Archive for December, 2013

2013 in review

December 31, 2013

The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 26,000 times in 2013. If it were a concert at Sydney Opera House, it would take about 10 sold-out performances for that many people to see it.

Click here to see the complete report.

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Sage Words Of A Surgeon

December 21, 2013

Blog # 133  Andrew Siegel, MD

Dr. Ray Lee was an obstetrician-gynecologist at the Mayo Clinic who died in 2012.  At the Mayo Clinic he was awarded “Teacher of the Year” as well as “Distinguished Clinician.”  He was instrumental in developing the subspecialty of female pelvic medicine and reconstructive pelvic surgery (my sub-specialty in Urology and that which I received board certification in in 2013, the first time the board exam was offered).

He spoke using many aphorisms that will be shared here  (this information is abstracted from an article that appeared in International Journal of Uro-gynecology, written by John Gebhart: Int Urogynecol J (2013) 24:1263-1264).  He taught compassion, pride, humility, and integrity–character traits important for surgeons, but equally important in all aspects of life. His words are in boldface and my explanations are in parentheses in order to help explain some of the lines that are most relevant to the context of the operating room and may not be understood by non-surgeons.

  • Never operate on a stranger.  (Really get to know your patient before applying the knife; have enough contact and contact time so that all parties are very comfortable with each other.)
  • Communication will be critical to your practice. Be an excellent listener.
  • You have a tremendous responsibility and a privilege in the care of the sick. Kindness has not gone out of style. It is better to have your name etched in the heart of your patient than having it engraved in granite outside of the building.
  • Anyone can operate with good exposure and it’s a shame not everyone tries it. (Exposure is creating the greatest amount of visibility of the operative field through the use of retractors.)
  • Avoid following complications with complications. (If a complication does occur, fix it definitively.)
  • Your true measure as a surgeon will be determined by your performance during the most adverse circumstances. These experiences will develop your character and better prepare you for the next challenge.
  • Pay strict attention to details, keep the operative field dry (free of bleeding), re-check the operative site… ensure that the anastomosis (the suturing of one hollow organ to another, typically bowel to bowel) shows perfect approximation… free of tension and perfect hemostasis (free of bleeding).
  • There is nothing hemostatic about a well-placed drain. (A surgical drain is used to avoid fluids accumulating within the operative site…it should not be used as a substitute for thoroughly stopping bleeding before closing the incision).
  • Do your work in such a way that you would be willing to sign your name to it…the operation was performed by me.
  • I’m convinced surgeons are made and not born. Be an active learner for the rest of your life. Commit yourself to staying up-to-date in this fast-changing arena.
  • Many times it will be more difficult not to operate than it will be to operate. It is important to learn the things not to do.
  • Errors and failures will make an indelible mark on your heart, and they should. Like a broken bone, it is better to experience this when you are young; albeit painful, it will heal faster. Be sure to learn something from each of your errors.  You will never become so accomplished that there will not be room for improvement.
  • With success, never forget who you are, for we all have numerous reasons to be humble. Never let arrogance creep into your practice. Success can be more dangerous than occasional failure. Recognize areas of weakness so they can be identified, and goals can be set to correct them.
  • Applaud your colleagues in public; criticize them behind closed doors, one-on-one. When giving advice, be aware that it may be least appreciated by those who need it the most.

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

Please visit page and “like.”

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

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

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Screening For Prostate Cancer Revisited

December 14, 2013

Blog # 132

The ignoramuses at the United States Preventive Services Task Force (USPSTF) gave Prostate Specific Antigen (PSA) testing a grade “D” recommendation and called for the complete abandonment of the test for prostate cancer screening.

Having lived and worked deep within the trenches of urology for over 25 years, I almost stroked when I read their recommendation. I previously crafted video responses: http://www.youtube.com/watch?v=d8fpxszVMTQ

and gave a “horse’s ass” award to the USPSTF in another video: http://www.youtube.com/watch?v=cIIZjk9lrlM

The Prostate Cancer World Congress took place in Melbourne Australia in August of 2013, where experts proposed a consensus view on the early detection of prostate cancer.  This material was published in the British Journal of Urology International.

The consensus was engendered by the great confusion generated after the USPSTF called for the total abandonment of PSA testing. The international experts who wrote the consensus statement included 14 international experts on prostate cancer, unlike the USPSTF, where there was not a single urologist on the committee.

The experts at the Prostate Cancer World Congress adopted the following five statements:   

  1. For men age 50–69, evidence demonstrates that PSA testing reduces death from prostate cancer by 21% and the incidence of metastatic prostate cancer by 30%.
  2. Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.  In other words, not everyone with prostate cancer will need to be actively treated and the potential side effects of active treatment should not influence the diagnosis of prostate cancer by the proper means.
  3. PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.  The experts proposed the use of prostate examination, family history, ethnic background, prostate volume, as well as a variety of risk models based upon PSA.
  4. Baseline PSA testing for men in their 40s is useful for predicting the future of prostate cancer. Men with baseline values that are high need further PSA testing.
  5. Older men in good health with over a 10-year life expectancy should not be denied PSA testing on the basis of their age.   This population of older men may certainly benefit from the early diagnosis of aggressive prostate cancers. This does not pertain to men with numerous other significant medical problems, but a healthy man in his mid-70s should not be denied PSA testing that might identify a cancer that has the potential to destroy his quantity and quality of life.  (In particular, the older man who comes to the office accompanied by his father should certainly not be denied!)

The consensus was that we should maintain the gains that have been made over the years since PSA was introduced—in terms of decreasing the number of men diagnosed with prostate cancer metastases (cancer that has spread) and reducing prostate cancer deaths—while minimizing the potential harms of over-diagnosis and overtreatment by increasing the use of active surveillance protocols in those men with low-risk prostate cancer.   Abandoning PSA testing as recommended by the USPSTF would lead to a reversal of all gains made over the course of the past 30 years.  Well-informed men should be offered the opportunity for early diagnosis of prostate cancer. To quote Dr. Jay Smith:  “Treatment or non-treatment decisions can be made once the cancer is found, but not knowing about it in the first place surely burns bridges.”

My take on the subject of screening for prostate cancer:

I like to keep things simple…I believe in two rules that are appropriate for medicine as well as just about everything in life.

Rule # 1: Do no harm.

Rule # 2: Do good.

To apply these rules to the game of golf, for example, “do no harm” means staying out of trouble as much as possible, keeping the ball out of the woods, bunkers and water hazards.  “Do good” by hitting the ball accurately in terms of distance and direction and setting up the next shot.

Screening for prostate cancer involves taking a medical history, doing a rectal exam to check the contour and consistency of the prostate, and a simple PSA blood test. “Do no harm” is satisfied because these tests are in no way harmful to the patient and provide information that is helpful, particularly when done on a serial basis, noting changes over time.

If exam shows an irregularity of the prostate, if the PSA is elevated, or if the PSA has accelerated significantly over the course of one year in a reasonably healthy man who has at least a ten-year life expectancy, doing a prostate ultrasound and biopsy is indicated. This test does entail a small risk of bleeding and infection, but the potential benefits far outweigh the risks.  “Doing good” is satisfied by the knowledge provided by the biopsy—the reassurance that comes from a biopsy report that shows no cancer and the potential for cure if the biopsy shows cancer.  Furthermore, the specific biopsy results along with other factors can predict which cancers are low-risk, which are medium-risk, and which are high-risk, important considerations in terms of active treatment versus active surveillance.

Many men who are found to have low-risk prostate cancer (low PSA; minimum number of biopsies showing cancer; low-grade cancer as determined by the pathologist) can be followed without active treatment (active surveillance) and those at greater risk can be managed appropriately (surgery or radiation), and many cured, avoiding the potential for progression of cancer and painful metastases and death—all while weighing the benefits of intervention against the risks.  Death from prostate cancer is unpleasant to say the least, often involving painful metastases to the spine and pelvis and not uncommonly, kidney and bladder obstruction, and our charge as urologists is to try to not let this scenario ever come to fruition.

One of our fundamental goals as urologists is to screen for prostate cancer—

the most common cancer in men present in 17% of the population—and if present, to provide appropriate guidance to best maintain both quality and quantity of life.  Anyone who reads the obituaries knows that prostate cancer is a cancer that is lethal, and if you don’t read the obituaries, I can promise you that prostate cancer kills in unkind ways. Even though only 3% of the male population dies from prostate cancer, that amounts to many thousands of men annually… and you do not want to be one of them.  I have my own PSA and prostate exam done every year and PSA screening was responsible for making an early diagnosis of my father’s prostate cancer in 1997, which was cured by surgery, resulting in a healthy and thriving, cancer-free 82 year-old man who will never die from prostate cancer.

BOTTOM LINE: PSA remains an invaluable screening tool for the detection of prostate cancer and ALL men ages 50 and over (40 if there is a family history) should be tested…IT JUST MAY SAVE YOUR LIFE!

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

Please visit page and “like.”

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

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

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

Rabies

December 8, 2013

Blog # 131

Who Knew? A rabies infection can cause sustained erections, and at times, uncontrollable ejaculations.  Still not a good enough reason to go into a cave and get bitten by a rabid bat!

Rabies is a deadly viral infection transmitted by infected mammals to humans and other mammals. The infection is spread by infected saliva that enters the body via a bite or broken skin.  The virus travels to the central nervous system and infects and inflames the brain and spinal cord, giving rise to symptoms that may include the following: pain at the bite site; fever; drooling; convulsions; excitability and restlessness; sensory symptoms including tingling, burning and pricking; muscle spasms; muscle paralysis; and trouble swallowing.  Once symptoms appear, death is virtually inevitable, usually by respiratory failure.  The key to avoiding a rabies infection and dying after a bite from a rabid animal is wound cleansing and flushing and immunization ASAP after contact.  This involves a series of preventive vaccines, generally 5 doses given over 28 days, as well as an immediate injection of human rabies immunoglobulin.

The minor annoyance of having to get our beloved pets vaccinated against rabies has actually produced one of the most significant public health victories. Vaccinations are not done primarily to protect our pets—although they most certainly do safeguard them—but to protect our human brethren.  Regular vaccination results in a defense that keeps all of us safe from rabies infections.  Because of the fact that dogs, cats and pet ferrets are now routinely vaccinated, human rabies infections in developed countries are now extremely rare, and bats are currently the source of most human rabies deaths in developed countries.  However, in the rest of the world, more than 50,000 people die annually of rabies. Most of these deaths occur in the continents of Asia and Africa and generally involve children who are bitten by rabid dogs, the source of the vast majority of human rabies deaths in third world nations.

Animal rabies infections are most often a problem of wild animals including not only bats but also raccoons, skunks and foxes.  When an animal is infected with the virus, it causes a profound change in their behavior, ranging the gamut between aggressive and tame.  Many afflicted animals make unusual sounds and may stagger, convulse and froth at the mouth, with death occurring within one week or so.

BOTTOM LINE: To minimize your risk of acquiring a rabies infection:

  • Stay away from wild animals
  • Keep your cats, dogs and pet ferrets vaccinated and indoors at night
  • Avoid attracting wild animals to your home via uncapped trash, bird seed, food left outside, etc.; keep chimney capped with a screen
  • If you are bitten by a wild animal or a domesticated one that appears to be behaving strangely, wash and flush the wound thoroughly and seek medical help immediately

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

Please visit page and “like.”

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

Available on Amazon in Kindle edition–on sale week of Cyber Monday for $2.99

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

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