It should include vision, dental care, long term care (that could cost $trillion alone) with open choice for the site of care. In England, hospitals, nursing homes, pharmacies, and medical device companies are owned by the government.

2) A system for financing the program (healthcare in the U.S. currently consumes one fifth of the GDP). Taxes must be greatly increased on all taxpayers (that leaves out half the population) to support healthcare for all no matter how poor the system. Estimated to be $30 trillion over 10 years.

3) Access to prescription medicines without cost and research to further medical advances. How many drugs will go over the counter like many countrys do? Where will financing come from for future medical treatments, as they come mainly from the pharmaceutical companies.

4) A workforce of medical professionals motivated and well-trained (who will be paid substantially less than the current medical workforce). It is estimated to as low as 40% less.

The pros of a Socialized Healthcare system:

1)The overutilization of this type of system will be balanced with less administrative costs.

2) Equal access to the system for all recipients without discrimination. However, any medical system discriminates on rural areas where healthcare does not exist and where access to care will suffer. Overutilizations will make it extremely difficult to see a doctor. Most of this will be shifted to drug store nurses, PAs, and urgent care facilities.

3) Improves the U.S. Public Health since all are potentially covered. But what about the homeless, those in terrible inner city communities? Are all people going to be required to have all vaccinations?

4) Less paperwork for medical professionals (are you kidding me!!!!). The electronic medical record has consumed more doctor’s time than any other form of paperwork and will not change).

5) It will stop medical bankruptcies. Is our government going to pay for terminally ill patients to have access to their life extending drugs at the cost of hundreds of thousands of dollars? How much rationing of covered care will occur? A second tier private insurance will be necessary to cover elective procedures, procedures for older Americans deemed unnecessary because of age. 

6) Self-employment could rise 2-3.5% because of not needing personally paid-for coverage. Those who work just because they need health coverage will quit which could counter those increased employment rates.

7) Businesses will no longer have to provide healthcare for their employees.

8) It will boost economy because people will be healthier???? This could take a generation or two before that occurs (if ever). Is the government going to make people lose weight, take their medicine, control their chronic illnesses with healthy behaviors, exercise, etc.???

9) Boosts human rights since healthcare will be deemed a right. And the world will come to the U.S.!!!!

Summary

  The last 2 reports have covered the pros and cons of a single payer socialized healthcare system. It is my great desire, as a physician, to see everyone have healthcare, but we must seriously consider leaving the private insurance and Medicare alone. Providing Medicaid for those uninsured and underinsured from Obamacare should be the focus of reforming our healthcare system. We must come to some compromise solution that is acceptable to the majority of Americans. If we don’t, the split in our country will only continue, no matter who is our president.

3. Medical Updates

     a. Low dose aspirin not recommended for people without heart disease

   Acetylsalicylic acid (aspirin) is commonly recommended to prevent cardiovascular disease and or mortality. It is an anti-inflammatory medication and is in a group of drugs called NSAIDs—non-steroidal anti-inflammatory drugs which includes ibuprofen and Aleve.

  It was discovered several years ago that a low dose of aspirin could help prevent as much as 20% of these vascular diseases, and in fact, even reduce colon cancer (not discussed in this report).

  2018 studies have reduced their enthusiasm about the benefit of prevention of heart disease, since it is about equal to the risk of bleeding from aspirin.

  The American College of Cardiology and the American Heart Association guidelines suggest that aspirin should be used infrequently in routine primary prevention of cardiovascular disease and limited to selected high risk patients with low bleeding risk.

  Based on newer studies, it is apparent that people without defined cardiovascular disease should seriously consider not be taking daily low dose (81mg.) aspirin for prevention. Even for some who may benefit will trade this for bleeding from the gut, or other areas of the body.  This contradicts previous studies, but it is of the upmost importance to talk to a person’s doctors before continuing or discontinuing aspirin according to the article in JAMA, July 23, 2019.

  It is totally naïve for a person to ignore his diet, excessive weight, lack of exercise, reduction of stress, abuse of alcohol or other drugs, and continue to smoke, have other risky behaviors, go without a quality amount of sleep, etc., and then expect aspirin to protect them from a cardiovascular event.

  Managing cholesterol, triglycerides, blood pressure, weight, an exercise program, a heart healthy diet, taking statins, mental health management, smoking cessation programs, and yes, low dose aspirin (if recommended by the physician) will give a person the best chance for a long and healthy life.

  Millions of Americans are taking aspirin (and other OTC meds) and not telling their doctors because people somehow feel drug store meds are safe. Doctors need to know every medication taken on a daily basis. Drug interaction is a real concern.

     b. HPV (human papilloma virus) infection in young non-smokers and vocal cord cancers

  A study in the Annals of Ear, Nose, and Throat Journal reported that 10 patients 30 years of age who were mostly non-smokers developed vocal cord cancers. Vocal cord and other laryngeal cancers usually occur in smokers after the age of 40. Hoarseness is the first symptom of vocal cord cancer, however, persistent sore throat can also occur. All 10 patient’s cancers tested positive for HPV (human papilloma virus), the well known virus responsible for other throat cancers and genital cancers (cervical, vaginal, vulvar, and anal).

  HPV viruses are well known to cause recurrent respiratory papillomatosis (RRP), which causes benign papillomas in the airway similar to genital warts (papillomas).

  This is just one example of how important the HPV virus vaccine (Gardasil) is a necessity to prevent these viral infections and prevent these cancers and perhaps the papilloma syndrome in the respiratory tract and the genitals. This vital vaccine is currenly recommended for both males and females 11-45 years of age, however, the most recent evidence is 11-26 is better in protecting people. The best way to protect is seeing to our children are vaccinated at 11 or before any sexual activity occurs, and that age seems to continue to drop.

     c) Added treatment may be necessary for gastric reflux and chronic cough—laryngopharyngeal reflux

  I have reported on gastric reflux on several occasions, not only regarding the effects on the lower esophagus, but the throat, and lungs from chronic reflux with aspiration into the lungs. This causes hoarseness and chronic cough especially at night. Clearing of the throat is also common.

  Most people will get better with sleeping propped up, not eating or drinking for several hours before bedtime, and taking reflux meds (PPI-proton pump inhibitors or H2 inhibitors) to suppress acid in the stomach, which is the culprit.

  However, some continue to cough. A report in a journal called Ailment Pharmacology Therapeutics stated that certain neuromodulators may stop the coughing. Gabapentin (Neurontin) is such a drug, used to treat neuropathy. Discuss this with your doctor.

  These patients need careful monitoring of deterioration of their lungs (peumonitis, fibrosis, etc.) even if their symptoms abate. The reflux must be controlled with medication, proper behavior modifications, and even surgery if resistant to medical therapy.

  Talk to your doctor about this innovative treatment that might be valuable.

  For in depth discussion on GERD (gastroesophageal reflux), click on:

www.themedicalnewsreport.com #41 and #81

    d) Nasal spray for acute depression-Esketamine (Spravato)

  There has been an anesthetic agent, ketamine, used since 1960s, which was used to perform surgery under local anesthesia. Recently it has been found to be quite valuable to patients with resistant depression. The nasal spray form (Spravato) has also been found to be as effective as intravenous treatments.

  Ketamine is a very good sedative for such surgeries and is used often in veterinarian surgeries even today. Recent research proved that a nasal spray contining ketamine was as effective as an intravenous treatment.

  I used ketamine exclusively on animal research while in surgical training and used it to perform surgeries under local using IV  ketamine sedation anesthesia. It has great value because it does not depress respiration and require ventilator assistance. It was also used in the battlefields of Vietnam extensively because of its safety. It also has bronchodilating properties for asthmatics. It can be used for pain as well.

  Unfortunately the recovery room personel had their hands full, because of the hallucinogenic side effects as the drug wore off, and over time was used in limited fashion because of the LSD-like effects it had. However, in proper dosage, it is helping depressed patients who otherwise might be facing shock treatments for their resistant depression.

  Recently hallucinogenic (psychodelic) agents have been tested on resistant cases of depression including LSD, ketamine, psilocybine, and others. As an inpatient treatment, ketamine has proven to relieve acute episodes of depression and even those suicidal.

  The FDA has approved a nasal spray of ketamine called esketamine (Spravoto) to treat these depressed patients who are resistant to other forms of therapy. Use for other disorders is not approved. 

  The results have been quite dramatic in a good percentage of cases and is rapid acting. Ketamine clinics have opened up around the country using intravenous ketamine to treat acute depression. Finding optimal doses with the least side effects is still being investigated.

  Because of the side effects, patients must use this spray in a clinician’s office. They are not allowed to drive for 24 hours. The dosing schedule begins with twice weekly use for 1-4 weeks, once weekly for 6-8 weeks, and then once every 1-2 weeks with a price tag of $4700-6800 per month.

  I foresee a problem with black market use of this Spravoto nasal spray. It is already on the streets marketed as Special K as a hallucinogen. It can be very dangerous because of overdosing and the effects of hallucinations, confusion, injury from these effects. It is similar to ecstacy, another MDMA* chemical. These are even sold as an herbal cigarette.

MDMA=a form of methamphetamine

  There are many side effects of any of these hallucinogenic street products that doctors need to be informed about, since patients may report these symptoms not tell them they are using the drug. There can be potential neurologic, psychologic, urologic, cardiac, ocular, and gastrointestinal effects.

  Continued research on these 1970s hallucinogenic drugs are bearing fruit, and time will tell how valuable they will be, while at the same time will open up yet another chemical to abuse. Stay tuned!

Reference- healthlline.com; Medscape

    e) New drug for daytime sleepiness for patients with obstructive sleep apnea or narcolepsy

Daytime drowsiness in patients with disorders such as obstructive sleep apnea (OSA) or narcolepsy may be on prescribed treatment including medications, CPAP or even have surgical procedures to relieve apnea. The truth is all of the treatments are frequently less than curative leaving the patient drowsy during the day. Now a medication is FDA approved for daytime drowsiness in these patients who are under treatment—Senos, plus an antidepressant.

  With the obesity epidemic, OSA has become one of the most diagnosed disorders in the past few decades.

  Narcolepsy creates sudden loss of consciousness caused by the brain suddenly going into a dream state (REM sleep), which is a hereditary disease. For more information, click on my website: www.themedicalnewsreport.com #25

  I diagnosed and treated a large number of these patients in my practice and performed many surgeries for OSA (uvulopalatoplasty). But patients needed to lose weight, often still needed CPAP, and didn’t tolerate the CPAP longer than 3-4 hours a night.

  The FDA has recently approved a new drug, solriamefetol (marketed as Senos) that is a brain receptor stimulator of dopamine in combination with a group of antidepressants (which keep the neurotransmitter levels of serotonin and  norepinephrine elevated--Zoloft, Prozac, Cymbalta, Pristiq, Celexa, Effexor, etc.).

  Side effects of this combination medication treatment are expected since they are stimulating brain receptors including difficulty sleeping, headache, nausea, loss of appetite, and anxiety. Blood pressure and pulse elevation can also be a side effect. It is not to be used with certain an MAO inhibitors and little used antidepressants (Parnate, Nardil, Marplan).

  Many doctors may not be aware of this new drug. If you are a patient with these disorders and still have daytime drowsiness, discuss this new combination of medications with a physician who deals with sleep apnea.

4. Nasal Allergies—new treatment approach

   There are many remedies for nasal congestion from inhalant allergies and colds, but none are better than salt water sniffs plus proper medications. Promoting sinus drainage and cleansing the nasal membranes is very helpful, and once a person gets used to performing this simple procedure, you will be amazed.

Through the years, we depended oral antihistamines and decongestants taken that were quite effective, but the side effects were potentially a problem.

Oral Antihistamines

  Oral antihistamines cause significant drowsiness (Actifed, Dimetapp, Chlortrimeton, Benadyl, etc.) but even the non-drowsy forms (Zyrtec, Claritan, Allegra, etc.) have side effects. 

  All antihistamines cause dry mouth, dry eyes, urinary retention, some blurred vision, erectile dysfunction, constipation, and even agitation.

  Patients with seizures, glaucoma, prostate problems, thyroid disorders, high blood pressure, and diabetes should not take these medications (over the counter) without guidance from a physician.

  Antihistamines can interact with sleeping pills, alcohol, seizure meds, mood disorder meds, muscle relaxants, pain pills, and MAO inhibitors (a special type of mood disorder medicine).

  Antihistamines do not shrink the membranes of the nose or sinuses. That requires an oral decongestant, which includes pseudoephredrine (Sudafed), phenylephrine (Sudafed PE), and generic phenylephrine. It is behind the counter in the pharmacy, and patients must sign for it, show a driver’s license, and in Florida, are only allowed 30 pills per sale. Pseudoephedrine can be used to cook crystal meth, but requires an enormous amount.

Decongestants

  Decongestants can raise the blood pressure, cause dizziness, upset stomach, nausea, nervousness, and dry mouth, nose, and throat. It can aggravate irregular heartbeats, mental conditions, urinary retention, etc.

Nasal spray decongestants

  Nasal spray decongestants are easy to abuse. Afrin nasal spray is the most popular, but others include Dristan, Vicks Sinex, and Neo-Synephrine. Although they work much faster than the oral decongestants, but if used more than a few days, there can be a troublesome rebound of the nasal membranes (turbinates) which stops up the nose. Most people immediately reach for the Afrin again. Over time, the nose gets used to the medication and essentially the nose gets “hooked” to the spray. In my practice, I saw many patients using a whole bottle of Afrin a day. Using large amounts of nasal spray can raise the blood pressure and damage the nasal lining.

  To get these patients to stop Afrin, cortisone (Decadron) tablets are necessary (dosepak-5-7 days) to reduce the chemical inflammation in the nasal membranes that occurs from chronic nasal spray use. Taking cortisone has its own side effects but the nasal spray form of cortisone sprays have few side effects and is a much better option than products such as Afrin.

Oral Mucus Splitting agents-Mucinex

  The only oral medication that really helps without causing many side effects is guaifenesin (Mucinex) 400 mg. every 4 hours, a mucus splitter, that can be helpful in bronchitis and upper respiratory disorders that thicken mucus. Mucinex 600 mg extended release 12 hour pill, therefore, only needs to be taken twice a day.

  It is not recommended by most doctors to take cold and allergy medicine that has all-in-one pills ot liquids with many medications. Many have unneeded ingredients such as cough suppressants, Tylenol, decongestants, mucus splitting agents, etc. It is much better to choose specific medications needed based on symptoms unless a patient is knowledgeable about the components of the all-in-one medications over the counter.

Nasal cortisone (steroids) sprays

Most Ear, Nose, and Throat physicians would recommend a regimen of nasal (steroid) cortisone spray, with or without an oral decongestant (if really stuffy), and salt water sniffs three times a day.

  Brand names include Nasacort, Rhinocort, Flonase, etc.). Most are 24 hour sprays once a day. This topical cortisone is not well absorbed into the blood stream, therefore, it does not have the side effects of oral cortisone. However, it can cause dryness and bleeding of the nasal membranes and sometimes sore throat if used for a prolonged time.

  It is best to start a steroid nasal spray 1-2 weeks before a person knows when their allergies are going to flare.

Alternative nasal sprays—Nasal Crom, Atrovent

  There are other nasal sprays that are effective against nasal allergies. NasalCrom is cromolyn sodium blocks the release of histamine, which causes the nasal and sinus congestion.

  A newer nasal spray is Atrovent Nasal, which is a chemical called ipratropium, which can treat a runny nose by reducing the production of mucus but does not stop congestion.

  Patients with glaucoma and an enlarged prostate should check with their doctors before taking most of these allergy medications.

  Nasal saline sprays also are of some help, but snorting salt water (Neti-Pot or not) will help siphon mucus out of the sinuses and help promote drainage, relieving sinus congestion, and help prevent secondary infection. The salt water cleanses the nasal memberanes of inhaled allergens, sooth swollen allergic membranes, and help relieve a sore throat usually caused by postnasal drip.

How to snort salt water

  Follow carefully. Mix half a tsp. of table salt into a 8 ounce glass of warm water (preferably previously boiled or bottle).

  Pour the water into the palm of your hand. Place a finger on one nostril to close it, lean over the sink, and snort the salt water forcefully from your palm through the other nostril. It will flow into the throat so you must stay leaned over the sink. Open the mouth and let the water out. Sniff several handfuls of salt water through each nostril.

  It may take a little getting used to without gagging on the water. An option is to follow the instructions found in a recent JAMA-Otolaryngology article. I personally think it is inferior to my instructions above, because it does not siphon the sinuses as well as snorting. This is not a passive irrigation.

  These techniques are better than using a Neti-Pot, in my opinion. Regardless of technique, the main message is JUST DO IT!

Salt water sniffs were originally intended for patients after nasal and sinus surgery.

Summary

  Consider staying away from oral antihistamines and nasal decongestant sprays. Consider cortisone (steroid nasal sprays and salt water sniffs. If congestion is present, consider an oral decongestant. As always, consult your doctor(s) about managing allergies.             

5. Psychotic disorders and Schizophrenia

Opening Remarks

  I have previously reported on several psychiatric disorders.  This report deals with two of the most serious—psychotic disorders and schizophrenia. The reason schizophrenia is singled out is not only for the significant number of people it affects, but that it is a specific illness whereas other patients with psychotic symptoms are likely caused by an underlying condition or another psychiatric disorder with overlapping psychotic symptoms.

  Since 2013, by agreement, the American Psychiatric Association has classified psychiatric disorders into 5 major categories: 1-anxiety disorders, 2-mood disorders, schizophrenia and 3-psychotic disorders, 4-dementia, and 5- eating disorders. This report will limit the discussion to psychotic disorders and schizophrenia.

Definition of Psychotic symptoms

  Psychosis is not an illness itself, rather it is a cluster of symptoms characterized by a loss with reality resulting in bizarre behaviors often accompanied by a misperception of various sensory stimuli (hearing voices, seeing images, feeling sensations, etc.). Paranoia and various delusions may be present. By definition, a psychotic person is out of touch with reality at least part of the time.

  There may be considerable changes in personality with or without impaired functioning. Symptoms may include incoherent speech, social withdraw, isolation, lack of motivation, and difficulty carrying out daily tasks. Delusions, false beliefs, paranoia, belief in conspiracies, and hallucinations can be found in these seriously ill patients.

  During a psychotic episode, a person may experience superimposed depression, sleep difficulty, and anxiety. They also may commit crimes and exhibit bizarre behavior necessitating incarceration or admission to a psychiatric ward for treatment. The prisons are full of prisoners with serious psychiatric disorders.

  In contrast, as stated, schizophrenia is a true illness, genetic in causation. The patients exhibit the same psychotic symptoms described above most often without an underlying cause.

  Confusion may exist between a patient being a psychopath and a psychotic. A psychopathic person is classified under antisocial personality disorders and a psychotic (other than schizophrenia) demonstrates a cluster of symptoms most likely with an underlying cause that may be treatable and relieve the patients of these symptoms.

Causes

  1-Medical conditions, 2-medication side effects, 3-head injury, 4-substance abuse, 5-alcoholism, or 6-withdrawal from any of these substances all can create psychotic symptoms. 7-Severe stress (PTSD, rape, incest, physical and mental abuse, etc.) can create these behaviors and certainly would make them worse.

  Medical conditions can range from stroke, head injury, migraine headache, epilepsy, autoimmune diseases, brain tumors and infections, multiple sclerosis, to HIV-AIDS.

   Medications may cause psychotic symptoms and it is estimated that 7-25% of patients who present with their first psychotic symptoms are due to medications that can range from pain meds, anti-parkinson’s drugs, heart and blood pressure meds, steroids, gastric reflux meds, antibiotics, muscle relaxants, and others.

Workup

  A detailed history, drug (toxicology) blood screen, family history, and a thorough medical, neurological, and psychiatric examination is necessary to uncover the spectrum of symptoms and possible underlying conditions that may be causing the disorder. A diagnosis of schizophrenia may have overlapping conditions which make treatment more complicated. 

  Brain imaging may be indicated to rule our brain tumors and cysts. A spinal tap may be necessary to rule out brain infections, HIV, syphilis, etc.

  All psychiatric disorders are characterized by psychopathologic domains with distinctive courses, patterns of treatment response, and prognostic implications. The correct diagnosis is therefore critical.

Incidence 

  The incidence of psychotic disorders is 1 in 100 in the U.S. (1% or 3.5 million in the U.S.). In comparison, bipolar disorder accounts for 2-4% of the population (which may have psychotic symptoms as well) and schizophrenia which occurs in 1.1% of population.

  Psychotic symptoms usually begin between 18-24 years of age. By the time the illness is full blown, patients are most often diagnosed in their 40s.

Neurologic basis for Psychotic disorders

  In simplified terms, psychosis is thought to involve a chemical reaction in the brain, the result of which distorts thought processes and perception. There are numerous neurotransmitters in the brain that are involved with cognition, thought processing, emotions, etc., and when factors interfere with these chemical reactions, symptoms appear over time.

  In my mind, it is impossible to separate neurological from psychological in these disorders. Neurologists, psychiatrists, psychologists, and internal medicine specialists must all work together to diagnose and treat these patients.

Early recognition critical

  As symptoms begin (called a prodromal period), there may be few obvious signs of behavior changes that could take months or years. As families reflect back on the behavior of their loved ones, it is usually obvious that aberrant behavior had been going on for years before full blown symptoms become obvious.

  The earlier a psychiatric consultation is sought, the better chances for control of these disorders.

The major psychiatric category of Psychotic disorders and Schizophrenia

  In 2013, many changes were made by the psychiatric community in classifying these disorders (based on the ability to properly code these disorders to submit to insurance). It is important to single out schizophrenia from other psychotic disorders. 

Diagnosis of schizophrenia

  At least one symptom from 3 categories of symptoms need to be present for diagnosis. Examples:

1) Delusions with reduction of normal functioning in various aspects of life may be present.

2) Symptoms for at least 6 months must be present.

3) Other psychiatric disorders must be ruled out, such as schizoaffective, depressive, or bipolar disorders.

4) If the psychotic symptoms are caused by a medication,  substance abuse, or medical condition, this is not schizophrenia, no matter how many symptoms are present. If these underlying causes are treated, the psychotic symptoms should potentially abate (unless a schizophrenic has one or more of these issues as well).

5) Although rarely diagnosed in autistic patients, they may be diagnosed with schizophrenia if psychotic symptoms are severe and have been present for at least 1 month.

Genetic and enviornmental risks in schizophrenia

  Risks include birth month (winter-spring=flu season?), maternal influenza during third trimester, living in urban areas, in some minority and ethnic groups, complicated labor with hypoxia, an older father, severe stress, infection, malnutrition, and maternal diabetes (American Psychiatric Association-APA)

  Schizophrenics frequently medicate with illegal substances which can complicate the diagnosis. These patients tend to be heavy smokers. Many chronic illnesses may coexist because of poor self care.

  As the field of gene therapy progresses, once specific gene mutations are discovered, schizophrenia may be one day treated with genetic removal of these harmful mutations.

Treatment of schizophrenia and other psychotic disorders

  As in most chronic disorders or illnesses, life long care is usual, including psychotherapy and anti-psychotic medications unless the cause is found and treated. Rarely, electroshock therapy may be necessary especially in psychotic depression.

Recurrence of symptoms

  If patients cannot sustain taking their meds, injectible anti-psychotic medications may be indicated. This can be court ordered and if the patient cannot afford the medication, it my be administered free of charge. Anti-psychotic medications will likely be necessary for the rest of the patient’s life.

Results of treatment

  It is reported that 70% of patients will improve and 40% will be able reduce their medication dosage. Psychotherapy plus medications provide better control of these patient’s symptoms.

  Life therapy may be necessary for many of these patients regardless of type of psychotic disorder to integrate them into society, find work, and redevelop social skills.

Medications for psychotic disorders

a) The older medications include:

  Thorazine, Mellaril, Prolixin, Haldol, Trilafon, Navane, and Stelazine. Intramuscular injection medicines can be used if necessary.

b) The newer medications are:

   Abilify, Arastada, Saphris, Clozaril, Zyprexa, Latuda, Seroquel, and Risperdol and others. Clozaril is the only medication that is FDA approved for schizophrenia if other medications do not work. Even though there can be serious side effects, the results can be life changing. Careful surveillance by the psychiatric community is extremely important including certain blood studies.

c) The newest medications are:

   Rexulti and Vraylar can be used with other antipsychotic medications in resistant cases.

Side effects of anti-psychotic medications

  Side effects of all these medications are not uncommon. The most worrisome side effect for most of the drugs is tardive dyskinesia, an uncontrollable movement disorder of the face, tongue, and neck. 

  Other side effects are dry mouth, drowsiness, dizziness, blurred vision, and even seizures.

  Psychiatrists must find the right medication and correct dose to control the major psychotic symptoms. It takes 6-8 weeks for the medications to take into full effect with control of symptoms allowing these patients to rejoin society in full capacity. Employment is a serious issue because of disruptive bizarre behavior.

Drug resistant psychotic disorders

  Some patients do not respond to these medications even after switching or adding a second medication. Alternatives include more intensive psychotherapy and electroconvulsive treatments. 

Less common categories of psychotic disorders

1---Attenuated psychosis syndrome—essentially if psychotic symptoms are diagnosed very early, treatment may be much better including treatment of other psychological issues such as depression, anxiety, etc. The symptoms of these patients do not go into full blown schizophrenia if treated early.

2---Catatonia—No longer considered a subtype of schizophrenia, this is a psychomotor state characterized by stupor and immobility (although rarely excitability in bipolar patients). Schizophrenics may have catatonia and respond best to medications-Lithium and Depacote. It is a separate entity and may be observed in other psychological disorders, including brain infections, many medical conditions, and some illicit drugs such as Molly (MDMA). Benzodiazepines are the usual treatment for catatonia.

3---Schizoaffective disorder—these patients may have some symptoms of schizophrenia, with 2 types—bipolar symptoms (mania, depression) and depressive. Suicide is a concern. Invega is the only psychotic disorder medication FDA approved for this disorder. If bipolar type, mood stabilizers are indicated, and antidepressants if depression is a prominent component.

4---Psychotic depression

  Depression is most commonly not associated with psychotic symptoms and is one of the most common mood disorders. However, when depression is associated with the symptoms of psychosis, it is a crippling illness.

  One out of four people with depression that require hospitalization have psychotic depression. Delusions are usually consistent with typical symptoms of a depressive (feelings of worthlessness or failure in life).

  Having psychotic depressive episodes increases the likelihood of developing bipolar disorder with recurring episodes of mania, depression, and thoughts of suicide.

  Treatment includes Risperidone, Zyprexa, Seroquel, Abilify, Rexulti, and Vraylor, all of these drugs are the same as the ones above for schizophrenia and other psychotic disorders. These patients are usually already on one of the standard antidepressants (SSRI, SSNI—serotonin type of drugs.

Drug resistant depression is defined as failure of two different drugs cited above. As in other resistant psychotic disorders, ECT (electroconvulsive therapy) may be very helpful.

5---Postpartum (depression) psychosis is a serious condition that can lead to self-harm and infant injury or death. It is rare and most do not have psychosis, but when present must be treated immediately. Confusion, obsessive thoughts about the baby, hallucinations, and delusions, thoughts of suicide, and other symptoms may lead to a life threatening thoughts or behaviors. It can come on before birth but becomes more manifest after delivery.

  Those with a history of depression, have bipolar disorder, a family history, or those under excessive stress during the pregnancy are all risk factors.

  For the first time the FDA has an approved treatment, Zulresso that is administered intraveneously over 60 hours. It can have serious complications (sudden loss of consciousness and excessive sedation), therefore, the patient must be hospitalized provided only through a special program.

Grateful Acknowledgement for assistance with this report

 Dr. Elton LeHew, a retired psychiatrist, and my life long friend, provided great oversite, additions, and corrections to my humble attempt to report on this very serious category of psychiatric disorders. His credibility and practical experience as a long time practicing psychiatrist has been invaluable in producing this document.

American Pschiatric Association-DSM-5 Manual; Psychiatric Times; WebMD; Medicine.net; Mayo Clinic

6. Cancer Survivorship series--#4—Side effects of chemotherapy; complementary cancer treatments

Background 

  As of January, 2019, there were 16.9 million cancer survivors in the U.S. 56% were diagnosed in the last decade and 64% were over 65 years or older. By 2030, it is projected that there will be 22.1 million survivors by 2030.

Post-treatment survivorship care plan

  Critical for each survivor is a post-treatment survivorship care plan to address potential issues that may arise after treatment—early and late.

  Key plan components created by the primary oncologist should include—diagnosis and stage, specific treatments and potential consequences of the cancer and its treatment, timing of followup, preventative practices enumerated, health maintenance and well being, legal protection regarding employment and access to health insurance, and the availability of psychosocial services in their community.

  Studies have proven that when survivors do not receive a care plan, they were more confused and not sure what to tell their primary care doctors. This care plan should not only be given to the survivor but should be sent to their primary care physician, who must understand he or she is an integral part of the cancer team and accept that role. This recent study reported only 5% of survivors were given this care plan, and that is a shame. Survivors must insist on such a plan and be proactive in discussing this with their oncologists.

Journal of Oncology and Survivorship, April, 2019

There is good news in cancer

  By 2026, there will be 20 million cancer survivors in the U.S. Deaths due to cancer have dropped 27% between 1991 to 2016, which equates to 2.6 million Americans averting death from cancer in the last 25 years primarily because of the decreased incidence of smoking cigarettes. In the next 20 years, genital and throat cancers should be dropping because of the HPV vaccine now recommended for those ages 11-45 to prevent these HPV caused cancers.

  As millions of Americans have been cured or are living with cancer for years, survivorship issues has emerged in the past 10 years and is now a major subject covered in oncology. Most survivors will be followed by primary care doctors and nurse practitioners. Education about cancer survivorship is ongoing, but expertise in this area still is lacking. Care plans, long term surveillance guidelines, and wellness recommendations are critical in following these survivors.

Reference--National Coalition for Cancer Survivorship and the Office of Cancer Survivorship at the National Cancer Institute.

  In 2005, there was a landmark publication written,  “Cancer patient to cancer survivor-lost in transition” in 2005. I encourage anyone who has or has had cancer to read this. Click on:

www.nationalacademies.org  

  This publication explains that cancer patients needed to think in terms of surviving cancer and going on with their lives, but need surveillance for a variety of post-treatment issues from recurrence, second cancers, and side effects of treatment. Cancer is not a death sentence!!

  I wrote an article (published in Ca-Cancer Journal, 2006) on the need for cancer survivorship monitoring and presented it to the staff at Memorial Sloan Kettering Cancer Institute in NYC in 2006. Before these early years, survivorship issues were not on the radar as a major issue for oncologists.  

   Doctors and patients have always been focused on screening, diagnosis, and treatment since the 1950s. As the 21^st century began, with cancer often being controlled, if not cured, recognition of side effects from treatment for the millions of survivors gained great momentum, and it joined in importance with the other aspects of cancer care.

  Today the estimated U.S. annual number of cancer cases is 1,735,350 with an estimated 609,640 deaths in 2018 according to the American Cancer Society. However, more people than ever are living after cancer with good quality of lives. For example, not long ago, before the innovation of immunotherapy, the average life span of advance melanoma was 2 years. With the administration of immunotherapy, 35% are alive at 10 years. Kidney and non-small cell cancers also are responding well to immunotherapy because all 3 of these cancers have genetic markers that treatment can target.

  As of 2016, it was estimated that there were 15.5 million cancer survivors in the U.S. and by 2040, 26 million will be living with cancer or cured according to the National Cancer Institute.

Definition of a cancer survivor

  A patient becomes a cancer survivor from the time of diagnosis to the end of life as agreed on by various cancer organizations. Some patients struggle with this concept, but the term implies that patients are starting their process of surviving cancer from the time of diagnosis til their last breath.

   After volunteering for 40 years, I spent 5 years with the National American Cancer Society creating guidelines for diagnosing and treating all major types of cancer survivorship’s side effects, all now published in cancer journals.

Side Effects of Cancer Treatment

  There are serious side effects of active cancer treatment which most are aware of, and I have discussed some of these issues in the first 3 parts of this series including fatigue, pain, and chemo brain in these reports found in these specific reports:

www.themedicalnewreport.com #53 , #54 and #80

   When patients are diagnosed with cancer they accept many serious side effects because they want to survive the cancer. But as the years go by, cancer survivors begin to realize the burden they are still carrying with them and it affects their quality of life forever.

  This is not to discourage patients from accepting treatment plans, rather, they must understand fully the consequences of these treatment and the price they will pay for a cure. I am a cancer survivor of a throat cancer (26 years), and I have had serious side effects from twice a day radiation therapy treatments, but I am blessed to have survived 28 years with a Stage II cancer.

  This report will deal with some of the side effects of cancer beyond the usual first year of treatment. Many side effects do not even appear for years, and now that we have better research, we are working on combating these side effects as early as possible and treating them.

Side effects of Chemotherapy

  The common side effects of chemotherapy are well known, including fatigue, chronic pain (in 1/3), hair loss, loss of appetite, weight loss, depression, chemo brain (happens with radiation too), skin rashes, hearing loss, visual loss, impotence, infertility, second cancers, dry mouth, dental decay and gum disease, swallowing difficulty, liver damage, gastric reflux, heart and blood vessel calcification and blockage, blood clots with embolism, bowel and bladder difficulty, chronic pain,  balance issues, cognitive and memory difficulties…..I could go on.

  This is a long list and these side effects are worse when using certain chemo agents than others. Some are temporary but some are permanent.

  Blood clots from the legs with embolism in cancer patients is now considered a high enough risk that anticoagulation is being recommended by the American Society of Hematology with heparin or aspirin if heparin is not feasible. Studies using oral anticoagulants is showing significant lowering of clots as well. Patients with gastrointestinal cancers, those with kidney impairment, and those with low platelet counts may be the exception for anticoagulation. NEJM, Dec, 2018

  Chemo brain (also from radiation) cause cognitive abnormalities in as high as 80%, but newer data have shown that as many as 30% have these cognitive deficits long term. Sleep problems, anxiety and depression are common along with the “fog” symptoms. These are real, but unfortunately there still is not a satisfactory treatment for chemobrain.

  Psychoeducational intervention helps the survivor cope and accept this side effect as a fact and accept stress management. Exercise has been proven to be quite beneficial and should be encouraged.

  It is known that exercise can reduce inflammatory cytokines, which is thought to play a role in chemobrain. Perhaps memory centers for cognitive rehabilitation will prove beneficial and should be explored.  Medscape Oncology, July, 2018

Cancer surveillance anxiety

  Now that cancer surveillance for prostate cancer and others in elderly patients is being recommended more often, anxiety has become a recognized condition for those who agree to this type of management.

  It is well known that a significant percentage of prostate cancers are low grade and will not be the cause of death in many of cancer survivors. A recent study found that 29% after one year of surveillance suffered from this condition, and five years later, 20% still suffered.

  Dealing with this issue must be customized to deal with anxiety based on psychological evaluation and should be considered when the survivor and oncologist make the decision to follow a cancer rather than treat it.

  10% of those studied (413) crossed over to surgery or radiotherapy. J.Urology, Dec., 2018

Treatments for anemia and low white blood count in cancer survivors

Anemia

  Patients receiving chemotherapy often are anemic and develop a low white blood cell count from chemotherapy. Even the cancer can induce these blood problems. Anemia makes healing slow, and low white blood cell counts can increase the likelihood of reducing the body’s ability to fight infection.

  The body makes blood (called erythropoiesis). A protein in the blood called erythropoietin stimulates the bone marrow to make red blood cells. When that ability is inhibited, oncologists may recommend a medication to stimulate that process (Procrit, Epo, Epogen, Aranesp). Folic acid and iron supplements might be necessary to assist making red cells.

  There is a recent article in NEJM-Journal Watch that reported these drugs increase the risk of blood clots (heart attack, stroke, blood clots and emboli). They rarely increase cancer growth, but caution must be taken and patients must be educated about the risks. Perhaps they should be placed on anticoagulants.  

NEUTROPENIA (LOW WHITE BLOOD CELL COUNT)

  Neulasta is the most common medication that can stimulate white blood cells in the bone marrow, specifically neutrophils. It is injected 24 hours after chemotherapy administration for 2 weeks. Mild bone pain is a common side effects treated with Tylenol.

  Leukine is a cell boosting agent administered IV over several hours. Patients allergic to yeast should avoid this medication.   

Complementary treatments in cancer—Marijuana and its products

  Probably the most common alternative medical product on the market (or illegal) are the cannibinoids, which are the chemicals in marijuana. As many as 27% of cancer survivors are using some form of marijuana products. CBD oil is probably the most purchased, which is now legal, and is the non-psychoactive component in marijuana. The oil can be placed under the tongue (sublingual), which is rapidly absorbed. Of course, the proper doseage is not known, and it also depends on why a cancer patient is taking it (reduce anxiety, help sleep, relieve pain, etc.). It is commonly prescribed for chemo induced nausea and vomiting.

  A recent study on breast cancer survivors (50% were using these methods) created a summary of recommendations that are applicable to most cancer survivors. I want to share them with you from the Journal of Clinical Oncology:

This completes the September report.

The October subjects are:

1. Communicable diseases coming from immigrants to the U.S.

2.Medical Tourism

3. Medical Updates--FDA approval process; blood clots and cancer; cannabis helps opioid abuse; too many people think cancer can be cured using alternative methods!

4. Dementia—causes and preventative methods

5. Update on triglycerides and cardiovascular diseases—the other fat

Stay healthy and well, my friends, Dr. Sam