Dr. Saleeby's Blog (Part IV)

Waterborne Diseases During and After Flooding (SC USAR TF-1)

2012-01-19T19:49:00.002-05:00

Crush Injury / Crush Syndrome / Compartment Syndrome (SC USAR TF-1)

2012-01-19T19:46:00.000-05:00

hCG Diet at Wellness One

2012-01-01T09:34:00.000-05:00

With mounting obesity epidemiological statistics, it is as important as ever for those that are overweight, obese or suffer from metabolic syndrome (obese, elevated lipids, hypertension and pre-diabetes) to seek a "reduction" in body fat. There are now easy steps in which to achieve quick reductions and establish lifestyle changes for good health. Dr. Saleeby is associated with Wellness One of Myrtle Beach, SC as their new medical director. Wellness One is a health and beauty medical spa that offers the proven hCG diet program and other protocols for weight management.

Watch the video below for more on the hCG Diet Program and contact information for Wellness One and Dr. Saleeby.

Call for an appointment today: (843) 444-WELL (9355)

As a feature of being an active patient of Dr. Saleeby and WellnessOne, you will be ability to gain access to Xymogen pharmaceutical-grade (physician-only dispensed) supplements.

Additionally, you are granted access to other health provider exclusive supplement lines with a 5% discount (Pure Encapsulations, Perque & Designs for Health DFH) via Emerson Ecologics. Both web sites give you access to high quality, pharm-grade, well engineered lines of dietary supplements. Many of the products the general public cannot purchase or order without access through a healthcare professional, so they are not available over-the-counter. To set up a free account to order is simple; follow the steps on this page:

For discounts (5% and more) on your supplements access code: yms333

Emerson Ecologics is an online distributor of many high quality and exclusive products and I recommend shopping for great deals on this site. You are sure to find any supplement you are looking for on this site. As an active patient of mine you have special access with additional discounts. The account comes with a 5% discount to you on ALL products over and above the discounted prices. You must have my access code to qualify for these discounts and access to some physician exclusive products. You can learn more about what is available by visiting: www.emersonecologics.com. Again as one of our patients you receive an additional 5% discount on your orders. Use Dr. Saleeby’s zip code 29512 and the access code: yms333 or take the shortcut link below (cut and paste into your browser if you get an error message):

https://www.emersonecologics.com/CustomOrder.aspx?RefID=00171325

XYMOGEN

Physician exclusive product access:

1) Visit this link: https://store.xymogen.com/PatientSignup.aspx this is a secure web portal to Xymogen.com.

2) Next click on the button that states: No, my doctor has provided me with a code to create a new account.

3) Enter for Code #: staywell (all lower case and no spaces)

4) Enter for Practitioners Last Name: saleeby (lower case)

5) Click on and this will allow you access to set up your own secure account in which you can order Xymogen products on your own. They are drop shipped directly to you. I am not involved in that process. The fact that it is online means you have access 24/7.

If you have questions regarding supplements, what may be the best products for you,

or how and when to take them, Dr. Saleeby is available via email to help answer questions: jpsaleeby@aol.com

Excessive Cancer Screening in our Elderly Population

2011-12-28T10:44:00.000-05:00

Excessive cancer screening in the elderly

Based on the National Health Interview Survey, researchers at the University of Connecticut have reported that patients ≥75 years of age continue to undergo cancer screening in spite of unproven benefit. Specifically, 57%, 62%, 53%, and 56% of patients 75-79 years of age have colorectal, breast, cervical, and prostate screening, respectively. More than 50% of patients > 75 years of age undergo cancer screening based on physician recommendations.

http://www.medicalnewstoday.com/articles/239052.php (MNT)

------------------

From MNT blog:

U.S. Preventive Services Task Force guidelines recommend against routinecancer screening, especially for breast, cervical, colorectal and prostate cancer, but adults 75 and older are still receiving regular cancer screenings. The report published in the December 12/26 issue of Archives of Internal Medicine, one of the JAMA/Archives journals, is a part of the journal's Less is More series, the aim is to educate healthcare professionals and patients alike in cuttings costs, but having a better service at the same time.

The authors write as background information in the article :

"In the United States, the number of adults 65 years or older, currently estimated at 36.8 million, is expected to double by the year 2030. Providing high-quality care to this growing population while attempting to contain costs will pose a significant challenge ...

While a great deal is known about cancer screening behaviors and trends in young and middle-aged adults, less is known about screening behaviors in older adults from different racial backgrounds."

Keith M. Bellizzi, Ph.D., M.P.H., of the University of Connecticut, Storrs, and colleagues analyzed data from the National Health Interview Survey, an annual in-person nationwide survey used to track health trends in U.S. citizens, to estimate the prevalence of cancer screening among older, racially diverse adults. The study population included 49,575 individuals, 1,697 of whom were 75 to 79 years of age and 2,376 were 80 years of age and older.

Percentages of those reporting cancer screenings are as follows :

62 percent Women age 75 to 79 - A mammogram within the past two years.
50 percent of women age 80 and older - A mammogram within the past two years.
53 percent of women ages 75 to 79 - A Papanicolaou screen (also known as a pap smear or pap test) for cervical cancer within the past three years.
38 percent of women ages 80 and older - A pap smear within the past three years.
57 percent highest of men and women 75 to 79 - Screenings for colorectal cancer.
57 percent of Men 75-79 - Prostate cancer screening.
42 percent of Men 80 and older - Prostate cancer screening.
40 percent of Men 50-74 and older - Prostate cancer screening

Analysis showed large differences in breast, colorectal and prostate cancer screening among older adults, but the authors found that these differences were accounted for by low education.

Individuals without a high school diploma were significantly less likely to be screened for breast, cervical and prostate cancer, compared with adults older than 75 years with a college degree. Adults older than 75 years were also significantly more likely to be screened for breast, colorectal, and prostate cancer if a physician recommended the test.

The authors concluded :

"A high percentage of older adults continue to be screened in the face of ambiguity of recommendations for this group ... Prevalence results from this study can serve as a benchmark for progress as we move the science of cancer screening in older, diverse adults forward."

In additional commentary, Louise C. Walter, M.D., of the University of California, San Francisco and San Francisco Veterans Affairs Medical Center, writes that :

"There are no quality measures that address appropriate target rates for cancer screening in persons older than 75 years ...

While at extremes in older age the likelihood of surviving long enough to benefit from potential detection and treatment of asymptomatic cancer becomes quite small and the likelihood of harm becomes quite large irrespective of other factors, Bellizzi et al were not able to calculate screening rates in subgroups older than 85 years owing to the small number participating in the survey ...

Still, the data by Bellizzi et al raise the issue of whether quality measures should address the overuse of cancer screening."

Dr. Walter concludes :

"While it is useful to determine screening rates among persons in whom screening will likely result in net benefit or net harm, between these two groups is a large number of older persons in whom screening offers small or uncertain net benefit ...

For these persons, the decision about whether the potential benefits of screening outweigh the risks is a value judgment that requires informed decision-making ...

While arguments persists about what is the 'right' rate of cancer screening in older persons, it seems clear that the rate of informed decision-making should approach 100 percent."

Written by Rupert Shepherd
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

Please use one of the following formats to cite this article in your essay, paper or report:

MLA

Rupert Shepherd B.Sc. "Cancer Screening In Older Patients Very Common." Medical News Today. MediLexicon, Intl., 13 Dec. 2011. Web.
28 Dec. 2011.

APA

Rupert Shepherd B.Sc. (2011, December 13). "Cancer Screening In Older Patients Very Common." Medical News Today. Retrieved from
http://www.medicalnewstoday.com/articles/239052.php.

Colorectal Cancer Screening

2011-12-09T08:39:00.000-05:00

Expert Insights (from Quest Diagnostics patient information page)

A Two-pronged Strategy for Combating Colorectal Cancer

Thursday, March 31st
By: John L. Marshall, MD
Category: Oncology

Colorectal cancer a disease that is preventable, treatable and beatable, and for which early detection is of paramount importance.

Last year, colorectal cancer (CRC) caused an estimated 51,370 deaths in the U.S1.

Most of those deaths could have been prevented.

“When colorectal cancer is detected early and treated, the 5-year relative survival rate is 90%,” notes Dr. John Marshall. “This drops to around 70% for patients diagnosed with regional disease and 12% for those diagnosed with end stage disease2.”

CRC is the third most common cancer in the U.S., but the second leading cause of cancer related deaths3. Dr. Marshall sees two keys to promoting survival from CRC: more widespread screening and more targeted therapy.

A glaring need for more widespread screening

“Colon cancer is one of those diseases where early detection clearly matters,” Dr. Marshall says. “Yet screening rates are terrible. Only 50% of Americans over 50 years of age receive any kind of screening for CRC. That compares with a screening rate for breast cancer of around 70%4. And it’s tragic because regular screening could prevent as many as 60% of CRC deaths.5”

Why are screening rates so low? "Partly because the tests for CRC are difficult for patients to undergo," says Dr. Marshall of colonoscopies and sigmoidoscopies. "Fecal tests help a little, but it's no fun to collect stool. People would rather have a needle stuck in their arm. Better screening techniques and early detection are critical. The field has been moving slowly, which is why recent developments, such as a DNA blood test, are important." This new blood test option, methylated Septin 9, is now available to aid CRC detection for the more than 52 million individuals over 50 years of age, who do not follow guidelines and remain untested.

Genetic profiling for more targeted therapy

In addition to advances in promoting more widespread screening, Dr. Marshall sees promise in targeted testing once CRC is diagnosed. “We give everybody the same treatment up front and just hope that it will help. But we don't know who will benefit.” he says, “We need to get smarter about who gets which drug. We should know which patients are at risk and who needs adjuvant chemotherapy. With stage 2 and 3 patients, for example, deciding who needs adjuvant therapy is critical.”

Dr. Marshall points to genetic profiling as a major step toward evaluating the risks and determining which treatments patients should receive. “Genetic testing is making its way into clinical practice and having an impact on therapy,” he says. “People are getting away from the microscope and looking at certain gene or protein expressions to understand which treatment to select.”

The promise of more effective treatment

Dr. Marshall is optimistic that advances in genetic profiling will lead to more effective therapies. “The only way we’re going to get more effective medicine is through this concept of molecular profiling and targeted drug development.”

"The hope is that this will lead to additional breakthroughs – not necessarily for everyone with colon cancer, but for subsets of patients with specific kinds of colon cancer. I expect we will start to see these efforts come to fruition over the next three to five years."

Testing for CRC via the ColoVantage test can be found online at http://www.estatlabs.com/ (under Cancer markers/screening tests)

References

National Cancer Institute, U.S. National Institutes of Health

www.cancer.gov/cancertopics/types/colon-and-rectal

National Cancer Institute, U.S. National Institutes of Health

http://seer.cancer.gov/statfacts/html/colorect.html#survival

American Cancer Society, Cancer Facts & Figures 2010

American Cancer Society, Breast Cancer Facts & Figures 2010

http://www.cancer.org/acs/groups/content/@nho/documents/document/f861009final90809pdf.pdf

National Health Interview Survey Public Use Data File 2000, 2003, 2005,and 2008.

http://www.estatlabs.com/products/ColoVantage-%28methylated-Septin-9-biomarker-for-colon-cancer-screening%29.html

Author contributing to Expert Insights:

John L. Marshall, MD

Professor of Medicine

Chief, Division of Hematology-Oncology

Director, Clinical Research

Lombardi Comprehensive Cancer Center

Georgetown University

Washington, DC

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2011-06-03T23:35:00.000-04:00

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Yusuf Saleeby, MD

ER Physician, Telemedicine in NC & SC. Herbal & dietary supplement formulator at AtroGene Telemedicine

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Colon Cancer Screening: To scope or not to scope?

2011-06-03T22:57:00.001-04:00

Colon Cancer Screening: To scope or not to scope?

Biomarkers to the rescue.

Yusuf M. Saleeby, MD

(Published in Nov/Dec 2011 edition of American Fitness magazine)

Colon cancer screening by fiberoptic colonoscopy is recommended by the vast majority of physicians and the American Cancer Society as a screening test for colorectal cancer. While colonoscopy is the “gold standard” for colon cancer screening, nearly 50% of Americans over the age of 50-years avoid the procedure and ignore the recommendation. There are some obvious and not so obvious complications and risks associated with the procedure and the notions people have with the bowel prep process and undergoing conscious sedation are not at all appealing. But many avoid the procedure due to expense, discomfort of procedure, and inability to devote the time for the relatively invasive procedure. A recent study by a British group of researchers published in the peer-reviewed medical journal Lancet calls into question the validity of conventional fiber-optic colonoscopy as a screening tool.

Colorectal cancer is the third most common cancer and the 2^nd leading cause of cancer death in the US, Canada and Europe. There are about 100,000 new colon cancer cases in the US each year and approximately 40,000 new cases of rectal cancer. Of these, there are about 50,000 deaths annually attributed to colorectal cancer. What causes colon cancer is a difficult and elusive question that has not been fully explained. However, epidemiological studies have revealed that dietary constituents are implicated in colorectal carcinogenesis. Those constituents are a diet high in fat and red meats, considered causative, and a diet low in calcium and fiber as these would be considered protective. Additionally, there are genetic factors. For example, researchers have found that certain biomarkers in both animal and human trials affect the dietary factors. Colon cancer develops by an adenoma-carcinoma sequence in the pre-cancerous or injured cell. The appearance of colonic polyps has been an end-point in some research trials, however, normal appearing mucosa can still contain very small foci of aberrant crypts (invisible to colonscopy) referred to as micro-adenomas and these will certainly lead to dysplasia. Researchers are studying these small foci and discovering what diet and chemopreventive agents work best at suppressing their growth. Omega-6 fatty acids affect lipid peroxidation of DNA and this exposure provides stimulation for precursor tumor cells. Diets low in calcium apparently inhibit apoptosis (cancer cell death) leading to higher risk as well. Calcium has also been shown to reduce the recurrence of adenomas in three recent trials. However, in one of these studies the use of fiber in the diet actually increased recurrence dramatically, counter to what we currently believed about fiber. Much study is needed to realize the impact of our diet and environment on our genes and how that interaction produces cancer.

It has been shown through many trials that colon cancer screening, effective follow-up and treatment can reduce risk of colon cancer death by as much as 35% and risk of getting colon cancer by 20% with early detection of precancerous polyps, this according to Dr. Otis Brawley, chief medical officer of the American Cancer Society. The much used, most efficient, least expensive and practical screening test is the stool occult blood test (aka FOB or Hemoccult®). With an abnormal finding (positive for occult blood) the next step can be taken. Most American physicians would opt for a referral for colonoscopy. But there are alternatives. There are less expensive and possibly safer alternatives to the more invasive conventional colonoscopy which has been the predominant method for further screening (and now primary screening) for colon cancer.

A 2004 research study performed in England over a 4-month period reviewed the results of some 9223 colonoscopies performed in the traditional flexible colonoscopy fiber-optic method, the majority of which were conducted in teaching hospitals. To paraphrase the study, it revealed that IV sedation was used in just over 94%, cecal intubation (the ability to run the scope to the end-point which is the cecum) was only 56.9%. Reasons for failure were attributed to patient discomfort (35%), looping (30%), and poor bowel prep (19%). Normal results were reported in 42.1%. Polyps were reported in 22.5% (a pre-cancerous finding) while evidence of carcinoma was only realized in 3.8% of cases. Rectal bleeding requiring admission was reported in six patients and the overall perforation rate was one in 769 cases. Colonoscopy was also considered a factor in six deaths occurring immediately following the procedure. The conclusion of this study revealed a wide variation of sedation guidelines, the studies were often incomplete and does not achieve the targeted 90% cecal intubation rate. Serious complications were comparative with previous studies and points out that while thousands are done in America, there are inherent risks and short-comings.

The American Cancer Society is now recommending the use of Virtual Colonoscopy as an alternative to traditional fiber-optic conventional colonoscopy (CC). Virtual Colonoscopy is the use of a spiral Computed Tomograph (CT) to visualize the colon. The trade offs are a little radiation exposure in virtual, but the gain is a better study technically, with no failure to “progress to the cecum” issue, the ability to re-visit the study and finer resolution. The upside continues as it is non-invasive and thus the risk of perforation, post-operative complications, bleeding and risks of anesthesia are eliminated. Cost is another factor in favor of VC over conventional fiber-optic method. The most obvious downside is that if a malignant lesion is noticed there is no way to perform an excisional biopsy for further pathological study; one would have to sit for a conventional colonoscopy.

Colorectal cancer screening with VC has been endorsed by the three major gastrointestinal societies: the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (AGSE), and the American College of Gastroenterology (ACG).

VC is also indicated after incomplete conventional colonoscopy, as up to 13% of incomplete CC were found to have lesions 6mm and larger. VC is better than a barium-air contrasted study due to reduction in sensitivity of the contrast. Because of the nature of the CC exam, and the unwillingness of the population at large to undergo this type of exam, this may explain the reason as to why 50% of eligible adults needing the CC do not get it performed.

When running a cost analysis, this is what I have found to be the case: A standard doctor’s office visit for consultation, pre-procedure lasting no more than 5-minutes costs $216. Estimates for the procedure itself for specialist performing it was around $850. The estimated cost for anesthesia was somewhere between $300 and $400. Not figured into this cost was the use of the GI suite/operating room. That would have been billed separately from the hospital used. So you are going to walk away with a bill at or over $1400. That is even before any intervention that may be involved. If a biopsy is taken, then you have that additional procedure billed and then there are the costs of the cyto-pathology report. So this becomes a very expensive screening process. Often too expensive for the vast majority of Americans who don’t have the health care coverage or who are uninsured. VC typically comes in at about $1200 for the procedure and reading, but that cost will certainly drop it becomes more popular. That being said, you are paying for convenience, comfort and putting yourself at less risk for untoward outcomes. More people can be screened with the less expensive VC procedure, thus eliminating the risks associated with CC, the expense and time involved. When positive findings are found on VC they can be referred to a gastroenterologist for CC and biopsy and further workup, thus lightening the screening burden on this sub-specialist group. Virtual colonoscopy may not be covered by third-party payers for screening purposes at this time; however that is likely to change in the near future.

But for most patients seeking screening exams there are still far less invasive, less costly and less time consuming options. The keyword here is medical biomarkers. Not to be overlooked, and worth mentioning again is the most simple and effective screening method on the first tier; the stool occult blood test (FOB, Guaiac® or Hemoccult® test). This test can be performed by your doctor or at home by yourself with a simple kit. The test kit is then developed with a chemical solution to detect microscopic blood in your feces that is typically associated with a pre-cancerous or cancerous lesion. While a positive test may mean other things besides malignancy (hemorrhoids, fissures, infection, recent intake of undercooked red meat) there are other tests used to back this screening modality up. This occult blood test can be had for a few dollars.

The reluctance of widespread use of these tests comes from the guidelines for the American Society of Clinical Oncology and the American Cancer Society which are still discouraging the use of cancer markers as “dedicated screening” tests. Their reasons are mostly the higher incidence of false positives. That would be a person with a positive test with no malignancy. Other reasons may be purely political, as a simple blood tests would “take away” expensive and profitable procedures from those performing flexible sigmoidoscopies and colonoscopies. However, that did not stop the New York State Health Department from giving the green light and approving one such biomarker for colorectal screening purposes.

While there is an increased demand for biomarkers of colorectal cancer (and other cancers for that matter), for early detection, risk assessment, prognosis and follow up post treatment, the perfect, gold-standard test has not yet been realized. Short comings are: too frequent false positives and false negatives as a stand-alone screening test. The National Cancer Institute has established an Early Detection Research Network to promote more research in this field of study. The emphasis of the network is on translational research and collaboration among scientists in the field of oncology with the hopeful development of better cancer markers in the near future.

A rather new and promising colorectal biomarker is the ColoVantage® (methylated DNA from SEPT9 gene marker) test. ColoVantage® is the brand name of a test launched in 2010 by Quest Diagnostic Labs and as of March 2011, has gained approval by the New York Health Department as a sanctioned colorectal screening test. With its reported 70% sensitivity and 89% specificity rating, it is a good first line test for screening large numbers of people less likely to undergo colonoscopy of any type (conventional or virtual). The American Cancer Society is also warming up to the idea, but is slower to act as they are advocating more scrutiny. Quest Diagnostic is offering the ColoVantage® at a retail cost of $355. Direct Access Testing sites such as eStatLabs offer this test direct-to-consumer for $300. Far less expensive and safer than the colonoscopy study.

My current recommendations to my patients are, with what is available to the public today, a viable biomarker testing protocol. It has a two-prong approach: First, the inexpensive and readily available FOB (Hemoccult®) test. This is still the mainstay of colorectal screening and probably will be into the foreseeable future. The second recommendation is not in the realm of colonoscopy, but rather a chemical biomarker. Cheap by comparison and readily accessible with no risk of untoward affects, the ColoVantage® test is my first choice. It would be done in combination with the FOB to complete the evaluation. Other cancer biomarkers used to detect colon cancer such as CA 19-9, CEA or the CA 242 biomarkers would be my distant second choice in biomarkers for initial testing. Finally, if either FOB or ColoVantage® tests are positive, the algorithm would proceed to a 2^nd tier, the virtual colonoscopy or conventional fiber-optic colonoscopy.

Yusuf M. Saleeby, MD is an emergency physician with a focus on patient advocacy for affordable health care delivery models. He is the Southeastern Regional Medical Director for Atrogene Telehealth and the DAT lab testing service eStatLabs (which offers the ColoVantage® test). He is also founder of RedBanyan a patient advocacy group.

References:

Bowles, CJ, Leicester, R., A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut 2004;53:277-283

http://www.radiology.uchicago.edu/index.php?q=physicians/virtual-colonoscopy-physicians, acquired 3/19/11

http://www.thedenverchannel.com/health/23293547/detail.html acquired 3/19/11

http://www.cnn.com/2009/HEALTH/expert.q.a/04/22/colonoscopy.age.brawley/index.html acquired 3/19/11

University of Cincinnati, Potential Colon Cancer Biomarker Revealed Through Study Of Human Tissue. ScienceDaily (2009, January 21).

Owen RW., Biomarkers in colorectal cancer. IARC Sci Publ. 2001;154:101-11.

Sudhir, S. Mukesh, V., Henson, D., Biomarkers for Early Detection of Colon Cancer, Clin Cancer Res May 2001 7; 1118

Koprowski H, Herlyn M, Steplewski Z, Sears HF. Specific antigen in serum of patients with colon carcinoma. Science 212 (4490): 53–5.

M Ugorski, A Laskowska (2002). Sialyl Lewis a: a tumor-associated carbohydrate antigen involved in adhesion and metastatic potential of cancer cells. Acta Biochimica Polonia 49 (2): 303–311.

Robertson A, Davidson B., Mirizzi syndrome complicating an anomalous biliary tract: a novel cause of a hugely elevated CA19-9. Eur. Jour. of Gastroent. & Hepa. 19 (2): 167–9.

Locker G, Hamilton S, Harris J, Jessup J, Kemeny N, Macdonald J, Somerfield M, Hayes D, Bast R., ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J. Clin. Oncol. 24 (33): 5313–27.

Spila A, Ferroni P, Comparative analysis of CA 242 and CA 19-9 serum tumor markers in colorectal cancer patients. A longitudinal evaluation. Anticancer Res. 2001 Mar-Apr; 21(2B):1263-70.

Griesenberg D, Nürnberg R, Bahlo M, Klapdor R., CEA, TPS, CA 19-9 and CA 72-4 and the fecal occult blood test in the preoperative diagnosis and follow-up after resective surgery of colorectal cancer. Anticancer Res. 1999 Jul-Aug; 19(4A):2443-50.

Carpelan-Holmström M, Louhimo J, Stenman UH, Alfthan H, Järvinen H, Haglund C.Tumour., CEA, CA 242, CA 19-9, CA 72-4 and hCGbeta in the diagnosis of recurrent colorectal cancer.

Biol. 2004 Sep-Dec; 25(5-6):228-34.

Eche N, Pichon MF, Quillien V, Gory-Delabaere G, Riedinger JM, Basuyau JP, Daver A, Buecher B, Conroy T, Dieu L, et al., Standards, options and recommendations for tumor markers in colorectal cancer], Bull Cancer. 2001 Dec; 88(12):1177-206.

American Society of Clinical Oncology 2006 Update of Recommendations for the Use of Tumor Markers in Gastrointestinal Cancer. http://www.asco.org Published in Journal of Clinical Oncology, Vol 24, No 33, 2006: pp. 5313-5327

Quest Diagnostic Laboratory web site, Information on ColoVantage. Acquired 3/25/2011.

http://www.estatlabs.com/products/Carcinoembryonic-Antigen-%28CEA%29.html Retrieved 6/1/11

New Metformin Test (AccuType Metformin) helpful in determining effectiveness

2011-05-24T09:04:00.000-04:00

Metformin: Glucose Control & Weight Loss
New Metformin Test (AccuType Metformin) helpful in determining effectiveness

by Yusuf M. Saleeby, MD

For more than forty years the drug named Metformin (Glucophage® manufactured by Merck, but now available generic as the patent has expired) has been used to treat Type II diabetics with great success. Unlike other medications used to lower blood glucose levels, Metformin will not cause hypoglycemia because it acts quite differently than other classes of diabetic medication.

Observing the nearly 4 decades of Metformin use in overweight diabetics with cardiovascular disease, hypertension and dyslipidemia brought to light the amazing transformation this drug has on this group of patients with this insidious and life-shortening disease. Metformin happens to be one of the only drugs used to treat type II diabetes that has an impact on reduction of death by heart attach and stroke. While other agents raise the insulin levels, Metformin's mechanism of action work to make endogenous insulin levels more effective on a cellular and molecular level by up-regulating insulin receptors. What is more, the ideal anti-diabetic drug for type II should exhibit enhanced cellular sensitivity to insulin (reducing insulin resistance and glucose intolerance), inhibit excessive intestinal absorption of sugars, reduce excessive liver production of glucose (gluconeogenesis), promote weight loss and correct lipid abnormalities. Many unfortunately raise insulin levels, a condition undesirable as type II DM has elevated insulin levels along with elevated glucose levels.

With the CDC’s predictions that one of every three children born after 2000 will develop type II diabetes, this is certainly a topic of paramount importance. Metformin answers the call today as probably the most important DM II drug on the market.

Take these well documented positive finding for glucose reduction, reduction in insulin resistance and metabolic syndrome, and apply them to the non-diabetic patient. Several studies have done just that, and a growing number of forward thinking physicians are prescribing this drug as a part of their regiments for patients over 40, with risk factors for diabetes, obesity and syndrome X (metabolic syndrome). It remains an FDA off-label use, but that is not unusual for drug prescribing today. A good physician who is a patient advocate cannot wait around necessarily for the FDA to approve drugs for certain uses. The FDA process is unbelievably slow, full of bureaucratic red tape and riddled with political interventions by Big Pharma and other interest groups.

Three placebo-controlled trials using Metformin in non-diabetics reported a reduction in fasting insulin and c-peptide levels, normalization of serum glucose and harmful low-density cholesterol (LDL-C) and apo B levels. One of the three even reported lowering of blood pressure and fasting triglyceride levels. It is shown time and again that Metformin is able to assist patients with weight loss. Now with new biomarkers and gene making efforts, it can be determined if a patient has the “right gene” that will allow for most effective use of this drug. A blood test called AccuType Metformin (offered by Quest Diagnostics and available online without a prescription on eStatLabs) can determine if Metformin is beneficial and effective for you.

Metformin has other uses too. It has been used to treat women with polycystic ovary disease (Stein - Leventhal syndrome) and infertility or menstrual irregularities. There are also studies published in the medical literature showing Metformin's activity against cancer and enhancement of cellular immunity. Metformin has been found to suppress growth of some tumors and enhance the activity of anti-cancer drugs. In one such study it reduced the incidence of chemically induced cancer in laboratory rats.

As with all medication there are some patients who should not take this drug and there are some side effects one should be aware. For example, people suffering from sever liver and/or kidney disease should not take this medication. Those with a history of alcohol abuse should avoid this because of an associated lactic acidosis when the two are taken together. Additionally, people who are to take an Iodine-based intravenous contrast agent for special radiological examinations need to stop the medication a couple of days prior and not resume use for up to 3 days following that type of exam. There is an associated risk of kidney damage when Metformin being taken when IV-iodine based dyes are used. One common side effect is diarrhea, especially at the onset of use, loose stools are common and dose dependent, but with time that goes away.

Finally, continuous use of Metformin will predispose a person to vitamin B12 malabsorption. So people taking Metformin for prolonged lengths of time need to supplement with vitamin B12. By and large this is a very safe drug and the benefits attained from its use outweigh the relatively small number of untoward effects.

The multiple positive effects of this single drug (for its ability to reduce development of diabetes, cardiovascular problems, endocrine disorder, nephropathies, retinopathies, decreased immune function and cancer, as well as weight loss) make it a top disease preventing & longevity medication. There are special doses recommended for the use of this medication for prevention purposes and it is best prescribed by physicians with this as their focus of practice. It is a regular recommendation in my practice as a “supplement” medication for continued good health and with a simple blood test, it can be determine effective in each patient on an individual basis.

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Dr. Yusuf Saleeby is a physician with prevention and nutritional interventions as a focus. He performs telemedicine consultations with the AtroGene Telehealth group. He is regional medical director of eStatLabs, a DAT direct to consumer lab testing Internet site. For more visit www.atrogene.com

References on file.

who-will-take-care-of-32-million-new-patients

2011-05-01T10:56:00.001-04:00

Who will take care of 32-million new patients?

Reprint from March 25th, 2010 by Dr Jon LaPook in Better Health Network

With the passage of healthcare reform, an estimated thirty two million new patients will try to find primary care doctors. That’s not going to be so easy because we already face a shortage of primary care doctors and about 13,000 more will be needed to take care of those newly eligible for insurance.

According to the American Medical Association, there are about 312,000 primary care doctors practicing in the United States. That includes family medicine, general practice (GP), internal medicine, and pediatrics. (In addition, there are 43,000 ob-gyn’s who also may serve as primary care doctors.) The estimate that another 13,000 will be needed comes from a study done by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in partnership with the Agency for Healthcare Research and Quality.

Sixty five million Americans already live in areas that don’t have enough primary care doctors. And relief is not on the way anytime soon. It takes 5 to 8 years for a first year medical student to be trained as a primary care doctor. And the trend for budding doctors over the past decade has been away from primary care and towards more lucrative specialties.

The new legislation contains some incentives for entering into primary care. Medicare will pay a ten percent bonus to doctors spending most of their time giving primary care to the elderly. Medicaid payments will be increased by about 20 percent in 2013 and 2014 to reach 100 percent of the Medicare rate. This is important because about 16 million new patients will be eligible for Medicaid and many doctors currently don’t accept Medicaid because reimbursement is so low. In addition, primary care doctors will be paid extra for coordinating care among a team of doctors.

The new incentives are a good start but more is needed to increase our supply of primary care doctors. For this week’s CBS Doc Dot Com, my producer, Heather Tesoriero, and I traveled to a rural community in Indiana and discussed the shortage with an old-fashioned family practitioner named Dr. Jason Marker. When he started practice eight years ago he was $140,000 in debt from medical school loans. He works long hours and sees about 100 patients a week, but still owes $125,000.

But Dr. Marker isn’t in it for the money and he’s not looking to heal only the well-healed. The day we visited him, a man walked five miles to his office from a homeless shelter. When I asked Dr. Marker what keeps him going after a rough day, he admitted that sometimes he wondered if it was all worth it. But then he added, “And then you go into the next room and you have a little old lady give you a big hug and you’re ready to go again.”

How can 9 patients run up $3Million in ED visits? It can be done.

2011-04-26T10:46:00.008-04:00

Reprinted from story on: http://www.kevinmd.com/blog/2009/04/9-patients-2678-ed-visits-3-million.html

9 patients, 2,678 ED visits, $3 million dollars

Author: Dr. Kevin

Apparently, 9 patients in Texas, the majority of whom had mental health issues, visited the emergency department nearly 3,000 times during the past 6 years.

Many of those visits were due to non-emergency causes, and it is speculated that these patients’ mental health history played a role, as this physician comments, “They have a variety of complaints, [and] a lot of anxiety manifests as chest pain.”

The proposed solutions, however, are not ground-breaking, and include “referring some frequent users to mental health programs or primary care doctors so they would go there first in the future.”

Mental health and primary care access are scarce resources, and patients who have chest discomfort often cannot wait for an appointment with a primary care doctor, and thus, head straight to the hospital. Combined with the fact that Texas has one of the largest proportion of uninsured patients, it becomes obvious why some choose to use emergency services.

Although these numbers may seem shocking, I’d bet that many doctors aren’t surprised at all. [for a solution visit this site and this site for interesting low cost solutions to overutilization of EDs for primary care issues]

Save our Antibiotics for Big Bacterial Infections NOT for use on viruses

2011-04-22T10:40:00.001-04:00

Antibiotic Stewardship

by JP Saleeby, MD

To open up, I want to make it perfectly clear the intentions of this article by stating a few facts. These are facts back up by loads of peer-reviewed publications. These facts are likewise rational and logical.

Fact: Antibiotics save lives.
Fact: Antibiotics reduce morbidity and mortality in severe and life threatening infections.
Fact: Antibiotics have in the past 20-years been overprescribed.
Fact: Antibiotics are necessary in the practice of good medicine and new guidelines need to be followed in light of present day resistance.

It is both intuitive and evidence based that appropriate use of antibiotics in modern medicine have saved thousands of lives. Prior to the discovery of the antibiotics (antimicrobials) infection was a leading cause of death in humans. Today, many life threatening illnesses such as pneumonia, sepsis, flesh-eating bacterial infections (necrotizing fasciitis), or meningitis are so dangerous, that delay in antibiotic therapy can cost a life.

For those pseudo-healthcare practitioners that are blinded by sheer bias and hatred toward contemporary western medicine (and suffer brain squeeze because their craniums are so far up their rectums), spouting the foolish notions that "you don't need antibiotics" or "antibiotics are never good for you", be warned. Those reading this article that are experiencing a grave illness due to a microbe should be aware that those advocating the cockamamie notion that all things antibiotic are evil, should run as fast and far away from those practitioners. Furthermore, they can and should be held culpable for the death of a patient should they intentionally delay people from getting life saving antibiotic therapy. Intuitive practitioners, some chiropractors and those who favor wave eagle feathers and crystals over folks in an attempt to cure a complex septic patient should put their unsubstantiated opinions and bias' aside and refer their patients to a medical doctor for definitive care. No need to stain you hands with blood over an idiotic notion unfounded by any empirical evidence. Enough ranting about unfounded prejudice against antibiotics amongst healers.

While there is no question about the helpfulness of antibiotics, it is also true that since their inception they have been abuse and over prescribed. Now we realize the ills of haphazard and unbridled use as we see resistant organisms appear more often and on the rise.

According to Dr. J. G Bartlett in a Medscape CME published in November of 2010 entitled "Addressing the Rising Tide of Antimicrobial Resistance" he spells out the rise of the top six microbes that are defying our current regiment of antibiotic therapy. They are Enterobacter, Staph. aureus, Klebsiella, Acinetobacter, Pseudomonas aeruginosa andEnterococcus. In the US methicillin-resistant Staphylococcus aureus (MRSA) is on the rise with some 94,360 cases a year and 18,650 deaths reported by Kelevens et. al., in JAMA in 2007. Those are some fierce numbers for a bacterium that only 10 years ago was only seen in hospital ICUs and nursing homes. Now greater than 60% of cultures of abscesses in my local region culture positive for MRSA. The whole penicillin class of drugs (Amoxil, Keflex, etc.) is useless against MRSA. Clostridium difficile infections are another example with diagnosed cases on the rise and antibiotic resistance mounting as well. Death by C. difficile infection has taken an exponentially rise since 1999.

Furthering the crisis of antimicrobial resistance and of great concern is that in the last ten-years the development of new antibiotics and antibiotic classes has all but dried up. A 2004 report by the Infectious Disease Society of America (IDSA) stated that there is“antibiotic discovery stagnation” were we are witnessing bad bugs with no new drugs to fight them. An example of how slow we are to develop new antimicrobials is seen in a study published in 2009 in theClinical Infectious Disease journal by Dr. H.W. Boucher reporting that between 1983 and 1887 sixteen new antibiotics were developed. From 1993 - 97 ten antibiotics were developed and this dropped to only five from 2003 - 07 and from 2008 projected until 2012 only one new antibiotic coming to market. From the 1930's through the 1970's there were eleven new classes of antimicrobials developed by pharmaceutical companies, with only four classes in the 1950, and during the 2000's only two new classes were developed. The 1980s and 1990's saw a dry spell, with no new antibiotic-class development. These are scary numbers considering the rapid rise in microbial resistant organisms just in the past decade.

So while antibiotic use is necessary and critical in the very ill, judicious use is necessary to save our "big guns" for those really bad infections. Most pharangitis infections are viral and despite this fact many GPs would prescribe antibiotics just to appease an anxious patient, and not treat the real root cause. This practice has to stop. No one will argue about utilizing a broad spectrum aggressive antibiotic regiment in a septic patient, but we need to look at the evidence of stopping drugs when cultures are negative and using effective shorter courses. Evidence is mounting that a three day course of antibiotics for community acquired pneumonia (CAP) is as effective as a seven- or ten-day course. On the other side of the continuum, those that don't advocate the use of antibiotics at all will harm the really sick. We must reach a happy medium.

JP Saleeby, MD is an emergency room physician who practices integrative medicine in solo practice. His weltanschauung is practical, pragmatic and not at all crunch or granola. For more information visit www.saleeby.net & www.AtroGene.com

Colorectal Cancer Screening - New biomarkers (ColoVantage)

2011-04-19T15:35:00.000-04:00

Colon Cancer Screening: To scope or not to scope?

By Yusuf M. Saleeby, MD

Virtual colonoscopy as it continues to develop, evolve and become more popular will realize a costs drop. Patients find it more comfortable, there is no need for procedural sedation, and the risk of penetrating iatrogenic complications are almost nil. Insufflations of colon with air is the only “invasiveness” and can be mildly uncomfortable, though nothing like the introduction of a scope. Another benefit is that a day off from work and limiting other activities is not necessary. By insertion of a short rectal tube, carbon dioxide is used to insufflate or expand the colon lumen for better visualization. No sedation is required, the spiral CT study only lasts 15-minutes at most and the patient can return to normal activities post study.

Specialized software is used to produce 2D and 3D reconstructions of the colon for radiological interpretation. Using VC permits assessment of colonic segments that are rendered inaccessible to CC as in the case of an obstructing lesion or patient intolerance. Additionally, the modality of CT in the performance of a VC allows detection of potentially important extra-intestinal findings (e.g. tumor in another solid organ) that would not be found by any of the other screening techniques.

In a recent clinical study involving 6,283 screening subjects, the diagnostic yield and use of resources for screening purposes compared VC to CC. The study found that VC and CC had similar rates for detecting advanced cancer, but CC had considerably greater complication. The American College of Radiology Imaging Network trial revealed that CC does have the advantage of being both a screening and therapeutic tool, but VC appears to be a good screening alternative due to its good performance in recent studies, less invasive method, and more efficient use of resources.

The one main concern with using VC is the radiation exposure. However, the use of very low dose scanning protocols that reduced radiation exposure can still maintaining image quality. Even with the use of multi-slice spiral scanners, radiation dose is kept to a minimum by reducing the mili-Amp current used. In one study researchers found that the absolute life time risk for cancer induction from a normal dose virtual colonoscopy was only 0.14% in a 50 year-old person and about 0.07% in a 70 year-old person. When you compare the 6% mortality risk from colon cancer against the much smaller cancer risk from VC radiation exposure, the benefits far outweigh the risks. Risk of perforation with current carbon dioxide pumps is about 0.005%, again far less than with standard CC procedures.

The advent of biomarkers has made the screening and management of many cancers less invasive in the 21^st century. There are dozens of biomarkers that already exist and many more in development with new tests coming to clinical use each year. There are biomarkers for the detection of prostate, breast, lung cancers and many more. For the purpose of this discussion we will limit ourselves to the biomarkers currently available for the potential screening and management of colorectal cancer. Chief among the markers is Carcinoembryonic Antigen (CEA), it is rather non-specific as it can detect different malignancies that arise under the diaphragm. Smokers typically have an elevated CEA for starters and this must be realized when using this test as a screening tool.

Another cancer biomarker is CA 19-9. The CA is shorthand for carbohydrate antigen. This test is also known as sialylated Lewis (a) antigen and is also a blood test like CEA, but more specific for colon cancer and pancreatic cancer. The CA 19-9 test was discovered in 1981. While elevated levels in the blood can be found in non-malignant conditions such as Mirizzi’s syndrome and diseases of the liver and bile ducts it is currently one of the key tests for pancreatic and colon cancer management. The reluctance of using these tests more widely comes from the guidelines for the American Society of Clinical Oncology and the American Cancer Society which are still discouraging the use of CA 19-9 and other cancer markers as “dedicated screening” tests. Their reasons are mostly the higher incidence of false positives. That would be a person with a positive test with no malignancy. Other reasons may be purely political, as a simple blood tests would “take away” expensive and profitable procedures from those performing flexible sigmoidoscopies and colonoscopies. The main use of CA 19-9 is with following pancreatic tumors that are being treated with chemo or surgery; by checking for increases in levels that would indicate recurrence or worsening of the disease. As with any test, there is never a 100% specificity/sensitivity. In CA 19-9 about 5% of the population does not possess the ability to produce the Lewis antigen because of a deficiency of a fucosyltransferase enzyme and thus no Lewis antigen or CA 19-9 would be produced even with large tumor burden.

There are other markers under investigation that may become more useful in the future. In 2009 researchers at the University of Cincinnati (UC) published in a genetics journal their findings about a gene called AMACR which regulates cancer development and discovered a polymorphism (mutation) related to colon cancer. Dr. Xiang Zhang, PhD who was the lead researcher of the UC study explains, "From the colon tissues, we've identified two types of genetic deletions [of the AMACR gene] that may allow us to predict whether people will have a good or bad cancer outcome," Dr. Zhang continued to say, "If a person carries one of the deletions, it may predispose him or her to a more aggressive type of colon cancer." While not developed as of yet as a screening tool, it will help physicians determine prognosis and treatment protocols for those that have colon cancer. Yet another cancer biomarker for colon cancer is CA 242. Elevated levels of CA 242 in colorectal cancer patients had similar rates of being positive as CEA and CA 19-9. The sensitivities are similar as well, and more so for recurrence and metastatic detection using CA 242.

While there is an increased demand for biomarkers of colorectal cancer (and other cancers for that matter), for early detection, risk assessment, prognosis and follow up post treatment, the perfect, gold-standard test has not yet been realized. Short comings are: too frequent false positives and false negatives as a stand-alone screening test. Other biomarkers under the microscope for consideration are APC, p53 and Ki-ras. These are still in development for use as viable clinical tests. The detecting of colon cancer in the early stages offers clinical advantages and better outcomes; therefore, the National Cancer Institute has established an Early Detection Research Network to promote more research in this field of study. The emphasis of the network is on translational research and collaboration among scientists in the field of oncology with the hopeful development of better cancer markers in the near future.

A rather new and promising colorectal biomarker is the ColoVantage® (methylated DNA from SEPT9 gene marker). ColoVantage® is the brand name of a test launched in 2010 by Quest Diagnostic Labs and as of March 2011, has gained approval by the New York Health Department as a sanctioned colorectal screening test. With its reported 70% sensitivity and 89% specificity rating, it is a good first line test for screening large numbers of people less likely to undergo colonoscopy of any type (CC or VC). The American Cancer Society is also warming up to the idea, but is slower to act as they are advocating more scrutiny. Quest Diagnostic is offering the ColoVantage at a retail cost of $355. Direct Access Testing sites such as eStatLabs offer this test direct-to-consumer for $300.

My current recommendations are with what is available to the public today a viable biomarker testing protocol. It has a two-prong approach: First, the inexpensive and readily available FOB (Hemoccult®) test. This is still the mainstay of colorectal screening and probably will be into the foreseeable future. The second recommendation is not in the realm of CC or even VC, but rather a chemical biomarker. Cheap by comparison and readily accessible with no risk of untoward affects is the ColoVantage test. It would be done in combination with the FOB to complete the evaluation. CA 19-9, CEA or the CA 242 biomarkers would be my second choice in biomarkers for initial testing. Finally, if both FOB & ColoVantage tests are positive, the algorithm would proceed to a 2^nd tier, the virtual colonoscopy or conventional fiber-optic colonoscopy.