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The Medical News Report November, 2019, #94 Samuel J. LaMonte, M.D., FACS
Do you want to subscribe to my reports? If you are already getting my reports monthly, you are subscribed! My mailing list has grown enormously, thanks to the interest in my reports over the past 12 years. The subscription is free, there are no ads, and I don’t sell your name, etc. to anyone, like business, and some hospitals do. This is my ministry, and my way of giving back for 30 years of a fabulous private practice. Just email me at samlamonte@gmail.com, and I will add you to my confidential list. I will confirm you are on the list when you request it. Put me on your contact list to prevent me from being blocked. Share with your friends and family. Thank you, Dr. Sam Subjects for November 1. Breast cancer screening—dense breasts; BRCA gene testing; all hormones for menopausal women increase breast cancer rise; when to stop screening?; other cancer risks 2. e-cigarettes (vaping)—causing death, pneumonia, and explosions; JUUL drops flavored e-cigs 3. Baldness—different types and treatments for hair loss 4. Driving as we age---when is it time to give up the keys?
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. If a reader disagrees with any of my reports, feel free to email me for further discussion. 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. Never stop a medication without discussing it with the doctors. 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 and Happy Thanksgiving!! Dr. Sam
1. Screening for breast cancer A. Breast density is a risk factor B. Breast cancer screening guidelines D. Hormones for postmenopausal women increase risk for breast cancer
A. Breast density and breast cancer A major issue in diagnosing breast cancer is the density of breast tissue. 50% of U.S. women have dense breast tissue (27.5 million women) ages 40-74. A large breast can occur from a large amount of fat, or actual dense mammary tissue, or both. Women with dense breast tissue have 4-6X greater risk of developing breast cancer as opposed to women with fatty breasts according to one source. It is because they have more actual breast tissue. Dense breasts can mask an early cancer. The federal task force on preventive services (USPSTF) does not recommend additional testing other than a mammogram for women with dense breasts, however, this is being closely studied by organizations such as the American Cancer Society to provide new guidelines for women with risk factors for breast cancer such as dense breast tissue. This is a followup to a report I wrote in 2016. Click on: Medical Report #56 40 million women have mammograms each year. 43% of women have dense breasts, therefore, the issue of notifying women and the consequences are considerable. 38 states and the District of Columbia have adopted legislation to address breast density and are required to provide information to women about the density of their breasts. Some states require doctors to not only inform patients with dense breasts but offer additional testing (ultrasound). The FDA proposed amendments to the laws and recently, but a final word on this is pending. The FDA is planning on recommending informing women of the dense breasts, however, guidelines have yet to be written. It appears to me that more testing might be indicated for women with dense breasts with dense breast tissue rather than fatty big breasts. Mammography requires penetration of X-rays through the entire breast, and large and dense breasts are harder to compress with the traditional technique, as women are quite aware of. Those with multiple cysts and benign adenomas also make interpretation more difficult making early cancer harder to detect. Digital mammography is a better choice than a standard mammogram according to many breast centers, but more expensive. Check with the insurance company to see if it is covered and talk to your doctor about the need. Below demonstrates mammographic evidence of stages of breast density. These MRI images show the range from extremely fatty to dense breasts:
Dense breasts may require additional studies (ultrasound) if the radiologist cannot see areas clearly because areas could be cancerous or just dense breast tissue. It is the decision of the radiologist and referring physician to recommend additional testing. However, there is some controversy about ultrasound’s effectiveness in diagnosing cancer over just mammography. In fact, there is no data to prove that supplemental imaging improves cancer recognition or cancer outcome, including mortality. Such additional imaging tests may lead to false positive results, unnecessary biopsies, and presumably overdiagnosis. An MRI is the most effective test, but too expensive to be used in routine screening of dense breasts. Even MRIs can only diagnose an additional 4-7 cancers per 1000 cases according to the authors of this report. No test is perfect. Of course, in patients with other risk factors, the risk rises (BRCA gene mutations, family history of breast cancer, etc.), and MRI may well be recommended. According to the National Cancer Institute, there are factors that increase density of breasts—women who have their first child later in life, fewer or no pregnancies, younger women, women on hormone therapy (including birth control pills), being premenopausal, and genetic factors (mother with dense breasts). According to the NCI, 20% of breast cancers are missed on mammography and this includes up to 40-50% of women who have dense breasts. This begs the question about frequency of more testing in certain women. 4 different categories for breast density on imaging: 1) almost all fat 2) scattered areas of fibronodular density 3) uniformly fibronodular density 4) extremely dense. Obviously the risk of hiding a small cancer would be highest in an extremely dense breast. Breast cancer usually is seen as calcifications, however, some are more difficult to diagnose with dense breast tissue present. However, fat and other benign breast masses can calcify as well. Below is a cancer in a dense breast.
Newer technology increases rate of diagnosis—3-D mammograms (tomosynthesis) This technology is better at detecting cancer in dense breasts than standard or digital mammography according to some studies. As they have become more available, some centers recommend these 3 dimensional studies, but they are more expensive and may not be covered by insurance. Studies report an extra 1.5 cancer cases per 1000 women are diagnosed with 3-D.
Notice the difference in clarity with the standard 2-D on the left image and 3-D mammogram on the right above diagnosing cancer. 3-D mammography is also called tomosynthesis, which produces multiple images of the breast layer by layer. Talk to your doctor about the wisdom of undergoing 3-D mammography if you have dense breasts. Longer term studies are still necessary before 3-D imaging is routinely recommended for women with dense breasts.
Summary How women are educated about breast density will be a challenge and may unnecessarily increase anxiety in some women. However, knowledge is power and further discussions when indicated can provide the best decision making. However, no test can discover all cancers. If changes occur in a breast in between mammograms, do not wait….talk to the doctor.
B. Breast cancer screening for general population
The American Cancer Society guidelines for screening for the average risk woman should begin at age 45, however, some women may choose to start at 40 based on a discussion with their physician. Annual screening should continue from 45-54. At age 55, continued screening every 2 years is recommended as long as the women’s life expectancy is 10 years or more. That could mean a woman at 75 could still chose to have mammograms if really healthy. Breast cancer screening can lower mortality rates by as much as 35%, thus emphasizing the importance of routine screening for the general population. Diagnosing breast cancer long before a lump is felt is crucial to reduce mortality. It is critical for women to discuss annual screening each year and what age to start and stop, because there are differences of opinion in some of the medical organizations.
Women with other risk factors for breast cancer If a woman has other risk factors too (e.g. cancer in first degree relative, BRCA* gene mutation, etc.), studies have proven annual testing with additional studies, perhaps 3-D mammogram or digital mammogram plus ultrasound can be valuable in detecting breast cancer. * BRCA=breast cancer gene mutation For those without these risk factors, annual testing may create more breast biopsies and unnecessary harm. The general population should not be tested for BRCA gene mutations without a history suggesting a BRCA gene mutation (see below) according to some federal and medical organizations.
What about developing breast cancer between recommended breast screening intervals? A recent report from the NEJM-Journal Watch cited the concern that women can develop breast cancer between interval mammograms, and if that occurs, they tend to be more aggressive and more often triple negative*. Between 20-30% of breast cancers are not diagnosed at the time of the mammogram. *triple negative breast cancer=breast cancer tissue is estrogen and progesterone negative, and HERS negative (these are more aggressive). The other discovery recently reported is that these women who have breast cancers that develop between mammograms are more likely to develop unrelated non-breast cancer tumors as well. Almost all people who have one cancer are more likely to have a second cancer compared to a person who never had cancer. The reason is genetic mutations (DNA) that may influence other parts of the body to have cancer.
Swedish report There were two groups in this Swedish study that report on 15,000 women. The groups were separated into those who develop these tumors: a) before being diagnosed with breast cancer and b) those after being diagnosed. The a) group developed more cancers of cervix, lung, colorectal, non-melanoma skin, brain, bladder, and kidney. The b) group develop more cervical, brain, and thyroid cancers. However, all sites can develop cancer. The bottom line is that even with having routine mammograms, women must be on the lookout for other cancers (breast and non-breast) even between mammograms. People who develop cancer are more likely to develop a second cancer. Cancer survivors tend to get tunnel vision for their cancer and often do not have other screenings. They do not pay attention to new symptoms in other areas of the body.
What about screening men for breast cancer Although extremely rare compared to women and breast cancer, if a man has women in the family with breast cancer (especially if BRCA+), screening might be indicated according to recent studies. It is also now known that men with prostate cancer tend to have more women in their family with breast and ovary cancer. Conversely, if a man has a family history of breast cancer in women, there is an increased risk of developing prostate cancer. Men can also carry the BRCA gene mutation. There are currently no current guidelines for testing. NEJM-Journal Watch, Sept 6, 2019 Most men have symptoms before seeking consultation, therefore, if there are symptoms of pain, a lump, hardness, etc. screening mammography is indicated.
C. Indicators for BRCA gene mutation testing For women with a family or personal history of breast or ovarian cancer, consideration for BRCA 1 and 2 genetic testing is recommended.
New recommendation regarding BRCA testing: * USPSTF= United Stated Preventative Task Force
1- Primary care physicians should actively screen women for a family history of breast, ovarian, peritoneal (lining of the abdomen), and tubal cancers. 2- There are currently several risk assessment tools* for doctors to use to predict the chance of a BRCA gene mutation being present. 3- Women who have a positive history for this gene mutation should be referred to a genetic counselor, and if indicated, testing for the BRCA gene. 4- Routine screening and genetic testing are not recommended for the general population without a history suggestive of a BRCA gene mutation. *Referral Screening tools can be found on this website: www.breastcancergenescreen.org
One of the screening tools points out that 2-7% of breast cancers and 10-15% of ovarian cancers are positive for either the BRCA 1 or 2 gene mutation. Women who carry one of the gene mutations have a lifetime risk of breast cancer of 45-90% with over half before the age of 50 and a 30 fold increase chance of ovarian cancer.
Family History factors influencing decision to test for BRCA gene mutation: 1- Breast cancer diagnosed before the age of 50. 2- A family history of bilateral or multiple breast cancers are at higher risk. 3- Ovarian cancer at any age. 4- A known member of the family with a BRCA gene or a member in the family with triple negative breast cancer (no hormone markers). 5- Ashkenazi Jewish relative with breast or ovarian cancer. 6- Male family member with breast cancer (maybe prostate cancer too!) Patients with a positive BRCA gene mutation have options: --MRI of the breasts, Tamoxifen*, bilateral mastectomy, bilateral ovary and tube removal, and testing for family members. *Chemical prevention (Tamoxifen, Raloxifen) For more information on prophylactic breast and ovarian (and tube) surgical removal click on my website report: Medical Report #27
Chemoprophylaxis There are patients who choose preventative therapies to prevent breast cancer from occurring instead of having prophylactic surgery or just having annual imaging exams. It is called chemoprophylaxis. There are estrogen receptor modifiers (Tamoxifen and Raloxifen) and aromatase inhibitors. Tamoxifen is the primary treatment, but raloxifene can be used in postmenopausal women (originally used to prevent osteoporosis in postmenopausal women). These oral medications block estrogen production, which helps prevent development of estrogen positive breast cancers. They cut the risk by 40%. Aromatase inhibitors lowers estrogen levels by blocking an enzyme, aromatase, from changing other hormones into estrogen. They are not yet approved in the U.S., but they are effective. (Arimidex, Aromasin, and Femara). These are used in postmenopausal women. Reference--American Cancer Society www.cancer.org
KEY POINTs about home genetic testing 23 and me at home testing only tests for 3 Ashkenazi Jewish mutations in BRCA genes and does not test for 98% of BRCA gene mutations!!
Summary As technology improves, so will the diagnosis of early breast cancers. It is quite important for breast cancer to be diagnosed as early as possible (long before they are felt in the breast). That is the value of mammograms, as they save lives! I have discussed breast cancer at length previously. Consult the Subject index in the website:
The American Cancer Society Mayo Clinic; JAMA, June 18 and July 2, 2019
D. All hormones for menopausal women increase the risk of breast cancer There has been some mixed messages in the past over the risk of peri-menopausal women taking replacement female hormone to treat menopausal symptoms for some women for several years. The main value has been to reduce cardiovascular risk with hormones, prevent osteoporosis, and treat severe postmenopausal symptoms. The Lancet European Journal reported that all forms of estrogen replacement hormones (except vaginal topical estrogen) increase the risk of breast cancer. Those taking estrogen and progesterone have a higher risk than estrogen alone. The risk rose the longer a woman took hormones, and rose as early as 1-4 years of ingestion with a 60% increase in risk. The risk lasted for as long as 10 years after stopping the hormones. These results came from analyzing 100,000 women. For women who have other risk factors for breast cancer (gene markers, obesity, dense breasts, etc.) are especially in need of careful consideration with their gynecologists before considering hormonal replacement at menopause, but it is always about the risk/benefit of any medical decision with a personal physician. There is still a great alternative- vaginal topical estrogen replacement, since it does not increase the risk, but there are some physicians who feel the time being used should be limited, therefore, check with your doctor about the length of time it can be safely used. All of this information discussed in this report require discussion with their physician, and no action should be taken soley on the basis of this report. Lancet, August 29, 2019
E. When to stop screening for cancer Many older women must come to grips with when to stop screening their breasts (cervix, colon). Usually it is suggested by most organizations to stop at age 75 unless there are circumstances of increased risk or previous breast cancer. it is also based on the 10 year longevity issue. For the general healthy population who have never had breast cancer by 75, it seems reasonable to consider stopping. However, estimating longevity after 75 (or any age) is tricky, and these organizations state that a person should stop if their life expectancy is less than 10 years. Consider the current average life expectancy in the U.S. for a woman is 81.1 years (men-76.1). Doctors are expected to provide the risks and benefits of screening later in life and then let the patient decide when to stop screening. Those who have risk factors or develop any symptoms should continue to be evaluated. Patients do not want to be told they should stop screening because they are not going to live another 10 years. They also do not want to feel abandoned by their doctors over this issue. It is now suggested after hearing the pros and cons, it is the patient who should make the decision. Unknown to most of us, some medical institutions provides financial incentives to continue screening. Also some radiology and or institutions send reminders that it is time for a screening forever, which can be confusing. JAMA, Sept. 18, 2019 One final comment!! We have seen tremendous success in treating estrogen positive breast cancer (HERS positive) with the addition of monoclonal antibodies (the biologic targeted cancer drugs) to standard chemotherapy. Even those with metastatic HERS positive breast cancer are living for years longer than before the additional therapy was added (called adjuvant therapy) to chemotherapy. So there continues to be good news in the fight against cancer.
2. e-cigarettes (vaping)—injuries, pneumonia, death; JUUL drops flavored e-cigs
Opening comments Late breaking information—JUUL e-cigarette company has voluntarily withdrawn most flavored products including e-cigarettes, however, menthol flavor remains in their products (the most popular flavor). Don’t pat them on the back too much. Keep in mind they sell approximately 35% of the products sold (65% of the market will still sell flavored products). 95% of e-cigarettes are produced in China, while Hong Kong banned them in 2009. Electronic cigarettes generated $2.3 billion in 2016 in the U.S. (expected to be $3.6 billion in 2018). Thanks to the FDA, they allowed unrestricted marketing of this product until 2022 while other countries banned the product. What a mistake by the FDA! They were thinking it might be the answer to smoking cessation. How naïve! I wonder which tobacco company paid them off? Now major networks are running e-cigarette ads in prime time. That cost $millions. And so far there is no scientific proof that e-cigarettes are effective in a large number of people wishing to quit smoking. The FDA is now urging people to not vape THC and any street drug especially those containing oils for fear of serious lung infections and potential death. They also strongly urge pregnant women not to vape THC for morning sickness. All those who vape should be on the alert for coughing, shortness of breath, and chest pain. FDA Med Watch, Oct. 7, 2019
Statistics are rising rapidly The rates of pulmonary and explosion injuries, hospital admissions, and deaths continue to rise by the day. As of Oct. 15, there have been 1479 reported cases from 49 states with 33 deaths. I will discuss the pathology later in this report.
Flavored e-cigarettes directed at young non-smokers Thanks to flavored e-cigarettes, 1 in 11 vape in the 8th grade, 1 in 5 in the 10th, and 1 in 4 in the 12th grade. 1 in 4 young people have vaped. 30 countries have banned them (Europe and India included) and yet the UK promotes it as a smoking cessation method when to date with no scientific proof.
States banning flavored cartridges and now JUUL ceases flavored e-cigarettes except menthol New York, Michigan, Washington, Rhode Island, and Oregon have already banned flavored e-cigarettes, and Massachusetts is planning to ban them.
The concern of those who will return to cigarettes if vaping is banned! Public health officials are worried folks will return to smoking cigarettes, and they will unless they really want to stop. After all there are several FDA approved smoking cessation methods (nicotine patch, gum, lozenges, and antidepressants that are effective). Their concern is that even though there are over 1400 lung damage cases reported by the CDC and 35 deaths, there are 480,000 lung cancer cases annually (smoking is linked to several other cancers including, oral, throat, larynx, pancreas, stomach, bladder, cervix, colon, and rectum) . People who are vaping to maintain their addiction rather than using the planned decrease of concentrations of nicotine in certain cartridges will stick with vaping until they are totally banned but will always be available on the streets. The question to ask is….are we concerned about the youth taking up a form of addictive nicotine and become future smokers perpetuating smoking in America, or are we concerned about some adults who will return to cigarettes because they were just substituting one form of nicotine addiction for another? It is a tough discussion. You decide! Electronic nicotine delivery systems (ENDS) use solvents to heat and aerosolize the flavorants (known as “juices”), which consists of various aldehydes and alcohol. This process creates new compounds that may be injurious to the airway. This is commonly used to deliver cannabis and other concentrates. Recently, with the explosion of popularity of e-cigarettes, many cheaper black market cartridges and e-cigarettes that are exposing people to oils including THC, CBD, and nicotine flavored oils that are causing what is equivalent to aspiration pneumonia. 20% of the lung cases still are coming from standard e-cigarettes. There have been over 1400 cases of severe pulmonary inflammation caused by vaping, including e-cigarettes. 60% required ICU admission. 80% vaped THC oils in addition to standard e-cigarettes according to the CDC. 35 deaths from lung damage have occurred as of Oct 15 reported to the CDC. Cough, shortness of breath, and fatigue are being reported when being admitted through the emergency room to the hospital requiring most to be admitted to the ICU. There is no data on the long term effects of e-cigarettes to date. An extract of vitamin E in the smoke has been discovered, which is an oil (whether in the nicotine cartridges or THC liquid (marijuana). There have been no contaminants seen in the nicotine used. Oils are known to cause lung damage as mentioned above.
4 categories of chest imaging abnormalities 4 imaging axial views of a lung CT scan patterns are common— -eosinophilic (white cell from allergic or foreign body damage) pneumonia, -diffuse alveolar damage (smallest component of the lung), -organizing pneumonia, and -lipoid pneumonia (from oils and fats). These are axial* or horizontal views of the lungs and heart seen below! *To orient you, you are looking at the lung as you would from the top of the head down into the body. Young people presenting with a form of lipoid pneumonia should be suspected and questioned about vaping. NEJM, Sept. 6, 2019
These patterns are also seen in environmental exposures.
Wake up Parents!! Parents must remember their children and teenagers have been vaping for some time, and they are not aware of it. If your youngster starts coughing with a fever and is short of breath, get them to the emergency room. Don’t expect a kid to tell you what they have been vaping. Search their rooms, backpacks, etc. for e-cigarettes. Even with the dangers of vaping, don’t expect young people to stop. Be on the alert parents!!!
Lung Pathology report on e-cigarette injuries; treatment One report from 17 different lung biopsies of these vaping injuries cited numerous pathological abnormalities including pneumonitis, pneumonia, and bronchiolitis. Some patients had to be put on ventilators (breathing machines), and most responded to corticosteroids. This improvement from steroids usually implies some type of allergic or inflammatory process. This would make the most sense that irritants from smoking anything is going to cause pulmonary problems especially for those with ongoing respiratory problem, in sensitive people, and those that are frequent users.
The Tobacco Industry; no safe e-cigarette!
A cartridge contains 200 puffs equivalent to a pack of cigarettes. Some kids go through a cartridge every day and even more. Adults may consume even more. Sadly, 63% of young people 15-24 don’t even know the liquid contains nicotine, according to one study. The National Academies of Science, Engineering, and Medicine report that there are several toxic chemicals in any vaping device, therefore, there are no safe devices for vaping. Propylene glycol (an alcohol) and vegetable glycerin (an oil) have proven toxic to human cells. They also contain acetaldehyde, benzene, diacetyl compounds, heavy metals, and formaldehyde. These chemicals are known to cause lung and cardiovascular disease and cancer. Acrolein, a herbicide, found in some of these e-cigarettes, is primarily used to kill weeds, which can cause lung damage, COPD, and may cause asthma and lung cancer. Inhaling smoke from tobacco emissions and e-cigarettes which is termed second hand smoke has been declared a hazard by the U.S. Surgeon General and other scientific agencies. The FDA has not found any e-cigarette or vaping device to be safe. It may assist in smoking cessation in adults (although not FDA recommended), but there is no excuse for younger people experimenting with a potentially dangerous device and running the risk of becoming nicotine dependent which could lead to becoming a cigarette smoker. If a parent smokes, consider your responsibility to your children.
e-cigarettes can explode in your face!! e-cigarettes are flammable and can explode. It occurs when the lithium battery inside the cylinder overheats especially when charged overnight. Lithium batteries explode in cell phones as well. Vaping products cause flame burns, blast injuries, and chemical burns. This has led to permanent tattooing of the skin, scarring, teeth loss, jaw fractures, and loss of soft tissue, requiring plastic surgery (plastic closures of tissue loss, skin grafts, scar revisions, and burn treatments). The FDA has warned about this and recommended these e-cigarettes not be recharged overnight and have holes for ventilation. The FDA must ban e-cigarettes.
The American Lung Association has a great resource for people, parents, and teens. Click on www.lung.org and then search for e-cigarettes and stop smoking techniques. There is also an helpful organization-- Parents against vaping e-cigarettes
Caution for people with respiratory disorders Anyone with any type of respiratory allergy, asthma, chronic lung disease, etc. should be particularly aware of the hazards of these devices and avoid them young or old! Teens are using e-cigarettes to smoke very concentrated marijuana (THC) in the cartridges of device. 13% of teens surveyed were using this device to use THC (the euphoric chemical in marijuana). Conversely, 82% of teens who smoke marijuana also use e-cigarettes. Ergo….they are connected and one is a gateway to the other. There has been a reported 11% drop in sales of e-cigarettes over 4 weeks ending Sept 22. Good news!!
Journal of Pediatrics, August, 2019; NEJM, Oct. 3, 2019; CDC, Associated Press
3. Baldness--Losing hair (Alopecia)—male (female) pattern baldness and other types
A. Hair growth biology
50-100 hairs fall out daily on a normal basis. Each follicle produces hair for 2-6 years and then goes through a rest (dormancy) phase. The hair falls out during this rest period. With an average of 100,000 follicles in the scalp, the turnover is not usually noticeable. More noticeable hair loss occurs when there is disruption with the growth and shedding cycles or if there is fallout followed by scarring in of the follicle. The hair growth cycle has some unusual names:
Hair loss can be caused by many health issues, and the second most common type of hair loss behind male pattern baldness is called telogen effluvium. Note the third phase of a hair follicle is called the telogen phase. Through the process called miniaturization, some follicles become more genetically oversensitive to DHT, dihydrotestosterone. This hormone interacts with an enzyme (type 2 alpha-reductase) in the follicle’s oil gland. When DHT binds with the receptors in the hair follicles, and over time the follicle shrinks, it produces thinner hairs. Eventually the area quits making hair and the baldness occurs.
B. Types of hair loss
1-Male pattern baldness (androgenic alopecia)
Male and female pattern baldness is the most common type of hair loss affecting 50% in males and 25% in females. Up to 50 million men (30 million women) in America experience hair loss. A receding hairline is usually where the hair loss begins whereas females begin with overall thinning of hair and rarely have a receding hairline. Approximately 30% of white people are affected by male pattern baldness by age 30, and 85% by age 50. White men followed by black men have the highest incidence. Orientals have the lowest rate. Balding presents as a gradual thinning of the top of the head with gradual thinning of the frontal hair (not in women). Although losing hair is an aging process, hereditary influence is a potent factor in men with male pattern baldness. Most men’s hair will thin with age, but not proceed to baldness.
Key to male pattern baldness
Male hormone (androgens) is responsible for stimulating body and facial hair, but not scalp hair growth. Keratin is a protein in skin cells and a certain type of keratin (keratin 37-KRT37) is the only form of keratin in the skin that is regulated by androgens and occurs only in human beings (not even monkeys). Although in the body hair follicles, keratin KRT37 is absent in scalp follicles. Because of the absence of KRT37 in scalp hair, this may be a factor in the loss of hair in male pattern baldness. It has been thought by many that excessive androgen was responsible for male pattern hair loss, but it is only partially true. There are, probably on a genetic basis, reduced amounts of certain types of androgens in male pattern baldness, but increased levels of others (dihydrotestosterone-DHT). Here is the reason. Testosterone is converted to dihydrotestosterone (DHT) from the action of an enzyme 5-alpha reductase, which is a much more potent form of testosterone. In male pattern baldness, there is increased amounts of this enzyme in men with male pattern baldness, which is responsible for excessive DHT, causing more body and facial hair and less scalp hair in classic hair loss patterns. Simplified, excessive DHT is the prime factor why men with male pattern baldness go bald, and this is genetically determined.
2- Women and Hair Loss There is a type of female pattern hair loss that is the most common type and has a strong genetic component according to WebMD. However, many women do not lose their hair on a genetic basis. There is usually a medical reason. Hormonal change with menopause or postpartum can cause hair loss. There are also several medical conditions that influence hair loss including thyroid deficiency, anemia, polycystic ovaries, dramatic weight loss, too much vitamin A, and certain skin conditions including seborrheic dermatitis. These types of hair loss are called telogen effluvium and are discussed below, because it is the second most common type of hair loss. Certain hair coloring, cornrolls, permanents, and tight hair styles including pony tails, and buns can cause hair loss. Men tend to lose hair in an M pattern sparing the sides and very back. Some start with loss on the back of the crown. Women tend to lose hair all over the head rather than in a pattern. 5% minoxidil is recommended (foam) once a day by WebMD. There is a 2% and 5% liquid which is used twice a day but is more messy. Over a few months, 81% of women should see some regrowth, but must be used forever to maintain hair growth. If there is an underlying medical condition, that must be managed for hair to return.
Most men and women are not happy with their hair loss causing loss of confidence and self esteem in many individuals. Most men can learn to cope with the issue, but if there are pre-exisitng psychological issues, this condition may aggravate those symptoms requiring professional help. It can be a life long issue and many men and women would do most anything to reverse the process. Thankfully, baldness is quite acceptable these days (in men), and many men will shave their head rather than put up with the male pattern hair loss. Because there are so many bogus treatments on the internet, men and women should stick with the FDA approved treatments, and the earlier the better. Also be careful in choosing a hair transplant doctor to prevent a poor and obvious result.
3- Involutional alopecia This type of loss occurs from aging. Hair follicles go into a dormant phase for longer periods of time, and results in thinning of hair over time.
4- Alopecia areata
This type of hair loss is autoimmune in cause, but there is no known actual cause why the immune system suddenly sees hair follicles as foreign, and it is attacked by the body’s immune system. There are genetic factors and a family history is not uncommon. Pitting of the nails is not uncommon.
Pitting of the nails
Lymphocytes* around the hair follicle are seen on microscopic examination in these patients. *Lymphoctes are white blood cells that are responsible for most of the immune response producing IgG, IgM, and IgE immunoglobulins. Pigmented hair may be more vulnerable to loss than graying hair, and regrowing hair will usually come back without color, gray or white. These patients may begin losing areas of hair in childhood, regrow the hair, only to lose it again. They are prone to hay fever, asthma, eczema, vitiligo, immune thyroiditis (Hashimoto’s disease), myasthenia gravis, and type 1 diabetes mellitus. Even syphilis can cause hair loss (usually a moth-eaten look such as the third photo above). A scalp skin biopsy confirms the diagnosis. Also the hair pull test is diagnostic for most of these types of hair loss. Looking at a hair shaft under a microscope will demonstrate various abnormalities.
Normal hair follicle
Treatment may include injectible corticosteroids right into the affected areas of the scalp to combat the immune reaction (every 3 weeks). Topical steroids are much less effective but preferred in children to prevent growth issues. Anthralin cream can also be used. Rogaine 5% topical can be used by both children and adults. Some sources suggest 2% for women but 5% is available too. Anthralin (a tar-like treatment) is applied to the scalp 30-60 minutes and then washed off. Diphencyprone is a preparation that causes an allergic reaction on the scalp site, which tricks the immune system, and after about 3 months, hair will regrow. It may require 2 treatments.
5- Alopecia universalis
This rare type of loss occurs throughout the body. It can be hereditary. It can come and go. There is no known treatment. Chemotherapy is a subtype of universalis, inducing loss of hair throughout the entire body caused by the toxic effects of some chemotherapeutic medications. Usually it will return after a time once chemo is stopped but in some cases does not return. The hair may return in different ways—curly, different texture, color, etc. It is also technically called anagen effluvium, because the hair falls out in the first phase of hair follicle growth.
6- Trichotillomania This usually occurs in childhood as a psychological disorder causing the person to pull their hair out. These patients suffer from obsessive-compulsion, anxiety, and depression and may pull their hair anywhere in the body to relieve stress. Broken hairs can be observed in these cases and suggest this diagnosis. These people frequently eat their hair out of this compulsion and can form hair balls (bezoars) in the stomach obstructing the bowel. They also pick their skin, bite their nails, chew their lips to relieve stress. They have difficulty at work, school, and social situations. They try to hide their pulling and their hair loss with wigs. Psychological counseling and medication is necessary to get these patients to quit pulling their hair out.
7- Telogen Effluvium
Explaining the name Earlier in this report, I discussed the phases of hair growth, and the third phase is the telogen phase. The second most common type of hair loss is caused by many forms of stress, diet, etc. Effluvium is another name for hair loss and means “outflow” and is used in different types of hair loss. This disorder can occur with obvious loss of hair from a prolonged change in the hair growth cycle, with a large number of follicles going into a resting phase (dormancy) at the telogen phase at the same time with subsequent thinning. At any one cycle of growth, about 80-90% of follicles are growing. The hair will usually return over time. Examination of the hair follicle is diagnostic showing 2 or 3 telogen hairs on a hair pull, which are immature hair follicles characterized by a more bulb-like follicle because of the extra keratin covering the tip of the follicle at that phase. See the above telogen hair follicle.
Causes A diagnosis of telogen effluvium is made when there is an abnormality of hormones, medications, stress, crash dieting, high fever, physical stress such as surgery-induced types of hair loss. A thyroid abnormality, vitamin (B6, B12), protein (amino acids), mineral (zinc) deficiency, menopause, post-partum, and even vaccinations can cause hair loss. Any type of stress can interfere with the growth cycle of a hair follicle especially in the telogen phase. Choosing a vegan diet has been linked to hair loss in some because protein is consumed by plant based proteins and may not be sufficient for normal hair growth. This is just a theory. The only exception in hair loss is caused by chemotherapy and officially called anagen effluvium, which is a type of alopecia universalis discussed above.
7- Scarring alopecia Many skin conditions can cause such serious inflammation with resultant permanent hair loss. Cellulitis, acne, folliculitis, etc.) can cause significant scarring in the hair follicles destroying the follicles.
8- Traction hair loss Hot combs, pulling hair into tight buns and pony tails or pig tails, cornrows, hot tightly placed curlers and permanents, etc. can damage the hair follicles as well. Hot oil hair treatments may cause hair loss. Hair loss may occur from cosmetic surgery as well from undermining the hair bearing tissues to tighten the face. Also if incisions are placed behind the side burn and up into the temple, the hair line will be pulled backward.
9- Chemical induced alopecia (Anagen effluvium) (chemotherapy and head radiation) Chemotherapy causes hair loss due to the toxic effects on the hair follicle and affects the earliest phase of hair follicle growth (anagen phase). 97% of the time the hair will grow back and are helped with minoxidil. The cooling cap during chemo treatments has been helpful in some cases. Chemotherapy induced hairloss was discussed previously with preventative and hair care tips Medical Report #10
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Before and after chemo |
Cooling cap attached to cooling machine to circulate |
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10- Hair styles, products Harsh chemicals, hair straightening products, ammonia, peroxide, etc. all can harm hair and cause fallout. Even harsh brushing repeatedly can be injurious.
C. Diagnosis To evaluate the cause of hair loss (unless obvious), blood tests to rule out certain underlying diseases are of value. The hair pull test allows a doctor to pull a few hairs out at one time, and the number of hairs easily extracted coincides with the shedding process of the hair growth cycle. 20-60 hairs are grasp and gently pulled. If more than 10% of the hairs comes out, that is a positive test, indicating there may be some issues with the hair follicles. Tests for ringworm if indicated, and a skin biopsy may be valuable as well to examine the hair follicle. Looking at the root of hairs may indicate disease under a microscope. As always, a clinical exam and history of the patient leads to most diagnoses.
D. Treatment options for balding
1- Medical option--FDA approved hair loss products –Rogaine and Propecia-how they work
Although there are a lot of internet sights touting miracle hair products, machines, and various unproven methods, there are only two products that are FDA approved. Minoxidil (Rogaine) and finasteride (Propecia) are both effective. As mentioned above, these products block the production of an enzyme (5-alpha reductase), which is responsible normally for converting testosterone to dihydrotestosterone (DHT). High levels of DHT inhibit scalp hair growth. Blocking the enzyme allows DHT to be reduced and hair growth can be restored in about 2/3 of men with male pattern baldness.
Rogaine was accidentally discovered when patients who were being treated for hypertension grew hair. Now as a topical product, it must be used forever, because of its stimulating activity (increasing blood flow to the scalp hair follicles and blocking the enzyme) must continue to keep follicles producing hair. It does not work for everyone (2/3) and may be more or less effective in some individuals. Once a significant amount of hair loss occurs, Rogaine is not very effective, so the earlier it is used, the better. Look for the generic product as it is the same as the brand name (minoxidil 5% topical foam once a day). Follicles that have stopped producing hair are likely not helped by any of these drugs. Some recommend for women to use 2% minoxidil and 5% for men, however, that is controversial. There is a 5% product for women in the stores. It does not help prevent facial and body hair in women, because of the different effect DHT has on the growth of the body and facial hair from the scalp. In fact, increased testosterone levels from any source that is injected or ingested (androgens) will cause hair to grow everywhere but the scalp, and in fact, it can cause hair loss. That goes for women as well.
Propecia was originally created to treat prostate enlargement. It also blocks the same enzyme (in the follicle oil glands just as Rogaine) that is necessary to convert testosterone to DHT (dihydrotestosterone). This prevents the hormone from negatively affecting the hair follicles and keeping hair growth to continue long term. It is not effective for women. Although it is off label, the prostate oral drug, dutasteride (Avodart), can be effective for men only. It works the same way as finasteride (Proscar), another drug for enlarged prostates, but is more effective in blocking the conversion of testosterone because it blocks both type 1 and 2 alpha-reductase. There are side effects when being taken orally for the prostate, but topically does not create the same issues. Both Propecia and Avodart do not affect the follicles that have stopped producing hairs. And it must be used every day for life. Starting this treatment early on before hair loss becomes too advanced is strongly recommended.
2- Low level laser (red light or cold laser) Laser treatments are mentioned but there are not many studies to prove its value, using as little as 15 patients in their studies. It supposedly stimulates stem cells in the scalp which help new follicles to form and thus growing new hair. It supposedly irradiates photons into the scalp which increases circulation. One site said it was particularly valuable for women. Buyer beware! The comments in a paper found in a journal called Laser Surgery Medicine, 2014, stated these treatments are used to prevent further hair loss and grow new hair and will help in some patients. Hats and laser combs with the “soft” lasers are sold online as well. This treatment has been used to treat wound healing, joint pain, and stroke recovery. The field of laser treatments has expanded widely with little sound double blind studies to prove their value. The treatments can cost $ thousands. Safety has not been established.
3- Wigs and hairpieces
There many expert wig stylists, so go to the best. Some can be sewn to the scalp.
4- Shaved heads are popular
A very socially acceptable alternative to hair restoration especially these days is to shave the entire head rather have the “Friar Tuck” appearance.
5- Hair transplants Follicular strips and plugs Transplants have come a long way since unsightly large hair plugs were used. Strips or microplugs from the posterior scalp are extracted, and a small number of hair follicles are used from these donor sites in an area of the scalp. Tiny punch defects are removed with a sharp rounded instrument (called a punch) (see photo below). It is crucial to place these plugs in an irregular fashion to prevent the obvious rows of hair plugs.
6- Scalp Reduction surgery
If the loss is not too large, it can be removed depending on the area of loss. This assumes more hair loss is not going to occur. It could take 1-3 different surgeries to reduce the bald area down to be able to perform fewer hair transplants or there may be no further need for surgery except a little comb over technique. For a high forehead line, there are two techniques that can be performed. With a open cosmetic forehead lift the forehead is shortened with resection of the forehead skin up to the hairline, which lowers the forehead. Or the scalp can be elevated and brought foreward. These were common procedures I performed in my practice.
Cost is usually per plug or a minimum amount. Forehead lifts and scalp reduction could cost $5-10,000. Since hair transplants frequently require several sessions, depending on the extent of the area of loss and the number of areas still needing a “touch up number of plugs”, will cost a wide range from $4-15,000. Insurance will not cover this type of surgery unless from from burns or traumatic loss of scalp. Some dermatologists or plastic surgeons recommend Rogaine after the hair plugs are healed to minimize hair loss.
E. New research Researchers from the University of Texas (Dallas) Medical Center have identified a protein (KROX20) which has the ability to turn a skin cell into a hair which in turn produces a protein called stem cell factor, which plays a role in hair pigmentation. They hope in the near future that a topical product can be created using this protein discovery which will stimulate hair follicle creation. Researchers feel that one of these proteins may be the reason for male pattern baldness. Genetic studies have identified 287 genetic regions involved in male pattern baldness linked to hair structure and development. After all, hair and nails are modified skin cells. Many of these genes are found on the X chromosome, which men inherit from their mothers. Work is ongoing to find out how to manipulate these genes to treat baldness. It would be even better if they could come up with a way to prevent baldness. The University of California at San Francisco Medical Center have found defects in an immune cell (Tregs), which controls inflammation, and may play a role in another type of hair loss (alopecia areata), that may play a role in male pattern baldness also. It has been discovered in animal models that Tregs stimulates stem cell in the skin cells. Without the Tregs cells, it was found that stem cells were unable to regenerate hair follicles. Immune therapy findings Hair growth can be restored by inhibiting the enzyme system called the Janus kinase (Jak) family of enzymes that are involved with immune system and inflammation. These are still in the research phase. Applying this Jak inhibitor directly on the scalp can prevent hair loss. There are 3 Janus enzyme inhibitors –ruxolitinib (Jakafi) that is FDA approved to treat polycythemia and myelofibrosis, and baricitinib (Olumiant) and tofacitinib (Xeljnaz) that are FDA approved to treat rheumatoid arthritis (all are in a class of drugs called DIMARDs- disease modifying anti-rheumatoid drugs). In a small clinical trial with Jakfi, there was a 92% recovery of hair in patients with alopecia areata. Stem cells are being tested to identify the effectiveness to transform into hair follicles.
F. Tips for hair care Gentle hair care is necessary when hair follicles are under siege for whatever reason. No tight hair styles, compulsive hair twisting, rubbing or pulling! People should avoid harsh hair treatments or medications that can have an effect on hair growth. Even ultraviolet light can damage hair. Stop smoking because it reduces blood supply to the scalp and can affect any type of hair loss. Hair color without harsh chemicals (no peroxide) and volumizers will give the appearance of thicker hair. Shampoo with gentle thinning type of shampoos should be used and only when the hair is dirty. Less is better. Proper hair and scalp care is necessary. Using a knowledgeable hair stylist is a good idea. Mayo Clinic Ball caps do not cause baldness. However, many men wear ball caps to cover their hair loss. Too much Vitamin A and not enough protein will cause hair loss. Many medications can affect the hair. Stress and chronic diseases affect the hair significantly. And as noted, there is some evidence that not taking in enough protein may affect hair growth (i.e. plant based diets, although there are plenty of plant proteins to eat). WebMD, Mayo Clinic
4. Aging and driving—when to give up the keys
Many of us have had to deal with a parent or loved one who has become impaired in some way and might become potentially dangerous behind the wheel. Bringing the subject up alone can create a major problem, because being independent is closely linked with driving an auto. Balancing safety with independence is a very difficult task we all face as we age. So when do we “hang up the keys”? There are driving efficiency programs such as--Keeping Us Safe—that seeks to provide solutions for older drivers. A Sarasota, Florida hospital (Sarasota Memorial) has a certified driver rehabilitation specialist, who helps determine when a person should quit driving. This includes patients who have had head and bodily injuries that have not been able to drive as well. Most of the clients are elder people who have aging issues, and I am sure are brought by caring relatives or caregivers to determine risk. Results of such a program take the pressure off the caregivers. I am sure there are specialists like this one in most major communities. Research shows that the older we get, the more likely we are to have auto accidents, even though many older drivers are much more cautious and avoid hazardous conditions. Primarily because of hearing and visual deterioration, death rates for drivers increase after the age of 65. Theoretically, states should require, after a certain age, that all drivers are competent to drive, passing a visual and driving test including parallel parking, and a three point turn according to some Registry of Motor Vehicles. Some feel anyone who drives should be able to pass a road test, so why are the rules so laxed when the statistics tell us otherwise? Should there be an absolute age when driving is no longer allowed? To date, there is no age restriction. There are states that don’t even require vision tests. These are all important questions when one considers driving on our interstates and major arteries which might as well be a NASCAR race. There are many driving competency requirements to get a drivers license (16 to get a driver’s license, 18 to join the military, 21 to buy liquor, etc.). And yet there are no age restrictions on the other end, and unnecessary deaths and destruction continue because of strong lobbying groups such as AARP that fight against restrictions. What about the most important question to ask……mental and cognitive capability? In Florida, we have a very powerful AARP lobby that keeps the rules pretty minimal. It should not be a political issue, but it is. How many times have we heard an elderly person missing the brake and hitting the accelerator pedal driving right into other cars or into the front of businesses with obvious consequences. Driving requires skill, concentration (no cell phones), decision making, depth perception, sobriety, etc. It is one of the most important responsibilities drivers will ever have. Medicare has now recommended a memory capacity test yearly (so far I am passing).
Here are some key facts about senior drivers from AAA: 1- 80% of people over 70 suffer from arthritis of the hands and spine, which makes turning the spine and neck difficult 2- Weaker muscles, reduced flexibility, and limited range of motion restrict senior’s ability to grip the wheel, press the accelerator, move quickly to the brake, or even reach the gear shift easily or use the side mirrors, etc. 3- 75% of those over 65 take one or more medication that could potentially have side effects that could impair driving. 4- Per mile traveled, fatal crash rates start to increase at age 75 and rise sharply after age 80. 5- Night blindness increases with age making night driving very hazardous. Many visual diseases create halos and visual distortions. Macular degeneration occurs with greater frequency with age causing blind spots in the visual field. 6- Fatality rates (for people 65 and older) are 17 times higher than younger drivers age 25-64. 7- In 2009, there were 30 million licensed drivers over the age of 65. By 2030, there will be 70 million people in the U.S. and 75-80% will be licensed to drive. 8- In 2009, 58% of the deaths due to auto accidents came from those 65 and over. Seniors 65 and older only represent 14.9% of those living in the U.S. as of 2015. 90% polled said that giving up driving would be problematic. Depression and isolation can accompany losing independence and must be addressed.
7 health conditions that may impair driving— 1) Dementia 2) Hearing and vision impairment 3) Stroke 4) Parkinson’s disease 5) Arthritis causing stiffness and decreased reaction time 6) Diabetes (visual, neuropathy, etc.) 7) Any medication that could impair judgment, cause sedation, or otherwise impair driving (i.e. anti-anxiety meds, sleeping pills, narcotics, etc.) Ref: Everyday Health Magazine
Danger signs it may be time to take the keys away: 1) Stopping at green lights or when there is no stop sign. 2) Getting confused by traffic lights. 3) Running stop signs or stop lights. 4) Having accidents or side-swiping other cars when parking. 5) Getting lost and calling for directions. 6) Hearing from concerned friends and relatives about the senior’s driving ability. 7) Loss of ability to assess distance between cars, distance to stop sign, loss of braking smoothly due to depth perception loss. 8) A serious illness which has taken the senior away from driving for an extended period of time.
One of the best ways to determine a senior’s driving ability is to drive with them (if brave enough)!!
Encouragement to give up the keys What can be done to encourage a senior to give up driving or at least limiting driving? I have been in this predicament with a relative, and for those of you who have had the same experience, it is a very difficult situation. There are some recommendations—ask their doctor to assess the senior’s capability, request a driver’s test, request physical therapy consultation to assess reaction time, physical restrictions, and the ability to drive through an obstacle course. Summary Unfortunately a serious incident often culminates in discussing driving cessation. It should not take a disaster to convince seniors but often it does. Giving up driving is giving up freedom to go places when desired. Independence is an unbelievable gift until it is taken from a person. Depending on relatives, senior ride programs, delivery services, mass transit, etc. However, creating a network of alternative transportation methods is very important. Visiting seniors is extremely important since these folks may have depression, which can lead to isolation, diminished cognition, and ultimately diminished quality of life. Living in an progressive facility is enormously helpful. Knowing what transportation services are available in each person’s community is very important.
5. Peripheral neuropathy—types of nerve pain
A. Defining neuropathy
3 basic types of nerves—sensory, motor, and autonomic.
1- Sensory neuropathy can have positive or negative symptoms. a)Positive symptoms would include itching, burning, tingling, or a sensation of needles and pins. b) Negative neuropathy includes numbness or imbalance. 2- Motor neuropathy could lead to weakness and atrophy (muscle shrinks) leading to falls, and difficulty walking (gait issues) or holding objects in the hands. Depending on the severity, deformity can occur with foot drop, and even foot deformity.
3- Autonomic neuropathy involves the system that provides innervations to the vascular and gastrointestinal systems and can cause orthostatic hypotension (just discussed in a recent report) and weakness of the gut muscles (esophagus-achalasia, stomach-gastroparesis, and intestines-ileus) which reduces the action of all these organs causing swallowing difficulty, gastric emptying (not uncommon in diabetes), and intestinal paralysis with bloating.
Neuropathy can affect one or multiple nerves—mononeuropathy and polyneuropathy
1- Mononeuropathy can involve major peripheral nerves of the upper and lower extremity—peripheral neuropathy Peripheral neuropathy usually implies pain or numbness in the extremities. The term is applied to any disease or injury that leads to dysfunction and damage to the peripheral nerves. It can be acute with rapid onset or chronic which is slow in onset and progressive.
a) Upper extremity nerves can involve the median, ulnar, and radial nerves. Compression of the median nerve (carpal tunnel syndrome), occurs from impingement of that nerve in the wrist. The ulnar nerve of the arm can also be caught in scar tissue or compressed (tardy ulnar syndrome), causing a sensation of pain from the the elbow down into the hand (ever hit your “funny bone”?). The radial nerve on top of the forearm can be compressed with prolonged pressure from the head lying on the area for extended periods of time (“Saturday night palsy”).
b) Lower extremity nerves involve the lateral femoral cutaneous, sciatic, peroneal, and tibial nerves.
2- Polyneuropathy involves multiple nerves.
a) Hereditary diseases such as *Charcot-Marie-Tooth syndrome and hereditary sensory neuropathy Charcot-Marie-Tooth syndrome is a disease of the peripheral nerves with progressive muscle wasting and loss of sensation in various parts of the body, most commonly in the feet. Pathological fractures, infection with foot ulcers, and leading to amputation. With muscle
wasting, high arched feet and swelling occurs. Poor circulation also occurs which leads to more rapid loss of the skin of the foot, gangrene, and loss of the toes, and even the foot. All of this is the result of loss of nerve function. Above photo is Charcot foot disease.
b) Inflammatory diseases such as *Guillain-Barre’ syndrome, chronic inflammatory demyelinating polyneuropathy, and certain types of vasculitis (polyarteritis nodosa) *Guillain-Barre’ syndrome is a form of polyneuritis often preceded by a respiratory infection creating a progressive ascending paralysis of the extremities. The immune system attacks the nerves in some ways like multiple sclerosis. Most any part of the nervous system can be involved so symptoms could start with weakness in the legs rapidly progressing to paralysis. Immediate hospitalization is necessary to support the neurological deficits, even respiratory muscle paralysis similar to polio. Fortunately, within time, patients recover perhaps with some residual neurological deficit.
c) Infectious diseases such as Lyme disease, HIV and leprosy, Shingles (Herpes zoster virus), fever blisters (herpes simplex virus), optic neuritis, and vestibulsr neuritis (acute vertigo caused by virus).
d) Systemic diseases such as cancer, lupus, protein related diseases, and diabetes.
Diabetics can suffer from 4 types of neuropathy-- peripheral neuropathy, proximal neuropathy, autonomic neuropathy, and focal or mononeuropathy. I have discussed type 2 diabetes at length in previous reports. Click on the Subject index of the website to search the many diabetic reports: www.themedicalnewsreport.com
e) Drugs and toxins including cancer drugs, isoniazid, and alcohol
f) Immune causes—multiple sclerosis including optic neuritis Medscape Clinical Focus, Nov. 17, 2017
B. Testing for neuropathy—EMG-electromyography
The electromyogram tests the function of nerves and is a test that is performed by neurologists. The time it takes an
electrical stimulus to travel down a nerve (to measure the speed of the nerve impulse) is compared to known normal values. They can also test a nerve to find out where along that nerve, there is a problem. Above diagram shows abnormal waves in the median nerve caused by carpal tunnel syndrome.
C. Common types of neuropathy
a. Diabetic neuropathy is one of the most common types involving the lower extremities and feet causing numbess and tingling sometimes very early in the disease. The feet are extremely important to prevent damage and injury from lack of feeling, causing ulcers, loss of toes, feet, and even lower extremities from a combination of neuropathy and vascular disease. Diabetics need to wear extremely well fitting shoes, and have special care of calluses and toe nails.
b. Autonomic neuropathy (dysautonomia) involves a different nervous system (sympathetic/parasympathetic system that provides nerve supply to blood vessels, the heart, and gastrointestinal system which can cause low blood pressure (hypotension), and reduced gut motility. This can occur in patients with diabetes, immune diseases, and spinal cord injury.
c. Optic neuritis is a focal neuropathy (mononeuroathy) affecting the optic nerve in the eye (usually just one eye) causing loss of vision, pain in the eye, loss of color vision, and flashing lights. Multiple sclerosis can cause this type of neuropathy as well as infections, diseases such as lupus and sarcoidosis. Even certain drugs can be the cause. The cause may be not known.
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Optic neuritis |
Normal retina |
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The optic nerve is the yellowish area on the retina seen on the right slide which is a normal retina. The left slide, optic neuritis, demonstrates swelling of the optic nerve (called the optic disc) caused by inflammation. Systemic cortisone is the treatment of choice to reduce inflammation and swelling of the optic nerve to preserve vision. Most recover, however, it can recur, especially in patients with MS. Mayo Clinic, WebMD
d. Alcoholic neuropathy can occur in the hands and feet and is usually due to a vitamin deficiency. Numbness and weakness are the most common symptoms. Alcoholics are very likely to experience these symptoms (up to 65% in one report). Vitamin deficiencies include Vitamin E, B6 and 12, thiamine, niacin, and folic acid. Nutrition is key for alcoholics since the liver can’t store these vitamins due to cirrhosis.
e. Trigeminal neuralgia-tic doloreaux A focal type of neuropathy such as trigeminal neuralgia involves the nerve that provides sensation to the face called the trigeminal nerve (frontal/ophthalmic, maxillary and mandibular)—This is one of the 10 cranial nerves.
The trigeminal nerve is one of the major cranial nerves (II), and is characterized by sudden onset of severe shooting pain in the face in one or more of the above branches. Even touching or stroking the skin, chewing, etc. can bring on an attack. It occurs usually on one side of the face and more common in women and after age 50. The episode can lasts minutes, days, or months. The cause is often unknown, however, compression by an intracranial blood vessel or rarely a tumor compressing the nerve can be the cause. Multiple sclerosis, shingles (herpes zoster rash seen below in photo), injury, stroke, Lyme’s disease, sarcoidosis, and certain collagen vascular diseases.
Shingles (Herpes zoster)
Shingles of the face not only causes a painful rash, but can blind the eye, attack the hearing nerve and cause deafness, and also cause facial paralysis. This is Ramsey-Hunt Syndrome.
D. Treatment of painful neuropathies Because there are so many causes of neuropathies, the medical workup is critical to focus the therapy in that direction, whether diabetes, multiple sclerosis, shingles, a pinched nerve in the spine, etc. However, the pain is the same and must be addressed. Neurontin is the treatment of choice , the original gabapentin, a anti-seizure medication. In herpes zoster, the eye can be involved and cause blindness. This medication and Lyrica do have some serious side effects, but people with this disorder are desperate for help. Muscle relaxants and antidepressants, and corticosteroids are also used in certain cases. In resistant cases of tic doloreaux, various types of surgigical techniques are recommended: glycerol injections into the sac surrounding the nerve root of the nerve (ganglion), sterotaxic radiosurgery (sending an extremely focused beam of radiation to the nerve ganglion), radiofrequency surgery sending an electronic current to the ganglion, or microvascular decompression of a intracranial blood vessel which is pressing on the nerve. Healthline, Mayo Clinic
That completes the November report.
The December report subjects will include: 1) Lawyers ads 2) Legalizing marijuana; CBD products use skyrocket 3) Ovarian cancer risk in BRCS gene mutations-new guidelines 4) Big Pharma—reducing drug costs-update 5) Smokers that quit—when does the health benefit kick in?; New information on Lung Cancer 6) Cleansing the body; Detox techniques-diets, etc.
As always, stay healthy and well, my friends, Dr. Sam
HAPPY THANKSGIVING Do you want to subscribe to my reports? If you are already getting my reports monthly, you are subscribed! My mailing list has grown enormously, thanks to the interest in my reports over the past 12 years. The subscription is free, there are no ads, and I don’t sell your name, etc. to anyone, like business, and some hospitals do. This is my ministry, and my way of giving back for 30 years of a fabulous private practice. Just email me at samlamonte@gmail.com, and I will add you to my confidential list. I will confirm you are on the list when you request it. Put me on your contact list to prevent me from being blocked. Share with your friends and family. Thank you, Dr. Sam
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