How much to wait between biopsy and prostate surgery. Ideal duration between biopsy and prostatectomy.

STUDIES SUGGEST A SMALL WAIT CAN IMPROVE SOME OUTCOMES

“Those who had a TP within six weeks of the biopsy were less likely to have a bilateral nerve sparing procedure.” [Source]  [Source is credible – a paper called Total prostatectomy within 6 weeks of a prostate biopsy: is it safe? by Kishore T. Adiyat; Manoharan Murugesan; Devendar Katkoori; Ahmed Eldefrawy; Mark S. Soloway of the Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA]

“Open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection. Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics.” [Source] – NOTE: THIS LIMITATION DOES NOT APPLY TO OPEN SURGERY [paper: Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative
outcomes by George L. Martin, Rafael N. Nunez, Mitchell D. Humphreys, Aaron D. Martin, Robert G. Ferrigni, Paul E. Andrews and Erik P. Castle Urology, Mayo Clinic Arizona, Phoenix, AZ, USA]

DOCTORS WHO BELIEVE IN 6-8 WEEKS DELAY AFTER BIOPSY

Q: How long do I need to wait after my biopsy to undergo a robotic prostatectomy?
A: Dr. Miller recommends a minimum waiting period of 8 weeks following biopsy prior to proceeding with robotic prostatectomy.  Significant inflammation occurs after a prostate biopsy resulting in temporary distortion of the anatomy (particularly when operating under such extreme magnification).  Since prostate cancer is such a slow growing disease, this relatively short wait does not impose an appreciable risk.” [Source]

“repeated biopsies can make it more difficult to perform nerve-sparing surgery.” [Source] – meaning that biopsies do impact the ability to identify nerves.

The doctor below suggests 6 weeks (for inflammation to be healed).

What should you do during this six weeks?

KEGEL exercise should be conducted prior to the surgery [Source]

common sense:

This is a slow growing cancer so a few weeks here and there will make no difference now. If it turns out after the op that it has spread, it has in all likelihood already done that – and not in the few weeks since your pSA test. Cancer doesn’t wait quietly until it is diagnosed and then go on the rampage [Source]

 

how long to wait between biopsy and prostate surgery?

how long to wait for surgery after prostate biopsy?

Safe waiting time from biopsy to prostate surgery

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Which is better for prostate cancer – surgery or radiation therapy?

Resources: Prostate cancer institute | Targeting Cancer |

 

NEED TO BUY THIS ARTICLE: Patient-Reported Outcomes Following Treatment for Localized Prostate Cancer: Helping Decision Making for Patients and Their Physicians

 

see: http://www.jstor.org.ezp.lib.unimelb.edu.au/stable/pdf/27736511.pdf?refreqid=search%3A453d76b3a293d97e6e920d13f26280ad

using a time horizon of 10 to 15 years, less than 3% of men diagnosed with Gleason score 6 and classified as low risk will die as a result of prostate cancer whether treated or not [Source]

Many former Gleason score 6 tumors are now reclassified as Gleason score 7 in the modified system. [Source]

Gleason score 4 + 3 = 7 demonstrates worse pathological stage and biochemical recurrence rates than 3 + 4 = 7 [Source]

Most cancers detected as a result of PSA screening are Gleason 6 (3 + 3) or 7 (3 + 4). [Source]

ACTIVE SURVEILLANCE

While surveillance may be stressful for some
men, the reality is that most patients with prostate
cancer, whether treated or not, are concerned
about the risk of progression. Anxiety about PSA
recurrence is common among both treated and
untreated patients. Patients who are educated to
appreciate the indolent natural history of most
good risk prostate cancers may avoid much of
this anxiety. [Management of Prostate Cancer – Eric A. Klein J. Stephen Jones
Editors]

patients should consider that if they wait
to treat the cancer until the tumor grows, the bigger tumor may mean either an
increased risk of side eff ects (because it requires more extensive surgery) or it may
mean a shift from curable to incurable disease.

Men under 60, for example, are better candidates if
they fulfill the Epstein criteria for insignificant
prostate cancer  – In my case this criteria is not fulfilled. Hence I am not suitable for active surveillance.

Further, “untreated, the… likelihood of disease progression is about three times greater than those without Gleason 4 pattern”  [Management of Prostate Cancer – Eric A. Klein J. Stephen Jones Editors]

In my case there are two small sections with Gleason 4 pattern. Therefore, again, active surveillance is ruled out.

To be a candidate for active surveillance, the
patient must meet certain criteria (as in a study from the Royal Marsden Hospital
in London): 2
• Ages between 50 and 80 years
• Gleason’s score less than or equal to 7
• Clinical stage T1 or T2 disease
• Total PSA less than 15
• PSA score doubling time less than 2 years
• 50 % or less of the biopsy samples positive for cancer
• A reasonable state of health with no other major medical problems [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

 

RADICAL SURGERY

About 40 % of the men who are diagnosed with prostate cancer undergo either
radiation or have radiation combined with surgery.    [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

Victoria has a Prostate Cancer Registry and the most accurate data available about which treatment patients are choosing. Victorian data from 2014 showed that 48 per cent of men in the state with prostate cancer chose surgery compared with just 18 per cent who chose radiation therapy. [Source]

The 5-year biochemical risk-free survivals for the 5 Grade Groups based on radical prostatectomy were – Grade Group 1 – 96.6% –

Grade Group 2 – 88.1%

Grade Group 3 – 69.7% –

Grade Group 4 – 63.7% –

Grade Group 5 – 34.5 % • (p < 0.001)

 

There is a real (albeit small) risk of prolonged illness or death would occur with surgery  [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

Removal of the prostate gland — a procedure called a prostatectomy — can offer patients the best chance to permanently cure their cancer. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

One of the principles of any cancer surgery is that all tissue within a half an inch of the cancer should be cut out to ensure all the cancer cells are removed. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

after removal of the prostate, when a man has sex, he will still have orgasm and all the good feelings that happen with sex, but he will not have the emission of any fluid. Th at means that during post-prostatectomy
sex, he will “shoot blanks” or have dry orgasms. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

I often recommend perineal surgery for all my patients because it can be done
rapidly (within 70 to 90 minutes) and with little bleeding. In general, you want
your surgery to be over quickly, because the longer you are under general anesthesia,
the higher the chance of complications. Also, a quicker surgery can mean a
shorter recovery time. From a surgeon’s point of view, the perineal approach
also provides a better angle to view the bladder and urethral area after the removal
of the prostate gland.   [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

  1. radical retropubic prostatectomy. – through abdomen
  2. radical perineal prostatectomy, – near anus – Th is is a more direct route yet is currently less common —
    only 4 % of prostatectomies are done through the perineum — because most urological surgeons have not been trained in the approach.

Robotic surgery can be more likely to be nerve sparing given the higher magnification and ability to see. robotic-assisted radical prostatectomy has virtually supplanted the laparoscopic
prostatectomy. Men who have the laparoscopic, robotic,
or perineal surgery can return to work and daily living faster — usually within
2 weeks — because there is less pain with the smaller incisions. With a traditional
radical retropubic procedure, it might take the full 6 weeks.

 

urinary incontinence persists in up to 15 % of men 2 years after surgery.
Th e incidence of the incontinence is higher among older men who have surgery.

Your unique anatomy
also plays a role as the nerves can be in slightly diff erent positions in diff erent
people, and on some people more than others, it may be harder for the surgeon to
avoid touching them or possibly nicking them when removing the cancerous tissue.
Because nerves don’t show up on scans, this is one of the factors that the surgeon
faces in the operating room, and thus cannot predict with absolute certainty
whether there will be any nerve damage in your case. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

For those particularly concerned
about urinary continence after surgery, I might steer them toward robotic or
perineal surgeries as these aff ord the best possible view of the urethral-bladder area
so the surgeon can have the best possible chance of joining the urethra and bladder
tightly and smoothly.  [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

PREPARATION:

In the weeks or months leading up to the operation,
I usually suggest increasing the amount of exercise, such as walking or swimming,
to be as strong as possible going into surgery. Th e physical training will help
with breathing and muscle tone and perhaps will help you to lose a few unnecessary
pounds of weight — all of which will help your recovery. Th ere are other exercises
that may prove even more important to your recovery: pelvic fl oor exercises.
When started in the weeks before surgery, these exercises can help your body
regain urinary continence faster after the prostate is removed ( see page 98).

 

The two muscles that affect the control of urine are the bladder neck, which
is not under your voluntary control, and the external urinary sphincter. Th e latter
muscle can shut off the urinary fl ow while you are urinating. To help with control
of the starting and stopping of urination, the muscle needs to be strengthened as
if you were weight-lifting. Th e more lifting, the stronger the muscle. Of course
there are no tiny weights to lift, but muscle strength can be increased with repetitive
exercise like a Kegel exercise. Th e best program is starting and stopping the
urinary stream. Th is can be started long before surgery. Each time you urinate,
stop the stream several times. Th at action will increase the strength and size of the
sphincter muscle and help with control after the surgery.

When the prostate gland is
completely removed, as happens with radical prostatectomy, that buff er is also
removed and control of urine leakage becomes dependent on the muscles of the
pelvic fl oor, known as the external urinary sphincter. By strengthening this muscle,
you can lower your chances of post-operative incontinence, or if you strengthen
post-surgery, you will increase your chances of returning to full continence.

Generally the best case for urinary control is THREE MONTHS after surgery

OPTION TO USE RADIATION

For men who experience a recurrence of their cancer after surgery (meaning that
some cancer cells remained in the body after surgery and reproduced), then radiation
known as salvage radiation is the best course.

GOOD TO UNDERTAKE RADIATION JUST AFTER SURGERY

http://www.medscape.com/viewarticle/842346

 

Costs

There is a debate between the benefits of robotic tools vs traditional surgery. Costs are quite different.

For a high-end operation in a top private hospital in Sydney men can expect to pay $7,000 to $30,000. In a public hospital the same operation can cost just $200. The out-of-pocket expenses of an open operation in a private hospital ranges from $3000 to $5000. [Source]

those with private health insurance tended to have double the out-of-pocket expenses than their public patient peers. [Source]

At Epworth, where most of Victoria’s private robotic surgery is performed, they’ve taken steps in past year to reduce its costs.” Moon says notes that paying for treatment for an early cancer can be far cheaper than paying for an advanced one. In Victoria, the average out of pocket cost for early treatment is $5000 compared to $14000 for advanced cancer. [Source]

There are major cost differences between the two main treatments, with surgery costing more than $20,000 in private hospitals, while radiation therapy is free in public hospitals. [Source]

it was not until after he told the surgeon he could not afford the operation that he was informed he could receive free radiotherapy in a public hospital.[Source]

After analysing claims data for the 12 months to last November, Bupa found 17 per cent of radical prostatectomies were fully covered but 28 per cent carried gap fees of $5001-$10,000 and 35 per cent gap fees of $2001-$5000. [Source]

CHOOSING THE PUBLIC HOSPITAL

The gender gap for Victoria was biggest at Geelong Hospital a comparison of wait times provided on the government’s MyHospital website shows. Prostatectomies, used in the treatment of prostate cancer in Geelong had a median wait time of 94 days compared to 7 days or breast cancer surgery — a difference of 87 days. [Source]

 

RADIATION

Because prostate cancer cells can be relatively resistant to radiation, high doses of energy are often used to kill the prostate cancer. Unfortunately these dosages can also cause damage to normal cells in the rectum and bladder. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

A recent study of more than 2,000 Australian prostate cancer patients, published in the Journal of Medical Imaging and Radiation Oncology, found no major difference in cure rates between each treatment. [Source]

UNDERSTANDING BRACHYTHERAPY FOR PROSTATE CANCER

risk of cancer recurrence in the robotic and laparoscopic prostatectomy patients was 3 times higher than in standard open radical prostatectomy patients. [Source]

brachytherapy, external beam radiation therapy and open radical prostatectomy were successful in the majority of patients. This was true for all risk groups, but higher dose radiation (EBRT + Brachytherapy) appeared to have better relapse-free survival outcomes in the higher risk and higher grade cancers.

patients in the surgical (radical prostatectomy) arms are typically younger and healthier before treatment than those in the EBRT or brachytherapy arms

the average age and health of the surgically treated patient (before surgery) is more favorable than the average age and health EBRT or brachytherapy patient. Multiple studies prove that younger, healthier patients recover from virtually any type of treatment better than older, sicker patients. So, all these studies have a built-in bias favoring the surgically treated patients.

patients treated with surgery suffer higher rates of incontinence and impotency than those treated with either seed implantation or IMRT radiation.

Those treated with radiation have higher rates of (usually temporary) increased urinary frequency and bowel frequency.

 

 

 

 

troubling is the higher rate of side effects associated with the radioactive seeds. Investigators from the Pacific Northwest Cancer Foundation reported that following interstitial brachytherapy, 5.1 percent of patients were incontinent, and in 1.7 percent, the incontinence was so severe that the men required a urinary diversion– attachment of a bag, worn under the clothes, to collect urine. Three other patients also required the urinary diversion procedure because of severe strictures or urinary retention. [Source]

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About prostate cancer – general, and up to the biopsy stage

GENERAL INFO

STAGING THE CANCER

A source: https://en.wikibooks.org/wiki/Radiation_Oncology/Prostate/Localized_Prostate_Cancer#Active_Surveillance_vs_Radical_Intervention

Prostate cancer has a 95 per cent survival rate, but it was still the second biggest cancer killer among Australian men. “You only have a small window for cure. When it’s closed, it’s closed for good,” Professor Loeb said. [Source]

MRI can reduce the number of men over-diagnosed with prostate cancer and improve the precision of biopsy to detect aggressive cancers, recent research suggests. [Source]

Get Vitamin D: There are well over 800 scientific studies confirming the link between vitamin D deficiency and multiple types of cancers, including prostate cancer. For example, according to a 2005 study, men with higher levels of vitamin D in their blood were half as likely to develop aggressive forms of prostate cancer as those with lower amounts. Another study published two years ago found that men with higher levels of vitamin D in their blood were seven times less likely to die from prostate cancer than those with lower amounts. [source]

Know that there is over-treatment: Watch this video. [55 per cent of prostate cancers should not be treated]

Ben Stiller reveals his battle with ‘aggressive’ prostate cancer

Fact sheet (US govt)

Very slow growing cancer, generally: Prostate cancer may follow an aggressive course, similar to that of other cancers. However, many prostate cancers are indolent, and will have no impact on health, even without treatment. The natural history of prostate cancer diagnosed in the 1970s and 1980s has been welldescribed. For example, Albertsen et al. (2005), reporting the long-term outcome of watchful
waiting, found that the 15-year prostate cancer mortality for men with a Gleason score of 6 was
18–30%, while their 15-year risk of death from other causes was 25–59%. [Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

Evidence comes from a randomised trial comparing radical prostatectomy and watchful waiting
(Bill-Axelson et al. 2005; Steineck et al. 2002), in men with localised, well to moderately well
differentiated prostate cancer (i.e. Gleason 6 or 7). Overall mortality, within 10 years of follow-up, was lower in men treated with prostatectomy than in those managed with watchful waiting: 27.0% versus
32.0% respectively (Bill-Axelson et al. 2005). Similarly, the rate of death from prostate cancer
within 10 years of follow-up was lower in the prostatectomy group than in the watchful waiting
group (9.6% vs. 14.9% respectively). Erectile dysfunction and urinary incontinence, however,
were significantly more likely in the prostatectomy group (Steineck et al. 2002). [Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

Over-detection: In comparison with those with clinically detected disease, men with PSA-detected cancers will have longer to endure any adverse effects of curative treatment, and longer to wait for any
beneficial effect on survival to emerge. [Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

“My advice to my patients is to be as aggressive in treatment as possible to cure a potentially curable cancer.” [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

TREATMENT RECOMMENDATION FOR LOCALISED CANCER

Healthcare professionals should offer radical prostatectomy or radical radiotherapy (conformal) to men with intermediate-risk localised prostate cancer. here is no strong evidence for the benefit of one treatment
over another.[Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

prostate cancer starts with tiny alterations in the shape and size of the prostate gland cells – Prostatic intraepithelial neoplasia (PIN). Any patient who was found to have high-grade PIN after a prostate biopsy is at a significantly greater risk of having cancer cells in his prostate

he diagnosis of high-grade PIN, which is based on a pathologist’s reading of a given tissue sample, is subjective. Partly for that reason, it is unclear how many men can expect to be diagnosed with high-grade PIN in any given year. Studies of men who have undergone prostate biopsies have found that anywhere from less than 1% to more than 20% had high-grade PIN. A respectable ballpark estimate is that 4% to 8% of men who undergo prostate biopsies will be diagnosed with high-grade PIN.

HOW AGGRESSIVE IS YOUR CANCER?

Caution: “Gleason grade from biopsy is frequently upgraded at prostatectomy, resulting in a reluctance to assign a low GS at diagnosis” [Source] – i.e. there is a small probability that my cancer is worse than the score. However, since locations to be assessed were guided by the MRI, there is a good chance that this is a genuine score.

“For prostatectomy specimens, 4 + 3 cancers were associated with a three-fold increase in lethal PCa compared with 3 + 4 cancers” [Source]

Gleason score 7 is made up of two grades (3+4=7 and 4+3=7), with the latter having a much worse prognosis. Cancers with a Gleason score of 7 can either be Gleason score 3+4=7 or Gleason score 4+3=7:

  • Gleason score 3+4=7 tumors still have a good prognosis (outlook), although not as good as a Gleason score 6 tumor.
  • A Gleason score 4+3=7 tumor is more likely to grow and spread than a 3+4=7 tumor, yet not as likely as a Gleason score 8 tumor.

Epstein criteria for insignificant prostate cancer (no more than one third of all cores positive, no more than half of any one core involved, and a PSA density <0.15).

  • In my case 3+1+4+2+1+2 (12) out of 4+4+4+3+3+3 (21) were positive (excluding one section that may have had 2-3 cores but no figures cited. This means at best 12/23 which is GREATER THAN ONE THIRD.
  • Further two sections had coverage of 50 and 55 per cent/
  • CONCLUSION: IT IS NOT INSIGNIFICANT

TREATMENT FOR SPREADING CANCERS

Prostate cancer tumours ‘shocked’ to death by flood of testosterone: researchers

Laetrile (amygdalin/ Vitamin B17) treatment for prostate cancer

Laetrile: How Much Proof Do They Need?

The cyanide released by amygdalin is one of the best killers of malignant cells as well. Amygdalin has a double punch. It lowers cancers resistance to treatment and it releases cyanide to kill cancer cells directly. [Source]

Laetrile contains an enzyme known as Emulsin that breaks down into cyanide when ingested. It is this chemical reaction that is responsible for Laetrile’s cancer-fighting properties. The most common form of laetrile, or vitamin B17, is derived from apricot seeds as these contain a large amount of the active ingredient that kills cancer…. Unlike conventional cancer treatments, Laetrile has the ability to destroy cancer cells without harming the body’s healthy cells.

 

There have been a number of studies performed in the US on the effectiveness of Laetrile against cancer, all of which claim that it has no effect on cancer cells. However, a study performed in China at the Bethune College of Medicine in 2013 found that the viability of human cervical cancer cells was significantly inhibited by amygdalin.  A 2006 study conducted at the College of Medicine in South Korea found that amygdalin was effective at killing human prostate cancer cells. [sOURCE]

  • Laetrile has shown little anticancer activity in animal studies and no anticancer activity in human clinical trials.
  • The side effects associated with laetrile toxicity mirror the symptoms of cyanide poisoning, including liver damage, difficulty walking (caused by damaged nerves), fever, coma, and death.
  • Laetrile is not approved for use in the United States.

BIOPSY ISSUES

Transperineal Prostate Biopsy – Normally, between 24 and 38 biopsies are taken. 

Australian Urology Association

NHS information sheet:  the results take around three weeks to come back. It can also diagnose other conditions such as benign prostatic hyperplasia (enlargement of the prostate), prostatitis (inflammation of the prostate, usually caused by a bacterial infection) or prostatic intraepithelial neoplasia (PIN), which is a change in the cell type but not cancer.

We give you antibiotics after your biopsy to reduce the risk of infection. You will need to take these for a minimum of three days.

Infections can be very serious after a biopsy so it is important that you seek medical attention if you have symptoms of infection even if it is in the middle of the night! [Source]

Blood when you pass urine: This is not uncommon and can range from peachy
coloured urine to rose or even claret coloured. It is rarely a sign of a serious problem.
Increasing your fluid intake will usually help ‘flush the system’ and clear any bleeding.
However, if there is persistent or heavy bleeding every time you pass urine you should
go to your nearest A&E department.

Difficulty passing urine: It is possible that the biopsy may cause an internal bruise that
causes you difficulty passing urine. This can happen in two in every 100 cases and is
more likely to happen in men who had difficulty passing urine before having the biopsy.
Should you have difficulty passing urine, you may require a catheter and you will need to
go to your nearest A&E department for assessment. A catheter is a hollow, flexible tube
that drains urine from your bladder.

Information sheet.  A general anaesthetic takes 24 to 48 hours to wear off, so please rest for this period of time

In the few days after your procedure: you may have mild discomfort in the biopsy area, with bruising around the skin of your testicles and an ‘aching’ sensation; you should rest and not do any heavy lifting; you may notice some blood in your urine and your semen may be discoloured (pink or brown) for up to six weeks, and occasionally longer — this is nothing to worry about. You should drink plenty of non-alcoholic fluids while you have blood in your urine.

If you display any of the following symptoms: • increased pain • a fever higher than 38 °C • eight hours without passing urine • passing large clots of blood • persistent bleeding.

 

 

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How to tame the unmanageable Zucchini plant

I planted NINE zucchini plants and they all came out. And they grew wild and crazy. I got very little zucchini out of it. I was very frustrated with this, since it appeared that I was going to get a lot of fruit, but then all I got was a massive and wild growth of leaves.

Some lessons. This video seems to be excellent. Just TWO are needed, and they need MASSIVE PRUNING while they are growing.

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Specialists charge different rates

Seeing a specialist. How variations in fees are hidden from patients

 

Out of pocket costs charged by specialists in 2015
Mean Median 10th percentile 90th percentile
Cardiology $73.70 $66.90 $22.60 $126.70
Endocrinology $94.70 $85.10 $31.70 $171.70
Gastroenterology $75.70 $66.90 $31.70 $131.70
Geriatric medicine $56.70 $58.30 $22.60 $85.10
Haematology $85.70 $71.70 $22.60 $156.70
Immunology/allergy $128.70 $141.70 $51.70 $176.70
Medical oncology $67.70 $65.55 $22.60 $111.70
Nephrology $67.70 $66.70 $22.60 $111.70
Neurology $123.70 $121.70 $22.70 $211.70
Respiratory medicine $82.70 $71.70 $31.70 $141.70
Rheumatology $107.70 $111.70 $46.70 $171.70
Source: MJA
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Mallet finger > little pinkie twisted > jammed? How to cure and rehabilitate mallet finger injury

CHRONOLOGY

At 7 pm on 11 February 2017. I found that while washing dishes something happened to my finger. Picture below.

I iced the finger but nothing happened. So I studied google and found that I might have a problem,

At 8 pm I went to the doctor, who referred me to emergency in Austin hospital . By 12:30 am I had got an -ray done, and a doctor had seen me and said I have a mallet finger injury, He gave me a splint:

On 13 February 2017 I went to a hand therapist (Melbourne Hand therapy) who put a custom splint. Photo below. It cost me $146.

KEY: DON’T LET THE FINGER DROP EVEN ONCE!!

During this time the finger must be supported straight at all times. If the finger drops for even one second the treatment can fail.

On 2 March 2017 I went back to the hand therapist to review progress. The finger was really painful (particularly skin). The splint grinds on the middle portion of the little finger. I’ve therefore been sporadically wearing splint loose so the skin can recover. (That’s a bad idea!)

I was shown how to use the splint (I was not using it properly) and asked to come back on 30 March. There was no charge for the review of healing process.

It is important to ensure that the tip of the finger is pulled upward. That will ensure that the tendon heals as straight as possible. Else it will be too long and the tip of the finger will dangle, Unfortunately, I guess my wrong way of using the split at the critical period of the first two weeks has meant my finger tip will dangle slightly inwards.

NOTES FROM THE INTERNET REGARDING THE HEALING PROCESS:

If the finger is painful then the splint can be carefully removed and the back of the finger massaged with an alcohol swab to prevent ulcer formation.

HOW TO WASH HAND WHILE SPLINTED AND ALSO CUT THE NAILS

ISSUES WITH STANDARD TREATMENT

13 March 2017: I discovered by accident that the finger has largely healed – within four weeks. However, the tip of the finger is dangling inward.

I had two weeks to go before meeting the therapist. I started doing some preliminary therapy.

30 March 2017: Visited the therapist ($80) – she flipped the splint around (by twisting it in hot water) and showed me some simple exercises, below:


THE FINGER IS UNLIKELY TO HEAL AS IT WAS ORIGINALLY

Mallet finger can drop [Source]

Unfortunately, some deformity is common after mallet injury [Source]

 

KEY: DON’T FORCE THE TENDON DURING REHAB!!

After the splintage period the finger should be gently exercised. It is best to regain full bend of the finger over a period of 6-8 weeks rather than force the movement and end up rupturing the tendon again.

NOTES FOR THERAPY

Finger passive range of motion: Gently bend the injured finger with your other hand. Then gently try to straighten out the injured finger with help from your other hand. Repeat slowly, holding for 5 seconds at the end of each motion. Do this 10 times. Do these exercises 3 to 5 times a day.

Fist making: Make your hand into a fist. If the injured finger will not bend into the fist, try to help it with your other hand. Hold this position for 5 to 10 seconds. Repeat 10 times.

Object pick-up: Practice picking up small objects, such as coins, marbles, pins, or buttons, with your thumb and injured finger.

Finger extension: With your palm flat on a table and your fingers straight out, lift each finger straight up one at a time. Hold each finger up for 5 seconds and then put it down. Continue until you have done all 5 fingers. Repeat 10 times.

Grip strengthening: Squeeze a soft rubber ball and hold the squeeze for 5 seconds. Do 2 sets of 15.

KEY: DON’T RUSH INTO PLAYING TENNIS

Also see: https://tt.tennis-warehouse.com/index.php?threads/when-can-i-play-tennis-after-sustaining-a-mallet-finger-injury.442694/

With early movement, the ends of the tendon pull apart again, tearing the fragile protein strands.

KEY: WEAR COBAN IN THE DAY DURING REHAB + SPLINT AT NIGHT

The splint is worn for one to two weeks at night and whenever the finger might be at risk of injury. A Coban bandage is used during the day for 2 weeks.

KEY: FULL CURE CAN TAKE MANY MONTHS

There may be slight loss of full straightening at the completion of treatment, and it may take several months to regain satisfactory function.  Redness, swelling and tenderness of the skin on top of the end joint are common for three or four months after injury, but usually settle eventually.

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Being fat is OK

Continuing from my post here.

Top Cardiologist Blasts Nutrition Guidelines (the incidence of cardiovascular disease in the PURE population increases as carbohydrate intake (as a percentage of total calories) rises.)

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This article: Survival of the fattest: Why we’re wrong about obesity

Weight tells you far less about a person’s health than you might think (Image: Richard I’Anson/Getty) Can you be fat and fit? Everything we think we know about obesity may be wrong – sometimes it be could actually be good for you

In 2002, cardiologist Carl Lavie began to see a confusing trend. The people he was treating for heart failure were living longer if they were obese or overweight than if they were thin. How could that be right? Obesity is notoriously bad for your heart and every other part of your body.

In the US, obesity is one of the biggest causes of preventable deaths after smoking. Worldwide, it has been linked to chronic diseases like hypertension, stroke, heart disease and type-2 diabetes. Even so, the world keeps getting fatter, a trend that may mean we will all be obese by mid-century, propelling those of us in the West ever closer to the first drop in our life expectancy since 1800.

But how much of this is true? Lavie wasn’t the only one to notice some troubling inconsistencies in the seemingly simple story. Under fresh scrutiny, conventional wisdom about the obesity epidemic is beginning to unravel, prompting some medical professionals to call for changes to everything from public policy to healthcare training.

It is small wonder we have become so obsessed with our weight. Between 1980 and 2008, body mass index (BMI) – a measure of obesity that divides weight by height squared – rose all over the world. Obesity rates nearly doubled, rising most strikingly in the US. It wasn’t hard to see where it was all heading. In the title of a widely cited paper investigating the progression and cost of the US obesity epidemic, the authors asked: “will all Americans become overweight or obese?” Yes, they concluded: by about 2050.

So it came as a surprise when, in the early 2000s, epidemiologist Katherine Flegal began to see evidence that obesity rates had stopped rising. In study after study, Flegal, who works at the Centers for Disease Control (CDC) in Hyattsville, Maryland, found that instead of continuing relentlessly upwards, obesity rates had levelled off.

Not everyone was convinced, but this was no flash in the pan. Flegal and her team continued to replicate their research and, in a study released in 2012, they announced that the prevalence of obesity in the US has failed to increase in any significant way since at least 2008 (JAMA, vol 307, p 491). It appears to have flatlined around the 34 per cent mark in both adults and adolescents (see “Obesity plateau”). And this “obesity plateau” is not limited to the US: similar trends and even declines have been described in other developed countries over the past 10 to 15 years.

Because the research is still in the early stages, no one is sure what is causing the obesity plateau. But some competing theories are emerging. Researchers at the University of Jena in Germany point to small studies showing the success of better food and exercise programmes. Whatever the reason, the idea that obesity rates will rise unchecked seems to be in need of revision.

Where does that leave the 34 per cent of people still considered obese? In 2004, the CDC warned that obesity could soon be second only to smoking as a cause of preventable deaths. Of course, it won’t be the extra pounds that kill you. What supposedly shortens your life is the link between obesity and the development of a host of diseases including type 2 diabetes, heart disease, cancer and rheumatoid arthritis.

Over the past 10 years, however, some of these links have been called into question as well. The most surprising of them is the one that always seemed the most intuitive: the relationship between obesity and heart disease. “Over a decade ago, I would have thought my heavy patient who just had a heart attack would have been worse off than my thin patient who just had a heart attack,” says Lavie, who is a cardiologist at the Ochsner Medical Center in New Orleans, Louisiana. “But it’s exactly the opposite.” Heart disease patients classified as lean had almost double the mortality rate of those ranked overweight and even obese.

Startled by his own anecdotal findings, Lavie began to dig into the literature. He found numerous large-scale studies that backed up his observations: some overweight patients with cardiovascular disease have better outcomes than their thinner counterparts. One of the largest, a 2012 study of 64,000 Swedish people with heart disease, found that obese or overweight participants had a reduced risk of dying compared with those of normal weight (European Heart Journal, vol 34, p 345). Underweight patients, meanwhile, upped their risk of death by a factor of three. In the paper, the authors went so far as to suggest that prescribing weight loss after diagnosis of heart disease might be a bad idea.

Heart conditions were far from being the only ailments where extra padding seemed to be an advantage. Equally surprising was the clear link between obesity and the fate of people with type 2 diabetes. Among others, a Northwestern University study of 2625 people recently diagnosed with type 2 diabetes found that normal-weight people were almost twice as likely to die over the period of the study as their overweight and even obese counterparts.

Next came rheumatoid arthritis and kidney disease. Over and over, the same pattern cropped up: people diagnosed with many medical killers fared better in the long run if they were overweight or even mildly obese than if their weight was normal. “Yes, this even remains true when researchers rule out weight loss attributable to other pre-existing illnesses such as cancer,” says Lavie. To be clear: becoming overweight is not a fitness goal – a sedentary lifestyle, poor diet and a BMI of 40 will not lead you to health. However, once you are overweight, it seems, being healthy is not synonymous with shedding pounds. Fatter people are more likely to survive many diseases. The phenomenon has been observed so often that it has earned the name “the obesity paradox”.

But how can flab be good for you in any way? One tentative theory doing the rounds is that body fat contains anti-inflammatory compounds and extra energy that can bolster the body’s defences against the ravages of disease. More specific experiments have pointed to the hormone leptin, which is stored in fat, suggesting that some extra fat may have protective effects for people with heart failure (Circulation Heart Failure, vol 2, p 676). People with more fat have access to these “extra reserves” stored within. In any case, the conflicting studies meant that, in 2005, even the CDC backed away from its earlier contention that obesity could be the leading cause of death after tobacco.

But last year, the plot thickened still further: could being overweight be healthier not just for sick people – but for all of us? In a meta-analysis that investigated the relationship between BMI and health in 2.88 million people, a CDC team led by Flegal – who had introduced the obesity plateau – showed that the relationship between health and weight was U-shaped rather than linear (see “Fat and fit”). That’s to say, being overweight or even mildly obese was associated with a lower risk of dying – from any cause – than being either underweight or extremely obese.

Flegal’s research started a firestorm of controversy. In a study of people with diabetes published last January, Deirdre Tobias of Harvard University found no similar benefits. When Tobias redid her analysis, focusing as Flegal had on death by any cause instead of diabetes, she found Flegal’s U-shaped curve. However, Tobias says taking out smokers changed the shape of the curve to a J. “There is no advantage for being overweight or obese,” she says, but her new curve does not clearly demonstrate the linear relationship between weight and health implied by BMI. Tobias’ group thinks the obesity paradox can be entirely chalked up to poor research methods. But can so many studies be so wrong? Or are the obesity plateau and the obesity paradox signs that it is time to abandon a metric whose inaccuracy verges on scandal?

The BMI system has been incorrectly used from the start (see “Why BMI?“). Its oft-cited flaws are almost too numerous to count.

First, whether applied to individuals or populations, BMI is a consistently unreliable indicator of actual fat. It fails to account for where fat is located on the body – according to several analyses, it is abdominal obesity, not total body fat, that truly predicts whether a person will develop cardiovascular problems or cancer. It also famously fails to distinguish between fat and muscle.

This familiar critique – that BMI cannot differentiate between Arnold Schwarzenegger and the Michelin Man – is often dismissed. After all, not many people who have an obese BMI look like Arnold Schwarzenegger. But the dismissal masks a subtler point: in many cases a person classified by BMI as overweight or “grade 1” obese (adjacent to the overweight range) may be metabolically healthier than their normal-weight counterpart simply as a result of better fitness. According to the standard BMI categories, however, this person is indistinguishable from a severely obese person with minimal fitness.

Worse, when an overweight person gains muscle, they change their health for the better but often change their BMI for the worse. Occasionally this even bumps them into the “obese” category. And this category is wildly over-inclusive, encompassing any BMI over 30, which conflates a range of weights that stretches, in theory, to infinity. Flegal, for one, thinks this is the confounding factor in many of the studies. In her 2013 findings, she says, she saw major differences in health between people classified as “grade 1” obese and people whose BMI was closer to 40. “Grade 2 to 3 obesity was significantly associated with excess mortality but grade 1 obesity was not,” she says. Most studies that rely on BMI, however, rarely make the distinction. Healthcare providers tend to ignore it as well.

This is why BMI consistently fails to account for healthy obese people and unhealthy thin people, two groups that keep turning up in new research. For example, in a 2013 study of 43,000 people that investigated the link between obesity and cardiovascular disease, 46 per cent of the obese population were found to be metabolically healthy, having none of the high blood pressure, high cholesterol and insulin resistance normally associated with obesity. This “healthy obese” group had the same chance of dying from cardiovascular disease or cancer as their normal-weight counterparts who were also metabolically healthy (European Heart Journal, vol 34, p 389). Based on the size of their 25-year study, the authors speculate that this state of being metabolically healthy but obese is common in the general population. Alongside the steadily growing body of work describing the obesity paradox, this reveals that BMI doesn’t even necessarily work as a proxy for the general health of a population.

“Weight is the wrong thing to be paying attention to,” says Linda Bacon, a nutritionist at the University of California, Davis. Lavie agrees. “There’s just not that much evidence that you’re gaining a lot by losing weight,” he says. So for anyone between 18.5 and 35 on the BMI chart, he says the key is physical fitness, not weight loss. “If I’m sitting with a mildly obese patient who just had a heart attack, they can actually have a good prognosis, or even a better prognosis than a thin person, if we can get them to become more physically fit,” he says. Bacon and Lavie are far from the only ones coming to this conclusion.

No size fits all

This represents a paradigm shift for cardiologists, who have tended to recommend weight loss to anyone whose BMI is above normal. It is a controversial position. After all, one concern raised frequently about Flegal’s work is that it could undermine policies to curb obesity rates. If everyone starts to think of higher weights as normal, parents might no longer understand that their overweight children have a weight problem, England’s chief medical officer recently told New Scientist.

However, research is beginning to show that the focus on BMI may not be helping. In a study published in February, researchers from the Johns Hopkins School of Medicine in Baltimore, Maryland, found that patients who felt their doctor judged them for their weight were more likely to attempt weight loss, though not more likely to succeed.

Indeed, the fixation on BMI could be causing actual harm, discouraging overweight and obese people from seeing their doctors in the first place. A team of researchers from Columbia University in New York identified weight-related barriers such as fear, modesty, insensitivity and lack of facilities, all of which were discouraging obese women from going for potentially life-saving mammograms and smear tests (Obesity, vol 20, p 1611).

The deeper question may be – why is anyone still using BMI? At least five alternatives have been proposed, ranging from a subtler mathematical formula to a waist-to-height system that better reflects actual risk of disease. At this point, however, no public health agencies have any plans to switch to another measure. Part of the problem is that BMI is alone in offering the official cut-offs that are so useful in making easy assessments.

To minimise the damage, in the shorter term, many recommend that doctors use BMI with more care. For young people, for example, classic BMI metrics appear to be relevant, but for the elderly in particular, Lavie thinks the BMI guidelines are misguided; research is accumulating to show that obesity in this population is associated with a lower, not higher, risk of death. Likewise, BMI does not apply equally to all races, and should be different for the genders – as the NIH understood in its original version of the guidelines (see “Why BMI?“). And under some circumstances, people with certain diseases including cancer and HIV might even consider gaining weight beyond the recommendations set by BMI.

Others wonder whether health concerns are truly at the heart of the obesity panic. “We live in a society that condones fat shaming,” says Abigail Saguy, a sociologist at the University of California in Los Angeles. “There remains a kind of social acceptance for this type of judgment, a lack of empathy.” Saguy notes that she has seen no evidence that discrimination, stigma and shaming is motivating in terms of weight loss. “It has no positive effects,” she says. The real public health epidemic, she suggests, is discrimination against the overweight and obese: “less social acceptance of weight-based discrimination and shaming could potentially save lives.” This article appeared in print under the headline “Flabbergasted”

Why BMI?

So where did we get the idea that general health and BMI are closely linked? The system was developed by a Belgian statistician in 1832, more out of academic curiosity about what constitutes the “normal” person than interest in obesity.

In the 1940s, life insurance companies adapted it as an easy way to determine policy risk. In 1985, it was adopted by the US National Institutes of Health (NIH), and then in 1995 by the World Health Organisation, to estimate obesity in large populations.

Even these guidelines have not been written in stone. In 1998 the NIH pushed the definition of obesity to 30 from 27 and added a new category – overweight – instantly classifying millions of previously “fit” Americans as fat. It also consolidated previously different guidelines for men and women.

No one ever suggested that it should be a proxy for a single individual’s health – its inventor warned explicitly against doing so.

But that is exactly how we use it today: anyone whose statistics stray outside the normal BMI range is advised to lose weight. Context-free online BMI calculators proliferate. There is good reason to rethink this approach (see main story).

Samantha Murphy is a journalist based in Lancaster, Pennsylvania

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