The Frankie Foundation: Watch our dogs sniff out thyroid cancer!

Frankie and Sophie detect thyroid cancer in human urine samples! The first dog you see, Frankie, sniffs a cancer sample (Frankie sits to signal the sample is cancer) followed by a benign sample (Frankie turns away and does not sit if the sample is benign). The second dog, Sophie, demonstrates a second method and sniffs out various cones. When she finds the cone with a cancer sample, she lays down and lets out a loud bark. Find out more on
www.frankiefoundation.org

Incisional Hernia

“Doctor, I had this abdominal surgery a couple of years ago, and now where my scar is, there’s a bump on the bottom half. It doesn’t usually bother me, but when I cough; wow, it’s like a knife. What is it?”

Many people develop an Incisional Hernia after they have had abdominal surgery. It’s a weakening of the tissue/muscle at the incision site where the surgeon cut through the abdominal wall.

The outside of our stomachs is skin. Underneath the skin is a layer of tissue (for us Americans, usually a fat pad) and then there is muscles of the abdoman. You know those “six packs” the athletic people are always trying to build, when you look at their belly, it isn’t the skin that is the six pack, it is the muscles underneath. This is where the “hernia” or “herniation of the muscle” occurs. During surgery, to get to your inner organs, surgeons must cut through this abdominal muscle.

More often than not, once the surgeon sews the muscle back together, it heals and is usually as stronger than ever. In few cases the muscle weakens at the incision area in the muscle and allows the intestine, stomach or other organ to push through the muscle and push up against the skin. (Woah; that’s gross.) The fact is, sometimes the intestine may squeeze out if the tear in the muscle is big enough. If it is unable to fall back in when you lay on your back, it may get stuck protruding out and cut off the circulation. This is known as an emergency called a “Strangulated Hernia”. If the circulation is cut off too long, the intestine may die. If the intestine dies, the person will become ill very fast and becomes a life threatening situation.

Little or big bumps or soft areas can occur at the incision site on your abdoman. If you cough or sneeze, it may get a little bigger during coughing due to the pressure you make in your belly during it. After the coughor sneeze, it goes back to what it was before. You may experience some pain at the sight; that usually means the already injured tissue may be tearing just a little more. If you have one of these abdominal/incisional hernias, just apply a little pressure with your hand right at the sight whenever you cough or sneeze; this helps support the tissue and won’t hurt as much.

What you need to do is get this hernia repaired before it gets any bigger. Most often, a surgeon will go through the skin right where your first surgery was, so there usually is not a new scar. Depending on what the physician finds, the physician can repair the muscle without inserting a mesh however the patient may have a reoccurrence.

There are multiple different types of meshes that can be implanted. Most of the meshes go right in the incision whole, and are sewn into place the tissue will grow in and around it to make that area stronger than it was. Many of the old style meshes were like a flat piece of cheese-cloth you sewed over the tear. Now, the meshes have become so sophisticated that the surgeon can usually use the style and size that is best for the patient.

If you have one of these bulging areas in an old incision, you should go see your Primary Care Provider and get a referral to your local surgeon. Hernia Repair is one of the most frequent surgeries performed at your local hospital. Incisional Hernia Repairs is a same day surgery and most times done with Local Anesthesia (Xylocaine injected into the surrounding tissue) and some sedation from the Anesthetist. Procedures are usually less than an hour long and you can go home within the hour after the procedure.

It will be so nice to move around, hack, cough and sneeze without that nagging hernia discomfort anymore. I strongly recommend having your hernia repaired. The only ‘Hernia’ I ever liked was the daughter of Hagar the Horrible in the cartoon strip. Yes, I believe her name was Hernia.

March Is Colon Cancer Awareness Month

I had a colonoscopy this morning, which required me to spend all day yesterday "prepping" for it. That means that in the past day-and-a-half, a heck of a lot more has come out of me than has gone in. In fact, post-procedure, the only thing I'm full of right now is air, although even that is beginning to make its way out of me and I am very grateful that I am home alone.

As humiliating medical procedures go, a colonoscopy ranks right up there, but it does have a few things going for it in my opinion. For one, it is an equal opportunity humiliater. Unlike the mammogram and pelvic exam which assault parts only women have, a colonoscopy is no respecter of gender. Both the object of its scrutiny as well as its point of entry are, like opinions, things everyone has.

Second, you at least get some pay-off for the crappy prep day in the form of a wonderful, drug-induced nap. As both a skilled napper and a veteran of four "scopings," I speak with some authority when I say this is one of the highest quality naps your insurance dollars can buy. You are out immediately and completely, no tossing, no turning, no counting of sheep. True, you are violated with a couple of feet of flexible tubing while you are asleep, but that seems a fair exchange, especially if it gets you out of work for a day or two.

Third, as unpleasant as the prep process is, when it's over, you feel oddly invigorated -- once the post-anesthesia goofiness passes, that is. You are, intestinally speaking, as clean as a whistle, purged of all the debris that was weighing you down and ready to make a fresh start. The physical sensation of newness might even motivate you to renew commitments in other areas of your life. You could use the prep process as a sort of reset button for all your flagging New Year's resolutions. Or you could just use it to justify eating a whole pint of chocolate gelato the next day; that's good too.

With a family history of colon cancer, regular colonoscopies are something I take very seriously. Getting hit from behind, so to speak, every few years is a small price to pay for preventing a deadly disease. Even so, such an intimate encounter, especially the first time around, can leave you and your dignity feeling a little compromised. A bit embarrassed after his initial experience, my friend told his doctor, "Jeez, you could at least offer to buy me to lunch after that." Yes, and cab fare home with a promise to call soon would be nice gestures as well, but dream on. Such expectations are unrealistic in today's "stick 'em and street 'em" society, so, you just gotta put on -- well, take off, actually -- your big girl panties/big boy pants and roll over on your side.

My doctor may never have bought me lunch or supplied my cab fare, but she has given me many a reassuring hug as well as her word that together she and I are doing all the right things to keep my bowels unobstructed and open for business. And, occasionally, like today, she even gives me a little bonus. Waking from my propofol slumber this morning, I found tucked into my hand a special reminder of our time together -- a souvenir photograph of my internal hemorrhoid. Now that alone, my friends, was worth the price of submission!

Photo: Caraman via Depositphotos
This article originally appeared on www.leegaitan.com

Report finds troubling breast cancer rates in black women

A new analysis of breast cancer is giving doctors and patients a wealth of information geared at helping to diagnose and treat the disease. The data was presented in a report released Monday by four major cancer groups in the U.S., including the American Cancer Society. It provides the most detailed analysis to date of breast cancer risk by age, race and geography.

According to the report black women have nearly twice the rate of triple negative breast cancer -- the deadliest form -- as white women and have the highest mortality rate from any form of breast cancer.

Zelma Watkins was only 44 when a routine mammogram turned up something suspicious.

"The fact that I had a mammogram every year and they never had to take additional pictures," said Watkins. "I was thinking that something was not quite right."

Watkins had triple negative breast cancer. Oncologists divide breast cancer into four different molecular types that help determine treatment. The most common form, with the best prognosis, is treatable with hormonal therapy. But Watkins' cancer required intensive chemotherapy.

"Once you hear the word 'cancer' you pretty much don't hear anything else," said Watkins.

Researchers used to think the poor outcome in blacks was due to higher poverty rates leading to delays in diagnosis and treatment. But new information surfaced in the report that suggests there are other factors at play.

"There were actually other clues that there might be some biological differences in breast cancer as well," said Dr. Lisa Newman, a surgical oncologist specializing in breast cancer. "This report confirms that suspicion. Breast cancer afflicts African-American women in different ways."

Watkins volunteers with Sisters Network Inc., a group that carries out breast cancer education and outreach for black women.

"I don't why I had triple negative breast cancer, it does not run in my family," said Watkins. "But the fact that I was receiving my annual mammograms, it was detected at an early stage."

Dr. Newman stressed that breast cancer has the best prognosis when caught early. She said that makes screening especially important in black women who are at the highest risk for the deadliest form.

Endoscopic Therapies for GERD

In the past 2 decades, acid suppressive medications such as proton pump inhibitors have remained the first-line therapy for patients with GERD. According to experts interviewed by Healio Gastroenterology, however, a substantial population of GERD patients assigned proton pump inhibitors are refractory or unsatisfied with long-term proton pump inhibitor therapy.

Refractory patients, which may account for up to one-quarter of all patients with GERD, experts said, are typically considered for surgery with the current gold standard laparoscopic Nissen fundoplication, especially if their symptoms include regurgitation, which is notoriously difficult to treat medically. Many of these patients, however, are unable or unwilling to undergo this invasive surgery despite its high efficacy.

Thus, an unmet need for a “middle therapy” to fill the treatment gap between medication and surgery persists. Despite a range of efforts to develop nonmedical and minimally invasive alternative treatments over the years, experts agreed that mounting data demonstrate that the only two endoluminal therapies for GERD currently approved by the FDA — the Stretta procedure (Mederi Therapeutics) and the EsophyX device (EndoGastric Solutions) — finally provide viable middle-ground options for patients seeking alternatives to long-term PPIs or surgery.

Treatment Gap

Stretta and EsophyX are quick, noninvasive outpatient procedures with demonstrated safety, efficacy and durability, which represent “a new day” for endoscopic GERD treatments, according to Kenneth Chang, MD, executive director of the H.H. Chao Comprehensive Digestive Disease Center at University of California, Irvine. “The desire to have effective endoscopic treatments for GERD has been around for years,” Chang said. “I have been doing GI for 26 years, and almost since my fellowship, there have been devices that have come and gone. The device graveyard for endoscopic GERD treatments is significant — and I’ve been involved with nearly all of them.”

Kenneth Chang

Some of them “really tanked,” he said. The Enteryx procedure, for example, was approved by the FDA in 2003 but was recalled by Boston Scientific shortly after because of a fatal complication. Many devices have similarly come to a dead end, “not necessarily due to lack of clinical efficacy,” Chang said, but more often because of safety concerns, fundraising and business development challenges, or the increasing rigor required by the FDA to approve new devices. “It has been a long history of trying to get to the finish line, with hopes and expectations rising and falling as these products come and go.”

What has fueled the enduring effort to develop viable endoscopic GERD therapies are the limitations of PPI therapy and surgical options, experts agreed. Although PPI therapy is highly effective in treating acid-related symptoms in about 80% of patients with GERD, this leaves 20% to 25% who are refractory to medical therapy, according to Chang. Furthermore, there is “an even larger, expanding population of patients who respond to medical therapy but want to get off the medications, and with good reason considering all of the studies coming out showing the possible risks of long-term PPI, especially in postmenopausal women who may be at risk for osteoporosis-related hip fractures.”

The gastroenterology community is increasingly recognizing the inadequacies of PPI therapy, according to Reginald C.W. Bell, MD, FACS, founder of the SurgOne Foregut Institute. It is primarily patients with symptoms of heartburn and regurgitation who fail PPI therapy, but there are some patients with laryngeal symptoms who also do not respond well to medical therapy, he said. “Of those patients, many don’t have the degree of anatomic compromise or distortion that requires a laparoscopic Nissen procedure to correct, so we have been looking for ways to treat the problem of reflux that aren’t as supraphysiologic as Nissen fundoplication is, or are more designed for mild anatomic deterioration.”

Although Nissen fundoplication has efficacy exceeding 90%, the main drawbacks include its adverse effects (dysphagia, bloating, inability to vomit, and diarrhea, according to a recent editorial), its durability where studies have shown up to 65% of patients may be back on PPI therapy 10 years after surgery and its irreversibility, Chang said. “Undoing this procedure is impossible, and redoing it is difficult. So if you’ve got a 35- to 50-year-old patient with GERD and you send them for a lap Nissen, 10 years later your options may be limited. Around 60 to 70 years old may be the sweet spot to do this. However, for symptomatic patients with a hiatal hernia larger than 2 cm, middle therapies are not available and the Nissen fundoplication is the best solution.”

Another relatively new and minimally invasive surgical option is laparoscopic magnetic sphincter augmentation with the LINX (Torax Medical) device, which the FDA approved in March 2012. Data from a recent prospective 3-year follow-up study involving 100 patients demonstrated the safety and efficacy of LINX, with reduced esophageal acid exposure (64% of patients; 95% CI, 54-73), reduced PPI use (93%), improved quality of life scores (92%) and a low rate of long-term adverse effects.

“The LINX procedure provides an alternative to the traditional antireflux surgery in a selected patient population,” Ronnie Fass, MD, FACG, director of the division of gastroenterology and hepatology and head of the Esophageal and Swallowing Center at the MetroHealth Medical Center in Cleveland, and professor of medicine at Case Western Reserve University, and colleagues wrote in a clinical review published in the Journal of Clinical Gastroenterology. “Although the results of the studies show great promise, concerns remain high about potential long-term adverse events, in particular the possibility of the ring eroding into the esophagus or migrating from its original anatomic placement. More long-term studies are needed.”

Chang also shared some concerns. “One of the major limitations for the LINX procedure is that these patients cannot have an MRI scan because it may demagnetize the LINX. Right now, MRIs are one of the most commonly used imaging modalities, and basically everyone who strains their back or blows out their knee will get an MRI,” he said. “So in my practice when I talk about LINX and mention that, patients usually say, ‘Let’s look at something else.’

“So for all the reasons stated above, there is a need for endoscopic treatment alternatives,” Chang said. “There are essentially two FDA-approved devices.”

Stretta Radiofrequency Energy Treatment

According to Fass, Stretta is the only endoscopic therapy for GERD “that has lasted since the introduction of these types of devices to the market more than a decade ago.” In addition, he and colleagues wrote in the aforementioned clinical review, “It is also one of the few endoscopic techniques for GERD that has been tested in a sham-controlled trial.”

A widely cited sham-controlled trial published in 2003 demonstrated that “patients who underwent Stretta had significantly improved heartburn scores at 6 months, but no significant improvement in esophageal acid exposure times,” Prateek Sharma, MD, from the Veterans Affairs Medical Center and University of Kansas School of Medicine in Kansas City, Missouri, and Philip Katz, MD, from Albert Einstein Medical Center in Philadelphia, wrote in a recent editorial. “Although the study showed promising results, [it] also had strict inclusion/exclusion criteria, enrolling only a select subpopulation of GERD patients. Open-label, long-term studies have shown promising results and there is a recommendation from [the Society of American Gastrointestinal and Endoscopic Surgeons] that it be considered in patients unwilling or unable to undergo fundoplication,” they wrote.

Although some reduction of esophageal acid exposure has been observed with Stretta, Fass and Chang said controlling symptoms should be the primary outcome goal of any GERD treatment.

“The outcome of normalizing 24-hour pH, in a sense, is not as clinically meaningful because even PPIs don’t normalize 24-hour pH; with PPIs, your goal is to control symptoms.” Chang said. “Stretta has been shown in studies to improve symptomatic control compared to placebo, but while pH does improve it may not normalize, although I’m not sure that’s a necessary outcome for clinical application.”

Fass agreed, referencing the recent systematic review and meta-analysis published in Clinical Gastroenterology and Hepatology, which found that Stretta was not superior to sham. “Even though, for example, it’s been shown in the meta-analysis Stretta was not able to normalize esophageal acid exposure, at the same time it improved symptoms,” he said. “Patients may not have normalization of esophageal acid exposure but still have resolution of symptoms.

“Large phase 3 therapeutic trials of PPIs, for example, have not used pH monitoring to verify that patients who demonstrated complete symptom resolution also had complete normalization of esophageal acid exposure, so we don’t know if that’s the case — maybe a lot of patients who did have complete resolution of symptoms did not normalize their esophageal acid exposure,” Fass said. “Endoscopic therapies have to meet a high bar when it comes to clinical endpoints for their trials, and the consequence of that may have influenced the results of the meta-analysis.”

“We want to hold these treatments to the same standard,” Chang said. “If normalization of pH is the primary indicator for effectiveness, then PPIs would not be around. The goal is symptomatic improvement.”

The international panel at DDW 2014 also agreed that Stretta has “an excellent safety record,” and of all the available procedures for GERD, Chang said he considered Stretta to be the safest.

“Stretta has evolved over time with many improvements made to the technique that markedly improved its side effect profile, and at this point it is unmatched,” Fass said, adding that many of the cited adverse effects associated with Stretta are often “from the first year that Stretta came out, and not necessarily the experience that we currently have after the technique has been improved by the manufacturers.”

Besides multiple randomized controlled trials demonstrating efficacy for controlling esophageal and extraesophageal symptoms, Chang said, Stretta has the longest follow-up of all the available endoscopic treatments for GERD. “We now have the long-term 10 year data showing that its durability may be as good as surgical fundoplication.”

The 10-year prospective follow-up study evaluated long-term safety, efficacy and durability of response to Stretta therapy in 217 patients with medical refractory GERD. Noar and colleagues found that 72% (95% CI, 65-79) maintained normalized GERD-related quality of life, and 41% were able to eliminate PPI therapy entirely. These findings “clearly show that 10 years down the line patients were able to maintain the same level of symptom control and health-related quality of life as they had immediately after the procedure, which was also significantly better than before the procedure. This provides the longest follow-up documented and published on the Stretta procedure,” Fass said.

“Stretta’s effectiveness is about 80% to 85%, so it’s not as high as the 90% with surgery,” Chang said, “but the durability looks good, it’s a minimally invasive, outpatient procedure with no surgical wounds that takes less than an hour, so it has a real advantage, as does the EsophyX TIF procedure,” although reimbursement has been more difficult with that procedure due to its lack of a CPT code. However, the manufacturer announced on March 10 that the procedure was granted a unique CPT code by the American Medical Association.

EsophyX TIF

The EsophyX transoral incisionless fundoplication (TIF) procedure has recently joined Stretta as being among the few endoscopic techniques that have been tested in a sham-controlled trial, after the publication of data from the RESPECT trial.

“We are proud of our achievements in the first ever randomized blinded trial that focused exclusively on regurgitation symptoms, and our ability to meet the most rigorous standards with regards to conducting the trials involving the sham procedure and optimized PPI therapy,” said Emir Deljkich, MD, senior director of clinical and medical affairs and medical science liaison for EndoGastric Solutions.

Conducting a sham-controlled trial is difficult, Deljkich said, but the importance of this effort is highlighted in a perspective written by Rita F. Redberg, MD, MSc, from the University of California, San Francisco Medical Center, recently published in The New England Journal of Medicine, which “challenges the medical device community to conduct more sham-controlled trials to get to a level comparable to the rigorous studies that pharmaceutical companies are doing,” Deljkich said.

“Blinded, randomized, controlled trials (RCTs), in which the proposed therapy is compared with a placebo or a ‘sham’ (nontherapeutic) intervention, are common for drugs but rare for medical devices,” Redberg wrote. “In light of mounting evidence that medical procedures can produce a strong placebo effect that can be mistaken for actual effectiveness, I believe it is time for more frequent use of interventional trials in which patients are unaware of their randomized assignment.”

Bell, who co-wrote the RESPECT paper, said a major strength of this study is that it was structured as “the surgical equivalent of a placebo-controlled trial. The reason for that is we know that patients often symptomatically improve even with a placebo effect or a sham surgery, so we wanted to make sure that the responses we had been seeing in other studies were not just due to a sham effect or a placebo effect.”

Of more than 20 other published studies on TIF, by Bell’s estimates, he was involved with one of the larger U.S. prospective studies involving 100 patients who underwent the procedure. “We showed that they symptomatically responded very well and that response seemed to be fairly stable up to 3 years of follow-up. So we had a background of observing a response and some improvement in pH, but we needed to be able to demonstrate that symptomatic response is not just a placebo effect.”

The RESPECT trial randomly assigned patients with confirmed GERD and hiatal hernias less than or equal to 2 cm to groups that either underwent TIF and then received placebo pills for 6 months (n = 87) or underwent a sham procedure and then received an optimized dose of omeprazole for 6 months. Based on intention-to-treat analysis, the investigators’ findings included:

• TIF was superior to PPIs in eliminating troublesome regurgitation (in 67% vs. 45% of patients; P = .23);
• Thirty-six percent of sham/PPI controls compared with 11% of TIF patients had no response at 3 months (P = .004);
• Control of esophageal pH improved with TIF (mean 9.3% before and 6.3% after procedure; P < .001), but did not with sham (mean 8.6% before and 8.9% after); and
• Severe complications were rare.

“The major impact of these data is that we saw improvement in regurgitation scores, which was the primary symptom that we looked at for enrolling patients,” Bell said. “We showed, compared to sham, that the TIF procedure produced a significantly better response with regurgitation than did continued medical therapy. We also saw heartburn improving as well and it associated with an improvement in pH. Other procedures have shown an improvement in symptoms but not correlated with an improvement in pH and we were able to demonstrate both — that pH goes down and symptoms improve after the TIF procedure.”

In the editorial by Sharma and Katz, which accompanied the publication of the RESPECT trial in Gastroenterology, they concluded that these data seem to make TIF “a viable option for treatment in carefully selected, well-informed patients, and puts endoscopic therapy ‘back in the game.’ How it compares with other endoscopic and minimally invasive therapies remains a question for subsequent studies.”

“This a significant turnaround from editorials I’ve seen in the past about the endoscopic and endoluminal therapies,” Bell said. “There is now recognition that this is a genuine procedure that should be made available to patients, not only in just a study setting.”

According to Deljkich, the RESPECT trial’s 12-month follow-up is currently ongoing, with plans for publication sometime this year. Additionally, 3-year data will be collected from a second randomized trial, TEMPO, which aims to compare TIF with optimized PPI therapy for treatment of atypical symptoms and regurgitation, whereas initial data from a third randomized trial in Europe also is expected this year.

Furthermore, EndoGastric Solutions recently partnered with the American Gastroenterological Association Center for GI Innovation and Technology to develop the STAR registry, “a large U.S. registry developed for a community-based prospective trial being conducted at 14 centers and involving 500 patients. This trial will for the first time present real-world data for the TIF procedure compared with laparoscopic Nissen fundoplication,” Deljkich said.

According to Chang, although the data on TIF is not as mature as the data on Stretta, “it certainly looks promising so far. So, finally, we’ve got two devices that have made it through the rigor of FDA approval, and more will come because if you have none in the space, then it’s hard to get into, whereas if you have one or two established, then it will be easier to piggyback on success,” he said. “The potential is huge for these devices to change gastroenterology practice, in terms of now routinely treating GERD with safe, quick and durable outpatient procedures as opposed to just throwing PPIs at patients.” – by Adam Leitenberger

References:

Bell RC, et al. Am Surg. 2014;80:1093-1105.
Dughera L, et al. Gastroenterol Res Pract. 2014;doi:10.1155/2014/531907.
Ganz RA, et al. N Engl J Med. 2013;doi:10.1056/NEJMoa1205544.
Hunter JG, et al. Gastroenterology. 2015;doi:10.1053/j.gastro.2014.10.009.
Lipka S, et al. Clin Gastroenterol Hepatol. 2014;doi:10.1016/j.cgh.2014.10.013.
Maradey-Romero C, et al. J Clin Gastroenterol. 2014;doi:10.1097/MCG.0000000000000125.
Noar M, et al. Surg Endosc. 2014;doi:10.1007/s00464-014-3461-6.
Redberg RF. N Engl J Med. 2014;doi:10.1056/NEJMp1406388.
Sharma P, et al. Gastroenterology. 2015;doi:10.1053/j.gastro.2014.12.009.

For more information:

Reginald C.W. Bell, MD, FACS, can be reached at reg@sofisite.com.
Kenneth Chang, MD, FACS, can be reached at kchang@uci.edu.
Emir Deljkich, MD, can be reached at edeljkich@endogastricsolutions.com.
Ronnie Fass, MD, FACG, can be reached at ronnie.fass@gmail.com.
Disclosures: Bell reports he received research grant support from EndoGastric Solutions. Chang reports he is a consultant for Cook Medical and is on the Medical Advisory Board of Mauna Kea Technologies. Deljkich is an employee of EndoGastric Solutions.  Fass reports he received research grant support from Evoke Pharmaceuticals and Ironwood, is a consultant/advisor to GlaxoSmithKline, Mederi Therapeutics, Reckitt Benckiser, Tulip and Vecta, and is a speaker for Takeda.

What's Up Doc? Gallstones affect 25 percent of American women

Q: My mom had a gallstone that caused her to turn yellow and get sick, but the doctors thought surgery was too risky and recommended removing the stone with an endoscope. Why isn’t this done for everyone?
A: The liver and pancreas make various enzymes and fluids to help digest food. The gallbladder sits under the liver and stores bile, a fluid made in the liver from bilirubin, cholesterol and other substances that helps digest fatty foods. The way the “plumbing” works is that a tube from the liver (hepatic duct) merges with a tube from the gallbladder (cystic duct) to form the common duct which eventually merges with a tube from the pancreas (pancreatic duct); from there all the digestive fluids empty through the ampulla of Vater into the small intestine.

Gallstones form in the gallbladder and/or bile ducts due to an imbalance of bilirubin and cholesterol; about 10 percent are pigment stones from too much bilirubin, the remaining 90 percent are cholesterol stones. Risk factors for developing gallstones include being female, being overweight, advancing age, family history of gallstones, certain medical conditions (diabetes, Crohn’s disease, others) and others.
Gallstones are common, affecting 25 percent of American women by age 60 and 50 percent by age 75. Although less common in men, 25 percent still develop gallstones by age 75.

Fortunately, most people never develop any problems or complications from their gallstones. Small stones can pass through the ducts to the intestines with no problem, and very large stones just sit in the gallbladder.

Ten to 20 percent of the population develops symptoms from their gallstones (biliary colic), classically manifesting as right upper abdominal pain sometimes radiating to the right scapula, and often accompanied by nausea and/or vomiting. Symptoms often begin after eating a fatty meal, which stimulates the gallbladder to squirt out bile. Stones of a size that pass into the ductal system and then get stuck may block the drainage of the gallbladder, liver and/or pancreas, causing inflammation (cholecystitis, hepatitis or pancreatitis respectively) and possibly predisposing to infection.

In most cases the gallstone works its way out of the ducts on its own, the patient’s symptoms then resolving. However, for some people the stone can be firmly “stuck” and a blockage of one or more of the ducts can cause secondary complications such as pancreatitis (inflammation of the pancreas), liver compromise (sometimes leading to jaundice, a yellowing of the skin and white parts of the eyes from a buildup of bilirubin in the blood), infection or other issues.

Ultrasound is the most common test used to verify the presence of gallstones, but CT, MRI and other techniques may be required in some patients. Blood tests to evaluate pancreatic and liver function may also be needed.

Since the majority of people with gallstones do not develop any problems, no intervention is routinely needed. However, of the 10 to 20 percent of people who suffer an episode of biliary colic, about 70 percent will have another episode within a couple of years. Since the gallbladder is not absolutely needed for good health (the liver can usually secrete sufficient bile, although loose stools are more common after the gallbladder is removed), removal is often recommended after an episode of cholecystitis.

In 90 percent of cases the gallbladder is removed via a minimally invasive procedure (laparoscopic surgery) where specialized tube-like surgical instruments are inserted through small incisions in the abdominal wall. For technical reasons, some people are not a good candidate for this approach, or sometimes the laparoscopic surgery must be “converted” to an open surgery where a larger incision is needed to directly visualize the gallbladder and then remove it.

For patients whose problematic gallstone does not pass on its own, or who develop complications from a blockage of one or more of the ducts, other interventions may be needed. Some patients may require temporary drainage via a tube stuck directly through the skin into the gallbladder (a percutaneous drainage).

An endoscopic retrograde cholangiopancreatogram (ERCP) is where an endoscope (yet another type of specialized tube-like device) is passed through the patient’s mouth into their esophagus (eating pipe), then onward to their stomach and small intestine. From there, the endoscope is guided through the ampulla of Vader retrogradely (in the opposite direction the digestive fluids normally flow) into the ductal system described above. At this point, specialized X-rays may be obtained to verify the diagnosis, and certain treatments may be performed. Although the gallbladder cannot be removed with this approach, an entrapped gallstone may be “snared” and removed (using a specialized addition to the endoscope), lesions suspected of being cancer may be biopsied, an overly narrowed duct can be widened, and if indicated, a stent (a cylindrical device to keep the duct pried open) can be inserted.

Patients who are surgical candidates after their clinical condition has improved, even if an ERCP was required, may have their gallbladder removed. Other patients may be treated with medications to help dissolve their gallstones to prevent subsequent episodes of biliary colic.

The specific treatments best suited for an individual patient should be made in close consultation with a physician experienced in treating gallbladder disease. For the many people with gallstones who have not had an episode of biliary colic, a watch and wait approach is usually the best option.
Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.

Foods to Eat and to Avoid to Take Care of Your Gallbladder

You likely don’t get up each day and give your gallbladder much thought, right? Maybe your heart, digestive system, and even your joints and your muscles, but your gallbladder? Eh, not so much. That is, unless it starts to give you trouble. Then, it’s likely all you think about. But we should all know how to take care of our gallbladder, since it’s important for our overall health and can greatly be affected by how well we take care of ourselves.

First though, what does the gallbladder do and where is located?

Gallbladder 101

Not to be confused with your actual bladder, the gallbladder sits right under your liver. Shaped like a tiny pear, the gallbladder stores bile that’s produced by your liver during digestion. Before you sit down and eat each delicious meal or snack, your gallbladder is full of bile. After you eat, it stores bile from the fat you eat, and starts to fill up until it’s full. As digestion and elimination hum along as normal, the gallbladder releases the stored bile into your small intestine where it enters into ducts (tubes). As it does, the bile helps digest the fats you eat. Though people can have their gallbladder removed and be fine, some people who have it removed may find they have issues with diarrhea and malabsorption. The take-away: Your gallbladder is there for a reason, so take care of it however possible.

Symptoms to Look Out For

If a person’s gallbladder isn’t functioning normally, it’s likely due to inflammation in the gallbladder, trouble digesting high amounts of fat, or could be because a duct in the small intestine that has become clogged. If a duct is clogged, this causes a back-up of bile, the condition known as gallstones. Gallstones can cause immense pain after a high fat meal because the bile storage and release process isn’t functioning as it should. Symptoms of gallstones include extreme pain after eating, nausea, vomiting, pain for days right under your ribs, and poor digestion after meals. You can have tests done at your trusted health professional’s office to see if you have gallstones. If so, you’ll have to have removed and will need to watch your diet carefully by eating a low-fat diet. If you don’t test positive for gallstones or another disorder related to your gallbladder, you may just be eating too many high-fat or inflammatory foods. If this is the case, switching up your diet is easy to do.

Foods to Eat for Your Gallbladder

Generally, not all fats are bad, so don’t get the impression you need to eat a fat-free diet. However, maintaining a healthy weight is key to taking care of your gallbladder since obesity increases your risk for gallbladder disease. The key is to choose smaller amounts of fat at each meal and eat a diet rich in fruits, vegetables, whole grains, beans and legumes (if you tolerate them), and modest amounts of nuts, seeds, avocados, coconuts and olives (no more than 2 tablespoons per meal, but for some it may be less). Avoid oils which are more refined than the whole foods they come from and are very hard on your gallbladder, especially when eaten in excess.

Also focus on adding fiber to your meals since a low-fiber diet is often associated with gallstones or gallbladder problems.

Here are some high-fiber foods to choose:

• Broccoli
• Cauliflower
• Leafy Greens
• Herbs
• Celery
• Carrots
• Sweet Potatoes
• Artichokes
• Onions
• Asparagus
• Apples
• Oranges
• Bananas
• Berries
• Zucchini
• Pineapple
• Papaya
• Cherries
• Whole Grains
• Beans
• Legumes

Foods to Avoid

Foods to avoid include animal fats, which lead to high cholesterol and are very hard on the body to digest, fried foods, processed foods, and oils. This will also help you naturally manage your weight, heart, and overall health much easier. Many researchers believe that gallbladder problems stem from the Western diet that is high in animal fats and processed, refined carbohydrates (which can also lead to obesity and gallbladder problems). You can follow our healthy, low-fat vegan meal plan if you’re unsure of what to eat to naturally set you up for success.

So, as with most health tips, when it comes to taking care of your gallbladder, healthy, whole foods from plants win again. Thank goodness, because we love them!

Try some of our recipes to get started and see our Plant-Based Nutrition Guide for more helpful information.

How Much Can Women Trust That Breast Cancer Biopsy?

When a woman is diagnosed with breast cancer, the person who does the diagnosing is a doctor she never sees — the pathologist.

But though pathologists do a great job of identifying invasive cancer, they aren't as good at spotting two less clear-cut diagnoses that bring women a lot of uncertainty and worry, a study finds.

The doctors correctly identified invasive breast cancer 96 percent of the time compared with an expert panel, according to a study published Tuesday in JAMA, the journal of the American Medical Association, and correctly identified normal tissue 87 percent of the time.

But they misdiagnosed ductal carcinoma in situ, or DCIS, 16 percent of the time, and atypia, or atypical hyperplasia, 52 percent of the time. That's troubling, because both conditions can go on to become invasive cancer.

With atypia, 17 percent of the readings were false positives, meaning that a woman might undergo surgery and other treatment she doesn't need, and 32 percent were false negatives, meaning women wouldn't know they are at increased risk of cancer.

"The first thing for women to remember is that making a diagnosis from tissue is part science and part art," says Dr. Jean Simpson, president of Breast Pathology Consultants in Nashville, Tenn., who was not involved in the study.

The science involves putting thin slices of biopsy samples onto glass slides, so a pathologist can look at them under a microscope.

Invasive cancer is easy to spot, according to Dr. David Rimm, a pathology researcher at Yale School of Medicine. "Here are criteria I can write down: This cluster of cells has enlarged and irregularly shaped nuclei and architecturally irregularly shaped clusters and high nuclear to cytoplasmic ratio."

But what if the sample has just some of those things? "And what if it has some suggestion of enlargement or some suggestion of arch irregularity?" Rimm asks. "Then we get into that gray area. That's what happens. That's the real world."

And as the JAMA study shows, it's not hard to fall into the gray area with DCIS, and especially atypia.

The study had three expert pathologists classify samples from 240 women, then gave them to 115 doctors to identify. It was a clever way to design a study, but it doesn't reflect how pathologists work, which includes reviewing the woman's medical record and often asking a colleague for advice on a confusing or complex slide. "Frequently it might be seen by more than one other person," Rimm says.

Experience matters, too, Rimm says. "When you've looked at breast cancer for 20 or 30 years you develop an eye where you can see something that you can't really define."

And the doctors will confer and try to make their best interpretation. But we should be able to do better than that, says Rimm, who was coauthor of an editorial accompanying the study. "There's a need for more scientific approaches to these borderline cases. Unfortunately, there's relatively little focused research in this area."

But for women who are wondering what do to with a diagnosis of DCIS or atypia, it's important to know that the diagnosis isn't infallible, both Simpson and Rimm say.

"It's a question of uncertainty and how you want to deal with it," Rimm says. His own mother went through this with a breast biopsy, he says. "She had the ability to call her son and say, 'David, what should I do?' I said, 'Let's see what happens; let's watch it.' "

But of course he did also say, "Mom, how about we look at it here at Yale — send it to us." He agreed with the first diagnosis.

Those of us without a pathologist in the family are more than justified in getting a second opinion, Simpson says. "I will tell patients that a second opinion is a fairly inexpensive process," and insurance often pays for it. "And what value can you put on peace of mind?"

Why Routine Blood Tests Often Fail to Detect Low Thyroid Function (And What We Can Do About It)

All too often the routine blood tests fail to detect a significant percentage of low thyroid cases. Frequently sick patients are told their labs are normal, with values falling within reference ranges, yet they are suffering. Symptoms can be debilitating and may include depression, anxiety, unexplained weight gain, severe fatigue, hair loss, brain fog, constipation and sleep issues. Women often have menstrual cycle irregularities and trouble getting or staying pregnant. I see it every day. It's unfortunately common and estimated that half of all thyroid disorders may be undiagnosed, leaving patients to suffer without treatment options.

The lab range used for routine testing has been a controversial topic in medicine in recent years. There is much debate and arguing as to what the actual range should be and what normal is. I began to examine this issue in the '90s in response to seeing literally hundreds of patients with thyroid-type symptoms and all with normal test results.

First some background:
The thyroid is a small butterfly-shaped gland located at the front of the neck just under the voice box. It produces hormones T4 (thyroxine) and T3 (triiodothyronine) responsible for driving energy production and metabolism in every cell in the body. Having the right amount is critical to good health and imbalances can manifest in many different ways depending on which tissue is affected.

Most doctors today diagnose thyroid disorders by doing a simple blood test to check levels of TSH. Some also include levels of T3 or T4. Thyroid Stimulating Hormone is released by a gland in the brain called the pituitary. As the name suggests, this is the way your brain talks to the thyroid to stimulate output. More gets released when thyroid function is low and not producing enough T4 and T3 to regulate the body. A high level of TSH is the brain's way of saying, "hey thyroid, you need to work a little harder." A TSH value that's higher than the lab range means function is very low and needs a push-sometimes in the form of medication.

Seems straightforward, but what level is considered high enough to treat?

Some doctors are still using the old standard and consider a TSH level over 5 mlU/L worthy of treatment. This isn't accurate, according to research. The American Association of Clinical Endocrinology currently recommends treatment for anyone over 4.1. Interestingly, back in 2002 they made a statement recommending a limit of 3mlU/L. The National Academy of Clinical Biochemistry however, has recommended beginning treatment at 2.5.

A study from 2005 concluded that the accepted reference range of 4.5mlU/L was too high and no longer valid due to A) increased sensitivity of testing assays and B) contamination of those ranges by including people with various levels of thyroid dysfunction who actually increased the average TSH level (1).

Why is all of this important? Inconsistencies and changes in reference ranges can be the difference between sick patients getting help or being told they are fine and denied treatment.

On a deeper level, Andersen et al studied this issue and found a huge difference between the population and individual reference ranges. A test result falling within the normal lab reference limit is not necessarily normal or optimal for the person being tested (2). I treat people, not their lab results. As clinicians we have a duty to practice personalized medicine based on the specific needs of each individual.

More problems with standard testing...

Thyroid hormone resistance cannot be detected on routine tests. Studies point out that levels of thyroid hormone can test normal in blood but may actually be low in the tissues that so desperately need it. Patients with reflux and Alzheimer's were found to have lower levels of T3 in esophagus and brain tissue than normal controls. Both groups tested normal on routine blood tests.

For some patients with hypothyroidism, the TSH levels may not rise in the blood. I see this frequently too. The TSH will be perfectly normal or even low due to a variety of mechanisms. Routine tests then will be unable to detect it.

Thyroid panels are too limited. A more comprehensive test would include looking beyond TSH to total T3 and T4, free T3 and T4, Reverse T3, and antibody levels commonly found with Hashimoto's disease (the most common cause of low thyroid function). I use an expanded panel plus a highly specialized test called the TRH stimulation test.

TRH -- Shining a light on undiagnosed low thyroid.

For almost 20 years, I have relied on a much more sensitive test called the TRH stimulation. This is a three-step challenge similar to a cardiac stress or glucose tolerance test. Thyrotropin Releasing Hormone is a natural compound normally made in an area of the brain called the hypothalamus. In this test, a small amount is injected into the patient, triggering the pituitary to release its stored TSH on command. Even if the TSH level is normally low in the blood, it will be quite high within the pituitary gland itself in cases of underactive thyroid. Upon stimulation, TSH will surge into the blood causing levels to rise to easily detectable levels. Because of this, I am able to pick up on cases of hypothyroidism at the onset of symptoms, sometimes years before the TSH reflects the disease.

There was a time when all doctors used the TRH. As medicine made advances and assays became more sensitive, the TSH replaced it becoming the widely accepted way to diagnose thyroid disorders. Doctors embraced the ease of doing one simple blood draw and lowered costs. The TSH does work to diagnose a large number of people every year, but it misses too many leaving them needlessly suffering.

Shortly after this change in testing methods took place, I noticed a huge rise in unexplained chronic fatigue cases. There was an epidemic in patients complaining of thyroid-like symptoms-all with normal lab results according to TSH levels. So back in the '90s I began working to find a way to bring back the TRH test. It wasn't easy but the results were amazing. So many of those with unexplained pain, symptoms and chronic fatigue actually turned out to have very treatable hypothyroidism.

Patients are more than a collection of lab numbers! Strictly relying on routine tests without careful consideration to how they feel doesn't serve them. It's about digging deeper, looking for function through provocation and shuffling things around in order to get to the truth and corroborate what patients already know. Who you are, how you feel, your lifestyle and comprehensive testing make up the whole and weave together to form the blueprint for treatment and the road to recovery. The art of medicine is just as important as the science.

Sources:

1) Wartofsky L, Dickey RA, The evidence for a narrower thyrotropin reference range is compelling. J Clin Endocrinol Metab. 2005 Sep;90(9):5483-8.

2) Andersen Stig, Michael Klaus, et al, Narrow Individual Variations in Serum T4 and T3 in the Normal Subjects: A Clue to the Understanding of Subclinical Thyroid Disease. Journal of Clinical Endocrinology & Metabolism 87(3):1068-1072

Study confirms strong association between diabetes and later stage breast cancer

Diabetes is associated with more advanced stage breast cancer, according to a new study by the Institute for Clinical Evaluative Sciences (ICES) and Women's College Hospital.

The findings, published today in the journal Breast Cancer Research and Treatment, confirm a strong link between diabetes and later stage breast cancer at diagnosis for Canadian women.

"Our findings suggest that women with diabetes may be predisposed to more advanced stage breast cancer, which may be a contributor to their higher cancer mortality," said Dr. Lorraine Lipscombe, a scientist at ICES and Women's College Research Institute.

In the study, Dr. Lipscombe examined stage at diagnosis among women aged 20-105 years who were newly diagnosed with invasive breast cancer between 2007 and 2012.

From an analysis of more than 38,000 women with breast cancer, 6,115 (15.9 per cent) of the women had diabetes. Breast cancer patients with diabetes were significantly more likely to present with advanced stage breast cancer than those without diabetes. Women with diabetes were 14 per cent more likely to present with Stage II breast cancer, 21 per cent more likely to present with Stage III breast cancer, and 16 per cent more likely to present with Stage IV than to present with Stage I. The results also show lower mammogram rates in women with diabetes, which could account for later stage disease. Women with diabetes also had a higher risk of lymph node metastases (spreading of the cancer) and larger tumors than women without diabetes.

"In addition, the risk of advanced stage breast cancer was greatest in younger women and those with longer-standing diabetes," added Lipscombe.

The study showed that the majority of diabetes patients presented with Stage II or III breast cancer, which translated into a 15 per cent decrease in five-year survival for diabetes patients at the time of cancer diagnosis.

The researchers suggest that breast cancer screening and detection practices may need to be modified in patients with diabetes to reduce the chances of later-stage detection.

Source:

Women's College Hospital

Symptoms of Gallbladder Problems

The gallbladder isn't an organ that gets a lot of attention — unless it's causing you pain.

The gallbladder is a little sac that stores bile from the liver, and it's found just beneath your liver.

The gallbladder releases bile, via the cystic duct, into the small intestine to help break down the foods you eat — particularly fatty foods.

Typically the gallbladder doesn't cause too many problems or much concern, but if something slows or blocks the flow of bile from the gallbladder, a number of problems can result.

What Can Go Wrong

Some common gallbladder problems include:

Gallstones (cholelithiasis): This is the name of the condition when small stones, or sometimes larger ones, develop inside the gallbladder.

Gallstones may cause pain known as biliary colic (see below), but about 90 percent of people with gallstones will have no symptoms.

Most symptomatic gallstones have been present for a number of years.

For unknown reasons, if you have gallstones for more than 10 years, they are less likely to cause symptoms.

Biliary colic: This is the term often used for the severe episodes of pain that can be caused by gallstone blockage of the cystic duct.

The gallbladder contracts vigorously against the blockage, causing spasmodic (or sometimes constant) severe pain.

Biliary colic episodes usually last only an hour or two. They may recur infrequently, often years apart.

Inflamed gallbladder (cholecystitis): Inflammation of the gallbladder can be caused by gallstones, excessive alcohol use, infections, or even tumors that cause bile buildup.

But the most common cause of cholecystitis is gallstones.

The body can react to the gallstone irritation by causing the gallbladder walls to become swollen and painful.

The episodes of inflammation can last for several hours, or even a few days. Fever is not unusual.

About 20 percent of the time, the sluggish, inflamed gallbladder is invaded by intestinal bacteria, and becomes infected.

Occasionally, the gallbladder actually ruptures, which is a surgical emergency.

Suspected episodes of cholecystitis always require medical attention, particularly if fever is present.

Dysfunctional gallbladder or chronic gallbladder disease: Here, the gallbladder may become rigid and scarred from gallstones and repeated episodes of inflammation.

Symptoms are more constant, but tend to be vague, including abdominal fullness, indigestion, and increased gas.

Chronic diarrhea is a common symptom, usually occurring after meals, and up to 10 times per day.

Common Gallbladder Symptoms 

Specific symptoms may vary based on what type of gallbladder condition you have, although many symptoms are common among the different types of gallbladder problems.

But most gallbladder symptoms start with pain in the upper abdominal area, either in the upper right or middle.

Below are common symptoms of gallbladder conditions:

• Severe abdominal pain
• Pain that may extend beneath the right shoulder blade or to the back
• Pain that worsens after eating a meal, particularly fatty or greasy foods
• Pain that feels dull, sharp, or crampy
• Pain that increases when you breathe in deeply
• Chest pain
• Heartburn, indigestion, and excessive gas
• A feeling of fullness in the abdomen
• Vomiting, nausea, fever
• Shaking with chills
• Tenderness in the abdomen, particularly the right upper quadrant
• Jaundice (yellowing of the skin and eyes)
• Stools of an unusual color (often lighter, like clay)

Some gallbladder problems, like simple gallstones that are not blocking the cystic duct, often cause no symptoms at all.

They're most often discovered during an X-ray or CT scan that's performed to diagnose a different condition, or even during an abdominal surgery.

If you spot any symptoms of gallbladder trouble, head to your doctor for a diagnosis and prompt treatment to get your digestive tract running smoothly again.

Young mother blogging breast cancer journey

GRAND RAPIDS, Mich. — A young mother in Grand Rapids who was recently diagnosed with breast cancer is documenting her journey online in a very unique way.

It’s only been a few weeks since her diagnosis, and she’s already created a Facebook page to document her battle, hoping it will inspire others going through the same thing.

“He eventually had me sit in his chair and then he just came out with it and said, ‘I think this is pretty serious. I think you have two forms of breast cancer,'” said Tammy Myers.

Tammy Myers, 33, said that after feeling a lump on her breast last month, she decided to make a doctor’s appointment. After several tests, she was given the answer she feared most that she did in fact have cancer.

“I would like for 2015 to be the bad year and good things to come in 2016,” said Myers. “Obviously I have a two year old, so I’m not planing on going anywhere soon.”

Focusing on a positive outlet, Myers created a Facebook page, posting pictures on hospital beds, and bringing to light the experiences so many women go through when diagnosed with breast cancer.

“Everything from finding the lump to the first appointment, the second appointment, the biopsies. The doctors and nurses I’ve connected with,” said Myers.

Without a history of cancer in her family, and at just 33-years-old, Myers said that she’s keeping up a brave face to stay positive for her 2-year-old daughter and husband.

“If I’m able to be strong right now, maybe I could help somebody else, and that helps me,” said Myers.

Knowing she had a long journey ahead of her that will include chemo and radiation therapies, Myers said that she is going to continue to post her journey online for the world to see.

“I can walk around right now, and I can do myself up like I’m totally normal and healthy and no one knows what’s going on, unless I tell them. But, the second I lose my hair, and I walk into a hospital or a restaurant or bookstore, people know and they look at you differently,” said Myers.

Her online posts are already getting attention, with people she’s never met reaching out to her, letting her know how grateful they are that she’s embracing her own struggle.

“They are saying things like I was diagnosed two years ago, and I wish I would have had the courage to do what you are doing. You are such an inspiration,” said Myers.

Myers also said that her doctors and nurses at Spectrum Health have truly become her friends over the past month, and that she couldn’t be more thankful for their support.

Also, as a professional photographer herself, Myers plans to take photos at this year’s Susan G. Komen Race for a Cure this September in Grand Rapids.

If you’d like to help the family, you can CLICK HERE for their fundraising page. To read her posts on social media about her cancer journey, you can CLICK HERE.

Should You Get Blood Tests To Check Your Thyroid, Even If You Have No Symptoms?

The scenario is fairly common: you are in your medical provider’s office for a checkup and also happen to be getting lab work done. You report that you have no symptoms of feeling cold or fatigue, denying weight gain or weight loss, and do not have palpitations or dizziness. Should your medical provider order blood work to evaluate the function of your thyroid gland, commonly known as TSH or thyroid stimulating hormone or T4, another component integral to thyroid function?

Well, according to the most recent report of the United States Preventive Services Task Force (USPSTF), a group of medical experts advising the  government, the answer is not clear, as more clinical trials and scientific evidence will be necessary to ultimately make a better decision.

In doing so, the USPSTF reverted back to its most recent recommendation, issued in 2004, which advised against routine screening for thyroid disease in persons who are not pregnant, and otherwise healthy and asymptomatic, without significant risk factors for hyperthyroidism or hypothyroidism.

As stated in today’s report:

“The Task Force concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults.”

In doing so, the USPSTF also warned against the potential risks for screening asymptomatic individuals, including falsely positive results which could result in potential physical harms from overtreatment as well as psychological effects from labeling persons with a specific condition or disease.

However, it is important to note is that these updated recommendations do not apply to those persons who have symptoms such as weight gain, weight loss, palpitations, fatigue, or skin changes.

For those with symptoms and laboratory-confirmed hypothyroidism, levothyroxine can be prescribed by a medical provider to alleviate symptoms. In fact, in 2011, based on data from the USPTF’s report, nearly 71 million people received a prescription for this medication.

The report continues:

“The USPSTF concludes that the evidence is insufficient and that the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults cannot be determined.

If clinicians offer screening for thyroid dysfunction to asymptomatic persons, they should first ensure that patients clearly understand the uncertainties surrounding any potential clinical benefit of screening as well as the possibility of harm this choice may engender.”

The thyroid gland, located in the front of the neck surrounding the voice box or larynx, produces important hormones which are integral to metabolism and growth, and abnormal levels can be linked to cancer and heart disease as well as death if not treated.

Disorders of the thyroid gland are among the most common conditions of the endocrine glands treated by medical providers, ranging from asymptomatic to mild disease states which can encompass asymptomatic as well as overt states of hypothyroidism or hyperthyroidism. In rare cases, potentially life-threatening complications can develop such as thyroid storm, related to untreated hyperthyroidism, or so called myxedema coma related to severe hypothyroidism.

A simple blood test for thyroid stimulating hormone, commonly referred to as TSH, is the first step in screening persons for thyroid disease, along with T4 as well as T3, other aspects of what we refer to as a thyroid profile.

Arguments To Screen According To USPSTF

The argument for early detection and treatment of asymptomatic persons (with abnormal levels of TSH) is to treat the potential complications of unrecognized disease such as cardiac complications including atherosclerotic heart disease, and resulting heart failure related to hyperthyroid states, along with potential fractures related to abnormal bone metabolism associated with hypothyroidism. The underlying risk of cancer remains another argument to embark on screening asymptomatic persons.

The flip side of the argument to screen, endorsed by USPSTF, is that such widespread screening practices, especially in cases of what we refer to as subclinical thyroid dysfunction–patients with abnormal levels of TSH but no overt symptoms–may lead to not only false positive results, but overtreatment and other emotional harms due to labeling those with a disease.

The USPSTF, however, does concede that screening can reliably detect “abnormal” TSH levels in persons without overt symptoms. That said, it should be noted there is no broad agreement by laboratories or even medical providers as to what reference ranges and values actually constitute an abnormal TSH level, referring to “cutoff points for the lower and upper boundaries of normal TSH levels in the general population and in subgroups, such as older adults.”

The Black Box Of TSH Screening

It turns out that generalized laboratory reference intervals currently in use are actually based on the statistical distribution of TSH levels across the general population rather than the correlation of a specific TSH level with symptoms, risk factors, or adverse clinical outcomes for disease.

As a result, the lack of clearly delineated reference levels may lead to confusion among patients who need validation for the risks of having a particular thyroid condition based on their levels of T4 and TSH.

Other medical conditions sensitive to TSH secretion can also impact results and cloud accurate interpretation of serum TSH levels, leading to inconsistent and variable results during testing.

As a result of these uncertainties, many professional societies recommend repeating thyroid function tests if the results are inconsistent at 3 to 6 month intervals in asymptomatic persons before making a diagnosis or planning specific treatment–unless the serum TSH level is greater than 10.0 or less than 0.1.

Health Benefits To Screening?

Overall, the USPSTF did not find evidence that screening for abnormal thyroid lab values reduces cardiovascular disease, complications or associated death, in healthy persons with no risk factors or family history to suggest abnormal thyroid function. It also found that screening healthy, asymptomatic adults “does not improve quality of life or provide clinically meaningful improvements in blood pressure, body mass index (BMI), bone mineral density, or lipid levels. It also does not improve cognitive function.”

Preventable Disease Screening

In the US, nearly 3% of men and 5% of women have subclinical hypothyroidism. However based on multiple studies, about 37% of patients actually normalize their lab values over several years time without any intervention. Only 2-5% of patients with subclinical hypothyroidism go on to actually develop symptoms or “overt thyroid dysfunction.”

In fact, a previous retrospective cohort study noted that those persons with subclinical hypothyroidism who took T4 had a lower risk for ischemic heart disease events and overall mortality. Unfortunately, the USPSTF was not able to pinpoint any prospective studies examining the relationship between treatment and risk for cardiac events.

Subclinical hyperthyroidism occurs in nearly 0.7% of persons in the US, more often in women than men. About 25 % of persons with subclinical hyperthyroidism will actually normalize their TSH without any medical intervention within 2 years. And close to 1% to 2% of persons with TSH levels less than 0.1 mIU/L develop “overt” hyperthyroidism (with or without symptoms). Overall, persons with TSH levels between 0.1 and 0.45 mIU/L generally do not go on to develop “overt” hyperthyroidism.

Potential Harms With Screening

As mentioned previously, the most important potential harms are false-positive results, labeling of patients with a specific disease, as well as overdiagnosis and overtreatment.

Its clear that false positive results may occur primarily due to the variable nature of TSH secretion often times the result of illness or particular medications. The lack of consensus on what constitutes a normal reference interval also makes treatment problematic.

Furthermore, agreement is not clear regarding the actual threshold when clinicians should begin medication, especially for hypothyroidism. There has not been any clear data from clinical trials to identify a numeric point to begin medication that can to improve clinical outcomes. Clinical consensus has been that a TSH level greater than 10.0 mIU/L is generally considered the threshold for initiation of treatment mainly due to risk of developing overt hypothyroidism. For those patients with a TSH between and 4.5 -10.0, the decision to begin treatment is controversial, and should be based on serial TSH levels, as well as development or progression of any symptoms.

Endocrine Specialty Groups Recommend Thyroid Screening: The Alternate View

The USPSTF, while endorsing evidence-based recommendations that are typically designed to treat large populations, realizes that the major endocrine specialty societies continue to recommend screening for thyroid dysfunction.

As an example, The American Thyroid Association (ATA) endorses screening in all nonpregnant adults beginning at age 35, and subsequently every 5 years.

In reality, the majority of practicing endocrinologists, including the American Association of Clinical Endocrinologists (AACE) recommends routine TSH screening in older female patients with nonspecific symptoms. And as mentioned, the bulk of the USPSTF recommendations are often based on evaluation of large populations of patients, as opposed to individual patient situations, and thus generally conservative in nature.

The USPSTF’s recommendations often point to the lack of randomized prospective trials showing benefits of treatment in mild hypo- or hyperthyroidism, typically related to treating large populations, while also addressing costs.

Meanwhile, the majority of practicing endocrinologists focus on individual assessment of patients, generally opting to treat mildly symptomatic patients with hypo- or hyperthyroidism to achieve potentially mild, but often significant benefits.

Hypothyroidism or Thyroid Imbalance Often Goes Undiagnosed

Menstrual irregularities, mood swings, joint pain, extreme fatigue, constipation, hair loss;  these are just a few of the many symptoms which are often associated with Hypothyroidism or hormone imbalance.

“Hypothyroidism is becoming one of the country’s most undiagnosed medical conditions and because many of the symptoms mirror that of other diseases or conditions, often people may be unaware that they are suffering from this often deliberating condition” says Kelly Nolan, Clinic Director of Avita Integrative Health and Restoration Clinic in Brampton.  

Hypothyroidism can be described as low-functioning thyroid where the output of healthy hormones is reduced which can affect the body’s metabolic functions including weight, growth and development, regulation of body temperature and heart beat and even our bone health.  Some of the more common causes of hypothyroidism may include the use of birth control pills, pharmaceutical drugs, fluoride in drinking water and even aging.   

What are some of the leading symptoms of Hypothyroidism?

Weight gain is not the only symptom. Other symptoms of hypothyroidism can include lethargy, extreme fatigue, brittle nails, thinning hair or hair loss, dry hair or skin, joint pain, muscle weakness or cramps, intolerance to cold, irregular or slow heartbeat, constipation, elevated cholesterol, a hoarse voice, worsened hearing and even weight loss.  

“The TSH (thyroid stimulating hormone) blood test that your doctor may request is just basic testing that is insufficient in providing a patient with a full snapshot of every aspect of thyroid function,” says Kelly Nolan, Clinic Director and Pharmacist of Avita Integrative Health and Restoration Clinic in Brampton. “Getting a full thyroid test panel which includes TSH, T3, T4 and thyroid antibodies is the best way to understand your current health. The Iodine/Bromine Test is like a snapshot of your thyroid health as it monitors your iodine intake and absorption to help determine an appropriate line of therapy to balance thyroid function. It is also important to recognize that as other hormone levels change due to stress or deficiencies, the thyroid hormone levels may change a well. Doing a Saliva Hormone test to check levels of cortisol, progesterone, estrogen, testosterone and DHEA is essential.”

The health team at Avita Integrative Health are able to get the full picture of thyroid health by completion of the Urinary Thyroid Test, Urine Iodine/Bromine test, vitamin D test to be able to customize an integrative healing program using the natural compounded desiccated thyroid, balancing herbal therapy and/or bio-identical hormone replacement therapy. Customized BHRT treatments can be determined using the results of the Saliva Hormone test which are highly recommended for all hormonal concerns.

Fatigue May Be a Sign of More Than Lack of Sleep

We all get tired every once in a while, but sometimes, that "run-down" feeling has nothing to do with a lack of sleep.

Prolonged fatigue is oftentimes linked to thyroid problems. Dr. Betul Hatipoglu, an endocrinologist at Cleveland Clinic, said fatigue is a symptom in both hyper and hypothyroidism. "A lot of patients will tell me they feel like they're wearing this heavy, leaded vest that they can barely walk around they feel drained," she said.

Thyroid problems are most commonly seen in middle-aged women and are typically caused by an auto-immune attack. That's when the immune system mistakes the thyroid as an outside invader, attacks, and damages it.

When this occurs your thyroid may stop producing enough hormones and the result is hypothyroidism. In addition to fatigue, symptoms of hypothyroidism can include weight gain and hair loss.

If your thyroid is overactive, you're experiencing hyperthyroidism, which may also cause heart palpitations, or nervousness, in addition to fatigue, because the thyroid is producing too much hormone.

Dr. Hatipoglu said if your fatigue lasts more than a week and starts to interfere with your daily activities you should see your doctor. She explained, "You have no energy to do much. You gain weight with underactive and sometimes with overactive thyroid you can gain weight as well. You can't do your daily activities, so some women they cannot do cleaning or cooking in their home, they cannot take care of their children, so it can be really, a big problem."

Dr. Hatipoglu said a simple blood test will tell you everything you need to know. If it is a thyroid problem she said your doctor will prescribe you medication that will balance your hormones.

Abdominal Aortic Aneurysm: Preventing Lethal Rupture

When doctors hear people talk about abdominal aortic aneurysms as “ticking time bombs,” they tend to grow a bit weary. In reality, they say, many patients diagnosed with a small, slow-growing AAA can be safely monitored for years. And if repair is needed, elective surgery is available.

Watchful Waiting

The aorta is the large, central artery that carries blood from the heart to your body. The upper section within the chest is the thoracic aorta, and the lower section is the abdominal aorta. Because the aorta receives pressure with each heartbeat, parts of the aorta's wall can gradually weaken in people at risk.

Aortic dissection involves a tear in the aorta’s wall, causing the layers to separate. Aneurysm, a bulge or ballooning in the artery wall, is more common in the abdominal aorta. A ruptured abdominal aortic aneurysm is a medical emergency.

Grafts are used to fix a weakened aorta.

By diagnosing an AAA early, while it’s still small, doctors can carefully monitor patients while treating their risk factors – known as watchful waiting.

Cecil Merritt, 81, a retired engineer in Leighton, Alabama, learned he had an abdominal aortic aneurysm in 2008. The previous year he’d been operated on for melanoma on his shoulder, and he needed a follow-up CT scan. It was his oncologist who told him he had an AAA. “Never felt it,” Merritt recalls. “Didn’t have any symptoms.”

Lucky Catch

“Most aneurysms are diagnosed with imaging studies that are done for some other reason,” says Benjamin Starnes, a professor and chief of the vascular surgery division at the University of Washington.

In terms of discovering an early AAA, unfortunately, most patients are “completely asymptomatic,” Starnes says. “They don’t come with any abdominal or back pain. The patient will typically come in because they’ve had an X-ray or they’ve had an ultrasound study for some other completely unrelated condition, and oh by the way, they found out that they have this aneurysm.”

Certain risk factors make you much more vulnerable: being male, 65 or older, a smoker and having high blood pressure or a hardening of the arteries. A family history of AAA also raises your risk.

In Merritt’s case, although he never smoked, he had almost every other risk factor include several relatives who’d had aortic aneurysms.

How Do You Know?

CT scans, ultrasounds and MRIs can all be used to diagnose and measure aneurysms. A single screening is recommended for all men ages 65 to 75 who’ve ever smoked. Older men who’ve never smoked should check with their doctors. Women aren’t routinely screened for AAA because their risk is much lower.

James Black, chief of the division of vascular surgery at Johns Hopkins Hospital, says women’s risks are closer to men’s at younger ages. However, at 65 and beyond, AAA risk “clearly predominates” for men, affecting three to five men for every woman affected. But “the problem is while aneurysms are more infrequent in women, they have a higher risk for rupture,” Black says. “So we sometimes get more nervous about aneurysms in women than we do in men.”

As for Merritt, six years after diagnosis his aneurysm hasn’t changed, and he’s still in watch-and-wait mode.

Size Matters

When you talk to your doctor about AAA, Black says, “The first question really should be – what’s the size of the aneurysm?”

“Most aneurysms when they’re small have a very low risk for rupture – perhaps at best it might only be 0.5 percent or 1 percent per year,” Black says. An aneurysm less than 4.5 centimeters (under 2 inches) across is considered small. These patients come in every six to 12 months for follow-up imaging tests.

The medical focus is on reducing their risk factors. “Things that are associated with a rapid growth trajectory of the [AAA] are blood pressure and smoking,” Black says. “So to that end we ask patients to wind down their smoking habit as soon as they can.”

Beta blockers, a specific type of blood pressure medicine, have been shown to slow aneurysm growth in the aorta, Black says, and “there’s some experimental evidence that statin medications help keep the blood vessel wall healthy.”

Exercise restrictions aren’t needed with a small aneurysm, Black says. However, when an aneurysm reaches a “moderate” level of about 4.5 to 5 centimeters, he advises sticking with “steady-state” exercise – such as swimming, or jogging or biking on a relatively level surface.

Catastrophe of Rupture

For patients with an unsuspected aneurysm, unchecked growth can turn into a dire emergency. “A ruptured aneurysm is a model of pure catastrophic hemorrhage,” Starnes says. It’s as if someone stuck a knife into the aorta and pulled it back out, he says.

Pain – sudden, intense and continuous – often starts in the patient’s back or abdomen, and can wrap around into the groins. Black describes “a real severe, double-over sort of pain where you want to turn off the lights and crawl into a ball. Not, ‘I feel a little sore from raking leaves or shoveling a little too much snow.’”

Starnes says a drop in patients’ blood pressure is the next phase, and they’ll need to lie down or even faint. The body then releases hormones to raise the blood pressure. Other signs of rupture include dizziness, sweating, clamminess, nausea or vomiting, fast pulse, shortness of breath and loss of consciousness.

If you or a loved one is having these symptoms, call 911 – timing is critical. “Typically,” Starnes says, “on average, patients will survive after a ruptured aneurysm about two hours.”

Starnes practices at the Harborview Medical Center in Seattle. The Level 1 trauma center covers patients in a five-state area, and as a result he sees more ruptured aneurysm emergencies than any hospital in the country.

“It used to be that the mortality rate once the patient got to the hospital – their risk of death was 50 percent,” Starnes says. “Flip of a coin. We implemented a program seven years ago to treat those patients without putting them to sleep with minimally invasive procedures. And we lowered the mortality rate to 16 percent.”

Tipping Point

Elective surgery is far preferable to emergency surgery, and most patients do well afterward. The question is: when to have it. With very small aneurysms, it’s likely the risks of surgical complications outweigh the risks of just leaving the aneurysm alone, Black says.

But “when the aneurysm crosses 5 to 5.5 cm in size, that is the tipping point where intervention should be very heavily considered,” he says. The threshold may differ for women and people with chronic obstructive pulmonary disease, he adds.

Surgical Decisions

Surgical options for aneurysm include traditional open surgery and less-invasive endovascular repair. A CT or MRI scan, along with other factors, will help determine the right option for you.

Endovascular repair is performed under either general or local anesthesia. A stent – a thin metal tube that makes up the core of a “stent graft” – is guided through the femoral artery toward the area of the aneurysm. Patients can usually leave the hospital in the next one or two days. A vascular surgeon, general surgeon or cardiac surgeon can perform the procedure.

Black notes that correct fit can be an issue with stents, and not all patients are good candidates. Patients must be willing to come back regularly, usually yearly, for a CT scan to make sure the device is working well.

Open surgery is always done under general anesthesia. A large incision is made straight down the middle of the abdomen, across the abdomen or to the side. The aneurysm is isolated between surgical clamps and opened, and a synthetic graft is sewn into place to replace the weakened part of the aorta. Surgical risks include bleeding, graft or wound infection, and blood clots.

Recovery takes longer with open surgery than endovascular repair. Patients spend a week or more in the hospital and about one to three months recovering fully at home.

An abdominal aortic aneurysm “didn’t grow overnight,” Starnes says. “It’s been something that developed over time and if it’s thankfully recognized at a small size, it can be monitored over time until it gets to a size where it can be electively repaired very, very safely.”

Mayo Clinic vascular surgeon explains abdominal aortic aneurysm screening, treatment

An abdominal aortic aneurysm is a potentially life-threatening condition: If the aorta, the body's major blood vessel, ruptures, it can prove deadly. In this video, Mayo Clinic vascular surgeon Peter Gloviczki, M.D., explains who should be screened for abdominal aortic aneurysms and when.

Atypical hyperplasia bigger breast cancer risk factor than previously thought, study says

Women with atypical hyperplasia of the breast have a 1 percent increased risk of developing breast cancer each year, suggests a study published Wednesday in the New England Journal of Medicine.

Previous research has shown that females with atypia, a precancerous condition in which breast cells begin to grow out of control and cluster in abnormal patterns, have a four- to five-fold increased relative risk. But few studies have assessed patients’ absolute risk, or the chance that she will develop the breast cancer over a period of time, according to a news release.

To define this risk, a team of researchers at the Mayo Clinic followed 698 women with atypia who had been biopsied between 1987 and 2001. They used medical and pathology records, as well as follow-up surveys, to determine which study participants developed the disease and when.  After an average of 12 and a half years, 143 of the women developed the disease.

Five years after a biopsy, 7 percent of these women developed the disease, and after 10 years the number jumped to 13 percent. Twenty-five years later, 30 percent of these women developed breast cancer.

To validate their results, researchers compared these findings with biopsies from a separate group of women with atypia, data that researchers at Vanderbilt University gathered.

Studying a patient’s pathology specimen also revealed that as the extent of atypia— measured by the number of separate foci, or atypia lesions— in a biopsy increased, so did breast cancer risk, according to the news release. Twenty-five years post-biopsy, 47 percent of women with three or more foci of atypia in the biopsy had developed breast cancer, compared to 24 percent of women with one focus.

Study author Amy Degnim, a breast cancer surgeon at Mayo Clinic, said the actual data used in the study is preferable to a statistical model, which is hypothetical.

The researchers say the findings suggest a need for greater screening and specialized medicine for the more than 100,000 women diagnosed annually with this condition. Atypical hyperplasia is thought to be a low risk factor for breast cancer.

"By providing better risk prediction for this group, we can tailor a woman's clinical care to her individual level of risk," lead study author Lynn Hartmann, an oncologist at Mayo Clinic, said in the news release. "We need to do more for this population of women who are at higher risk, such as providing the option of MRI screenings in addition to mammograms and encouraging consideration of anti-estrogen therapies that could reduce their risk of developing cancer."

Clinical trials have shown that anti-estrogen medications such as tamoxifen can lower the risk of breast cancer by 50 percent or more. However, Degnim said that many women with atypia are not taking their medications because their physicians haven’t had solid estimates of their breast cancer risk and administer treatment accordingly.

Abdominal Aortic Surgery | Ron Rolett's Story

Ronald Rolett, a retired physician from North Carolina, learned that he had an abdominal aortic aneurysm from a routine ultrasound screening. He then had follow-up ultrasound tests every six months until it had reached a critical size.

Rescue Dog Sniffs Out Aggressive Breast Cancer, Saves Life of Owner

Josie Conlan saved border collie Ted from what appeared to be an abusive home, and now he's saved her, sniffing out a tumor that led to the discovery that she had aggressive breast cancer.

Having come from an abusive home, Ted was usually reserved. He was not very affectionate, so when he started pawing at Conlan, crying and nuzzling at her chest, she knew something was up. After checking the area Ted was pawing at, she spotted a bump. A visit to her doctor confirmed that she has grade three cancer.

As devastating as the news was, Conlan couldn't help but be relieved because Ted was able to call her attention to a bump in her chest. Had she ignored the dog's cries, she would likely be dead by summer.

The deadly tumor in her chest has been removed, and Conlan was told the cancer did not spread to her lymph nodes. This means that it will be unlikely for the cancer to spread and affect other parts of her body.

All that is left now is for Conlan to undergo chemotherapy for 18 weeks and radiotherapy for four to guarantee that the cancer does not make a comeback.

Ted is two years old and the Conlans have had him for around a year. Having suffered as a puppy, the dog was timid, taking work on Josie's part to get him to warm up to the family. Once Ted turned around, he and Josie formed a very close bond, a highlight in the dog's dramatic recovery.

"I think a lot of people would probably just push a dog away if it started clawing at their chest, but dog owners should take notice, because Ted really did save my life," said Conlan.

The American Cancer Society estimates that there were 207,170 new cases of breast cancer in women aged 45 years old and above and 133,310 cases in women aged 65 years old and below in 2014 in the United States.

This estimation shows that those most at risk are between 45 and 65 years old, although the cancer can strike anyone. Risk factors include age and genetics, both of which can't be changed, as well as weight, fitness level and diet. By opting for the healthiest lifestyle choices available, women can take an active role towards lowering their risks for contracting the cancer.