New Approaches to Early Prostate Cancer

Men today diagnosed with early prostate cancer, Gleason Stage 7 or less, have the option of a new arm of care called watchful waiting. With periodic PSA blood tests, prostate biopsies and imaging studies; urologists and oncologists can follow the patient with disease felt to be not aggressive rather than radiate the lesion or surgically remove it as was done in the past. In some cases, they can watch it even closer with an approach called Active Surveillance. This week a new research treatment was made public.

MedPage Today published work by Steve Raman, M.D., of the UCLA Medical Center on his TULSA-PRO ablation clinical trial. One hundred-fifteen men with localized and low, or intermediate, risk prostate cancer underwent ultrasound blasting of the cancer using the MRI imaging equipment to direct the therapy. In his study, prostate volume decreased from 39 cubic centimeters before treatment down to 3.8 cubic centimeters after a year. Clinically significant cancer was eliminated in 80% of the study participants and 65% had no evidence of cancer after biopsy at one year. PSA blood levels decreased by 95%. The side effects were minimal with low rates of incontinence and impotence and few bowel complications.

The study leader noted that if prostate cancer reoccurred then the modalities of repeat ultrasound treatment, surgery or radiation were still possible. In August 2019, the FDA approved the TULSA-PRO Device for use. The procedure involves placing a rod-shaped device into the urethra. The device has ten ultrasound probes which are controlled by a computer program while the patient is observed in an MRI machine. The probes shoot out sound waves that heat and destroy the tissue the sound is directed at. The procedure is an outpatient procedure which can also be used to shrink a non-cancerous enlarged prostate from benign prostatic hypertrophy.

Natural Substances That Work

In an article published in the pharmaceutical journal MPR, pharmacist Cassandra Pardini, compares the use of melatonin to provide sleep to hospitalized patients taking sleep medicine zolpidem (brand name is Ambien). The patients were hospital inpatients over 18 years of age who were unaware whether they were receiving melatonin or zolpidem to sleep. These patients completed a questionnaire using the Verran and Snyder-Halpem sleep scale to respond.

There were a total of 100 patients included in the study which showed that the favorable sleep effects of melatonin were as effective as the favorable sleep effects of the zolpidem. Both sleep aids were well tolerated and there were few, if any, adverse effects such as morning grogginess or headaches.

The authors concluded that melatonin may be a better choice for inpatient sleep aid because of the lower profile for serious adverse effects. Further studies looking at dosages and drug interactions are in the planning stages.

The same periodical presented a review of the scent Lavender used to reduce anxiety. The authors performed a literature review of all the published studies on the subject. There are over 65 randomized controlled studies and 25 non -randomized studies.

When lavender was used in an inhalation method, they found a general decline in reported anxiety. The inhalation method did not lower systolic blood pressure which is felt to be a physiological marker of anxiety. When the lavender was administered as an oil preparation (Silexan 80 mg per day), for at least six weeks, there was a reduction in anxiety as measured by an accepted Anxiety scale. In a smaller study, lavender administered by massage had a positive effect as well.

There were few if any adverse effects in these studies. Clearly lavender does reduce anxiety in subsets of patients and should be considered as part of our treatment options.

Environmental Pollution Linked to Decreasing Lifespan and Increased Deaths

Worsening air pollution is killing more people at a younger age. We read on a daily basis about a White House sponsored movement back to the use of coal for fuel. At the same time, rules and regulations designed to keep our air and water clean are being relaxed by Administration appointees to the Environmental Protection Agency.

Instead of protecting the environment so that future generations have clean air to breathe, and water to drink, we see rule after rule put in place to protect our countries environment scraped by officials who cite economic profit and jobs over environmental concerns for future generations. When the discussion gets heated, officials cite the fact that even if we use clean energy, developing countries like China and India and third world nations produce enough environmental pollution to offset our best efforts.  The rhetoric goes back and forth between advocates for developing and exporting clean energy (solar, wind, natural gas and nuclear) versus coal products. But, what do the facts say?

A recent study published in the Journal of the American Medical Association Open Network directly linked air pollution and its contribution of fine particulate matter to the atmosphere with an increased burden of death from several causes. The researchers followed 4,522,160 military veterans in the USA from 2006 to 2016 and linked their exposure to increased particulate matter or pollution to increased deaths from nine causes including:

  1. Heart Disease
  2. Cerebrovascular Disease
  3. Chronic Kidney Disease
  4. Chronic Obstructive Pulmonary Disease
  5. Dementia
  6. Type II Diabetes Mellitus
  7. Hypertension
  8. Lung Cancer
  9. Pneumonia

The increased death rate was more noticeable in persons of color living in poor socioeconomic communities. The causes of death were in no way related to accidents.

The concentration of pollutants the study population was exposed to was actually lower than the new relaxed standards the current Environmental Protection Agency has approved. Last month a similar study was presented at a worldwide meeting of the World Health Organization.

The message is quite clear.  Unless we want to see a rising death toll due to air pollution, we need to improve the air quality and ask for more stringent standards. At the same time, the USA needs to support the development of clean fuel and energy sources that we can export to developing countries so that their reliance on coal and polluting sources diminishes.

We need to do what we can to control the issue rather than continuing policies that increase the deaths of our citizens in the name of profits.

Taking BP Medications at Night More Efficacious Than in the Morning

The European Heart Journal published the Hygia Chronotherapy Trial which followed hypertensive patients in Spain for a decade between 2008 and 2018. There were 19,000 participants of whom 10,600 were men, all older than 18 and all being treated for high blood pressure.  The group was randomly selected to either take their blood pressure medications at bedtime or in the morning.  They were followed with frequent blood pressure checkups plus 48-hour ambulatory blood pressure monitoring to assess their sleep time blood pressures.

The study was performed only on Caucasian participants who went to sleep on what would be considered a normal day/night schedule.  The results were significant and important.

Those who took their blood pressure medications at bedtime saw the risk of dying from a heart or blood vessel related problem drop by two-thirds compared to those who took their meds in the morning.  Night time administration of blood pressure medications resulted in a 44% drop in heart attack risk, a 40% drop in the need for coronary artery revascularization, a 42% drop in the risk for heart failure and a 49% drop in stroke risk.  The overall reduction in risk for cardiovascular death was 45%.

This is a significant study which must now be performed in patients of color who tend to have higher night time blood pressures.  While these studies are in progress, it appears that taking your blood pressure medication before bed is the correct choice.

Healthy Aging – Adjustments for Living & Reality

For several years now my wife has been complaining that I do not hear her when she talks.  I have gone for regular ENT checkups with audiology testing and while there is clearly a drop in hearing certain frequencies, my word discrimination and comprehension put me in a position of delaying using hearing aids for another year.

I was aware I had trouble hearing my middle adult daughter’s voice frequency.  I was missing words on TV especially when foreign accents were present leading to the purchase of TV Ears which solved the problem.  Still I knew that without auditory stimulation your brain deteriorates at a faster rate.

Last year the ENT doctor sent me home with a pair of hearing aids to try.  “Your wife called and said that if you don’t try them she may find me and kill me in my sleep.”  I was so angry with my wife for interfering that I made a point of pretending not to hear her every time she addressed me and I had the hearing aides in.  Those hearing aids were returned within the 30-day trial period because I could not use my stethoscope with them in.

One year later I was back again and this time my hearing test showed some drop in my word discrimination. They suggested trying a blue tooth compatible pair of hearing aids and even took out a stethoscope to show me how my hearing was enhanced using the stethoscope thus eliminating my favorite argument.   I wore them home and frankly they are wonderful.

The next day I had an appointment for my six-month eye exam. My acuity was off and I suspected my visual field in one eye had diminished based on driving and athletic pursuits.  The test confirmed my suspicions with my ophthalmologist diagnosing “normal pressure glaucoma” in my right eye.  “We need to lower the pressure by 3% with the drops I am prescribing and if the pressure doesn’t decrease we will recommend a laser surgery procedure in three weeks.  You are not going blind, but we want to preserve your visual field.”

The look on my face advertised my disappointment.  “It’s not so bad, you have sent me hundreds of patients with this situation and we helped them all. Why are you so troubled over this?  Looking at your med sheet and problem list at least you aren’t complaining about ED.”    When I didn’t answer her there was a long pause and she said, “Oh, I am sorry if I brought up a difficult topic.”   The best I could mutter was that in geometry what was once an acute angle is now an obtuse one.”

I tried to sell the fact that my dermatologist had me on a short-term course of prednisone which was raising the ocular pressure, but she wasn’t buying that argument.  New glasses, nightly eye drops and hearing aides all in a 72-hour period.

Instead of being grateful and thankful that I had minor correctable issues, and I could afford to spend the $6000 plus dollars for hearing aides and new trifocal lenses, I was moaning and groaning about the trials and tribulations of healthy aging. It was like running into the ocean surf on a hot day preparing to dive in to the surf and cool off and an unexpected wave smacks you down and stuns you before you can dive below its crest and avoid the strong impact.  I was devastated.

It took about 72 hours to adjust.  At my regular Friday night dinner with friends my buddy said, “Steve you seem to be hearing much better tonight. We did not have to repeat anything. What are you doing?”   I told him I was wearing new hearing aids which he had not noticed.  I hear better through my stethoscope than I did before.  When I walk my dogs or take my daily walk I hear the birds chirping, the children playing, the sprinklers initiating their watering cycle. These are all sounds I had forgotten about.  At lectures and movies I am hearing clearer. The blue tooth connection to my cellphone makes calls easier to complete.  My new trifocals allow me to read up close far more easily and see distance much better.

As a physician and geriatrician, I stress eye exams, hearing tests and evaluations to determine our ability to stay independent and functional. I cannot explain why I was so resistant to applying the same principles to my own health.

My day-to-day life has improved markedly with the hearing enhancement and new glasses. I hope my patients and students will look at my stubbornness and reluctance to accept healthy age-related changes as an example of how hard we cling to our independence and how reluctant we are to give up pieces of it even when we know it is for the best.

Restorative Dental Surgery, the Elderly and Shared Decision Making

A wise professor of medicine always told me as a young physician, “Eighty-year olds are to be revered and not messed with.”   This is especially true for those 90 or older.  Here in South Florida there is always some senior citizen telling us today’s 80 is yesterday’s 60 and today’s 70 is yesterday’s 50.  It just isn’t so.  I see this erroneous belief of the elderly having the healing power of younger individuals   highlighted in the area of cosmetic and restorative surgery and dentistry in my affluent youth-seeking community.

We all want to look our best. In many cases this requires pulling teeth, placing implants and covering those implanted posts with crowns to produce that young smile and maintain a chewing surface. Most times it’s better to do less.

Pulling rotten teeth, obtaining dentures or using a bridge and practicing meticulous hygiene on the gums may be the better course.  Don’t tell this to 91 year old Hal who is mildly cognitively impaired, and his loving caring daughter who sent him for extensive dental surgery.   This gentleman had an artificial aortic valve placed by the less invasive TAVR method a few years back. He was required to take antibiotics before the procedure to prevent a heart valve infection as per the guidelines of the American Heart Association, American College of Infectious Disease and American Dental Society.

His former physician taught infectious diseases in a major academic center and felt he needed a longer course of antibiotics than the guidelines recommended.  Several weeks later he had intractable back pain and severe diarrhea. He was diagnosed with antibiotic related colitis and treated appropriately with oral vancomycin. The back pain was more problematic.  His daughter self-referred him to a physical therapist who could not find a way to obtain relief.

He came to me as a new patient with severe back pain and, after hospitalizing him for pain relief and with the assistance of an infectious disease expert, we were able to document an infection of the heart valve and an infection of the back disc space causing the excruciating pain. The infection originated with the disturbance of his gums and teeth during the dental work. He received 10 weeks of intravenous antibiotics and four months of physical therapy at a skilled nursing facility before he was able to return to his home with help.

At that point he and his family were advised to limit the dental work, follow antibiotic guidelines for the work being done and clear the work and antibiotic regimen with his internist and local infectious disease physician prior to undergoing non-life-threatening non-emergency procedures. It was no surprise however when I received a phone call from his aide saying he had diarrhea after a dental procedure and the daughter chose to use the prolonged antibiotic protocol that the former doctor had recommended years ago.  One of the aides had given the patient immodium several days prior to the call to me to slow down the diarrhea so now the body’s natural clearing response to a pathogen had been delayed by a medication choice.

He was examined and found to have a mildly tender abdomen. A digital rectal exam identified microscopic blood in his loose stools.   A stool evaluation identified clostridia difficile as the causative agent of his antibiotic related colitis. He is now back on medications for this entity and hopefully it will control the disease while we keep him hydrated and out of the hospital again.  More is not always better. The frail elderly need to be revered and not messed with. Palliative rather than aggressive therapy may be best in this patient population.

Mrs. Sommerville is another example. A beautiful mid-eighties woman, she looked years younger. She signed up for pulling all her teeth on her lower jaw and recreating her smile with implants. She was given an opioid medication for pain control. Post-surgery she ran a fever for several days.  After taking the opioid for pain relief she fell and hit her head. She was referred to a hospital ER where she was noted to have a subdural hematoma from the fall (blood on the brain) and positive blood cultures from the oral bacteria which seeded the bloodstream during her dental procedure.  I suggested transferring her to a facility that had the neurosurgical capabilities to treat the complications of a subdural hematoma. The patient did not want to be transferred and, in the era of shared decision making, the consulting neurologist was comfortable obtaining serial MRI scans to observe the brain bleed and follow its course.  The MRI’s didn’t get done on a timely fashion because the patient had just had hair extensions placed by her hair stylist and the metal clips were not permitted in the magnetic range of the MRI machine. The patient refused to allow anyone but her hair stylist to remove the extensions and his schedule didn’t permit his visit to the hospital for 48 hours.

Both situations exemplify the zest for life and vitality human beings exhibit. In both cases, less would have been preferential.

I suggest that as we get older before considering cosmetic procedures, we discuss it with our medical doctors and review the pros and cons and alternatives. I am not accusing the dentists of being too aggressive but maybe too accommodating with no real geriatric training to help them in their clinical decision making.

Hypertension Guidelines Versus Life Experiences

One of the advantages of practicing clinical medicine, and seeing patients daily for many years, is you develop your own long-term study regarding certain medical health issues. In the area of hypertension, I have been taught by the best since my internship with pioneers such as Eliseo Perez Stable and Barry Materson at the University of Miami affiliated hospitals, Jackson Memorial Program, ensuring that their trainees were up to the task.

The goals and guidelines have changed. Lifestyle changes including salt restriction (sodium chloride), weight reduction, smoking cessation, reducing alcohol intake and regular exercise will always be mainstays of non-pharmacologic treatments.  We used to be taught to keep the systolic blood pressure at less than 140 and the diastolic blood pressure at less than 85.  These numbers have changed over the years, having been lowered, with everyone over 120 systolic now being classified as having some degree of increased risk of cardiac, cerebrovascular or vascular disease and hypertension.

We originally were taught to start with a diuretic and keep raising the dosage until the blood pressure was controlled or the patient developed adverse effects. We learned that when we used one medication, pushing it to its limit inducing adverse effects along the way, patients just stopped taking their medications. This resulted in a change in strategy to using several medicines each with another pathway to controlling blood pressure but all at a lower dosage which did not produce any ill feeling adverse effects.  The downside of more medications was additional costs and more pills to remember to take.  As hypertension experts pushed us to lower systolic blood pressure to 120 or less in our geriatric population I was concerned that lowering the pressure that much would again create adverse effects which were as or more troublesome than the risk  of having a BP between 120 and 140 systolic.  An article in JAMA Internal Medicine looked at this issue. They looked at patients over 65 years of age who were hospitalized for non-cardiac related problems and whose blood pressure was over 120. They studied these patients at Veterans Administration hospitals over two year period. Patients with elevated blood pressure above 120 were given more medications and higher dosages to bring their pressure down to meet the more stringent guidelines. The result was that there were no fewer cardiac events than anticipated and no better blood pressure control at a year.  In addition, these patients suffered from an increased number of re-admissions to the hospital and “serious“ adverse events within 30 days.

The new guidelines for blood pressure control may be applicable in a younger healthier population.  In the geriatric population we may need to readjust our goals to account for the physiologic changes that occur in men and women who age in a healthy manner. More specific data on why there were more re-admissions and what serious adverse effects occurred needs to be made public to determine if the effort to tightly control blood pressure is to blame.