The Medical News Report

#98

March, 2020  

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for March, 2020:

1. Why has the U.S. been  so dependent on foreign countries (China) for critical emergency supplies and medications?  Update on Flu and Coronavirus

2. Insomnia-- a serious health hazard

3. Medical Updates-

     a) Certain dietary supplements can be toxic for chemo patients!! Alert!!

     b) Understanding the validity of medical research

     c)  Oral anticoagulants have antidotes now!--guidelines

     d) Why are high risk cigarettes smokers not getting low dose lung CT scans to find their lung cancers earlier?

4. Mental health of young people?

5. Brain aneurysms

6. Defining the roles of Ophthalmology, Optometry, and Opticians. Roles

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

1. Why is the U.S. so dependent on foreign countries (China) for medication development and supplies? Update on the Flu and coronavirus

Over 1700 healthcare workers have become infected with the coronavirus. The head of the Wuhan hospital, a neurosurgeon and whistleblower, is dead from the virus (we are told).

  China lied about the number of infections and failed to quarantine the city fast enough allowing travel of their citizens to infect people all over the world. This is the same country that has stolen our most important technical secrets for decades. And yet, we are to this day dependent on foreign countries like China for medical supplies, devices, and ingredients to make medications. Medicines are becoming in short supply (insulin and antibiotics for example).

  The U.S. has passed regulations in previous administrations making it almost impossible for industries including Big Pharma to work in the U.S. pushing them into other countries.

  Now we are in a crisis of another global viral illness (coronavirus now named COVID-19 by the WHO) to realize we are also not staying ahead of infectious diseases, because we have become so global in our travels that disease in other countries has a direct impact on the U.S.

  Fortunately, the current administration stopped travel for Chinese and other foreigners, and now requires quarantine for 14 days before our own citizens can go home. They are being sent to military bases for their quarantine.

  Currently the U.S. has donated $100 million to the World Health Organization (WHO) to fight this virus. Why are we shelling out money to fight a virus in China, when that country practically owns us? I guess that is the way we have always dealt with any emergency or crisis and have for decades. We always need to help people, but maybe who receives our charity might ought to go to our friends and allies.

  Our president has called for more direct dependence on the U.S. for drug manufacturing. When it is hard to find a face mask (which usually is made in China) these days, it reminds us we need to do a better job at home of manufacturing our own medical needs.

  Health and Human Resources Services ,Alex Azar, needs to provide incentives to drug manufacturers to develop medical supplies and drugs in the U.S. according to a Townhall website. We find ourselves trying desperately to reduce prices for drugs here and yet, expect Big Pharma to play ball with lowering prices. We can’t have it both ways.

  Most people do not know that the U.S. has a U.S. National Strategic Stockpile which maintains a stockpile of medical equipment to meet emergencies.

  Luciano Borio, former director of medical and biodefense preparedness at the National Security Council warned Congress that the U.S. has not sufficiently protected the supply chain of essential medicines and medical equipment, according to this article written by Betsy McCaughey, Chairman of the Committee to Reduce Infectious Deaths and former Lieutenant Governor of New York.

  Do we have adequate Hazmat protective suits, masks, and goggles to contend with a national infectious crisis? We should feel secure that we are protected but are not.

  Finally, we must remember fear can be much worse than the virus. We must all take daily common sense actions to protect ourselves. Hygiene is critical! Avoidance of crowds and frequently cleaning our hands can reduce the chance of any infectious disease. 

A word on Influenza and Coronavirus

  Our area is seeing primarily type A influenza virus. The type B strain is supposedly more prevalent in other areas of the country and more severe for children, but my personal primary care doctor is seeing type A only.

  The flu vaccine covers the Type A strain better than Type B. The current vaccine only helps about 50% of type B strains and 55% for type A in children according to the CDC. For adults the vaccine has been only about 45% of the population and the CDC considers a successful year for a vaccine to be 90%. They also mentioned that the type A strain in young adults was ineffective with this vaccine.

  The CDC estimates 350,000 Americans have been hospitalized, 14,000 have died from the flu so far this year along with 92 children.

  The flu remains much more of a concern in the U.S. than coronavirus (COVID-19 virus), but it is a wake up call for us to be better prepared for any infectious disease pandemic.

  In contrast, the COVID-19 virus has caused 73,424 cases and 1,873 deaths globally according to the WHO (World Health Organization) including 19 cases in the U.S. as of Feb. 20.

  However, until the CDC can get into China and find out the real story, the statistics are in question as are the methods they are using to control the virus.

  There are 479 cases in the U.S. under investigation for the virus. There are no confirmed cases in Florida and the South. It does not include the Diamond Princess cruise ship.

Comparison of viruses

  After the second week of February, there were 350,000 people that have been hospitalized with the flu in the U.S. this flu season and 25,000 deaths. 31 million cases are estimated globally.

  The COVID-19 virus is a distraction from the immediate threat of the flu. However, it is not as deadly as the COVID-19 virus. As the warmth of the Spring comes, this virus should diminish.

  Prevention and treatment is the same for both viruses since they are spread in similar manner. Less contact in crowds, frequent hand washing, and keeping the hands off the face, coughing into our elbow (not in the hand) is the best a person can do. Masks bought at the store do not prevent viruses from penetrating to the nose. The virus can live on most surfaces for hours.

  Even though Tamiflu may reduce the symptoms of flu by one day if taken early in the disease process, it would not help the other virus.

  Several companies are working on a vaccine against the COVID-19 virus. It will be available in several months, but I would doubt full scale vaccination will be recommended unless travelling to the Orient.

  Consult the CDC’s website for more updated information

www.cdc.gov

2. Insomnia a serious health hazard

  There are many sleep aids on the market that provide an enormous income to the industry. Looking into these supplements and medications, there is some evidence that these might be helpful in certain cases and not in others.

 People with insomnia often have a variety of underlying causes including depression, worry, anxiety, medication side effects, sleep apnea, prostate or bladder issues, menopause symptoms, hypothyroidism, and even obesity without apnea.

  44% of older people have insomnia (American Sleep Foundation). 1 in 10 people have insomnia from time to time.

Consequences of poor sleep

  Consequences of poor or lack of adequate amounts of sleep include fatigue, mood dysfunction, lack of concentration, worsening of mood disorders (depression, anxiety, etc.) and create a vicious cycle. It also can make a person gain weight with all the health consequences. Lack of quality sleep stimulates cortisol, the stress hormone. High cortisol levels can make people gain weight. It also can raise blood sugar levels leading to type 2 diabetes.

Insomnia affects hormones

  There are hormones secreted by the stomach (leptin and ghrelin). The former makes us feel full and the latter makes us hungry. Lack of sleep stimulates ghrelin. Studies have proven that sleepy people gain more weight, and this is one of the mechanisms. Also people who have poor sleep habits have lower testosterone levels in men which is important for muscle building. When tired, people exercise less.

  Some of the following information comes from a blog by Dr. Jimmy Westbrook. He also recommended a book “Why We Sleep” by Dr. Matthew Walker.

Why is sleep so important?

  Rest is necessary for all of us, and good natural sleep is medically necessary to function.  From birth, people spend a third of their life sleeping, and when deprived, there are many medical and psychological consequences.

  For infants 16-18 hours are necessary, and teenagers require 9-10 hours of sleep a night. Adults require 7-8 hours, and for seniors even more for some, since the deep sleep part of the cycle occurs less often. This includes REM (rapid eye movement) sleep, which is the cycle when dreams occur. The body is most relaxed during dream sleep and is critical for adequate restful sleep.

  The risk of disease rises rapidly with poor sleep. It is one of the most common problems that patients seek help from their doctor, and recent reports cite Americans are purchasing more and more sleep aids over the counter as well.

  4% of adults take sleep aids, including sedatives and hypnotics.  Women take more than men, and report more sleep disturbances.

  Use of sleep aids increases with higher education. If diagnosed with a sleep disorder, 16% are prescribed sleep aids. Yet, only 4% have prescribed certified sleep studies to determine any underlying cause.

  Brain waves undulate through the 5 cycles of sleep at night from light to deep sleep and are necessary for restful sleep. This includes REM (rapid eye movement) sleep. With too much or too little REM sleep, problems can occur (narcolepsy sends the brain from wakefulness to REM sleep).

  Sleep is necessary for the body (liver) to detoxify the byproducts of metabolism , the brain to recover from wakefulness, and the body to recover from exercise and the rigors of the day.

Classification of insomnia/sleep disorders

  Although most insomnias have some origin, there is a list of possible causes. Sleep studies which include an EEG are necessary in the workup plus a medical and neurological consultation.

1. Sleep related breathing disorders ( i,e. obstructive and central apnea)

2. Hypersomnias of central origin (daytime sleepiness without nighttime lack of sleep-i.e. narcolepsy and several neurological diseases that demonstrate central insomnia)

3. Circadian rhythm disorders (shift work, non-24 hour-sleep wake disorder).

4. Parasomnias (sleep walking, bruxism, night terrors,etc.)

5. Sleep related movement disorders (restless leg syndrome) 

6. Isolated symptoms

7. Others

*any of these can be researched on the internet                                                               

HERE ARE SOME PRACTICAL TIPS TO COMBAT INSOMNIA:

a. Any airway, hormonal, anatomic, or psychological disorder must be dealt with including side effects of medications, foods (caffeine) and alcohol that could be interfering with sleep.

b. There are certain foods that help sleep (cheese and yogurt, eggs, milk, nuts, seeds, banana, and honey contain tryptophan-an amino acid that is sedating).

c. Some rules for good quality sleep---small snack before bedtime, no alcohol for a few hours before bedtime, avoid, spicy or heavy foods especially if reflux is an issue, cut fluids off by 2 hours before bedtime, avoid heavy proteins and high fat content foods in late night dinners, and avoid tobacco.

  Stimulants include decongestants, nicotine, caffeine, diet pills, pain meds, unless absolutely necessary need to be stopped 6-8 hours before bedtime, if possible.

d. The bedroom must be examined for traps that will interfere with quality sleep, such as blue light, TV, computers cell phones, bright lights before bedtime, exercise before bedtime, temperature of the room (optimum is 68 degrees), bed clothes, animals, and bright clocks.

e. A comfortable bed and pillow are a must (mattresses last only 7-8 years). Enclose your mattress and pillow with an anti-allergy cover to prevent mites, mold, etc. Avoid feather pillows. Use the bathroom before bedtime even if there is no urge. Going to sleep and awakening at the same time each night is recommended.

f. Using a white noise machine or fan will help. Be sure you get in good natural light for 5-30 minutes during the day  and stay out of bright light 2-3 hours before bed including blue light emitted from cell phones, computers, etc. Wear ear plugs if your partner snores (get him tested for apnea and get him some nasal strips), and wear a sleep mask if you don’t have blackout shades.

g. Daily light will stimulate melatonin production by the pineal gland of the brain.

h. Read before bedtime, take a warm bath, wear comfortable bed clothes, put the thermostat on 68 degrees (best temperature for sleep), and leave your computer and smart phone in the living room. Avoid TV in the bedroom. No blue lights in the room. Sex before sleeping, if not too energetic, can be calming. 

i. Never have a heated conversation before bedtime. Naps during the day should be avoided. It is necessary to have 6-7 complete cycles of sleep to feel really rested.

j. Illness and disease can play havoc on sleep. Allergy post-nasal drip, asthma, chronic lung disease (COPD), obstructive sleep apnea and severe snoring, restless leg syndrome, nighttime leg cramps, neurological diseases such as multiple sclerosis, ADHD in adults, gastric reflux, arthritis, headaches, severe fatigue, bladder and prostate trouble, and many more will distract you trying to go to or staying asleep.

k. 45% of American adults snore at some time, and it interferes with a bed partner’s sleep. There are many studies that correlate snoring with not going through the normal sleep cycle, because it interferes with the airway even without apnea. Suggest a sleep evaluation.

l. To prevent separate bedrooms because of snoring, lose weight, avoid alcohol (interferes with the sleep cycle too), use nasal strips after snorting some salt water through the nose before bedtime. If apnea is suspected, get tested.

m. Sleeping on the back will create mouth breathing and create snoring.  Sew a tennis ball in the back of a night shirt to prevent sleeping on the back (worst for snoring), and stay well hydrated during the day (keeps secretions thinner), but stop drinking fluids a couple of hours before bedtime to prevent the need of frequent nighttime urination.

n. Most people have one of two types of sleep issues most commonly. People can get to sleep but wake up one or more times a night. Others can’t get to sleep, but once asleep can stay asleep. Stress is the most common reason for the former, and depression for the latter.

o. Women tend to need more sleep, but both sexes need 6-7 hours. Sleeping less than 5 hours increases health issues and more than 9 hours will make you gain weight. 

p. If a person can’t get to sleep in 30 minutes, it is recommended to get out of bed and go elsewhere and read.

Medications, supplements, and herbal remedies

  The over-the-counter sleep medications for sleep are mostly antihistamines (i.e dyphenhydramine (Benadryl), etc. and have lasting effects (drowsy in the morning) and aggravate obstructive sleep apnea just like alcohol and drugs. They cause confusion in the elderly.

  Melatonin is produced by the pineal gland in the brain which is stimulated by light during the day and darkness at night.

  Melatonin works to get a person to sleep but not keep asleep. Valerian root, St.John’s Wort, lavender and sage oils and chamomile are herbs that may have some benefit. Meditation is extremely helpful. Even a small glass of wine before bedtime may help some (I said small!) or a warm Epsom salt bath (Epson salts contains magnesium, a muscle relaxant). Melatonin should be taken 2 hours before bedtime and if a person wakens and can’t get back to sleep, consider trying  melatonin.

  Learning breathing and relaxation techniques from yoga can help a person to relax and is similar to meditation.

Pharmacotherapy—sleeping pills

  The most common prescription meds include Lunesta, zolpidem (Ambien, and Ambien CR). Ambien CR has two types of Ambien in the pill…one for getting to sleep and another for staying asleep. Rozerem, Sonata, some antidepressants, Restoril, Seconal, and Placidyl are other examples. The last two are habit forming. None of these should be used for long periods of time. 

  Benzodiazapines (Valium, Librium) can help as well, especially if back or other types of pain are present. They must be taken with caution if also taking opioids, the combination could create airway obstruction, snoring, and poor sleep.

  Lunesta and Ambien should be taken at bedtime while other medications must be taken 2 hours before bedtime. Regular Ambien is generic and Lunesta is about to go generic, but rarely covered by insurance.

  Gabapentin (Neurontin) and pregabalin (Lyrica) may help especially if a person is fighting pain. These assist melatonin to get into sleep (melatonin agonists). Avoiding alcohol is a must.  

Non-24 hour sleep wake disorder

  A new circadian rhythm disorder (jet lag) medication now FDA approved is tasimelteon (Hetlioz), which is a melatonin agonist (means it acts like melatonin). This has been valuable for totally blind people who can’t tell light from dark and can’t make melatonin. This affects more than 100,000 blind people in the U.S. alone.   

  Behavioral counseling may be very important if a person can’t get the stress under control. 

  One interesting study reported that those patients taking sleeping pills often have a 48% chance of dying younger, but thought to be from the lack of quality sleep.

Serious side effects of Hypnotics

  The FDA reported 20 deaths from hypnotics including carbon monoxide poisoning, drowning, hypothermia, falls, gunshot wounds, car accidents with the patient driving, and apparent suicides. 46 reported non-fatal injuries include near-drowning, falls, gunshot wounds, and attempted suicide. Many of these events occurred with lower doses as well as higher doses. Never drive with these medications in the system.

  The warnings on the package include sleepwalking, sleep-driving, and other unusual behaviors (i.e. using a stove while asleep). The FDA has announced that these medications are not allowed in these patients.

FDA MedWatch as read in the NEJM-Journal Watch, May, 2019

3. Medical Updates

   A. Dietary supplements can be toxic to patients on chemotherapy

  A recent study in the Journal of Clinical Oncology, 2019 found that dietary supplements, especially those who are touted to be antioxidants, actually are associated with an increased rate of recurrence and death in breast cancer patients who are taking chemotherapy.

  These include carotenoids, CoQ 10, Vitamins A, C, and E were 41% more likely to have a recurrence and 40% more likely to die of their cancer. Also other vitamins such as Vitamin B12, Omega 3 fatty acids, iron, and antioxidants lower the effectiveness of chemotherapy. 

  The above nutrients are abundantly available in a normal balance diet which includes lean meats, fruit, and vegetables. For those on some of the restrictive unbalanced diets, need to consult a nutrition expert to find out what supplements may be necessary.

  The nutritionists who ran this study went to great lengths to calculate the levels of vitamins and minerals in these participant’s diet.

 Ref. NEJM Journal Watch, April, 2019  

 B. Understanding the validity of medical research

Clinical Drug Trials

  The information in my reports and all of the medical journals come from clinical trials that have been scrutinized by their peers. This is required by the FDA to approve any medication.

  Evidence-based medicine is the standard for deciding how doctors take care of patients!

 Unpublished clinical trials can hide bad results

  The Annals of Internal Medicine published an article about many of the negative studies never being published or even made public, sometimes hiding bad results. The cost of these studies and who is paying for them are at the center of the issue. If a pharmaceutical company is trying to prove the value of  a drug, drug company investigators must report negative results along with the positive ones.

  It is critical to know what works, its safety, its effectiveness, and short or long term side effects. Also interactions between drugs are very important. The FDA requires that all these issues are covered before a procedure, medical device, or medication can pass through the stages of clinical trial approval.

  This study looked at 500 large clinical trials, and too often found that the results are never made known to the public. 67 trials were found to not publish their adverse results. This is important information and has a great impact on future clinical trials. These trials involved 90,000 participants, and the results were not made available.

  The ethics of research are under attack. Small clinical trials should be especially suspect and must be repeated by independent researchers. Otherwise, how are doctors to trust the information published?

  Reputable medical journals are peer-reviewed* and usually highly scrutinized (unless their data is falsified, which does occur). Large medical institutions have been severely damaged thanks to scientists that have falsified research results.

*peer reviewed=independent doctors review the results and conclusions of published data

  Conflict of interest statements by the investigators are a necessary part of any legitimate published article. Many times the actual company who will sell a medication, device, or product pays for a study. This must be taken into consideration when reading the results of any journal article. The authors must divulge if they are being paid by the company.

  I review hundreds of articles a week before I select those studies I publish in my reports. The internet is full of falsehoods, bogus studies, and results based solely on poor studies and antecdotal information (word of mouth and testimonials). Do not believe these.

  One of the worst and most abused areas of healthcare is in the area of nutrition, dietary supplements, and studies based strictly on an observational connection.

  Double blind, peer reviewed studies are the best to trust, but they are expensive, and research dollars are scarce, especially from medical centers.

  I am amazed at the number of research projects that are now performed outside the U.S. and that makes me concerned. Drug companies fund their own research, and when $billions are at stake, you can understand conflict of interest can be a problem.

  This is fertile ground for the legal profession, but that is not all bad in many cases. Lawsuits are unfortunately one ways to keep these studies and their results honest, because if a medication gets on the market and has significant adverse consequences, they open themselves up to lawsuits.

The Annals of Internal Medicine, May, 2019

Comment

  The medical profession has to up their game on policing these studies, and provide accurate and reliable information to doctors and the public.

C. Oral anticoagulants (blood thinners) now have reversal drugs—new guidelines

Blood thinners have come a long way since oral warfarin (Coumadin). The new NOACs (novel oral anticoagulants) are slowly replacing the need for Coumadin. Until recent years, it was the only anticoagulant for 60 years and is still prescribed 70% of the time. Valvular heart disease requires Coumadin to protect from clots and NOACs are FDA approved for valvular disease.

   Coumadin requires frequent blood tests (Prothrombin time) to adjust the dose on a weekly basis. Vitamin K injections can reverse the drug while the newer DOACs had no antidote until recently. These are used to prevent emboli from atrial fibrillation primarily but also for narrowed blood vessels which can clot off (usually Plavix).

  The half life for Coumadin is 60 hours and 10 hours for the DOACs (sometimes called NOACs-novel oral anticoagulants). So unless there is a need for immediate reversal of these agents, time alone will remove the threat.

The NOACs directly bind to blood clotting factors and prevent blood clots in non-heart valve cases.

  The current FDA approved NOACs are dabigatan (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa). They are much more expensive than Coumadin.

  Currently, they are not indicated for heart valve blood clots, however, these medications are being studied for possible use in heart valve replacements in the near future. For now, Coumadin is still the drug of choice for chronic use of valvular diseases or artificial valves and Heparin or low molecular weight heparin for short term use.

  There is one other oral anticoagulant, Plavix, that works differently, by interfering with the platelets, similar to how aspirin works. Indications for Plavix and the NOACs overlap, so it is important to discuss these medications when undergoing anticoagulation. It is less expensive than the NOACs.   

  With the advantage of an anticoagulant not needing blood tests, and not having an antidote, this was a problem. But now there are reversal drugs!! However, there is a 3% chance of bleeding with the NOACs and 0.5% for Coumadin, but Coumadin can cause more serious bleeds.

  If a person sees blood in their stools, it is prudent to see a gastroenterologist for a colonoscopy, because a polyp or colon cancer could be the reason.

  Also some doctors also prescribe aspirin in addition to the anticoagulants, and may be the reason for bleeding. Fewer doctors are using the combination now.

  Also kidney function must be checked every 6 months to be sure the renal function is not being interfered with.

Guidelines for use of the reversal drugs

  The members of the Anticoagulation Forum have recently published guidelines for using these antidotes in emergency situations. The FDA has only approved idarucizumab (Praxbind), andexanet alfa (Andexxa) and ciraparantag) are in the evaluation process. These drugs do not stop bleeding….they only reverse the NOACs.

Guidelines:

1. These agents should be used in life threatening bleeding or major bleeding if other measures fail (drug discontinuation, compression of the bleeding site, or transfusions).

2. Reversal agents can be used prior to invasive procedures (when discontinuation is not recommended).

3. Not recommended in overdose unless bleeding is occurring or in cases of trauma without bleeding.

4. If these agents are not available, there are specific alternative reversal products for Pradaxa, Xarelto and Eliquis.

  Advantages of the DOACs include less chance of severe bleeding than Coumadin, however, ischemic strokes were not better in either group.

Special note on higher risk patients:  All patients at risk for clots and embolism need to be considered such as all cancer patients at risk for thrombosis, inpatients with venous thromboembolism, narrowed carotid arteries at risk of stroke, atrial fibrillation, and stroke patients. NEJM, June, 2019

Drug interactions with the oral anticoagulants:  There are numerous drugs that can interact with these medications, especially Coumadin, therefore, it is crucial these medications and over-the- counter herbs and supplements not be taken without the consent of the treating doctor. I have discussed coagulation and blood thinners in depth before, and to review them, click on:

www.themedicalnewsreport #26  and #82

  D. High risk smokers not getting  screened for lung cancer with low dose CT scans! Why?

Low dose CT scans of the lung can reduce the death rate for lung cancer by 20% by discovering these cancers when they are curable.

  The cure rate for lung cancer is less than 10%. 70% are diagnosed late in the disease and rarely curable. Over 200,000 cases are diagnosed annually in the U.S., and 151,000 Americans die of lung cancer every year. Lung cancer accounts for 25% of all cancer deaths.

  Why are only 2% of these high risk people being screened?

  Fear, denial, doctors not ordering the CT scan, and many people just don’t want to know if they have a problem!

  Remaining smoke free for 7 years decreases the chances of developing cancer, but for those who have smoked a pack of cigarettes for 30 years or those who smoke 3 packs a day for 10 years still run a higher risk of lung cancer for life and can benefit from these low dose radiation CT scans of the lung. Some groups even feel smokers with less smoking history should be screened.

  20% of people who never smoked still get lung cancer, but that means 80% were smokers or former smokers.

  The downside risk, is that there could be a false positive test, meaning, other tests and even a lung biopsy may have not been needed. That is something to discuss with a primary care doctor when considering this screening test.

  SMOKERS AND FORMER SMOKERS—GET TESTED!!

4. Mental health of our youth? Why so different?

Milllennials (18-34) are the largest group of current Americans in the country and are molding the way our country is going forward. But these young people have been raised differently than other generations and it is potentially a problem as ethey mature.  Their traits are shown in the graph above.

  What has happened to some of our youth? Were we such bad parents that our children decided to raise their children to be so weak that they want to commit suicide over the loss of a boyfriend or a bad grade in school, or because of bullying, or that their internet sites don’t compete with their friend’s sites? These are important issues facing our youth today. The internet has way too much power over this generation of millenials.

  Of course, I am not talking about all parents and all young people, but with the suicide rates rising in children and young people, I felt compelled to write an article about these issues of the changes we are seeing in our youth.

  A recent study stated the rate of suicide in the youth has increased by 56% in the past 10 years ages 10-24, and tripled in ages 10-14 according to the CDC statistics. It is now the second leading cause of death with homicide being ranked third. NEJM, Psychiatry, Sept 3, 2019

Factors affecting millennials

  Their coping skills for many are often lacking. Their dependence on their parents and the lack of wanting to be independent is really showing these days, with a number of issues that have changed.

  Changes include staying at home til their 30s, not wanting to get their driver’s license, settling for the least paying job (even if they are willing to work), the internet, and electronic games.

  Being told that they can act out without consequences and break rules without punishment will in fact have dire results. These young people seem to not be able to handle stress that young people have to normally endure (competition in schoolmates, stressing over life’s little ups and downs, not getting their way, not being as popular as some of their friends with fewer “likes” on social media).

  Other issues include not being able to excel in sports, peer pressure, bullying, weight issues especially in girls, sibling rivalry, and an entitled attitude promoted by certain groups. Many academic institutions are teaching them that they deserve free everything, and are brain washed by rights groups that have become so powerful, that a child can turn their parents if they spanked.  School officials have lost control of the youth in middle and high schools, in my opinion.

  Bad behavior used to mean being sent to the principle’s office, and now they are sent to “time out” or sent to the psychological counselor to be diagnosed with ADHD, anger issues, and frequently placed on medications and given weekly therapy sessions. Who is limiting internet and phone time in these young people to move them to explore other avenues of entertainment and outlets?

  It is well documented that the amount of time spent on social media is linked to increased risk for depression and anxiety.

  In a recent study, 7000 adolescents were questioned about internalizing and externalizing their problems. With those who spent 3-6 hours a day on social media, they were 60% more likely to internalize their problems. More than 6 hours increased the risk to 78%. JAMA Psychiatry, Sept.12, 2019.

Over diagnosing mental disorders

  Are we creating an issue by over diagnosing and over-treating students having a significant percentage seeing school counselors, psychologists, and psychiatrists? After all, the cry for more and more mental health revenue may be backfiring, when students brag about their psychological issues to other students creating competition about who is worse mentally.   

  Believe me, I realize many of these young people need help, and the parents have turned to the school for the parenting in many ways. Many parents are not prepared to deal with some of these issues. When are parents today going to realize that discipline must come from the home, consequences of actions are necessary, and rewards for just showing up are not ok (participation trophies…really!).

  Discrimination has been raised to a new height, and political correctness has ruined many of them.

  Those that run away wind up dead, on drugs, in sex trafficking, or live on the streets.

  Parents want to be more friend to their child than parent. What happened to tough love?

  As our country is sliding more to socialist ideology especially with half the millennias voting for an even more  progressive agenda. Bernis Sanders is soaring in the polls and winning state’s democratic caucuses.  Many endorse everything being given to them with no responsibilities, no discipline, and no direction toward adulthood. This creates weakness in the largest group of Americans.

  Parents are calling college professors asking them why their child was given a B or C instead of an A (like this was middle school). Others are bribing colleges to get their children in prestigious schools.

  Colleges can’t hire enough psychological counselors to keep up with the needs of their students. This is not about just treating mental disease…this is about getting to the core of issue…parents today, the media, the overly progressive movement, and academic professors spending too much time teaching their own ideologies.

Teens who abuse opioids are at high risk for many other harmful behaviors

  Teens who abuse opioids are at risk for many other harmful behaviors. 14% of 15,000 high schoolers reported misusing opioids usually stealing them from their parents or buying them from other teens.

  As many as 22 harmful behaviors occur at higher risk including auto accidents from texting, no seatbelts, drinking and driving, having intercourse before the age of 13, intoxication before sex, not using condoms, sex with greater than 4 partners, carrying weapons, engaging in fights, violent behavior, and attempting suicides.

  The abuse of opioids group had as much 30% higher risk for most of these behaviors compared to the non-abuse group. There was as high as 80% higher risk of smoking cigarettes and pot (and all other elicit drugs). If the parents misuse opioids the percentage went even higher, probably because of the access of more drugs.

  Parents must realize their behavior has a big impact on their children especially risky behavior such as misuse of drugs, smoking cigarettes (and pot), alcohol, etc. Physicians who become aware of these teens behaviors must be on high alert for many other harmful behaviors.

Pediatrics Journal, January, 2020

Teen suicides rising since 2007

The rate of suicide from age 10-24 increased 56% between 2007-2017, making suicide the second most common cause of death in this age group after car accidents.

  Self poisoning has increased 400%. Education in the schools about suicide and individual discussions will reduce the incidence according to a professor of psychology and coordinator of suicide prevention at a hospital in Columbus, Ohio (Dr. John P. Ackerman). Social media is implicated, however, the opoid crisis is not.

  A Yale Medical School article suggested that one of the reasons teen suicides are rising is called “contagion”, one suicide creates a chain reaction of suicides.

  A Netflix movie, called “13 Reasons Why”, apparently sparked a number of suicides, when the theme of the movie was a girl who killed herself left a list of the reasons why she did it.

  The authors also agree that those vulnerable to suicide turn to social media with sites about committing suicide. They, however, reminded the reader that the longstanding causes are still factors (romantic breakup, bullying, end of a friendship, a death, or divorce combined with an underlying psychological disorder such as depression, anxiey, or bipolar disorder). One of the factors is the perception teenagers have of the world (they see things in a starker, more vivid colors, and see fewer gray areas than adults).

  Dr. Eli Lebowitz, Director of the Anxiety disorders at Yale Study Center, stated that “their view (just mentioned) makes a problem more daunting and a solution less likely than an adult”.

Social Media is king!

   With social media, how popular a young person is is measured by the number of likes on Instagram. These kids are spending as much as 8 hours a day on the internet (mostly at night when their folks are sleeping), where there is a lot of negativity, competition, and jockeying for status. They reverse their hours awake and asleep, preventing interaction with friends and family.

  School functioning, attendance, ability to get along with classmates, adequate sleep, having a social life in and out of school are all potent indicators that a teen is functioning normally.

  Dr. Lebowitz is also in favor of parents asking those in trouble if they are thinking of hurting themselves (i.e. cutting being an indicator of self abuse and a risk factor). If they say yes, how often, what plans for attempts, and access to guns, pills, etc.. This author feels that a teen thinking about it and showing outward signs, will be at higher risk if they don’t have someone to express their ideations and concerns.

  Treatment of suicidal ideation might include antidepressants and cognitive therapy to allow the patient to recognize their own thinking patterns.

  This article did state that 40% of patients will not respond to antidepressants (even of they switch to a different one). If the issue is in crisis mode, the teen must be taken to the emergency room for crisis counseling and management.

  For resistant cases, the use of ketamine (Esketamine) nasal spray has been quite effective, working within 24 hours compared to several weeks before antidepressants (SSRIs)*  start working. I refer you to my website for in depth discussions of antidepressants and ketamine. Studies at Yale are ongoing proving their value.

  We can provide all the mental health in the world, but by the time the youth gets help, many times the damage is done. How can the obvious paradigm change? I don’t know, but we are going to see more drug abuse (including marijuana), suicides, and helpless young people unable to transition into adulthood and lead this great nation.

  How are we going to man a military when over half of the youth don’t even qualify for military duty?  They are overweight, not physically fit, can’t pass the entrance exams, or have a history of mental illness and substance abuse.

Teens feel that mental illness admission is seen as a positive trait in one study:

1- 18% of teens do not feel “life is worth living”.

2- 27% disagreed that their life has purpose.

3- 41% felt they were more confident online than in person.

4- 46% feel that comparing their life to others on social media makes them feel inadequate.

5-  Seeing others online makes me feel anxious about my future in 48%.

6- 57% felt that social media creates an overwhelming pressure to succeed.

7- 60% find it difficult to compare their lives to the lives of others using the internet.  Quora.com using Prince’s Trust Index

  It is well known that self-harming, eating disorders, substance abuse, experiencing abuse, ADD, ADHD, anxiety, depression, family and upbringing trauma, conduct disorders, online bullying, and even suicidal ideation, attempts, and completion are the result of mental instability.

The statistics are worrisome….. from studies in the UK in teens using a questionnaire—alarming!

1- 18% disagreed with the statement “I find life really worth living”.

2- 27% disagreed with the statement “I find my life has a sense of purpose”.

3- 41% said “I feel more confident online than I do in person”.

4- 46% said “Comparing my life to others on social media makes me feel ‘indequate’”.

5- 48% said “I feel more anxious about my future when seeing the lives of my friends online”.

6- 57% said “ Social media creates an overwhelming pressure to succeed”.

7- 60% said “I find it difficult not to compare my life to others online”.

   There are many questions but few answers as long as social media has such a central way of communicating

 https://www.yalemedicine.org/search/?q=teen+suicide

Major depressive mood disorder diagnosis

—at least 5 of these symptoms must be present to diagnose and the person must be to the point of impairment:

1- irritable mood in children

2- diminished interest in school work or acivities

3- weight gain or failure to maintain expected weight

4- sleep disturbance-insomnia, or sleeping too much

5- psychomotor agitation or retardation

6- fatigue or loss of energy

7- feeling of worthlessness

8- inability to concentrate; indecisiveness

9- suicidal ideation

Sex without protection in young people

17% of young people going to an emergency department stated they had unprotected sex. These were ages 14-17. They were even higher in blacks, those who engaged in casual sex, and those who used substances such as marijuana or drinking alcohol during sex.

  The LBGTQ group was not studied but is known to engage in non-protected sex and has the highest rate of STDs. Clearly screening for such activities and education about STDs and pregnancy are mandatory. Academy of Emergency Medicine, Oct.9, 2019

ADHD link to early pregnancy

  A Swedish study published in JAMA, October, 2019 found a significant correlation between teenagers with ADHD and earlier teen pregnancy than other teenagers. This begs the need for not only diagnosis but more education for parents and teens with this disorder.

  The world-wide prevalence is 5% of children. These teens are known to be risk takers including two-fold rate of mortality, more STDs, less sexual protection, and unplanned pregnancies. They are more likely to smoke and have low birth eight babies.

  This study was published by Kaiser Permanente Health Systems and reported a 43% increase of newly diagnosed ADHD in adults in the past year. If a person has anxiety, depression, or eating disorders, they are 2.5-5.0 fold greater risk of ADHD.

  The CDC has quoted the incidence of this disorder at 6.1 million children (9.4% of children in the U.S.), while there are 4.5% of adults in the U.S. as of August, 2019.

Eating disorders

  Eating disorders (anorexia nervosa, bullimia nervosa, binge-eating disorders) are another side effect of stress in teenagers, and the highest incidence of diagnosed eating disorders in young men and women is 21 years of age. The prevalence was estimated (in an analytical model study) to be 1 in 7 boys and 1 in 5 girls by age 40. The incidence of anxiety, depression, and substance abuse is much higher than the general population of young people, and relapse for these disorders is higher as well. JAMA, Oct., 2019

How will millenials perform in the “real world” when they get there?

  Based on many articles and my own experience, maturity is coming somewhat slower in these young people. Coddling and giving them their “space”, and letting them “experience” a wide variety of experiences, not to mention the brainwashing they are getting in colleges has made some of these folks ill-prepared to become an adult.

  It is my humble opinion girls start to grow up around 25 or so. Boys are taking 3-4 years longer. That fits with some articles on the subject.

  Wouldn’t it be nice if all the little buggers had 2 years of mandatory military! The trouble is 50% don’t even qualify for the armed services based on weight, drug use, lack of grades, etc. Of course, there are many options to give these folks 2 years to grow up some. Getting 30 year olds out of the house today is becoming a challenge.

5. Brain aneurysms

  If you watched Game of Thrones, the beautiful blond star, Emilia Clarke (Mother of Dragons), revealed recently that she had not one but two brain aneursyms, the first one shortly after the first season ended. She developed a sudden onset of a headache and vomiting, and as she was rushed to the hospital, developed a “fog of unsciousness”. She was diagnosed with a subarachnoid bleed from a rupture cerebral artery aneurysm (often referred to as a berry aneurysm, because of the size).

2 procedures to treat berry aneurysms clip vs coil

  She underwent a cerebral endovascular uncoiling to address the aneurysm and recovered only to find out that 2 weeks later, another smaller aneurysm on the other side of her brain was present, but was told they would watch it.

It, however, did not stay dormant, and required another uncoiling on second smaller aneurysm , which failed, requiring an open brain procedure to clip off the aneurysm.

  She developed aphasia (could not speak or could not express her feelings), however, after the procedure, it completely cleared and felt 100% and returned to film the second season.

  Movie star Angie Dickinson experienced a ruptured aneurysm as well.

What is an aneurysm?

Cerebral aneurysms are congenital weak blood vessels whose lining balloon out with time causing the deformity and can rupture or cause pressure on certain nerves and cause neurological symptoms.

  It is estimated that 6 million Americans have this deformity (1 in 50 Americans). Approximately 30,000 ruptures occur annually.

  They become symptomatic most commonly between the ages of 30-60, and more women have the abnormality (3:2 ratio). They vary in size from 1/8 inch to 1 inch. It is twice as common in blacks and Hispanics. It is estimated that 500,000 deaths occur annually worldwide. 20% have more than one aneurysm. 50-80% do not rupture. Most do not cause symptoms until they enlarge or rupture.

  If they become symptomatic, symptoms may include headache, pain behind the eye, numbness, weakness, paralysis of the one side of the face, a dilated pupil, vision difficulty or double vision.

  When it ruptures, there is irritation of the lining of the brain from blood causing nausea, vomiting, stiff neck, sensitivity to light, loss of consciousness, and cardiac arrest. Some may leak slightly causing a headache that passes (sentinel bleed), however, they usually rupture within a week or two. Sudden headache should be evaluated.

  25% die of the aneurysm and another die within 6 months of complications from the bleed. Many may suffer permanent disabilities if they survive. However, as in the case of the Mother of Dragons, recover completely.

  These are diagnosed with an MRA (MRI of the blood vessels) or a CTA (CT scan with dye).

  It is important to aggressively treat any co-existent diseases especially cardiovascular disease, diabetes, etc. especially hypertension.

  Treatment may be conservative or require open brain surgery (craniotomy). With conservative treatment, endovascular coiling, which can be performed. It also may need to be repeated at a later date based on repeat studies. Stents can also be used to block flow in very large aneurysms or those not able to undergo a craniotomy.

  The open procedure is the most aggressive but definitive procedure but requires a craniotomy.   

6. Roles of Ophthalmology, Optometry, and Opticians

Both ophthalmologists and optometrists are called eye doctors and it causes some confusion. And there are opticians as well, who are technicians.

Ophthalmology(M.D. or O.D.)

  To qualify for a residency in Ophthalmology, you must have an MD or DO degree. After completing a 4 year medical school, a physician must apply for a certified residency program in Ophthalmology, which includes diagnosing and treating eye diseases that may require medical and or surgical intervention.

  Many physicians who complete a general eye residency perform cataract surgery and take care of most eye diseases (3-4 years).

  There are many subspecialties in Ophthalmology requiring fellowship training (1-2 years) in such diseases as corneal disease (who would do corneal transplants, refractory corneal surgery-LASIK), glaucoma (which requires very specialized surgery in about 10% of patients), retinal diseases (retinal detachment, and macular degeneration, diabetic retinopathy), neurological eye diseases (require neurology and ophthalmology fellowships), and oculoplastic and reconstructive surgery (cosmetic eyelid and brow surgery and reconstructive surgery of the eye, brow and forehead from cancers of the eyelids and surrounding tissue).

  Due to the complexity of ophthalmologic diseases and special surgical training, it is advised to seek a fellowship trained eye surgeon.

Optometry(O.D.)

  These special eye doctor are not medical doctors, but require a 4 year college degree before completing a 4 year certified optometry program and are graduated with an OD (Optometric Doctor).

  As of 2015, there were over 35,000 optometrists in the U.S.   

  They are specifically trained to treat vision issues that can be corrected with eye glasses or contact lens.  They do not perform surgery, although that has become a political issue in recent times.

  3 types of certifications for optometrists—general optometry, therapeutic optometry, and therapeutic glaucoma optometrists.

  General and all optometrists test for pressure in the eye (glaucoma) and visual acuity, with a slit lamp eye exam visualize the retina and optic nerve, diagnose cataracts and other eye diseases such as diabetic retinopathy, etc. They diagnose and treat visual acuity issues such as astigmatism, near and far sightedness, and eye diseases. They fit contact lens and glasses for vision correction.  

  Therapeutic Optometrists must have a special license to  prescribe most eye drops for infection, allergy, including non-steroidal and steroidal drops. License number ends in T. 

  In certain states, there is a special license for some optometrists to treat glaucoma with eye drops and their license number ends in TG (Therapeutic Glaucoma Optometrists). They can prescribe one round of 10 days of antibiotics, anti-fungals, non-steroidal medications, and cortisone drops, and antihistamines, etc. and 3 days of controlled substances for pain (opioids, etc.). 

Ophthalmic Opticians(O.O.)

  These eye professionals are college educated in Optical Science, are not doctors, but are trained technicians, who design, fit, and dispense eye glasses and contact lens to correct visual abnormalities. Some fit eye prostheses, and other eye prosthetics. Some licensed opticians manufacture eye lens for glasses or contact lens.

Wikipedia, medicinenet.com

 This completes the March, 2020 report

The April, 2020 report will include:

1. Alzheimer’s disease update

2. “Sugar Babies”-a new way for college girls to pay for tuition and much more

3. Raynaud’s disease

4. Medical Marijuana update

5. Timeline for smokers who quit to see health improvements; new information on lung cancer

6. Treating resistant depression 

Stay healthy ans well, my friends, Dr. Sam