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The Medical News Report January, 2020, #96 Samuel J. LaMonte, M.D., FACS
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Subjects: 2. A close look at treatment for Asthma A. Rotovirus vaccine—new; Norovirus, Hepatitis A outbreaks C. At what age should one consider stopping routine cancer screenings D. Atrial Fibrillation- the new Watchman procedure 4. Immunotherapy for cancer—success and side effects (Cancer Survivorship Series #5)
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
Obstructive sleep apnea (OSA) is epidemic in the U.S. primarily due to increasing weight of the average American. 18 million Americans have OSA according to the National Sleep Foundation, and a good portion of these people go undiagnosed for years. A simple sleep study (in a certified sleep lab) will define sleep apnea and how severe it is. During the second half of the study, the treatment of choice (CPAP-continuous positive air pressure) can be used to calibrate how much pressure through a mask is needed to overcome the obstruction in airway. Note the tongue obstructing the airway in the drawing below on the next page. There is now a home sleep study that may be a screening technique for those unsure they are having apneic episodes. However, to certify the need for C-PAP, and have insurance pay, a certified sleep lab test is necessary. The goal of relieving OSA is to prevent complications such as cardiovascular and pulmonary disorders, daytime drowsiness, resistant hypertension, heart failure, risk of car accidents falling asleep at the wheel, daytime fatigue, overeating to stay awake, mood disorders, marital stress, poor libido, cognitive deterioration, to name a few.
I have discussed this issue at length, and for those interested, please click on the Subject Index on the website under SPECIAL REPORTS, WHICH IS IN THE FRONT OF THE SUBJECTS, including other techniques to relieve special types of apnea. Also for a more succinct report, click on: www.themedicalnewsreport.com #69 Reported symptoms of OSA (often by the bedmate) are daytime drowsiness, difficulty concentrating, headache, frequent urination at night, feeling tired when a person awakens in the morning, snoring, and pauses in snoring heard by bed mate.
A. CPAP machines and different nasal and facial masks There is a variety of masks and nasal pillows available to treat OSA. The success depends on the appropriate apparatus, a snug fit, and using it correctly, and completely relieving the apnea episodes. Without relief, the symptoms will not stop. Here are 10 tips from an article I obtained from the Mayo Clinic that could be valuable for those who are using CPAP. Some of the major problems experienced by these patients include stuffy nose, difficulty sleeping, leaky mask, and dry mouth.
1. The wrong size or style of mask Try a different mask. There are many to choose from. Some fit over mouth and nose, and others fit just in the nostrils (nasal pillows), but may or may not work based on the severity of the apnea. Some masks may make a patient claustrophobic, but can be overcome with practice. If one mask does not fit, try another one. It is very important to know how to adjust the mask.
A certified technician shoule be used to work these issues out. Respironics is one dealer for these and other devices for sleep apnea. There is a website that may be valuable www.thecpapstore.com I am not recommending these as this is the place for the technicians and physicians treating a person with CPAP.
2. Trouble wearing the CPAP apparatus Try wearing the mask several times without it hooked up. Then try the mask, hose and machine during the day to again get used to it. Once a person is used to the apparatus, it should be used every night, and even naps. Getting used to the pressure of the air will also get some nights to adjust to, and will give you time to find out what pressure is optimum for you to overcome the obstruction of the airway. The machine will be calibrated for your specific amount of apnea, but may have to be adjusted. As a person gains or loses weight, the severity of apnea may change.
3. Difficulty tolerating forced air Some machines can start with a low flow of air and slowly build up to the necessary force needed to overcome the obstruction in the airway. It is called a “ramp” feature. Another type of machine called BiPAP (bi-level positive airway pressure), adjusting the pressure with the maximum needed pressure when you inhale and less during exhalation. This is usually necessary for more severe cases. Another side effect can be bloating from air being forced down the esophagus. Getting the correct pressure set for the amount of apnea a person has is vital not to force too much air down the airway and if a person has a hiatal hernia, air is easier to be forced into the stomach. Sleeping propped up might prevent bothersome reflux and bloating.
4. Stuffy and dry nose A leaky mask can dry out the nasal lining causing stuffiness. If it is too tight for comfort, it means the mask is not fitting a person correctly, and needs to be replaced with a different size. Vaseline in the nose and the use of saline nasal spray may help, but the best solution requires a humidifier attachment to the machine (recommended).
5. Feeling claustrophobic Relaxation methods and yoga type breathing will help a person to go to sleep and tolerate the “enclosed feeling”. Also sleeping with just the mask without the hose and then with the hose, etc. may also acclimate a person to having a mask on the face. Also trying the nasal pillows (type of mask) may work better, but will not work for those with more severe apnea.
6. Leaky masks, irritated skin, or pressure sores These symptoms occur when the pressure is not being attained and leaks occur because the mask does not fit well. Air blown into the eye also can dry the eye or cause irritation, even corneal abrasion. Consult the mask supplier for advice or a change of types including the nasal pillows. If redness and swelling occur, consult your doctor.
7. Difficulty falling asleep All of the above issues must be managed to create a healthy environment for sleep. Quality sleep is a must for good health. Consult my website for addressing sleep issues, by clicking on the Subject index at www.themedicalnewsreport.com If sleep is still an issue with all the above fail, consult the sleep apnea doctor about medications. Keep in mind alcohol and sleep aids will interfere with quality sleep and can worsen sleep apnea. Some over the counter sleep aids dry the mouth as well.
8. Dry Mouth If a patient is a mouth breather, a chin strap to keep the mouth closed may be a solution or a full face mask to cover the mouth and nose with a cool mist humidifier attachment may alleviate the problem. Also there are dry mouth gels and mists that will help. Biotene products are sold in stores, and other brands (Stellalife) are available online.
9. Unintentionally removing the mask at night Those with restless legs or those who move from side to side may find a full mask will be more valuable. If the nose becomes congested, patients may pull the mask off, therefore, if allergies are an issue, with postnasal drip, the use of cortisone sprays and decongestants may be necessary. Salt water sniffs before bedtime may also be valuable to cleanse and soothe the nasal membranes and siphon the sinuses of excess mucus. Many will remove the mask during sleep. Setting an alarm 3-4 hours later in the night to check that the mask is still in place may be necessary. Going to the bathroom at night requires that the mask be replaced and that the fit is good. The average time people keep the mask on at night is 4 hours.
10. Bothersome noise The newer models are almost silent, so it may be time for a switch. The filter must be clean and unclogged for maximum efficiency of the machine and minimize noise. Earplugs or white noise machines may help. Using a tubing extender to place the machine further from the bed to minimize sound may be necessary. Talk to the technician about any adjustments contemplated.
B. Keeping the mask clean A clean CPAP machine is important and there is a commercially available machine (So Clean) to pace the mask in each day to sterilize the mask. It can prevent infection from a dirty mask.
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SoClean sterilizer
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Prime Clean
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www.mayoclinic.org May 17, 2018 There are several other cleaners now available. Please go online for choices that are much less expensive than SoClean. There are no comparison studies regarding the effectiveness of these various cleaners, but everyone should pick one. C. Options for treating OSA
1. Dental appliances for obstructive sleep apnea-an alternative Please examine the drawings below carefully.
The primary abnormality in sleep apnea is the tongue falling into the back of the throat blocking the airway. This is made worse by a small or short lower jaw (mandible).
If the jaw can be advanced only a few millimeters forward, this can be enough to help air get past the obstruction from the base of the tongue. Some tongues are thicker and larger for the mouth due to a narrow dental arch caused by a high arched palate. This dental deformity can be overcome in some patients with a dental device placed over the upper and lower dental arch. With the expertise of a special dentist, various materials can be use to pull the lower jaw forward fixing it to the upper jaw with elastics, plastics, or metals as seen above in the 2 photos. Mandibular advancement devices (MAD) can assist or relieve sleep apnea. The devices can have fixed amount of advancement or can be adjustable (Thompson Adjustable Positioner-TAP). There is a much less used tongue retaining device that is a splint that holds the tongue in a fixed position. These are difficult to adjust to but can be effective. These dental devices are much more likely to be used all night and are less cumbersome than CPAP machines. But as in any treatment, there can be side effects including an altered bite, movement of teeth, jaw joint pain, but may be overcome by the dentist or orthodontist who had the device made. Surgical advancement of the lower jaw also may be an approach. This requires major surgery from an oral or plastic surgeon.
2. Bariatric Surgery for Obstructive Sleep Apnea-OSA Weight reduction surgery is a time-tested procedure for morbid obesity. OSA is made more severe as the weight increases. Weight reduction using diet is a failure in most of these cases, and bariatric surgery should be in the equation when discussing options in the very overweight. CPAP is more difficult to relieve OSA, even if it is partially successful. To prevent the complications of OSA, the apneic episodes must be relieved.
3. Sleep apnea surgery (UVP) Having performed many of these surgeries for sleep apnea, I can attest to the effectiveness of the surgery, called a UVP—uvulo-phargngo-palatoplasty in the selected patients who fail or refuse CPAP or a dental device. In a modified form it is quite effective for snoring. This procedure removes part of the soft palate, tonsils, and redundant soft tissue in the back of the throat. Weight loss always helps any treatment for sleep apnea, and is a necessary addition to success with surgery.
Pre and Post op appearance of throat below! This surgery opens the airway and partially prevents the tongue from falling in the throat because of the tightness of the soft palate.
Selection of patients for surgery Expertise in this field is a must, and patients should seek those that have great experience in treating sleep apnea. Selection of the type of treatment must be made on several different factors beginning with a desire to accept treatment which should include weight loss in most patients. A thorough ENT exam is necessary including whether there is nasal obstruction, anatomy of the oral cavity, length of the soft palate, presence of tonsils, a large tongue, redundant soft tissue in the back of the throat, and several dental anatomical factors. It is a complex issue requiring consideration for several options.
4. Pacemaker stimulation for sleep apnea For selected patients, a pacemaker can be implanted with wires attached to the nerve that stimulates the tongue muscle (hypoglossal nerve), which helps keep the tongue from falling into the back of the throat because it has more tone from the stimulation. www.themedicalnewsreport.com #27
The cost is $28,000, however, Medicare does cover it in selected cases, however, 1/3 do not respond to the procedure and 6% need revisions.
WebMD
5. Tracheostomy When obese patients are not candidates or fail to improve with other choices, the airway can be permanently opened with a tracheostomy, bypassing the upper airway. The permanent tube is left in place and during the day, a plug can easily be placed in the trachesotomy opening for speech, swallowing, and protection of the airway.
2. Asthma—a close look at treatment options Having discussed asthmatic bronchitis as a cause of chronic obstructive pulmonary disease, I refer you to a previous discussion on COPD: www.themedicalnewsreport.com #77
Introduction Asthma is a condition in which the lung’s tissues are constricted preventing easy flow of air in and out of the lungs. Above in the left drawing, there is a comparison between a normal bronchial tree segment and what one looks like when constricted, trapping mucus. When mucus gets trapped, it can become infected. Asthma is an inflammatory disease caused by allergens inhaled. It can occur with any type of allergy causing severe breathing difficulty and even death. 1 in 13 Americans have asthma (25 million Americans-8.3% of all Americans-same percent in children and adults) and continues to increase each year according to the CDC. There are 439,000 hospitalizations per year from asthma and 1.3 million emergency room visits annually. Asthma claims 5000 Americans each year, and nearly half of those who die of asthma are 65 years of age or older, according to the American Academy of Allergy, Asthma, and Immunology. Asthma is more common in boys than girls, but more common in adult women. Asthma is the leading chronic disease in children and a leading cause of missed school days. Contrary to what is said, allergy commonly is not “grown out of” as a child. Also many people never develop asthma until they are adults depending on exposure to certain allergens. The cause of asthma is not known, however, it is known that it is hereditary in some (called atopy). These genetic tendencies seem to increase the risk of reactions to allergens and even viral infections in infancy. The response to allergens is an immune response which causes inflammatory reactions by certain chemicals called kallikrines. The response to histamines and other inflammatory markers creates swelling in the airway, whether in the nose, sinuses, or lower respiratory tract. Swelling of the throat and larynx can cause hoarseness and stridorous breathing.
Anatomy Drawings to explain Lung effects When the lungs are affected by asthmatic bronchitis, there is constriction of the muscles in the lining of these tubes that connect the throat to larynx to the trachea to the lung bronchi, and as a tree arborizes to the smaller tubes (bronchioles), and finally to air sacs (alveoli). It is at the alveoli where oxygen is absorbed and exchanged for carbon dioxide by the pulmonary blood vessels.
When bronchoconstriction occurs, the alveoli do not get enough oxygen rich air and the patient becomes short of breath, and with the narrowing causes the noise of wheezing. But not all asthma comes in attacks especially in adults. There can be ongoing wheezing in the lungs most of the time or intermittent. That is why maintenance drugs need to used, and when an attack occurs, rescue medication is needed that is fast acting.
Triggers for asthmatic attacks Common triggers for asthma include allergies, colds, and exercise. Chronic inflammation must be controlled when the airway is challenged. Children especially 5 and under may trigger their asthma from emotional outbursts, crying, exposure to second hand smoke, and changes in the weather especially cold weather.
Diagnosing and treating children with asthma
Diagnosing asthma in children is difficult. Many children may only complain of a cough, but wheezing and airway noises are common. However, other disorders may be the cause of airway obstruction including congenital abnormalities, foreign bodies, and infections. Other symptoms may include shortness of breath and trouble breathing. Nighttime symptoms may be worse in children. A trial of treatment may be recommended by a pediatrician if asthma is suspected. Daily short acting medications are usally used to prevent attacks. Facial chamber masks (seen above) to provide inhalation of nebulized medication may be necessary if breathing into a nebulizer is not successful. Parental education is critical when dealing with a child who has asthma. It is scary and thorough parental knowledge and experience will minimize the anxiety.
Allergens and irritants As in adults, prevention of environmental influences is key by avoiding air containing smoke, smog, allergens, danders from animals, with intensive cleaning of the house to reduce house mites, danders, mold, pollens, and allergens, removing cotton containing fabrics, drapes, bed coverings, etc. is also helpful. Keeping windows closed is important as well. Treating allergy symptoms with allergy medication prescribed by the doctor is important as well in seasons known to flair the asthma. Prevention is the key! Severe asthmatic attacks deserve a visit to the emergency department for rapid treatment. This is especially true if rescue inhalers are not effective, such as, albuterol mist inhalers (Ventolin HFA, ProAir HFA). Allergy shots may needed to be administered from an allergist.
Options for treating asthma The primary goal in treating asthma is reduce inflammation in the lining of the respiratory tract, combat allergens that are the cause, and improve the airway breathing capacity by dilating the bronchioles by relaxing the smooth muscles of the bronchi and bronchiole. There are aerosol inhalers, powder inhalers, and medications breathed with the use of a nebulizer. There are also syrups and pills. The choice comes from experienced physicians in knowing the right medication for each occasion. Powders are difficult for some to inhale causing hoarseness and dryness of the throat. Aerosols are the alternative. Addressing upper and lower respiratory allergies requires trying typical allergy medication and decongestants with mucus splitters and cortisone nasal sprays. 50% of those with upper respiratory allergies have asthma. Seeing an allergist may be required to be tested for specific allergans and take allergy shots to reduce the response to those allergens when confronted. For children under 12, treatment regimens may be different. Even patients with intermittent asthma can have severe or fatal exacerbations (recurrences), and it is known that daily inhaled corticosteroids can prevent them. However, recent studies have found that as needed steroid inhalers combined with a bronchodilator are just as effective as every day use of inhalers.
Change in recommendations for asthma treatment Basically, asthma can be somewhat artificially separated into mild, moderate, and severe. For each of these stages of severity, there are suggested treatments. However, asthma is a very dynamic disease, and the severity differs based on triggers for increased symptoms, and need to treat acute vs chronic symptoms. The options are to use corticosteroid inhalers alone or bronchodilator inhalers alone. Most American physicians use a combination of these 2 medications. They can be short acting or long acting, depending on whether a chronic issue is being addressed or someone who is having intermittent acute asthmatic attacks. That is where the physician must make the decisions about types of inhalers. Alternatives could also be a nebulizer, pills, liquids, etc. More physicians are using as-needed steroid/bronchodilator inhalers for mild cases. Preventing attacks is key in the management of asthma. Below is a look at each of these options for treatment.
Medihalers-options
A. Rescue inhalers and long acting bronchodilator combined with corticosteroid inhalers Short acting (rescue) bronchodilators are most often used for an acute asthmatic attack. Anyone who has asthma should have this type of inhaler available in case of emergency. The effect lasts 4-6 hours. Bronchodilators relax the smooth muscles in the bronchi and bronchioles. Long acting inhalers last 12 hours to help control the disorder. These inhalers usually are combined with a corticosteroid which relieves the inflammatory component of asthma.
B. Inhaled Corticosteroids Corticosteroid inhalers can control the chronicity of asthma and prevent acute episodes. Steroids are combined with bronchodilators in most inhalers. *Note—there are medihalers that are not to be used for asthma, rather they are reserved for patients with COPD (chronic obstructive pulmonary disease).
C. 3 classes of Bronchodilators—beta-adrenergic, anticholinergic, and xanthine derivatives
Note-Bronchodilators expand the constricted bronchial tree by affecting the smooth muscle fibers in the wall of the bronchi. There are 4 different types of drugs to accomplish this in somewhat different ways. a) beta-adrenergic agonist bronchodilators (they are similar to drugs that stimulate sympathetic nerves). These beta-adrenergic drugs relax the beta-2 receptors in the smooth muscles in the walls of the bronchi and bronchioles allowing dilation of the bronchi. Short acting beta adrenergic drugs—Albuterol or levoalbuterol (Provental HFA and Ventolin HFA), and epinephrine injections (Epipen). Long acting beta-adrenergic bronchodilator drugs—powders-salmeterol (Servant diskus) and formoterol (Perforomist). Aerosol inhalers include budesonide and formoterol (Symbicort). Many of inhaler contain the medication in powder form, and to prevent fungal infections in the mouth and throat, the mouth should be cleaned by swishing and gargling. The teeth should be brushed immediately after inhaling the medication. There are a few that come as a liquid inhaler. Side effects to be aware of when taking a bronchodilator including migraine and non-migraine headaches, nausea, stomach upset, flu-like symptoms, dry mouth, hoarseness, cough, palpitations, worsening of asthma, low potassium, fast pulse, elevated blood pressure, and chest pain.
b) anticholinergic bronchodilators These inhalers block acetylcholine, a chemical in the receptors of nerve endings. These cholinergic chemicals can cause contraction of these smooth muscles in the bronchi and bronchioles, and the anti-cholinergic medications block that action creating bronchodilation. Side effects of these inhalers are similar to the beta-adrenergic inhalers, however, they may interfere with urination in those with an enlarged prostate, and can aggravate glaucoma. Anticholinergic bronchodilator drugs are ipratropium (Atrovent) and tiotropium (Spiriva Respimat), and umeclidinium (Incruse Ellipta).
c) Xanthine derivatives This class also relaxes the smooth muscles of the bronchi and bronchioles by blocking certain enzymes (PDE) that are involved with the smooth muscles in the lungs. Examples include theophylline (Theo 24) and aminophylline. Side effects are similar to beta adrenergic drugs, however, they may drop the blood pressure, cause shock, seizures, severe dermatitis, and cardiac arrthymias.
D. Leukotriene inhibitors Oral medications are also valuable for some. These medications block the inflammatory chemicals (leukotrienes) that trigger airway inflammation and cause asthma. Montelukast (Singulair), zafirlukast (Accolate), zileuton (Zyflo) are long acting medications to control asthma.
E. Oral corticosteroids These steroids are used in hard to control asthmatics especially when inhalers are not very successful. Steroids are an anti-inflammatory medication as well. They should be used sparingly since they do have significant side effects. Aerobid and Aerospan are examples.
F. Antibody treatment (biologic therapy) Omalizumab (Xolair) is limited to severe cases of asthma when other forms of therapy are not successful. Antibody therapy prevents cells from responding to the inflammatory process created by allergens and irritants.
G. Immunotherapy (allergy shots) Allergy shots contain a very small amount of what a person is allergic to. The strength of the allergen is increased over time. Usually shots are administered in the allergist’s office in case there is an anaphylactic reaction to the allergy shot. Epipens should be available at all times when taking these shots to combat an acute reaction. There are FDA approved sublingual tablets (Grastek, Oralair, Ragwitek) work similar to allergy shots. These have black box warnings as they may cause an acute reaction similar to allergy shots and are not recommended for severe cases of asthma.
H. Interactions with bronchodilators There are serious interactions with bronchodilators and other medications. Please consult the package insert or search under the specific medication prescribed.
I. Complications of resistant asthma
J. Outcome of Asthma Many people think that children grow out of asthma, and that is NOT TRUE. Most children never grow out of asthma and therefore will deal with it as an adult, but may not be aware of it. Many may have very mild episodes as a child and then become symptomatic as an adult. 50% of patients with nasal and sinus allergies have clinical or subclinical asthma. If a person suffers from significant upper respiratory allergies, and has any shortness of breath, cough, and productive sputum, with or without wheezing, a doctor visit is in order. A significant case of bronchitis may bring out the asthma as well. Self Help www.asthma.com provides a self help guide in assisting the physician with the management of asthma. www.aafa.org/facts American Allergy Foundation, Mayo Clinic, WebMD, medicine.net
Rotovirus is the leading cause of severe diarrhea in young children. As a grandparent (for most who read my reports), it is important to know this virus is easily prevented with the vaccine given at 2 months, 4 months, and 6 months (Rototeq)—alternative-Rotatrix at 2 and 4 months (drops under the tongue). 9 out of 10 who receive the vaccine are prevented from developing a severe case of diarrhea, vomiting, fever, and abdominal pain according to the CDC. The key for parents is to accept vaccinations to prevent disease, and accept the fact that vaccinations are safer than risking severe disease to affect their child and expose others to serious disease. For grandparents, check with your children to encourage vaccinations for your grandchildren! Before the vaccine, 50-70,000 children were hospitalized annually from the rotovirus infections. For more information, click on the CDC website, and search for rotovirus infections. Although my readers are not millennials usually, I feel brief information on childhood disease would be of interest and will start including information on children, and adolescents, and young adults in coming reports.
Norovirus outbreaks Norovirus is a very contagious virus causing vomiting and diarrhea. In November, there were schools who have had
to be closed because of this virus. It comes from direct contact with infected people, eating food or drinking water contaminated by the virus, touching hands or surfaces with the virus present. A school in England closed recently because of a suspected norovirus outbreak. The virus is most likely to occur November-April. Over half of the reported cases have come from long care facilities. Restaurants are also a source—lettuce, fruit, shellfish especially oysters. They also occur in schools, childcare centers, and cruise ships. Prevention is the key—wash hands frequently, eat cooked food, and wash vegetables and fruit. 50% of food related illnesses are caused by norovirus. It is a self limited illness, but those elderly, immunosuppressed, or those with chronic illnesses are more likely to have more severe cases creating dehydration, abdominal cramps, and feeling extremely ill. There is no treatment, so prevention is the key.
Hepatitis A outbreaks in Florida Florida has had several outbreaks recently, and the Health Departments in Florida have been offering free vaccinations. 736 cases have occurred in Florida, but those are only the reported cases. Central and South Florida have had aa most cases especially in the Tampa Bay area. Many cases have few symptoms and the incubation period is 2-6 weeks. Kitchen workers in restaurants have been one of the sources. Lettuce is notorious for being contaminated. IV drug users, homeless, and men having sex with men are at high risk. Once symptoms occur there is fatigue, abdominal discomfort, some nausea and vomiting, clay colored stools, yellow jaundice, with joint pain. Resulting cirrhosis of liver can occur as in any form of hepatitis. The best way to prevent it is with the hepatitis A vaccine. It is strongly recommended in those who go to certain parts of the world traveling (Orient, Central and South America, and Eastern Europe).
B. Drugs for gastric reflux safe for long term use or not?
Quote from an article in the Huffington Post, written by Dr. Craig Bowron, M.D., FACP written in 2013.
Stomach acid We need acid in our stomach to help the digestive process. The stomach has specific cells in the lining that produce acid (the hormone, gastrin, stimulates the cells to produce hydrochloric acid). The lining also produces enzymes (pepsin, rennin, and lipase) that also are critical in digesting proteins. The stomach also produces a substance called, intrinsic factor, that allows for the absorption of Vitamin B-12. I have written about the function of the stomach and its diseases previously: www.themedicalnewsreport.com #43 And yet, that same acid which is meant to stay in the stomach, commonly refluxes into the esophagus, throat, mouth, and even the larynx (voice box) and lungs causing aerodigestive erosions, ulcers, pain, bronchitis, and even aspiration pneumonia. It would certainly aggravate asthma. Acid suppressors have become a $billion business for the pharmaceutical industry thanks to expansion of America’s waistline. Acid suppressors (PPIs and H2 blockers)—side effects It is estimated that 10% of Americans take these medications for heartburn, indigestion, and reflux. There are several reported side effects of these reflux medications. They include dementia, osteoporosis, bone fractures, micronutrient deficiency, pneumonia, spontaneous bacterial peritonitis, kidney disease, and gut infections.
Zantac recalled due to fear of carcinogen in product Recently rantidine (Zantac), an H2 inhibitor across the counter, has been found to contain more than acceptable amounts of a carcinogen, nitrosamine, and has been removed from the market. No other reflux medicine has been implicated. Note that nitrosamines are in many foods, especially processed meats (ham, bacon, sausage, cheeses, beer, non-fat dry milk, and sometimes fish. Tobacco smoke, and e-cigarettes also contain nitrosamines. Nitrosamines are associated with stomach and esophageal cancer. The drug manufacturer is Sanofi, who makes the brand name drug. Apotex, but Sandoz, maker of the OTC drug (rantidine) pulled the drug in Walgreen’s and Rite Aid. GlaxoSmith Kline recalled the drug in India and Hong Kong. If there is rantidine or the brand name Zantac in the medicine chest, throw it out or return it for a refund. These reports of side effects scare people when some side effects are honestly not well documented, and they stop taking their medication without reporting this to their doctors. It is important to discuss this with the primary care or treating physician when stopping a medication so that an alternative might be prescribed. Further studies need to corroborate all of these reported side effects.
Types of reflux medication There are 2 groups of medications that suppress acid secretion (and decrease intrinsic factor unfortunately) plus antacids—PPIs (proton pump inhibitors) and H2 blockers (histamine 2). They are effective in treating reflux, stopping acid indigestion, and help heal stomach ulcers
PPIs—proton pump inhibitors Examples are Prevacid, Nexium, Dexilant, Aciphex, and Prilosec. These are stronger and are said to be more effective for reflux.
H2 blockers—histamine 2 blockers Examples that block histamine (which increases secretion of acid), are Tagamet, Axid, Zantac, and Pepcid. Unfortunately, with the suppression of stomach acid, iron in food can be blocked from being absorbed including Vitamin B12. Both can cause anemia. In addition to iron malabsorption and anemia, other side effects include gastrointestinal symptoms (gas, constipation, diarrhea, pain, fever, vomiting, a risk of fractures , pneumonia, and overgrowth of a bacteria called C.diff. (Clostridium difficile), which can cause gastrointestinal disease. Low magnesium, chronic kidney disease, and dementia may occur. Patients on long term acid suppressors
need to have their doctor check for evidence of
anemia (red blood cells may be
deficient in iron, which is necessary to produce hemoglobin, which
is the pigment that carries oxyge
Antacids Tums and other antacid liquids (Gelusil, Mylanta, etc.) containing aluminum and magnesium hydroxide do not block the absorption of iron. These antacids contain significant amounts of calcium, and should be avoided in those with kidney disease and a history of kidney stones. For immediate relief, they are valuable.
Summary Do not take PPIs or H2 blockers over the counter for more than 2-3 weeks without seeing a doctor to address gastrointestinal symptoms (reflux, acid indigestion, etc.). Seeing a gastroenterologist may be necessary.
New study refuting the myth of harm from long term use of PPIs There have been several studies in the medical literature stressing the side effects for long term use for gastric reflux. A recent large study has dispelled that information from previous research, because of questionable design of these studies, and found in 17,600 participants over 65 did not have an increase in diabetes, chronic kidney disease, dementia, COPD, stomach cancer, etc. There is, however, a slight increase in gut infections other C.diff. However, in a recent report on dementia in one of my Medical News Reports, there was good evidence reported that these reflux drugs over a long time may increase the risk slightly. It is all about risk versus benefits. Most patients requiring these meds need to be endoscoped to rule hiatal hernia, reflux esophagitis, cancer, Barrett’s esophagus (precancerous), etc. Keep in mind those meds over the counter are only half the strength of the prescription meds, so a person may need to double the dose if they want prescription strength levels. Reflux is epidemic especially in patients who are over weight, but the bottom line is, don’t ever take an over the counter (OTC) drug long term without medical direction and supervision. Do not stop taking reflux medications (or any medications) without talking to physicians about the risk/benefit situation. Gastroenterology, May, 2019
C. When to stop screening for cancer in general population Many older men and women must come to grips with whether to stop screening for cancer (PSA, cervix, colon) or face an otherwise undetected cancer late in life. Usually it is suggested by most organizations to stop at age 75 (with less than a 10 year life expectancy) unless there are special circumstances such as increased risk or previous cancer, precancerous colon polyps, precancerous breast tissue, etc. Or, you just don’t want to stop. There are consequences either way. The cancer organizations ask doctors to estimate the 10 year survival for a patient, and if the person is not expected to live for another 10 years, they should consider stopping. This is a very tricky issue and one that can’t be taken lightly. Defining longevity is also a subjective issue. But a recent article in JAMA provided a study that asked elders about this. Most did not want to be told to stop, rather they preferred for the doctor to discuss their current health status and provide a discussion about the risks of over diagnosis and harm versus the benefits. They did not want to feel that their doctor was abandoning them. Patients must be proactive in requesting these discussions. This is a perfect example of patient-centered care, which has been supported by the medical community for several years to bring the patient to the table for decisions about their health from information from their doctors. But for the general healthy population who have never had cancer by 75, it seems reasonable to consider stopping. No one is out of the woods, but it is a decent indicator. With a 10 year life span expected, that puts a person at 85 years of age, and the current average life expectancy in the U.S. for a woman is 81.1 years and 76.1 years for men. White women average 81 and men 76.5; Hispanics average 84 for women and 79 for men; Blacks-78-women and 72-men. Doctors are instructed to provide the risks and benefits of screening later in life and then let the patient decide in conjunction with their doctor. Keep in mind this does include those with symptoms that would require evaluation. Patients do not want to be told they are not going to live another 10 years. They also do not want to feel abandoned by their doctors if they do stop having screenings. It is now suggested after hearing the pros and cons, it is the patient who should make an informed decision! Realize that there will be circumstances that may reverse the decision or symptoms will prompt evaluation of a certain organ system. Patients must continue to be very diligent to listen to their bodies and report any significant changes at any age. Unknown to most of us, some medical institutions provide financial incentives to continue screening which confuses people whether they should continue screening. Also some radiology and or institutions send reminders that it is time for a screening regardless of age. Always discuss this serious issue with your doctor and be informed about the risks and benefits of continuing to screen (for the general healthy population). JAMA, Sept. 18, 2019
Patients with atrial fibrillation can have two areas of the heart that are affected. The right and left atrial chambers of the heart. There is a small pocket of tissue derived from the left atrium, called the left atrial appendage, which can form clots. When atrial fibrillation occurs, the most common serious cardiac irregularity, prevention of blood clots is very important, and the goal is stop the irregular heart beat. The main cause is atherosclerosis (hardening of the arteries). Please take a moment to find the left and right atrium chambers of the heart, see below. The arrow points to the little appendage off the left atrium that is the focus of our discussion. Note the left atrial appendage is a pocket off the left atrium.
When the atrium (left or right or both) fibrillates, it quivers instead of squeezing blood into the right ventricle and the left ventricle. With the atrium quivering, abnormal flow of blood occurs and creates pooling of blood in the atrium which can create blood clots. The blood clots from the right atrium travel into the pulmonary artery blocking valuable blood flow to the lungs. The left atrium clots can back up into the left atrial appendage and lodge there to eventually leak out into the left atrium and then out of the heart and then to the brain, creating a stroke (90-95% of strokes created by an embolus come from blood clots in the left atrial appendage).
What is the function of the left atrial appendage? Embryologically, the left atrial appendage is derived from the left atrium. It functions as a decompression chamber or a reservoir to prevent surges of blood in the atrium when the mitral valve is closed during the heartbeat. The lining is very rough (with trabeculae) cords while the left atrium is smooth. Because the atrial appendage does not have a smooth lining, blood clots are more likely to form there. It is like a pop-off valve to prevent blood from surging toward the mitral valve when the valve is closed. Over time, without this benefit, the valve could be damaged. The left atrial appendage also forms stem cells to help the heart heal, which are secreted from granules in the lining, a Natriuretic Factor, which can lower the blood pressure. As one ages, the use of the left atrial appendage, although it can be valuable for exercise, becomes more of a liability than a value. If surgery is required in certain cases of resistant atrial fibrillation, the focus is on tying off, using Atria clip, or removing the left atrial appendage. It is written that for some patients who even have their atrial fibrillation cured, they still should consider removing the left atrial appendage. This is somewhat controversial.
The Watchman Procedure A procedure has been devised called the Watchman procedure, that sends a catheter through the walls of the heart into the opening of the left atrial appendage. The catheter contains a basket to block off the connection of this appendage to the left atrium.
The need for Warfarin (Coumadin) to prevent blood clots is usually successful. However, strokes can still occur if clots stay in the left atrial appendage, even when atrial fibrillation is stopped. It is still early since this procedure was developed, and selection of patients is critical. All procedures, the use of anticoagulants, and recurrence of atrial fib. all must be take into consideration when discussing procedures to block off or remove the left atrial appendage. The training and experience of the physician is critical for success. Time will tell whether this procedure stands the test of time. The Mayo Clinic website cites the Watchman device as a possible option for surgically blocking the appendage to prevent non-valvular blood clots from the left atrial appendage. These patients are on warfarin and many patients find it inconvenient because blood must be drawn to follow clotting studies so that the dosage of Warfarin can be adjusted when the prothrombin time is too high or low. The procedure requires general anesthesia and has risks. The catheter is introduced through the vein in the groin up the inferior to the superior vena cava into the right atrium through the wall from the right heart to the left side of the heart. It is then passed into the left atrial appendage, where the parachute shaped basket that is left in the appendage to block off this small pocket of heart tissue as seen in the drawing below:
Patients will stay in the hospital overnight for monitoring and possible complications. Warfarin will be continued for 45 days until the postop appointment occurs where a transesophageal echocardiogram will be placed to determine if the appendage is blocked. If blocked, warfarin will be stopped and an oral anticoagulant (Plavix) and aspirin will be started. At 6 months, Plavix can be stopped and the aspirin continued. There is another device called the Amplatzer Plug device which has been used in Europe since 2008, and it is being tested now in the U.S. Stay tuned! The Watchan device can be used in patients who undergo ablation procedures or heart surgery. I have discussed atrial fibrillation in detail: www.themedicalnewsreport.com #59 www.themedicalnewsreport.com #72 www.themedicalnewsreport.com #79 Mayo Clinic, Cleveland Clinic
4. Immunotherapy for cancer-Good news but know the side effects—Cancer Survivorship Series #5 Introduction Before speaking about one of the great advancements in oncology, I ran across an article in JAMA, Sept, 2019, that reported on some astonishing facts about the burden of cancer. Globally, in 2017, there were 24.5 million cancer cases (7.7 million cases of skin cancer—basal and squamous cell carcinoma), 9.6 million deaths, and 234 million life adjusted years of disability. There has been a 33% increase in cases between 2007-2017. As expected lung and prostate cancer lead the cases in men with the most deaths from lung, liver, and stomach cancer. For women, breast and colorectal cancer lead with the most deaths from lung, breast, and colorectal cancer. We have a long way to go, but there has been some valuable advances in oncology and immunotherapy may lead the pack.
Immunotherapy treatments There are newer treatments such as immunologic and genetically driven treatments, but their side effects have not been publicized much until the last year. But, for many, it has kept 35% alive for over 10 years with advanced melanoma as mentioned above. Other cancers also respond to this treatment. Standard chemotherapy is toxic to the cancer cells without targeting any specific genetic information, but it also is toxic to normal cells too. They do not affect them as badly because the normal cells do not grow as fast as cancer cells, and that makes the cancer cells more vulnerable to chemotherapy. Immunotherapy, in contrast, targets the immune information in a cancer cell to let the patient’s immune system fight the cancer cells. Although there are serious side effects, these targeted medications to do directly affect normal tissue as does standars chemotherapy.
Terms that may confuse There are different terms when considering drugs that manipulate the immune system of the patient or the cancer. Immunotherapy is a type of biologic therapy and most are targeted therapy, in that they hone in on a specific genetic marker to act against the cancer cell. These medications render the cancer cell more vulnerable to the patient’s own immune system defense. Our immune system provides accelerator points and checkpoints to modulate therapeutic responses to normal cells. This treatment requires a normal immune system for best results.
Immune Checkpoint Inhibitors A specific type of targeted therapy called immune checkpoint inhibitors can be administered to block the PD-1 and PD-L1 surface proteins (programmed death ligand) on the surface of cancer cells that allow cancer cells to hide from the natural immune system’s T-cell lymphocytes. Not all cancers have these PD proteins, and patients must be tested for their presence to effectively utilize these agents. Tumor specific gene mutations allow oncologists to tailor treatments based on these mutations. Testing the DNA sequence allows for specific known targeted therapies to treat these tumors more aggressively. If a tumor does not have known specific gene mutations, some of these agents will not be successful, and therefore it allows the oncologist to be more selective in treatment regimens. Oncologists are testing for these gene mutations routinely now, which directs more successful therapy. Well known immunotherapeutic agents are Keytruda, Optivo, and Libtayo that target PD-1, and Tecentriq, Bavencio. Imfinzi targets the PD-L1 gene mutation, but it also can treat a rare kind of skin cancer called Merkel cell carcinoma. Because of success treating these cancers, major cancer centers are offering this treatment in multiple clinical trials to many cancer patients who have failed with standard treatment regimens in clinical trials. But many patients do not respond even with the tumor specific gene mutations, and considering the enormous cost, expectations can be artificially inflated. Optimism and hope is always good, but cancer centers are eager to sign up anyone eligible considering the revenue received. Medpage, June, 2019 By the time immunotherapy is initiated (which is approved for only advanced cancers), the average extended life span is 3-6 months at a cost of $1-300,000 with a co-pay of approximately $60,000.
Expanded use of immunotherapy Newer clinical trials are finding that immunotherapy in select patients may be used up front (in addition to chemotherapy) in treating certain cancers (called adjuvant therapy). Also the FDA has approved these immunotherapies for other cancers in a fast track system. Advanced and metastatic head and neck cancers are approved for Keytruda with chemotherapy (cispalatin and 5-FU) extending life on the average of 3.5 months longer than chemotherapy alone. Triple negative breast cancer (locally advanced or metstatic) has been approved by the FDA to use Tecentriq and the chemo agent Abraxane to block the PD-L1 genetic marker. Studies have shown 3-4 months more survival compared to chemo alone (7.4 months compared to 4.8 months—at one year 29% were alive at one year compared to 16%). However, chemo alone vs immunotherapy alone has equal survival but the combination makes a difference in survival. However, there are more side effects using them in combination. Patients desperate for extending life will consider this. Ultimately finding immunotherapy’s place in the treatment of cancer continues to be researched. But it is clear the combination of immunotherapeutic agents in combination with chemotherapy is amking a difference.
Side Effects of immunotherapy Although there is great success in some patients with advanced cancer, these patients are already compromised in many ways and susceptible to multitude of side effects from immunotherapy: infections, sudden death, myocarditis-arrhythmias (1%), hepatitis (10%), severe rashes (25%), colitis (25%), pituitary inflammation-hypophysitis (10%) and insufficiency (loss of cortisone necessary for regulation of blood pressure, heart function and metabolism, hypothyroidism, vision impairment, lung inflammation (pneumonitis-5%), nerve dysfunction (1%) including neuropathy, Gullain Barre syndrome, brain swelling, kidney failure, severe skin rash, and elevated blood sugar. Some of these side effects may not appear until treatment has ceased. Patients must acknowledge a problem and bring it to the attention of their oncologist. Many deny an issue or are afraid if they tell their doctor about a side effect, they will be taken off a potentially effective therapy. Minor side effects today can be major effects tomorrow and this is especially true for immunotherapy.
Treatment benefits linger for some time Even stopping an immunotherapy treatment prematurely does not mean the cancer fighting effects stop as it would with chemo or radiation. In fact, in studies, those who have to stop a treatment regimen live just about as long as those who continue immunotherapy.
Treatment of side effects About 20-40% of those on checkpoint inhibitors will suffer more serious side effects (Optivo, Yervoy) from an overstimulated immune system. Many of these symptoms can be treated with cortisone, because this slows the immune system down temporarily.
New innovations and hope! There is a clinical trial using neoadjuvant therapy* with these medications prior to surgical removal of breast cancer, showing long survival rates. *Neoadjuvant therapy is defined as a medication is used prior to standard therapy. Cancer survivors should not be discouraged because of side effects, rather they need to be educated and report them early. There are alternative FDA approved therapies that may be just as effective. The rate of response can be from 15-65%, therefore, survivors may be switched from one regimen to another with or without additional chemotherapy. The search is still on to find other biomarkers that will help guide therapy. Immunotherapy is not yet considered first line treatment. Immunotherapy is still a very new but exciting treatment but with significant side effects. This area of cancer research is aggressively searching for more biomarkers that allow doctors to tailor treatments. Reference--Excerpts from Cure Today magazine special issue on immunotherapy, July 9, 2018; JAMA, 2018 Immunotherapy, Vol. 5, May, 2019, Biomarkers and Molecular Testing taken from Conquer Magazine for cancer survivors
This completes the January, 2020 report.
Next month, the February, 2020 report will include: 1) Supplements for brain health and other quack treatments 2) Stem cell treatments—abusing unproven methods 3) Plant based diets, body cleansing, and othjer methods 4) Steps (walking) to take to decrease mortality 5) Treating chronic pain in cancer patients 6) Robotic minimally invasive knee replacement surgery-new technique 7) Effect of menstrual periods on productivity As always, stay healthy and well, my friends, and have a fabulous year!! Dr.Sam
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