Regatta Health

07/29/2022

"I didn't get my second booster because I'm waiting until the new one comes out." I hear this almost every day and I don't really understand it. Today comes the headline that US Government bought $1.7 billion more Moderna vaccine for a big booster push in the fall. Most eligible folks haven't taken the second booster. I personally know I'm not smarter than the CDC on this stuff. Sometimes they are wrong but they spend all day looking at boring immunization data, reports, trials, studies, etc. Most of us don't have the time or inclination to do all this research, so it's good that part of our taxes goes to pay people to check all this stuff out. Maybe I'm an excessive "rule follower."
They are saying now if you are over 50 to get a second booster. They are not saying, "Wait until the new one comes out."
Especially as health professionals, we set an example for our patients. Most conversations about vaccines end with, "What did you do, doc?" I think it's important to be able to truthfully say I take the guidelines seriously and I think others should as well.
The immunocompromised should also look into Evusheld.

07/20/2022

What is a coronary calcium score? This is a rapid noninvasive imaging test that helps determine if you need treatment for high cholesterol. National guidelines recommend testing for coronary calcium score if the cholesterol is high. If the coronary calcium score is zero, you would not need cholesterol treatment. If it's over zero, you would talk to your doctor about treatment for high cholesterol. It's a CT scan, minimal radiation, takes about 10 minutes. Talk to your doctor and see if it's right for you!

07/18/2022

Is cannabis "safer" than alcohol for your teen?

I have heard people assume that cannabis is "safer" than alcohol for teens and would urge you to consider the problem of marijuana-related psychosis. ER visits for youth cannabis psychosis increase in areas after legalization. Marijuana-related psychosis can be short term but can also be long term. Psychosis can manifest as auditory hallucinations, visual hallucinations, or delusions. "Mind playing tricks on me." Whether cannabis "causes" psychosis or is just somehow related is not clear but scientists think that the earlier you start the more likely you are to have psychotic features. Some of these patients will qualify for a full-blown schizophrenia diagnosis and need to be treated as such.

Clearly the adolescent mind is not fully developed, some say until age 25-30 (or longer in some cases ha), and this may be why some users are particularly sensitive to permanent mental illness with cannabis use. There are other health risks of cannabis use including increased anxiety, vomiting, cognitive impairment, and dependency. Up to 10% of users will manifest a cannabis use disorder that can be as severe as alcoholism.

Obviously teen alcohol use also comes along with a whole host of health risks including impaired driving, sexual assault, dependency, binge drinking, cognitive impairment, and liver damage.

So take your pick, possibility of short or even long term mental illness in cannabis vs risk of other severe health risks with alcohol. Neither choice seems too appealing and parents and teens need to be aware of the risks and have discussions based on up to date information. Happy to respond if there are comments.

NYT also had a recent article with some compelling narratives from patients and families. https://www.nytimes.com/2022/06/23/well/mind/teens-thc-cannabis.html

04/06/2022

Check your Covid home test expiration dates! I was ready to toss a bunch of March 2022 date tests but NYT had an article yesterday showing that FDA has extended shelf life of several tests, look up your test and don't toss it if it has extended shelf life! https://www.nytimes.com/2022/04/05/well/live/covid-test-expiration-date.html

A quirk in the regulatory process for home tests can mean the real expiration date doesn’t always match what’s on the box.

09/10/2021

Announcing Covid Pfizer and Moderna vaccine clinic at Regatta Health friends and family round - eligible folks only please - first dose 12yo+, second dose 12yo+, third dose immunocompromised only (steroids, active cancer treatment, HIV, etc CDC def here https://bit.ly/3nmwiHL). Friday mornings in West Hills, plenty of convenient free parking! Post questions below..

Pfizer

https://myturn.ca.gov?config=ad65d8a5-1a4f-41a4-8d9c-9d7676965f3b

Moderna

https://myturn.ca.gov?config=c5240049-101a-446f-aae2-e96565586908

05/05/2021

04/18/2021

Bleeding disorders can be confusing to patients and families and can be tricky to diagnose and treat. At Regatta Health, we have the expertise and experience to diagnose and treat multiple types of bleeding disorders. Bleeding disorders, where the blood is too thin, can lead to significant bleeding either during or after an invasive procedure, or at any time.

Across all patients, von Willebrand's Disease (vWD) is the most common diagnosed bleeding disorder. It can manifest with bleeding symptoms like nosebleeds, bleeding around the time of surgery, gum bleeding with tooth extraction, or heavy menstrual periods. Lab testing can show a prolonged PTT clotting time. Specialized testing can reveal a vWD diagnosis. Treatments may include a nasal inhaler called ddAVP, or replacement with clotting factors like Humate-P® or Vonvendi®.

Occasionally we do also find clotting factor deficiencies, known as hemophilia. Factor VIII (8) deficiency is the most common and actual cases are only seen in males. There are many other hemophilias besides Factor VIII hemophilia (Hemophilia A) but thankfully these are rare. Current guidelines include prophylactic treatment to prevent bleeding problems.

Many patients are referred for a prolonged PTT (partial thromboplastin) or PT (prothrombin time) on lab testing prior to a procedure. Many surgeons and other doctors routinely order these clotting times to "clear" a patient for surgery. Usually abnormal clotting results do not reflect a real problem with blood clotting, but they usually require a workup in the office to rule out any kind of underlying blood disease and to assess the risk of surgery or other procedures.

Antibodies like antiphospholipid antibodies can also cause prolonged clotting times. This is known as "Hughes' Syndrome" and can cause thickening of the blood.

The key to evaluating a suspected bleeding disorder is a careful history from the patient and then evaluation of the prior lab tests and planning a set of lab tests to work up the potential problem. Ideally this evaluation happens well before any planned procedure to reduce any delay to a procedure if it becomes more urgent. Sometimes we have to do testing while the patient is planning to have a procedure soon, so we try to proceed with due caution while trying to get the answer ASAP.

As board-certified hematologists, Dr. Benjamin and Dr. Melkonian are able to evaluate your potential bleeding disorder and recommend the right testing program to make an accurate and rapid diagnosis. They have treated many patients with hemophilia, von Willebrand's Disease, and other bleeding disorders. Making a rapid diagnosis could improve the safety of procedures you might be planning, or reduce the risk of bleeding during your daily routine.

04/18/2021

Lung cancer is increasingly treated with molecularly targeted agents, including EGFR inhibitors like Tagrisso®. This EGFR targeted agent, also known as osimertinib, has been shown to prolong survival in advanced lung cancer (“NSCLC”) for an average of over three years, as reported by the FLAURA study, reported in NEJM in 2018.

FDA has approved Tagrisso® in the setting of adjuvant (postoperative) treatment for lung cancer, treatment of lung cancer that has progressed after primary treatment, or initial treatment of lung cancer that harbors mutations in EGFR known as T790M or L858R.

EGFR-based treatment for lung cancer is a concept that emerged almost 20 years ago with the approval of Iressa® in 2003 and then Tarceva® in 2004 for EGFR-mutated lung cancer.

The EGFR is the Epidermal Growth Factor Receptor. This receptor is thought to regulate the growth of epidermal cells like lung cells. Usually this regulation is orderly and controlled. Due to environmental conditions such as to***co smoke or other factors, the gene that encodes the EGFR protein can become mutated. Some of these mutations can disrupt the orderly regulation of cell growth, leading to cancer.

Medications like Iressa® and Tarceva® originally were targeted to block the activation of the EGFR in the mutated state. These drugs worked but they had many side effects and the cancer cell evolved ways of surviving, known as resistance mechanisms, despite treatment.

Tagrisso® has been approved now for several years and works by overcoming the resistance caused by several specific DNA mutations in the EGFR gene.

Many patients wonder why treatment planning for lung cancer takes a long time. In past years, doctors could order a biopsy and have a diagnosis within a day or so. The only main question was whether the patient had a non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC). Chemotherapy was the only treatment and the protocols were different depending on the type of cancer.

In the modern era, biopsy and conventional pathology reporting is not sufficient for lung cancer treatment planning. Oncologists need to know whether the patient has so-called “driver mutations” that follow set patterns. Sometimes these results take up to a week or longer to receive from the lab. In the pandemic era, results like molecular testing for lung cancer have been taking a long time to receive. Families are understandably requesting these results as soon as possible.

In the case of Tagrisso®, a specific mutation in EGFR is required to qualify for the medication. It only works in the proper setting. Biopsy specimens must be sent to particular laboratories, often in different states, in order to move forward with treatment planning.

At Regatta Health, we have helped many patients access Tagrisso® and other advanced targeted therapy for lung cancer, through our in-office dispensing program. Many patients find it more convenient to pick up their medications in the office while they are visiting the doctor, rather than having to make phone calls to specialty pharmacies to arrange shipments and deliveries. Patients enjoy being able to call us or come in to check on their medication directly with staff they know and trust. Regatta Health staff also have expertise on obtaining copay assistance from foundations and other organizations to help patients afford these costly medications. Find out how we can help you access advanced medication at affordable prices for you or your loved one. Call for an appointment with Dr. Benjamin or Dr. Melkonian today.

04/18/2021

Many adults experience symptoms of anemia including fatigue, daytime sleepiness, and lack of energy. Anemia is a condition of low blood hemoglobin. Normal levels of hemoglobin are between 12.5 and 17.0.

Anemia can be a sign of more serious underlying problems. The possible causes of anemia are broad and include blood loss, bleeding, iron deficiency, vitamin B12 and folate deficiencies, renal disease, hereditary anemias like thalassemia, hemolytic anemia, and cancer or blood disorders like leukemia. Another blood disorder, known as MDS or myelodysplastic syndrome, accounts for some anemias as well but thankfully it’s rare.

Anemia should first be checked out by a physician and many patients are referred to hematologists to get a full workup for their anemia. Often, simple causes are discovered like iron deficiency or renal disease. Other times, more extensive workup will need to be done to discover the cause of anemia including scans or other procedures.

Many times, the aging process causes a reduced kidney function. Scientists estimate that humans lose about 1 cc per minute of glomerlular filtration rate (GFR) per year of life. The GFR is the rate at which the kidneys can filter blood to produce urine.

In addition to producing urine, the kidneys also produce a hormone known as EPO or erythropoeitin. This hormone then goes to the bone marrow and stimulates the production of red cells.

With reduced kidney function can come reduced levels of EPO. Hematologists can replace reduced EPO levels with medication called ESAs or erythropoiesis stimulating agents. Erythropoiesis is the process by which the body produces red cells.

These agents, including procrit and aranesp and also the newly-approved retacrit, can help treat anemia due to reduced renal function.

Patients may have more than one cause for anemia so before starting on these medications, they should have a full workup to rule out other causes for anemia.

Many patients find that they have improved energy levels while taking medication like procrit. Symptoms like fatigue and lack of energy may respond within a week or so to treatment with ESAs.

Medicare guidelines indicate that patients may only start treatment with ESAs in the setting of renal disease for a hemoglobin less than 10.0 and may only continue treatment when their hemoglobin is less than 12.0.

Side effects of ESAs include thickening of the blood and even strokes if the treatment is targeted to hemoglobins above 12.5. Ideally treatments with ESAs would target a hemoglobin between 11 and 12.

Hemoglobin is the protein in the red cell that gives it the red color. It is a pigmented molecule that carries oxygen. Doctors can directly measure hemoglobin in the blood by using a laser and a detector to determine the red color of the blood in the lab.

You may also hear about hematocrit and that could be low in the setting of anemia as well. Hematocrit is the percent of blood that is red cells (as opposed to water, called plasma). Usually hematocrit and hemoglobin are related to each other by a factor of 3:1.

Your doctors at Regatta Health are able to instantly check the hemoglobin when you visit the office using FDA-approved technology. If your hemoglobin is low, they may suggest a workup to determine the reasons why, and they may suggest treatment with medication like procrit. Treatment with procrit or other ESAs is usually covered by insurance if treatment guidelines are followed.

04/17/2021

09/26/2017

Sure to be controversial, FDA has advised the public that it intends to take most of the ni****ne out of ci******es within the next year. The new leader of the FDA, Scott Gottlieb MD, came out with the surprise announcement in July.
We had a speaker on e-ci******es at the hospital last week, and today an article in WSJ about this event. https://www.wsj.com/articles/meet-the-man-behind-the-fdas-ni****ne-fix-1506427200
Big federal announcements like this don't come that often, and produce a big influence on industry and society.
The idea is to make "combustible" to***co products less addictive, encouraging current smokers to turn to "e-cigarette" and "v**e" products as safer alternatives.
Of course we don't fully understand the health risks of these products yet and it might be decades before research is complete. Most current research, and common sense, suggest that the electronic products are safer for health though probably no less addictive.
Research also suggests that taking the ni****ne out of ci******es encourages people to smoke less, quit more, or switch to electronic products. There is some compensation, but not as much as expected.
The other problem is kids. These electronic products are appealing to kids, and some research reports that up to 10% of kids have tried them by the time they reach high school. Federal validation of these products might lead Americans to assume a more permissive attitude towards them, which might trickle down to more underage ni****ne use.
Clearly combustible to***co is a terrible product that contributes to hundreds of thousands of deaths per year. There are still millions of "legacy" smokers, many of whom will develop cancer, chronic lung disease, or premature coronary disease.
Since the FDA has regulatory control over to***co, they could have weakened the product a long time ago but smokers would probably have turned to a black-market solution. Ni****ne is probably not completely going away.
I'd like to see increased regulation of e-to***co products to go along with the less-ni****ne initiative. Still, combustible to***co products are so dangerous, I don't disagree with the "lesser of two evils" approach taken by the FDA.

Scott Gottlieb was once a critic of the FDA, arguing it should move faster. Now as its leader, he has seized on an idea that the agency had worked on for years: getting almost all the ni****ne out of ci******es.

09/12/2017

A whole passel of studies came out today in NEJM about immunotherapy in melanoma in connection with a European oncology meeting. http://www.nejm.org/doi/full/10.1056/NEJMoa1709684 =article
This is still a developing story but where we are right now is that after surgery for a Stage III melanoma, nivolumab (Opdivo) is better than Ipilimumab (Yervoy). Stage III melanoma is an invasive melanoma that has spread to lymph nodes, usually identified in the context of a lymph node dissection in the region of the original tumor. Today's publication is the CheckMate 238 study. After 3 years, 70% of patients treated with postop Opdivo were alive and disease free, more than the patients treated with postop Yervoy. I should point out that as of today, only Yervoy is FDA approved for treatment after surgery.
We do have an older immunotherapy approved for melanoma after surgery in Stage III, pegylated Interferon alfa, product known as Sylatron. Sylatron has not been compared head to head versus opdivo or yervoy, but numbers have been reported in that medication also and it's useful to try to draw inferences from the literature.
Probably opdivo is better than sylatron. At three years on sylatron, about 50% of patients had not relapsed, not quite as good as opdivo's 70%. Different patient populations, true, but that's a pretty big numerical difference. Opdivo isn't FDA approved yet in this setting but sylatron is.
Sylatron is probably not worse than yervoy. Yervoy offered a 60% freedom from relapse at 3 years compared to sylatron's 50%. Again, different patient populations, so take it for what it's worth. Yervoy is also pretty toxic, most patients had to stop the protocol partway through. The FDA did approve it but most people will get a disabling diarrhea and some of those cases require hospital admission.
Sylatron is no picnic either but it had about a 70% rate of patients continuing on the plan.
Opdivo is not nearly as toxic, only about 9% of patients had to stop taking it because of side effects.
Taking all these facts together, we probably have enough information to ask the FDA for approval of opdivo in the postop setting, and it probably works the best out of the different medications studied in this setting. I wouldn't be surprised if we didn't see an FDA approval soon.
I would be happy to see Yervoy in the adjuvant setting go away. It carries a ton of toxicity and you have to give it at a whopping dose of 10mg/kg which translates to $100k per infusion, $400k total cost for the initial four infusions and you're supposed to continue it every three months for up to three years. I suspect this was a case of "our efficacy at the regular 3mg/kg dose wasn't very good, so let's see if a huge higher dose will give us the response we're looking for."

On another related note, "combination" therapy with Opdivo AND Yervoy in the metastatic melanoma setting electrified the community only about two years ago and garnered an FDA approval. Today we also saw in NEJM updated results from this study, the Checkmate 067 study. The executive summary is that Yervoy doesn't seem to add much, unless you're BRAF positive, which is only a minority of these cases. If the BRAF is positive, you also have another option in the BRAF oral inhibitors such as Zelboraf or Mekinist and Tafinlar combo. The combination therapy therefore also probably goes away. Look for yervoy, so promising only two years ago, to become at most a niche player.

And another related note we now have a trial of the all-oral Mekinist and Tafinlar combo in the postop BRAF-positive melanoma setting, producing also about a 60% chance of being alive and disease free at three years, comparable to sylatron and yervoy but perhaps a little less good than opdivo. 26% of patients had to stop treatment due to side effects, about the same as sylatron.

Debates will rage on (at least in oncology circles) whether oral combo therapy or IV immunotherapy will be more useful to us clinicians. We know more than we did yesterday but there is still a lot to learn tomorrow.

Original Article from The New England Journal of Medicine — Overall Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma

09/12/2017

Today came the ongoing question: has there been a study on giving Xarelto for Hughes' Syndrome? Traditionally we treat these patients who have a benign propensity for blood clots, with warfarin, an older blood thinner. While there have been a ton of studies comparing the newer blood thinners such as Xarelto, Eliquis, and Pradaxa to warfarin (Coumadin) in settings such as pulmonary embolism, stroke prevention in atrial fib, and postop orthopaedic surgery, we don't have many studies looking at their use in Hughes' Syndrome.
Hughes' Syndrome accounts for up to 10% of all DVT, blood clots that usually start in the calf. This syndrome is also known as antiphospholipid syndrome, an autoimmune condition where the immune system produces antibodies that thicken the blood and can cause clots.
Looking into this further as a result of a patient question, we do find a small British study comparing the use of warfarin to Xarelto in these patients. It was known as the RAPS study and it only involved about 100 patients that were followed for 8 months. There were no differences in clots between the two groups, and the Xarelto appeared to work as well as the warfarin in lab testing.
There is a nice talk by Dr. Hannah Cohen, the lead author of the study, linked here: https://www.youtube.com/watch?v=i3En-dnqerE
Anyway, I think I'd still like to see more information before concluding that xarelto is as safe as warfarin in this setting. The conclusion of this video talk agrees. For most patients with a clot, Xarelto is an excellent treatment. For patients with higher risk due to antiphospholipid antibodies, we are still waiting for more data. Xarelto has been out now for about six years now so hopefully we will get more information as time goes by.

The results of the multi-centre Rivaroxaban in APS trial presented by Dr Hannah Cohen at Patients' Day 2016 in London.

09/12/2017

OMG Alecensa® (alectinib) wasn't just a little better than Xalkori (crizotinib) for advanced ALK-positive lung cancer. Hopefully FDA expands indication soon for first line! NEJM article today: http://www.nejm.org/doi/full/10.1056/NEJMoa1704795…
We hardly ever get these Coke vs. Pepsi studies in oncology, and when we do, they aren't blockbuster results like this one. Right now Alecansa is only FDA approved for after a failure of Xalkori®.
Unlike Alecensa, Zykadia® (ceritinib) is approved in the front line setting but wasn't studied in this paper. Zykadia shows a longer response duration, almost two years vs. Xalkori's one year though these are apples-to-oranges comparisons. We may never see that head-to-head study.
Alecansa had a median progression free survival (PFS) that wasn't reached in the publication. This means the 68% of patients who made it out to a year without a relapse may have achieved long term remission. I think that's the first time I've ever been able to say that about lung cancer. We had similar news for the PDL1 therapies in melanoma and now it appears we can tell a similar story in some lung cancers.
The even better news is that Alecansa prevented CNS (brain) metastases way better.
While ALK-positive lung cancers are not common, I do a profile on every new lung cancer patient to identify these. My current panel includes ALK, ROS1, PDL1, and EGFR. Positive findings in any of these markers can be life-altering in advanced lung cancer.

08/15/2017

Exciting results from ASCO 2017: Abiraterone (Zytiga) delays progression of advanced prostate cancer by over 1 year when added to conventional hormonal therapy. Chemo had been found to work in this setting also, so it's great we now have proof that a pill works at least as well.