Archive for February, 2013

Liquid Gold

February 23, 2013

Liquid Gold

Andrew Siegel, MD  Blog # 95

 

Urine is as valuable as gold is—at least when it comes to its potential for revealing our underlying health or infirmity.  Our kidneys work 24/7/365 filtering and removing from our bloodstream toxic wastes.  These include nitrogen-rich soluble products generated from cellular metabolism, numerous other organic and inorganic chemicals, salts and metabolites, as well as excessive water.  Urine—the end product appearing in our bladders—can provide amazing insight into our overall health.

With every pulsation of our heart, arterial blood flows into the kidney via the renal arteries; after the blood is filtered, the cleansed blood is returned via the renal veins.  In essence, the artery brings “dirty” blood to the kidneys for filtering, with the renal veins providing transport back of cleansed blood. Urine is a sterile by-product of this filtering process.  For this reason, when operating on the urinary tract (for example when the bladder is opened and urine enters the abdominal cavity), it is of no concern from an infectious point of view.

Using a simple and inexpensive dipstick, in a matter of moments, diabetes, kidney disease, urinary tract infection and the presence of blood in the urine can be diagnosed.  Although there are many benign causes of blood in the urine, the worrisome possibilities are kidney and bladder cancer.  The dipstick also reveals specific gravity, a test that can indicate dehydration, over-hydration, and other potential health issues. Not only can the dipstick disclose the presence of diabetes mellitus (sugar diabetes), but it can also reveal a condition known as diabetes insipidus, in which the kidneys lose their ability to concentrate urine. As a result, massive amounts of dilute urine are produced, which can have dire consequences.  Urine testing can also reveal substance and performance-enhancing drug abuse. Who knew that a waste product could be so revealing?  Of all the waste products that humans produce, urine uniquely provides the best “tell” regarding our health.

Urine odor can provide information as well. A sweet smell is consistent with diabetes mellitus; a foul odor may indicate a urinary infection or the intake of certain foods such as asparagus.  Vitamin intake can also cause the urine to have an unpleasant odor. Vitamins B and C are water soluble and therefore not stored in the body.  Any excess above what is necessary for the body’s use is immediately excreted in the urine.  Malodorous urine that has a feculent scent may indicate an abnormal connection between the colon and the bladder that is known as a colo-vesical fistula. This happens most commonly on the basis of diverticular disease of the colon.  When it occurs, there is often air in the urine, designated by the term pneumaturia.

Color is a “tell” with respect to hydration status.  When well hydrated, our urine will look clear or very pale yellow, like a light American beer.  When dehydrated, our urine becomes very concentrated, appearing dark amber, like a strong German beer.  Excessive B vitamins can result in light orange urine. Red urine is most often blood in the urine, which may indicate a potentially serious underlying condition, although overconsumption of beets, blackberries, and rhubarb may sometimes impart a red color to urine.  “Iced tea” or “cola” colored urine is often indicative of old blood, as opposed to the bright red color of urine indicative of fresh and active bleeding. Dark brown urine may indicate jaundice.  Pyridium, prescribed for the discomfort of urinary infections, turns the urine a neon orange color.  Other urinary analgesics that contain methylene blue can turn the urine blue or green.  Cloudy urine may be indicative of a urinary tract infection, but can also occur when phosphate salts crystallize in the urine on the basis of dietary intake of foods high in phophates.

When our urine is occasionally foamy or sudsy, it is considered to be normal. When it occurs consistently, it can be a sign of protein in the urine, indicative of kidney disease.

Bottom Line:  Urine is an invaluable waste product and offers many clues as to our overall health or presence of illness.

 

What a dipstick can reveal:

specific gravity…status of our hydration

pH…acidity of urine

leukocytes…urinary infection

blood…many urological disorders including kidney and bladder cancer

nitrite…urinary infection

ketones…in the absence of carbohydrate intake, fat is used as fuel and ketones are by-products of fat metabolism; may also indicate a very serious condition known as diabetic ketoacidosis

bilirubin…a yellow pigment found in bile, a substance made by the liver; its presence may be indicative of jaundice

urobilinogen…a byproduct of bilirubin breakdown formed in the intestines by bacteria—when elevated may indicate: impaired liver function; hepatitis; cirrhosis; excessive breakdown of red blood cells—when low may indicate bile obstruction or failure of bile production

protein…kidney disease

glucose…diabetes

—————————————————————————————————————————————————————————————————————

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Vaccinations Are Not Just For Kids

February 16, 2013

Andrew Siegel, M.D.  Blog #94

Vaccinations are not just for kids! Vaccinations are as equally important for “grownups” as they are for children.   Many assume—mistakenly so—that vaccinations are only administered by pediatricians or that the vaccinations they received as children provide indefinite protection.  That stated, most adults are aware of the importance of obtaining an annual flu vaccine, particularly in light of the severe flu season we’ve experienced this year.  This is one vaccine that needs to be updated and modified annually because of the dynamic nature of influenza viruses, and is typically effective for only a several-month period of time.

As much as I am not a “pill-prescribing”-oriented physician and believe in lifestyle management as a first-line therapy for many medical issues, I strongly believe in vaccines.  Vaccines are exceptions because they don’t treat disease but actually prevent disease before it has an opportunity to arise. Vaccines contain the very same microorganisms that cause disease, although they are weakened to the extent that they do not actually incite the infection. This small dose of attenuated microorganisms stimulates one’s immune system to produce antibodies, resulting in immunity to the disease without having to suffer through the actual disease.

As a result of vaccinations, certain infectious diseases have become extraordinarily rare.  Polio is a prime example of this. So why is it important to continue vaccinating for a disease that has become so rare?   To help explain this, I borrow an analogy from the CDC  (Center for Disease Control). The vaccine situation is analogous to bailing out a boat that has a slow leak. When beginning the bailing process, the boat is quite filled with water. After laborious bailing, the boat eventually becomes near dry. We could be complacent and stop the bailing process and rest on our laurels and enjoy the almost dry boat.  However, the root cause–the leak–is still present.  Eventually, water would seep in to the extent that it would be up to the same level as when we first began bailing.   Until we can stop the leak (i.e., completely eliminate the disease), it is important to keep bailing (i.e., immunizing).   Even if there are only sporadic cases of a particular disease today, if we eliminate the protection afforded by vaccination, more and more people will ultimately be infected and spread the disease to others; as a result, the progress that has been made over the years will be for naught.

With respect to smallpox, we were able to stop the “leak in the boat” completely, eradicating the disease. Smallpox vaccinations are no longer necessary because the disease no longer exists at all. If we keep aggressively vaccinating, hopefully other diseases including polio and meningitis will no longer be around to infect, maim, or kill children.  Thus, the goal of vaccinations is not only to preempt the disease in an individual but also to eventually wholly eliminate the disease for the benefit of the society at large.

In 1974, Japan had a successful vaccination program for whooping cough (pertussis) with nearly 80% of children vaccinated. That year, only about 400 cases of whooping cough were reported in the entire country and there were no deaths. For some mysterious reason, rumors abounded that the vaccine was no longer needed nor was it safe, and by 1976 only one of 10 infants was getting vaccinated. Subsequently, in 1979, Japan suffered a major pertussis epidemic with more than 13,000 cases and over 40 deaths. Ultimately, the government resumed their aggressive vaccinating program and the number of cases dropped significantly, once again.  The point is that if we stopped vaccinating, diseases that have seemingly been abolished would resurface. More people will get ill and some of them will die.

Thus, we vaccinate not only for the individual, but to protect the future of our community.  This concept is referred to as “herd immunity,” the protection against disease that occurs when the vaccination of a significant portion of a population provides a measure of security for those who have not developed immunity.   When large numbers of the population are immune to a disease, the probability that a susceptible individual will come into contact with one who is infected is diminished. Vaccination acts as a “firewall” in disease spread, slowing or preventing transmission of the infectious disease to unvaccinated individuals who are indirectly protected by vaccinated individuals.  In order for herd immunity to be effective, it is advantageous that only a small fraction of the “herd” is left unvaccinated.   This population should be those who cannot safely receive vaccines because of medical conditions such as immune disorders, organ transplants, or certain allergies.

Vaccines for pneumonia, influenza, hepatitis, HPV (human papillomavirus) and the combined tetanus, diphtheria, and pertussis vaccine are available for adults. The recent resurging incidence of pertussis has led to an update of the traditional booster.  Pneumonia vaccine is recommended for adults 65 and older, particularly those with asthma, diabetes, cardiac disease, and in any other situation that compromises the immune system and places individuals at a higher risk for pneumonia.  Additionally, the vaccine is recommended for those who are in close contact with high-risk individuals. The hepatitis A vaccine is recommended particularly for those who travel to Third World countries. The hepatitis B vaccine is recommended for those with diabetes and those who are otherwise at risk, such as healthcare workers. The HPV vaccine is recommended for adolescents and young adults up to the age of 26.

Shingles—aka herpes zoster—results from the same virus that causes chickenpox. After exposure to chickenpox, the virus never quite completely leaves one’s system, living dormant in nerve endings.   For most people, the antibodies manufactured by the body keep the virus in check for many, many years. However, when our immunity becomes compromised by age or other factors, the virus can be re-activated in the form of a painful skin rash known as shingles. A one-time vaccination for shingles can prevent the occurrence of this painful condition.  The FDA has approved the vaccine for adults 50 or older, although some insurance companies will not cover it until age 60.

Bottom line:  Staying up-to-date with adult immunizations provides important protection for ourselves as well as our loved ones and other members of our “herd.”

For the CDC recommended vaccination schedule for adults, go to the following site:

http://www.cdc.gov/mmwr/preview/mmwrhtml/su6201a3.htm

 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

The New CPR (Cardiopulmonary Resuscitation): Hands Only

February 9, 2013

Andrew Siegel, M.D.   Blog # 93

The majority of people who experience sudden cardiac arrest (when the heart stops beating) will be dead within a few minutes of the arrest or, if they survive, will suffer permanent central nervous system damage because of inadequate blood flow to the brain.

A new and modified method of CPR called “Hands–Only CPR” can substantially increase the survival rate of those undergoing cardiac arrest, without the necessity for mouth-to-mouth breathing.   It is a relatively easy technique that can be performed by most anyone with little training.

According to the American Heart Association, despite the newer guidelines that make it much easier to perform CPR, less than one third of cardiac arrest victims receive the potentially life-saving procedure from bystanders.   Hands–Only CPR involves repeated chest compressions to maintain blood circulation until the time emergency help arrives. The difference in the newer CPR guidelines is that instead of focusing on airway, breathing, compressions (A, B, C), the order has been changed to focus on compressions, airway, breathing (C, A, B). The previous standard was to ensure an open airway, tilt the head back, lift the chin, pinch the nose, seal the mouth, and administer mouth-to-mouth resuscitation. The problem with this was its focus on breathing as opposed to circulation.  The crux of the issue is that after cardiac arrest, there is usually plenty of oxygenated blood present, but a non-functioning circulatory system to pump the oxygenated blood.

So, if you witness a person collapsing, the first thing to do is to call 9–1–1 for help. Secondly, shake the person and evaluate to see if they are breathing. If they are unresponsive, have no pulse and are not breathing or not breathing normally, lock your hands together and push hard and rapidly on the center of the chest 100 times or more.  The chest compressions should be 1 ½-2 inches in depth. If the situation was not a cardiac arrest and the collapse occurred for other reasons such as low blood sugar in a diabetic, the victim will usually perk up when sufficient pressure is placed on the chest.  In the event of this happening, leave the patient alone and wait for emergency help.

The bottom line is that you do not need to waste time pulling the victim’s head back and giving mouth-to-mouth because of the presence of plenty of oxygenated blood which is simply not moving; thus chest compressions become the greatest priority and can be delivered in a manner that is much less invasive and potentially risky than mouth-to-mouth breathing.  Hands-Only CPR can dramatically increase survival for sudden cardiac arrest patients.

Of course, if the victim fails to respond, and no breathing or heart beating ensues and help has not yet arrived, then it comes time to add airway and breathing to the regimen.  Generally, two breaths followed by 30 chest compressions (at a rate of 100/minute) will be adequate, with stopping every two minutes to see if breathing and pulse have returned.

How to Do the New CPR:

The following is a step-by-step guide for the new CPR:

1. Call 911 or ask someone else to do so.

2. Try to get the victim to respond; if they do not, roll the person on his or her back.

3. Start chest compressions. Place the heel of your hand on the center of the victim’s chest. Put your other hand on top of the first with your fingers interlaced.

4. Press down so you compress the chest at least 1½ to 2 inches in adults and children and 1½ inches in infants; 100 times a minute is optimal.

5.  If you’re been trained in CPR, you can now open the airway with a head tilt and chin lift.

6. Pinch closed the nose of the victim. Take a normal breath, cover the victim’s mouth with yours to create an airtight seal, and then give two, one-second breaths as you watch for the chest to rise.

7. Continue compressions and breaths — 30 compressions, two breaths — until help arrives.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Bladder Cancer

February 2, 2013

Bladder Cancer

Andrew Siegel, MD  Blog #92

 

Bladder cancer is such a common public health problem that I thought it would be worthy of an educational blog.  Few people realize that its occurrence is more highly linked to tobacco than is lung cancer.

In the USA, the incidence of bladder cancer has increased greatly over the last few decades, with more than 60,000 new cases diagnosed each year.  It is the fourth most common cancer in men and the eighth in women. With the exception of skin cancers, bladder cancers are the most frequently recurring cancer, with up to 70% of patients experiencing recurrence.  The occurrence of bladder cancer increases with age and is three times more common in men than women.  80% of newly diagnosed individuals are 60 years of age or older.  At present, about 20% of patients die each year, but when the disease is diagnosed and treated in the early stages, the chances of survival are excellent, highlighting the importance of a timely and accurate diagnosis.  More than 90% of newly diagnosed bladder cancers are urothelial cell carcinomas  (cancers originating from the unique lining of the urinary tract).

The majority of patients with newly diagnosed bladder cancer have superficial cancer that involves the very inner layers of the bladder wall.  About 20% have invasive disease that involves the deeper layers of the bladder wall.  The remaining 5% present with metastatic disease, defined as spread beyond the confines of the bladder.

The highest prevalence of bladder cancer is in industrialized nations.  Cancer-causing agents (carcinogens) are most often responsible for bladder cancer.   Bladder cancer is highly associated with tobacco smoking—even if one stopped smoking years ago, the risk is related to the quantity of tobacco smoked over the years.  The carcinogens that are present in tobacco are absorbed through the lungs into the bloodstream and are filtered through the kidneys directly into the bladder, where their prolonged contact time with the lining of the bladder leads to cancerous changes.   Certain occupations are at higher risk for bladder cancer because of exposure to chemicals—these include: hairdressers, painters, machinists, printers, and those who work with dyes, textiles, rubber, leather, and petrochemicals.

Bladder cancer most commonly manifests with blood in the urine, either visible or microscopic (seen only under microscopic magnification).  It may also cause irritative lower urinary tract symptoms including urgency, frequency, discomfort with urinating, and urinary leakage.

The evaluation for blood in the urine includes imaging, cytology, and cystoscopy.  Imaging tests are means of visualizing the anatomy of the urinary tract, typically through ultrasound, computerized tomography (CT), or magnetic resonance imaging (MRI).  Cytology is a microscopic inspection of a urine sample by a pathologist for the presence of abnormal or cancerous cells that slough off the lining of the bladder, similar to a Pap smear done to screen for cervical cancer.  Cystoscopy is a visual inspection of the entire lower urinary tract (bladder and urethra) using a tiny, flexible, lighted instrument attached to a camera and monitor.

When a bladder tumor is identified on cystoscopy, attention is directed to the number of tumors present, their size, location within the bladder, and physical appearance.  A papillary appearance consists of fronds (finger-like projections floating in the bladder) with a narrow attachment to the bladder lining versus a sessile appearance, in which the tumor appears solid and is widely attached to the bladder lining.

Once a bladder tumor is recognized, it needs to be removed and sent for pathological evaluation.  This is performed under general or spinal anesthesia via cystoscopy, using an electric loop which is used to remove the area of concern as well as cauterize (use electricity to coagulate tissue) the underlying and adjacent tissue, both to stop bleeding and further destroy tumor cells.

The biopsed tissue is carefully examined by a pathologist, who will provide valuable information regarding malignancy vs. benignity, the type of tumor, depth of tumor, and grade of tumor.   Again, the vast majority of bladder tumors are urothelial cancers, referring to the cells that line the bladder.  A minority of bladder tumors are squamous cell cancers or adenocarcinomas.   Depth refers to the degree that the cancer is growing into the bladder wall.  Bladder cancers are broadly categorized into superficial and deep.  Superficial tumors are largely confined to the bladder lining and superficial layers and do not penetrate the muscle layer of the bladder, whereas deep tumors have “roots” that penetrate the muscular wall of the bladder.  Tumor grade refers to how much the microscopic appearance of the cancer deviates from the microscopic appearance of healthy bladder cells.  Low-grade cancers are similar in cellular appearance to normal bladder cells and generally behave in an indolent (slow) fashion versus high-grade cancers that can often behave aggressively.  Other factors of prognostic importance are the number of tumors present, the size of the tumors, and their physical characteristics.

In general, the best prognosis is for a solitary, small, superficial, low-grade papillary tumor and the worst prognosis is for multi-focal (originating from many different areas of the bladder), large, invasive (deep), sessile, high-grade tumors.

The biopsy information will enable the staging of the bladder cancer, a means of classifying the cancer.  It is extraordinarily unlikely for a superficial cancer to cause lymph node or distant spread, these events occurring with much greater likelihood with more deeply invasive cancers.

Staging of bladder cancer is as follows:

  • Ta: Superficial cancer is found only in polyps (papillary) on the surface of the inner lining of the bladder.
  • Tis: Carcinoma-in-situ. Tumor is found only in flat lesions on the surface of the inner lining of the bladder.
  • T1: Tumor is found in the connective tissue below the lining of the bladder but has not spread to the bladder muscle.
  • T2: Tumor has spread to the muscle layer deep to the lining of the bladder.
  • T3a: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer as identified under microscopic examination.
  • T3b: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer and is capable of being identified without a microscope.
  • T4: Tumor has spread to the prostate in men and to the uterus or vagina in women, or to the pelvic or abdominal wall in either gender.

Superficial cancers are usually managed with cystoscopy, with regular “surveillance” due to the high predilection for recurrence.  It is imperative to have frequent check-ups (every 3 months for the first year after initial diagnosis), consisting of periodic urinalysis, urine cytology, imaging, and cystoscopy.  If surveillance does not demonstrate any recurrences, the interval between follow up can gradually be increased (to every 6 months in the 2nd year; if there are no recurrences, to an annual check-up).  If a recurrence is found, treatment must be repeated and the surveillance frequency then starts anew with the every 3-month cycle.

To help prevent recurrence, under certain circumstances it is beneficial to use a medication that is instilled in the bladder on a weekly basis—this is especially useful when many tumors are present, in the presence of a high-grade tumor, or cancers that have recurred.   It is particularly useful for carcinoma-in-situ (CIS), a variant of bladder cancer that is very superficial, flat, yet of a high-grade pathological nature.  The medication of choice is tuberculosis vaccine—BCG (bacillus Calmette Guerin), which is a live, attenuated (weakened) form of tuberculosis bacteria!

Muscle-invasive cancers most often need to be treated with a major surgical procedure involving either partial or complete removal of the urinary bladder.  In the circumstance that the entire bladder needs to be removed, the ureters (tubes that conduct the urine from the kidneys to the bladder) need to be diverted to a piece of intestine that is either attached to the skin to a collection bag (ileal conduit) or attached to the urethra (neo-bladder or “reconstructed” bladder).  At times, in lieu of surgery, chemo-radiation can be utilized (a combination of radiation therapy provided by the radiation oncologist and chemotherapy provided by the medical oncologist).

Bladder cancer often behaves as two separate types of diseases—one that typically presents as multiple, superficial papillary tumors that have a tendency to recur but are not lethal (similar to many skin cancers), versus another, more deadly form characterized by high-grade, non-papillary, muscle-invasive tumors that have a tendency to metastasize.  Fortunately, the vast majority of bladder cancers are the superficial type.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

For an educational video on bladder cancer that I have done, please go to the following link: http://www.youtube.com/watch?v=WvEOcCzw2gQ

Blog subscription: A new blog is posted every Saturday morning.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts by email. Please avail yourself of these educational materials and share them with your friends and family.