October is Breast Cancer Awareness Month

Breast cancer is the most common type of cancer in women and is the second leading cause of death, after lung cancer, in women. Every woman has a 12 percent (1 in 8) chance of developing it at some point in her life. The good news is that only about 3 percent of women will die from breast cancer. A number of risk factors will play a role in a woman's particular risk to breast cancer. Age plays perhaps the most important role in breast cancer risk as two out of three invasive breast cancers are found in women age 55 and older. About 10% of breast cancer cases are thought to be inherited (genetic) and the most common cause is a mutation (change) in what are called the BRCA genes. A family history of breast cancer may also be significant. Having one first-degree relative (mother, sister or daughter) with breast cancer will double a woman's risk and having 2 first-degree relatives will increase her risk about 3 x. Women who have had a longer menstrual history (i.e., before age 12 and after age 55) have a slightly higher risk of breast cancer. Post-menopausal hormone especially with progesterone has been shown to increase the risk of breast cancer. Obesity and excess alcohol use (3 or more daily) will also increase a woman's risk of breast cancer.


Risk Factors: (you cannot change)
 Age
 Inheritance (genetics)
 Family history
 Caucasian women (slightly higher)
 Dense breast tissue
 Previous breast cancer
 Prolonged menstrual history
 Previous radiation therapy
 History of diethylstilbestrol (DES) exposure


Risk Factors: (you can change)
 Obesity
 Excessive alcohol use
 Post-menopausal hormone therapy (especially synthetic hormones)
 Having no children or later in life (after age 30)
 Sedentary life style (just 2 hrs of exercise weekly will help)
 Night shift work (? changes  levels)
 Smoking (controversial)

Signs of breast cancer can be many and confusing. Lumps, swelling in the breasts or under the armpit are common signs of breast cancer. A lump that is painless, immobile, and has uneven (prickly) edges is more likely to be cancer than one which is painful, smooth and rounded. The outer quadrants of the breast are also more likely to develop a cancer than the inner quadrants. Changing of the skin especially around the nipple could also be a sign of breast cancer. The skin around the nipple may become reddened, scaly, flaky or pitted like an orange. Changes in the size and contour of the breast may also be a sign of breast cancer.


Symptoms:
 Lumps (especially fixed and prickly)
 Swelling in the breast or armpits
 Skin changes (especially around the nipple)
 Inverted nipples
 Changing contour of the breast
 Persistent pain in the breast

Breast cancer screening is extremely important and should begin with self exams at an early age. Women should familiarize themselves with their own breasts and begin self exams in their twenties. Women should know how their breast normally look and feel. Breast cancer screening guidelines for women with no increased risk factors include: 1) monthly self breast exams (after menses preferable), 2) clinical breast exams every 3 years for women in their 20s and 30s and then every year for women over 40, 3) mammograms every 1-2 years starting at age 40 and then yearly after age 50 (a screening mammogram at age 35 may also be considered).


Mammography can detect breast cancer about 1.5 years before a women can feel a lump in her breast. Remember is that when breast cancers are detected early (stage I), the survival rate in nearly 100%. 

Smoking Cessation

Tobacco use is considered the most common cause of preventable death and about half of habitual smokers will likely die of smoking-related illnesses. Quitting smoking (or at least significantly reducing smoking) will provide many health benefits. After you stop smoking, blood pressure and circulation improve, breathing becomes easier, your sense of smell and taste return and other issues such as anxiety will often improve. There is no doubt that giving up tobacco will help you live longer and the risk of cancer decreases yearly.

Quitting smoking may be the most difficult thing that you have ever done. You probably will experience intense short-term effects such as irritability, insomnia, anxiety or weight gain. Most people will try to quit a number of times before succeeding. There are a number of helpful ways to quit smoking including prescription medications and products that reduce nicotine addiction. Most experts suggest not quitting "cold turkey" due to the severely addictive nature of nicotine. You should remove all ashtrays and try to remove all traces of cigarette residue from the home. A majority of former smokers say a support network of family and friends was vital during their trials with smoking cessation. You should be open about your plans to quit and try to spend time with ex-smokers for guidance. You must try to avoid social situations with current smokers especially if they include alcohol.

Stop smoking programs, especially group ones, are designed to help smokers recognize and cope with significant difficulties that arise when attempting to quit. These programs  provide support, guidance and encouragement during the process. The best programs should include one-on-one and group counseling. There is a strong correlation between how often and how long counseling lasts and the success rate. Overall, the more intense the program, the greater the chance of success.

Nicotine Replacement: 
Nicotine patches: give a continual dose of nicotine through the skin. Several different strengths are available and the 16-hour patch works well if you are an average smoker. You slowly wean off of nicotine by switching to lower-dose patches over a course of weeks. Sixteen hour patches have less side effects like a racing heartbeat, sleep problems or headache, but may not be right for those with early morning withdrawal symptoms. The 24-hr patch provides a steady dose of nicotine through the night, therefore it helps with early morning withdrawal. The rule of thumb is that regular smokers will probably be better suited for a 24-hr patch. The recommended initial dosage for people who smoke more than 10 cigarettes per day is one 21-mg patch per day for four to six weeks. After which, you should step down to one 14-mg patch per day for two weeks. Finally, you should use one 7-mg patch (preferably a 16-hr patch) per day for the final two weeks of treatment. The patch should be put on in the morning on a clean, dry area of the skin without much hair. It should be placed below the neck and above the waist, such as on the upper arm or chest.

Most common side effects of the nicotine patch include:
 Skin irritation
 Dizziness
 Racing heartbeat
 Sleep problems
 Headache

 Nausea

Nicotine gum: is a fast-acting form of nicotine replacement. If you have sensitive skin, you may prefer the gum to the patch. You can buy it without a prescription and it comes in 2 mg and 4 mg strengths. If you smoke more than a pack a day or upon waking, you may need to start with the higher gum dose (4 mg.) For best results chew the gum slowly until you note a tingle or hot taste. Then "park" it next to your cheek until the taste fades. Repeat the process for 20 or 30 minutes. Do not eat or drink for at least 15 minutes before and during gum use. Chew no more than 20 pieces of gum in one day. Nicotine gum is usually recommended for 6 to 12 weeks. You should taper down the amount of gum you use within six weeks. The gum can be used as needed or on a fixed schedule and most research has shown that scheduled dosing works better. A schedule of 1 to 2 pieces per hour is most common.

Side effects of nicotine gum:
 Bad taste
 Throat irritation
 Mouth sores
 Hiccups
 Nausea
 Jaw discomfort
 Racing heartbeat
 Nausea

Nicotine nasal spray: relieves withdrawal symptoms very quickly and smokers usually like the nasal spray because it is rapid and easy to use. Since nicotine is so addictive, a person can also become dependent on the nasal spray. The FDA recommends that the spray be prescribed for 3-months and that it not be used for longer than 6 months to help reduce this risk.

Common side effects can include :
 Nasal irritation
 Runny nose
 Watery eyes
 Sneezing
 Throat irritation
 Coughing

Nicotine inhalers: are available only by prescription. When you use the inhaler, a nicotine vapor which is absorbed in the mouth, not the lungs. Each puff contains about 10 times less nicotine than a puff of a cigarette. The absorption of nicotine is slower than from a regular cigarette, with peak nicotine doses occurring about 10 minutes after the end of puffing. The best results have been achieved by frequent puffing for 20 or more minutes. The recommended dose is between 5 and 15 cartridges a day, for up to 6 months.

Common side effects include:
 Coughing
 Throat irritation
 Nausea

Nicotine lozenges: are non-prescription and are available in 2 mg and 4 mg strengths. You should stop smoking when you start using the lozenge. Smokers may also consider the lower dose if they smoke less than ten cigarettes daily. The recommended dose is 1 lozenge every 1 or 2 hours for 4-6 weeks, then 1 lozenge every 2 to 4 hours for weeks two weeks and finally, 1 lozenge every 4 to 6 hours for the final two weeks. Do not eat or drink for 15 minutes before using the lozenge. Suck on the lozenge until it is fully dissolved, about 20 minutes. Do not bite, chew or swallow it.  Do not use more than one lozenge per hour, or more than 20 per day. Discontinue the lozenges after 12 weeks if not sooner. Do not use the lozenge if you continue to smoke or use any other product containing nicotine.

 Possible side effects  include:
  Trouble sleeping
  Nausea
  Hiccups
  Coughing
  Heartburn
  Headache

Medications for smoking cessation:
Welbutrin (bupropion): the mechanism of action for this agent, originally marketed as an antidepressant, is thought to be due to its ability to increase the neurotransmitters dopamine and norepinephrine, reducing cravings and symptoms of withdrawal. Patients should initiate bupropion therapy 1 to 2 weeks before their quit date, starting with 150 mg once a day for a few days, then increasing to 150 mg twice a day. Cessation rates in patients who use bupropion are generally 2 times higher than those who do not.
Clonidine: is an antihypertensive agent that also doubles smoking cessation rates. Initial recommended doses include 0.1 mg orally twice a day or the 0.1-mg/day patch applied weekly. The dose may be increased to .3mg twice daily (orally) and to 0.2 mg patch (transdermally) for up to 12 weeks.
Nortriptyline (Elavil): a tricyclic will also greatly increase the success rates of quitting smoking. The recommended initial dose is 25 mg at bedtime, gradually increasing to a target dose of 75 or 100 mg daily for 12 weeks.
Chantix (Varenicline): is in a class of medications called smoking cessation aids. It works by blocking the pleasant effects of nicotine on the brain. Your doctor will probably start you on a low dose of varenicline and gradually increase your dose over the first week of treatment. Chantix is usually taken once or twice a day with a full glass of water after eating. You will probably take varenicline for around 12 weeks. Some people have had changes in behavior, hostility, agitation, depressed mood, and suicidal thoughts while taking varenicline.

Natural herbal therapies:

Bupleurum D: is based on the formula bupleurum and dragon bone; it decreases irritability, reduces cravings, and stabilizes the emotions.  

Crave Arrest:i s a proprietary blend which has been shown to help up to with the cravings.

5HTP(5-hydyoxytryptophan): keeps serotonin levels balanced which helps with mood, cravings, and 

general well being.  

Calm Spirit: helps with excessive anxiety, stress, and emotional disturbance.

Other options:
Acupuncture: works by balancing the flow of Qi (chi) in the body and mind.Qi is frequently translated as life force or "energy flow." In acupuncture theory, addictions are due to a number of potential imbalances in the way that energy flows through the body, which is often believed due to a history of abuse or a betrayal.
Hypnosis: is now used in hospitals and medical centers. The hypnotherapist can decrease cravings and help address fears one might have about quitting, like gaining weight by giving you helpful subconscious suggestions.
Yoga: helps calm the mind and strengthen the determination. It also helps bring heightened awareness to breathing and the body, which helps with a healthier attitude toward the lungs.

Other tricks:
For those who desire to simply decrease their level smoking, try these tips:
 Buy no more than two packs of cigarettes at a time.
 Do not smoke in the house or car.
 Try different brands of cigarettes each time you buy them.
 Wait an extra 10-15 minutes when you disire a cigarette.
 Chew gum.
 Avoid smokers.
 Exercise 

Managing Tics and Tourette's

Tic disorders are characterized by sudden, repetitive, involuntary movements or vocalizations which appear out of context and usually last a brief second. These disorders must appear before the age of 18, they are most common in Caucasian males and cannot result from other causes such as the ingestion of stimulants or other medical conditions. Tics are either transient with a duration of less than 12 consecutive months or chronic lasting more than a year. They are fairly common in childhood and the majority of cases resolve on their own. However, in some children the tics may persist and become more complex and severe. They can be either primary (unknown cause) or secondary to things such as anxiety, stress or fatigue. Common motor tics include blinking, jerking, picking, grunting, sniffing and shoulder shrugs. Vocal tics are less common and include sounds such as coughing, grunting, belching and throat clearing. Complex tics are slower, longer, and more purposeful; they include facial grimacing, biting, banging, arm or hand flapping, coprolalia (use of obscene words) or copropraxia (obscene gestures). The best known of these disorders is Tourette's syndrome. 

Types of tic disorders

Transient (simple) tic disorder: most commonly appears at a young age and affects between 10% and 20% of school-age children. Transient tics are characterized by the presence of one or more tics, usually motor, for at least one month but less than one year. Children may experience multiple episodes of these transient tics which will usually vary in intensity over time.

Chronic tics: will last for a year or more. During that time, the patient is never without symptoms for more than three consecutive months. They may be either motor or vocal, but not both, and the symptoms must begin before age 18. The severity of the symptoms and impairment is usually much less than for patients with Tourette's disorder. Chronic tics are much less common and occur in less than one in 100 children (1%).

Tourette's syndrome: occurs less common, is more severe and is characterized by the presence of both motor and vocal tics. The estimate is that around 250,000 (one in a thousand or less) people in the U.S. have this condition. Tourette's is three or four times more common in males than females and symptoms typically begin between ages 7 and 17. In 75% of Tourette's patients, the symptoms appear by age 10 or so. The severity of Tourette's syndrome often changes over time, waxing and waining. The tics occur many times a day, usually in bouts, most days or intermittently for more than one year. Fortunately, the symptoms often improve as Tourette's patients get older. Tourette's syndrome may also be more likely to occur in children whose mothers smoked or drank alcohol in pregnancy or were low birth weight infants. Adolescents with Tourette's frequently experience a number of additional problems including: aggressiveness, behavioral disorders, self-harming behaviors,  immaturity, social withdrawal, physical complaints, psychological disorders including anxiety or panic attacks, stuttering, sleep disorders, and inappropriate sexual behaviors.

Types of phonic tics: 1) simple phonic tics which are meaningless sounds or noises like throat clearing, coughing or sniffling and 2) complex phonic tics which include syllables, words or phrases. The "echo phenomenon" is the immediate repetition of one's or another individual's words. Coprolalia (rare, 10% or less of tic disorders) is made up of inappropriate, obscene or aggressive words. It often appears first in adolescence and causes considerable distress for individuals, teachers and their families.

Younger children (under the age of 10 or so) with simple tics will generally find them difficult to control, whereas, most older people can suppress them for varying lengths of time. Often, tics are more obvious in a relaxed situation, such as watching television. Tics may be worsened by things such as stress, anxiety, illness, fatigue or excitement. Additives in food (ie, red dye 40), certain medications or stimulants may worsen tics. The symptoms of tic disorders are usually absent while sleeping. Playing a sport or concentrating on an enjoyable task (ie, books, puzzles...) are known to reduce the severity and frequency of tics.

Tics seem to worsen during the adolescent years as the symptoms become more unpredictable from day to day. Teenagers may often refuse to go to school when their tics are severe. Older children with more complex tics frequently describe feelings of strong urges relieved by the performance of a motor tic in that particular area.  A sensation of relief and reduction in anxiety levels generally follows the tic. Many sufferers also describe an inner conflict over whether or not to give in to these urges. The energy required to suppress the tics may also contribute to anxiety, preoccupation, fatigue and social withdrawal. Low self-esteem and feelings of hopelessness are also common with tic disorders.

Causes

No definitive cause of tics has been discovered; but it is believed that abnormal activity of the neurotransmitters dopamine and serotonin (chemical messengers in the brain ) may be the cause. Multi factorial genetic factors are present in about 75% of cases. Researchers also believe there is an link between genetic and environmental factors. Tic disorders may be worsened by recreational drugs such as amphetamines or cocaine or certain prescription stimulants such as Ritalin or Focalin. Occasionally, medications such as antihistamines, antidepressants, antiseizure medications, and opiates have been shown to worsen tics. Some tics may be triggered by ones environment; a barking dog may initiate a barking tic or cough may continue as vocal tic.

PANDAS: stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus. In some cases tic disorders and obsessive-compulsive disorders have been shown to develop after streptococcal infections between the ages of two and eight. No precise cause for this connection has been found, although it appears to be related to the immune system and basal ganglia of the brain. Tics will often worsen with subsequent strep infections. The treatment is different and somewhat controversial if PANDAS is suspected in that intravenous immunoglobulin (IVIG), 750 mg/kg/day for two consecutive days, may be administered and the patient may then be placed on supressive antibiotics.

.  

Diagnosis

There are no diagnostic laboratory tests to screen for tic disorders. Physical and neurological examinations are generally normal, except for the tics. Surprisingly, it is also common for the patient to have fewer tics in a doctor's office than at home. The diagnosis can be made by directly observing or videotaping the patient in a more natural setting. Children quickly learn to mask their symptoms and convert them to more socially acceptable movements and sounds. 

Physicians often disagree as to whether tic symptoms should be classified as tics or compulsions; as there is a significant overlap between tic disorders and obsessive-compulsive disorders (OCD). More than half of patients with tic disorders or Tourette's have been diagnosed with OCD; however, only a third of those meet the full criteria for OCD. Distinguishing tics from compulsions and true OCD can be very difficult. Compared to only obsessive-compulsive disorder in individuals, there will likely be an earlier age of onset and a greater percentage of males. These patients will see less response to medications such as selective serotonin reuptake inhibitors (SSRIs) and may require a neuroleptic (considered a stronger medication) to bring about improvement.

As many as 50% of children with Tourette's disorder have symptoms of attention-deficit hyperactivity disorder (ADHD). Symptoms include poor concentration, a short attention span and restlessness. On average, ADHD symptoms will manifest about two years before the tics begin. ADHD combined with a tic disorder is associated with more severe tics and greater social withdrawal. These impairments lead to higher underachievement in school and more social disabilities than one disorder alone. Although children with tics or ADHD do not  appear to have a significant impairment in intellectual functioning, they do have abnormal visual-perceptual performance and reduced visual-motor skills. Children with tic disorders are much more likely to require special education programs as these children often have underlying learning disabilities.

A team approach is best with the affected child's parents, health care providers and teachers. A comprehensive treatment plan should include the following:

 Direct observation.

 Self-reports of tic activity by the patient and parents.

 Educating the patient and family about the course of the disorder.

 Involvement with school personnel to create a positive learning environment.  

 A comprehensive assessment including cognitive ability, motor skills, behavior and social

 functioning.

Treatment

 Includes behavioral or cognitive/behavioral therapy in combination with medical treatment as

 needed.  

 

Behavioral and cognitive/behavioral therapy:

Habit reversal (is the most commonly used technique): combines relaxation exercises, awareness, and contingency management for positive reinforcement. This method shows a high success rate, 70+% . Adding the cognitive technique of distraction has been shown to help patients resist urges and to restore the patients sense of control over the tic.

Massed negative practice (MNP): is another frequently used behavioral therapy technique. The patient is asked to deliberately perform the tic movement for specified periods of time with brief periods of rest  until a conditioned level of fatigue is reached. Patients have shown some decrease in tic frequency, but the long-term benefits of massed negative practice are unclear.

Contingency management: is based on positive reinforcement, usually the by parents. Children are praised and rewarded for not performing tics and for replacing them with alternative behaviors. Contingency management appears to be of limited use outside of controlled enviroments

Self-monitoring: consists of having the patient record tics and is fairly effective in reducing some tics by increasing awareness.

 

Medications

Medication is the main treatment for refractory motor and vocal tics and should be used in conjunction with behavioral or cognitive/behavioral therapy. Because the symptoms of tic disorders overlap those of OCD and ADHD, it is essential to determine which symptoms are causing the greatest concern and impairment. 

Alpha-adrenergic receptor agonists: including clonidine (Catapres) and guanfacine (Tenex) are often first line therapy. Sedation occurs in 20% or more of cases and can often be controlled through adjusting the dosage.

Neuroleptics (antipsychotic medications): including haloperidol (Haldol) and pimozide (Orap) have significant side effects including decreased concentration, cognitive impairment, tremor, sedation, depression and rarely, tardive dyskinesia (a movement disorder that consists of lip, mouth, and tongue movements). 

Phenothiazines:  such as chlorpromazine (Thorazine) or triflupromazine (Stelazine)  may be used when haloperidol or pimozide has proven ineffective.

Atypical antipsychotics: and other agents that block dopamine receptors include risperidone (Risperdal) and clozapine (Clozaril).

Tetrabenazine: is a promising new medication and is marketed under the trade names Nitoman in Canada and Xenazine and has fewer side effects than other typical neuroleptics. It can also be used in combination with other antipsychotic medications, allowing for lower doses of both medications with substantial relief.

Selective serotonin reuptake inhibitors (SSRIs): which include such medications as fluoxetine (Prozac) and sertraline (Zoloft), can be used to treat depression and the obsessive-compulsive behaviors associated with tic disorders.

Benzodiazepines: including lorazepam (Ativan) or clonazepam (Klonipin) are used in some cases to lower patients anxiety levels.

Nutrition

Dietary changes and nutritional supplements may help treat the symptoms of tic disorders. Unknown  food or chemical allergies may worsen tic disorders. Nutritional deficiencies may also influence the severity of tic disorders. Recommendations include organic foods, avoiding pesticides, antioxidants, supplements including folic acid, magnesium, zinc and B vitamins; eliminating caffeine, and avoiding artificial sweeteners, colors and dyes (especially red dye 40).

 

Prognosis

There is presently no absolute cure for tic disorders and there is no method to determine whether the tics will be mild, severe, chronic or transient. The general consensus is that if a tic disorder is the only diagnosis, the prognosis is favorable and most patients report that their tics decrease markedly or disappeared as they enter the teenage years.  A number of studies suggest complete remission rates to be around 50% and appear to be related to early treatment when he or she was a child. While the tics themselves may decline, however, other associated problems such as obsessive-compulsive disorders and behavioral problems become more pronounced. Learning disabilities may also worsen in early adolescence. Panic attacks, anxiety, depression and alcoholism are most significant in the early adult years. Persons who were misunderstood, abused and stigmatized experience greater functional impairment as adults than those who were supported, understood and treated as children.

 

Prevention

There is some evidence that severe maternal emotional stress during pregnancy as well as severe nausea and vomiting during the first trimester may affect tic development. People with tic disorders are sensitive to stress and attempting to maintain a low-stress environment will help minimize severity of tics. Dietary changes and nutritional supplements as outlined above may help in the severity of the tics.