As I leave for a brief vacation over the holiday, I wonder (as do most Americans) what’s going to happen to that impending fiscal cliff. Somehow, I reassure myself our divided congress will get this settled. But I am less complacent about the outcome for healthcare in the year and years to come. Just before I got on a plane, I glanced at the New England Journal of Medicine (my reading choices are not as literate as they should be) and came across a special report titled: “Implications of the 2012 Election for Health Care- The Voters’ Perspective.”  So as we go into the new year, I thought it might be appropriate to share the results of this report with you…

Obama won! (Excuse the exclamation point.) We also now know how those who voted for him felt about health care. Here are the stats: Obama voters were three times as likely to say that healthcare was the most important problems facing the country as those who voted for Romney. Obama voters want the Affordable Care Act  (ACA, also known as Obama care) implemented and not repealed. Obama voters want a more activist federal government intervening in the US healthcare system over the next four years. Seventy eight percent of Obama voters favor implementing or expanding the ACA and having the federal government continue its efforts to ensure that most Americans have health insurance coverage. And 85% of Obama voters support having the government try to fix the healthcare system, including 55% who believe that the federal government should have more responsibility than state governments for fixing it. And, (just a few more statistics) the majority of Obama voters upholds changing the structures of the current Medicare program ( 83%) and Medicaid program (78%). Finally 8 in 10 Obama voters believe abortion should be legal in all or most cases.

Yes, we live in a democracy but that doesn’t mean that what the majority of voters favor will, indeed, be accomplished. Thirty of the nation’s 50 states will have Republican governors in 2013, many of whom may not consider the establishment of state health insurance exchanges and Medicaid expansion as their state’s mandate. It’s clear that this may become a contentious year for many reasons and healthcare may lead the “it’s not for us” list.

Meanwhile, back to the personal, each of us should do what we can to ensure our individual health. And I will try to continue to help you do this with timely information about prevention, diagnosis and health care innovations in the year to come.

I and my staff wish you a happy and healthy New Year!

That “one in eight” lifetime risk for breast cancer is scary for every woman but unfortunately, it remains a valid statistic. Too many of my patients have been told (often by me) that  they had breast cancer, but with appropriate therapy most are now doing well. Of course, they and I have a continued concern about appropriate follow-up. How intensive and frequent should it be? Is there a point at which a woman who has had breast cancer can “relax” and get the same screening as women who have never had  breast cancer?

The American Society of Clinical Oncology recently came out with their updated recommendations for follow-up care for breast cancer survivors; but actually, they made no changes from the guidelines they released in 2006. The Society formed a special practice guidelines committee which then studied outcome data on disease free survival, overall survival, quality of life and cost-effectiveness. (I know the latter may not be that important to women who actually have had this disease but every public health organization has to assess cost.) They studied nine reviews on the topic and five randomized controlled trials. Here are the old, and now new recommendations for follow up of breast cancer survivors:

  • A physical exam and history every 3 to 6 months for the first three years after initial therapy. Subsequently a history and physical exam every 6 to 12 months for the next two years, then yearly.
  • If breast conserving surgery i.e. lumpectomy was done, the first mammogram should be performed at least six months after completing radiation therapy, followed by a mammogram every 6 to 12 months. Once mammographic findings are stable, mammography can be repeated yearly.
  • Monthly self breast exams. Women should report any symptoms such as lumps, bone pain, chest pain, breathlessness, abdominal pain or persistent headaches to a physician.
  • Genetic counseling for the following reasons: Ashkenazi Jewish heritage; a history of ovarian cancer at any age in the patient or any first or second degree relatives; any first degree relative with a history of breast cancer diagnosed before the age of 50; two or more first or second degree relatives diagnosed with breast cancer at any age; a patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative.
  • Regular annual gynecologic care. Women who take tamoxifen should tell their doctor about any vaginal bleeding since they are at higher risk for endometrial cancer.

I assume most of my patients who are breast-cancer survivors are doing all of the above and indeed I make sure they do so when I see them, as do their oncologists and surgeons. But if you or a friend or relative have had breast cancer, please make sure that these guidelines are followed. So many of us have come through this disease and continue on with our normal lives as well as having an expectation for a healthy, long life span. We just have to make sure that our follow-up is appropriate.

The CDC, most medical journals, and mainstream media have been covering the disastrous infections caused by the contamination of the steroid that was distributed by a compounding pharmacy in New England. Three potentially contaminated lots of this steroid were used by physicians in epidurals, and joint injections in over 14,000 persons. They have, so far, caused stroke, meningitis, bone infections and in some instances death, in over 137 patients.

The initial detection of this serious contamination reads like a detective story. On September 18, 2012 the Tennessee Department of Health was alerted by an observant physician that a patient had a confirmed fungal infection (to be exact, Aspergillus fumigatus) diagnosed 46 days after epidural steroid injection. By September 27, an investigation carried out by the Tennessee Department, in collaboration with the CDC and the North Carolina Department of Health, had identified 8 more cases. All nine patients had received epidural steroid injections with preservative free methyl prednisone acetate solution (MPA) compounded at the New England Compounding in Framingham, Massachusetts. And as of October 10 (when last reported in JAMA) a multistage investigation by the CDC together with local health departments and the FDA have identified 137 cases and 12 deaths associated with this outbreak in 10 states. The invoices from the pharmacy showed that approximately 17,500 vials of MPA were distributed to 75 facilities in 23 states!  By October 6, the vials not already used were recalled. And as of October 10, health departments reported that 90% of patients exposed to the medication from one of the suspected infected lots of MPA had been contacted at least once.

The patients and their doctors have been advised that they should get tested if they develop neurological symptoms such as headache, neck rigidity, fever, nausea, unsteady gait or sensitivity to light…and if so a lumbar puncture should be done to check for the fungal infection. Those patients that had joint injections should notify their physician if they develop increasing pain, redness or swelling, in which case fluid should be aspirated from the affected joint for culture. This all sounds ominous and in fact it is! Right now it’s postulated that the incubation periods for infection range from 4 to 42 days, but the maximum incubation for this infection is not known. Treatment with high dose anti-fungal therapy for months may be necessary.

If anyone doubts the importance of the epidemiological sleuthing carried out by our health departments and the CDC…this should dissuade them. And additionally, there is the issue as to whether products from compounding pharmacies are indeed safe. In an article published on December 6 in The New England Journal of Medicine, the authors summarized the evidence for compounding safety…. First, they explain what these pharmacies do: “Pharmaceutical compounding refers to the combining, mixing, or altering of ingredients of a drug by a licensed pharmacist to produce a drug that is tailored to an individual patient’s medical needs on the basis of a valid prescription from a licensed medical practitioner.” They go on to state that ” there are few reliable data on the prevalence of compounding, but it has been estimated that 0.25% to more than 2% of dispensed  prescriptions in the United States are compounded drugs. Under certain conditions, compounding may serve an important public health benefit by providing access to the needs of individual patients when a commercially available product is unavailable; however, compounded drugs are not approved by the FDA and should not be confused with generic drugs all of which must be approved by the FDA before marketing. Compounded drugs are not reviewed and approved by the FDA; therefore, their safety, efficacy, quality and conformance with federal manufacturing standards have not been established…. The regulatory authority of the FDA over compounding pharmacies is different and more limited than is its authority over pharmaceutical manufacturers.”

 

Bottom line: Thank you to the FDA and CDC. Even though regulations can be burdensome and costly they are worth it; they protect the purity and sterility of our medications. And if I do prescribe a compounded medication, I tell the patient and request that she fill the prescription in a closely monitored pharmacy.

I no longer have to take exams (except for recent on-line traffic school), nor do most of my contemporaries. But we all have to maintain our learning and memory skills in order to live our daily lives and to perform adequately or hopefully, better than adequately, in our professions. Even if we don’t have to take academic tests, our children and grandchildren do. And we all stay up for hours in front of our computers, iPads and tablets trying to get our work done, making sure we have not forgotten something or are not behind in our virtual lives. It seems that everyone crams, often at the expense of sleep. Well, it turns out that the best way to study for an exam, prepare for that next day’s task or keep the necessary data going in our brain’s memory is to get a good night’s sleep. Studies have shown that even a little sleep loss may impair our memory and learning skills.

This was the conclusion of research presented at the Society for Neuroscience meeting in New Orleans this past week, reported in JAMA. A team of researchers from Pennsylvania studied the effects of a single night of lost sleep on 22 healthy adults who agreed to stay in the lab for five days and undergo brain imaging and memory testing. (I’m not sure how anyone could sleep in a lab but hey, research of this nature requires consenting adults who agree to have sleep-overs in strange places.) The participants  were tested after a normal night of sleep and then after a night of sleep deprivation and then once more after two nights of “recovery sleep”. Lo and behold, the participants didn’t perform well on memory tasks after a sleepless night. And when imaging tests were done, their sleep deprived brains had decreased connectivity between the hippocampus (where memory is stored) and other areas of the brain necessary for performance of memory tests and tasks. It was as though parts of their brains had gone to sleep (or strike), in protest of the forced state of sleep deprivation.

The good new is that needed memory connectivity was not lost for long after a night of lost sleep. In the study, the brain connections and the participants’ performance on memory tasks were back to normal after a couple of nights of recovery sleep.

Bottom line: If you get a good night’s sleep you’ll be more likely to remember what you just read and what you should do with the information the next day…I usually write articles telling you to eat right, exercise, maintain a healthy weight, get the appropriate diagnostic tests, therapies, medications and immunizations. This time my advice should be somewhat more relaxing… sleep well.

I no longer have to take exams (except for recent on-line traffic school), nor do most of my contemporaries. But we all have to maintain our learning and memory skills in order to live our daily lives and to perform adequately or hopefully, better than adequately, in our professions. Even if we don’t have to take academic tests, our children and grandchildren do. And we all stay up for hours in front of our computers, iPads and tablets trying to get our work done, making sure we have not forgotten something or are not behind in our virtual lives. It seems that everyone crams, often at the expense of sleep. Well, it turns out that the best way to study for an exam, prepare for that next day’s task or keep the necessary data going in our brain’s memory is to get a good night’s sleep. Studies have shown that even a little sleep loss may impair our memory and learning skills.

This was the conclusion of research presented at the Society for Neuroscience meeting in New Orleans this past week, reported in JAMA. A team of researchers from Pennsylvania studied the effects of a single night of lost sleep on 22 healthy adults who agreed to stay in the lab for five days and undergo brain imaging and memory testing. (I’m not sure how anyone could sleep in a lab but hey, research of this nature requires consenting adults who agree to have sleep-overs in strange places.) The participants  were tested after a normal night of sleep and then after a night of sleep deprivation and then once more after two nights of “recovery sleep”. Lo and behold, the participants didn’t perform well on memory tasks after a sleepless night. And when imaging tests were done, their sleep deprived brains had decreased connectivity between the hippocampus (where memory is stored) and other areas of the brain necessary for performance of memory tests and tasks. It was as though parts of their brains had gone to sleep (or strike), in protest of the forced state of sleep deprivation.

The good news is that needed memory connectivity was not lost for long after a night of lost sleep. In the study, the brain connections and the participants’ performance on memory tasks were back to normal after a couple of nights of recovery sleep.

Bottom line: If you get a good night’s sleep you’ll be more likely to remember what you just read and what you should do with the information the next day…I usually write articles telling you to eat right, exercise, maintain a healthy weight, get the appropriate diagnostic tests, therapies, medications and immunizations. This time my advice should be somewhat more relaxing… sleep well.

We all know what happened on the East Coast a few weeks ago. Even Governor Christie thinks that climate change instigated or at least impacted the occurrence of hurricane Sandy. As a former New Jersey-ite, I was horrified to see what happened to the beaches of my childhood and the communities where I grew up. As a Californian, I felt a need to pay attention to a recent article in JAMA titled “Record Heat” May Have Contributed to a Banner Year for West Nile Virus”. Four thousand cases of West Nile virus have been reported to the CDC as of early October, and this is more than five times the number of cases reported in 2011. (Note epidemiologists state that there are more than 5 cases for every one that is reported, so the actual number of cases was much higher.) This viral surge was concentrated in Texas, Mississippi, Michigan, South Dakota, Louisiana, Oklahoma, and yes California; probably as a result of the higher than normal temperatures.

West Nile virus began in Africa and large outbreaks occurred in warmer climates. Then it spread… The initial outbreak of West Nile virus in the US was in New York City in 2002 and 2003 and was associated with warm weather. It turns out that warmer than average weather does a few things: it increases reproduction or replication of the virus in mosquitoes making them more infectious; it also shortens the incubation between the time from when the mosquito takes an infectious blood meal to when the mosquito can become infectious and spreads the virus by biting a person or a bird.

A quick West Nile virus epidemiologic review… mosquitoes breed in dry streams and standing water  where they begin their life cycle. Birds are the reservoir host for the virus. The mosquito gets the virus from a blood meal from the infected bird. The virus then replicates in the mosquito, which can either bite an uninfected bird and infect it, or bite a human and transmit the virus. And if a person is infected with the virus she or he can either develop mild flulike symptoms or get really ill. The milder form of the disease may seem like any flu… Symptoms include fever, headache, diarrhea, muscle aches, fatigue, and /or swollen glands. But some infected individuals go on to develop severe neurologic disease. This is thought to occur in one in 150 persons and symptoms include headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, convulsions and even paralysis.There is no treatment…

The first eight months of 2012 were the hottest on record in the United States. And if climate change continues and we have ongoing heat (together with standing water) we will probably see an even greater increase in West Nile virus. Thankfully the current administration has and will continue to address global warming (I do realize this is not a PC term.) At the present time the best way to combat West Nile virus is through prevention; that means giving some of the same advice that we would give to a traveler in Africa: Wear mosquito repellent, particularly at dawn and dusk. And the repellents that work usually contain DEET, oil of lemon eucalyptus, or a substance called picaridim. (Apparently other so-called repellents that may smell better don’t really work.) And in addition, municipalities will have to use pesticides sprayed by trucks or planes to prevent the spread. According to the author of the article (he is the director of the Division of Vector-Borne Diseases at the CDC), very small amounts of pesticide need be used – less than an ounce per acre. He writes that these have no known health effects and are rapidly degraded and do not persist in the environment.

One more thing to be concerned about…But hopefully appropriate policies that address and eventually contain ongoing climate change as well as personal precautions will diminish the risk of this global viral threat.

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