Prostate Cancer, Digital Rectal Exams, PSA and Screening

The PSA blood test, to detect prostate cancer, clearly has saved lives according to numerous studies. The United States Preventive Task Force (USPTF) recognizes this but has decided that screening for prostate cancer is not a great idea in men aged 55-69. They point out the PSA can be elevated from an enlarged prostate, an inflamed or infected prostate, a recent orgasm while having sex and other causes.

Elevated PSAs led to trans-rectal ultrasound views of the prostate and biopsies of the prostate. These biopsies were uncomfortable, even painful, and often followed by inflammation and infection of the prostate. Many times the prostate biopsy was benign with no cancer detected. The USPTF felt the cost, worry, and potential side effects were a risk far outweighing the benefits of screening. They consequently came out against screening men in this age group.  Naturally this position produced a tidal wave of criticism from urologists and other.

So, the USPTF has produced new recommendations calling for patient education and making a shared decision whether or not to obtain a PSA measurement before you send it out. This is a bit confusing because we always discuss the pros and cons of a PSA before we draw it. Adult men are entitled to hear the pros and cons so they can make their own informed decision.

To complicate matters, a study out of McMaster University in Canada reveals physicians are poorly trained in performing a digital rectal exam. They cite the lack of experience coming out of school and going into training and cite numerous research studies showing a rectal exam is a low yield way to detect prostate cancer. They do not recommend performing digital rectal exams for prostate cancer screening.

This received much media hype and the blur between the efficiency of detecting prostate cancer via a rectal exam and the use of the rectal exam to detect rectal and colon disease has been lost. We perform digital rectal exams to detect prostate cancer and look at the perirectal area for disease. We test the strength and performance of the anal sphincter muscle. We feel for rectal polyps and growths and, in certain situations, test the stool for the presence of blood.

During my internal medicine training my teachers always required a digital rectal exam, stool blood test and slide of the stool as part of the exam. As trainees, we realized the invasiveness of the exam and did our best to be polite, gentle and caring. I always asked for permission first, and still do. How can you tell if something is abnormal if you haven’t performed normal exams?

Last but not least, Finesteride, a medicine used to shrink an enlarged prostate by inhibiting male hormones, has finally been shown to be protective against developing prostate cancer. A study published in the journal of the National Cancer Institute found that men taking it for 16 years had a 21 % lower incidence of prostate cancer.

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Artificially Sweetened Beverages, Stroke and Dementia Risk

An observational study in the Journal “ Stroke, A Journal of Cerebral Circulation” examined the question of whether there is an a relationship between consuming “ diet” beverages with artificial sweeteners and the development of a stroke or dementia using data from the Framingham Heart Study Offspring Cohort. They looked at 2888 individuals older than 45 years of age for the development of strokes and 1484 participants over age 60 for the development of dementia. They followed the group for ten years and were able to gauge their intake of artificially sweetened beverages from food questionnaires filled out at exams. After making adjustments for age, sex, education, caloric intake, diet quality, physical activity, and smoking they found that higher consumption of artificially sweetened beverages was associated with a higher risk of strokes and dementia. This was not seen in individuals drinking sugar sweetened beverages.

In a comment section, the author acknowledged that diabetic patients had a higher risk of stroke and dementia than the general public and they consumed more artificially sweetened beverages than others. While the study did not show cause and effect it does leave us wondering just how safe these diet drinks are?

Hospital Discharges and the Handoffs

Fred Pelzman, M.D. is an experienced internist who practices in the NY Metropolitan area and trains young doctors at a well-deserved renowned academic medical center. His corporate behemoth medical system tries to engage in the latest and greatest business practice models for care, using technology and staff generally unavailable to the mom and pop medical practices that once dotted America.  Meanwhile, Dr. Pelzman cares for people compassionately while training his young disciples in an ever changing and complicated health care environment. I love reading his blog posts discussing his thoughts, concerns and efforts.

This week’s article or “post” is about the difficulty and danger entailed when a patient leaves the hospital, after being cared for by hospital based physicians, and returns to their homes and the care of their outside doctor’s. I give Dr. Pelzman much credit for taking ownership of the problem and attempting to solve it. I think there is a much simpler solution to his problem than creating a fast track computer program for patients who need to be seen quickly post discharge. It is called the telephone.

There was a time when physicians actually picked up the phone and called their colleagues and discussed the transfer of care before initiating it. During my internship and residency at the University of Miami Jackson Memorial Program; when a patient was being transferred, the receiving physician received a page resulting in a phone call from the transferring physician to discuss “the case.” The transferring physician wrote a transfer summary in the chart to be reviewed by the receiving physician. When patient’s went home, especially non-private patient’s, the handoffs were inadequate since often there was no receiving physician to communicate with.

After finishing my training and entering private care in a suburban community, the transfer of care was quite simple because most physicians cared for their own patients in the hospital and in the community so the transfer of care was smooth and seamless. This changed with the institution of “managed care” run by insurers at the request of employers and by the development of hospitalist physicians.

Employed hospital based physicians were the idea of Robert Wachter, M.D., the father of hospitalist medicine and the current director of hospital physician training at University of California in San Francisco. When he was completing his training in internal medicine he noticed that general internists in private medicine were not being paid very well in the field. He also noticed that his academic teachers, who were required by Medicare and insurers to actually spend time taking a history, doing a physical exam and writing a progress note on each patient on their teaching service if the facility was going to get paid for their care hated actually interacting with patients. They preferred to be in their research labs or teaching students and future doctors.

Hiring someone to do that work and creating a specialty gave them the freedom to go back to what they wanted to do. It also gave administration a certain amount of control over the tests ordered, medications ordered, length of stay and costs. At the same time this was occurring, “administrative and management experts” were out in the community, convincing private physicians that the solution to their low reimbursement was to stay in the office and see more patients and give up caring for hospital patients. It was deemed inefficient to cancel or delay patients in your office or clinic so you could run to the hospital or emergency room to see an acutely and seriously ill patient.

As hospitalist medicine took hold, medical and surgical specialties decided it was more efficient to use their services than to take the time to admit the patients with issues they were best trained to care for. Orthopedic surgeons stopped admitting patients to the hospital with fractures that needed surgical repair. They asked the hospitalist to do it. Oncologists stopped admitting patients with fevers and infections and abnormal blood counts as a consequence of their cancer or treatment of cancer. They asked the hospitalist to do it. Gastroenterologists stopped admitting acute gastrointestinal bleeders who needed endoscopy and cardiologists stopped admitting acute heart failure and pulmonary edema and heart attacks. These specialists preferred to be “consultants” and let the hospitalists perform the tedious medication reconciliation, admitting orders and mandated quality metrics forms and the deep vein thrombosis prevention forms. The hospitalists became their interns and medical students performing the time consuming , bureaucratic, labor intensive low paid administrative work so the specialist could arrive like the cavalry and just do their procedure and leave.

The problem is that the hospitalist didn’t know the patient. The referring doctor never called the hospitalist or ER physician to send the records and explain why the patient was coming and there was little if any communication. The same occurs when the patient leaves the hospital and is sent for post hospital care. No one coordinating care in the hospital contacts those responsible for the patient’s outpatient care to discuss a care plan. The fault lies with both the inpatient and outpatient physicians who don’t take the time to communicate.

Above anything else, the patient must come first. Picking up the phone and calling the receiving physician and discussing the nuances of the necessary care and creating a plan which is explained to the patient is in the patient’s best interests. All care givers need to remember this and create local environments, climates and systems that encourage communication between hospital-based physicians and community physicians.

Allergies Worsening Due to Climate Change

The American Academy of Allergy, Asthma and Immunology and the World Asthma Organization just concluded their joint congress in Orlando, Florida. One of the topics of concern is how climate change is making everyone’s allergy symptoms much worse.

We read about more powerful hurricanes and cyclones, seasonal tornadoes occurring out of season, horrible beach erosion and flooding due to large volume rains, lack of rain causing poor harvests leading to waves of migration for survival for animals and humans. Climate change also exacerbates allergy symptoms. Nelson A. Rosario, MD, PhD, professor of pediatrics at Federal University of Parana (Brazil) discussed longer pollen season and increased allergens caused by fallen trees and ripped up plants, mold growing following flooding and irritants in the air due to wildfires. An international survey in 2015 found that 80% of rhinitis patients blamed their symptom exacerbations on climate change items. Pollen seasons have more than doubled in some areas.

The argument should not be about whether climate change is due to cyclical planetary changes or man-made pollutants. It should be about what we can do as a society to maintain economic growth while limiting man made contribution to adverse climate changes. The health and survival consequences of not addressing this issue will ultimately involve our survival as a species.

Does Curcumin Use Help with Cognitive Dysfunction?

Recently, more and more patients have been adding curcumin or turmeric to their cooking to help with their memory. Curcumin is a metabolite of Turmeric and has been available in health food stores for years.

A study a few years back on Alzheimer’s patients published by J. Ringman and Associates showed no benefit in slowing the development of symptoms and no improvement in symptoms when supplied with curcumin. When they looked closely at their study, and analyzed the participant’s blood, they found that curcumin was not absorbed and never really entered the bloodstream.

Last month a study was published in the American Journal of Geriatric Psychiatry by Dr. Gary Small and colleagues. They looked at 40 patients with mild memory complaints aged 50 – 90.  Some were administered a placebo and others were administered nanoparticles of curcumin in a product called “Theracumin”. The participants were randomized and blinded to the product they were testing. The study designers felt the nanoparticles would be absorbed better than other products and would actually test whether this substance was helpful or not. At 18 months, memory improved in patients taking the nanoparticles of curcumin and they had less amyloid deposition in areas it usually found relating to Alzheimers Disease.

Robert Isaacson MD, the director of the Alzheimer’s Prevention Clinic at Weil Cornell Medicine and New York- Presbyterian, has been suggesting his patients cook with curcumin for years. Until the development of the Theracumin nanoparticles, cooking with curcumin was the best way to have it absorbed after ingestion. There is now some evidence to suggest that curcumin, in this specific nanoparticle form, may play a role in both the risk reduction and potential therapeutic management of Alzheimers Disease.

Can My Relative, the Physician, Review My Hospital Chart?

I practice in a community, Boca Raton, with a multitude of seasonal visitors. Many of these “snowbirds” have long term relationships with physicians “back home” and a developing relationship with their local physicians. When they become ill enough to be admitted to the hospital, I often get a request to allow a family member to review their medical chart. I have never objected to transparency, especially if it allows the patient and family to feel more comfortable with the caregivers and plan we are following.

When we used a paper chart the process was simple and involved writing an order in the chart to allow that family member to read the chart. I usually spoke with the patient’s nurse and the floor charge nurse to inform them of my permission. The family member simply sat in the patient room or at the nursing station with the complete medical record and reviewed it.

The switch to paperless charts has made it far more complicated. Giving patients’ relatives access to the chart now involves granting them access to the hospital computer record system. It now involves asking medical records to get involved and either devote time and cost of supplies (printing out records) or labor time – asking an employee to sit down with the family member and give them access. It is far more difficult than it once was.

I still grant them access but it must be through the hospital’s information technology and medical records department and protocol. This week I was asked by the physician son of a patient for permission to review his parent’s chart. I had no objection to this request as long as the son went through the medical records department protocol. This was poorly received by the son who saw my actions as an obstruction rather than a necessary process.

If anyone should be understanding regarding these protocols it should be that of a fellow physician.

Fitness Lowers Your Risk of Dementia

Over the years I have read and passed on to my patients the benefits of exercise on quality of life and healthy aging. This hypothesis was supported by a recent publication in the journal “Primary Care” by Peter Lin, MD, CCFP. Dr Lin and colleagues followed a group of woman aged 38 to 60 years for 44 years to determine the relationship between fitness and development of dementia. They chose to follow 191 women from a group of 1462 patients and selected a balanced number of patients in each age group up to age 60. They performed a physical fitness test on the women in 1968 and then grouped them into high fitness category, intermediate fitness category and low fitness category based on their performance in the physical fitness test. The women then received neuropsychiatric evaluations in 1974, 1980, 1992, 2000, 2005 and 2009.

The patients within the high fitness group showed an 88% reduction in dementia rate compared to those with medium fitness. Those in the lowest fitness group had a 41% increase d risk of dementia compared to the medium fitness group. Those patients in the high fitness group who developed dementia showed symptoms 9.5 years later on average than the patients in the medium fitness group.

The message for young adults is simple. Stay fit at a high level doing something you enjoy and you may reduce your risk of developing dementia by up to 90%.