5 Reasons to Consider the Human Papilloma Virus (HPV) Vaccine in 2020: Prevention of Warts and Cervical Cancer in Adults.

By Natan Schleider, M.D. Written January 14th, 2020 3 MINUTE READ

Vintage Medicine Container for Treatment of Warts. Circa Early 1900s.

Basic Facts About Human Papilloma Virus (HPV) and Disease in the USA as of 2020:

Human Papilloma Virus (HPV) is the most common sexually transmitted infection in the United States infecting 1 in 4 Americans (79 million of the infected based on USA population of 330 million in 2020). This virus likes grows in skin cells where sexual contact has occurred and condoms do not prevent it. While causing a bunch of different cancers like Cervical Cancer, Anal Cancer, and Mouth (Oropharyngeal), it far more commonly causes little painless fleshy bumps called warts.

While ‘painless’ in that warts do not hurt physically, the look at you (former) new partner’s face running out the door after seeing your wart hurts. Getting the wart removed by the doctor also hurts and they can be stubborn and grow back.

HOW TO KNOW IF YOU OR YOUR PARTNER HAVE HPV:

HPV infection may not be obvious to the naked eye (nor obvious to the infected patient which is why doctor do PAP smears and HPV DNA tests during women’s health exams) sitting dormant for months to years until causing a wart or cancer, it is difficult to know whether your partner carries HPV. By the way, there is no test to confirm skin infection of HPV in men, at least nothing done routinely. We do not swab or scrape a man’s genital region to look for HPV infection, If anyone reading this wants to know why, contact me.

While the HPV vaccine better known as Gardasil has been recommended since 2006 for ages 11-26, now all men and women should consider it so….

Five Reason to Consider the HPV Gardasil Vaccine If You Have Never Been Vaccinated:

  1. You are sexually active and your partner is infected with HPV.
  2. You want to reduce your risk of getting HPV infection and are open to vaccination
  3. While considered about the risks of safety of any vaccine, 8-10 years of data not only in adults (more in children) show no evidence of any long term disease or risks of the vaccine.
  4. You do not like cancer.
  5. You have not figured out a clever, cool way to ask prospective or current sexual partners about HPV infection–if there is one?

Given this new information, I will be contacting my doctor for the Gardasil vaccine and will keep you posted. Thanks for reading.

Citation

Oshman LD, Davis AM. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP). JAMA. Published online January 13, 2020. doi:10.1001/jama.2019.18411

Four Ways to Treat Chronic Pain WITHOUT Medications

Written By Natan Schleider M.D. on January 13th, 2020

3 MINUTE READ

Dr. Gustav Zander, a Swedish physician known for inventing mechanotherapy, which was defined in 1890 as “the employment of mechanical means for the cure of disease.” Zander exhibited his exercise machines at the 1876 Centennial Exhibition in Philadelphia where they won a gold medal. By 1906 Zander had established his first gyms with these machines in 146 countries.

In my arsenal of pain management treatments are plenty of evidence based treatments that do not require you to swallow a pill.

If you suffer from chronic pain, your doctor may walk into the cold exam room you’ve been waiting in with your paper gown and say something like: “Here at A1 Pain Management Center, an integrative, multi-modal, team delivers interdisciplinary care. Before initiating analgesics, my staff will give you some resources. Follow up one week.” Was that English?

Below are definitions and explanations of 5 ways to manage chronic pain you are likely to hear about so let’s sort through the jargon.

  1. Mind Body Therapy incorporates a blend of light exercises and meditation along a continuum. Examples include meditation, mindfulness, mindful based stress reduction (MBSR), yoga, and Tai Chi. Evidence supports that Mind Body Therapy causes SMALL improvement in chronic pain with moderate improvement range of motion, depression and anxiety.
  2. Exercise Therapy is most effective for patients with orthopedic or musculo-skeletal pain like chronic back, shoulder, hip, or knee pain. Examples included graded, resistance, aerobic, and pilates exercise. Medical evidence, while not strong, does suggest that exercise therapy causes SMALL to MODERATE reduction in chronic pain with improved quality of life.
  3. Manual Therapy involves another trained professional helping your movements and include Rehabilitation, Manipulation (IE chiropractic movement, osteopathic manipulative movement, passive movements done with physical therapist), Acupuncture, and Massage. While massage therapy has data to support short term improvement, manipulation and acupuncture can provide chronic pain relief for short to intermediate amounts of time (days to weeks).
  4. Psychological Therapy, namely cognitive behavioral therapy (CBT) and Acceptance and Commitment Therapy (ACT) can improve chronic pain. These will be helpful for those patients who are interested in cause, effect, and prevention of pain triggers; however, if you are thinking ‘I don’t see how sitting around and talking about crap is going to help my back pain’ then exercise or manual therapy may be more for you.

So what did the doctor mean with all that jargon before?

Essentially the doctor is saying that there are resources other than pills, surgery, and injections that can help chronic pain. It is up to the patient and doctor to chose which work and which do not. That said, unlike a pill, all above therapies will involve the patient be willing to put in time and effort.

Source: Using Non-Pharmacologic Treatment Modalities: Practical Guidance for Pain Management by American Medical Association December 12th, 2018

Three Keys to Ensuring a Lifetime of Healthy Bones: Vitamin D Supplementation Effective for Bone Health but ONLY with Calcium supplementation

By Natan Schleider, M.D. Written January 8th, 2020

Young child with Rickets, a disease common in the USA until the early 1900s resulting from inadeuqte intake of Vitamin D and or Calcium and or Sunlight. Image circa 1900.

If your doctor told you your Vitamin D levels are low and you live in the United States, join the club. In my practice here in New York City, at least 50% of my patients labs (along with my own labs) show low levels of Vitamin D (below 32 ng/mL is considered deificient with 10-20 mg pg/mL or lower considered severely deficient).

‘So should I be taking a Vitamin D supplement? Get a prescription supplement from your doctor? Isn’t sunlight enough to increase my Vitamin D levels which will probably increase when summer returns?’

These are all common questions and reasonable ones!

A little basic science: Vitamin D is a fat soluble vitamin (like Vitamins A, K, and E) which is why it is packaged in a light brownish clear round or oval capsule at the pharmacy and found in good quantities in fatty fish (and in edible mushrooms exposed to ultraviolet light). When the USA began fortifying cow’s milk with Vitamin D (breast milk does not have as much as we would like), cases of rickets dropped significantly by the mid 1920 to 1930s. Vitamin D increases absorption of magnesium, calcium, and phosphate in the intestine. Since our bones like a good steady supply of calcium, we need Vitamin D to get it absorbed or risk osteoporosis (severe thinning of bone to the point patient is high risk for bone fracture, especially of the hip or vertebrae of spine). That frail looking older person that looks like they have a hump (called Dowager’s Hump almost always due to broken weak vertebrae in the neck or upper back) on their back you see walking around might walking with normal posture had they followed the advice below when they were younger and taken Vitamin D with calcium daily.

There are different types of Vitamin D (five actually but I will just mention the important kinds that will confuse us as they are named on labs or at the pharmacy):

  1. Cholecalciferol is the name for Vitamin D3 which is available over the counter at the pharmacy (usually at doses of 1000 to 4000 International Units, take 1 capsule daily). Vitamin D3 is the ACTIVE form of Vitamin D but it only becomes active if we ingest enough Vitamin D2 or ergocalciferol.
  2. Ergocalciferol is the name of Vitamin D2 which is found in foods and or in supplements. Ergocalciferol is INACTIVE when swallowed but our intestines turn it into Vitamin D3 as does sun exposure.
  3. SINCE I ALWAYS TRY TO WEAR SUNBLOCK AND SUN PROTECTIVE CLOTHING REGARDLESS OF SEASON TO KEEP MY SKIN FROM GETTING WRINKLED AND SPOTTY, I DO NOT RECOMMEND SUN EXPOSURE FOR MY VITAMIN D DEFICIENT PATIENTS; HOWEVER, AS I DO NOT LIKE TO FORCE ANY PATIENTS TO TAKE A PILL WHEN THEY DO NOT WANT TO, SO ABOUT 15 MINUTES OF NATURAL SUNLIGHT A DAY AND NO MORE COULD ALSO WORK PRESUMING YOU HAVE ENOUGH VITAMIN D IN YOUR DIET. SINCE I DO NOT LIKE HAVING BLOOD TESTS DONE EVERY FEW MONTHS TO SEE IF I NEED VITAMIN D SEASONALLY OR ALL YEAR ROUND I ADVISE AND TAKE IT ALL YEAR.

If you are found to be Vitamin D deficient on your labs, many doctors (including me) will recommend Vitamin D supplementation BUT they often forget to mention the following: you MUST add calcium supplements with Vitamin D supplements or the extra Vitamin D you are taking will likely not have enough calcium for our bones. THIS IS WHAT WAS CONCLUDED IN A LARGE STUDY IN THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION DECEMBER 2019. Calcium needs to be taken twice daily minimum for best absorption, I usually recommend and take 600 mg in the morning and 600 mg in the evening. You can also use some antacids like TUMS for calcium supplementation and take care of mild heartburn and bones all at once.

While on the subject of Vitamin D, other studies show that taking Vitamin D reduces risk of falls in elderly patients and reduces stress fractures in high impact athletes.

While my smart patients know that Vitamin D3 is the better form of Vitamin D to supplement, many patients prefer prescription strength Vitamin D2 ergocaciferol 50,000 International Units once a week which can be easier to remember, just don’t forget the daily calcium!

SOURCE: Yao P, Bennett D, Mafham M, et al. Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(12):e1917789. doi: https://doi.org/10.1001/jamanetworkopen.2019.17789

The 7 Effective Treatments for Common Cold Symptoms in Adults

September 8th, 2019

By Natan Schleider, M.D.

Department of Health Advertisement on Cold and Flu Prevention (Circa Early 1900s)

‘We can put a man on the mood but can’t cure the common cold.” My grandmother would shake her head. saying this repeatedly, making me chug grape flavored Dimetapp and prune juice. This was her cold remedy cocktail and my have the cold remedy cocktail options grown. Walk through a large pharmacy’s Cold and Flu section without the Physician Desk Reference and you’re lost.

So while no cure exists for the common cold, also called a viral upper respiratory tract infection or URI, studies have been done revisiting whether common remedies used were, in fact, helpful or not. Some are even harmful.

The following seven remedies have good data to support their efficacy in relieving cold symptoms:

  1. Acetaminophen (aka Tylenol)
  2. Combination anthistamine plus decongestant (IE Zyrtec-D)
  3. Intransal ipratropium bromide (aka Atrovent) – particularly helpful for reducing the lingering cough after the infection which can last weeks
  4. Intranasal oxymetazotine aka Afrin – not to exceed 10 days
  5. Lactobacillus casei 22 grams per day in dairy products for 3 months
  6. NSAIDs – ie Advil or Alleve
  7. Zinc acetate or zinc gluconate – 80 to 92 mg per day within 3 days of symptom onset and continue until symptoms resolve

And now the list of remedies historically thought to have worked but proven no better than placebo for cold symptoms like cough: acetylcysteine, antibacterial antibiotics, antihistamines taken alone (that is, without a decongestant bundled in), antitussives and expectorants, codeine, echinacea, intranasal corticosteroids, African geranium, steam, garlic, Vitamin C. Vitamin D, and Vitamin E which actually worsened cold symptoms at doses of 200 mg or more.

So use the above list to help shop for cold symptom remedies and feel free to comment.

SOURCE: AMERICAN FAMILY PHYSICIAN V. 100 No.2, 9.1.2019

Thanks for reading,

Natan Schleider, M.D.

HEART / ARTERY HEALTH, & ATHEROSCLEROSIS FOR DUMMIES PART II: SIGNS OF ARTERY CLOGGING (AKA ATHEROSCLEROSIS)

Vintage American Heart Association Poster Circa 1970s

July 20th, 2019

By Natan Schleider, M.D.

As our arteries clog with cholesterol and get occluded by thick unhealthy walls for high blood pressure, smoking, and other risk factors, most of us feel nothing. Then things hit a tipping point–that is, the arteries which bring oxygen rich blood to our organs and muscles become so narrow that the following examples can happen often quite suddenly:

  • A stroke occurs in our brain resulting in paralysis or weakness or difficulty speaking or seeing (depends on which artery of the brain has stopped feeding the part of the brain responsible for our movements, thoughts, vision, etc)
  • Our hearts suffer damage which patients describe as chest pain/pressure OR can loose so much blood flow so quickly it stops pumping and the patient dies in what is called Sudden Cardiac Death
  • The arteries that feed our kidneys (an organ that requires almost as much oxygen-rich blood as the brain and heart’) clog and the patient suffers leg swelling, electrolyte problems, and ultimately kidney failure
  • The arteries in our legs get clogged resulting in pain or fatigue in the legs with exertion, often relieved by rest

What I want to emphasize is that while atherosclerotic disease can kill quickly and suddenly, it can also leave the patient severely disabled and in pain so if your attitude is: ‘Well, I’ll just enjoy my greasy cheeseburgers ’cause I gotta live and then I’ll keel over and die painlessly,’ you may want to think again.

An excellent example of this is one major risk factor for artery clogging caused hypertension or high blood pressure, know as the “Silent Killer.’ Most of the time people do NOT feel their high blood pressure and it only causes death or serious non-reversible damage. How? High blood pressure causes artery walls to become thick and really stiff. As the walls thicken, less blood flow occurs until, you got it, the lumen of the artery is too small to provide oxygenated blood.

So there are some basic (rather over-simplified) warning signs on atherosclerotic disease.

In Part III we will looks at more specific risk factors for artery clogging.

Thanks for reading!

Natan Schleider, M.D.

‘You’re at risk for artery clogging like a heart attack, stroke, kidney disease. See the plumber.’ Says my General Practitioner.

HEART / ARTERY HEALTH, & ATHEROSCLEROSIS FOR DUMMIES PART I: HISTORY AND CULTURE AND THE SCARY STATISTICS OF ARTERY CLOGGING (AKA ATHEROSCLEROSIS)

By Natan Schleider, M.D.

July 11th, 2019

Vintage Anatomical Print of The Heart

6:00 AM: Opened my weekly pill organizer taking an aspirin, a statin (IE atorvastatin generic for Lipitor), blood pressure medicines, and quickly drank my coffee through a straw (which supposedly prevents teeth staining)

6:15 AM: My 6 year old daughter Ellie wakes up, rubs her eyes, and says ‘Daddy, cereal?’ I pour a bowl of ‘CAN HELP lower CHOLESTEROL‘ Cheerios with Silk Almond milk at 30 calories per serving.

Cardiovascular disease (CVD) which includes clogging of arteries to the heart, brain and kidneys namely accounts for approximately 800,000 deaths in the United States (US), or one out of every three deaths. On an average day in America of 2192 die from CVD. Note these number does not include people that just have non fatal events like heart attacks, angina, and strokes that leave you weak or paralyzed.

To keep things in reference 2,977 people were killed on 9/11 while last year 192 Americans died from opiod overdoses during our media frenzied nationwide opiod epidemic.

As far as I’m concerned, every newspaper headline every day should read “Another 2000 Americans Die From Preventable Illness” and no, it was not a zombie invasion!

I love America, greasy fries, a quality cheeseburger, stagnating in my chair playing chess vs a computer that always wins, and salt be it kosher, seasoned, Tajin, or any of the number of gourmet salts celebrity chefs tout on about.

The causes of our nation’s greatest killer are so woven into the fabric of American culture and history that we not only take it for granted but celebrate it. Tobacco was America’s number one economic export before there was a USA and central to George Washington’s wealth and the Revolutionary war. Which American president didn’t pose biting into a McDonalds or Burger King burger?

So I wanted to give you a smorgasbord of background and education before digging into our nationwide epidemic: atherosclerotic disease.

Part II of this article blog will focus on signs, symptoms, and other things most of us do daily (or neglect to do) that causes the clogging.

Thanks for reading!

Natan Schleider, M.D.

Screening Options for Colon Cancer

THE BEST COLON CANCER SCREENING TEST IS THE ONE THAT GETS DONE!

By Natan Schleider, M.D.

July 9th, 2019

Source: American Family Physician Vol. 100 No,1 July 1st, 2019 p.10-11

As I approach 50 years old, I am thinking about which colon cancer screening test is right for me.

I will likely go with the gold standard, screening colonoscopy. If you don’t know what this is, the patient is put to sleep under mild anesthesia which is quite safe and a fiberoptic tube is placed up the anus all the way through the large intestine to look for colon cancers or precancers which appear as polyps. Pros of screening colonoscopy: you need it only every 10 years (5 if you are high risk or more often if you have colon cancer or have been treated for colon cancer); the procedure only takes about 20 minutes and you are home same day. Cons or the biggest complaint I hear is being up all night with diarrhea as patients are given a strong laxative to flush out their colon (aka large intestine) which allows the doctors to see the lining of the intestine without stool being stuck to the walls.

Screening colonoscopy is my choice because while there are many of good noninvasive tests which I will review below, if they are negative, reassuring; but if positive, you will need a colonoscopy anyway to confirm whether it is a true or false positive.

Other screening tests for colon cancer:

  1. Stool testing for blood also called Fecal Immunotherapy Testing (catches about 58% to 72 % of colon cancers). This is a cheap easy option an with a 97 percent specificity (meaning if the test is negative, you probably do not have colon cancer) this is a nice easy choice.
  2. mSEPT9 Blood Test (Epipro Colon) detects 73 percent of colon cancers with a specificity of 82 percent. This may be a nice option if you are not inclined to sending your poop to a lab, understandable.
  3. Cologuard is a stool DNA test where you ship your poop to a lab where the examine it for colon cancer risk. This can be done every 3 years and I like this alternative option.
  4. Computed tomography colonography means no invasive testing but you will still need to have your intestines cleaned meaning you’re up all night with diarrhea but at least this is not invasive.
  5. Flexible sigmoidoscopy is like a mini colonoscopy which while still approved, is hardly done anymore as it only looks at the first part of the colon potentially missing cancers in the middle or distal colon.

If you opt against colonoscopy, you can do some or all of the noninvasive tests. Any testing is better than no testing and unlike most cancers in the 21st Century, colon cancer is one we can catch and treat early. Go get tested!

Thanks for reading!

Natan Schleider, M.D.

Lofexidine (Lucemyra) for Treatment of Some Opiod Withdrawal Symptoms

By Natan Schleider, M.D.

Source: American Family Physician V.99 No.6 March 15th, 2019

While I am pleased that a new medicine recently FDA approved for mitigating some symptoms of opiod withdrawal (IE sweating, increased heart rate, some of the physical symptoms of anxiety) I am cautiously optimistic at best that this medicine will see much

The pros of lofexidine:

  1. Most importantly it demonstrates that someone / the pharmaceutical industry realizes a need for more medicines to address the current opiod epidemic. This is extremely important given the few resources available for treating opiod dependence so kudos to all who did the work to get this medicine approved seriously.
  2. See point 1

The cons of lofexidine:

  1. It costs about $1,776 dollars for a seven day supply whereas there is an older virtually identical medicine (also commonly used to mitigate withdrawal symptoms) clonidine which costs nine dollars for a 30 day supply.
  2. Dosing is 4 times a day (presuming a patient in acute withdrawal isn’t vomiting everything they try to swallow which is often the case).

I don’t mean to ‘poo-poo’ this medicine and I will certainly prescribed it when indicated. I will be astonished if an insurance company covers it but at least there is one more weapon in the arsenal.

Thanks for reading.

Natan Schleider, M.D.

Aspirin: Good or Bad for Preventing Heart Attacks?

BY NATAN SCHLEIDER, M.D.

JUNE 24, 2019

Image result for vintage aspirin

As a physician in private practice for 15 years, the specialty I once viewed as rigorous in the scientific method and always backed by strong data in powerful studies has been disappointing me. When paying half a million dollars for medical school, the professors tend to omit the fact that 50 percent of what they are teaching as the latest important clinical findings will be completely wrong.

For example, in medical school I was taught that hormone replacement for women after menopause would reduce risk of heart attack and osteoporosis. Hormone replacement not only helped hot flashes but was good for you, right?

Wrong. In 2002 The Women’s Health Initiative (a large study dwarfing the studies that had provided the info I learned in medical school) found that hormone replacement significantly increased breast and uterine cancer risk. Suddenly, prescriptions for menopausal symptoms went the way of the dodo.

I was also taught that Oxycontin was not addictive, ha!

For years aspirin has been considered an excellent choice for reducing risk of heart attack, stroke, and even colon cancer. Suddenly this month’s editorial in American Family Physician says with need to ‘rethink’ aspirin’s role in primary prevention. Really! Aspirin is the oldest pain medicine around since the mid to late 1800s. And we still are unclear about it’s efficacy?

In medicine’s defense, new large studies are constantly done (as the cornerstone of science is ability to repeat results given the same questions and data but often the second study does not jive with the first. So medical students are left knowing less then when they started [but at least the tuition bills are consistently on the up and up].

Simply put, for patients with risk factors for artery clogging/heart attacks (but with little or no risk for aspirin inducted gastrointestinal bleeding) aspirin 81 mg daily is recommended, especially age 50 to 70.

I am 43, have high cholesterol (addressed with Lipitor) and high blood pressure (addressed with medicines). Rather than perfoming certain convoluted risk calculations to determine my need for aspirin, I just take it daily.

Do I won’t to over-medicate you dear reader? No. But you can take comfort in the fact that if the ‘experts’ praise the results of a study this year, 10 years from now they will likely praise a newer study which discredits the first one.

As objective as medicine presents itself, the good doctor knows the art and science of good medical practice.

A Succinct Review of the Top Medical Research Studies of 2018 for Family Physicians

By Natan Schleider, M.D.

May 19th 2019

SOURCE: AMERICAN FAMILY PHYSICIAN V.99 # 9 MAY 2019 P.565-573

Every year I try to some up the most important easy to understand studies for my patients, doing my best in eliminating fancy medical mumbo jumbo.

Here are the important points for 2018:

  1. Home blood pressures are more accurate than doctor’s office blood pressures. Sooo, if your blood pressure is high at the hospital or doctor’s office (which it should be unless you are super zen), check your blood pressure at home with any machine that measures above the elbow OR ask a friend who knows how to check blood pressure. If you find yourself surrounded by machines as in the above photo, you are doing something wrong…that photo is actually an old ECG machine.
  2. Lower blood pressures are almost always better EXCEPT in elderly patients 85 or older.
  3. Shorter courses of antibiotics are almost always as effective and have fewer side effects than longer courses. So, for example, if a Zpack usually helps your bronchitis or ear infection or sore throat, opt for the 3 day Zpack rather than the 5 day.
  4. For women who suffer from 3 or more UTIs annually, drinking an additional 1.5 liters of water daily reduces risk of future UTI by 50%.
  5. Several studies show that non-opiod pain medicines are as effective for relieving acute injury of arm or leg pain in the emergency room compared to opiods.
  6. Patients who exercise (at least 150 hours per week or more) have lower risk of depression.
  7. For patients being medically treated with anxiety who then stop their medicines, 1/3rd will have a relapse and require medication again. 1/6th of all patients with anxiety will have worsening anxiety despite treatment.
  8. Stool testing for colon cancer screening using DNA found in stool (called Fecal Immunochemical Tests or FIT) is better than standard stool testing for blood and an optional substitute for colon cancer screening other than colonoscopy.
  9. Type II diabetics should shoot for a HbA1c of 7-8 percent (and not lower as previously advised).
  10. If you are 60 or older, a blood pressure of 150/90 or lower is ok presuming you do not have other serious medical issues. Below 60 lower than 140/90 is ok.

Please contact me with any questions or comments.

Thx,

Natan Schleider, M.D.