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.

Dog Ownership & Staying Alive

An article published in the Journal of Circulation and Cardiovascular Outcomes in October 2019 looked at the effect of owning a dog on survival and mortality. The authors looked at research studies, published between 1950 and May 2019, that evaluated dog ownership with all-cause mortality and cardiovascular related deaths – including almost 4 million patients and 515 events.

Dog ownership was associated with a 24% risk reduction for all- cause mortality when compared to non-ownership with six of the studies showing a significant reduction in the risk of death. Those individuals who previously had a cardiovascular event (MI, heart attack, etc.) had an even more pronounced reduction in the risk of death of all causes.

When they just looked at the issue of cardiovascular death risk in dog owners who had a previous cardiac event, the risk reduction for cardiovascular death was 31%.  The reviewers concluded that, “dog ownership is associated with lower risk of death over the long-term, which is possibly driven by a reduction in cardiovascular mortality.”

My wife and I lost our treasured Pug of 15 years, “Pug Sly”, and his sweet mix-breed partner “Chloe” two years ago.  Losing these two just one year apart was like losing beloved family.

So, we adopted a rescue Pug and then a young pup who had been returned to its breeder.  At our first dog checkup with the new pets and our vet, my wife expressed concern that at our age the dogs might out-live us. Our vet told us that if that were to occur, and no family members wanted the dogs, he and his family would adopt them and care for them. He said that is common in many practices and they encourage senior citizens who can provide a loving and caring home to not worry about that aspect of continued care and adopting a dog.

While there is no data on this topic, I suspect pet ownership of cats and birds and other domestic animals requiring care and love confers similar benefits.

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.

Lab Grown Mosquitoes Reduce Dengue Fever

Dengue Fever is a serious viral infection transmitted by Aedes mosquitoes that become infected by biting a carrier and then bite a non-infected individual. There are four distinct Dengue virus types so humans can contract the disease four times. The mosquito that transmits Dengue can also transmit the Zika virus and Chikengunya virus.

Dengue has been a disease primarily seen in the Caribbean islands, Central America, South America and Asia. With climate change and migration the disease is moving northward and cases are seen routinely now in Southern Florida and Texas.  Most cases are self-limiting and considered non-life threatening with symptoms of headache, eye pain, severe bone pain, muscle and joint pain, rash and sometimes nausea and vomiting. Treatment is supportive with hydration and pain relief

Individuals who survived an initial Dengue infection and then are re-infected are more likely to develop the severe form of the disease. When their initial fever resolves they develop severe abdominal pain, vomiting and bleeding from the nose or gums. This is a life threatening illness and requires immediate emergency medical attention.

At the recent meeting of the American Society of Tropical Medicine and Hygiene, investigators discussed the success of the release of genetically modified Aedes mosquitoes carrying the Wolbachia bacterium in reducing Dengue infections. This bacterium prevents the transmission of the Dengue virus from mosquito to humans. These modified mosquitoes have been bred and released in Brazil, Indonesia and Australia with a marked reduction in Dengue infections in humans.

Currently a Dengue Fever preventive vaccine is in the experimental phase as well. With climate change and population growth, the CDC expects up to 60% of the world’s population to be at risk from Dengue in the future.

40 Years of Service & a Misspelled Plaque – Thanks!

I attended my hospital’s medical staff quarterly meeting last week. At one time these meetings were mandatory.  If you missed a meeting, you were fined or even suspended.

Voting on major issues required a quorum of three quarters of the active staff.  Hospital employed physicians, or anyone being paid directly by the hospital, were not permitted to vote because they were felt to have a conflict of interest.   Much like the original Federal government which set checks and balances between the Executive Branch, the Legislative Branch and the Judicial Branch we had checks and balances between administration, medical staff and the community mission statement.   All of that is gone today. Meeting attendance is now voluntary.

For the most part, the only medical staff attending are hospital contracted physicians there to push an issue or vote which is beneficial to hospital administration. I have been a harsh critic of the loss of power of the community, and community doctors who support our hospital, but being a small fish in a large pond my thoughts and opinions are rarely considered because the bottom line is the bottom line and that seems to be all that counts in today’s health care environment.

The meeting had some of the vestiges of past meetings including awarding scholarships to worthy young doctors in training, introducing new members of the medical staff and a speech about the future from our new CEO.  The elected Chief of Staff stopped after each introduction and posed for a picture with each scholarship winner and each new staff member.  It was a ritual performed for years at these meetings. The final discussions were about new rules and regulations starting January 1, 2020 regarding ordering of imaging tests and prescriptions. There was no discussion of the communication issues between physician to physician, no discussion of the new policy of nurses not accepting verbal orders from physicians either face to face or over the phone. No discussion of the impact of protocol medicine, one- size-fits-all on individuals with individual problems and needs.

The next morning a representative of the hospital’s marketing department arrived unannounced in our office. She comes monthly to make sure we aren’t having problems ordering outpatient tests at the hospital. On this day, after discussing nothing of earth-shattering importance, she turned to leave and then turned back and reached into her bag and pulled something out. “I almost forgot to leave this here for Dr Reznick.”

The item was incorrectly placed by my staff in my emergency message call box.  I saw it between patient encounters, lifted it up, turned it over and realized it was a plaque for me from Baptist Health System Boca Raton Regional Hospital.  There was a picture of the hospital and inscribed below was a message, “In recognition of 40 years of staff service providing care for the community.”

My name was spelled incorrectly using the spelling of a neurologist who is not on staff and practices 25 miles away.  For years now I have been complaining to no avail that my imaging and lab results are being sent to this physician in error. No one at Boca Raton Regional Hospital has done anything to correct the matter.  So, about twice a month I receive a middle of the night call from Mount Sinai Hospital in Miami Beach looking for their Steven Resnik (with an “R”) but mistakenly calling me (with a “Z”).

I did not ask for any recognition of my 40 plus years on the staff of Boca Raton Community now Regional Hospital.  Although a mention at the quarterly staff meeting, after they introduced the scholarship winners and the new members on staff, would have been nice.  And, receiving a plaque presented as an afterthought, by someone I do not know, with my name misspelled seemed rather disingenuous.

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.