Cancer Prevention

Prevention — Perhaps nothing scares a patient than the word ‘cancer’. However, a number of measures can be taken to prevent cancer, including:

●Avoidance of tobacco

●Being physically active

●Maintaining a healthy weight

●Eating a diet rich in fruits, vegetables, and whole grains, and low in saturated/trans fat

●Limiting alcohol consumption

●Protecting against sexually transmitted infections

●Avoiding excess sun

●Getting regular screening for breast, cervical, and colorectal cancer

Prevention is most effective for cancers that are strongly and causally associated with tobacco use: cancers of the oropharynx, bladder, esophagus, and lung.

Breast cancer — Major risk factors for breast cancer in women are age, genetic predisposition, and estrogen exposure. Evaluation for hereditary breast and ovarian cancer syndromes should be considered in men and women with a personal or family history that is concerning.

●Family history – Men and women at risk for hereditary breast and ovarian cancer syndromes should be identified by taking a thorough personal and family history, with a focus on both the maternal and paternal sides of the family. Patients with concerning family history should be referred to a genetic counselor for a formal genetic assessment.

●Screening for average-risk women – Clinicians should discuss breast cancer screening with all women starting at age 40. The decision to perform mammography should be determined by individual patient risk and values through shared decision-making. It should be emphasized that the relative benefits and harms of screening change as a woman gets older. The absolute benefits, in terms of numbers of lives saved, are lower for younger women than for older women because of both decreased incidence of breast cancer and sensitivity of mammography in younger women.

Screen with mammography every two years. 

●Age to stop screening – We suggest that breast cancer screening with mammography be continued as long as a woman has a life expectancy of at least 10 years.

We suggest that breast self-examination (BSE) not be performed except by women who express a desire to do so and who have received careful instruction to differentiate normal tissue from suspicious lumps. BSE should only be performed as an adjunct to mammography and clinical breast examination, not as a substitute for these screening methods.

Cervical cancer — We recommend cervical cancer screening for immunocompetent women ages 21 to 65 years who have an intact cervix.

●For average-risk women (without human immunodeficiency virus [HIV] or immunocompromise) aged 21 to 29, we suggest Pap smear screening every three years.

●For average-risk women (without HIV or immunocompromise) aged 30 to 64, we suggest either Pap smear screening every three years or co-testing (Pap smear and human papillomavirus [HPV] testing) every five years if both initial tests are negative.

●Women ≥65 years who have had adequate negative prior screening and are not at increased risk do not need to be screened.

However, even in older women who have been adequately screened, it may be reasonable to continue to screen those with good life expectancy who have risk factors for cervical cancer. Risk factors include a history of an abnormal Pap test, current smoker or history of smoking, previous HPV-related disease, or new partners. We continue to offer screening to women with good life expectancy who have risk factors for cervical cancer until about age 80, but the upper age limit may vary with the risk factor (eg, women with good life expectancy and a history of CIN 2 or greater should be screened for at least 20 years following diagnosis).

●Older women who have not been adequately screened should be screened until age 70 to 75 years.

●Women who have had a total hysterectomy for reasons other than cervical cancer or high-grade cervical cancer precursors need not be screened.

Ovarian cancer — Screening for ovarian cancer is not recommended for average-risk women.

Colorectal cancer — The age of initiation and frequency of colorectal cancer screening varies with the risk:

●No risk factors – We recommend that average-risk patients aged 50 and older be screened for colorectal cancer. We suggest that screening be continued until the life expectancy for an individual patient is estimated as less than 10 years. For most patients, it is reasonable to stop screening at age 75 years or 85 years at the latest. One-time screening with colonoscopy (to age 83) or sigmoidoscopy (to age 84) is advised for adults who have never been screened for colorectal cancer.

Lung cancer — Smoking tobacco products (primarily cigarettes) is the most important risk factor for the development of lung cancer. All patients who smoke should be counselled to quit smoking as the most effective intervention to reduce the risk of lung cancer.

We suggest annual screening with low-dose helical computed tomography (CT) for patients in whom the cost of screening is not an issue if they are in good health, at risk for lung cancer (age 55 to 74 years; history of smoking at least 30 pack-years and, if a former smoker, and had quit within the previous 15 years). 

Prostate cancer — Individual patient preferences for specific health outcomes are a deciding factor in determining whether to screen for prostate cancer.

Health care providers should periodically discuss prostate cancer screening with men who are expected to live at least 10 years and are old enough to be at significant risk for prostate cancer. We suggest that discussions begin at age 50 in average-risk men. We suggest discussions begin at age 40 to 45 in men at high risk for prostate cancer (including black men, men with a family history of prostate cancer, particularly in relatives younger than age 65, and men who are known or likely to have the BRCA1 or BRCA2 mutations).

When a decision is made to screen, we suggest that screening be performed with prostate-specific antigen (PSA) tests at intervals ranging from every two to four years. We suggest not performing digital rectal examination as part of screening.

Melanoma

●We recommend that individuals at highest risk (history suggesting a familial melanoma syndrome or with multiple atypical nevi) have a regular full-body skin examination by a clinician with skin expertise.

●We suggest that persons at higher risk for melanoma (white men over 50 years, individuals with a history of significant sunburn, or multiple moles) have a periodic full body skin examination performed by a clinician who has had appropriate training in the identification of melanoma.

●We also suggest that individuals at high risk for skin cancer be counseled about self-skin examination and advised to examine their skin regularly and notify their clinicians if moles change.

While we may not be able to prevent all cancers, by taking above precautions we can at least detect them in early stages and start appropriate treatment. 

If you need any testing for cancer, please visit Dr.Paul’s Clinic at your convenience. Call us at 814 424 2095. 


Threats to Patient Confidentiality

Today let us see some common things in the medical practice which jeopardize confidentiality. 

Medical records — The physical (or electronic) medical record belongs to the clinician, practice, or institution that is responsible for maintaining it. During the transmission of medical records from doctor to doctor, some confidential patient information may slip out. It is essential that all information is sent with utmost care. 

HIPAA — The health privacy regulations (sometimes referred to as the Health Insurance Portability and Accountability [HIPAA] Privacy Rule) issued under the HIPPA Act of 1996, which took effect in 2002, provide important protection for medical records. Medical provides should familiarize themselves with HIPAA rules. 

Electronic records — The electronic medical record is another potential area where the confidentiality of a patient could be breached. The records for a particular visit should be accessible only by those who need to know the details. Log in and Log outs should be done. Access to ex-employees should be blocked. Non-clinical staff should have no access to patient’s medical records. 

Details about patient’s sexual health, mental health, and behavioral issues are vulnerable to stealing. Care should be taken to prevent ‘hacking’ into the electronic medical records. 

Patient portals — Patient portals, which parents and patients use to access information regarding scheduling and laboratory test results through electronic medical records systems, pose another potential risk to confidential care. Educate patients on to protect their portals into electronic health records. 

Pharmacists: Pharmacists may divulge confidential patient information while filling the prescriptions. They should take precautions to protect patient confidentiality. 

Insurance companies: Insurance companies collect a lot of confidential patient information as they pay for provider services. Lot of patient information slip out while collecting medical records and their transmission to insurance companies. Special precautions should be taken in this area to safeguard patient information. 


Adipex and Topamax: Some Facts

Because the regulation of food intake is controlled by several pathways, it has been hypothesized that combining two drugs with different mechanisms of action could improve efficacy (and tolerability if used in lower doses) compared with single-drug therapy.

Phentermine-topiramate — In 2012, the US Food and Drug Administration (FDA) approved a preparation of  phentermine and extended-release topiramate (in one capsule) for adults with a body mass index (BMI) ≥30 kg/m2 or with a BMI ≥27 kg/m2 with at least one weight-related comorbidity (eg, hypertension, diabetes, dyslipidemia). We do not recommend phentermine-topiramate  for patients with cardiovascular disease (hypertension or coronary heart disease). Phentermine-topiramate may be considered for obese, postmenopausal women and men without cardiovascular disease, particularly those who do not tolerate orlistat, lorcaseri or liraglutide. The efficacy and safety of combining generic phentermine with generic topiramate for weight loss (each taken individually) has not yet been established.

Efficacy — This combination has been shown to enhance weight loss in the first year of use, as illustrated by the following trials:

A combination of controlled-release phentermine-topiramate (7.5/46 mg or 15/92 mg) was compared with placebo in 2487 adults with BMI of 27 to 45 kg/m2 and two or more comorbidities [57]. After one year, mean weight loss was greater in those assigned to active treatment (8 to 10 versus 1.4 kg with placebo [8 to 10 percent versus 1.2 percent of baseline body weight]). Only 61 percent of participants completed one year of treatment.

In a 52-week extension of the above trial (78 percent of eligible subjects participating), mean total weight loss (from baseline to 108 weeks) was significantly better than placebo (9.6, 10.9, and 2.1 kg [9.3, 10.5, and 1.8 percent of baseline body weight] for low dose, high dose, and placebo, respectively) [11]. Of note, phentermine-topiramate was less effective for weight loss in the second year of use, although most individuals were able to maintain the weight they lost in year 1. In those subjects who were able to participate in the second year of the trial, the therapy was well tolerated.

In another trial, men and women with BMI ≥35 kg/m2were randomly assigned to controlled-release phentermine-topiramate (3.75/23 mg or 15/92 mg) or placebo [58]. After 56 weeks, mean weight loss was greater in the active treatment groups (mean reduction 6, 12.6, and 1.9 kg [5.1, 10.9, and 1.6 percent of baseline body weight]). Among those assigned to active treatment, 45 to 67 percent lost at least 5 percent of baseline weight compared with 17 percent of placebo patients.

Adverse effects — The most common adverse events in these trials were dry mouth (13 to 21 versus 2 percent), constipation (15 to 17 versus 6 percent), and paresthesia (14 to 21 versus 2 percent) [57,58]. There was a dose-related increase in the incidence of psychiatric (eg, depression, anxiety) and cognitive (eg, disturbance in attention) adverse events in the active treatment group. Although blood pressure improved slightly with active therapy, there was an increase in heart rate (0.6 to 1.6 beats/min) compared with placebo.

Dosing and contraindications — The initial dose of phentermine-topiramate is 3.75/23 mg for 14 days, followed by 7.5/46 mg thereafter. If after 12 weeks a 3 percent loss in baseline body weight is not achieved, the dose can be increased to 11.25/69 mg for 14 days and then to 15/92 mg daily [59]. If an individual does not lose 5 percent of body weight after 12 weeks on the highest dose, phentermine-topiramate should be discontinued gradually as abrupt withdrawal of topiramate can cause seizures.

Combination phentermine-topiramate is contraindicated during pregnancy because of an increased risk of orofacial clefts in infants exposed to the combination drug during the first trimester of pregnancy. Women of childbearing age should have a pregnancy test before starting this drug and monthly thereafter. It is also contraindicated in patients with hyperthyroidism, glaucoma, and in patients who have taken monoamine oxidase inhibitors within 14 days. Because topiramate can produce renal stones, this combination preparation should be used cautiously in patients with a history of renal stones.

Clinicians who prescribe phentermine-topiramate are encouraged to enroll in a Risk Evaluation and Mitigation Strategy (REMS), which includes an online or print formal training module detailing safety information .Pharmacies that dispense the drug require certification, which involves identifying a representative to oversee the REMS program, and providing patients with a medication guide and brochure each time the drug is dispensed, detailing the risks of birth defects.


Asthma Management

 

COMPONENTS OF ASTHMA MANAGEMENT — The successful management of patients with asthma includes four essential components:

Routine monitoring of symptoms and lung function

Patient education to create a partnership between clinician and patient

Controlling environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity

Pharmacologic therapy

GOALS OF ASTHMA TREATMENT — The goals of chronic asthma management may be divided into two domains: reduction in impairment and reduction of risk.

Reduce impairment — Impairment refers to the intensity and frequency of asthma symptoms and the degree to which the patient is limited by these symptoms. Specific goals for reducing impairment include:

Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath)

Minimal need (≤2 days per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms

Few night-time awakenings (≤2 nights per month) due to asthma

Optimization of lung function

Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise

Satisfaction with asthma care on the part of patients and families

Reduce risk — The 2007 NAEPP guidelines introduced the concept of risk to encompass the various adverse outcomes associated with asthma and its treatment. These include asthma exacerbations, suboptimal lung development (children), loss of lung function over time (adults), and adverse effects from asthma medications. Proper asthma management attempts to minimize the patient’s likelihood of experiencing these outcomes. Specific goals for reducing risk include:

Prevention of recurrent exacerbations and need for emergency department or hospital care

Prevention of reduced lung growth in children, and loss of lung function in adults

Optimization of pharmacotherapy with minimal or no adverse effects

MONITORING PATIENTS WITH ASTHMA — Currently, the majority of medical visits for asthma are for urgent care. Effective asthma management, however, requires a proactive, preventative approach, similar to the treatment of hypertension or diabetes. Routine follow-up visits for patients with active asthma are recommended, at a frequency of every one to six months, depending upon the severity of asthma. These visits should be used to assess multiple aspects of the patient’s asthma and to discuss steps that patients can take to intervene early in asthma exacerbations (an asthma “action plan”). The aspects of the patient’s asthma that should be assessed at each visit include the following: signs and symptoms, pulmonary function, quality of life, exacerbations, adherence with treatment, medication side effects, and patient satisfaction with care.

By consensus from panels of asthma experts, well-controlled asthma is characterized by daytime symptoms no more than twice per week and nighttime symptoms no more than twice per month. SABAs for relief of asthma symptoms should be needed less often than three days out of the week, and there should be no interference with normal activity (preventative use of a SABA, such as prior to exercise, is acceptable even if used in this way on a daily basis). Peak flow should remain normal or near-normal.

Symptom assessment — Symptoms over the past two to four weeks should be assessed at each visit. Assessment should address daytime symptoms, nighttime symptoms, frequency of use of SABAs to relieve symptoms, and difficulty in performing normal activities and exercise.

Assessment of impairment — The following questions are representative of those used in validated questionnaires to assess asthma control:

Has your asthma awakened you at night or in the early morning?

How often have you been needing to use your quick-acting relief medication to relieve symptoms of cough, shortness of breath, or chest tightness?

Have you needed any unscheduled care for your asthma, including calling in, an office visit, or an emergency department visit?

Have you been able to participate in school/work and recreational activities as desired?

If you are measuring your peak flow, has it been lower than your personal best?

Have you had any side effects from your asthma medications?

Assessment of risk — The following questions can be used to address the most important risk factors for future exacerbations.

Have you taken oral glucocorticoids (“steroids”) for your asthma in the past year?

Have you been hospitalized for your asthma? If yes, how many times have you been hospitalized in the past year?

Have you been admitted to the intensive care unit or been intubated because of your asthma? If yes, did this occur within the past five years?

Do you currently smoke cigarettes?

Have you ever noticed an increase in asthma symptoms after taking aspirin or a nonsteroidal antiinflammatory agent (NSAID)?

Monitoring pulmonary function — Peak expiratory flow rate (PEFR) (performed in the office and/or at home) and spirometry (performed in the office) are the two most commonly employed modalities for monitoring pulmonary function in children older than five years of age and in adults. The 2007 NAEPP guidelines state a preference for use of spirometry in medical offices, when available. Children older than five years of age are usually able to perform the peak flow or spirometric maneuver.

Office monitoring — Measurement of PEFR can be a useful indicator of airflow obstruction, the hallmark finding of asthma. PEFR can be measured with handheld peak flow meters in settings not equipped with a spirometer. Average normal values for men, women, and children are listed in the tables. Adolescents have values closer to children than to adults.

It is important to understand the limitations of PEFR. A reduced peak flow is not synonymous with airway obstruction; spirometry is needed to distinguish conclusively an obstructive from restrictive abnormality.

Spirometry, which additionally measures forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), can be used to document airflow obstruction (by demonstration of a reduced FEV1/FVC ratio) and provides additional information that is useful in monitoring asthma, such as risk for exacerbations, by detecting important reductions in lung function in patients who have few symptoms or physical findings of asthma. Spirometry can detect airflow obstruction in the presence of a normal peak expiratory flow.

Home monitoring — Home monitoring of the peak expiratory flow rate (PEFR) may be helpful in patients with moderate to severe asthma. It is also useful in patients who poorly perceive limitations in airflow.

CONTROLLING TRIGGERS AND CONTRIBUTING CONDITIONS — The identification and avoidance of asthma “triggers” is a critical component of successful asthma management, and successful avoidance or remediation may reduce the patient’s need for medications. Adults should be questioned about symptoms not only in the home, but also in the workplace, as asthma can be exacerbated by both irritant and allergen exposures in occupational settings.

Inhaled allergens – The patient should be questioned about symptoms triggered by common inhaled allergens, at home, daycare, school, or work. Indoor allergens, such as dust mites, animal danders, molds, mice, and cockroaches, are of particular importance. Food allergy rarely causes isolated asthma symptoms, although wheezing and cough can be symptoms of food-induced anaphylaxis.

If the history suggests the patient has allergic triggers, basic avoidance measures can be advised, and evaluation by an allergy specialist should be considered.

Respiratory irritants – Inhaled irritants include tobacco smoke, wood smoke from stoves or fireplaces, strong perfumes and odors, chlorine-based cleaning products, and air pollutants.

Smoking cessation and avoidance of environmental tobacco smoke are reviewed in detail elsewhere.

Comorbid conditions – Clinicians should be vigilant for comorbid conditions in patients with poorly-controlled asthma. In adults, these conditions include chronic obstructive pulmonary disease/emphysema (COPD), allergic bronchopulmonary aspergillosis, gastroesophageal reflux, obesity, obstructive sleep apnea, rhinitis/sinusitis, vocal cord dysfunction, and depression/chronic stress.

In young children, potential alternative or comorbid conditions include respiratory syncytial virus infection, foreign body aspiration, bronchopulmonary dysplasia, cystic fibrosis, and obesity.

Medications – Non-selective beta-blockers can trigger severe asthmatic attacks, even in the minuscule amounts that are absorbed systemically from topical ophthalmic solutions. Selective beta-1 blockers can also aggravate asthma in some patients, especially at higher doses.

Aspirin and non-steroidal anti-inflammatory drugs can trigger asthma symptoms in approximately 3 to 5 percent of adult asthmatic patients. The incidence of aspirin-exacerbated respiratory disease is higher among asthmatic patients with nasal polyposis.

Complications of influenza – Annual administration of influenza vaccine is recommended for patients with asthma because they are at increased risk for complications of influenza infection.

Complications of pneumococcal infection – Administration of pneumococcal vaccination is recommended for adults whose asthma is severe enough to require controller medication and for children with asthma who require chronic oral glucocorticoid therapy

Dietary sulfites – Sulfite compounds are used in the food industry to prevent discoloration. Fewer than 5 percent of patients with asthma note significant and reproducible exacerbations following ingestion of sulfite-treated foods and beverages, such as beer, wine, processed potatoes, dried fruit, sauerkraut, or shrimp. Affected patients typically have severe asthma.

References: 

https://www.uptodate.com/contents/an-overview-of-asthma-management?source=history_widget


FDA approves opioid 10 times stronger than fentanyl

WASHINGTON — The Food and Drug Administration on Friday approved a new form of an extremely potent opioid to manage acute pain in adults, weeks after the chairman of the advisory committee that reviewed it asked the agency to reject it on grounds that it would likely be abused.

The drug, Dsuvia, is a tablet form of sufentanil, a synthetic opioid that has been used intravenously and in epidurals since the 1980s. It is 10 times stronger than fentanyl, a parent drug that is often used in hospitals but is also produced illegally in forms that have caused tens of thousands of overdose deaths in recent years.

Although the F.D.A. advisory committee charged with evaluating the new formulation ultimately recommended in a 10-3 vote last month that the agency approve it, the panel’s chairman, Dr. Raeford Brown, wrote a letter to top F.D.A. officials afterward expressing deep concern.

In the letter, which he wrote with leaders of the consumer advocacy group Public Citizen, Dr. Brown, an anesthesiology professor at the University of Kentucky, described Dsuvia, made by AcelRx Pharmaceuticals, as “an extremely divertible drug,” adding, “I predict that we will encounter diversion, abuse and death within the early months of its availability on the market.

After the final approval on Friday, Dr. Scott Gottlieb, the F.D.A. commissioner, released a lengthy statement defending the agency’s decision. He emphasized that Dsuvia is delivered through a “pre-filled, single-dose applicator,” and said that its only permitted use will be in hospitals, surgical centers and other medically supervised settings. It is ideally suited for certain special circumstances, he said, particularly for soldiers wounded on the battlefield who might not have access to intravenous painkillers.

Dr. Gottlieb wrote that Dsuvia will not be dispensed to patients for home use or available at retail pharmacies, and that it should only be administered by health care providers with the single-dose applicators. It will likely hit the market early next year.

“These measures to restrict the use of this product only within a supervised health care setting, and not for home use, are important steps to help prevent misuse and abuse,” he wrote.


Black Doctor on Flight not believed

Sadly, some airlines are still showing insulting bias towards doctors of color. Dr.Fatima Stanford is actually an MD but the flight attendants did not believe her when she wanted to help a fellow passenger in distress. They wanted to know whether she was lying when she presented them her medical license. Then they posed her questions like ‘Are you really a doctor?’

We should recognize we are all created by one God and is loved by Him. Peace!

Reference: New York Times

Are You Actually an M.D.?’: A Black Doctor Is Questioned as She Intervenes on a Delta Flight